Abstracts from the 2025 Annual Meeting of the Society of General Internal Medicine

1. Get the Facts on Older Americans. June 1, 2024. Accessed September 12, 2024. https://www.ncoa.org/article/get-the-facts-on-older-americans/ 2. Geriatrics Workforce by the Numbers. American Geriatrics Society. https://www.americangeriatrics.org/geriatrics-profession/about-geriatrics/geriatrics-workforce-numbers 3. Tip Sheet: The 5Ms of Geriatrics | HealthInAging.org. Accessed July 24, 2024. https://www.healthinaging.org/tools-and-tips/tip-sheet-5ms-geriatrics RELEVANCE OF TOPIC TO SGIM MEMBERS: With the older adult population growing exponentially, patients 65 and older receive the majority of their care by generalists in the inpatient and outpatient settings. The goal of this Update is to discuss how the latest advances in the care of older adults can be applied to clinical care provided by generalists. In addition, the session will provide clinicians with the tools to advance evidence-based age-friendly care in their academic institutions, consistent with the meeting theme. Clinical Update - Healthcare Delivery and Redesign UPDATE IN CLIMATE AND HEALTH William G. Weppner1,2; Arnab K. Ghosh3; Lesley B. Gordon4; Elizabeth J. Gillespie5; Linnaea C. Schuttner6. 1Department of Medicine, University of Washington, Boise, ID; 2Boise VA Medical Center, Boise, ID; 3Medicine, Weill Cornell Medical College, New York, NY; 4Department of Medicine, MaineHealth, Portland, ME; 5School of Medicine, University of Colorado, Denver, CO; 6Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA. (Control ID #4177602) COLLABORATION: Environmental Health Interest Group, Health Policy Clinical Practice Subcommittee, Medical Society Consortium on Climate & Health SESSION SUMMARY: Climate change threatens planetary health and human wellbeing. As clinicians, we are obligated to understand the evolving evidence regarding potential and observed harm to our patients. As health care leaders, we called to identify and address how health care contributes to the drivers of climate change. As educators, we need to be able to explain the causes and consequences to learners, empowering them to address these issues. This session will review the most informative practice-changing evidence, guidelines and policies on the health-related drivers and impacts of climate change in the prior 24 months (as a first time, novel update). Presenters will select articles with high topical relevance through a structured review of relevant published peer-reviewed evidence and noteworthy white or grey literature, selecting 6-8 articles based on relevance, quality, impact, and potential for actionability within general internal medicine. Given the nature of climate change to impact those that are least likely to have contributed to it, and least able to respond to it, additional time will be spent highlighting potential inequities and related social determinants of health. Participants will answer pertinent clinical or systems questions during the session, to support interaction and application. The presenters will then summarize the key points of each article, analyze the evidence in a structured format, and contextualize it for general internists. At the end of the session, participants will be empowered with the latest evidence to provide better clinical care to patients potentially at risk of experiencing climate-related health effects, educate patients and learners on climate-related health risks, advocate for improved health system activity within climate-actionable areas (e.g., prescribing choices), and to identify areas to address to mitigate or adapt to future changes in the rapidly evolving health-climate ecosystem. RELEVANCE OF TOPIC TO SGIM MEMBERS: SGIM members are particularly well-positioned to understand and address the drivers of climate change from health systems through clinician-level changes and system-wide advocacy, respond to growing health needs in patients from climate harms, and to educate trainees and patients on the current and future health harms of climate change. Clinical Update - Health Care Policy and Health Services Research UPDATE IN RESEARCH METHODS FOR THE GENERALIST Melissa Y. Wei1; Seth A. Berkowitz2; Himali Weerahandi3. 1Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2Division of General Medicine & Clinical Epidemiology, UNC School of Medicine, Chapel Hill, NC; 3Medicine, University of California San Francisco School of Medicine, San Francisco, CA. (Control ID #4185683) COLLABORATION: Research Committee SESSION SUMMARY: Generalists must stay abreast of novel research methods to understand, generate, and use the most important research findings and 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 critically appraise research methods to select the most appropriate methods to answer a research question. Innovation and methodologic rigor are also criteria for successful NIH, VA, PCORI, and other foundation 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 4-5 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 academic medicine, healthcare access, utilization, and delivery, we will highlight at least one publication that features novel methods relevant to academic GIM. We also identified the following research methods of high interest: artificial intelligence, machine learning, causal inference, and network 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, “Catalyzing Change in Academic General Internal Medicine.” We will use a modified Delphi process and devote at least two Research Committee meetings to discuss and select the top 4-5 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 top papers to present based on consensus. For the presentation we will use 60 minutes for an introduction, presentation of papers (10 min/paper), and discussion fielded by questions from the audience. 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 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. UPDATES IN HEALTH POLICY Anders Chen1; Tracey Henry2; Arnab K. Ghosh3; Celeste M. Newby4; Anna M. Morenz5. 1Internal Medicine, University of Washington, Seattle, WA; 2Medicine, Emory, Powder Spgs, GA; 3Medicine, Weill Cornell Medical College, New York, NY; 4John W Deming School of Medicine, Tulane University School of Medicine, New Orleans, LA; 5Department of Medicine, Banner - University Medical Center Tucson, Tucson, AZ. (Control ID #4185069) COLLABORATION: Health Policy Committee SESSION SUMMARY: This session will provide major updates in health policy across education, research and clinical practice, the 3 subcommittees of SGIM’s Health Policy Committee. In clinical practice, major Medicare physician payment reform proposals are being considered, and state-based Medicaid waiver programs continue to expand, improving equity and access to care. In education, anti-DEI bills that would limit the scope of medical education threaten recent gains in health equity, while primary care workforce issues continue to be addressed. In research, proposals to restructure the National Institutes of Health (NIH) loom, which have the potential to fundamentally alter health services research. The Primary Care Research Network (PCRN) continues to adapt and requires the voices of academic primary care physicians. Clinical Practice: Medicare Physician Payment Policy: The Senate Finance Committee and Senate Budget Committee are working on legislation to reform overall Medicare Physician Payment and primary care payments respectively, with one bill released and another draft in progress. The outcome of these bills would have huge ramifications for primary care. Medicaid 1115 waivers: Under the Biden administration, states have been encouraged to apply for 1115 waivers to expand care for the most vulnerable Medicaid patients and address upstream social drivers of health. Multiple states have had waivers approved and are implementing programs, including two states which will begin limited use of Medicaid dollars for housing. Medicaid expansion: 10 states have still not expanded Medicaid, including Florida. This limits access to care, health equity and quality of care. Education DEI: We will provide updates on any bans or bills to ban DEI In Medical Education, including updates on the EDUCATE Act. If passed, this could end federal funding for US medical schools with programs related to DEI. Workforce: We will provide updates on projected physician shortages and various bills proposing to expand GME Slots. We will also provide updates on Title VII funding to support primary care training and updates on the Conrad State 30 program which impacts International Medical Graduates coming to US residency programs on J1 visas. Research NIH restructure: Recent bills propose to fundamentally alter the nature of the NIH, leading to de-prioritization of health services research, particularly in primary care. PCRN: the newly created PCRN aims to bring clinical trial design into the primary care space, with the goal of ensuring diversity in clinical trial populations. The PCRN also has a role in working towards improving structure, payment, and operations in primary care delivery. RELEVANCE OF TOPIC TO SGIM MEMBERS: The topics we will cover impact the vast majority of SGIM members who teach, conduct research, and/or practice clinical medicine. 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 #4186001) COLLABORATION: This is presented in collaboration with the Academic Hospitalists Commission. SESSION SUMMARY: The care of hospitalized patients has become increasingly complex. Providers (including physicians, trainees, advanced practice providers, pharmacists, and others) responsible for this care should be equipped with the most recent evidence to provide high-quality, safe, patient-centered, cost-conscious, equitable care. This session, developed for hospitalists and non-hospitalists who provide care in the inpatient setting, will present an update in hospital medicine, outlining the most significant publications and their potential impact on care since the 2024 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 (10-15 total articles). The articles will be selected using a modified Delphi method engaging 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. There will be 10 minutes for question and answer and 5 minutes for evaluations. RELEVANCE OF TOPIC TO SGIM MEMBERS: The Society of General Internal Medicine (SGIM) is a global association which a the professional home for academic general interests. SGIM includes self-identified hospitalists, general internists who provide inpatient and outpatient care, and those focused primary on outpatient medicine. This session, providing a literature update focused on hospitalized patients, will be high-yield for all generalists in SGIM. UPDATE IN PERIOPERATIVE MEDICINE Ryan Munyon1; Richard Silbert2; Matthew A. Pappas3; Maleka Khambaty2; Felicia R. D'Souza4. 1Internal Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA; 2General Internal Medicins, Mayo Foundation for Medical Education and Research, Rochester, MN; 3Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH; 4Hospital Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4184847) COLLABORATION: SGIM 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 author 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. 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 will need surgery, requiring internal medicine care. This update provides essential skills and knowledge for internists to fill their role within the spectrum of care. Clinical Update - Medical Education and Scholarship UPDATE IN MEDICAL EDUCATION Rebekah Gardner1; Peggy B. Leung2; Sreekala Raghavan3; Jordan See4; Yihan Yang5. 1Department of Medicine, Alpert Medical School of Brown University, Providence, RI; 2Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY; 3Medicine, Mount Sinai Beth Israel Hospital, New York, NY; 4Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 5Medical Education and Clinical Sciences, Washington State University, Pullman, WA. (Control ID #4176903) COLLABORATION: SGIM Education Committee SESSION SUMMARY: Innovation and scholarship in medical education have paralleled broader social trends, including a focus on racial justice and advocacy, evolving workplace norms, the changing climate’s impact on health, and the adoption of new technology for education and patient care, all of which general internists are uniquely positioned to address. In line with the meeting theme, “From Ideas to Action: Catalyzing Change in Academic General Internal Medicine,” the 2025 Update in Medical Education will highlight publications that explore these trends and provide tools for innovation and adaptation. We will seek articles that address competency-based education, professional identity formation, inclusive learning environments, precision education, emerging technology, education related to planetary health, and diversity, equity and inclusion efforts. We will build off the well-attended and highly-rated 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 academic 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 track record 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, committee members will score the identified articles in the following categories: relevance to meeting theme, importance of the study question, quality of study methodology, and impact/generalizability of the study findings. Each article will be rated by at least two reviewers. The most highly 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 volume of medical education literature that is published annually, it is challenging for our members to stay up-to-date on the latest innovations. For many of our members, a primary objective of attending the SGIM national conference each year is to learn about important trends in medical education. Our diverse group of educators will develop a concise summary of relevant, high-impact medical education literature to support our SGIM educators and their learners. Clinical Update - Mental/Behavioral Health and Substance Use Disorders CLINICAL UPDATES IN ADDICTION MEDICINE Carolyn A. Chan2; Stefan Kertesz4; Katherine P. Mullins5; Kenneth L. Morford3,1. 1General Internal Medicine, Yale School of Medicine, New Haven, CT; 2University of Cincinnati College of Medicine, Cincinnati, OH; 3Internal Medicine, Yale University School of Medicine, New Haven, CT; 4Medicine, Birmingham VA Medical Center & U. Alabama Birmingham, Homewood, AL; 5NYU Langone Health, New York, NY. (Control ID #4176248) COLLABORATION: Alcohol, Tobacco and other drugs (ATOD) SESSION SUMMARY: Nearly 48.7 million Americans had a diagnosis of a substance use disorder (SUD) in the past year, according to the most recent US National Survey on Drug Use and Health (2022). Furthermore, in 2023 alone, there were an estimated 107,000 overdose deaths in the U.S. Despite the high prevalence of SUD and the burden of overdose death, fewer than 1 in 4 individuals with SUD obtained any addiction treatment in the past year. General internists can make a crucial difference by staying current on caring for individuals with SUD. In this session, we will critically review and present high-yield, peer-reviewed literature from the past year that can guide internists in caring for patients with SUD. We will highlight content relevant for academic general internists to inform clinical education and advocacy. Content areas will include medication and behavioral treatment for SUD, management of co-occurring medical conditions for persons with SUD, models for integrating SUD care in generalist settings, health policy implications, and disparities in SUD screening and treatment. We will apply a case-based approach to emphasize clinical implications and facilitate audience engagement. Key findings from these articles will be summarized to provide practical strategies for internists to implement in their general practice when caring for individuals with SUD. RELEVANCE OF TOPIC TO SGIM MEMBERS: General internists are crucial in caring for patients with SUD. Starting in 2023, all physicians with a DEA license must complete a minimum of 8 hours of SUD education for new applications or renewals. ACGME requires addiction medicine training for residents, yet many institutions face a shortage of trained faculty, which limits addiction educational opportunities for residents. This session is designed to provide general internists with the education needed to help fulfill these requirements. UPDATES IN MENTAL HEALTH Helen E. Jack1; Ruth A. Bishop2; Ellie Grossman5; Lisa Ochoa-Frongia3; Shyam Sundaresh4. 1Medicine, University of Washington, Seattle, WA; 2Internal Medicine, Medical University of South Carolina, Charleston, SC; 3Medicine, University of California San Francisco, San Francisco, CA; 4Department of Medicine, Mount Sinai Health System, New York, NY; 5Medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #4180430) COLLABORATION: SGIM Mental Health Interest Group SESSION SUMMARY: Background and importance: More than 1 in 5 US adults lives with a mental health condition (1). Since the COVID-19 pandemic, the US has faced a worsening mental health crisis. Primary care providers provide the majority of mental health care in the US (2), and it is estimated that general practitioners write 50% of prescriptions for anxiety and depression (2016-2018) (3). Given the prevalence and impact of mental health conditions, all internal medicine physicians must be prepared to screen for, diagnose, and manage or co-manage common mental health conditions in their practice. Session overview and article selection strategy: This session will review the latest evidence in mental health, with a focus on conditions and interventions most relevant to the general internist. We will use a comprehensive search strategy to identify and review potential mental health update articles published in top psychiatry (e.g., JAMA Psychiatry, Lancet Psychiatry, World Psychiatry, American Journal of Psychiatry, Psychiatric Services) and general medicine journals (e.g., JGIM, JAMA, NEJM, Annals of Internal Medicine). We will also review clinical guidelines (e.g. Veterans’ Health Administration, USPSTF, American College of Obstetrics and Gynecologists, American Psychiatric Association) published between April 2023-March 2025. We will then select the highest impact and most practice changing articles relevant to the general internist, based on the presenters’ mental health expertise. Studies will be presented in thematic categories: 1) Epidemiology: evolving incidence and relationship between mental health and physical health outcomes; 2) New medications or new applications of existing medications that the internist should be prepared to prescribe, 3) New medications or new applications of existing medications that the internist likely will not directly prescribe but patients may be on or inquire about, 4) Non-pharmacologic interventions (e.g. apps, lifestyle interventions), and 5) implementation science (i.e. strategies for delivering evidence-based mental health care within internal medicine practice settings). Session format: For each study or guideline, we will introduce a case and interactively ask the audience a multiple choice question using a phone-based interactive polling app. We will then share key details of the study or guideline, provide a critical appraisal, and explain its relevance to general internal medicine practice.

1. 2021 National Survey on Drug Use and Health. 2. Olfson M, Kroenke K, Wang S, Blanco C. Trends in office-based mental health care provided by psychiatrists and primary care physicians. J Clin Psychiatry. 2014 Mar;75(3):247-53. doi: 10.4088/JCP.13m08834. PMID: 24717378. 3. Jetty A, Petterson S, Westfall JM, Jabbarpour Y. Assessing Primary Care Contributions to Behavioral Health: A Cross-sectional Study Using Medical Expenditure Panel Survey. Journal of Primary Care & Community Health. 2021;12. doi:10.1177/21501327211023871 RELEVANCE OF TOPIC TO SGIM MEMBERS: General internal medicine (GIM) physicians, both in ambulatory and inpatient settings, care for patients who have mental health conditions and manage mental health conditions independently or in collaboration with psychiatrists. The latest evidence in mental health care should inform their clinical practice and how they educate their patients. Given the shortage of mental health professionals, it is imperative that GIM physicians incorporate mental health care into their professional identity. 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 #4175431) COLLABORATION: n/a 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 2024 through April 2025. 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 "EBV’S RARE ABDOMINAL MANIFESTATIONS: A CASE OF ACALCULOUS CHOLECYSTITIS AND APPENDICITIS" Tijin A. Mathew1; Rajashree Hariprasad2; Benjamin M. Easow1; Lydia George1. 1Internal Medicine, Southeast Health, Dothan, AL; 2Alabama College of Osteopathic Medicine, Dothan, AL. (Control ID #4269695) CASE: This is an 18-year-old female with no significant past medical history who presented to the emergency department with abdominal pain for the last one week. Her abdominal pain was constant aching pain more pronounced in the right upper and lower quadrant abdominal pain. She denied any fever or sore throat however reported she also noticed mild generalized body aches. On examination, she had a positive Murphy sign and right lower quadrant tenderness. Her CBC with differential count was normal however her CMP showed elevated Aspartate Transaminase 235, Alanine Transaminase 250, Alkaline Phosphatase 264, and Total Bilirubin 1.1. Her CT abdomen and pelvis showed a prominently thickened gallbladder wall with trace pericholecystic fluid, inflamed appendix, and splenomegaly at 14.2 cm. Her Ultrasound abdomen showed a positive Murphy sign with no obvious gallstone and a normal common bile duct at 0.3 cm. Her Monospot test was positive and her hepatitis panel was negative. Her EBV IGM is>160 and her EA IGG is>150 indicating her EBV infection. General surgery was consulted and she underwent appendectomy for her appendicitis however opted for conservative management for her acalculous cholecystitis given for etiology considered in the setting of EBV. On the day of her discharge, her abdominal pain resolved with a down-trending hepatic functional test. IMPACT/DISCUSSION: Primary Epstein-Barr infection (EBV) is common in children and young adolescents and typically presents with features of fever, pharyngitis, and lymphadenopathy. However rare complications include acalculous cholecystitis, appendicitis, mesenteric lymphadenitis, etc. Acute acalculous cholecystitis is usually seen in critically ill and hospitalized patients and very rarely in healthy young patients. Even though isolated cases of acalculous cholecystitis and appendicitis have been reported there is no evidence that a patient presented with both acalculous cholecystitis and appendicitis and importantly this patient did not have any typical infectious mononucleosis symptoms. Acalculous cholecystitis and appendicitis are considered to be the atypical presentation of EBV infection. The pathogenesis is considered due to the release of pro-inflammatory cytokines. No surgical intervention is required in acute acalculous cholecystitis. However, the literature review shows that given the potential sequelae of appendicitis, all the patients underwent appendectomy. There is no role of antibiotics in these conditions.

Acalculous cholecystitis and appendicitis are rare but potentially serious complications of Epstein-Barr virus infection. Clinicians should consider these conditions in patients presenting with abdominal pain and suspected EBV infection. While acalculous cholecystitis typically does not require surgical intervention, appendicitis is generally managed surgically, depending on the severity of the case. A CASE OF COMBINED IMMUNODEFICIENCY DIAGNOSED IN LATE ADOLESCENCE AFTER UNEXPLAINED ANAPHYLAXIS Tyler Schaeffer1; Chen Rosenberg2. 1Medicine, Cambridge Health Alliance, Cambridge, MA; 2Allergy and Immunology, Lahey Hospital & Medical Center, Burlington, MA. (Control ID #4269652) CASE: A 17-year-old male presented to an Allergy/Immunology clinic with a history of three episodes of lip swelling and respiratory symptoms requiring epinephrine. History did not reveal a clear cause for his anaphylaxis, including stinging insects, foods or medications. Medical history includes well controlled persistent asthma and allergic rhinitis/conjunctivitis. He outgrew eczema. He reported recurrent ear infections, recurrent Strep throat that resolved after tonsillectomy and adenoidectomy, staphylococcal abscesses, impetigo and molluscum infections, and two pneumonias. He has not been hospitalized for infections. Laboratory findings included: normal tryptase; normal IgE, low IgG, high IgM and IgA; and monoclonal lambda peak. Flow cytometry showed increased naive T and B cells, decreased memory B cells, decreased memory and effector T cells. He had absent antibody responses to childhood pneumococcal, Hib and diphtheria vaccines. After vaccine booster doses, repeat tetanus titer was protective, but post-vaccine titers to Hib and S. pneumoniae remained absent. A primary immunodeficiency gene panel revealed a variant of unknown significance in CARD11, a scaffold protein invovled in immune regulation. This was thought to be clinically significant, though has not been reported in the literature. CARD11 mutations are implicated in combined immunodeficiencies including those with atopic phenotype. In summary, this is a 17-year-old male with a history of recurrent sinopulmonary and skin infections, atopic disease, idiopathic anaphylaxis, and MGUS whose evaluation supports a diagnosis of combined immunodeficiency, specifically, Hyper IgM syndrome. The patient has had marked clinical improvement on replacement immune globulin. IMPACT/DISCUSSION: A combined immunodeficiency (CID) involves impairment in both T and B cells. Severe combined immunodeficiency (SCID) involves the absence of T and B cell function and typically is fatal before age 2 without intervention. Mild-moderate CID can present in the second decade of life or later. Susceptibility to infections is a hallmark. Notably, some cases may present with autoimmune disease and/or atopy. Lymphocytes are classically low, but lymphocytes present may be dysfunctional, leading to a dysregulated state of autoreactivity and inflammation. Internists working with young adults should be comprehensive in their infectious history evaluation of patients with a high allergy burden. This adolescent patient went 15 years with significant atopic disease and frequent though mild infections before an immune evaluation was initiated. This was only after he was referred to a specialist due to unexplained anaphylaxis. This case highlights idiopathic anaphylaxis and atopic disease as presenting features of CID and describes a novel CARD11 mutation causing CID.

A diagnosis of immunodeficiency is frequently delayed to young adulthood due to variable clinical presentations. Atopy has a close and underrecognized relationship with primary immunodeficiency. A CASE OF LEAD POISONING IN ADOLESCENT Ishan R. Gonehal1; Mimi S. Biswas2. 1Student, Martin Luther King High School, Riverside, CA; 2Assistant Professor of Medicine, University of California Riverside, Riverside, CA. (Control ID #4271805) CASE: A 15-year-old male presented with severe headaches, mental fog, fatigue, and reduced appetite. Routine labs and TSH levels were normal. Clinic considered lead poisoning after the patient's mother incidentally tested for elevated BLL (30.5 μg/dL) outside the US, triggering the family to get tested. Patient's BLL was 23.0 μg/dL, and his Father's was 20.0 μg/dL. The public health department investigation concluded that their severe BLL abnormality resulted from consuming imported turmeric contaminated with lead for over two years. Symptoms included general exhaustion and daily cluster headaches at 8-9/10 in intensity, with episodes lasting up to two hours. Physical examination was normal, only revealing low BMI (18.7 kg/m2). Initial management included discontinuing turmeric consumption, daily calcium and zinc supplementation (50 mg each), and increased hydration. Within seven days, BLL dropped to 18 μg/dL but subsequently increased to 19 μg/dL. Over the next 25 months, the patient's BLL gradually declined, reaching 6.3 μg/dL. Regarding symptomatic improvement, headache frequency shortened from every few days to every few months, yet pain and mental fog remained unchanged. Chelation therapy was rejected due to potential developmental risks. IMPACT/DISCUSSION: This case highlights the risks of lead exposure through food contamination. Imported turmeric is considered a global health concern due to exceeding lead safety thresholds. The patient underscores lead's neurotoxic and systemic effects, particularly during stages of physiological growth and metabolic activity. The logarithmic decline in the patient's BLL aligns with lead's toxicokinetics. Lead initially accumulates in soft tissues and is later deposited in bones, where it can be mobilized back into the bloodstream during periods of adolescent bone growth, a likely contributor to the patient's slowing rate of BLL reduction. Although lead poisoning is common, symptoms are vague and varied, while testing guidelines don't even exist past age two. Calcium and zinc supplementation effectively reduced the patient's BLL and mitigated symptoms, yet his persistent mental fog underscores the long-term impacts of lead toxicity past initial exposure. Therefore, by promoting the increase of BLL check-ups, raising awareness for contaminated foods, and advocating for stricter import regulations, similar patients, especially those with varied symptoms, can avoid further toxicity and moderately reverse damage.

In conclusion, dietary sources contaminated with turmeric can result in moderate to severe lead poisoning. Additionally, early identification, supplementation, and lifestyle changes can effectively reduce BLL but may not fully reverse neurotoxic effects. To combat lead poisoning, public health measures, such as stricter import regulations, public education, and medical awareness, can mitigate lead exposure risks. BREAKING IT DOWN – SPIN CLASS INDUCED RHABDOMYOLYSIS IN A HEALTHY YOUNG ADULT Aaron Pathak1; Anna Young1; Ifeanyi Anyaoha2; 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 #4216771) CASE: A 21-year-old healthy female presented with diffuse soreness, bilateral thigh pain, and dark colored urine after an intense spin class five days prior. Two days ago, the patient presented to an urgent care clinic and was told that she had blood and protein in her urine due to a UTI and prescribed an antibiotic and instructed to hydrate. The day prior to presentation, she reported worsening pain and stiffness in her legs, lower abdominal pain, and difficulty with ambulation, prompting presentation to the ED. She was found to have a CK>100,000 U/L, AST 1463 U/L, ALT 485 U/L, creatinine 0.5 mg/dL, negative pregnancy test and UA with 3+ blood, 4 RBC. She was admitted and aggressively hydrated with an improvement of CK to 64,000 U/L the following morning and modest clinical improvement in pain and movement. However, on the third day of admission, she complained of increasing left leg swelling, prompting surgical evaluation who found no signs of compartment syndrome. Bilateral lower extremity ultrasound was negative for DVT. Over the next couple of days, the patient’s labs and symptoms continued to improve with hydration. IMPACT/DISCUSSION: Although rhabdomyolysis is not necessarily an uncommon medical diagnosis, there has been a recent surge in admissions particularly among young people due to the increasing popularity of spin cycling. Stationary bike “spin” class is a type of group exercise activity that pushes individuals beyond normal solo performance. Previous literature has described the risks of developing rhabdomyolysis particularly in those who maintain a sedentary lifestyle and rapidly engage in high-intensity exercise. Rhabdomyolysis typically has a serum CK>10,000 U/L, reaching a peak 24-72 hours from time of exercise. UA is usually positive for heme while showing few or no red blood cells. Other labs may show kidney and hepatic damage. Compartment syndrome is a severe complication caused by an increase in pressure within a closed anatomical space that can cause necrosis of muscles and nerves due to compromised perfusion. Signs include severe pain, swelling, numbness, pulselessness, or even paralysis and should prompt urgent surgical evaluation. Treatment of rhabdomyolysis is primarily fluid resuscitation to a goal of 200 to 300 mL per hour of urine output. Although our patient was young and healthy, she was unaware of the dangers of engaging in a high intensity spin class. Additionally, she was misdiagnosed at the urgent care clinic resulting in a delay in appropriate treatment which could have been detrimental.

This case highlights the intersection of fitness culture and clinical awareness in the diagnosis and management of exercise-induced rhabdomyolysis, particularly among young, healthy individuals. Physicians should be aware of the increased risk of rhabdomyolysis particularly in sedentary individuals who rapidly increase their activity levels in exercises such as an intensive spin class. FIGHTING FATIGUE IN LONG COVID: OFF-LABEL BENEFITS OF LOW DOSE NALTREXONE Selamawit A. Addissie1; Jane Abernethy2. 1Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD; 2General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4272365) CASE: A 41-year-old female presented to clinic with a past medical history of depression, anxiety, and a COVID infection in January of 2022 complicated by persistent migraine, brain fog with speech delay, dizziness, tachycardia, palpitations and fatigue. The patient underwent a thorough workup to rule out reversible causes and saw multiple specialists including Pulmonology, Neurology and Physical Medicine and Rehabilitation. After comprehensive assessment, her new symptoms were attributed to long COVID. Her migraines, depression and anxiety, and dysautonomia associated with tachycardia and palpitations became well controlled with medical management. However, the patient’s fatigue continued to be so severe that she stopped working and moved in with her parents. While she was able to manage her activities of daily living, she relied on her parents for her instrumental activities of daily living (IADLs) such as meal preparation, house cleaning, and management of her doctor’s visits. To address her fatigue, she participated in physical and occupational therapy without significant improvement. Two years following her initial diagnosis, the patient was started on low dose naltrexone (LDN). Within a few months, the dose was up titrated. She noted significant improvement in her energy level and exercise tolerance. She resumed management of her IADLs and started working part time for her family business. IMPACT/DISCUSSION: Long COVID is thought to be caused by persistent activation of immune cells leading to chronic inflammation, though the exact mechanism is unclear. Over 200 symptoms have been identified as symptoms of long COVID, and among those, fatigue, brain fog and post-exertional malaise are most commonly reported and the most debilitating. Management of those symptoms has traditionally been approached with implementing intense physical therapy, diet changes and taking supplements such as niacin and NAD. Naltrexone is an opioid antagonist at doses greater than 50mg, but at low doses it has been proposed to have immunomodulatory and anti-inflammatory properties. LDN is typically started at 0.5 mg daily dose and up titrated as tolerated up to 5-6 mg daily. Common side effects that limit dose up-titration include nausea, vomiting, somnolence and decreased appetite. Several small retrospective studies have shown efficacy at various doses, with results typically measured by self-reported improvement in ability to participate in activities of daily living, energy levels, pain levels, levels of concentration, and more. It may take up to 12 weeks before seeing response to treatment. Larger randomized controlled trials are needed to determine standardized dosing, duration of treatment and which patient populations can most benefit from treatment.

The off-label use of low dose naltrexone has been shown to improve multiple symptoms in patients with long COVID. Further studies are needed to understand and maximize the benefits and therapeutic potential of LDN in long COVID. MISSED OPPORTUNITIES: THE IMPORTANCE OF UNIVERSAL HIV SCREENING IN ADOLESCENTS AND YOUNG ADULTS WITH ACUTE PRESENTATIONS Elizabeth Bolton2; Laura J. Benjamins1; Latonya Riddle3. 1Pediatrics, Wayne State University School of Medicine, Detroit, MI; 2Wayne State University School of Medicine, Detroit, MI; 3Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4271627) CASE: A 19-year-old male with a history of multiple STIs, including pharyngeal gonorrhea, urine and rectal chlamydia, and more than 20 lifetime partners (both male and female), was prescribed emtricitabine/tenofovir alafenamide for HIV PrEP. Unfortunately he never took it. One year later, he presented with a positive urine chlamydia test. All other sites tested negative; a 4th generation HIV test was also negative. The patient reported no sexual activity in the past two months. One month later, the patient developed a 103 F fever, back pain, myalgias, headache, abdominal cramping, diarrhea, nausea, vomiting, and a sore throat. In the days following symptom onset, the patient was seen in three different emergency departments, where various workups were performed. Notably, none included HIV testing. Six days after symptom onset, the patient was seen in clinic; a rapid strep test was positive, and he received IM Penicillin. Serum testing included a reactive 4th generation HIV test, indeterminant HIV-1 Ab, a viral load of 3,652,943 copies/mL HIV-1 RNA, and a 280 CD4 count. He returned two days later and was started on Bictegravir/Emtriciabine/Tenofovir alafenamide treatment. IMPACT/DISCUSSION: According to the CDC youth aged 13 to 24 account for more than 1 in 5 new HIV diagnoses in the United States. Despite this, approximately 60% of youth living with HIV do not know that they are positive. Additionally, youth with HIV are the least likely out of any age group to be linked to care. Several organizations, including the CDC, USPTF and the AAP have all advocated for screening adolescents and young adults for HIV, however teens consistently report that they are not offered this testing, and several studies have found that medical professionals do not consistently test according to guidelines. Teens may present with early HIV infection in atypical ways, or with no symptoms at all. This case illustrates that acute HIV does not always have a classic presentation and can mimic other common illnesses, making it challenging to diagnose. Having a low threshold for testing, a high suspicion even when other disease processes may be present, as well as advocating for universal screening is key to ensuring that new HIV diagnoses are not missed among this population.

- HIV screening should be implemented universally for adolescents and young adults, regardless of self-reported behaviors as these may be unreliable. - Acute HIV infection can mimic or overlap with other common disease processes. Clinicians must maintain a high index of suspicion to avoid missed or delayed diagnoses. - Emergency room settings are critical opportunities for HIV testing. Consistent adherence to HIV testing guidelines, including integrated screening without separate consent, facilitates early and timely diagnosis. - A comprehensive understanding of HIV diagnostic tests is essential, including the utility of HIV RNA testing to resolve ambiguous or indeterminate results. OSTEOPOROSIS MANAGEMENT IN A YOUNG ADULT Rachel Barlow. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4270933) CASE: This patient is a 19-year-old female with a past medical history of spastic quadriplegic cerebral palsy. She initially presented in September 2018 with a left femur fracture that required casting only and a few months later she had a contralateral hairline fracture incidentally found and treated with a splint. In January 2019, bone mineral density showed a Z score of the femur's neck of -15.9 with a total of -8.1. She was diagnosed with osteoporosis based on these findings and a history of fractures. Therefore she underwent bisphosphonate infusions approximately every six months over the next several years, from March 2019 to June 2023. She received six infusions in total. Meanwhile, DEXA scans were repeated in 2021 and 2023, which showed improvement with treatment. She transitioned to adult endocrinology in May of 2024. At this time, no new fractures have been reported since 2018. IMPACT/DISCUSSION: Regarding diagnosis, it is important to rule out secondary causes of osteoporosis by checking the following labs: alkaline phosphatase, phosphorus, magnesium, vitamin D, parathyroid hormone, and thyroid hormone. Our patient has normal menstrual cycles after menarche, and she is not taking medications that could contribute to secondary osteoporosis. In this case, the likely predisposing factor for her developing osteoporosis is immobilization, but given the severity of the case are also completing a workup including genetic testing. In terms of treatment for osteoporosis, bisphosphonates are first-line therapy in post-menopausal women. No guidelines exist for bisphosphonates in young adults. Given the side effect profile of the medication, it is common practice to consider a bisphosphonate holiday after 3-5 years on the drug if patients are deemed to have a low fracture risk. Typically, indicators of low fracture risk include stability on Z scores on DEXA scans and normal bone turnover markers, specifically P1PN 72 and C tele-peptide. Our patient does have normal turnover markers and stable DEXAs, so taking a bisphosphonate holiday might be a consideration. Additionally, guidelines state anabolic therapy such as teriparatide or abaloparatide could be considered for women at very high risk of fractures, including those with multiple fractures. Given our patient’s young age, would need to determine ephyisial closure before considering anabolic therapy.

Osteoporosis can affect young patients as well as post-menopausal women. When deciding when to perform a bisphosphonate holiday consider DEXA scans and bone turnover makers to help guide decisions. RARE CASE OF HAEMOPHILUS INFLUENZAE SEPTIC OLIGOARTHRITIS IN THE POST-VACCINE ERA Daiki Kuriyama1; Koki Kikuchi2; Shu Toyama1; Koji Matsuda1. 1Resident, Teine Keijinkai Byoin, Sapporo, Hokkaido Prefecture, Japan; 2Infectious Diseases, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan. (Control ID #4272635) CASE: A 38-year-old healthy male presented to the emergency department with fever, left shoulder and left knee pain. 10 days before admission, the patient developed a cough and rhinorrhea, followed by fever and left shoulder pain 2 days before admission. On the day of admission, left knee pain and generalized weakness prompted him to seek medical care. On admission, vital signs were stable (temperature: 37.4°C, blood pressure: 129/76mmHg, heart rate: 96/min). There was erythema, swelling, and tenderness in the left shoulder and knee, with restricted range of motion. Lab results were WBC 9,500/μL and CRP 24.33 mg/dL. Arthroscopic lavage and debridement of the left shoulder and knee were performed and synovial fluid analysis revealed Gram-negative small bacilli. Both synovial fluid and blood cultures confirmed Haemophilus influenzae type b (Hib). Empiric antibiotics with ceftriaxone and vancomycin were initiated and switched to ampicillin after confirmation of Hib on hospital day 5. Further immunologic evaluation revealed low IgA, normal IgM, IgG, CH50, C3, and C4 levels, and no evidence of HIV or asplenia. He was discharged for rehabilitation on hospital day 27, with full recovery achieved by follow-up. IMPACT/DISCUSSION: The Hib vaccine has drastically reduced invasive Haemophilus influenzae disease (IHD). A Japanese study (2014–2018) reported that non-typeable H. influenzae caused 95% of adult IHD cases, with only 1% attributed to Hib, highlighting the vaccine’s effectiveness. However, rare Hib infections persist, mostly in individuals with significant comorbidities or immunodeficiencies. This is the first reported case of Hib septic oligoarthritis in a healthy young adult in the post-vaccine era. Of 71 documented cases of H. influenzae septic arthritis, 92% involved patients with underlying conditions, and most were monoarthritis. This patient’s lack of significant medical history and oligoarthritis underscore the rarity of this case. Clinicians should consider Hib in the differential diagnosis of septic arthritis, even in immunocompetent individuals. This case also highlights the importance of systematic immunologic evaluation in IHD. Ongoing surveillance is critical to track shifts in H. influenzae epidemiology, including waning immunity or incomplete vaccination coverage. Public health efforts must prioritize high vaccination coverage and awareness of atypical presentations.

1. Rare cases of septic arthritis caused by Hib can still occur in immunocompetent young adults, even in the post-vaccine era. 2. Early recognition, systematic immunologic evaluation, and targeted therapy are vital for optimal outcomes in atypical cases. 3. Continued surveillance and high vaccination coverage are crucial to monitor and mitigate emerging trends in IHD. RARE MANIFESTATION OF TUBERCULOSIS: A CASE REPORT ON HEPATIC INVOLVEMENT Tehreem Tasawar. Medicine, University of Sargodha Sargodha Medical College, Sargodha, Punjab, Pakistan. (Control ID #4241881) CASE: A 25-year-old male presented in December 2023 with abdominal pain and distension, worsening over the past month. He reported significant weakness, making it difficult to sit, but had no nausea or vomiting. He was able to eat only small amounts, approximately a spoonful per meal. His medical history included a 3-week hospitalization during which 14 liters of ascites were drained, and he experienced pleuritic chest pain with 200 mL of pleural effusion aspirated three days before admission. He had no history of COVID-19 infection or vaccination, though his symptoms began before the second wave of the pandemic in his country. On examination, the patient was weak but afebrile, with no signs of jaundice, gastrointestinal bleeding, or abnormal stool. He had significant weight loss and reduced appetite over the past four months. He had been smoking 2 packs of cigarettes daily since age 15. There was no family history of tuberculosis (TB), and no known exposure to TB patients. Laboratory results showed hypoalbuminemia and anemia. A chest radiograph revealed a left pleural effusion, which was subsequently drained. A triple-phase contrast CT scan of the abdomen revealed multiple nodules with distinct margins in both liver lobes and ascitic fluid in the abdominal and pelvic cavities. Biopsy of the liver lesions revealed granulomatous inflammation with widespread necrosis but no malignancy. Serial ascitic fluid tests were also negative for malignancy. The patient was diagnosed with hepatic tuberculosis and started on intensive anti-TB treatment. His condition showed significant improvement, indicating a positive response to therapy. IMPACT/DISCUSSION: This case highlights the diagnostic challenges of hepatic tuberculosis (TB), an uncommon manifestation of TB. A 25-year-old male presented with progressive abdominal pain, distension, and systemic symptoms over several months. Key findings included massive ascites, left pleural effusion, hypoalbuminemia, and significant weight loss, compounded by a history of heavy smoking and poor nutritional intake. Despite a lack of TB exposure or family history, imaging and biopsy confirmed granulomatous inflammation and necrosis in hepatic nodules, ruling out malignancy. The delayed presentation and absence of typical pulmonary TB features emphasize the importance of maintaining a high index of suspicion for extrapulmonary TB, especially in resource-limited settings. This case also underscores the value of core biopsy and imaging in diagnosing hepatic TB. Following the initiation of the intensive phase of anti-TB therapy, the patient showed a favorable response, demonstrating the efficacy of early intervention in managing this rare but treatable condition

Early diagnosis and treatment of hepatic tuberculosis can lead to remarkable recovery, even in cases with extensive symptoms and complications RIME AND REASON: PRIME PAIN CONTROL TIME Alexander Morris1; Athina Vassilakis2. 1Medical School, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 2Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4272992) CASE: A 14-year-old girl presented with seven days of fever (Tmax 40°C) and pharyngitis, progressing to eruptions of the oral mucosa, lips, and vulva and two days of poor oral intake due to severe pain. She was admitted for supportive care and treatment. She appeared in distress, with yellow slough overlying erosions on both lips, small erosions on the tongue, buccal mucosae, and palate, oropharyngeal erythema, and labial erythema, edema, and tenderness. A rapid pathogen panel was positive for Mycoplasma pneumoniae, and a lip culture grew Staphylococcus aureus. Other lab findings were unremarkable, including WBC at 7.93 and a negative oral HSV PCR. Dermatology consultation supported the diagnosis of reactive infectious mucocutaneous eruption (RIME). She received azithromycin, mupirocin, oral dexamethasone, Zofran after vomiting in the ED, and IV hydration. Topical corticosteroids were initiated after RIME diagnosis. Initial standing Motrin, Tylenol, and Magic Mouthwash were inadequate for pain management. She could only eat, sleep, and talk after escalation to IV Morphine and Toradol, which she received for two days before returning to oral medications. She was discharged one day later. IMPACT/DISCUSSION: RIME, a mucocutaneous adverse reaction most commonly due to Mycoplasma pneumoniae and also to Chlamydia pneumoniae and SARS-CoV-2, manifests as painful mucositis with possible cutaneous involvement. Differentiation from similar conditions such as herpes simplex virus (HSV) and Stevens-Johnson Syndrome (SJS) is important to expedite treatment with antibiotics and supportive care. Erythematous clusters of ulcers warrant an HSV swab. Blistering, circular patches after a systemic prodrome, especially after a new medication, should raise suspicion for SJS. After an initial case, RIME recurs in 8% to 38% of patients (i, ii). Recurrent RIME presents more commonly with isolated oral lesions without a viral prodrome, which may lead to misdiagnosis. Recurrence triggers are not always identified and can be distinct pathogens from those found on initial presentation (iii, iv). Under-recognition of RIME delays interventions and leads to prolonged mucositis burden (v). Severe pain leads to dehydration and malnutrition, lengthening hospitalizations (vi). Hence, pain control and mucosal care, on top of antibiotics, are first-line treatments for this self-confined illness that could allow sparing systemic steroid use (i, vii). In this case, early diagnosis enabled rapid antibiotic treatment, and only aggressive pain management initiation led to recovery.

Consider RIME for patients with mucocutaneous lesions and systemic symptoms, particularly with Mycoplasma pneumoniae infection or prior RIME. Alongside notoriously painful conditions such as Sickle Cell Disease or Nephrolithiasis, RIME warrants liberal use of pain medications. SURGICAL INTERVENTION FOR ANNULAR PANCREAS IN A 16-YEAR-OLD: A RARE CASE HIGHLIGHTING THE ROLE OF LAPAROSCOPIC DUODENODUODENOSTOMY Kairo Noronha1; Alexander Weiss1; Thomas Pietrowsky2; Syed-Mohammed R. Jafri3. 1School of Medicine, Wayne State University School of Medicine, Detroit, MI; 2Henry Ford Health System, Detroit, MI; 3Gastroenterology, Henry Ford Health System, Detroit, MI. (Control ID #4273105) CASE: A 16-year-old female with a history of nephrolithiasis and gastritis presented to the clinic with back pain, abdominal pain, and nausea. She was diagnosed with nephrolithiasis and was treated appropriately. However, over the course of a few months, her symptoms returned, and the pain transitioned into a sharp, waxing and waning pain, localized to the right upper quadrant (RUQ) of the abdomen and epigastrium with no evidence of nephrolithiasis. She underwent an esophagogastroduodenoscopy (EGD), which demonstrated severe gastritis and an annular pancreas with dilatation of the proximal duodenum. It was determined her symptoms were likely due to NSAID induced gastritis and not the annular pancreas, as the duodenum did not exhibit significant scarring. Despite appropriate treatment of gastritis with a proton pump inhibitor, her symptoms of nausea and RUQ abdominal pain persisted. She underwent a second EGD which showed persistence of the annular pancreas, causing narrowing of the second segment of the duodenum with subsequent dilatation of the duodenal bulb and first segment. She had a nasojejunal tube (NJT) placed to address her weight loss due to the constant nausea, and she was scheduled for a laparoscopic duodenoduodenostomy (LDD). However, she continued to have several bouts of emesis, leading to displacement of her NJT. She was admitted to the hospital for reinsertion of her NJT, and her morning tube feeds continued without difficulty. After meeting weight gain requirements, it was decided to proceed with operative management earlier than expected due to her constant symptoms, and she underwent the procedure with no complications. Since the operation, she has not experienced any symptoms of nausea, vomiting, or abdominal pain. IMPACT/DISCUSSION: Annular pancreas is a rare congenital anomaly, with a prevalence of approximately 3.4/100,000, typically diagnosed in neonates or adults aged 20 to 50 years. Diagnosis can be challenging when there are overlapping co-morbidities as well as a delayed onset of symptoms. Conservative management including NJT feeding and medication treatment can be used to manage symptoms. However, in severe cases with persistent symptoms, surgical intervention may be required. LDD is an uncommon procedure in adolescents to treat annular pancreas, with a 5-10% repair rate, primarily due to the technical precision required and the challenges posed by smaller anatomical structures. Regardless, this approach offers significant benefits, including reduced postoperative pain and faster recovery, making it a valuable option in carefully selected cases.

This case emphasizes the need to recognize atypical presentations of annular pancreas in adolescents, especially those that do not fit a bimodal age distribution of diagnosis. It highlights how overlapping, nonspecific symptoms, and variable intermittent symptom pain can delay diagnosis. Clinicians must maintain a high index of suspicion to assess the suitability of LDD in managing delayed-onset cases. THE SILENT EPIDEMIC: DEADLY OUTCOMES OF UNDIAGNOSED HIV/ AIDS IN YOUNG PEOPLE Raksha Ramdas. Internal Medicine-Pediatrics, Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL. (Control ID #4245245) CASE: We have a 20-year-old male with no significant history presents with non-specific, intermittent abdominal and chest pain of 1 week. Associated symptoms that developed concurrently include remittent fever, nausea, non-bloody emesis, and non-productive cough. He tried to manage it at home, but due to the worsening symptoms, he decided to come to the ER. He does have some history of substance use, and he is sexually active. He identifies as male, he is bisexual, and he reports occasional contraception use, He has a moderately elevated fever, tachycardia, 2 anal warts, and his mood is reported to be flat. Otherwise, all other systems are normal. Sodium, chloride, potassium, glucose, calcium, mag, WBC, Hemoglobin HCT, and platelets are abnormal, as are his lipase, lymphocytes, and monocytes. He was found to be HIV positive, which was unknown to him. They did CT abdomen and pelvis and found several malignancies involving his appendix, lungs, liver, abdomen, and colon. It was discovered that he had 16-pound weight loss in recent months. Infectious workup revealed extremely low CD4 counts and very high viral load. Syphilis, CMV infection, and Karposi sarcoma were also found. After a repeat CT, they found worsening retroperitoneal adenopathy, periportal edema, collapsed gallbladder, mild ascites. In the third week, we start to see rapid decline. We see significant drops in platelet counts. Kidney, respiratory, and liver function are in decline. The patient goes into respiratory failure. The patient struggles, and after several severe events, he unfortunately passes within 4 weeks of his diagnosis of advanced HIV. IMPACT/DISCUSSION: It’s likely that this patient fell through the gap somewhere, and it could have been prevented. 13% of people living with HIV in the US are unaware. Those at higher risk shouldbe tested annually, if not every 3-6 months. HIV has a disproportionate impact on certain populations: men who have sex with men account for 67% of new infections, Black or AA persons account for 27% of new infections, and likewise, Hispanic/Latino persons account for 33% of new infections. Here in the South, we have over half of the country’s new HIV infections. We are also seeing a high number of infections and deaths within the adolescent and young adult age group. We should start educating early, having routine and open conversations on sexual health to individualize prevention.

Regarding health disparities, supplementing clinic visits with case managers, mental health sessions, and other services helps us make sure that no one else falls through the gaps of the system. Data tells us that patients who are now living with HIV had poor experiences during transition. As health care providers, we can advocate for more comprehensive sexual education in our communities with these simple steps, so that we can ensure our young people can live their adult lives without the burden of chronic disease. UNTREATED SEVERE RHEUMATOID ARTHRITIS CAUSING HYPERVISCOSITY SYNDROME WITH BLEEDING AND SEVERE PULMONARY ARTERIAL HYPERTENSION Malak Tahsin, Naomi Habib, Mateen Khokhar. Internal Medicine, Creighton University School of Medicine, Phoenix, AZ. (Control ID #4271785) CASE: Hyperviscosity syndrome (HVS) is a critical condition that manifests with neurological deficits, visual disturbances, and mucosal bleeding. Waldenström macroglobulinemia is the most common cause. In this case we report a rare complication of untreated Rheumatoid Arthritis (RA) leading HVS. A 55 year-old female with history of systemic lupus erythematous (SLE) , RA, not on treatment, presented with 30lb weight loss, night sweats, gums and nose bleeding, lower extremity and tongue swelling with shortness of breath and progressive dyspnea. White blood count (WBC) was 3.4 k/uL , hemoglobin 7.6 g/dL , Platelet 90 k/uL. IgA, IgG and IgM levels were significantly elevated. Serum viscosity was 8.4 with mild splenomegaly, all suggesting Felty syndrome and HVS. The patient’s dyspnea was progressively worsening, Echocardiogram showed Pulmonary artery pressures systolic pressure of 55 mm of Hg and was found to have pulmonary fibrosis with pulmonary arterial hypertension. IMPACT/DISCUSSION: HVS is rare complication of monoclonal and polyclonal disorders associated with increased levels of immunoglobulins. It presents with visual changes mucosal bleeding and neurological deficits. It results from red blood cell shape deformity or a pathological increase in serum proteins, red blood count (RBC), WBC, or platelets. Rheumatic conditions such as seropositive rheumatoid arthritis, systemic lupus erythematosus, and Sjogren syndrome compromise polyclonal causes of HVS. Untreated HVS can lead to pulmonary hypertension which can be treated with plasmapheresis, otherwise can lead to impaired blood flow, stroke, arrythmia and respiratory failure.

HVS is rare in the context of rheumatic disease. Given its rarity, diagnosis can be delayed, leading to greater morbidity. It should be considered in patients with long standing RA presenting with bleeding diathesis or pulmonary symptoms. Diagnoses is confirmed by checking viscosity level. Early identification and treatment are important to prevent complications. WHEN CHILDHOOD DISEASES GROW UP: THE DIAGNOSTIC CHALLENGE OF ADULT NIEMANN-PICK Michele Ly1; Amy Paul1; Reed Van Deusen2. 1Medical Education, UPMC, Pittsburgh, PA; 2Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4273098) CASE: A 22-year-old female with history of learning disability, dysphagia, and schizophrenia presented with progressive clumsiness, gait imbalance, and falling spells. Her history was significant for undifferentiated learning disability and clumsiness until 4 years ago, when family noticed frequent falls, toe-walking, difficulty swallowing liquids, and speech regression. She developed involuntary upward eye movements with difficulty looking downward. She also had episodes of feeling disconnected and falling after strong emotions. Work-up for seizures was negative. Two years later, she began to have paranoid delusions and auditory hallucinations, resulting in psychiatric admissions and diagnosis of schizophrenia. Since then, she had ongoing clumsiness and spells. Physical exam was notable for inability to elevate eyes spontaneously from downward position and vice versa, appendicular ataxia, and inability to walk tandem. MRI brain showed cerebellar atrophy and spacious infratentorial region. Ataxia genetics panel revealed pathogenic variant of NPC1c gene. This confirmed diagnosis of Niemann-Pick Disease Type C (NP-C), providing a uniting diagnosis for her psychiatric, cognitive, and neurologic impairments. Her spells of sudden falls were determined to be gelastic cataplexy, a characteristic symptom of NP-C. She has since begun treatment with Arimoclomol, the first FDA approved treatment for NP-C and established care with a clinic dedicated to patients with complex diseases to manage her progressive symptoms and optimize her functionality. IMPACT/DISCUSSION: Niemann-Pick C disease is an atypical lysosomal lipid storage disorder causing build-up of unesterified cholesterol in lysosomes and endosomes. It has a broad clinical presentation, from rapidly fatal neonatal disorder to adult-onset neurodegenerative disease. For adults, disease often presents as ataxia, dysarthria, dysphagia, and progressive dementia. The most characteristic sign of NP-C is vertical supranuclear gaze palsy. Many children with late-infantile and juvenile onset NP-C reach adulthood and make up a third of total cases. Thus, the transition process from pediatric to adult to geriatric care must be proactive and thoughtful. Multi-disciplinary teams should regularly follow functional assessments from the time of diagnosis throughout disease course to optimize quality of life.

Niemann-Pick C disease should be considered in adults with progressive symptoms of ataxia, dysphagia, dysarthria, and psychosis. Ventricular supranuclear gaze palsy and gelastic cataplexy are characteristic signs of Niemann Pick C disease. Regular multidisciplinary functional assessments are important to optimize care. Clinical Vignette - Ambulatory Medicine A BLISTERY MYSTERY - A CASE OF AUTO-ECZEMATIZATION WITH SHINGLES-LIKE PRESENTATION Aloukika P. Shah, Mia F. Williams. Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4235938) CASE: A 57-year-old female with a history of epilepsy and invasive ductal carcinoma s/p lumpectomy and radiation therapy (2021) presented to ambulatory care with 1 month of skin lesions. She was first treated in the ED with acyclovir for a right vesicular thigh rash for suspected shingles and 3 days later with cephalexin for superimposed cellulitis. 5 days later, she developed new facial pruritis. Her PCP discontinued cephalexin for suspected drug reaction and symptoms resolved. 1 month later, she presented with new pruritic vesicles on her left leg, which was preceded by a fever 3 weeks prior, but no new systemic symptoms. She denied travel, sick contacts, new medications, changes to detergents, lotions, etc. She had hiked in wooded areas but denied exposures like ticks. Medications were lamotrigine and anastrozole. Vital signs were normal. Exam only showed grouped vesicles on an erythematous base along the left leg and right wrist and vesicular crusting over the prior right thigh rash. All were non-tender to palpation. Given concern for disseminated zoster, though atypical in an immunocompetent patient, she was transferred to the ED and started empirically on IV acyclovir. CBC, CMP, and an immunologic workup (HIV, HbA1c, lymphocyte subsets, and immunoglobulin levels) were normal. Swabs of active lesions for HSV/VZV and bacterial cultures were negative. Dermatology noted the rash to be pruritic rather than painful with grouped vesicular crusting distinct from the individualized vesicle crusting typical of shingles. On re-discussion, she recalled potential exposure in a poison oak-infested area. With this knowledge, disseminated zoster was deemed unlikely. The diagnosis was revised to contact dermatitis from poison oak complicated by auto-eczematization resulting in papulovesicular eruptions at sites distant from the initial exposure. IV acyclovir was discontinued, and the patient was discharged with a topical steroid. Her contact dermatitis appeared to be resolving at 2 week follow-up. IMPACT/DISCUSSION: This case highlights the diagnostic complexity of vesicular rashes with a generalized distribution. The rash spanning > 2 dermatomes warranted empiric treatment for disseminated zoster, though this is rare in immunocompetent individuals. Negative high-sensitivity viral swabs prompted detailed clinical reassessment and examination ultimately arguing against zoster. Auto-eczematization is a delayed hypersensitivity response characterized by skin reactions at sites distant from the initial irritant exposure. Research suggests it to be a T-cell-mediated immune response to antigens released during keratinocyte damage. While rare, this phenomenon underscores the importance of integrating clinical, laboratory, and exposure histories to avoid misdiagnosis and unnecessary treatments.

HSV/VZV PCR swabs from active lesions are highly sensitive diagnostic tools. Auto-eczematization should be considered in patients with pruritic eruptions distant from an initial site of contact dermatitis. A CASE OF ACUTE BLISTERING CUTANEOUS DISEASE IN A PRIMARY CARE SETTING Giuliana Di Bono2; Henry Mancao2; Ivan Berezowski1; Sarah E. Boutwell1. 1Medicine, George Washington University Medical Faculty Associates, Washington, DC; 2The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4273087) CASE: A 67-year-old man with history of hypertension presented with a vesicular rash of unclear etiology. He reported a one-week history of blistering lesions on his hands that were initially pruritic. He denied any associated symptoms, exposures, dietary changes, allergies and any family history of autoimmune or dermatologic conditions. Exam revealed scattered ruptured vesicles over bitaleral hands as well as tense gray vesicles with an erythematous rim. Although he had no risk factors other than living in an urban setting with multiple recorded cases, he was evaluated by Infectious Disease who, based on appearance of lesions tested them for Mpox, as well as for HSV and VZV. He was evaluated by Dermatology who performed punch biopsies to rule out immune blistering conditions. Mpox, HSV, and VZV PCR were negative, while biopsies revealed subepidermal bulla with superficial dermal edema and perivascular lymphocytic infiltrate. Total plasma porphyrins, urine porphobilinogen and urine porphyrins were ordered. IMPACT/DISCUSSION: Differential diagnosis included Porphyria Cutanea Tarde (PCT), Pseudoporphyria (PP), Bullous Pemphigoid (BP) and viral infections. Given biopsy findings, differential was narrowed to PCT, PP and BP. PP was less likely given he was not on any medications and BP presents with mixed inflammatory dermal infiltrates with eosinophils. PCT is the leading diagnosis given the perivascular infiltrate in congruent with the blistering skin lesion. PCT is the most common form of porphyria, resulting from a deficiency in Uroporphyrinogen Decarboxylase (UROD) which leads to build up of uroporphyrinogens in the liver and skin. It's classified into Sporadic PCT and Familial PCT and most commonly present in men in 5th – 6th decades of life. Precipitating risk factors are alcohol, HCV, HIV, smoking and estrogen use. The diagnosis consists of urine and plasma porphyrin levels and UROD enzyme activity. Molecular genetic testing can be done to identify mutations and confirm Familial PCT. The first line treatment is phlebotomy to reduce iron level stores and Hydroxychloroquine to increase the excretion of porphyrins.

Primary care providers should maintain a broad differential when evaluating cutaneous blistering disease and utilize a multidisciplinary approach to guide testing. Ruling out common etiologies is straightforward through viral testing but we should use expertise from Infectious Disease for consideration of Mpox when risk factors are not evident. Porphyria diseases are rare and underdiagnosed, with estimated fewer than 200,000 cases in the United States. Guidance from Dermatology should be sought out in patients presenting with a blistering cutaneous disease of uncertain etiology. Our patient with a new-onset blistering disease in 6th decade of life had clinical presentation and histologic testing concerning for PCT. He had negative prior testing for HIV and HCV, and no history of smoking, however reported drinking 5-6 beers per week, which increases risk of PCT. A CASE OF DISSEMINATED MYCOBACTERIUM MARINUM Philip Sang1; Mark Davis2. 1General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Dermatology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271522) CASE: Patient is a 56-year-old female, without significant past medical history, who presented for three months of progressive skin rash. The rash began on her right wrist, and then spread to her trunk, bilateral thighs, and bilateral buttocks. It appeared that the spread of the lesions followed a right-handed itching pattern across her body. Through her local provider she had trialed several topical steroids, without any change in the severity or character of her skin rash. She denied any other symptoms. She worked as a technical writer, and had a fish tank at home that she changed the water and cleaned every two weeks. She notably did not use gloves or other protective equipment during her aquarium care. Her physical exam was significant for widespread, hard, tender, pruritic and violaceous nodules with some noted to have necrotic and crusted centers. There was no evidence of peripheral lymphadenopathy, and the remainder of her physical exam was otherwise unremarkable. For her evaluation, biopsy of the lesions were obtained and sent to dermatopathology for further review. Given the high suspicion for culprit organism, QuantiFERON IGRA was obtained and resulted as positive. While awaiting the results of her biopsy, a chest x-ray was obtained to rule out latent tuberculosis, which was negative. Broad range PCR performed on the lesion showed no bacterial DNA detected. The biopsy histology showed that the superficial portion of a neutrophilic abscess was admixed with lymphocytes and histiocytes, with few scattered acid-fast bacilli consistent with a cutaneous mycobacterial infection. Culture confirmed a diagnosis of disseminated Mycobacterium marinum (M. marinum). She was subsequently initiated on twelve months of Mycobacterium focused antibiotics: Azithromycin, Ethambutol and Rifampin. She had no complications from the therapy, and after one year she had near total resolution of the skin lesions aside from scant remnant scarring. IMPACT/DISCUSSION: Disseminated M. marinum infection in immunocompetent patients, though rare, underscores the potential severity of this pathogen even in the absence of immunosuppression. This case demonstrates the need for vigilance in diagnosing and managing atypical mycobacterial infections in patients without known immunodeficiency. An area of further discussion, from both a training and educational perspective, is the utility and short falls of interferon gamma release assays (QuantiFERON). QuantiFERON assays are primarily designed to detect specific antigens for M. tuberculosis, however M. kansasii, M. szulgai, and M. marinum have been documented to cause positivity.

This case highlights the importance of considering M. marinum in the differential diagnosis of atypical skin lesions, even in immunocompetent patients, particularly those with a history of aquatic exposure. Early recognition and appropriate antimicrobial therapy are crucial to prevent complications and improve patient outcomes. A CASE OF ELEVATED LIVER ENZYMES Shirin Nour. General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4270517) CASE: A 36 year old African American female with past medical history of vitamin D deficiency and migraines presented for evaluation of elevated ALT and AST on prior lab testing. Her medications included nortriptyline. Upon further discussion, she noted additional symptoms that had been occurring for the last few months. She had developed a red rash involving her face and upper chest. She also had weakness of her arms and legs. She noted difficulty lifting objects. She denied joint pain, dysphagia, or weight loss. She didn't use tobacco or alcohol. On physical exam, an erythematous papular rash was present on bilateral cheeks, chin, and upper chest. She had reduced proximal muscle strength in both upper and lower extremities. Cardiovascular and pulmonary exam were normal. Lab results showed AST of 244, ALT of 286, GGT of 15, creatine kinase (CK) of 11,575, aldolase of 107.6,TSH of 3.4, sedimentation rate of 22, CRP of 5.5(mg/L), negative antinuclear antibody, and negative hepatitis serologies. Skin biopsy showed microscopic features suggestive of neutrophilic urticarial dermatosis. EMG showed severe diffuse myopathy with frequent fibrillation potential and myotonic discharges. Additional lab testing revealed elevated HMG-COA reductase antibody levels of 474.2(CU). She was referred to rheumatology and neurology for treatment of immune-mediated necrotizing myopathy. A PET scan was negative. Echocardiogram and pulmonary function testing were normal. She was initiated on IVIG and solumedrol. After 3 months of treatment, CK levels declined to 276. She was initiated on methotrexate. She continued to have proximal muscle weakness which impacted her ability to work. IMPACT/DISCUSSION: This patient was originally seeking care for elevated AST and ALT. However, she was experiencing a list of symptoms that led to the rare diagnosis of non-statin associated IMNM.IMNMs were differentiated from polymyositis and dermatomyositis in 2004. They can be associated with anti-signal recognition particle antibodies, anti-HMGCR antibodies, or seronegative in 20% of cases. There is increased risk of malignancy in seronegative IMNM and anti-HMGCR IMNM. Patients can also develop interstitial lung disease or myocarditis. The skin rash in this case had features of neutrophilic urticarial dermatosis which can be seen in several autoimmune conditions. Treatment regimen typically consist of oral or IV steroids depending on the severity. Additional treatments include IVIG, rituximab, and methotrexate. The disease course is typically prolonged.

IMNM is a rare cause of muscle weakness that is important for the internist to recognize. The antibodies associated with it differ from the ones present in polymyositis and dermatomyositis. Anti-HMGCR IMNM can occur in patients who have not been exposed to statins. Malignancy should be considered in patients with IMNM, especially the seronegative subset. A CASE OF METASTATIC CHOLANGIOCARCINOMA WITH NEGATIVE IMAGING AND ERCP-GUIDED BIOPSIES Mary Metkus, Jane Abernethy, Paul O'Rourke. Internal Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4271342) CASE: A 71-year-old male with a history of type 2 diabetes mellitus presented to his primary care physician with 2 weeks of fatigue and unintentional weight loss. He was found to be diffusely jaundice and urged to present to the hospital. He denied any abdominal pain, nausea, vomiting, diarrhea, night sweats, fevers or chills. Social history was negative for substance or alcohol use. Physical exam was notable for diffuse jaundice, non-tender non-distended abdomen without hepatosplenomegaly or stigmata of cirrhosis. Lab workup revealed cholestatic liver injury with AST 556, ALT 366, total bilirubin 6.9 with direct bilirubin 5.5, total protein elevation to 8.5 with a gamma gap. Extensive serologic workup for causes of liver injury, including infectious and autoimmune etiologies was unrevealing. Initial imaging was notable for mildly prominent common bile duct and intrahepatic biliary ductal dilatation on right upper quadrant ultrasound and normal liver on CT scan. MRCP redemonstrated intrahepatic biliary ductal dilation with apparent cutoff of the mid common bile duct. ERCP subsequently showed biliary duct stricture. Biopsies and cytologic brushings were taken which showed reactive tissue without evidence of malignancy. The patient was discharged with an unrevealing workup. On outpatient follow up, he was noted to have persistent liver injury. Given ongoing concern for hepatobiliary malignancy, he underwent exploratory laparotomy. Operative findings showed multiple soft tissue masses on the abdominal wall and visceral organs. Intraoperative pathology confirmed metastatic perihilar cholangiocarcinoma. IMPACT/DISCUSSION: Cholangiocarcinoma is an aggressive malignancy arising from the biliary tree. It comprises 3% of all gastrointestinal malignancies and the incidence continues to rise. It is divided into intrahepatic and extrahepatic subtypes based on anatomical origin with extrahepatic further parsed into perihilar and distal. Cholangiocarcinoma often arises without genetic predisposition or clear etiology. Despite advances in diagnostic modalities, the sensitivity of the most used tools, such as ERCP-guided and cytologic brush biopsies remains low, estimated at 56% and 76% respectively. Often, in perihilar cholangiocarcinoma, the most common subtype accounting for 50% of cases, dilated bile ducts or a biliary stricture is the only finding on imaging, as seen in this case. Given the low yield of other diagnostic modalities, exploratory surgery is often indicated.

Cholangiocarcinoma remains difficult to diagnose due to limited sensitivity of diagnostic modalities. Surgical exploration should be considered in patients presenting with persistent liver injury and otherwise negative workup. A CASE OF PARANEOPLASTIC AUTOIMMUNE MYOSITIS WITH INTERSTITIAL LUNG DISEASE IN A PATIENT WITH METASTATIC PROSTATE ADENOCARCINOMA Sayeeda Rab1; Craig Noronha2. 1Internal Medicine, Boston Medical Center, Boston, MA; 2GIM, Boston University Chobanian & Avedisian School of Medicine, Boston, MA. (Control ID #4269755) CASE: A 68-year-old man with DMII presented with a 1 year history of unintentional 30-pound weight loss, fatigue, and diffuse joint pains. He denied fever, night sweats, or cough. Initial workup for weight loss revealed unremarkable CBC and CMP, negative HIV and QuantiFERON gold, elevated ESR/CRP, and a PSA of 49.2 ng/mL. CT chest/abdomen/pelvis showed invasive prostate cancer with regional lymph node involvement and bilateral lung fibrosis with bronchiectasis. The patient was referred to urology, oncology, and pulmonology. A prostate biopsy confirmed Gleason 4 + 5 = 9/10 adenocarcinoma. The weight loss was deemed disproportionate to the prostate cancer burden. The elevated inflammatory markers and arthralgias warranted further investigation and referral was made to rheumatology. At the rheumatology evaluation, physical examination revealed hyperpigmentation over the knuckles and abdomen and palpable synovitis in bilateral PIP joints. Significant laboratory findings included elevated creatine kinase at 1282 U/L and positive anti-OJ antibody on a myositis panel. Based on findings, he was diagnosed with anti-synthetase syndrome (ASS), which is characterized by myositis, interstitial lung disease (ILD), arthritis, and skin findings. The pulmonology evaluation identified the findings consistent with ASS as the likely cause of the patient’s ILD. The team noted that while ASS is often idiopathic, in this case, it may represent a paraneoplastic phenomenon secondary to metastatic prostate cancer. Immunosuppressive therapy with prednisone and rituximab was initiated, resulting in the resolution of the myositis, rash, and joint pain. While his pulmonary fibrosis remained irreversible, systemic immunosuppression stabilized his ILD and prevented further progression. IMPACT/DISCUSSION: This case shows the importance of avoiding anchoring on a diagnosis when a patient presents with multiple symptoms. It is important to utilize a multidisciplinary approach in evaluating unexplained systemic symptoms such as weight loss and fatigue. Anti-synthetase syndrome is a rare autoimmune condition associated with myositis and ILD. While most cases are idiopathic, this presentation suggests a paraneoplastic origin due to underlying prostate adenocarcinoma. Autoimmune conditions may precede or accompany malignancy. Early recognition of paraneoplastic syndromes can lead to prompt intervention and improved outcomes. It also emphasizes the utility of targeted immunosuppression in managing complex presentations of systemic inflammation. This serves as a reminder that weight loss in older adults may uncover multilayered diagnoses requiring nuanced investigation and multidisciplinary care.

Unintentional weight loss in older adults may signal a complex, multi-system condition. When malignancy alone does not explain systemic symptoms, consider paraneoplastic syndromes or overlapping autoimmune conditions. ASS is typically idiopathic however it can be associated with malignancies, such as prostate cancer. A CASE OF PARTIAL EMPTY SELLA SYNDROME PRESENTING WITH HYPOGONADISM Manisha Uppal1; Aisha Parihar2; Rohit Jain2. 1Internal Medicine, The George Washington University, Washington, DC; 2Endocrinology, The George Washington University, Washington, DC. (Control ID #4273560) CASE: A 44-year-old otherwise healthy man presented to his primary care provider with several years of low energy, reduced erections, and loss of hair from his armpits and face. He had an intact visual field, sparse hair but otherwise normal skin, and a normal genital examination. No thyroid abnormalities or gynecomastia were noted. Laboratory evaluation revealed low morning total testosterone < 3 ng/dL (normal: 300-1000), high fasting prolactin 40 ng/mL (normal less than 20 ng/mL), normal LH 0.5 IU/L, and FSH 1.4 IU/L. He also had low T3 1.9 ng/dL, T4 0.59 ng/dL, ACTH 41.4 pg/mL, and AM cortisol 4.5 microgram/dL. Based on laboratory results, a diagnosis of secondary (hypogonadotropic) hypogonadism with hyperprolactinemia in the setting of panhypopituitarism was established. No contributory medications (known to cause high prolactin) could be identified. Further testing revealed normal transferrin and iron. Genetic testing revealed normal male karyotype 46, XY. MRI brain showed a partial empty sella and no masses. The patient was started on hormone replacement therapy with transdermal testosterone gel 25mg/2.5g (1%), levothyroxine 75 mg, and hydrocortisone 10 mg. He is pending follow-up since treatment initiation. IMPACT/DISCUSSION: Laboratory evaluation of a male with suspected hypogonadism begins with hormone measurement. This confirms the diagnosis and helps distinguish between primary hypergonadotropic (resulting from disease of the testes) and secondary hypogonadotropic (resulting from disease of the pituitary or hypothalamus) hypogonadism. Once a diagnosis is established, further testing is undertaken to identify the etiology. Genetic testing is often necessary. Iron and transferrin are measured to assess the possibility of hemochromatosis as the cause of hypogonadism. An MRI brain should also be performed if other pituitary hormones (like an elevated serum prolactin in our case) are also abnormal, and can ultimately be revealing. Partial empty sella is a condition where the sella turcica is only partially (<50% ) filled with cerebrospinal fluid with some of the pituitary gland visible on the MRI brain scan. Prevalence of incidental empty or partial sella on pituitary imaging can range from 2 to 35%. In a majority of patients, this is an incidental finding with normal pituitary function. However, some may present with endocrine dysfunction with hyperprolactinemia (in 10%) or panhypopituitarism (in 4%), or in some cases such as these - both.

- Evaluation of hypogonadism may require an MRI brain when levels of other hormones are deranged, especially with elevated prolactin and/or low age-based testosterone levels. - An incidentally discovered partial or empty sella in the setting of features of hypogonadism or other features of hypopituitarism like adrenal insufficiency or thyroid dysfunction warrants further workup as hormonal replacement therapy may be required. A CASE OF SEVERE MUCOCUTANEOUS HERPES ZOSTER WITH SUPERIMPOSED BACTERIAL INFECTION IN AN IMMUNOCOMPROMISED PATIENT Juanita Gyamera1; Charlotte Gopinath1; Parvinder Khurana2. 1Internal Medicine, The George Washington University, Washington, DC; 2Medicine, The George Washington University, Washington, DC. (Control ID #4271122) CASE: A 74-year-old woman with scleroderma-lupus overlap and chronic hepatitis B infection with undetectable viral load presented with a 6-day history of painful, pruritic lesions on the face. The lesions, which were initially localized to the right chin, gradually spread towards the right mouth and ear. On examination, she had multiple vesicular and pustular lesions on the right chin, the right side of her lips and the right cheek. A few lesions had overlying honey-colored crusting and drainage. She had white plaque-like lesions on the right side of her tongue and on the mucosal surfaces of the right cheek and lower lip. Though the patient had received the live zoster vaccine, she had not received the zoster recombinant vaccine. Given her age, autoimmunity and immunocompromised state, she was prescribed valacyclovir and doxycycline due to concern for herpes zoster with superimposed impetigo. On follow-up a week later, the lesions on her face were healing and the oral mucosal lesions were no longer visualized. She reported pruritis and congestion of the right ear. She had granulation tissue within the external auditory canal that obstructed view of the tympanic membrane and was diagnosed with otitis externa. As her symptoms did not improve after a week with neomycin-polymyxin B-hydrocortisone ear drops, ENT was consulted. She was noted to have an intact tympanic membrane and a blister with seropurulent drainage within the external auditory canal consistent with herpes zoster. She was advised to continue with the ear drops and had improvement in symptoms a week later. IMPACT/DISCUSSION: Herpes zoster results from reactivation of latent varicella zoster virus that gained access to sensory dorsal root ganglia or cranial nerve ganglia during primary varicella infection. It is characterized by painful, unilateral vesicular eruptions in 1-2 contiguous dermatomes. Risk factors for reactivation include advanced age, female gender and immunocompromised states. Treatment with antivirals is indicated within 72 hours of symptom onset, or in patients who are immunocompromised, older than 65 years, or with lesions in the V1 dermatomal distribution. While presentation of cutaneous zoster infection is well recognized, immunocompromised hosts may have atypical skin presentations with extensive mucosal involvement. Furthermore, bacterial superinfection can change the clinical picture as there may be erythema, warmth or purulence surrounding the lesions. Appropriate treatment should include Staphylococcus and Streptococcus coverage with systemic antibiotics.

-Severe mucocutaneous herpes zoster with superimposed bacterial skin infection is an important condition that clinicians must be able to recognize. -Herpes zoster with bacterial superinfection should be treated with systemic antivirals and antibiotics. A COMMON PLAGUE OF A PAST AGE William D. Brown, Richmond S. Doxey. Internal Medicine, University of Utah, Salt Lake City, UT. (Control ID #4230742) CASE: A 71 year old man with a past medical history of lumbar spondylosis, hypertension, psoriasis, COPD, GERD, presented to clinic to establish care. He reported loose, watery stool and a poor appetite. He described a regular diet of TV dinners with very few fruits or vegetables. His blood pressure was 154/75, BMI was 17.6, and he had dry skin and brittle appearing hair on exam. He resumed omeprazole and blood pressure medications, and was counseled on diet. On follow-up, his MOCA was 22/30. Vitamins B1 and C were checked: vitamin C was undetectable at <5 (normal range 23-114), and he was referred to a dietician. Vitamin C level one month later was still low at 11. He was gien supplementation but continued to have poor follow-up, financial barriers to adequate diet, ongoing abdominal complaints of nausea, diarrhea, and abdominal pain. Repeat Vitamin C several months later was 27, BMI remained 17.7, and repeat MOCA was 13/30. IMPACT/DISCUSSION: Vitamin C is an essential vitamin: we can only get it through our diet. It is involved in many reactions and functions in the body, including bone and collagen formation, wound healing, conversion of cholesterol to bile acids, serotonin and antioxidant synthesis. Vitamin C deficiency, or scurvy, is often thought to be a disease of ancient times and the developing world, but estimated prevalence in the United States is as high as 7/100. Initial symptoms are often non-specific, includng fatigue, irritability, myalgias and arthralgias. After a month or more of poor intake, more specific symptoms appear: petechiae, perifollicular hemorrhage, corkscrew hairs, easy bruising and anemia. Gingival swelling, bleeding, and loosening of teeth are common. Patients may report worsening fatigue, depression or anxiety. In later stages of scurvy, often after several months of low intake of vitamin C, patients can present with generalized edema, hemolysis, spontaneous bleeding, jaundice, cardiac arrhythmias, seizures, and if left untreated, death. Risk factors for scurvy include history of alcohol use disorder, disordered eating, picky eating in children, and lower socioeconomic status. As with our patient, one must maintain a high index of suspicion. A dietary history, in addition to a careful physical exam, is often key to determining if testing is warranted.Treatment is supplementation with vitamin C, and evaluation and treatment of concomitant deficiencies if present.

Scurvy, a common plague of a past age, is still surprisingly prevalent in the United States and globally. The initial presentation can be vague, and often the neurologic and constitutional manifestations overshadow the more classic skin findings and hematologic abnormalities. Scurvy should remain on the differential in these cases, especially among high-risk populations, and a dietary history can be key in revealing the etiology of a seemingly complex case. A COMPLEX CASE OF SERONEGATIVE MYASTHENIA GRAVIS AND VARIABLE VEGF: A CLINICAL AND GENETIC PERSPECTIVE Pratikshya Thapa1; Erin Penn2; Indresh Yadav1. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Rheumatology, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4269468) CASE: A 41-year-old woman with a history of hypothyroidism, Raynaud's phenomenon developed progressive neurological symptoms post-flu infection in 2016, including pseudo seizures. Her symptoms evolved to resemble Myasthenia Gravis (MG), with muscle weakness, eyelid twitching, ptosis, facial droop, and dysphagia. Extensive testing, including acetylcholine receptor,voltage-gated calcium channel antibodies, electromyography, and muscle biopsy, were inconclusive, leading to a diagnosis of seronegative MG. Treatment with Pyridostigmine showed a limited effect, necessitating steroid infusions every 4-5 months with partial relief. Fluctuating vascular endothelial growth factor (VEGF) levels prompted a referral to a rheumatology office. On examination, the patient reported fatigue and exhibited exertional weakness. Repeat blood work showed low VEGF and negative MG serologies, with no evidence of systemic rheumatic disease. To reduce steroid use, Mycophenolate was introduced, leading to functional improvement. Due to the complexity, a broader differential was explored. Genetic testing revealed a homoplasmic MT-RNR2m.2971A>G variant and a CNNM2p.H599Q variant, both of uncertain significance. After six months of magnesium supplements and Mycophenolate, symptom improvement supported the theory of CNNM2 gene dysfunction as the underlying cause. IMPACT/DISCUSSION: Seronegative MG is a rare neurological disorder marked by the absence of typical antibodies, posing diagnostic challenges. VEGF, a key regulator of blood vessel growth, is usually elevated in autoimmune conditions and seropositive MG but low in neurodegenerative diseases. Disorders linked to the CNNM2 gene are mostly present in infancy, with limited studies on adult-onset cases. In adults, CNNM2 variants are often asymptomatic, though some may exhibit seizures, cognitive impairment, and muscle weakness, as many variants lack functional studies confirming pathogenicity. CNNM2 encodes cyclin M2, which is crucial for magnesium reabsorption and neurological function. Our patient with Seronegative MG had fluctuating VEGF levels and no systemic rheumatic disease. Genetic testing revealed an adult-onset CNNM2 variant. According to the literature, magnesium supplementation is vital for CNNM2-related hypomagnesemia. The patient's improvement with magnesium highlights the importance of personalized care, while mycophenolate effectively reduces steroid dependence.

This case highlights the diagnostic challenges of atypical MG presentations and the need for a broader differential diagnosis. It emphasizes the potential benefits of magnesium and mycophenolate, especially in patients with CNNM2 gene variants. Further research is vital to elucidate the genetic factors in MG pathogenesis and to develop innovative treatment strategies. ACUTE ASYMPTOMATIC RENAL FAILURE IN A PATIENT WITH CHRONIC PAIN AND HYPERTENSION Angela Wong1; Jessica Chen2. 1University of California San Diego, La Jolla, CA; 2University of California San Diego, La Jolla, CA. (Control ID #4270574) CASE: A 62-year-old male with hypertension, hyperlipidemia, chronic pain, eosinophilic esophagitis, and obesity presented to the ER with acute renal failure after routine labs revealed a serum creatinine (sCr) of 8.76 mg/dL (baseline 0.9). He reported fatigue, decreased appetite, dry mouth, and reduced urine output for several days but denied fever, chills, hematuria, dysuria, or recent illness. For 10 months, he had been taking lisinopril 10 mg three times daily, hydrochlorothiazide 25 mg daily, naproxen 500 mg twice daily, and tramadol 100 mg as needed. Two weeks prior, he increased naproxen to three times daily for joint pain, and four days prior, he received ketorolac 15 mg IV for acute back pain. In the ER, his vital signs were BP 103/60, P 94, T 97.9°F, and weight 248 lbs. Physical examination was notable for left flank/paraspinal pain. Labs revealed BUN 67, Cr 8.55, anion gap 22, CPK 144 (0–175 U/L), uric acid 14.8 (3.4–7.0 mg/dL), CRP 10.17 (<0.5 mg/dL), WBC 12.3 (4–10 × 1000/mm3), urinalysis with 1+ protein, 6–10 WBCs, hyaline casts, and specific gravity 1.018. Fractional excretion of urea (FEUrea) was 12.8%, and a CT scan of the abdomen/pelvis was unremarkable. The patient was hospitalized for three days. NSAIDs were withheld, and IV fluids were administered. Renal function improved, with sCr decreasing to 1.2 mg/dL at discharge. He avoided NSAIDs thereafter, with no recurrence of renal failure. IMPACT/DISCUSSION: NSAIDs, including COX-2 inhibitors, can cause AKI, often hemodynamically mediated (pre-renal) or immune-mediated (acute interstitial nephritis). Pre-renal AKI is associated with symptoms of dehydration (e.g., tachycardia, dry mouth, decreased urine output) and typically responds to NSAID cessation and rehydration, with recovery occurring within 3–9 days. In contrast, interstitial nephritis may present with systemic hypersensitivity features (fever, rash, eosinophilia) and nephrotic syndrome, requiring steroids for recovery. In this case, renal dysfunction was likely due to disrupted autoregulation caused by NSAIDs, ACE inhibitors and diuretics. An FEUrea of 12.8% indicated a prerenal etiology, while a BUN:Cr ratio of 7.5 suggested a concurrent intrinsic component. NSAIDs reduce renal blood flow via afferent arteriolar constriction, ACE inhibitors/ARBs lower glomerular filtration pressure via efferent arteriolar dilatation, and diuretics decrease plasma volume. These drugs acted synergistically to impair renal perfusion and filtration – hence, potentially causing decreased renal function. While any patient on long-term NSAIDs can develop AKI, risk factors include age (>65), pre-existing renal disease, dehydration, hypertension, diabetes, and concurrent use of ACE inhibitors/ARBs.

NSAIDs can cause acute renal injury when combined with ACEi/ARBs and diuretics. Renal function should be monitored in at-risk patients. AKI from NSAIDs is usually reversible, and prognosis is favorable after cessation. ACUTE BILIARY PANCREATITIS PRESENTING AS PAINLESS JAUNDICE Gunner Gilbert1; Robert Nhim1; Sheena CarlLee2. 1Internal Medicine, Washington Regional, Fayetteville, AR; 2Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR. (Control ID #4270078) CASE: A 25-year-old female presented with 1.5 weeks of dark urine and nonspecific constitutional symptoms followed by three days of jaundice. On physical examination, scleral icterus, abdominal jaundice, and sublingual jaundice were noted, with no tenderness in the right upper quadrant or stigmata of chronic liver disease. Initial evaluation revealed a bilirubin of 2.2 mg/dL, alkaline phosphatase of 276 U/L, AST of 194 U/L, and ALT of 355 U/L. Complete blood count (CBC) and the remainder of the comprehensive metabolic panel (CMP) were unremarkable. An infectious workup, including hepatitis panel, HIV, Epstein-Barr virus, and urinalysis, was negative. The absence of abdominal pain complicated the initial differential diagnosis. Liver ultrasound was ordered; however, on the day she was scheduled to get her ultrasound, the patient developed right upper quadrant abdominal pain radiating to her right shoulder blade and presented to the Emergency Department. Abdominal ultrasound demonstrated cholelithiasis with a mildly thickened gallbladder wall and a dilated common bile duct (CBD) suggestive of a recently passed stone. CT and MRCP confirmed these findings without evidence of retained stones or acute cholecystitis. On hospital day four, she underwent a cholecystectomy Postoperatively, her jaundice resolved, her urine normalized, and her lipase returned to baseline. She tolerated a regular diet and was discharged. IMPACT/DISCUSSION: This case highlights an unusual presentation of gallstone pancreatitis: painless jaundice. Painless jaundice typically raises concern for hepatobiliary malignancies, hepatitis, autoimmune diseases, genetic conditions, or medication-related liver injury. Pain, however, is considered a hallmark feature of gallstone pancreatitis. In this patient, the absence of abdominal pain initially obscured the diagnosis. While painless choledocholithiasis is more commonly observed in patients over 65 with significant comorbidities and is associated with increased morbidity and mortality, this case underscores that atypical presentations can occur in younger, healthier individuals. Abdominal ultrasound remains the first-line imaging modality for painless jaundice, although its sensitivity is limited to approximately 78%. Thus, clinicians should maintain a broad differential diagnosis and pursue further imaging, such as CT or MRCP, when appropriate.

This case serves as a reminder that painless jaundice, while often associated with malignancy or autoimmune diseases, can also be an atypical presentation of gallstone pancreatitis. Recognizing atypically presentations early is essential to avoid diagnostic delays and provide appropriate management. Despite limited sensitivity, abdominal ultrasound is a first-line imaging modality for painless jaundice and can be used in combination with further imaging. ACUTE PROGRESSIVE WEAKNESS AFTER RSV VACCINATION Unna Albers1; Jessica Chen2. 1Internal Medicine, University of California San Diego, La Jolla, CA; 2Medicine, Universityo California at Sa Deig, San Diego, CA. (Control ID #4266941) CASE: A 79 year-old female with a history of DM, HTN, CKD3, UC s/p colectomy, J pouch & ileoanal anastomosis, multiple SBO, cervical DDD who presented to the ED for acute inability to stand or walk. Patient denied recent trauma, confusion and headache. Brain MRI and head/neck CTA were negative for stroke. Symptoms quickly progressed to inability to sit-up, problems speaking and swallowing within a few days. Spinal imaging did not show clear abnormalities, EMG was negative for acute inflammatory demyelinating polyneuropathy. CSF protein was markedly elevated with additional elevation of WBC and RBCs. Given the progression of motor weakness and the CSF findings, she was treated with steroid for possible GBS. After decompensation with steroids, IVIG was started. On the 2nd day of IVIG, the patient showed improvement in her speech, swallowing and overall strength. She was discharged after 4 days of IVIG to a SNF. Her neurological symptoms returned to 95% in 3 months. She received RSV vaccine (Arexvy) 13 days, influenza vaccine 2 months, and COVID vaccine (Moderna) 6 weeks prior to onset of neurologic symptoms. In addition she had nasal congestion a few weeks prior to her acute weakness. IMPACT/DISCUSSION: Guillain-Barre Syndrome is a rare disorder of acute immune-mediated polyneuropathy causing acute, acquired weakness. The exact cause of GBS is unknown, but about 2/3 develop GBS days or weeks after diarrhea (Campulobacter Jejuni) or flu or other illnesses such as CMV or EBV. On very rare occasions, they may develop GBS after getting certain vaccinations (Shingrix, Janssen COVID-19, or influenza vaccines) with a study showing more than 96 % of post vaccine GBS develops within 21 days of vaccinations. Our patient received three different vaccines in the preceding two months, only RSV vaccine was at 13 days. GBS is reported in 1.5 case/million who received the GSK(Arexvy)RSV vaccine, and 5 cases/million in Pfizer(Abrysvo)RSV vaccine. The CDC states "a small number of people developed serious neurologic conditions, such as GBS, within 42 days after RSV vaccination. Given the small number, it was unclear if the vaccines caused these events or occurred due to chance”. Per CDC, circumstances when vaccinations may be delayed or withheld include the followings: Delayed routine vaccination is suggested for patients who are within three months to two years after the onset of GBS. Future avoidance vs precaution when re-vaccination with the same vaccine is suggested when GBS occurs within six weeks following any specific immunization.

GBS is a rare but common cause of acute, acquired weakness/polyneuropathy, often provoked by a preceding infection or certain vaccinations. GBS is reported in 1.5/million in GSK(Arexvy)RSV vaccine, and 5/million in Pfizer(Abrysvo)RSV vaccine. Vaccinations should be deferred when a precaution is present although a vaccination might be indicated in the presence of a precaution if the benefit of protection from the vaccine outweighs the risk of an adverse reaction. A HIGH PRESSURE SITUATION: MANAGEMENT OF PAROXYSMAL HYPERTENSION Devika Das, Jordan Kautz. General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4267737) CASE: A 68-year-old female with a history of neuroendocrine tumor of the colon with liver and omental metastases, essential hypertension, chronic kidney disease Stage 3a, obstructive sleep apnea, depression, anxiety, breast cancer, and Sjogren’s syndrome presented to a general internal medicine clinic for paroxysmal hypertension requiring frequent emergency department visits. Episodes began prior to a then new diagnosis of metastatic neuroendocrine tumor of the colon, subsequently treated with surgical resection and monthly somatostatin injections, thought to be clinically quiescent. She was hospitalized several times due to both severely elevated (SBP > 200 mmHg) and significantly reduced (SBP < 80 mmHg) blood pressures. These events occurred randomly but repeatedly and were not associated with emotional distress or stress. She underwent evaluation with a 24-hour ambulatory blood pressure monitor showing no significant elevations in blood pressure during the time the monitor was applied with an average reading of 121/69 mmHg and a maximum SBP of 155 mmHg. She was evaluated for secondary causes of hypertension as well as adrenal insufficiency, revealing normal renal ultrasound with Doppler, urinalysis with microscopy, thyroid function studies, serum metanephrines, renin and aldosterone levels, and adrenocorticotropic hormone stimulation test. In addition, she underwent an autonomic reflex screen (tilt table) that did not show orthostatic hypotension. However, a PET CT Dotatate Scan ordered to determine the status of her neuroendocrine tumor revealed new somatostatin receptor rich hepatic and osseous metastases. Ultimately, she was started on peptide receptor radionuclide therapy (PRRT) for her neuroendocrine tumor, with her blood pressure regimen altered to include a combination of a beta blocker, alpha blocker, and selective serotonin reuptake inhibitor with improved overall control and less frequent episodes of paroxysmal hypertension. IMPACT/DISCUSSION: This was a case of paroxysmal hypertension likely due to recurrence of a gastrointestinal neuroendocrine tumor. All patients presenting with severe paroxysmal hypertension should be assessed for a pheochromocytoma. Additional conditions that present with abrupt severe hypertension should also be considered, including carcinoid syndrome as in this case. This condition can be challenging to manage chronically but includes a combination of medications and psychological interventions designed to decrease sympathetic activation.

Causes of paroxysmal hypertension include pheochromocytoma, panic disorder, hyperthyroidism, migraine, acute coronary syndrome, renovascular hypertension, central nervous system lesions, seizures, carcinoid syndrome, and drugs. Chronic paroxysmal hypertension may be treated with a combination of a beta blocker and alpha blocker in addition to an antidepressant agent. A JOURNEY FROM GASTRITIS TO VASCULITIS: A CASE OF LEUKOCYTOCLASTIC VASCULITIS IN A CHINESE IMMIGRANT Amit Sagar2; Aala Dweik1; Brian Nudelman1; Aditi Quadri1; Syeda Hussain1. 1Internal Medicine, Memorial Healthcare System, Hollywood, FL; 2College of Medicine, Florida Atlantic University Charles E Schmidt College of Science, Boca Raton, FL. (Control ID #4272464) CASE: A 41-year-old Chinese woman with a history of erosive gastritis presented for post-hospitalization follow-up with severe epigastric pain and a relapsing rash on her extremities. She denied nausea, vomiting, diarrhea, constipation, and appetite changes but reported a childhood diagnosis of "vasculitis" in China. She smoked a few cigarettes daily and drank five cans of beer weekly. Her family history includes gastric cancer in her uncle. She relocated to the U.S. two years ago. On physical exam, she was underweight (BMI 18.63) and in acute distress with a diffuse maculopapular rash of the bilateral upper and lower extremities. She had epigastric tenderness to palpation. She had visited the ED three times with unremarkable workup (including EKG, gallbladder ultrasound, CT of the abdomen and pelvis, and CBC) showing normocytic anemia (hemoglobin 10.5 g/dl and MCV 82.4 fL), thrombocytosis (platelets 550), elevated alkaline phosphatase (168 Units/L), ALT (45 Units/L), and CRP (17.32 mg/dl). Her abdominal pain was unresponsive to PPIs and sucralfate. During hospitalization, erosive gastritis was confirmed on endoscopy and common infections were ruled out. Given the persistent symptoms and negative workup, her vasculitis diagnosis was reconsidered. She was diagnosed with leukocytoclastic vasculitis (LCV) based on a skin biopsy. Further workup was ordered to search for an underlying cause, revealing a history of hepatitis B and a positive QuantiFERON TB gold test. At follow-up, her epigastric pain had resolved, but she continued to experience rash flare-ups. Leukemia/lymphoma workup is pending, and she was counseled on smoking cessation. Rheumatology is considering treatment with azathioprine, pending evaluation for risk of hepatitis B reactivation. IMPACT/DISCUSSION: LCV is a rare condition that results from inflammation of the dermal small vessels. It typically causes a maculopapular rash that is often on the bilateral lower extremities. Up to 50% of LCV is idiopathic. Such cases are generally mild, self-resolving, and can be treated supportively. However, a workup should be performed to identify secondary inflammatory triggers such as an infection, drug reaction, autoimmune disorder, preexisting vasculitis, or malignancy. Work-up includes but is not limited to a CBC, ESR, RPR, C-Reactive Protein, immunoglobulins, cryoglobulins, hepatitis panel, tuberculosis test, and HSV 1/2 test. Our patient has a remote history of vasculitis, hepatitis B, latent tuberculosis, and severe abdominal pain out of proportion with erosive gastritis treated with PPIs. This raises a high suspicion for a secondary condition, often treated empirically with steroids or immunosuppressants.

LCV should be suspected in patients with a relapsing maculopapular rash, particularly in association with abdominal pain. It is essential to perform a workup for secondary causes of LCV to create a treatment plan and avoid missing a potentially life-threatening diagnosis. A JOYOUS TRANSFORMATION: SUCCESSFUL TREATMENT OF CHRONIC PAIN WITH BUCCAL BUPRENORPHINE IN A PATIENT WITH OPIOID USE DISORDER Avery Glover1; Sumitha Raman2. 1Internal Medicine, The George Washington University Hospital, Washington, DC; 2Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4273192) CASE: A 62-year-old-man presented for chronic low back pain requesting opioid therapy. He first developed low back pain following a traumatic fall 15 years ago for which he underwent cervical and lumbar fusion. His symptoms progressed to daily pain, limiting his functioning, for which he tried a multimodal regimen including NSAIDs, acetaminophen, gabapentinoids, SNRIs, epidural injections and physical therapy, with minimal relief. He was prescribed short courses of full agonist opioids which offered relief, but providers were reluctant to prescribe chronic opioids as he had a history of opioid overdose and severe depression with prior SI. DSM-V criteria revealed a mild heroin use disorder in remission. He reported a fentanyl overdose 3 years ago. He denied current opioid use; review of the PDMP and a urinetoxicology were consistent with his history. On exam, he used a walker and had lumbar spine tenderness. Lumbar spine MRI showed multi-level spondylosis and canal stenosis. He agreed to a trial of low-dose buprenorphine for chronic pain. A prior authorization was submitted for buccal buprenorphine (Belbuca) but initially denied due to a reported lack of medical necessity. A peer-to-peer verbal appeal was completed, and the medication was approved. We initiated Belbuca 75mcg once daily and titrated up to twice daily. The patient's pain significantly improved; he now walks independently and performs all his daily activities of living without assistance. IMPACT/DISCUSSION: This case highlights the challenges of treating severe chronic pain. Given our patient's history of prior overdose, providers were hesitant to treat his pain with chronic full agonist opioids. Although the risks of dependence, respiratory depression, and misuse are well-documented with opioids,1 buprenorphine offers distinct advantages for treating chronic pain. Studies show a ceiling effect on respiratory depression without analgesic limits, less opioid-induced hyperalgesia, and less euphoria.2,3,4 Buccal and transdermal buprenorphine are FDA approved for severe pain requiring daily opioid therapy when alternate options are inadequate. The Department of Veterans Affairs recommends buprenorphine as first line therapy when opioids are indicated for treatment of chronic pain.5 Our case demonstrates that low dose buprenorphine is an effective alternative to full agonist opioids in treating chronic pain and can be safely initiated in the primary care setting. All providers with a DEA license can prescribe buprenorphine. Providers should be aware that a priorauthorization and additional appeals might be necessary to obtain insurance approval.

Buprenorphine is a safe and effective alternative to full-agonist opioids for long-term treatment of chronic pain Low-dose buprenorphine is approved to treat chronic pain in patients with or without opioid use disorder. Insurance companies may be unfamiliar with its use in patients without active opioid use disorder. ALL THAT WHEEZES IS NOT ASTHMA OR COPD Palwasha Khan, Vijaya S. Ramalingam, Shahzaib Khan. Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4270501) CASE: In 2020 a 50-year-old woman was intubated for 10 days. In 2022, she was evaluated by her primary care physicians (PCP) for new-onset-wheezing. Pulmonary function test (PFT) obtained at this time revealed truncation of flow volume loops representing tracheal obstruction vs suboptimal effort. Giver her smoking history and age she was diagnosed as COPD and PFTs were disregarded as poor effort. Despite treatment, she continued to worsen, ultimately presenting to our clinic. VS significant for tachycardia and tachypnia, oxygenation status was wnl. Examination revealed audible stridor and diffuse wheezing at rest. Labs unremarkable. When pt was asked to blow out a whistling sound was present. Repeat in clinic PFTs also revealed truncation of flow volume loops. CT neck and chest did not reveal airway lesions. Further evaluation by ENT surgeon revealed poor vocal cord movement and confirmed type II posterior Glottic stenosis (PGS) with 30% airway patency. She underwent successful posterior cordotomy and medial arytenoidectomy resulting in improved breathing and resolution of stridor. IMPACT/DISCUSSION: 15-million Americans are diagnosed with Chronic Obstructive Pulmonary Disease (COPD) which is expected to become the fourth leading cause of death worldwide by 2030. Diagnosing COPD requires spirometry and clinical skills. Due to ease of cost and access patients are diagnosed by PCPs who rely mainly on history, age and smoking to make this diagnosis, using Spirometry in 23% of cases compared to 80% by specialists. When Spirometry is used it is poorly interpreted and often overlooked if not aligning with COPD. 26% of patients with recorded spirometry had results incompatible with COPD yet continued to be treated as such because PCPs interpreted this as poor patient effort or other external factors. It is estimated that between 3-21% of patients are misdiagnosed with COPD such as what occurred here. Posterior glottis (PG) is comprised of the posterior third vocal cords, posterior commissure (PC), arytenoids, and mucosa. There are four types of PGS characterized by fibrotic changes in the PG leading to partial or complete fixation of the vocal cords and narrowing of the glottic opening. Symptoms include stridor, apnea, dyspnea, and tachypnea. It can be congenital or acquired, with intubation injury being a frequent cause due to trauma to the interarytenoid mucosa. The incidence of PGS in patients intubated between 5 and 9 days is 5%, whereas those intubated more than 10 days is as high as 12%. Prevalence of PGS is underestimated and often misdiagnosed.

It is important to take a comprehensive history when patients present with respiratory symptoms regardless of time elapsed. Maintaining a broad differential and using a multidisciplinary approach in older individuals who smoke and come in with shortness of breath will help prevent misdiagnosis of life threatening conditions such as PGS especially when initial testing is inconclusive or misleading. A LOT ON YOUR SHOULDERS: DIFFERENTIAL DIAGNOSIS FOR SHOULDER PAIN Eileen Galvani1; Shyam Sundaresh2. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272291) CASE: A 76 year-old Spanish-speaking man with hyperlipidemia, type 2 diabetes, and peripheral artery disease presented to the Emergency Department with 3 days of non-traumatic right shoulder pain radiating to his wrist. Interpreter use was not documented. Physical exam was significant for right shoulder flexion limited by pain. X-ray of the shoulder revealed chronic degenerative changes and subacromial spurring. He was discharged with follow up with an orthopedic shoulder specialist in one month. Before his orthopedic follow up, he presented to our primary care clinic with subacute worsening of his shoulder and now neck pain. On further interview using a phone interpreter, he also reported trouble opening jars, buttoning shirts, and feeding himself. His exam was significant for gait imbalance, active range of motion limited to 90 degrees flexion in the right shoulder, right elbow flexion 3/5, right handgrip 5-/5, and decreased sensation at the lateral right forearm to light touch. Subsequent MRI revealed moderate to severe canal stenosis and severe right foraminal stenosis with myelopathy. He is currently undergoing surgical planning for cervical laminectomy. IMPACT/DISCUSSION: Notably, myelopathy was initially missed because of early anchoring on osteoarthritis given its prevalence and imaging findings. When evaluating shoulder pain, the general internist needs to be vigilant for more concerning diagnoses like myelopathy, which presents with neck or shoulder pain 79% of the time (Schneider, 2022), before narrowing on osteoarthritis. We recommend initial differential building to delineate intrinsic versus extrinsic causes. Intrinsic causes present with symptoms localized on exam to the rotator cuff, labrum, scapular muscles, AC/SC joints, or biceps tendon. In our patient, the presence of wrist pain did not fit with intrinsic causes and should have prompted exploration of extrinsic causes. Extrinsic causes are grouped by system and include neurological, abdominal, cardiac, and thoracic etiologies. In patients with abnormal neuromuscular findings, the presence of gait symptoms can be key in identifying myelopathy. In this case, gait instability, weakness in different myotomes, and sensory deficit in a discordant dermatome were also important in differentiating myelopathy from radiculopathy. Extrinsic causes of shoulder pain were likely not considered on initial evaluation due to the impact of language discordance on history gathering. Language discordance increases errors in history taking, can delay appropriate care, and puts patients at higher risk of adverse events. Medical interpreters can help bridge these gaps. Best practices when using interpreters include speaking clearly and slowly, address the patient directly, avoiding jargon and complex language, and pausing to allow for interpretation.

In nontraumatic shoulder pain, it is important to differentiate intrinsic and extrinsic etiologies. It is also important to recognize how language barriers can impact care. AMBULATORY WORKUP OF OSTEOPOROSIS IN A PREMENOPAUSAL WOMAN Stephen Conn. Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4273348) CASE: A 50-year-old premenopausal woman with history of eczema presented to clinic to establish care. One month earlier, she had sustained a right acetabular fracture from a ground-level fall while trail running. The fracture was managed conservatively. Two weeks after the fracture, she presented to an academic medical center with left-sided pleuritic chest pain and was found to have bilateral non-massive pulmonary emboli and bilateral lower extremity DVTs. She was started on apixaban and advised to establish primary care upon discharge. The patient had no personal or family history of venous thromboembolism or osteoporosis. She had been taking combined oral contraceptive pills for 19 years, which were discontinued during her hospitalization. She denied tobacco use and reported minimal alcohol consumption. Regular, light menses commenced at age 14. She exercised every day, noting regular running, hiking, and yoga. On physical exam, her BMI was 18 kg/m2. Laboratory evaluation revealed a 25-OH vitamin D level of 7 ng/mL. Basic metabolic panel, phosphorus, and albumin were within normal limits. Parathyroid hormone was 58 pg/mL prior to vitamin D repletion. DEXA scan revealed a lumbar spine T-score of -3.2 and femur T-score of -2.3. Medications at follow-up included ergocalciferol, apixaban, and topical triamcinolone. IMPACT/DISCUSSION: This case presents a premenopausal woman with osteoporosis. The diagnosis of osteoporosis is similar in pre- and post-menopausal women, but in premenopausal women (and others), it should trigger evaluation for primary and secondary causes of osteoporosis. In this patient, the combination of low BMI and intensive exercise regimen raises consideration of the "female athlete triad" as the primary driver of bone fragility. Severe vitamin D deficiency raises concern for calcium and vitamin D malabsorption as further contributing factors. The diagnosis of osteoporosis was established by the presence of a low-trauma fracture, which meets diagnostic criteria regardless of bone mineral density. Such fractures are considered diagnostic when occurring at the hip, vertebral, proximal humerus, or pelvis. Initial laboratory workup of secondary osteoporosis should include 25-OH vitamin D, TSH, and PTH. When evaluating calcium metabolism, it is crucial to ensure adequate vitamin D repletion and calcium intake before obtaining a 24-hour urine calcium collection. A spot urine calcium-to-creatinine ratio can serve as a useful proxy for the 24-hour collection.

Active, premenopausal women with low BMI presenting with low-impact fractures should be evaluated for the "female athlete triad" of energy deficiency and menstrual dysfunction leading to impaired bone health. A ccost-effective approach to secondary osteoporosis evaluation includea vitamin D, TSH, and PTH measurement, followed by appropriate calcium metabolism assessment Vitamin D repletion and adequate calcium intake should be established before obtaining 24-hour urine calcium studies to ensure accurate results AMYLOIDOSIS: A HETEROGENEOUS DISEASE AND CHALLENGING DIAGNOSIS Samay Shah, Andrew Davis, Jillian S. Catalanotti. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4248555) CASE: An 89-year-old man with stage 4 CKD, HTN, afib, complete heart block with pacemaker, and CABG presents with weight loss, fatigue and left hand pain. PE reveals hypotension, left hand swelling with restricted range of motion in all fingers and decreased sensation in digits 1-3 with negative Tinel’s. Labs reveal hgb 8.6, creatinine 2.77 (baseline), bicarb 15, 24-hour proteinuria of 2118 mg, normal LFTs, ESR, CRP and SPEP, and elevated serum kappa and lamda light chains with preserved ratio. NCS reveals left carpal tunnel syndrome (CTS). CT torso was unrevealing. Bone marrow biopsy reveals normal cellularity with faintly positive Congo Red stain suggesting amyloid; quantity was insufficient for mass spectroscopy. Losartan, nifedipine and furosemide were held for hypotension with limited response. Metoprolol was held with resulting normotension and resolution of fatigue. Due to patient preference, further diagnostic workup was halted. Congo Red staining and symptoms (fatigue, weight loss, CTS, extreme response to metoprolol) suggest ATTR amyloidosis. IMPACT/DISCUSSION: Amyloidosis, a disorder of protein folding, affects <200,000 Americans. Primary subtypes are immunoglobulin light chain (AL), transthyretin (ATTR) and serum amyloid A (AA). Symptoms are vague and variable, in part because amyloid may deposit in nearly every organ. Nearly 90% of patients with AL experience weight loss, marked fatigue and edema, and in nearly a third, 3 or more organs are involved, contributing to diagnostic confusion. Variable presentation is further compounded by lack of knowledge among physicians and suspicion needed to perform biopsy. ATTR generally manifests as heart failure with preserved EF due to restrictive cardiomyopathy, arrhythmias and AV block. After echocardiogram shows suspicious features, typically biventricular wall thickening and biatrial enlargement with preserved EF, technetium pyrophosphate scan confirms ATTR. Both AL and ATTR subtypes may have cardiac manifestations; differentiating between them is critical because they are treated differently. CTS or other neuropathies are also common. In AL, caused by misfolded light chains, diagnosis requires serum free light chain assay and serum and urine immunofixation electrophoresis. If a light chain abnormality is found, diagnosis is confirmed with fat pad, lip, or bone marrow biopsy revealing AL deposits. Organ biopsy is generally not required. AA is linked to longstanding inflammation, which may be due to autoimmune diseases, chronic infections, or IBD. Diagnosis is made by elevated levels of serum amyloid A, an acute phase reactant, and appropriate disease history, with confirmatory biopsy. Mass spectroscopy of tissue is the gold standard to identify amyloid subtypes. Treatment includes chemotherapy (AL), targeted therapy (ATTR), or treatment of underlying inflammatory disease (AA).

Amyloidisis AL, ATTR and AA can have similar, vague, varied presentations. Diagnosis is generally confirmed by biopsy with mass spectroscopy. AN ATYPICAL COMPLICATION OF SYSTEMIC LUPUS ERYTHEMATOUS Faysal Sadeq2; Omaima Chaudhary1; Hamza Saber3; Erin McFadden1. 1Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA; 2Internal Medicine , The Wright Center for Graduate Medical Education, Scranton, PA; 3Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA. (Control ID #4273292) CASE: The patient is a 41-year-old female with a medical history including coronary artery disease status post stent placement, obesity, gastroesophageal reflux disease, anxiety, depression, polycystic ovarian syndrome, peripheral neuropathy, familial Mediterranean fever, and systemic lupus erythematosus (SLE). She presented to her primary care provider with right breast pain, itching, erythema, and swelling, which had been present for the past two months. Additionally, she noted a peri-areolar mass that had been increasing in size. She denied recent trauma, fever, or nipple discharge. Physical examination revealed warmth, erythema, and swelling around the right breast areola, with no axillary lymphadenopathy. A recent mammogram was normal. Given her history of SLE, lupus mastitis was suspected, and the patient was prescribed betamethasone valerate 0.1% cream to be applied daily for 30 days. At a one-week follow-up, the patient reported improvement in symptoms. IMPACT/DISCUSSION: Lupus mastitis (LM) is a rare manifestation of SLE characterized by inflammation of the breast tissue. It is often grouped with the SLE feature called lupus panniculitis which refers to inflammation of the subcutaneous fat and is seen in only 2-4% of SLE cases, with fewer than 100 reported instances of lupus mastitis, It results from autoimmune damage to the breast tissues leading to swelling, pain, and, in rare cases, abscess formation. Patients typically present with breast tenderness, erythema, and a firm, painful mass in the breast, that may resemble breast cancer. Diagnosis is typically made through clinical examination, imaging (such as ultrasound or mammography), and biopsy to rule out malignancy. Lupus mastitis can be differentiated from other conditions by identifying systemic lupus erythematosus in the patient’s medical history or via serological testing (positive antinuclear antibody, anti-dsDNA antibodies, etc.) Treatment includes corticosteroids or immunosuppressive therapy to manage the underlying lupus activity. In some cases, drainage of any abscesses may be required. With proper treatment, the condition can resolve, but flare-ups of SLE may lead to the recurrence of lupus mastitis.

Though rare, lupus mastitis should be considered in patients with a history of lupus who present with unexplained breast masses. AN INCREASINGLY COMMON COSMETIC COMPLICATION: MYCOBACTERIUM ABSCESSUS INFECTION IN A CASE OF LIPOTOURISM Anshel Kenkare2; Rebecca Hyman1; Adarsha Selvachandran2. 1Albert Einstein College of Medicine, New York, NY; 2Internal Medicine, Montefiore Health System, New York, NY. (Control ID #4273027) CASE: A 38-year-old female presented 4 months after an abdominoplasty in the Dominican Republic with pain and drainage from the surgical site. She reported no complications until 1 month prior to presentation when she started having abdominal pain when lifting her children followed by 1 week of redness and drainage at her surgical site without fever or chills. On presentation, vitals were within normal limits, exam revealed erythema and purulent drainage from the surgical site, and lab work showed a normal WBC count. CT findings were concerning for abdominal wall abscess. Plastic surgery performed bedside debridement and culture. After 3 days without culture growth, she was discharged with a 5-day course of amoxicillin-clavulanate. On day 6, cultures grew rare mycobacterium abscessus. The patient was instructed to return to the hospital. On representation, she had continued drainage from the abdomen and was started on an oral regimen of azithromycin, clofazimine, omadacycline and linezolid for a minimum of 3 months and scheduled for Infectious Diseases (ID) follow up. IMPACT/DISCUSSION: Lipotourism is defined as international travel for cosmetic procedures. Although difficult to quantify given the unregulated market, google searches for lipotourism have been increasing. Case reports consistently associate lipotourism with increased risk of developing cutaneous non-tuberculous mycobacteria (NTM) infection, specifically mycobacterium abscessus. Cosmetic procedures in the Dominican Republic specifically have been linked to an outbreak of cutaneous multidrug resistant NTM infections in 21 patients from 2013-2014. Like prior case reports in immunocompetent hosts, our patient had no signs of systemic infection. In a previous case series, infection with NTMs caused symptoms within a median of 7 weeks of inoculation. In this case, symptoms began more than 12 weeks after inoculation. This suggests even a small degree of contamination can result in NTM infection with an indolent course, which may be more likely to present at a primary care office than inpatient. Thorough interview, including travel and surgical history, can aid primary care physicians in recognizing risk for NTM infections, leading to prompt referral to ID and decreased rates of hospitalizations.

-NTM infection may be indolent, mimicking bacterial cellulitis; primary care providers should consider NTMs in patients who have undergone international procedures and obtain cultures at initial presentation -NTMs are often multi drug resistant; therefore, prompt referral to an ID physician to determine appropriate outpatient regimen is essential -Index of suspicion for NTM infection should be lower in patients with a history of lipotourism in the past few months ANTI-HMGCR ANTIBODY AUTOIMMUNE NECROTIZING MYOPATHY WITH UNDERLYING RYR1 MUTATION: A CASE OF IRREVERSIBLE MUSCLE DAMAGE FOLLOWING STATIN THERAPY Julia B. Quinn1; Elizabeth Appel2; Narinder Maheshwari3. 1School of Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT; 3Internal Medicine, UConn Health, Farmington, CT. (Control ID #4267047) CASE: A 78-year-old female with a history of hyperlipidemia on atorvastatin and spinal stenosis presented to her PCP in 2019 with worsening bilateral lower extremity weakness. The weakness had begun over 10 years earlier in an episodic nature attributed to dehydration. These episodes would be so severe that she couldn’t stand but improved with rest and rehydration. Exam was significant for 3/5 strength in the right and 4/5 strength in the left proximal lower extremity, normal sensation, abnormal gait, and 1+ reflexes bilaterally. Upper extremities had 5/5 strength and 2+ reflexes bilaterally. Atorvastatin was held with suspicion of a statin myopathy, but there was no improvement after a month. Creatine kinase (CK) was normal at 173 and lactate dehydrogenase (LDH) was elevated at 244. All other lab work, autonomic studies, and electromyography (EMG) were unremarkable. In 2021, the patient had a Wallenberg stroke and was restarted on atorvastatin, later switched to rosuvastatin. At this time, CK peaked at 2436 but soon down trended to 700-800. By July of 2022, the patient had worsening lower extremity weakness with abnormal gait. CK was elevated again at 1050 and repeat EMG showed evidence of muscle irritability. Muscle biopsy confirmed an autoimmune necrotizing myopathy with positive HMGCR antibodies and weakly positive anti-threonyl-tRNA synthetase (PL-7) antibodies. The patient trialed prednisone therapy, methotrexate, and intravenous immunoglobulin (IVIG) with only mild improvement. Genetic testing found a mutation in the RYR1 gene associated with rhabdomyolysis and central core myopathy, explaining the chronic weakness, heat sensitivity, and lack of significant improvement following treatment. IMPACT/DISCUSSION: This case highlights the complexities of diagnosing and treating chronic muscle weakness in elderly patients, especially when rare autoimmune diseases and genetic conditions intersect. Initial normal CK levels and unremarkable EMG findings delayed early detection of the autoimmune necrotizing myopathy, demonstrating the diagnostic challenges posed by this condition. The eventual discovery of the HMGCR antibodies and RYR1 mutation demonstrates the importance of repeating labs and pursing additional testing when symptoms persist despite treatment or when initial workups are inconclusive. Clinicians should maintain a high index of suspicion for anti-HMGCR myopathy in patients with muscle weakness on statins, and when treatment fails, broaden the differential to include genetic conditions to optimize treatment strategies and improve outcomes.

● Muscle weakness has a broad differential that requires thorough and persistent evaluation to assess for all potential underlying causes ● PCPs are essential in undercovering rare conditions through recognizing atypical presentations, ensuring follow-up on diagnostic results, and advocating for further investigation when symptoms persist AN UNCOMMON CAUSE OF DYSPNEA IN A 61-YEAR-OLD MAN Nicole Gamboa, Ha Mieu Ho, Jessica Chen, Bernice Ruo. Medicine, University of California San Diego, La Jolla, CA. (Control ID #4271085) CASE: A 61-year-old male with history of myocardial infarction and unprovoked recurrent deep vein thrombosis presented with a one-year history of occasional dyspnea on exertion. He noted a gradual onset when climbing stairs, which worsened after eating, with weight gain, and with less exercise. Family history included emphysema in his father and asthma in his sister. Pt denied any tobacco use. Physical exam was unremarkable except for blood pressure of 143/96. Patient was taking apixaban and had declined other medications. BMP, CBC, and LFTs were unremarkable. LDL was elevated (162 mg/dL). Echocardiogram showed normal LVEF with no signs of pulmonary hypertension. Cardiac stress test demonstrated excellent exercise capacity (11 METS) and no evidence of ischemia. Six months after presentation, the patient’s dyspnea remained unchanged. Chest x-ray showed hyperexpanded lungs with linear scarring in the bilateral lower lungs. PFTs showed severe obstructive defects in small airways consistent with emphysema, and decreased DLCO. CT scan showed hyperexpanded lungs with severe air trapping in bilateral lower lobes. Alpha-1 antitrypsin levels were low. He is currently being treated with alpha-1 antitrypsin augmentation therapy with improvement of dyspnea. IMPACT/DISCUSSION: Alpha-1 antitrypsin deficiency (AATD) is an inherited disorder affecting the lungs, liver, and skin. Individuals of Northern European descent are more commonly affected, with men and women being affected equally. Testing should be considered in patients with early onset emphysema, emphysema in non-smokers, basilar dominant emphysema on imaging, unexplained liver disease, or panniculitis. AATD is underdiagnosed, with delay of five to eight years between symptom onset and diagnosis. It is estimated that only 15% of 100,000 affected Americans have been formally diagnosed. Clinical manifestations of severe deficiency typically involve the lung (dyspnea, chronic cough, phlegm production, or wheezing), liver (chronic hepatitis or cirrhosis), or skin (panniculitis). Pulmonary disease classically presents as dyspnea with a basilar predominant pattern of emphysema on chest x-ray. Patients with AATD should avoid lung irritants, such as smoking and occupational exposures, as they can markedly lower age of onset and increase disease severity. Treatment includes alpha-1 antitrypsin augmentation therapy (Prolastin-C) and commonly used COPD treatments (bronchodilators, inhaled corticosteroids, and supplemental oxygen). Our patient presented at an older than average age (45 years old) for AATD, but with typical symptoms of dyspnea, classic finding of basilar predominant emphysema on imaging, and obstructive findings on PFTs. Patients presenting with fixed airflow obstruction on spirometry should have their alpha-1 antitrypsin levels tested.

AATD can present with pulmonary, liver, and/or skin dysfunction. Patients with fixed airflow obstruction on spirometry should undergo testing of AAT levels. AN UNUSUAL CASE OF RECURRENT BLOATING AND NAUSEA Terry Lou, Jessica Chen. Internal Medicine, University of California San Diego, La Jolla, CA. (Control ID #4270577) CASE: A 66 year-old female with past medical history of hypertension, hypothyroidism, and fibroids presented to the emergency room with episodes of severe epigastric pain that feels like a “gas ball,” bloating, and nausea for one week, along with associated dizziness and shortness of breath. She denied fever, chills, diarrhea, vomiting, dysphagia, palpitations, or trauma. Physical exam was notable for diffuse abdominal tenderness. Labs were unremarkable. CT abdomen/pelvis demonstrated a 2.7 x 3.7 cm gastric mass. Upper endoscopy showed a diverticulum in the gastric fundus containing solid and liquid debris. The patient’s symptoms resolved with endoscopic removal of the solid debris. Repeat upper endoscopy three months later showed the gastric diverticulum with negative biopsies for celiac disease or H. Pylori infection. She continued to have recurrent episodes of epigastric pain, nausea, and bloating, including one episode with syncope. Repeat CT abdomen/pelvis revealed a slight increase in fundal gastric diverticulum at 4cm. Due to her persistent symptoms, the patient proceeded with partial gastrectomy to resect her gastric diverticulum. The patient's nausea, bloating, and dizziness completely resolved with resection. IMPACT/DISCUSSION: A gastric diverticulum is an anatomical outpouching of the stomach wall, usually in the fundus and asymptomatic. It is the rarest form of gastrointestinal diverticula with a prevalence rate of 0.01–0.11% and is usually an incidental finding. It is seen equally in men and women, and it typically presents in patients 50-70 years of age. Although most patients with gastric diverticula are asymptomatic, some can present with abdominal symptoms. The most common symptom is upper abdominal pain but can also present with nausea, vomiting, dyspepsia, early satiety, frequent belching, halitosis, anorexia, and dysphagia. Complications include ulceration, gastrointestinal bleeding, perforation, and very rarely abscess formation and adenocarcinoma. If patients are asymptomatic, they do not need further intervention. Symptomatic patients can try acid suppressive therapy. If they do not respond to conservative management, resection (endoscopic versus surgical) is needed, especially for diverticula >4 cm (high risk for food impaction). This patient presented with a rare symptomatic gastric diverticulum with refractory epigastric pain and bloating. Her dizziness and syncope were attributed to a vasovagal response and resolved after resection of gastric diverticulum.

- Gastric diverticula are rare and usually asymptomatic but can cause symptoms including upper abdominal pain, nausea/vomiting, and dyspepsia. - Symptomatic gastric diverticula and large diverticula >4cm can be considered for resection for curative treatment. A PAIN IN THE NECK Lisa Pastel1,2; Ila K. Kaul2. 1General Internal Medicine, DHMC, Etna, NH; 2Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH. (Control ID #4273124) CASE: A 55 year old healthy female veterinarian was seen for severe neck pain two days after an Emergency Room (ER) visit for the same concern. In the ER, CT cervical spine was negative for fracture. She was diagnosed with cervical strain and given methocarbamol and gabapentin. At follow up she described worsening neck pain with little response to treatment, dysphagia and odynophagia, sore throat and headache. She denied fevers, chills, sweats, nausea/vomiting or recent travel. Six weeks prior she had fallen off a horse and sustained a non-displaced fibular fracture. Exam revealed normal vitals, limited neck mobility, diffuse anterior neck tenderness, and limited ability to open her mouth. She had a mildly elevated WBC. CT of the neck showed nasopharyngeal edema and longus capitis/colli swelling with retropharyngeal fluid felt to be the sequelae of calcific tendinitis of longus colli.The patient was treated with Ibuprofen 800 mg three times a day with improvement in her symptoms over the next 48 hours. IMPACT/DISCUSSION: Cervical neck pain is prevalent in 10-20% of the world’s population. Our patient was initially diagnosed with cervical strain, one of the most common causes of neck pain, and advised to treat her pain with muscle relaxants. Her pain worsened over the next 24 hours requiring repeat urgent evaluation. CT scan of her neck confirmed calcific tendinitis of the longus colli muscle. Calcific tendonitis is caused by precipitation of basic calcium phosphate (BCP) crystals at sites of local tissue damage. In our patient’s case, it may have been triggered by her initial fall off a horse. BCP tendinitis presents with acute severe pain involving a single joint, tendon, or bursal area. The most common site reported is the shoulder. Involvement of the longus colli muscle leads to inflammation in the prevertebral space, which causes severe neck stiffness, dysphagia and odynophagia, as seen in our patient. Labs are generally normal, sometimes with elevated inflammatory markers. X-ray imaging can show extra-articular calcifications and prevertebral edema which can be confirmed on CT. First line treatment is NSAIDs until symptoms resolve. Recurrence can occur in 50-85% of cases within 1-5 years. This case was unique in that there are few reports of this presentation in primary care. The majority of cases are seen in the ER given the acuity and severity of pain. It is important to be aware of this presentation in order to treat the associated severe pain and reassure patients regarding the benign nature of this diagnosis. .

Longus Colli Tendinosis is an uncommon cause of severe cervical pain presenting with acute neck pain, dysphagia and odynophagia. It is caused by calcific tendonitis of the Longus Colli muscle causing retropharyngeal swelling. The diagnosis is made clinically and confirmed with Xray or CT imaging. This diagnosis can be effectively treated with NSAIDs. A SILENT INTRUDER - MYCOBACTERIUM AVIUM COMPLEX PULMONARY DISEASE Kevin DiBona2; Daniel Bourque1. 1Infectious Diseases, Boston Medical Center, Boston, MA; 2Boston Medical Center, Boston, MA. (Control ID #4270800) CASE: A 60-year-old female born in Peru, has a history of latent tuberculosis (treated in 1995), asthma, bronchiectasis, recurrent pneumothorax (status-post VATS pleurodesis in 2022), and severe malnutrition. Over the past 2-3 years, she has experienced worsening lung disease with frequent infections requiring hospitalization, non-productive cough, exertional dyspnea, and 9 kg weight loss. CT scans since 2009 show progressive biapical scarring, upper lobe fibrosis, and traction bronchiectasis. In February 2024, bronchoscopy confirmed MAC-PD (M. avium isolated). She began azithromycin, ethambutol, rifampin, and IV amikacin, with plans to transition to inhaled liposomal amikacin. IMPACT/DISCUSSION: Non-tuberculosis mycobacteria (NTM) are environmental bacteria found in soil, dust, and water. With over 200 species, 140 pathogenic to humans. Mycobacterium avium complex (MAC) is the most common NTM linked to pulmonary infections. Though MAC is ubiquitously encountered in everyday life clinical disease requires risk factors. In immunocompetent individuals, it often stems from comorbid respiratory diseases like bronchiectasis, COPD, asthma, ILD, or solid tumors. Tuberculosis history also raises MAC-PD risk. This patient had multiple risk factors, and the additional question is raised about possible about prior undiagnosed TB contributing to her bronchiectasis and new MAC-PD. In primary care, there are many challenges in progressing towards a diagnosis of MAC-PD. Individuals with MAC likely have chronic lung disease, thus identifying symptoms as distinct or new can be challenging. Moreover, given its insidious nature, the severity and progression of MAC infections and symptoms can vary significantly as was apparent from this case. This patient likely had subclinical MAC infection for years before rapid progression led to more intensive diagnostic evaluation. MAC-PD symptoms often include persistent cough, fatigue, weight loss, and exertional dyspnea. Less common symptoms are night sweats, hemoptysis, and rarely, skin infections. Once suspected, formal diagnosis requires additional radiographic and microbiologic evidence. Imaging demonstrates evidence of ill-defined micronodules and bronchiectasis often in the right middle lobe (Lady Windermere Syndrome). Cavitary lesions and ground glass opacities may be observed though are less common. The final diagnostic criteria is positive culture results which can come from either two separate expectorated sputum samples, one bronchial wash/lavage, or a transbronchial biopsy with histologic features (granulomatous inflammation) and positive culture.

- MAC is a common pathogen, but MAC-PD is rare. Careful attention to past medical history is crucial to form initial suspicion for possible underlying MAC disease. - Distinguishing lung disease progression from MAC infection is challenging. Patients with new or worsening symptoms should undergo imaging, and microbiologic workup is needed if radiography reveals bronchiectasis or small nodules. ATYPICAL GIARDIASIS- THE ROLE OF THOROUGH HISTORY-TAKING IN DIAGNOSING TRAVEL-RELATED INFECTIONS Sulochana Gnanasekaran, Siddharth Gandhi. Internal Medicine, New York Medical College, Valhalla, NY. (Control ID #4273505) CASE: The patient is a 61-year-old male with a medical history of diabetes, hypertension (HTN), gastroesophageal reflux disease (GERD), and Barrett’s esophagus without dysplasia. He presented one day after returning from a trip to Mexico, reporting abdominal pain and cramping, high-grade fever, bloating, and fatigue. On examination, he had no abdominal tenderness. An initial COVID-19 and flu test were negative, and he was treated conservatively under the assumption of viral gastroenteritis. Of note, the patient had an esophagogastroduodenoscopy (EGD) six months prior, which showed no progression of Barrett’s esophagus. Despite treatment, his symptoms persisted. He continued to experience fevers once weekly, along with fatigue a few times per week, for the next four weeks. During this period, he also developed severe, intermittent abdominal pain and experienced unintentional weight loss, dropping 16 pounds over the month. Initial lab work showed normal findings, except for an elevated CRP of 7.8. A month after the initial visit, a CT scan of the abdomen with contrast was performed, revealing prominent mesenteric lymph nodes with misty mesentery. Following the scan, he developed persistent diarrhea, characterized by 2–3 episodes of non-bloody loose stools daily, which continued for several weeks. Stool studies were subsequently performed, and the patient was diagnosed with a Giardia infection. Further history-taking revealed that he had swum in the spring while in Mexico in May, potentially exposing him to Giardia. After a single dose of 2000 mg of Tinidazole, his diarrhea resolved, and he regained 4 pounds. IMPACT/DISCUSSION: This case underscores the diagnostic complexity of giardiasis, particularly in atypical cases. While diarrhea is the hallmark symptom, other presentations include abdominal pain, bloating, and fatigue. A delay in diagnosis often stems from clinicians overlooking atypical presentations and incomplete histories. Studies have shown that many giardiasis diagnoses are missed or delayed due to non-classic symptoms. Imaging findings, including mesenteric lymphadenopathy, although uncommon, should be considered as a potential secondary manifestation of giardiasis. Research highlights the pathogenic mechanisms of giardiasis, including disruption of intestinal mucin biochemistry and its association with dysbiosis, which provide protective effects and reduce the presentation of diarrhea.

This case underscores the importance of heightened clinical suspicion for giardiasis in returning travelers with unexplained gastrointestinal symptoms, even in the absence of classic diarrhea. In an ambulatory care setting, comprehensive history-taking and prompt diagnostic testing can significantly enhance patient outcomes by facilitating timely diagnosis and treatment. This approach not only improves the quality of care but also minimizes the risk of complications and ensures a more efficient recovery for patients with atypical presentations. ATYPICAL PRESENTATION OF HERPES SIMPLEX VIRUS 2 AND SYPHILIS CO-INFECTION Zunaira Imran1; Juliana Chaves De Oliveira2; Neelima Thati3. 1Medical Program, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Detroit Medical Center, Detroit, MI; 3Internal Medicine, Wayne State University, Detroit, MI. (Control ID #4272161) CASE: A 24-year-old male presented with swollen inguinal lymph nodes and multiple non-tender penile lesions for 2-3 weeks. The patient was sexually active with multiple partners in the past year with inconsistent condom use. He denied dysuria, hematuria, discharge, fever, or painful genital ulcers. Physical exam revealed multiple well-demarcated, macular, pink, hypopigmented, non-ulcerated and non-vesicular lesions on the penis and scrotum, and two enlarged 2 cm, firm, mobile, non-tender inguinal lymph nodes. Additionally, there were several dry, circular hyperpigmented lesions on the torso, back, and abdomen. He was positive for Herpes Simplex Virus 2 (HSV2) and had a high nontreponemal serologic titer of 1:128. The patient received a dose of intramuscular penicillin G benzathine and was referred to an STI clinic, which prescribed 1 day of Bicillin for secondary syphilis and Descovy for PrEP. The importance of partner notification, treatment, and safe sex practices were discussed, along with side effects of medications, such as the Jarisch-Herxheimer reaction. Further workup for HIV, hep C, and hep B were all negative. IMPACT/DISCUSSION: This case presents an atypical presentation of secondary syphilis with primary HSV2 infection. Typically the syphilis rash is maculopapular on the palms and soles, while HSV2 lesions confine to the genital area. This patient presented with nonpruritic, nontender lesions extending beyond the groin, which is uncommon for either infection. Atypical syphilis presentations occur in 25.8% of patients as pruritic erythematous plaques, annular lesions, and isolated lymphadenopathy. Co-infection with HSV2 may contribute to atypical presentations of syphilis. Syphilitic and HSV2 ulcers disrupt the mucosal barrier, creating an entry point for further infections, and promote the concentration of dendritic and CD4+ T cells in the cellular microenvironment of the lesions, promoting access to HIV target cells and increasing HIV acquisition risk. Altering the expression of receptors CCR5 and langerins also promotes HIV acquisition in these infections. Given the increased risk of HIV, initiating PrEP is crucial. PrEP, consisting of oral tenofovir with or without emtricitabine, reduces HIV risk in high-risk individuals. Educating patients on PrEP, safe sex, and partner notification is essential to prevent further transmission. Patients should also complete treatment, abstain from sexual activity until symptom-free, and undergo retesting.

A thorough physical exam can be crucial in diagnosing STIs, especially in atypical presentations. Co-infections alter the cellular microenvironment and immune responses, increasing HIV acquisition risk. Initiating PrEP, educating on partner notification, and promoting safe sex practices are critical in managing STI patients. AVOIDABLE RISK: THE SPECTOR OF METFORMIN ASSOCIATED LACTIC ACIDOSIS IN THE SETTING OF ACUTE ILLNESS Clariza Borile, Davida Flattery. Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4272353) CASE: A 60-year-old woman with cerebrovascular disease and type 2 diabetes mellitus, well controlled with insulin and metformin, presented to the emergency department with one day of nausea and vomiting with poor oral intake. On arrival, her serum creatinine was 7.7 from a baseline of 1.0 and her serum lactate was 17.9 with a serum pH of 6.7. She was initially hypertensive with a systolic blood pressure of 190-200. Shortly thereafter, she became hemodynamically unstable and required pressor support. She was presumptively treated for sepsis with fluids and empiric antibiotics. Despite these measures, her pressor requirement increased. A thorough investigation revealed no underlying infectious process or other etiology of shock. She ultimately underwent renal replacement therapy to reverse her acidosis, after which she no longer required pressor support and returned to her baseline kidney function. Given that she was not initially in shock but presented with lactic acidosis, toxin-induced type B lactic acidosis remained on the differential diagnosis. IMPACT/DISCUSSION: Metformin is a first-line treatment option for type 2 diabetes. It is thought to contribute to decreased oxidative phosphorylation leading to lactate accumulation and is eliminated by the kidneys. Patients who develop acute kidney injury are at higher risk of metformin accumulation and associated lactic acidosis. Several case reports describe a similar presentation of volume depletion in the setting of illness leading to profound lactic acidosis with critical pH and severe hypotension of unclear etiology requiring renal replacement therapy. In these cases, the differential for the lactic acidosis was broad given concurrent hypotension. However, after negative work-up for other etiologies, metformin-associated lactic acidosis became a potential diagnosis. While metformin is not implicated in lactic acidosis in patients without risk factors, acute illness leading to dehydration and AKI can put patients at risk. Although studies have shown that mortality rates are better in metformin-associated lactic acidosis when compared to other causes, it may be possible to avoid hospitalization altogether with proper patient counseling.

This case illustrates the potential for rare but severe lactic acidosis in patients who have acute or chronic risk factors for volume depletion and acute kidney injury while taking metformin. Those on the primary care team who interface with patients taking metformin should be aware of this risk so that they can consistently and adequately counsel patients about holding metformin on days that they are ill with symptoms that could lead to volume depletion. Brief, patient-centered counseling can allow patients to confidently and safely use this efficacious, generally well tolerated and inexpensive medication. BACK TO THE BASICS: DETAILED HISTORY UNCOVERS CAUSE OF PERSISTENT LYMPHADENOPATHY IN YOUNG FEMALE. Mariya Pogorelova1; Shari J. Zaslow2. 1GIM, Mayo Clinic Minnesota, Rochester, MN; 2Mayo clinic, Rochester, MN. (Control ID #4257794) CASE: Female in her 30’s presented with persistent tender cervical, left axillary and inguinal lymphadenopathy, fatigue, and increased frequency of upper respiratory and soft tissue infections in the last 2 years. Her medical history was significant for poorly controlled type 2 diabetes, hypertension, hyperlipidemia and obesity. On additional questioning she revealed increased frequency of oral and vaginal candidiasis, urinary tract infections and development of chronic intermittent diarrhea. She was concerned that her body could no longer fight infections. No fevers, chills, sweats or unintentional weight loss. She reported a strong history of multiple cancers in her family. She was seen by multiple providers over the course of 2 years and had extensive evaluation including two negative cervical and axillary lymph node biopsies. She had persistent hypermetabolic widespread lymphadenopathy in the cervical, axillary, hilar, mediastinal, pelvic and inguinal nodes detected on PET- CT. She was initially given a working diagnosis of Sarcoidosis however her lymphadenopathy did not improve with a trial of prednisone. During her current presentation a sexual history was taken and patient shared that she had 7-8 sexual partners and did not use barrier protection. Last negative HIV screen was approximately 10 years ago. This prompted HIV testing which returned positive. CD4 count was 727 and HIV 1 RNA is 180,000 copies per/mL. She was prescribed Bictegravir/tenofovir alafenamide/emtricitabine. IMPACT/DISCUSSION: This case highlights many important concepts in primary care. Firstly, the importance of obtaining a sexual history and universal screening for HIV. Per our chart review, there was lack of sexual history discussion in the 2 years she struggled with lymphadenopathy. Research into clinician practices in sexual history taking commonly involve surveys which are subject to reporter bias, however a retrospective chart review found that sexual history was discussed in only about 34% visit and specific questions about sexual practices occurred in only 17.9%. Additional studies suggest that perceptions of sexual activity based on gender and age influence whether clinicians ask about sexual history. It is also likely that inefficiencies in accessing outside records prevented clinicians from noticing her trend of recurrent infection as these records came from different centers and institutions – urgent care, tertiary medical center, and primary care office. This case also demonstrates the broad differential of lymphadenopathy, including malignant, auto immune, and infectious etiologies which were explored but not easily communicated between providers resulting in redundant testing and increased costs.

Persistent Lymphadenopathy has a broad differential diagnosis but HIV testing should be included in the evaluation. Providers should utilize the EMR aid in obtaining a sexual history in a fast and efficient manner. BEATING THE ODDS: HYPOPLASTIC LEFT HEART SYNDROME IN AN ADULT: A CASE REPORT Stephen A. Akinfenwa1; Ghalib Shaikh1; Stephanie Everest1; Angela Hart2. 1Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT. (Control ID #4269718) CASE: A 25-year-old male with a history of Hypoplastic Left Heart Syndrome status post-surgical intervention as a newborn presented for a follow-up at the clinic. His care has been under the Pediatric Congenital Health Disease Center until age 18. He was admitted for hyperkalemia and a new right bundle branch block after increasing his lisinopril dosage in the setting of chronic kidney disease and nephrotic range proteinuria. An echocardiogram was performed during that admission that showed a significant decline in his single right ventricle function from mildly depressed in 2 years to moderate to severely depressed, though he remained asymptomatic. He had moderate systemic tricuspid regurgitation (TR) and mildly elevated diastolic blood pressure. He underwent a further work-up with a Holter Monitor showing no arrhythmia sign. Cardiopulmonary Exercise Testing (CPET) revealed very poor endurance and declining oxygen utilization, suggesting a poor prognosis. Cardiac MRI showed moderate single ventricle dysfunction, ejection fraction of 34%, trivial TR, no significant collaterals noted, no obvious arch obstruction, and left lung normal flow distribution to the lung. Given his history and several medical comorbidities, he required cardiology follow-ups. Several attempts to establish care with an adult cardiologist in the setting of congenital HLHS have been unsuccessful due to limited expertise in providing specialized care for the condition. He was subsequently referred to the pediatric cardiologist for continuity of care while being managed for his other associated co-morbidity at the PCP clinic. IMPACT/DISCUSSION: Hypoplastic Left Heart Syndrome (HLHS), a rare congenital heart defect involving underdevelopment of the left side of the heart, has witnessed improved survival rates in recent decades, particularly with enhanced surgical interventions during infancy. The success in addressing HLHS in childhood has resulted in a growing population of survivors transitioning into adulthood, necessitating specialized adult care. As the population of adults living with HLHS grows, specialized expertise is imperative to address their unique challenges. Although advanced fellowships are available for congenital heart disease, basic training could be included on recognizing, screening, and monitoring adults with congenital heart disease in primary care. Primary care training should encompass not only the anatomical and physiological aspects of HLHS but also the psychosocial and quality-of-life dimensions, ensuring a holistic approach that extends beyond the pediatric realm.

As medical advancements continue to improve outcomes for HLHS patients, shifting the focus toward determining optimal medical management for those surviving into adulthood is vital. This case exemplifies the evolving landscape of HLHS care, emphasizing the urgency of enhancing training programs to meet the specialized needs of this growing patient population BEYOND THE ITCH DIAGNOSING AMA NEGATIVE PRIMARY BILIARY CHOLANGITIS Michihiro Matsugaki, Geeta Varghese. Internal Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY. (Control ID #4269870) CASE: 75-year-old female with controlled hypertension, hyperlipidemia, type 2 diabetes and fatty liver disease presented with a two-week history of diffuse pruritus. Prior to seeing her PCP, she went to urgent care and was given a trial of antihistamine and steroids without relief. She then went to a dermatologist, where initial lab work was done remarkable for ALP 857, AST 339, ALT 345, T. Bili 1.4. Upon further history at the PCP visit, her symptoms were associated with decreased appetite and a mild 5lb weight loss. Exam revealed normal abdominal findings and no visible rash. Additional labs and imaging were obtained, and was trialed on ursodiol for symptomatic relief. Repeat blood work showed ALP 866, AST 483, ALT 481, T. bil 1.9, direct bil 0.9, INR 1.0, GGT 1260, antinuclear antibody negative, antimitochondrial antibody (AMA) negative, hepatitis panel negative. Abdominal ultrasound presented heterogeneous normal sized liver with no intrahepatic biliary duct dilatation. Lastly, liver biopsy revealed findings compatible with early Primary Biliary Cholangitis (PBC). IMPACT/DISCUSSION: PBC is a chronic, autoimmune, progressive cholestatic disease that commonly affects middle aged woman. Patients with PBC are often asymptomatic, however pruritus without rash is one of the most common presenting symptoms, with up to 70% of patients reporting pruritus prior to diagnosis. Diagnostic criteria for PBC include two of the three following conditions: ALP twice the upper limit of normal, positive AMA, histologic evidence of PBC. Histologic evidence is typically not needed in diagnosis as 95% of patients are AMA positive. In cases where suspicion for PBC given clinical context is high, liver biopsy is the next step. Studies show that clinical and serological features of AMA-negative PBC are like AMA-positive PBC, with pruritus and fatigue being the most common symptoms (1). AMA-negative PBC also has similar histologic features of AMA-positive PBC. As AMA tests have become more sensitive, there are rare instances where seroconversion may occur over time. Some reports have shown that AMA-negative patients may have a poorer prognosis (2), but further studies are needed as AMA-negative PBC are rare.

For patients with pruritus, clinicians tend to lean on dermatological/allergic causes, as seen in this case when the patient went to urgent care and a dermatologist; however, it is important to widen the differential especially when initial treatments have failed. Due to the rarity of AMA negative PBC, diagnosis of AMA-negative PBC can often be delayed. Given this patient’s clinical presentation, there was a high clinical suspicion for PBC, and moving forward with a liver biopsy proved valuable in obtaining the diagnosis. BEYOND THE MASS: GALLSTONES AS THE TRUE CATALYST FOR EXTREME CA 19-9 ELEVATION Rithvik Vutukuri1; Peng-Sheng Ting3; Stephen Landreneau2. 1Tulane University School of Medicine, New Orleans, LA; 2Gastroenterology, LSU Health New Orleans School of Medicine, New Orleans, LA; 3Division of Gastroenterology and Hepatology, Tulane University School of Medicine, New Orleans, LA. (Control ID #4269850) CASE: A 59-year-old male with hypertension and type 2 diabetes mellitus presented to gastroenterology clinic with 6 months of intermittent epigastric pain, scleral icterus and yellow palms. The patient reported a 20-pound weight loss due to decreased appetite and denied any GI bleeding, confusion, or fever. Physical examination revealed global jaundice, scleral icterus, abdominal prurigo nodularis, but no abdominal tenderness. Ultrasound showed a 15 mm dilated common bile duct and mild intrahepatic biliary dilatation, with no evidence of cholecystitis. Labs revealed elevated liver enzymes (AST 58, ALT 90, ALP 460, total bilirubin 20.5), and a significantly elevated CA 19-9 level of 16,947 U/mL. Viral hepatitis serologies and anti-mitochondrial antibodies were negative. MRCP 19 days later confirmed the presence of choledocholithiasis, cholelithiasis, and two 4-mm foci of increased signal adjacent to the pancreatic duct, without main pancreatic ductal dilatation. EUS 8 days later demonstrated widespread bile duct dilation and a mass with irregular borders in the pancreatic neck. FNA of the mass showed no evidence of malignancy, but many single cells were positive for synaptophysin and neuron-specific enolase, suggesting neuroendocrine differentiation. ERCP was performed, including sphincterotomy, biliary sweep significant for sludge, and biliary stent placement, but stones remained impacted. Subsequent tests showed a reduction in CA 19-9 to 2,629 U/mL, with improved liver function (AST 93, ALT 50, ALP 378, total bilirubin 6.1). A repeat ERCP occurred 21 days later with electrohydraulic lithotripsy (EHL) and partial stone extraction, and laparoscopic cholecystectomy was performed 62 days after initial presentation, resulting in resolution of scleral icterus and jaundice, and normalization of labs: CA 19-9 37 U/mL, AST 24, ALT 15, ALP 111, and total bilirubin 0.9. Two additional ERCPs with EHL removed biliary stents and remaining stones within 2 months. Spyglass cholangioscopy was performed in each of these sessions to rule out malignancy. IMPACT/DISCUSSION: Carbohydrate antigen 19-9 (CA 19-9) is a well-known marker associated with pancreatic cancers, with levels exceeding 1000 U/mL having a specificity over 99% for the disease. Here, we present a patient with a pancreatic mass and an elevated CA 19-9 level of 16,947 U/mL, which showed marked resolution after treatment for choledocholithiasis, a benign condition. Accurate interpretation of CA 19-9 is crucial for guiding clinical decisions and determining the need and timing of further diagnostic workup. A careful differential diagnosis prevents premature conclusions and accounts for alternative causes such as elevations due to benign conditions.

Elevated CA 19-9 Can be the Result of Benign Conditions Such as Cholangitis or Choledocholithiasis Diagnostic Approach to Elevated CA 19-9 Levels Should Be Stepwise, Including MRCP and/or EUS and ERCP if Necessary CA 19-9 Level Can be Used as a Dynamic Marker of Clinical Improvement BEYOND THE ROUTINE EYE EXAM: A CASE OF IATROGENIC PERIORBITAL CELLULITIS Angela Wong, Jessica Chen. University of California San Diego, La Jolla, CA. (Control ID #4271314) CASE: A 68-year-old female with hypertension and hypothyroidism presented via video visit to her primary care physician. She was incidentally noted to have acute left eye pain, erythema, swelling, purulent discharge, and difficulty opening the eye, along with mild fever and chills. The day before, she had been evaluated by an optometrist for bilateral conjunctivitis, photophobia, and discharge following a week of upper respiratory infection symptoms. During that visit, she experienced significant pain from “aggressive left eye swabbing” and was prescribed ofloxacin 0.3% ophthalmic solution for bacterial conjunctivitis. Due to the rapid worsening of her symptoms, she was referred to the ED to evaluate periorbital cellulitis versus orbital cellulitis. In the ED, her vital signs were BP 155/96, P 88, and T 99.2°F. Physical examination revealed significant periorbital swelling, redness, conjunctival edema, and mild pain on eye movement without proptosis. Extraocular muscles were intact. Labs showed CRP 2.26 mg/dL (<0.5 mg/dL) and ESR 37 mm/hour (<30 mm/hour). A CT orbit without contrast revealed left preseptal periorbital soft tissue swelling and conjunctival enhancement consistent with cellulitis, with no postseptal extension, mass lesion, or abscess. She was treated with IV clindamycin, discharged on oral clindamycin for 7 days, and fully recovered. IMPACT/DISCUSSION: Periorbital (preseptal) cellulitis occurs anterior to the orbital septum and affects the eyelid and surrounding tissue but not the eyeball. It is usually caused by trauma or sinus infections, particularly in children under five. Treatment typically involves outpatient oral antibiotics, and progression to orbital cellulitis is rare with timely intervention. Orbital cellulitis, which occurs postseptally, is a more severe infection affecting the eyeball and orbital tissues. It is often caused by sinus infections, trauma, or infections spreading from the teeth, ear, or face. Symptoms include decreased vision, eye pain, proptosis, and constitutional symptoms such as fever, chills, and malaise. Complications may include abscess formation, vision loss, bacteremia, intracranial infection, cavernous sinus thrombosis, and even death, making it a medical emergency requiring hospitalization. Our patient’s initial presentation was consistent with left bacterial conjunctivitis. However, aggressive swabbing likely compromised the mucosal barrier in the palpebral conjunctiva, allowing the introduction of infection to the periorbital soft tissues, which progressed to cellulitis. Prompt antibiotic therapy resulted in complete recovery.

Understanding the differences between periorbital cellulitis and orbital cellulitis is critical to ensuring timely and appropriate treatment. Recognizing the impact of iatrogenic trauma in precipitating periorbital cellulitis is essential for preventing such infections. BEYOND THE SURFACE: A RARE CASE OF SUBCUTANEOUS LEIOMYOSARCOMA ON LOWER LIMB Lu-Yi Kang, Badrunnisa Hanif. University of Nevada Las Vegas, Las Vegas, NV. (Control ID #4271208) CASE: A 68-year-old African American female with history of Class III obesity, lipomas on the back, diabetes, and hyperlipidemia, presents to the primary care clinic with a painless soft tissue mass on the left upper medial thigh. She notices it appeared spontaneously three months ago and has been growing rapidly since then. She denies any history of trauma. The mass is firm to touch, measuring approximately 11 cm in width. Additionally, she denies experiencing any B symptoms, such as weight loss. Given the concern for malignancy, MRI was performed and revealed two masses. One was a heterogeneous mass up to 11 cm, suggestive of malignancy, and the other was a multilobulated fat-containing mass up to 24 cm, exerting pressure on the bladder. Subsequently, surgical intervention involving radical resection of the masses as well as superficial inguinal lymph nodes dissection was done. Pathology identified the larger mass as a lipoma and the smaller one as leiomyosarcoma. The margins and lymph nodes were negative for malignancy. However, due to the high rate of recurrence of the leiomyosarcoma, a PET scan was done, showing metabolically active lymph nodes, suggestive of metastasis. Patient was then referred to oncology for further management. She underwent radiation therapy and achieved remission, with plans for a follow-up PET scan. IMPACT/DISCUSSION: Our patient with a history of multiple lipomas of the back, presents with rapid-growing, painless, firm mass on the thigh, which has been diagnosed as leiomyosarcoma. LMS makes up for around ten percent of soft tissue sarcomas. Risk factors associated with this disease include radiotherapy and genetic disorders such as Li-Fraumeni syndrome. While LMS can occur at any age, it is more commonly observed at age 50-80 years old. Given its high rate of distant metastasis, it tends to have worse prognosis among other soft tissue sarcomas. This case highlights the importance of early consideration of malignancy in patients who present with subcutaneous masses, even when they initially appear to be lipomas. Thorough examination of every mass individually in a patient with multiple lipomas or other benign-appearing masses is essential for accurate diagnosis and appropriate management. Prompt imaging and immediate surgical referral should not be delayed to ensure timely care and better outcome.

Leiomyosarcoma (LMS) is challenging to diagnose. It is often misdiagnosed due to its potential resemblance to a lipoma. Given its capacity for metastasis, surgical excision is needed accompanied by long-term follow up. Careful evaluation of each individual mass in patients with multiple benign-appearing masses is important for early identification of the tumor and guide treatment approach. BEYOND THE USUAL SUSPECTS: CYTOMEGALOVIRUS IN AN IMMUNOCOMPETENT ADULT Felicia Tanu1; Vivek Sreepathi2; Clara Weinstock2. 1School of Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Internal Medicine, University of Connecticut School of Medicine, Farmington, CT. (Control ID #4272303) CASE: 41-year-old male with metabolic associated liver steatosis was evaluated for nighttime fevers of up to 101.6 F, chills, and diaphoresis. He lives with his wife and 10-month-old daughter, who is frequently sick ever since starting daycare at age 6 months. He presented to urgent care for dysuria and received Bactrim DS after urine dipstick was positive for leukocyte esterase. Urine culture was sterile. When he was seen by his primary care physician (PCP), the physical exam and labs were unremarkable aside from transaminitis at the patient’s baseline. He continued to have nightly fevers and presented to the Emergency Department where tick panel and blood cultures were negative. Bactrim was stopped after 11 doses as the patient developed severe generalized itching and a maculopapular rash on the trunk and bilateral arms. In a follow up PCP visit, the physical exam was again unremarkable, but repeat labs 3 days later showed doubling in AST. After 3 weeks of symptoms, consultation with infectious disease revealed a positive immunoassay result for Cytomegalovirus (CMV) IgM. Epstein Barr Virus NAAT was also positive, but IgM levels were low. The patient was managed conservatively and after 3.5 weeks of nightly fevers, he drank 2 oz of pumped breast milk given to him by his wife on 2 consecutive nights. Fevers resolved and liver enzymes normalized by 4 weeks from onset. IMPACT/DISCUSSION: Though CMV is more commonly diagnosed in immunocompromise patients as the infection can be more severe, it affects about half of adults by age 40 and commonly circulates around daycares. Presentation ranges from asymptomatic to symptomatic with fever, fatigue, transaminitis, and lymphadenopathy. This case highlights the need to consider CMV in immunocompetent adults with prolonged fever of unclear etiology to help prevent diagnostic delay and unnecessary costs. This patient sought care four times and experienced a rash provoked by inappropriate antibiotic use before receiving a diagnosis. Clinicians often face challenges in CMV diagnosis due to a wide range of nonspecific symptoms similar to other pathologies. The benefits of breast feeding on the immune system in young children are well documented, but there is little known about the effect, if any, of acutely ill adults consuming breast milk. We present a case in which nightly fevers for 4 weeks resolve within 3 days of drinking breast milk.

CMV should be considered in the differential for fevers of unknown etiology in immunocompetent patients, especially with a child in daycare. There is a scarcity of research about the effect of acutely ill adults consuming pumped breast milk. BLIND IN ONE EYE, FEEL A TINGLE - COULD IT BE SHINGLES Keyla Payano1; Jennifer P. Weintraub2. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273148) CASE: A 66 year old male with PMH of CAD, pre-diabetes, and myeloproliferative disease presented to our clinic one month after an episode of complete vision loss in his left eye. The vision loss occurred spontaneously when he was driving, lasted for 2 hours, then fully resolved. It was accompanied by an acute left sided headache but no other neurologic or cardiovascular symptoms. The headache persisted after the event and was associated with allodynia, paresthesias, and unilateral tearing. He presented to clinic three weeks later and noted a new left sided facial rash. On the initial physical exam, there were no focal neurologic deficits and crusted lesions in the V3/C1 dermatomes were noted. The patient was diagnosed with shingles and treated with valacyclovir and gabapentin. Given his symptoms and cardiac risk factors, there was still concern for TIA or giant cell arteritis (GCA) so the patient was referred to neurology, ophthalmology, and further testing was ordered. ESR and CRP later came back normal, making GCA less likely. CTA head and neck demonstrated no vascular abnormalities and MRI brain was negative for stroke. Carotid doppler is pending. The patient was seen by ophthalmology and had a normal exam, and the working diagnosis is headache and vision loss related to early shingles. The patient has since had complete resolution of symptoms. IMPACT/DISCUSSION: Herpes zoster is more prevalent in older age and the immunocompromised (1), and can have serious sequelae. Rarely herpes zoster ophthalmicus can present with unilateral vision loss which has been documented in a number of case reports and small case series (2). One proposed mechanism is myositis of various orbital structures. Other data suggests an increased risk of stroke/TIA in patients with herpes zoster, though this is debated. The most common physiology behind monocular vision loss is ischemia to the retinal or optic nerve, which can happen in stroke, GCA, etc; other etiologies include papilledema, migraine, and damage to the optical structures. In our case, the presence of pain with vision loss made stroke/TIA less likely as these are typically painless, and the quick resolution of symptoms with normal inflammatory markers made GCA less likely. Further evaluation of monocular vision loss would include Carotid dopplers for TIA, and temporal artery biopsy for GCA. Less common causes such as herpes zoster should be considered as prompt treatment can help prevent permanent vision loss (3).

Consider herpes zoster in a patient with transient vision loss while evaluating other common etiologies Recognize that older age and immune suppression increase the risk of herpes zoster, with ophthalmic involvement being a rare complication BREAST MASS WITH RECURRENT BREAST ABSCESSES AS INITIAL PRESENTATION OF LANGERHANSCELL HISTIOCYTOSIS(LCH) Mariya Pogorelova, Ibrahim Y. Abubeker. GIM, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4253939) CASE: This is the case of previously healthy female in her 30’s presented with breast mass, recurrent culture negative right breast abscesses, painful oral and genital ulcers and culture negative osteomyelitis of three ribs. She initially developed tenderness of right-sided chest wall until 4 cm right breast mass had been detected . Despite initial suspicion of neoplasm, core biopsy ruled out malignancy and infection but did confirm inflammatory abscess. She underwent a partial mastectomy-with biopsies showing acute on chronic inflammation. Additional imaging confirmed recurrent abscesses in 3,4 and 5th rib At the same time she noticed pustular rash along the frontal hairline, and developed painful oral and genital ulcers. She underwent several rounds of antibiotics but continued to experience recurrent drainage and slow wound healing with negative repeated cultures. Later she developed symptoms of polyuria and polydipsia Patient evaluation revealed increase of FDG uptake of the right anterior chest wall, ribs, and adjacent pleura, L3 vertebral body, right upper lobe subpleural nodule. MRI of brain detected marked thickening of pituitary infundibulum. Dense perifollicular Langerhans cell infiltrate with mixed lymphohistiocytic inflammation on the right breast punch biopsy confirmed the diagnosis of LCH. IMPACT/DISCUSSION: LCH is an inflammatory myeloid neoplasm of mixed cellularity, characterized by accumulation of pathological CD1a+/Langerin cells. LCH is rare disease with few hundred diagnosed every year has multiple clinical presentations ranging from single organ involvement to multisystem involvement with significant morbidity and mortality. Adults have various presentation with bone lesions present in 80% of LCH patients, rash , pulmonary nodules and anterior pituitary hormone deficiency resulted in diabetes insipidus. LCH can affect almost any organ. Involvement of the liver, spleen and hematopoietic system affects survival. Pathophysiology of LCH was poorly understood for may years with debate if condition inflammatory or neoplastic in origin. Our understanding of Langerhans cell histiocytosis( LCH) improved after discovery mutations in the mitogen-activated protein kinase (MAPK) pathway, most commonly the BRAFV600 E mutation followed by MAP2K1 mutations. Immunohistochemical stains, including CD1a, S100, and CD207 (langerin) are needed for a definitive diagnosis. Treatment options range from local therapy for patient with single organ involvement to systemic therapy with chemotherapeutics . Combination of vinblastine and prednisone the most commonly used . New targeted therapy, such as BRAF and MEK inhibitors had been developed recently.

Early recognition and multidisciplinary approach to management is essential.Survival for patients with disseminated LCH improved but long term effects including neuroendocrine dysfunction and neurodegeneration is concern.General internists have curtial role to coordinate care for patients affected by LCH. CAPTURING THE BROKEN HEART: A CASE STUDY ON TAKOTSUBO CARDIOMYOPATHY IN SETTING OF CHRONIC STRESS Jessica Chen, Natalie Prussak. Internal Medicine, University of California San Diego, San Diego, CA. (Control ID #4270670) CASE: A 67-year-old female with a history of irritabl bowel syndrome, migraines, and chronic stress presented with acute substernal chest pressure radiating to the back, associated with shortness of breath while eating breakfast. Given a family history of aortic dissection, she went to emergency room. In the ER, her blood pressure was 200/90, and EKG showed ST segment elevations. Emergent cardiac catheterization revealed no significant coronary artery disease, and echocardiogram demonstrated apical akinesis. She was treated with lisinopril and metoprolol. Her chest pain resolved within two days, and she was discharged after three days. Echocardiographic findings improved significantly within three months and resolved completely after several years. IMPACT/DISCUSSION: Takotsubo cardiomyopathy, also known as “broken heart syndrome,” is a stress-induced condition characterized by transient left ventricular wall motion abnormalities, typically triggered by acute emotional or physical stressors. The regional wall motion abnormalities often extend beyond the territory of a single coronary artery. While the exact etiology remains unclear, Takotsubo cardiomyopathy accounts for 1–2% of acute coronary syndrome cases and predominantly affects postmenopausal females, with males experiencing worse outcomes. The mean age of onset is 66.4 years. Poor prognostic factors include male gender, age >70 years, physical stressors, and LVEF <40%. Though generally self-limiting, the condition can persist for weeks to years, with a 4% overall mortality rate. Treatment is primarily supportive, tailored to the clinical presentation. This patient met diagnostic criteria for Takotsubo cardiomyopathy based on transient left ventricular dysfunction, ST segment elevations with elevated troponin, non-obstructive coronary findings on catheterization, and exclusion of other causes. Notably, she lacked an acute stressor, instead experiencing chronic stress, challenging the traditional understanding of Takotsubo cardiomyopathy as arising solely from acute stressors.

1. Takotsubo cardiomyopathy should be considered in the differential diagnosis in postmenopausal females presenting with acute chest pain associate with stress. 2. Chronic psychological stress may precipitate Takotsubo cardiomyopathy without acute stress. CARE PLUS: A MULTIDISCIPLINARY APPROACH TO EMPOWERING COMPLEX PATIENTS AND IMPROVING HEALTH OUTCOMES Jessica Koontz, Jiaqian Xu, Ashley White, Jessica Valente, Luisa M. Paredes Acosta. General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4229714) CASE: A 66-year-old male patient with insulin-dependent diabetes, bilateral above knee amputations, end-stage renal disease (post-kidney transplant) and scalp squamous cell carcinomas was referred by a graduating Internal Medicine resident, who was concerned about a new first year resident taking over his complex care. The patient had frequent hospitalizations for hypoglycemia and ischemic strokes. Upon joining our Care Plus program, we coordinated care with a clinical pharmacist to adjust his insulin and educate his support system on medication management, connected him with a community health worker for transportation, and ensured regular frequent follow-ups with our team nurse. As his condition worsened, we shifted to home visits and coordinated realistic care goals with his oncology team. He was ultimately transitioned to hospice, passing peacefully surrounded by family. Another example is a 44-year-old male patient with poorly controlled diabetes, end-stage renal disease on dialysis, diabetic retinopathy, hearing impairment, and food insecurity who was referred by his PCP, a seasoned nurse practitioner. His A1c was 13.8% and he was unable to administer insulin due to vision impairment. Over 18 months, our multidisciplinary team helped facilitate eye surgeries to improve his vision, weekly pill box management to improve his A1c to 7.3% and avoid high-risk insulin use, and provided support for social determinants of health resulting in access to transportation, food, disability income, and insurance. IMPACT/DISCUSSION: Care Plus is a multidisciplinary, high-intensity primary care model for patients with high healthcare needs and resource utilization in our healthcare system. Our team includes medical providers, dedicated nurse, behavioral health clinician, scheduler/transportation coordinator, community health worker, chaplain, and clinical pharmacist. The multidisciplinary, coordinated, low-barrier approach of Care Plus can improve chronic diseases and decrease healthcare utilization, but it also empowers patients to understand their conditions, improve their own health, and die with dignity. These patient-centered outcomes are often not captured by standard metrics of success but are arguably some of the most important.

The cases demonstrate that the unmeasured metrics matter more to describing patient successes. These cases highlight the importance of developing patient trust, consistent presence and outreach by team members, and offloading an overstretched primary care workforce when patients’ medical and psychosocial care coordination becomes overwhelming. CASE OF HEREDITARY LEIOMYOMATOSIS AND RENAL CELL CANCER (HLRCC) AND THE NEED FOR ONGOING LITERATURE REVIEWS IN CLINICAL PRACTICE Tyler Hinckley1; David Lapham2,1. 1Medical school, Tufts University School of Medicine, Boston, MA; 2Primary Care Family Medicine Internal Medicine Norway, MaineHealth, Portland, ME. (Control ID #4254882) CASE: A 56-year-old male presented to the outpatient clinic for a routine annual visit in the fall of 2023 with a new provider. At that visit, he was noted to have multiple rubbery, non-tender flesh-colored papules and nodules up to 1 cm in size located on his trunk and extremities, predominantly the back and arms. His medical history was significant for hypertension, obesity, and prediabetes. The nodules and papules had previously been diagnosed as pilar-type leiomyomas in 1999. His family history is notable for several family members with similar cutaneous findings. There was no other significant family history, and specifically, no relatives with renal cell carcinoma. His social history was positive for smoking. The cutaneous lesions were re-evaluated with the patient’s new provider, and a review of the current literature identified a possible association between cutaneous leiomyomas and hereditary leiomyomatosis and renal cell cancer syndrome (HLRCC) , which had been described in 2001, well after patient’s initial skin biopsy . Genetic testing revealed the patient to be heterozygous for a missense mutation in the fumarate hydratase gene, a “likely pathologic variant” for HLRCC. Genetic counseling was done, and screening tests were initiated. An MRI with a nephrogenic phase was acquired to screen for RCC, which was negative. Laboratory studies were within normal limits. It was recommended that ongoing semi-annual to annual screening with cross-sectional modalities, such as contrast-enhanced MRI (preferred) or contrast-enhanced abdominal CT, be conducted. The patient is alive at this writing, and no malignancies have been detected. IMPACT/DISCUSSION: HLRCC is an autosomal dominant condition affecting the fumarate hydratase gene, resulting in an inborn error of metabolism within the Krebs cycle. The resulting process can include cutaneous piloleiomyomas, uterine leiomyomas, and RCCs. The primary management of HLRCC is RCC screening. The most common RCC are papillary type 2, with approximate lifetime risk of 15-20%, which are more aggressive than those in similar conditions like Von Hippel Lindau. These RCC’s often metastasize early, even while asymptomatic. Early detection significantly improves survival, with advanced stages reducing life expectancy to around 16 months. Current guidelines recommend biannual MRI, favored for sensitivity, specificity, and reduced radiation exposure over CT. This case highlights factors that can delay recognition of genetic syndromes, including the volume of medical literature and limited clinician time, and factors that can assist in diagnosis, including extreme phenotypes and stewardship of the EMR/problem list.

- HLRCC’s features are cutaneous piloleiomyomas, uterine leiomyomas, and RCC. - RCC screening in HLRCC requires biannual cross-sectional imaging, MRI preferred. - Extreme phenotypes may suggest genetic conditions and should prompt literature review. CHANGING X-PECTATIONS: THE ROLE OF X-RAY IN DETECTING OSSEOUS METASTASES DHIKSHITHA BALAJI, Anna Kho. Medicine, Emory University, Atlanta, GA. (Control ID #4271652) CASE: A 74 year old male with history of tobacco abuse and depression presented with 9/10 intermittent lower back pain associated with bilateral leg tingling to the emergency department. After getting an XR spine with degenerative changes and a normal neurologic exam, he was diagnosed with degenerative disease of the spine and referred to primary care. He visited the ED again 2 weeks later with extreme pain prior to PCP and got another XR spine with stable findings. At PCP visit, he reported 10/10 pain radiating down both legs. On exam, there was no tenderness to palpation over the spine, strength was 5/5 in all extremities, mildly decreased but symmetric patellar reflexes, and negative bilateral straight leg raise. Basic blood work was ordered. Labs showed an elevated alkaline phosphatase to 1124 with normal liver function tests, including a normal GGT. Additional labs were added, including a PSA, which was elevated at 396. Due to high suspicion for prostate cancer, an expedited appointment with Urology was arranged, along with a bone scan, CT Lumbar Spine and Abdomen/ Pelvis, and urine culture. The CT scans showed numerous lesions in the abdomen and pelvis, numerous sclerotic osseous metastases with pelvic and retroperitoneal lymphadenopathy and 3 indeterminate focal liver lesions. The bone scan showed diffuse osseous metastases with extensive involvement of the cervical and thoracolumbar spine. A transrectal ultrasound-guided prostate needle biopsy confirmed prostatic adenocarcinoma with a Gleason score of 9. He was subsequently started on flutamide. He underwent 10 cycles of palliative radiation and eventually expired 1 year later. IMPACT/DISCUSSION: Prostate cancer is the 1st or 2nd cancer-related cause of death in men in most Western countries. Early detection of osseous metastases is critical for staging and treatment, as bone is the third most common organ affected by metastasis. Ninety percent of patients with advanced prostate cancer have bone metastases. Gleason’s scores and PSA values at diagnosis are the strongest predictor of bone metastases, with a PSA >100 with 100% positive predictive value (PPV) and Gleason score >7 with 81% PPV. Radiography is cost-effective and simple, but is insensitive for asymptomatic metastases; more than 50-70% of bone must be destroyed to be reliably detected by plain film. Plain film is thus not suitable as a screening test, but is important to evaluate bone pain especially for pathological fracture. CT scan also requires significant cortical destruction before visualization. While bone scintigraphy is better at detecting osseous involvement, it is associated with high false-positive rates but remains part of most diagnostic algorithms. Newer modalities such as PET/CT or PET/MRI associated with tumor-specific agents may provide the most accurate diagnoses.

Normal readings on plain films should not exclude the consideration of metastatic bony disease in prostate cancer. Consider further imaging guided by clinical suspicion. CHOLANGIOCARCINOMA AFTER TREATMENT FOR WILMS TUMOR: A CALL FOR RESEARCH INTO CANCER SURVEILLANCE AFTER THERAPEUTIC RADIATION Zeina Bani Hani, Andrew Davis, Jillian S. Catalanotti. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4246287) CASE: A 48-year-old man with a history of familial hyperlipidemia and a right-sided Wilms tumor at the age of 2 years, for which he received chemotherapy, radiation to the right flank, and a nephrectomy, presented to primary care clinic with “heartburn” associated with left upper quadrant pain, steatorrhea, and dark urine. Physical exam was unremarkable except for his baseline scoliosis and asymmetric muscle development on the right flank compared to the left. Labs revealed alkaline phosphatase of 671 IU/L, AST of 324 IU/L and ALT of 506 IU/L. He was sent to the emergency department, where CT abdomen/pelvis with IV contrast showed occlusion of the left portal vein and mild intrahepatic biliary duct dilation concerning for potential neoplasm. He underwent ERCP with biliary stenting and biopsies revealing adenocarcinoma, with final diagnosis of cholangiocarcinoma (CCA). IMPACT/DISCUSSION: Cholangiocarcinoma (CCA) is a relatively rare malignancy, accounting for approximately 3 % of all gastrointestinal malignancies, with a prevalence in autopsy studies of 0.01 to 0.46%. (1) Considerable progress has been made to understand the pathogenesis of CCA. Chronic inflammation, which is thought to promote carcinogenesis, is an important contributor to the malignant transformation of cholangiocytes. (2) Established risk factors for CCA include primary sclerosing cholangitis, choledochal cysts, and hepatolithiasis. Our patient had none of these. Increased risk of secondary malignancies following therapeutic radiation has been identified in several studies. (3,4) The association between radiation exposure and hepatobiliary malignancy remains unclear, but some hypothesize that biliary epithelium is sensitive to radiation, and it may contribute to the development of secondary malignancies. Prior radiation to the right flank is our patient’s only potential risk factor for CCA. Several national organizations have promoted current standards of practice in transitioning from oncology to primary care for long-term management, including creating detailed survivorship care plans. (5,6) Patients who received therapy for cancers during childhood or adolescence are at particular risk for delayed complications, including secondary malignancies. The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are a resource for those providing care to survivors of pediatric malignancies. (7) Although existing guidelines do not promote surveillance for biliary malignancies after abdominal radiation, physicians should maintain a high index of suspicion for secondary malignancies in any radiation field.

Cancer survivorship plans should include evidence-based long-term surveillance for therapeutic complications, especially in adult survivors of pediatric malignancies. Physicians should maintain a high suspicion for secondary malignancies in any radiation field. COMMOTIO CORDIS CAUSED BY HORSE BUCKING: A HEART-STOPPING CASE Cameron R. Dang, Christopher T. Nguyen, Christopher Brown, Nicholas A. Taylor. None, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4272509) CASE: A healthy 32-year-old woman with no prior medical history became unresponsive after being bucked off a horse. She was found pulseless, and CPR was initiated. 911 was called, and EMS arrived. After three rounds of defibrillation and epinephrine with CPR for 30 minutes, return of spontaneous circulation was achieved. She was brought to the emergency department. On examination, her vital signs were stable. She was unresponsive to both verbal and painful stimuli. Patient had intact gag reflex; all other reflexes were absent, and her Glasgow coma score was 3T. EKG showed QTc interval of 501ms, but was otherwise unremarkable. Echocardiogram was unremarkable with an EF of 58% and normal wall motion without valvular disease. High sensitivity troponin was >7000 ng/L post CPR. Head CT showed diffuse hypoxic injury, with no signs of trauma or hemorrhage. Without evidence of underlying cardiac pathology, it was concluded that her cardiac arrest was due to arrhythmia from the blunt trauma of her fall, known as commotio cordis. Subsequent MRI of head confirmed diffuse hypoxic injury. Given no significant neurologic improvement, the patient’s family proceeded with comfort care measures, and she expired one week after the initial incident. IMPACT/DISCUSSION: Commotio cordis is a condition of cardiac arrhythmia, most commonly ventricular fibrillation, induced by blunt trauma and leading to sudden cardiac arrest. A typical presentation involves blunt trauma to the chest from sport injury. Commotio cordis is the second most common cause of sudden cardiac death in adolescents and young adults, only behind hypertrophic cardiomyopathy. It is thought to be due to a blow to the chest affecting one small area of precordium, which causes electrical instability of the myocardium. The cardiac arrhythmia may occur immediately or within a few hours after the initial injury. Commotio cordis has been reported in sports such as baseball, football, soccer, hockey, and other events leading to a blunt blow to the chest. The increase in awareness of this entity has led to the use of chest protectors and the availability of AEDs. The survival rate has increased from 10% between 1970-1993 to 58% from 2006-2012. From literature search, there have been cases of commotio cordis from horse kicking, but to our knowledge, this is the first case report of commotio cordis caused by horse bucking.

Commotio cordis is a rare but fatal condition. Increasing awareness of commotio cordis among primary care physicians may prompt counseling and education for patients who are heavily involved in sports to take measures to avoid blunt chest trauma. Early recognition of commotio cordis and immediate treatment with CPR and AED are the keys to survival. DELAYED CSF LEAK SECONDARY TO POST-TRAUMATIC SKULL BASE INJURY Suman M. Atluri1; Nabeeha Engineer1; Frank Ajatta1,2; Yaira Navidad2. 1Margaret M. and Albert B. Alkek Department of Medicine, Baylor College of Medicine, Houston, TX; 2Michael E DeBakey VA Medical Center, Houston, TX. (Control ID #4250640) CASE: A 53-year-old male with hypercholesterolemia presented with three weeks of clear rhinorrhea from the right nostril triggered by forward head tilt. He reported a dull, strange taste in his mouth over the past few days but denied fevers, chills, headaches, stiff neck, vision changes, or hearing loss. Notably, the patient sustained a left orbital floor fracture extending to the lamina papyracea 20 years prior during an assault. Initial management involved observation due to concerns about surgical risks, but he later experienced right-eye lateral gaze restriction. Physical examination revealed clear fluid dripping from the right nostril upon forward head tilt, enlarged moist nasal turbinates bilaterally, and no erythema or tenderness of the sinuses. Neurological, pulmonary, cardiovascular, and musculoskeletal examinations were unremarkable. Maxillofacial CT revealed old orbital floor and lamina papyracea fractures with herniation of intraorbital fat into the maxillary sinus, thickened right recti musculature, and moderate fluid in the right maxillary sinus. Beta-2 transferrin testing of the nasal fluid confirmed CSF leak. The patient was referred to ENT, who discussed surgical options, including endoscopic sinus surgery with nasoseptal flap repair and lumbar drain placement, scheduled within 2–3 weeks. IMPACT/DISCUSSION: Cerebrospinal fluid leaks often present as clear rhinorrhea triggered by head position changes, raising concern for communication between intracranial and sinonasal spaces. In adults, particularly those with a history of trauma, primary care providers and hospitalists must maintain a high index of suspicion for CSF leaks due to the risk of meningitis, brain abscess, and other severe complications if left untreated. Beta-2 transferrin testing remains the gold standard for confirming CSF leaks, offering high specificity to differentiate CSF from other nasal secretions. This test is particularly critical in differentiating CSF leaks from allergic or infectious causes of rhinorrhea, which are much more common but less urgent. In this patient, the combination of historical trauma, suggestive imaging findings, and a positive beta-2 transferrin test provided a clear diagnostic pathway, avoiding potential misdiagnosis or delay in care. Surgical repair, typically performed via endoscopic sinus surgery, aims to seal the defect with a mucosal graft or nasoseptal flap. The adjunctive use of lumbar drains may reduce intracranial pressure, enhancing repair success. Early recognition and coordinated care between hospitalists and otolaryngology teams remain key to optimizing outcomes.

1. Prompt recognition and biochemical confirmation of CSF leaks are crucial for preventing complications such as meningitis. 2. Beta-2 transferrin testing should be considered in adults presenting with clear, unilateral rhinorrhea to confirm the diagnosis of a CSF leak and facilitate timely intervention. DELAYED DIAGNOSIS OF BILIARY DYSKINESIA IN A FEMALE PATIENT WITH ABDOMINAL PAIN Laura Snyder, Rachel D. Kroencke. University of Utah Health, Salt Lake City, UT. (Control ID #4272503) CASE: A 27-year-old female with a history of anxiety, depression, PCOS, and obesity on Mounjaro presented to the ED for acute onset of supra-umbilical sharp abdominal pain without an inciting factor. Workup with ultrasound (US) was negative for gallstones and pericholecystic fluid. CMP, CBC, and lipase were normal. She was sent home with Prilosec, Pepcid, and Sucralfate for presumed gastritis. She re-presented to the ED four days later with negative repeat imaging, including abdominal CT this time. Despite reported ongoing severe pain, she was again reassured and sent home with PCP follow up. Mounjaro was stopped without symptomatic improvement. At this point it was felt that her pain was most likely irritable bowel syndrome vs functional pain related to her depression and anxiety, which had recently worsened with new passive SI. She was referred to gastroenterology and their initial management was based on a presumed diagnosis of functional abdominal pain following a negative EGD. One month after initial presentation, an outpatient HIDA scan revealed biliary dyskinesia with gallbladder EF of 2% resulting in a general surgery referral. However, before her appointment, she presented to the ED for intractable abdominal pain. This time, she had a leukocytosis to 14.4 and was admitted for laparoscopic cholecystectomy. She recovered well from the surgery with complete resolution of abdominal pain. IMPACT/DISCUSSION: When evaluating patients with abdominal pain, there exists a balance between timing of patient reassurance and escalation of testing in search of underlying etiology. This patient had multiple encounters where her abdominal pain was normalized based on initial work up. This led to higher healthcare related costs, emotional distress, and ongoing pain. This case highlights clinicians’ tendency to minimize abdominal pain in women, and to suspect functional pain earlier in their course without an exhaustive workup. It also demonstrates the higher sensitivity of HIDA scans over US in the workup of abdominal pain for biliary pathology. Following a negative abdominal US, a HIDA scan identified the etiology of this woman’s pain and resulted in definitive surgical management.

Clinicians should avoid normalizing and therefore dismissing abdominal pain in female patients. Early diagnosis of functional pain without a full workup is inappropriate and can lead to higher healthcare costs and increased emotional distress for patients. The role of HIDA scan in workup of abdominal pain is valuable when biliary pathology is suspected based on a patient’s symptoms despite inconclusive US data DELAYED DIAGNOSIS OF BIRT-HOGG-DUBé SYNDROME IN A 77-YEAR-OLD FEMALE: HIGHLIGHTING THE CHALLENGES OF RECOGNIZING A RARE MULTISYSTEM DISORDER IN OLDER ADULTS Dana Dhami1; Christopher Solowiej Singh2; Shreyesi Srivastava2; Deepanshu Garg2. 1Abrazo Health Care, Phoenix, AZ; 2Internal Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4272327) CASE: Birt-Hogg-Dubé Syndrome (BHDS) is a rare autosomal dominant disorder caused by mutations in the FLCN gene. It typically manifests as a triad of fibrofolliculomas, pulmonary cysts or pneumothoraces, and renal neoplasms, along with an increased risk of malignancies. The heterogeneity of its clinical presentation often delays diagnosis. It typically presents in mid-adulthood, with patients often diagnosed between their 30s and 50s due to symptoms such as pulmonary cysts, renal neoplasms, or characteristic skin lesions. Late diagnoses, particularly in elderly patients, are uncommon but highlight the variability in clinical recognition. This case highlights a 77-year-old female with multisystemic findings, culminating in the likely late diagnosis of BHDS, and underscores the importance of recognizing this rare syndrome to guide appropriate management. Patient is a 77-year-old female presented to the clinic with a several year history of facial cysts. She noted a family history of recently confirmed diagnosis of BHDS in her brother, son and daughter. Her medical history included excision of multiple basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) of the skin. Additionally, she has a history of pulmonary nodules, initially concerning metastatic disease. Chest CT demonstrated bilateral cystic lung changes consistent with BHDS, though she had no history of spontaneous pneumothoraces. Renal imaging identified a Bosniak II cyst without malignant features, requiring ongoing surveillance. Furthermore, she had a history of numerous colon polyps removed during surveillance colonoscopy, none showing malignant transformation. Given her family history of confirmed diagnosis of BHDS and similar constellation of signs and symptoms in our patient, we conclude the likely diagnosis of BHDS in our patient. IMPACT/DISCUSSION: This case illustrates the diagnostic complexity of BHDS, particularly in older patients with overlapping risk factors for other common conditions. The pulmonary findings in BHDS can mimic metastatic disease, highlighting the need for familiarity with its imaging features. Renal surveillance is critical, given the elevated risk of renal cell carcinoma, even in cases with benign cysts. Although fibrofolliculomas are a hallmark of BHDS, other skin malignancies such as BCC and SCC may predominate, as seen in this patient. Additionally, while the presence of colon polyps raises the question of a broader tumor predisposition, further research is needed to clarify any association between BHDS and gastrointestinal malignancies.

This case underscores the importance of a multidisciplinary approach to BHDS, particularly in older patients with complex medical histories. Increasing awareness of BHDS across specialties may prevent delays in diagnosis and enable timely interventions, including tailored surveillance and family risk assessment. DIAGNOSING TRANSTHYRETIN AMYLOIDOSIS: A CASE OF AN 70 YEAR OLD MAN WITH UNEXPLAINED DYSPNEA Murali K. Duggirala. Internal Medicine, Mayo Clinic, Rochester, MN. (Control ID #4270056) CASE: The patient is a pleasant 70-year-old with no significant health history except for multiple orthopedic injuries. He does not have a history of diabetes, hyperlipidemia, or cardiopulmonary disease. Over the past two years, he has experienced a gradual worsening of shortness of breath. Initially, this was noticeable only with exertion but has since progressed to dyspnea minimal activity. Initial evaluation included normal hemoglobin (14.3 g/dL), creatinine (0.82 mg/dL), liver function tests, and thyroid profile. A urine analysis showed no proteinuria. ECG demonstrated nonspecific ST-T changes, and an elevated D-dimer prompted a pulmonary angiogram, which ruled out pulmonary embolism. Cardiac investigations showed mildly elevated troponin levels (22 ng/L), but a coronary angiogram revealed only minimal disease. A transthoracic echocardiogram demonstrated significant left ventricular hypertrophy (LVH) with a characteristic apical sparing pattern of systolic longitudinal strain. A nuclear medicine cardiac amyloid scan, which showed strong myocardial uptake of technetium-99m pyrophosphate, consistent with transthyretin (TTR) amyloidosis. Serum monoclonal protein studies were normal, and a fat pad aspirate for Congo red staining was negative. Based on these findings, the patient was diagnosed with TTR amyloidosis and initiated on tafamidis therapy. IMPACT/DISCUSSION: The differential diagnosis for left ventricular hypertrophy includes hypertensive heart disease, hypertrophic cardiomyopathy, aortic stenosis, athlete’s heart, cardiac amyloidosis, sarcoidosis, and other rare infiltrative conditions. In this case, the patient’s history and investigations did not support these other diagnoses. Echocardiography, provided critical clues to the underlying etiology by revealing LVH and a characteristic apical sparing pattern of global longitudinal strain, which is highly suggestive of TTR amyloidosis. The definitive diagnostic test for TTR amyloidosis is endomyocardial biopsy, however, non-invasive diagnostic methods such as technetium-99m PYP scintigraphy have high specificity and positive predictive value. Genetic testing of the TTR gene is recommended to differentiate between hereditary and wild-type TTR amyloidosis once the diagnosis is established. The absence of monoclonal protein in serum and urine, combined with negative Congo red staining on a fat pad aspirate, effectively excluded AL amyloidosis in this patient.

This case highlights the importance of a systematic approach to diagnosing TTR amyloidosis in patients presenting with unexplained dyspnea and left ventricular hypertrophy. Non-invasive diagnostic tools such as technetium-99m PYP scintigraphy, combined with echocardiographic findings, can guide clinicians to an accurate diagnosis, enabling timely initiation of therapy. DIAGNOSIS OF PRIMARY BILIARY CHOLANGITIS IN AN ELDERLY FEMALE PATIENT Sarita Sooklal1; Sara Towne2. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2General Internal Medcine, Mount Sinai Health System, New York, NY. (Control ID #4272642) CASE: An 86-year-old woman with hypertension, hyperlipidemia and osteoporosis presented with two years of pruritis and intermittent right upper quadrant pain with meals. Labs showed an elevated alkaline phosphatase and gamma GT that persisted on repeat testing. Her R factor of 0.3 was consistent with a cholestatic process. A right upper quadrant ultrasound showed hepatic steatosis and an extrahepatic common bile duct of 0.8cm without intrahepatic ductal dilatation. MRCP was obtained to rule out choledocholithiasis and did not show gallstones, obstruction, or strictures in the bile ducts. An autoimmune workup was sent, and AMA and ANA were both positive, with ANA staining of 1:1280 in a centromere pattern. The patient was diagnosed with primary biliary cholangitis (PBC) and referred to a hepatologist who prescribed ursodeoxycholic acid (UDCA). IMPACT/DISCUSSION: The classic illness script of PBC is a woman aged 35-65 presenting with elevated alkaline phosphatase and fatigue.1 Up to 17% of patients may present with right upper quadrant pain.2 The diagnostic criteria for PBC include: an elevated alkaline phosphatase > 1.5 times normal, positive AMA (> 1:40), and histological evidence of destruction of interlobular bile ducts; individuals must meet at least 2 criteria to be diagnosed.2 When PBC or other disorders of cholestasis are suspected, MRCP or ERCP should be performed to rule out extrahepatic biliary obstruction and to evaluate for interlobular bile duct destruction. PBC is increasingly being recognized as a condition that presents in older adults. Liver biopsy is not required for diagnosis, and is less often pursued in older adults; however, older adults are more likely to have advanced fibrosis on biopsy at the time of presentation.3 Once diagnosis is made, patients should be started on ursodeoxycholic acid, which has been shown to decrease risk of disease progression in PBC.1,2 Studies show that older patients may respond more robustly to UDCA, preventing progression to end-stage liver disease.4,5

1. It is crucial to perform a thorough workup for all patients who present with persistently elevated liver enzymes, including ruling out autoimmune etiologies, regardless of patient age. 2. PBC can present in elderly patients with atypical symptoms including abdominal pain. DIAGNOSTIC CAT AND MOUSE: AN UNUSUAL CASE OF CAT SCRATCH DISEASE PRESENTING AS SUBACUTE UNILATERAL LEG SWELLING Michael E. McCarthy2; Jane Abernethy1. 1General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; 2Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4272038) CASE: A sixty-three-year-old female with a history of hypertension, asthma, fibromyalgia, and severe obesity presented with six months of worsening left lower extremity edema. She experienced 10 years of chronic bilateral leg edema that previously resolved with elevation and intermittent furosemide. Exam was notable for 2+ non pitting edema from left ankle to knee, with trace edema on the right leg. Skin exam was remarkable for chronic venous stasis changes on bilateral legs without erythema or pain, and no lymphadenopathy was noted in groin, though she endorsed subtle tenderness with deep palpation. Labs were notable for NT-proBNP 121 pg/mL, albumin 4.2 g/dL, and an otherwise unremarkable complete blood count and complete metabolic panel. Thyroid function was normal. Urine microalbumin was negative. Bilateral venous duplex ultrasound revealed no evidence of thrombus or venous reflux. Echocardiogram was unremarkable. She was seen by vascular surgery who felt symptoms were not consistent with vascular insufficiency, and she was recommended for follow up with occupational therapy for lymphedema management. On further questioning, she endorsed a prior vesicular rash on the same foot that she had thought was a blister due to ill-fitting shoes. She also noted having a new kitten at home. She was initiated on 5 days of azithromycin for presumed cat scratch disease, and her left lower extremity edema improved back to her prior baseline within 4 days of treatment. IMPACT/DISCUSSION: Cat-scratch disease (CSD) is an infectious disease caused by Bartonella henselae, and classically presents as painful, regional, unilateral lymphadenopathy with flu-like symptoms. Patients typically describe a cat scratch or bite with subsequent vesicular eruption around the inoculation site. While CSD is more common in children and is typically self-limited, it may also present in older adults with atypical features, such as neuroretinitis, granulomatous hepatitis, splenitis, osteomyelitis, chronic arthropathy, and more. Diagnosis of CSD is often presumptive when a patient presents with unilateral lymphadenopathy and known exposure to felines. Diagnostic modalities are limited by the organism's fastidious growth on culture, enzyme immunoassays or indirect fluorescence assays with poor sensitivity and specificity, and complications from tissue sampling. Our patient’s chief concern of unilateral leg edema has not been described as a hallmark finding in CSD; however, it possibly occurred due to a disruption in lymphatic drainage or secondary to chronic inflammation. In immunocompetent patients, empiric antibiotic treatment with azithromycin is appropriate when clinical suspicion is high, and improvement with treatment as well as down-trending antibody titers following antibiotic administration reinforces its suspected diagnosis.

CSD should be considered for any patient presenting with regional lymphatic symptoms of any chronicity and known exposure to cats. ERDHEIM-CHESTER’S DISEASE IN A GERIATRIC FEMALE DEVELOPING AORTITIS AND CARDIAC TAMPONADE Mohammed A. Arefin1; Zack Westenhaver1; Thomas Tran2; Eric Yang1. 1Internal Medicine, The University of Texas Health Science Center at San Antonio Joe R and Teresa Lozano Long School of Medicine, San Antonio, TX; 2The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4271818) CASE: Our patient is a 77 year old female with a history of chronic, controlled hypertension. She presented in 2020 with painful vulval lesions which progressed to oral lesions. One year later, symptoms had not improved with topical estrogen and lidocaine, and she underwent biopsy of the right mandibular vestibule and vulval lesions. Pathology results showed loosely aggregated epitheloid cells at the dermal epidermal junction positive for CD1a and S100 and negative for MART1 suggestive of NLH. BRAF V600E was negative. After consultation with hematology, patient was started on methotrexate and a prednisone taper, and underwent full body positron emission tomography (PET) scan which confirmed vulval and oral involvement in addition to intimal wall calcifications involving the lower thoracic aorta. As the patient was stable, further workup of the suspected aortitis was done outpatient, and CTA (computed tomography angiography) protocol including chest was negative for aortic dissection; thus the diagnosis of aortitis was confirmed. Six months later, the methotrexate was discontinued and steroid taper completed. Symptoms were well controlled with topical creams. Three months after systemic therapy was discontinued, patient insidiously developed dyspnea on exertion with recurrence of vulvar lesions. Imaging with CT chest, abdomen and pelvis showed bilateral pleural effusions and a large pericardial effusion. She was admitted to cardiology, and pericardiocentesis performed by interventional cardiology drained 720 ml of serous fluid. Fluid studies were also consistent with NLH. Her hospital course was complicated by new onset atrial fibrillation. Her NLH symptoms are now controlled on low dose methotrexate. IMPACT/DISCUSSION: Diagnosis of NLH is made with pathology staining of tissue biopsy showing non-Langerhans features. Treatment includes systemic steroids and other immunosuppressive therapy.

While ECD is a rare, systemic diagnosis, in biopsy confirmed patients, there is prudence in cardiac evaluation with CTA to identify aortitis as a possible site of systemic retroperitoneal tissue inflammation. EXERCISE-INDUCED ILIAC ARTERY VASOSPASM: A RARE CAUSE OF LOWER EXTREMITY PAIN IN ENDURANCE ATHLETES Eva Schaible1; Mohammed N. Bhuiyan2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4230602) CASE: The patient in this case was an extremely healthy 64-year-old female endurance athlete who was an avid runner and competed in iron man competitions. The patient presented to our institution for evaluation of left leg pain induced by exercise. The patient described exercise-induced pain in her left thigh and calf for 2 years. This pain occurred any time she exercised for 4 minutes or more and resolved with rest. There were no associated neurologic symptoms or skin changes. Outside facility imaging; including MRI of the hip, pelvis, and L-spine; nerve conduction studies, and CTA of the leg; were reportedly negative besides minor L2-L3 impingement that could be contributing. Lower extremity angiography and ultrasound at rest and with activity performed at our facility revealed narrowing of the mid-distal external iliac artery and significant decrease in post-exercise Ankle-brachial index (ABI) in the left leg. The reproducible elevation in flow velocity and luminal narrowing of the left external iliac artery with gradual return to baseline over 5-15 minutes after cessation of exercise was consistent with exercise-induced iliac artery vasospasm. There was also left external iliac wall-thickening consistent with arterial endofibrosis. The patient successfully underwent bovine patch angioplasty of the left external iliac and proximal common femoral artery and release of the left inguinal ligament with vascular surgery. Post-operatively, the patient limited her activity for 6 weeks, after which she was able to gradually resume her prior activities and returned to her previous exercise capacity without symptom recurrence. IMPACT/DISCUSSION: Exercise-induced arterial vasospasm is a rare cause of lower extremity pain in endurance athletes. The phenomenon was first described in male cyclists and has since been documented in runners and cyclists of both genders (male>female). This diagnosis is difficult, and clinicians must have a high index of suspicion, as exam and imaging at rest is normal. These patients are also otherwise healthy without other vasospastic or atherosclerotic disease. Diagnosis requires duplex US and ABI at rest and with exercise, revealing significant decrease in luminal diameter that worsens with exercise and resolves with rest. Treatment requires vein patch angioplasty to improve luminal flow and prevent recurrent stenosis.

Exercise-induced arterial vasospasm is an important etiology to consider in endurance athletes, especially if symptoms are related to or induced by exercise. This requires imaging that is completed during exercise in order to diagnose. EYES ON GONORRHEA: A CASE OF INFECTION PROGRESSING TO OPHTHALMOLOGIC EMERGENCY John Debella, Catherine Cai, Peggy B. Leung. Internal Medicine, NewYork-Presbyterian Weill Cornell Medical Center, New York, NY. (Control ID #4270935) CASE: A 42 yo M with PMH of HIV (last VL UD, on Biktarvy) and prior IV drug use (meth) presented to urgent care with 2 days of R eye redness and pain. Presumed bacterial conjunctivitis was treated with ofloxacin gtt. 2 days later, the patient presented to his PCP given persistence of symptoms and lack of improvement. He was advised to continue the antibiotic gtt without other recommendations. Over the next week, symptoms progressed to severe R eye swelling, difficulty opening the eye, copious discharge, with new-onset headaches and blurry vision. Concerned by these changes, he contacted his PCP’s office and was referred to the ED for evaluation. On ophthalmologic exam, R eye showed significant chemosis, 2+ edema, diffuse corneal thinning, with no view of lens or anterior vitreous. Labs revealed leukocytosis to 13.3. CT was significant for R preseptal cellulitis with eyelid abscess. Pt underwent intravitreal tap and was started on systemic & intravitreal antibiotics with improvement. Subsequent examination by the cornea team suggested severe gonococcal keratoconjunctivitis vs endophthalmitis. Cultures from the blood and eye discharge remained with no growth, however throat and rectal NAAT was + for gonorrhea. Upon chart review, last STI screen was 9 months prior. Despite improvement, he had permanent vision loss in the R eye. IMPACT/DISCUSSION: The patient's clinical course underscores critical gaps in initial management that contributed to permanent vision loss. Key systemic risk factors (HIV status and history of IV drug use) and physical exam findings (presence of eye pain and tenderness to palpation) were not adequately considered during initial evaluations, leading to delayed specialist referral. When assessing conjunctivitis, it is crucial that generalists recognize the “eye warning signs” of vision loss, pain, immunocompromised state, and associated nausea/vomiting that make specialist evaluation urgent. This case also demonstrates the importance of comprehensive patient assessment, particularly for the immunocompromised. Clinicians must maintain a high index of suspicion for atypical infections and recognize red flags that necessitate urgent intervention. Moreover, it emphasizes the crucial role of routine STI testing and comprehensive sexual health screenings in preventing potentially devastating complications. Given negative culture results and absence of recent IV drug use (UDS was unrevealing), ID and ophthalmology agreed that gonorrhea was the likely culprit organism, with final diagnosis of endophthalmitis vs severe keratoconjunctivitis. Given that the patient was overdue for routine (q3-6 month) STI testing, more timely evaluation could have prevented this manifestation.

Presence of vision loss, pain, immunocompromised state or systemic symptoms in the setting of conjunctivitis warrants referral to ophthalmology. In immunocompromised patients, including those with HIV, it is important to consider disseminated infection. Routine STI testing in this case. FEVERS, NIGHT SWEATS, AND LYMPHADENOPATHY: AN ATYPICAL CASE OF LUPUS Medha Vyavahare. Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4272138) CASE: A 41-year-old of female with a history of obesity presented to her PCP with 1 month of fatigue, drenching night sweats, unintentional 30-pound weight loss, and a new axillary lymphadenopathy. She moved from Haiti to the US five years ago for a job in airport sanitation. She had no significant alcohol use, drug use, or history of malignancy. Her initial workup showed leukopenia with a WBC of 3.4 and anemia with a Hgb of 8.8. Her Cr and LFTs were unremarkable. A QuantiFERON TB test was negative. Her CRP and ESR were 32 and 130 respectively. Given suspicion for cancer, she underwent a diagnostic mammogram, breast ultrasound, and a core axillary biopsy of which showed no evidence of malignancy. She ultimately presented to the hospital given worsening swelling in her inguinal region and low-grade fevers. Her labs showed a microcytic anemia with a Hgb of 6. A CTPE was negative for clot but demonstrated new bibasilar fibrotic changes concerning for ILD. A broad infectious and tick-borne workup, STI testing, and blood cultures were all negative. Ultimately, an ANA was obtained and was positive with a titer of 1:1280. Further rheumatologic workup revealed positive anti-Ro, anti-SM, anti-Smith, and U1RNP antibodies. She disclosed a history of a chronic facial rash and joint pains in her hands. She met both clinical and immunological domains for lupus diagnosis. Given her concern for ILD and positive U1RNP antibodies, she was ultimately diagnosed with a lupus / MCTD overlap syndrome and started on prednisone and hydroxychloroquine with improvement in her symptoms. IMPACT/DISCUSSION: Given the variability of its initial presentation, lupus diagnosis is often delayed or misdiagnosed. The most common presenting symptom of lupus is fatigue – however, many patients experience fever, lymphadenopathy, and night sweats which can bias investigation towards infection or malignancy over autoimmune etiologies. In patients with these presenting symptoms, basic inflammatory markers, a complete blood count, and an ANA titer should be considered as part of the initial workup. Leukopenia can present before other hematologic abnormalities and is a marker of active disease. An ESR elevated out of proportion to CRP is another hallmark finding. In addition, although ANA is nonspecific, the vast majority of lupus patients have positive ANA titers greater than 1:80. Positive ANA titers in lupus are attributed to antibodies to DNA components and RNA binding proteins. Anti-Smith antigens are more specific for lupus while anti-U1RNP antibodies are more specific for MCTD.

Lupus misdiagnosis is common. In patients with fatigue, lymphadenopathy, or unexplained fevers, consider ANA and inflammatory markers early in the workup. FISTFUL OF POTASSIUM: AN UNCOMMON CAUSE OF PSEUDOHYPERKALEMIA Abdulla Sabry2; Jessica Santucci2; Nabeel Akhtar1. 1Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA; 2Penn State College of Medicine, Hershey, PA. (Control ID #4271757) CASE: A 68-year-old male with a past medical history of osteoarthritis and hypercholesterolemia underwent routine laboratory testing prior to his annual exam. Basic metabolic panel (BMP) was notable for a potassium level of 6.2 mmol/L. He was recommended to go to the emergency department (ED), but he deferred because he was in his usual state of health. The remainder of his BMP was normal. Furthermore, he was not on any potassium supplementation, anti-hypertensives, diuretics, or beta blockers, and he did not have any known autoimmune or adrenal disease. He had not been transfused with blood products as well. Repeat testing was ordered, and his potassium was 5.2 mmol/L and 4.2 mmol/L the following day and month, respectively. During the initial lab draw, the patient reported that he clenched his fists, but he did not during subsequent testing. IMPACT/DISCUSSION: Hyperkalemia refers to potassium levels above 5 mmol/L. It is caused by impaired renal excretion, transcellular shifts, excessive intake, and medication side effects. Hyperkalemia can cause a variety of critical clinical manifestations, notably arrhythmias. Pseudohyperkalemia happens when potassium appears to be falsely elevated due to localized hemolysis or tissue damage during blood collection. It is important to differentiate between hyperkalemia and pseudohyperkalemia. In this case, the patient remembered that he clenched his fists while having his initial labs drawn. He then avoided clenching his fists during subsequent blood draws, and his hyperkalemia resolved. Fist-clenching causes cells in activated muscles to depolarize and lyse, releasing intracellular potassium into the bloodstream to transiently elevate the potassium level. Before he was thought to have pseudohyperkalemia, additional causes of hyperkalemia were excluded. The World Health Organization guidelines regarding best phlebotomy practices discourage fist clenching during daily blood draws. Primary care providers should understand the causes of pseudohyperkalemia and educate their patients and healthcare personnel about techniques during venipuncture known to contribute to pseudohyperkalemia, as this leads to unnecessary diagnostic testing, ED visits, and healthcare-associated costs for patients and institutions.

This case highlights that fist clenching during blood draws can contribute to pseudohyperkalemia. This case reinforces the need to educate our patients and healthcare personnel about appropriate blood-drawing techniques to provide efficient and cost-effective care. FROM HEADACHE TO HEARTACHE: A CHALLENGING CASE OF GIANT CELL ARTERITIS LEADING TO HEARING LOSS AND ANXIETY Ahmar Alam1; Nicole Hershkowitz1; Patricia Ng2. 1Medicine, Stony Brook University Hospital, Stony Brook, NY; 2Internal Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY. (Control ID #4273133) CASE: A 78-year-old male with a history of Prostate Cancer presented to primary care with sharp, right sided headache for one week; the pain was behind his right eye and ear. Review of systems was positive for photophobia, and negative for fever, trauma, nausea, or respiratory symptoms. Physical exam was notable for a small right ear effusion and negative for any facial tenderness. MRI brain was negative and he was trialed on saline nasal spray and acetaminophen for migraine vs. mild sinusitis. Two weeks later, he presented to the Emergency Department for worsening headache and intermittent right temporal paresthesia. Neurology was consulted who recommended pregabalin and methylprednisolone taper for possible trigeminal neuralgia. On outpatient Neurology follow-up, he was found to have an elevated ESR to 42 (age-adjusted normal ESR 39) and treatment was switched to Prednisone for Giant Cell Arteritis (GCA). Patient subsequently had negative temporal artery biopsy but recurrence of headache symptoms after steroid discontinuation and minimal improvement with other therapy supported a diagnosis of GCA. Course was further complicated by the development of new right sided hearing loss and severe anxiety surrounding his headaches, where he was visibly tearful on follow up. Patient was started on escitalopram and referred to ENT for further management. ENT evaluation revealed mixed hearing loss and he underwent eustachian tube placement, which did not improve symptoms and thus GCA was suspected to contribute to his hearing loss. Upon completion of the patient’s steroid taper, his anxiety significantly improved. IMPACT/DISCUSSION: This case highlights atypical complications of GCA and the importance of considering GCA when evaluating new headache in adults over 50 years old since delayed diagnosis can significantly impact mental health and quality of life (QOL). Current literature shows that common mental health effects of GCA are due to glucocorticoid side effects, fear of vision loss, and physical symptoms of Polymyalgia Rheumatica. One case-control study shows no statistically significant impact of GCA on QOL in patients who are appropriately treated with corticosteroids. Furthermore, hearing loss is a rare complication of GCA where it is reported in only a few case reports. In addition, one prospective study showed that hearing loss is significantly higher in patients with GCA compared to those with only Polymyalgia Rheumatica.

Clinicians must always consider GCA in their differential diagnosis when evaluating new headache in patients over 50 years old. Anxiety and hearing loss are rare but serious complications of GCA, and prompt diagnosis is essential in preventing its negative impact on mental health and quality of life. FROM HOMEBOUND TO WALKING THE NEIGHBORHOOD: A CASE OF SIGNIFICANT FUNCTIONAL IMPROVEMENT WITH PYRIDOSTIGMINE IN LONG COVID Stephanie L. Grach. Division of General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4245571) CASE: A 54 y.o. female with medical history of constipation and a child with postural orthostatic tachycardia syndrome (POTS) developed Long COVID 2 years prior to presentation to our Midwest academic general medicine clinic. At our visit, she described persistent fatigue, cognitive dysfunction, postural lightheadedness (with several episodes of (pre)syncope), bilateral extremity weakness, GI dysfunction, headaches, temperature dysregulation, and tachycardia. Functional capacity had decreased from working full time and 1.5hr daily walking with her dogs to being homebound and limited to approximately two small chores per day without exacerbating symptoms (post-exertional malaise (PEM)). Physical therapy did not improve function. EKG, CXR, TTE, CT-Chest/Coronary prior to our assessment were negative. Autonomic testing at our center was notable for reduced heart rate response to Valsalva maneuver and orthostatic intolerance without meeting POTS criteria. Given PEM, orthostatic intolerance, extremity weakness, and constipation, pyridostigmine was started and titrated up to 60mg three times daily. Patient reported direct functional benefit with initiation of pyridostigmine, thereafter being able to walk around her neighborhood or go to the grocery store without PEM. In addition to Long COVID symptoms, chronic constipation also improved. IMPACT/DISCUSSION: Pyridostigmine, an acetylcholinesterase inhibitor, is well known for its use in myasthenia gravis. Its utility in other neurologic diseases such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and POTS has recently emerged in the literature and specialist practices. There are multiple mechanisms by which pyridostigmine may help these conditions, including 1) heart rate and vascular regulation via increased parasympathetic signaling, 2) improvement of peak VO2 via increased cardiac output and right ventricular pressures, and 3) reduction of systemic inflammation. Long COVID is a heterogenous condition that encompasses any persistent symptom(s) lasting at least 3 months after initial COVID-19 infection; the term “syndromic Long COVID” is increasingly being used to describe patients who have sustained fatigue, brain fog, PEM orthostatic intolerance, and other symptoms that reflect ME/CFS, POTS, or other infection-associated conditions. Estimates of orthostatic intolerance/POTS and ME/CFS overlap in Long COVID are as high as 80% and 60% respectively. Pyridostigmine has been shown to reduce mortality in patients hospitalized with severe COVID-19, but has not been studied in Long COVID specifically. This case highlights the need for further research and literature on the use of pyridostigmine in Long COVID.

Long COVID is a heterogenous condition. Syndromic Long COVID often resembles or meets criteria for other infection-associated conditions such as ME/CFS and POTS. Pyridostigmine may be a helpful medication for people with Long COVID, especially in those whose symptoms resemble or meet criteria for ME/CFS and POTS. FROM SPOT TO SYNDROME: RECOGNIZING SJS/TEN IN A BACTRIM-INDUCED REACTION Sherry Yan, Sonia Bagga. Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4238434) CASE: 40-year-old female with obstructive sleep apnea presented to urgent care with acute urinary frequency, urgency, and dysuria. She was started on 5 days of Bactrim DS 800-160mg BID. 2 days later at primary care clinic, she reported L thenar eminence swelling, erythema, and pain without trauma that began 1 day prior. The area was tender to palpation without itching or burning. Bedside ultrasound was negative for abscess. She was diagnosed with cellulitis; cephalexin was added. At clinic follow-up 5 days later, she reported lip and vaginal edema, vaginal discharge, and a truncal maculopapular rash. On exam, a L thenar eminence black blister was present at the initial site of swelling and pain. Labial angioedema, a diffuse blanching papular forearm rash, fever, and tachycardia were present. She went to the emergency room where she received diphenhydramine IV, methylprednisolone IV, and epinephrine IM. There, she developed oral ulcers concerning for Stevens-Johnson Syndrome (SJS). Per dermatology, she received etanercept 50 mg subQ and triamcinolone 0.1% cream. Urine and blood cultures were negative. Initial urine cultures from urgent care returned negative. On exam, her L thenar eminence had developed a targetoid violaceous plaque. She had inflamed papules coalescing into plaques on extremities, trunk, and palms; lip desquamation; and tender labial erosions. HIV, tuberculosis, and Hepatitis B/C screenings were negative. Ophthalmology exam was negative. She started triamcinolone ointment to the vulva and estradiol cream intravaginally. Later on admission, with plaque worsening and new knee blistering, she was thought to have SJS/TEN overlap syndrome secondary to Bactrim. Upon further chart review, initial exposure was 8/2022. Given her continued rash progression, care was escalated to cyclosporine A. On discharge, she was written for cyclosporine 150 mg BID, transitioned to 50 mg daily 3 days later with dermatology follow-up. IMPACT/DISCUSSION: Fixed drug eruptions (FDEs), especially early on, can be difficult to discern from SJS. Both present with erythematous dusky macules and can occur on hands and feet. FDEs may progress to generalized bullous fixed drug eruptions (GBFDEs) which, unlike in our case, usually have mild to no mucosal involvement. Furthermore, GBFDEs typically resolve in 7-10 days after stopping the offending drug. Our patient's symptoms unfortunately progressed despite discontinuation of Bactrim and receiving steroids. With the body surface area involved, including 2 mucosal areas, her case is more representative of an SJS/TEN overlap. In our patient’s case, the timing of an immune mediated reaction to a second exposure to sulfamethoxazole would not be unreasonable.

SJS is an acute and potentially fatal skin disorder involving skin loss and mucosal membrane involvement. SJS is often medication-induced, and sulfamethoxazole is strongly associated. Initially, SJS may present similarly to a FDE; in both cases the offending drug should be stopped immediately. GETTING THE AMIODARONE BLUES Saji Packal4; Angus H. Chatham3; Margaret C. Lo2; Robert J. Hall1. 1Internal Medicine, University of Florida, Gainesville, FL; 2Medicine, Internal Medicine, University of Florida College of Medicine, Gainesville, FL; 3Medicine, University of Florida College of Medicine, Gainesville, FL; 4Internal Medicine, VA North Florida South Georgia Veterans Health System, Gainesville, FL. (Control ID #4271034) CASE: A 74-year-old male with tachy-brady syndrome previously on amiodarone presented with chronic skin discoloration and worsening leg paresthesia for 6 months. Symptoms began after complications from a right total knee replacement (TKR) 3 years ago due to two prosthetic joint infections and recall of the cobalt-chromium hardware. Discoloration was constant, painless, and non-itchy, starting in the feet and progressing anteriorly to just below the knees. Paresthesia was most pronounced on plantar surfaces and extended above the ankles. Medical history included CAD, tachy-brady syndrome treated with amiodarone 200mg (2017-2021), and S. canis/P. aeruginosa prosthetic knee infections treated with IV cephalosporins and surgical revision (2022-2023). No minocycline treatment was given. He reported childhood and military heavy metal exposure. Physical exam noted blue-gray hyperpigmentation of anterior/posterior lower legs over non-hyperkeratotic skin from feet to knees, sparing plantar and high-pressure dorsal foot surfaces. There was no warmth, erythema, swelling, tenderness, or edema. Dorsalis pedal pulses were 2+ bilaterally. Cardiopulmonary, HEENT, and neurologic exams were normal. Work-up revealed normal A1c, B12, and serum/urine mercury, lead, chromium, cobalt, and arsenic levels. ABI was normal. Venous mapping showed great saphenous vein insufficiency. EMG confirmed peripheral neuropathy. Dermatology diagnosed Blue-man syndrome due to amiodarone. The patient declined skin biopsy. IMPACT/DISCUSSION: “Blue-man syndrome” is a rare cutaneous adverse effect of amiodarone, typically affecting photosensitive areas at high doses.1 It can resemble venous stasis dermatitis, which presents with brown discoloration and pitting edema. Blue-man syndrome involves blue-gray pigmentation, often on sun-exposed arms and face.2 Amiodarone’s lipophilicity, lysosomal accumulation, and long half-life cause dermal lipofuscin-like deposits.2–4 Hyperpigmentation may persist for months to years.1 Our case is unique due to isolated lower extremity presentation, onset after drug discontinuation, persistence for years, and associated neuropathy. TKR history and venous insufficiency complicated diagnosis, but testing excluded vascular and metal toxin causes. The patient was reassured of its benign nature and counseled to avoid sun exposure and use SPF 50+ sunblock.

- Blue-man syndrome usually occurs in sun-exposed areas e.g. face and arms but can present atypically in the lower extremities - Blue-man syndrome may occur even after discontinuation of amiodarone and persist for years - Counsel patients on amiodarone to avoid sun and wear sunblock in sun-exposed areas GLP-1 AND DONE? EXPLORING ATYPICAL DIABETES Sally El Sammak, Mary Solis. Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4273107) CASE: A 69-year-old man with a new diagnosis of invasive adenocarcinoma of the colon presented for evaluation of hyperglycemia. The patient had completed 3 months of neoadjuvant immunotherapy with Ipilimumab and Nivolumab. He reported polyuria, polydipsia, nocturia, and dry mouth. He also reported intermittent pale and loose stools, but denied abdominal pain, nausea, or vomiting. BMI was 24 kg/m2. Blood glucose was elevated at 500 mg/dL. HbA1C was 10.8% (5.1% 9 months prior). CT abdomen revealed new mild peripancreatic fat stranding, suggestive of acute uncomplicated pancreatitis. Lipase level was elevated at 92 U/L. Anti-GAD 1 and Islet cell IgG antibodies were negative. C-peptide was normal at 0.7 ng/mL. He was prescribed insulin therapy. His immunotherapy was held and follow up CT abdomen showed resolution of the peripancreatic inflammation with evidence of mild pancreatic atrophy. The patient was ultimately diagnosed with new-onset diabetes due to acquired pancreatic insufficiency secondary to immunotherapy. IMPACT/DISCUSSION: This case highlights the need for vigilance in recognizing atypical forms of diabetes. While non-insulin therapies, such as GLP-1 receptor agonists, are among the most prescribed agents, their use may not always be suitable, such as in this case of pancreatic insufficiency. Approximately 40% of atypical cases go misdiagnosed, which affects management and patient outcomes. Three general features should prompt further investigation. 1) Atypical patients: New onset diabetes in an older individual with a normal BMI and no risk factors raises suspicion for latent autoimmune-diabetes in adults or an underlying pancreatic abnormality. Conversely, new diabetes in a younger individual with a strong family history may suggest monogenic diabetes, e.g. maturity-onset diabetes of the young. 2) Atypical natural history: Rapid onset severe hyperglycemia in a healthy person, ketosis with acute and rapid decompensation, or early insulin resistance all warrant further testing. Lastly, 3) Atypical clinical features: Abdominal pain with nausea, vomiting, and steatorrhea may indicate pancreatic insufficiency or advanced chronic pancreatitis, causing pancreatogenic diabetes. A rash, necrolytic migratory erythema, suggests an underlying glucagonoma. Other atypical clinical features can serve as diagnostic clues for various diseases.

It is important to recognize aspects of new onset diabetes that should prompt further investigation. Reviewing the patient’s history, risk factors, and clinical presentation is crucial for accurate diagnosis and treatment. HEMATURIA ASSOCIATED WITH TIRZEPATIDE: A CASE REPORT ON A RARE ADVERSE EFFECT Jessica Lutkenhoff4; Ayushi Garg2; Vamsi Krishna Lavu3; Mekdes Asfaw2; Zain Kulairi1. 1Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI; 2internal medicine, Wayne State University School of Medicine, Detroit, MI; 3Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 4University of Medicine & Health Sciences, Basseterre, Saint Kitts and Nevis. (Control ID #4253762) CASE: We present a case of a 36-year-old Middle Eastern man with a past medical history of class III obesity, prediabetes, and hypertension on low-dose lisinopril. Despite regular exercise, his weight loss plateaued and he subsequently began tirzepatide in November 2022. Within one week, he experienced painless gross hematuria. Laboratory tests were unremarkable except for a urinalysis showing 1+ blood, 11–20 red blood cells (RBCs) per high-power field, and ketones of 20. A urologist performed a cystoscopy and a CT urogram, which revealed no structural abnormalities or infection. Tirzepatide was discontinued, and the hematuria resolved. The patient intermittently experienced urethral discomfort for several months following the cessation of tirzepatide, but routine urinalysis performed during routine follow-ups were unremarkable, and the symptom eventually resolved. His urethral discomfort was treated with a short course of antibiotics, though no infection or other specific cause was identified. The patient’s gross hematuria did not return. IMPACT/DISCUSSION: Tirzepatide, a popular medication used to manage type 2 diabetes and support weight loss, is generally well-tolerated, with common side effects like nausea and vomiting. However, there is limited information about its potential impact on the urinary system. The exact mechanism of tirzepatide-associated hematuria remains unclear and was previously seen in only a few other reported cases, specifically with semaglutide. Tirzepatide may exacerbate underlying conditions like urinary tract infections or renal microvascular changes which could explain the etiology behind hematuria. However, the presence of urinary ketones in our patient without other significant findings suggests dehydration, potentially amplified by tirzepatide’s gastrointestinal side effects, as a contributing factor to the hematuria. By ruling out other causes of hematuria, this case reveals a possible additional contributing factor to hematuria, that may be seen in patients taking tirzepatide.

This case raises awareness of a rare but important potential side effect of tirzepatide. While hematuria appears to resolve after stopping the medication, healthcare providers should be aware of this possibility and consider it during evaluations for unexplained blood in the urine. Further studies are needed to understand this potential link better. HIDRADENITIS SUPPURATIVA IN THE SETTING OF CHRONIC GRANULOMATOUS DISEASE Nguyen Truong, Brynn Zerbe, Eric Hu, Morgan C. Chadwick. Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #4228804) CASE: A 21-year-old male with a history of Chronic Granulomatous Disease (CGD) and Hidradenitis Suppurativa (HS) presented to an immunology clinic to follow up on his skin abscess and CGD. He was first diagnosed with CGD at age 9 and HS at 18 after numerous periumbilical and groin abscesses. His treatment included Clindamycin, Bactrim, and Itraconazole, however, socioeconomic barriers resulted in treatment lapse, leading to insufficient management of his HS. His physical exam revealed a perineal wound with a small amount of debris and excess moisture, and a left axillary wound approximately 1-1/2 x 4 cm with no significant depth. The remainder of his exam was unremarkable. The patient’s HS eventually progressed to Hurley stage III which negatively impacted his self-image resulting in depression and a feeling of hopelessness. Surgical excision of skin lesions was recommended and completed. The patient is now post-surgical intervention and reported improvement in his mood and social activities. IMPACT/DISCUSSION: Chronic granulomatous disease (CGD) is a rare group of primary immunodeficiency disorders due to defective nicotinamide adenine dinucleotide phosphate (NADPH) complexes. Clinical presentations included pyogenic infections such as pneumonia, skin/soft tissue abscesses, and lymphadenitis. This case highlights an atypical complication of CGD with superimposed hidradenitis suppurativa (HS). HS classically presents with chronic deep nodules, abscesses, sinus tracts, and fistula in intertriginous areas such as the groin and axilla. HS can progress to disfigurement which can cause significant pain, reduced self-esteem, depression and overall reduced quality of life. Patients with CGD and HS are typically started on prophylactic antibiotic and antifungal treatments, however, the lack of consistent prophylaxis in this patient for his CGD may have contributed to the increased inflammation and infection that promoted HS. HS management often consists of systemic antibiotics, retinoids, and hormonal therapies. While surgical resections can be used for refractory cases, TNF-a antagonists are the only FDA-approved treatment for this condition. Despite these different models of treatment, the prognosis of HS, especially in the context of CGD, is variable. Most therapies are aimed toward symptomatic relief and prevention of progression. This case highlights the importance of recognizing HS as a potential complication of CGD, and considering management options when barriers to care lead to ineffective conventional treatments.

In summary, HS may be a rare complication of CGD likely attributed to the increased risk of trauma and infection to regional hair follicles. While cutaneous involvement in CGD has not been well documented in the literature, clinicians should aim for close control of CGD and remember to include HS in the differential for atypical abscess development. HIGH BLOOD PRESSURE, LOW LIBIDO: A TALE OF TWO GLANDS Lauren Phinney. Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4270672) CASE: A 65-year-old man with a history of hypertension, hyperlipidemia, diabetes (A1C 13.5%), hepatitis C cirrhosis, atrial fibrillation, and stimulant use presents to clinic to discuss chronic erectile dysfunction. Since establishing care two years prior, visits had addressed hepatitis C, hypertension, diabetes, stimulant use and housing. This visit, the patient’s highest priority was to discuss erectile dysfunction. He reports inability to achieve any erection, including with masturbation or nocturnal erections, for the last five years. He has no urinary incontinence or urgency, penile lesions, or a history of sexually transmitted infections. He is marginally housed in an urban area, has not been sexually active recently, and uses methamphetamine one to two times weekly. His medications include xarelto, metformin, gemfibrozil, metoprolol and lisinopril and misses doses two to three times weekly. Blood pressure is 175/95, pulse 75, respiratory rate 14 and 100% saturation on room air. Exam is negative for penile plaques, abnormal testes size, or abnormal cremaster reflex. Upon further history, the patient mentions that symptoms suddenly started after a brain surgery done for visual changes five years prior, not previously documented in the chart. Labs returned with low random cortisol of 3, FSH of 2.7, LH of 0.7, GH of 0.06, IGF1 less than 20, T4 of 9, testosterone of 21, and free testosterone of 0.6. Subsequent examination revealed bilateral homonymous hemianopsia. Diagnosis of panhypopituitarism secondary to presumed pituitary adenoma removal was made. He started on hydrocortisone and referred to endocrinology. Endocrinology initiated injectable testosterone and levothyroxine in addition to hydrocortisone. Endocrinology noted paradoxical hypertension in the setting of panhypopituitarism. Plasma metanephrines returned elevated, confirming concomitant pheochromocytoma, and doxazosin was started. IMPACT/DISCUSSION: This is a case of erectile dysfunction as a presenting symptom for panhypopituitarism. Diagnosis was delayed given hypertension secondary to concomitant pheochromocytoma. Implicit bias related to race, substance use and perceived medication adherence certainly played a role in this case. Clinical assumptions were made, such as stimulant use contributing to hypertension and erectile dysfunction as secondary to uncontrolled diabetes. This case highlights the importance of patient self-advocacy— with the patient prioritizing erectile dysfunction—in uncovering overlooked diagnoses.

- This case highlights the importance of avoiding premature diagnostic closure in complex patients, with erectile dysfunction and hypertension ultimately revealing panhypopituitarism and pheochromocytoma respectively. - Erectile dysfunction can be a presenting symptom for pituitary lesions. - Implicit bias delayed the diagnosis of panhypopituitarism and pheochromocytoma, emphasizing the need for providers to challenge their assumptions and biases. HIV AND HLD – WHAT’S THE CATCH? Ann Fee. Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4270922) CASE: 26-year-old male with well-controlled HIV on HAART undergoes routine labs which find direct-measure LDL elevated at 205. He has no family history of hyperlipidemia, MI, or stroke. IMPACT/DISCUSSION: Human Immunodeficiency Virus (HIV) has a known impact on cholesterol levels, even in patients without a detectable viral load and with an adequate CD4 count. Furthermore, HIV is an independent risk factor for cardiovascular events, similar to diabetes or hypertension. This clinical vignette aims to explore the correlation between HIV and hyperlipidemia (HLD) and to outline the need for HLD screening in this patient population. The chronic inflammation of active HIV viremia lowers high-density lipoprotein (HDL) through various mechanisms. However, the correlation between HIV and HLD can also partly be attributed to metabolic derangements secondary to highly active anti-retroviral therapy (HAART). While isolated hypertriglyceridemia is the most common, elevated cholesterol and low-density lipoprotein (LDL) are often seen as well. HAART medications, especially protease inhibitors and nucleoside reverse transcriptase inhibitors, are thought to impair usual lipoprotein metabolism through a variety of proposed mechanisms.

These biochemical processes, both studied and theoretical, lead to abnormal lipid panels in our patients with HIV. Independent of this, living with HIV also doubles a person’s lifetime risk of cardiovascular events. We also know that the elevated lipids in patients with HIV are also more atherogenic (due to a variety of factors). While some studies have shown that switching HAART classes can improve LDL cholesterol, most patients are already on the newer, less-toxic HAART formulations. Therefore, our role as internists is to screen these patients early for elevated cholesterol, educate them on the importance of lifestyle modifications, and start them on lipid-lowering therapy when appropriate (keeping in mind any drug-drug interactions between their HAART and the medications we might prescribe). HOW SHOULD WE MANAGE ABDOMINAL PAIN AND DIFFICULTY INTERPRETING CT ARTIFACTS? Kyohei Itakura1; Kazuo Komamura1; Mitsunori Iwase2; Yoshitomo Nishikawa1; Kayako Morikawa1. 1General Medicine, Toyota Kinen Byoin, Toyota, Aichi Prefecture, Japan; 2Cardiology, Toyota Memorial Hospital, Toyota, Aichi, Japan. (Control ID #4273168) CASE: Upper gastrointestinal (UGI) studies are typically performed by endoscopy. Barium studies are less common in North America , but remain essential for the diagnosis of conditions such as achalasia. This report highlights a rare complication, rectal perforation, that occurred five days after a barium-based UGI study. A 79-year-old woman with a history of cesarean delivery underwent a UGI study six days prior and had no post-procedure bowel movement. One day before admission, she developed abdominal pain and vomiting. CT at a referring hospital showed barium stool impaction in the sigmoid colon and rectum. Manual disimpaction and enemas failed and she was transferred to our hospital. On arrival, her vital signs were : temperature 37.5 °C, blood pressure 117/57 mmHg, heart rate 106 bpm, respiratory rate 36/min, and SpO2 92%. Examination revealed abdominal distension, hyperactive bowel sounds, and localized tenderness with rebound pain. Laboratory results showed leukocytosis (WBC 1600 /μL) and elevated CRP (11.05 mg/dL). CT showed barium stool impaction with intestinal wall edema consistent with gastrointestinal perforation with peritonitis. Surgery revealed a 4 cm perforation extending from the sigmoid colon to the rectum with barium stool spilling into the pelvic cavity. The peritoneum was inflamed and the small intestine was adherent to the pelvic floor. No ischemia or mass was found. The perforated segment was resected and a stoma created. The patient had an uneventful recovery. IMPACT/DISCUSSION: This case demonstrates a rare occurrence of delayed rectal perforation after a barium study in a patient with a previous cesarean delivery. Early recognition of the barium-related perforation based on clinical history allowed for timely surgical intervention. Although barium studies are rare in North America, they remain essential for the diagnosis of conditions such as scirrhous gastric cancer. However, complications such as gastrointestinal perforation, while rare, are serious due to the inflammation and morbidity caused by barium and stool leakage into the peritoneal cavity. CT artifacts caused by barium may delay diagnosis, emphasizing the need for clinical suspicion and a detailed history. In cases where the history is difficult to obtain, such as altered mental status or language barriers, prior barium exposure must be considered.

This case of delayed gastrointestinal perforation following a barium-based UGI study highlights the diagnostic challenges posed by CT artifacts. It underscores the critical role of a comprehensive history and physical examination for timely and effective management. IDENTIFYING PULMONARY EMBOLISM IN THE AMBULATORY SETTING AFTER MAJOR CARDIAC SURGERY Jacob LaFleur1; Mary C. Wirtz2. 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4273363) CASE: A 65-year-old female presented to ambulatory clinic 17 days after aortic valve and ascending aortic arch replacement for critical valve stenosis and dilated ascending aorta. Her hospital course was notable for left lower extremity deep vein thrombosis (DVT) in the left posterior tibial vein. Considering the low risk of embolization for a DVT distal to the knee, the primary team deferred anticoagulation in an effort to decrease risk of bleeding. She was discharged to home on antiplatelet therapy with full dose ASA (325mg) daily. Following discharge, she developed intermittent fevers up to 100.9 °F, as well as bilateral chest wall pain and a dry cough with deep inspiration, prompting her presentation to the office. Upon arrival, her vital signs were within normal limits: BP 116/55, HR 60, RR 18, SpO2 98% on RA, and afebrile. She denied SOB, DOE, chest pressure, worsening lower extremity edema, pain, redness, or swelling. She endorsed overall clinical improvement since surgery including improved mobility, increased activity capacity and well-controlled post-operative pain. Based on her symptoms of intermittent fevers and pleuritic chest pain with deep inspiration following an invasive surgical procedure, there was high suspicion for pulmonary embolism (PE). Immediate ED evaluation was deferred given her clinical stability, and an urgent outpatient CT PE was ordered. Clinic staff coordinated same-day CT scan at a nearby clinical site. The CT PE revealed a segmental left lower lobe pulmonary embolism, and the patient was directed to the ED for anticoagulation initiation. IMPACT/DISCUSSION: This case presented challenges due to the ambiguity of the presentation. While risk factors of a recent invasive surgery and known DVT were present, the pleuritic chest pain could be attributed to post-operative pain in a cardiac surgery patient, cough to post-operative atelectasis, and fever to viral illness. It also presents a learning opportunity for distal lower extremity DVTs and risk of embolization. Isolated distal clots that remain confined to the calf veins are at low risk (<1%) of embolization on 3-month follow-up, and there is lack of convincing data in favor of anticoagulation in the absence of risk factors. Further studies are needed to confirm the best treatment for distal DVT.

Physicians in the ambulatory setting must keep a high clinical suspicion for pulmonary embolism in patients with risk factors and symptoms, even if vital signs are stable. Physicians in the ambulatory setting must have a knowledge of available outpatient resources and utilize appropriate resources and support staff to coordinate quality and timely care for patients. IF IT DOESN’T QUACK LIKE A DIABETIC DUCK, IT’S IGA NEPHROPATHY Taylor M. Adams1; Catherine Larned2. 1Internal Medicine, Naval Medical Center Portsmouth, Portsmouth, VA; 2Nephrology, Naval Medical Center Portsmouth, Portsmouth, VA. (Control ID #4271920) CASE: A 42-year-old Asian female with no personal or family history of kidney disease was referred to the Nephrology clinic for an elevated urine microalbumin/creatinine ratio of 2400mg/g on a screening microalbumin panel as part of her yearly diabetic screening. She was then noted to have microscopic hematuria and an elevated urine protein/creatinine ratio of 0.5g that predated her diagnosis of diabetes by at least 1 year. The patient had a baseline creatinine of 0.5-0.7 mg/dL and an estimated glomerular filtration rate of >90 ml/min. A secondary proteinuria workup was initiated to include serologies for paraproteinemia, infection, autoimmune pathology, and membranous nephropathy. Retroperitoneal ultrasound was unremarkable. The patient had no dermatologic symptoms. Renal biopsy results were consistent with IgAN, categorized as low risk for progression by the International IgAN Prediction Tool and with low risk pathologic features by Oxford criteria demonstrating M0E0S0T0C0. Findings also indicated glomerulomegaly likely secondary to her coexisting uncontrolled diabetes. Steroids were not initiated due to the absence of a crescentic component and negligible interstitial fibrosis and tubular atrophy (IFTA), and she is currently being observed for improvement on maximum renin-angiotensin blockade and sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy. IMPACT/DISCUSSION: While diabetes is the most common cause of end-stage kidney disease in the United States, Immunoglobulin A Nephropathy (IgAN) is the most common cause of primary glomerulonephritis worldwide, manifesting with hematuria, proteinuria, hypertension, and variable progression of chronic kidney disease. 1 in 10 renal biopsies result in a diagnosis with IgA nephropathy, emphasizing that this etiology should be considered in all cases of proteinuria. We presented a case of longstanding proteinuria confounded by a history of uncontrolled type 2 diabetes with renal biopsy resulting in a diagnosis of IgAN.

Diabetic nephropathy develops over a long period of time, and it is advocated to start screening for microalbuminuria at the time of diagnosis of type 2 diabetes mellitus. However, this case provides context that not all proteinuria in patients with uncontrolled diabetes is strictly from diabetic nephropathy. The time course of her proteinuria and diabetic diagnosis did not align as expected and elicited suspicion for an underlying glomerulonephritis rather than attribute her proteinuria solely to diabetic kidney disease. This led to further workup and a tissue diagnosis of IgAN which has treatment and prognostic implications and underlines the importance of further diabetic control in this patient, as she has two components of nephropathy with increased risk for progression of chronic kidney disease. INADEQUATE PAIN RELIEF FROM OXYCODONE IN A PATIENT WITH POOR CYP2D6 METABOLISM Michael Stephens1; Serena Cheng3; Renae Boerneke3; Stacy T. Charat1,2. 1Internal Medicine, University of California San Diego, La Jolla, CA; 2Primary Care, VA San Diego Healthcare System, San Diego, CA; 3Pharmacy, VA San Diego Healthcare System, San Diego, CA. (Control ID #4272091) CASE: The patient is a 36-year-old male with past medical history of superior mesenteric artery (SMA) syndrome status post Roux-en-Y gastric bypass and duodenojejunostomy who presented with fractures of the face, femur, and humerus following a motor vehicle collision (MVC). He underwent open reductions and internal fixation of complex zygomaxillary, femur, and humerus fractures. He experienced severe pain while inpatient, requiring 15mg oxycodone every 3 hours, and 2mg IV hydromorphone every 2 hours. The patient had taken high doses of opioids for SMA syndrome but had not taken opioids in the two years prior to the MVC. After a prolonged admission, he was discharged on oral oxycodone and hydrocodone. After discharge, he reported taking 160mg oxycodone SA, 180mg oxycodone IR, and ~48mg of hydrocodone daily to control his pain and prevent withdrawal symptoms. The patient was referred to an integrated pain team to optimize pain control and reduce opioid use. His urine toxicology showed active opioid metabolites indicating medication absorption, but he did not have side effects typical of high dose opioids. The patient was started on a low dose crossover initiation of buprenorphine/naloxone as well as a multimodal pain regimen including gabapentin, duloxetine, and psychotherapy. The pain team suspected inadequate metabolism of certain opioid medications, and a pharmacogenetics panel was obtained. The patient was found to have poor CYP2D6 metabolism, the enzyme which converts tramadol, codeine, oxycodone, and hydrocodone to active metabolites. The patient continued buprenorphine/naloxone 2mg/0.5mg daily and stopped other opioids. This maintenance dose was lower than expected relative to his morphine equivalent dose at initiation. His pain improved and he was able to resume activities he enjoyed including walking and surfing. IMPACT/DISCUSSION: The patient demonstrated a remarkably high tolerance to opioid medications. His pharmacogenetic profile suggests that he may not have been optimally metabolizing oxycodone and hydrocodone to active metabolites for effective analgesia. Several studies have demonstrated that CYP2D6 poor metabolism leads to inadequate pain relief from tramadol and codeine, but data is limited for the impact on hydrocodone and oxycodone. This vignette suggests CYP2D6 poor metabolism may play a larger role in pain relief in patients receiving oxycodone and hydrocodone.

Patients with unexpectedly high tolerance to opioids may be poor metabolizers of common opioid medications. Pharmacogenetic testing may provide tailored metabolic profiles that allow for selection of optimal analgesics for patients with refractory pain. An integrated pain team with a physician, pharmacist, and psychotherapists may be helpful in identifying patients with unexpected high opioid tolerance and transitioning them to buprenorphine/suboxone. INCIDENTAL ELEVATION OF CA 19-9 LEVEL AT A HEALTH FAIR AND OCCULT GASTRIC CANCER Essam Rashad1; Brandon Gordon1; Abdul Haseeb2. 1Hospital Medicine, Parkview Health, Fort Wayne, IN; 2Interventional Gastroenterology, Parkview Health, Fort Wayne, IN. (Control ID #4271077) CASE: A 55-year-old male presented to the Gastroenterology Clinic for evaluation of incidentally elevated CA19-9 (232 U/mL) at a health fair. He was adopted, with limited family history. Medical history included acid reflux controlled with omeprazole, obstructive sleep apnea, tobacco use disorder and prior cholecystectomy. Recent screening colonoscopy showed diverticulosis and a < 1 cm rectal hyperplastic polyp that was resected. He denied abdominal pain, weight loss, or signs of overt gastrointestinal bleeding. Clinical exam and vital signs were unremarkable. Laboratory studies including complete blood count, metabolic panel, and liver chemistries were normal. However, a repeat CA 19-9 level showed persistent elevation leading to further evaluation. An MRI of the abdomen revealed normal appearance of the bowel, pancreas and the hepatobiliary system. Further investigation with esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) revealed a cratered gastric ulcer with heaped-up edges. EUS revealed a large hypoechoic 30 mm by 18 mm irregular hypoechoic mass extending to the serosa Fine needle biopsy results revealed gastric adenocarcinoma. IMPACT/DISCUSSION: Elevated serum CA19-9 level is traditionally associated with pancreatic cancer; however, it can be elevated in other gastrointestinal (GI) malignancies, including biliary tract cancer (60-70%), gastric cancer (20-50%), colorectal cancer (20-40%), and hepatocellular carcinoma (30-35%). Several non-malignant conditions can also elevate CA19-9, including chronic pancreatitis (30%), biliary obstruction (60%), and cirrhosis (20%). The diagnostic performance varies significantly between malignancies - for pancreatic cancer, meta-analyses show sensitivity of 79%, while for gastric cancer sensitivity is lower at 30%. Though CA19-9 has a low positive predictive value (<1%) in asymptomatic populations, this tumor marker is often obtained at cancer screening events, and if elevated may pose a diagnostic challenge. If further workup is pursued, etiologies apart from pancreatic cancer should be systematically considered, including occult gastric cancer.

CA19-9 levels have poor sensitivity and can be elevated in several GI malignancies including pancreatic, gastric, and biliary tract cancers. Systematic evaluation, including endoscopy, should be considered in unexplained elevations in CA 19-9 levels. INTRAHEPATIC HYPOTHYROIDISM TREATMENT WITH RESMETIROM: A CASE REPORT Ishita Gupta1; Fahiye Ali1; Serena Thomas1; Duha Al-Smadi1; Paige I. Nappier1; Chitharanjan Duvoor2. 1Internal Medicine, St. Bernard's Medical Center, Jonesboro, AR; 2Endocrinology, St. Bernards Medical Center, Jonesboro, AR. (Control ID #4270824) CASE: 64 year old female with a past medical history of depression, diabetes mellitus, chronic kidney disease stage 3, hypertension and hypothyroidism maintained on 88 mcg of levothyroxine. On her routine annual check up with her primary care provider, liver ultrasound showed fatty liver. Patient was started on semaglutide weekly injections along with diet and exercise counseling. Given persistently elevated liver enzymes, a FibroScan was ordered which indicated severe fatty liver (S3) and stage III fibrosis. Metabolic Associated Steato-Hepatitis (MASH) was diagnosed and Resmetirom 80 mg once daily was started. Routine blood work showed low TSH levels of 1.63 UIU/ML, which was a significant drop from previous TSH value of 5.42 UIU/ML. Free T4 levels were 0.89 NG/DL. The patient had no symptoms of hyperthyroidism and denied the use of biotin. Thyroid Stimulating Immunoglobulin level was < 0.10 IU/L, Thyroid Peroxidase Antibody level was <1 IU/ML and TSH Receptor Antibody level was <1.75 IU/L. The patient was seen by an endocrinologist and the levothyroxine dose was reduced. Repeated liver enzymes showed improvement as well. It was suspected that the patient was euthyroid since her hepatic transaminases and hepatic fibrosis were improving on Resmetirom. IMPACT/DISCUSSION: Given that Resmetirom is a newly approved drug, it has changed our management of liver fibrosis. This case has highlighted the importance of regularly checking thyroid functions in a patient on Resmetirom as improvement in liver fibrosis can drastically improve hypothyroid state. In a liver that is not fibrous, deiodinases 1 (DIO1) drives the conversion of T4 to active T3. In chronic liver injury a decreased DIO1 activity coupled with an increase in DIO3 activity leads to increased conversion of T4 to inactive reverse T3 subsequently leading to accumulation of lipo toxic species, cyclic liver injury and local intrahepatic hypothyroidism. Population studies have shown association between MASH and overt hypothyroidism subclinical hypothyroidism and low thyroid hormone in the normal range. Patients with higher baseline TSH levels and no evidence of liver disease were more likely to develop MASH.

Our case brings forth an important effect of the new FDA approved medication Resmetirom. Primary care physicians, internists and endocrinologists should be aware that improvement in thyroid function can occur once improvement in liver fibrosis begins and titrating levothyroxine accordingly would be required. Given the paucity in existing literature, more large scale clinical trials are needed to assess further effects of Resmetirom which would help guide evidence based guidelines and algorithms. IRON DEFICIENCY PRESENTING AS REFRACTORY MIGRAINES Jenna Wettstein1; Whitney Lynch2. 1Medical School, Medical College of Wisconsin, Milwaukee, WI; 2University of Kentucky, Lexington, KY. (Control ID #4248790) CASE: 36-year-old female with a history of hypertension, post-partum pre-eclampsia, gestational diabetes, anxiety, ADHD, hyperhidrosis, menorrhagia, and migraine headaches consulted her primary care provider due to increased frequency of migraines that were significantly impacting daily life. She requested a refill of Sumatriptan which previously aborted her headaches. However, due to ongoing, refractory symptoms, she was changed to Rizatriptan ultimately titrated to 10mg with minimal response. Recent menstrual cycles were not heavy, but patient had a history of menorrhagia. Bloodwork was obtained and results were consistent with significant iron deficiency (ferritin 3ug/mL, iron 16ug/dL,TIBC 472ug/dL, transferrin saturation 3%, and unsaturated iron binding capacity 456ug/dL). Iron infusions were initiated once weekly for 3 weeks with resolution of symptoms. Bloodwork was repeated post-infusion and showed a normalization of iron deficiency markers (hemoglobin 10.6g/dL, ferritin 162ug/dL, iron 85ug/dL, TIBC 313ug/dL, transferrin saturation 27%, and unsaturated iron binding capacity 228ug/dL). Patient was instructed to begin oral iron supplementation with ferrous sulfate 325mg twice daily with plan for additional workup to rule out possible sources of bleeding given absence of recent heavy menstrual cycles. Upper and lower endoscopies were obtained to evaluate for evidence of an H. pylori infection, celiac disease, or structural lesions which were normal. Hematology was consulted to discuss other potential sources and noted many cases to be idiopathic. They agreed with plan for endoscopy and advised screening for tea use. Additionally, they remarked on the absence of PPI therapy on the patient’s medication list, as this was another potential source of iron deficiency. The patient didn't drink tea regularly and had not previously been on PPI therapy. Hematology recommended continuing oral iron supplementation and advised monitoring iron levels 2-3 times per year with replacement as indicated with goal ferritin >50 ng/mL along with a normal hemoglobin level. Labs were repeated 2 months after initiation of oral replacement and showed continued normal levels of iron stores and hemoglobin. IMPACT/DISCUSSION: Iron deficiency has been recognized by the WHO as the most common nutritional deficiency worldwide and is the predominant form of anemia. Common causes of iron deficiency include menorrhagia, gastrointestinal bleeding, and deficient dietary iron intake or absorption. Reduced blood oxygen levels that result from iron deficiency can cause symptoms of shortness of breath, tachycardia, heart palpitations, fatigue, headaches, and dizziness.

This case presents the importance of considering the diagnosis of iron deficiency when faced with intractable and/or worsening migraines. Patients may not always have a historical feature that would suggest this diagnosis and many are without a clear source making ongoing follow up lab monitoring pertinent to avoiding recurrence of symptoms. IT'S GETTING HOT IN HERE: FEVER OF UNKNOWN ORIGIN SOLVED WITH A NOVEL DIAGNOSTIC TOOL Lauren D. Pomerantz2; Omar Abu Saleh3; Ji Yuan4; Ryan W. Kendziora4; Michael Torbenson4; Natalie Griffin1. 1General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 3Infectious Disease, Mayo Clinic Minnesota, Rochester, MN; 4Pathology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4230713) CASE: A 51- year-old male presented with 2 years of fever of unknown origin (FUO), unintentional 70lb weight loss, lymphadenopathy, and diffuse myalgias. He denied any gastrointestinal symptoms. Previous workup included unremarkable MRI and CT scans. PET scan showed mildly FDG-avid lymphadenopathy, which prompted a lymph node biopsy that was negative. Labs were notable for CRP peak at 173, ESR 46, minimal thrombocytosis, leukocytosis, and anemia of chronic disease. Extensive infectious disease, rheumatologic, and hematologic workup were unremarkable including testing for genetic fever syndrome, bone marrow biopsy, and vasculitis testing. The patient underwent EGD and colonoscopy given weight loss, with normal biopsy results and negative PAS staining for Whipple’s disease. As the patient continued to fever and lose weight to the point of malnutrition, Karius testing was completed, revealing Tropheryma whipplei. Blood testing for whipplei, previously not conducted given negative gastrointestinal biopsies, confirmed positive Tropheryma whipplei via PCR. An axillary lymph node, previously removed during workup, was re-stained and revealed positive Tropheryma whipplei via PCR. A lumbar puncture ruled out CSF involvement, and the patient was started on Ceftriaxone followed by Bactrim with symptom resolution. After diagnosis, the patient noted recent work on water lines, which may have been the exposure source. IMPACT/DISCUSSION: The Karius Test is a commercially available diagnostic assay that utilizes plasma microbial cell-free DNA (mcfDNA) sequencing to detect and quantify a broad spectrum of pathogens from a blood sample. It can detect 1250 different bacteria, viruses, fungi, and parasites. Clinical guidelines regarding the utilization of Karius testing are not yet defined. Retrospective studies suggest that Karius testing has a clinical impact (impacting diagnosis, treatment, or outcome) in only 11% of cases in which it is used, often FUO cases, suggesting that traditional investigative methods are usually sufficient. However, as our case shows, there is clinical utility to Karius testing in complex, yet undiagnosed cases. The question remains as to whether Karius testing should be completed early in workup of FUO or as later testing once traditional testing modalities are exhausted. While a cause remains unknown in up to half of FUO cases, many of those patients do not have poor outcomes. However, in our case, the patient continued to fever and ultimately suffered from malnourishment. In similar severe cases suggesting poorer outcomes, it is critical to find reversible causes of FUO. Karius testing provided an important additional diagnostic tool and impacted patient treatment and outcome by revealing a very unusual case of Whipple’s disease without GI tract involvement.

In cases of FUO without clear cause after diagnostic testing and with continued patient decompensation, Karius testing is an additional tool that can provide a diagnosis and change clinical outcomes. KNEAD FOR CAUTION: A CASE OF RHABDOMYOLYSIS AFTER MASSAGE Ari M. Fish1; 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 #4270560) CASE: PM is a 55-year-old male with a history of hypertension, coronary artery disease, and gout. He presented to the rheumatology clinic for routine follow-up. His medications included aspirin, atenolol, moderate-intensity atorvastatin, and allopurinol. Vital signs were normal. Initial bloodwork revealed normal kidney function and marked elevations in transaminases and creatine phosphokinase (CPK) (ALT 122, AST 361, CPK 23,996). Notably, the patient reported receiving a whole-body, deep-tissue Gua Sha massage the night before, describing it as unusually deep and painful. He denied recent illness, trauma, seizures, drug use, urinary changes, or new medications. Once his labs resulted, he was instructed to go to the emergency department for suspected rhabdomyolysis. Intravenous fluids were administered and repeat lab work showed a normal urinalysis, improvement in CPK levels (5,291), and a downward trend in liver function tests. All labs normalized on repeat bloodwork one week later. IMPACT/DISCUSSION: Rhabdomyolysis is a condition characterized by the breakdown of skeletal muscle, leading to the release of muscle contents into the blood. Elevated serum creatine phosphokinase (CPK) is the most sensitive and specific marker for muscle injury, with levels typically exceeding five times the upper limit of normal in rhabdomyolysis. Additional laboratory findings include myoglobinuria and electrolyte abnormalities (e.g., hyperphosphatemia, hyperkalemia, hypocalcemia) (1). Elevations in liver function tests are also well-documented. However, the elevation of AST and ALT can be misleading, as these enzymes are also found in skeletal muscle. Thus, their elevation in rhabdomyolysis often reflects muscle injury rather than true liver damage (2). Common causes of rhabdomyolysis include trauma, excessive exertion, prolonged immobilization, and drugs. Cases implicating massage as a trigger for rhabdomyolysis are rare (3-5). Gua Sha massage, a traditional East Asian healing technique, involves deeply pressing a smooth-edged instrument across the skin, often resulting in significant petechiae. Historically, this technique has been used to manage conditions such as chronic neck and lower back pain (6). Mechanistically, it is plausible that intense deep tissue massage can cause sufficient muscle breakdown to trigger rhabdomyolysis. To our knowledge, there are no prior documented cases of Gua Sha-induced rhabdomyolysis; thus, this case highlights a novel instance of rhabdomyolysis from massage. While massage remains a widely used alternative medicine modality, it is important to recognize its associated potential adverse effects.

1. Clinicians and patients should be aware that intense massage, including Gua Sha, can cause rhabdomyolysis. 2. Elevated ALT and AST should be correlated with clinical history and other biomarkers, such as CPK, to differentiate muscle injury from true liver pathology. LOST SENSES, FOUND DEFICIENCY: A CASE OF ANOSMIA LINKED TO HYPOZINCEMIA Malik Alqawasmi, Jeanne Lunz. School of Medicine, University of New Mexico School of Medicine, Albuquerque, NM. (Control ID #4263578) CASE: A 78-year-old male with a medical history of uncontrolled diabetes mellitus, hypertension, and hyperlipidemia presented with a two-year history of anosmia and ageusia, significantly affecting his quality of life. These symptoms began shortly after a presumed COVID-19 infection, initially attributed to post-viral sequelae. Despite interventions, including evaluation by otolaryngology and use of a taste-testing kits, his symptoms persisted without improvement. The patient expressed increasing frustration, reporting loss of appetite and diminished interest in food, leading to potential nutritional deficiencies. Additional workup was pursued, revealing a normal metabolic profile and heavy metal panel, including both urine and serum arsenic, lead, and mercury levels. However, serum zinc was found to be low at 57 mcg/dL. Notably, the patient reports that he had been taking zinc supplements, but concurrent intake with meals and other medications. IMPACT/DISCUSSION: Anosmia and ageusia are multifactorial conditions often associated with infectious, neurologic, or metabolic etiologies. The differential diagnosis includes a wide range of etiologies such as post-viral olfactory dysfunction, sinonasal disorders (e.g., chronic rhinosinusitis, nasal polyps), neurologic conditions (e.g., Parkinson’s disease, Alzheimer’s disease), nutritional deficiencies (Ex: zinc, vitamin B12), medication side effects, and exposure to environmental toxins. In this case, the initial onset of symptoms following a suspected COVID-19 infection highlighted post-viral olfactory dysfunction as a possible mechanism. However, the protracted course and lack of response to standard interventions necessitated further evaluation. The eventual identification of hypozincemia as a contributing factor underscores the importance of micronutrient evaluation in persistent anosmia and ageusia. Zinc is critical for the function and regeneration of gustatory and olfactory receptors, and deficiency can impair these sensory modalities. In this patient, the suboptimal zinc absorption likely resulted from concurrent intake with food and medications, which are known inhibitors of zinc bioavailability.

This case highlights the importance of a thorough and nuanced approach to evaluating persistent anosmia and ageusia, especially in the context of presumed post-viral sequelae. While COVID-19-associated olfactory and gustatory dysfunction is well-documented, this case demonstrates that overlapping etiologies, such as hypozincemia, must also be considered. Correcting zinc deficiency through optimized supplementation practices may offer symptom relief and improve quality of life for affected individuals. MEDICAL MASQUERADING – RED HERRINGS IN A CASE OF DYSPNEA AND FATIGUE Anthony J. Mauro1; Brielle Spataro2. 1Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4244594) CASE: A 73-year-old male with a history of acute myeloblastic leukemia in remission, coronary artery disease, and asthma presented to his primary care physician with months of profound fatigue, exertional dyspnea, and a 10-lb weight loss. He denied chest pain, palpitations, or syncope, and he described his mood as “up and down” due to his health concerns. Daily medications included 5μg liothyronine for depression, a multivitamin containing 30μg biotin, and 5mg nebivolol. Physical exam, including vital signs, was unremarkable. Prior evaluation by his oncologist revealed B12 deficiency, mild pancytopenia, and moderate neutropenia. Intramuscular/oral B12 repletion was initiated without improvement in his fatigue. Repeat B12 levels were normal, though his pancytopenia persisted. Pulmonary function testing revealed a mild obstructive pattern but was otherwise unremarkable. Electrocardiography, stress testing, and transthoracic echocardiography were also unremarkable. Following these tests, thyroid laboratory examination was performed; TSH was undetectable, and thyroid hormones were markedly elevated. Liothyronine was discontinued and labs were checked after two weeks with no improvement. He then stopped his multivitamin for one week with no change in labs. Finally, he underwent thyroid ultrasonography and thyrotropin receptor antibody testing and was diagnosed with Graves’ disease. Due to his neutropenia, low-dose daily methimazole bridge therapy was recommended. Five months after his initial presentation, he underwent thyroidectomy. He was started on 137μg daily levothyroxine and had full resolution of his symptoms. IMPACT/DISCUSSION: The differential diagnosis for dyspnea with fatigue is broad, including cardiac, pulmonary, hematologic, neuromuscular, endocrine, and drug-induced etiologies. Likewise, Graves’ disease symptoms are nonspecific, including dyspnea, fatigue, weight loss, anxiety, heat intolerance, tremor, and exophthalmos, with goiter being a common manifestation. In older adults, hyperthyroid symptoms are more often indolent and may present without other classic findings. Laboratory evaluation of thyroid function may be complicated by supplementation of biotin, which can falsely suppress TSH and elevate T3/T4, or exogenous thyroid hormone, which masks physiologic functioning of the hypothalamic-pituitary-thyroid axis. In the outpatient setting, scant hyperthyroid symptoms, a history of other conditions that may cause symptoms, and use of biotin and/or exogenous T3/T4 may delay the diagnosis and treatment of Graves’ disease.

Graves’ disease should be considered in patients with dyspnea, fatigue, weight loss, and anxiety, regardless of alternative diagnoses. Medications should be evaluated before pursuing thyroid function laboratory testing. METASTATIC LOBULAR BREAST CANCER MIMICKING GASTRIC LINITIS PLASTICA Izma N. Khaliq1; Laiba N. Khaliq2; Rishita Gupta3; Keri Angers1; Howard Terebelo2. 1Medical Sciences, Wayne State University School of Medicine, Detroit, MI; 2Hematology/Oncology, Ascension Michigan, Warren, MI; 3Trinity Health Ann Arbor Hospital, Ypsilanti, MI. (Control ID #4271118) CASE: A 62-year-old female with history of stage III invasive lobular carcinoma of the right breast diagnosed in 2016 completed adjuvant chemotherapy with Adriamycin and Cytoxan followed by Taxol and radiation. The patient was then started on a 10-year treatment with anastrozole. In 2023, the patient presented with new onset early satiety and a 10-pound weight loss. She was seen by her PCP and referred for an EGD which demonstrated hypertrophied folds and friability in the stomach. Biopsy at that time revealed adenocarcinoma with HER-2/neu 2-3+ immunohistochemistry staining pattern. CT showed gastric wall thickening without evidence of metastatic disease. She was then seen by her oncologist who requested further studies to differentiate between primary gastric adenocarcinoma or metastatic disease. Thus endoscopic ultrasound was done and reinforced the CT results which depicted a 15cm thickening throughout the stomach consistent with linitis plastica. The examination of the biopsied tissue revealed features consistent with the patient's initial diagnosis of lobular breast carcinoma. This was supported by positive immunohistochemistry staining for Gata-3 and pan-keratin, alongside negative CDX-2, providing adequate evidence to exclude gastric cancer as the primary. The tumor cells were found to be estrogen receptor-positive and progesterone receptor-negative. The patient was started on treatment with Perjeta/Herceptin every three weeks with Taxol therapy weekly. IMPACT/DISCUSSION: Lobular breast cancer is the single histological subtype most associated with disseminated disease, accounting for 85% of cases. In particular, gastric metastases have been found in up to 18% of patients with breast cancer. Gastric metastases from lobular breast carcinoma can appear many years after the original breast cancer diagnosis. These cases often mimic linitis plastica in up to 73% of patients, leading to frequent misdiagnosis. It is essential to compare the subsequent biopsies with the original breast biopsy to ensure correct identification. This case emphasizes the importance of maintaining a high level of suspicion for metastatic gastric disease in the setting of lobular breast carcinoma.

Prioritize review of patient history in creating differential diagnoses, as pathologies linked to past cancers may arise years later. Recognize that breast cancer metastasis to the gastrointestinal tract can mimic linitis plastica. MISDIAGNOSIS OF ASTHMA IN A YOUNG ADULT WITH UPPER AIRWAY OBSTRUCTION William H. Bull1; David A. Feldstein2; Linda Baier2. 1Internal Medicine, UW Health, Madison, WI; 2Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI. (Control ID #4272430) CASE: 30 yo male with a history of premature birth, protracted tracheostomy, developmental delay, and undifferentiated chronic lung disease with presumptive diagnosis of asthma presented to clinic with dyspnea. Chronically treated for asthma with ICS and LABA combination therapy. Gradual progression of audible breath sounds and mild dyspnea for 6-9 months. Treated with albuterol inhaler, Symbicort, and hypertonic saline nebulizers without improvement. Exam: normal vitals with pulse ox of 98%; audible upper airway noises without respiratory distress; diffuse rhonchi/stridor on pulmonary auscultation; no expiratory wheeze. CXR: no acute abnormalities. Unable to obtain lung function tests (PFTs) due to developmental delay. CT scans: tracheal narrowing with abnormal morphology of cricoid cartilage and arytenoids consistent with prior tracheostomy, mass-like lesion of scar tissue. Flexible endoscopy: significant prolapse of right aryepiglottic fold. Treatment: CO2 laser resection of redundant right aryepiglottic fold, removal of thyrohyoid mass and dermoid cyst. Overall symptom improvement. IMPACT/DISCUSSION: Asthma affects 25 million people and 7.7% of US population. Diagnostic guidelines include combination of medical history, physical exam, PFTs, and additional tests. PFTs are deferred in children under age 6 due to inability to participate, and diagnosis is based on symptoms. Lack of diagnostic PFTs may lead to childhood overdiagnosis persisting into adulthood. A study of 652 children diagnosed with, or treated for, asthma showed only 16% had spirometry-confirmed diagnoses and 54% were over-diagnosed. A study of 613 adult patients previously diagnosed with asthma showed 33% had no evidence of asthma when objectively evaluated. The studies suggest that asthma diagnosis may originate from childhood misdiagnosis and PFTs are critical to establish diagnosis. American College of Chest Physicians’ guidelines emphasize objective testing because many patients with typical symptoms do not have asthma. Thus, consider alternative diagnoses for patients who lack objective diagnosis, or have an obstructive pattern on PFTs without response to guideline-directed inhalers. Our patient had presumed asthma from childhood; his worsening respiratory symptoms were treated as exacerbation. With no objective diagnosis and no improvement with bronchodilators, he appropriately received further evaluation leading to upper airway obstruction diagnosis. This case taught me to confirm diagnosis of asthma in patients presenting with atypical symptoms.

Asthma overdiagnosis is common PFTs are often deferred in children which may lead to misdiagnosis and inappropriate treatment Consider alternative diagnoses for patients diagnosed with asthma who do not exhibit notable improvement with bronchodilator therapy MISSING THE FOREST FOR THE TREES Tyler Shimfessel1; Michelle A. Sandoval Cabanas1; Emily N. Bufkin2. 1internal medicine-pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX; 2Internal Medicine (Internal Medicine-Pediatrics Division), The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4273532) CASE: A 72-year-old female with prior tobacco use presented to the emergency department with six months of progressive 20-lb weight loss, generalized weakness, fatigue, shortness of breath, and intermittent hematochezia. Her physical exam was unremarkable. Labs revealed significant proteinuria (>500 mg/dL). Imaging showed new emphysema and colitis. She was discharged with outpatient follow-up. One month later, she returned with worsening shortness of breath and new lower extremity edema. She was diagnosed with a segmental pulmonary embolism, NSTEMI, a small pericardial effusion, and heart failure with preserved ejection fraction, characterized by severe concentric left ventricular hypertrophy and diastolic dysfunction. Her hospital course was complicated by persistent hypotension despite a normal cortisol stimulation test and negative sepsis workup. Repeat labs showed persistent proteinuria. Follow-up visits with multiple subspecialists failed to elucidate an underlying diagnosis. Three months later, she sought a second opinion from a new primary care provider, who ordered UPEP and light chain testing. Within days, she was hospitalized for cardiogenic shock and a reduced ejection fraction (32%). AL amyloidosis was diagnosed based on elevated free lambda light chains, cardiac MRI findings of diffuse late gadolinium enhancement, and bone marrow biopsy showing green birefringence on Congo red stain. Despite aggressive management, her advanced disease stage and poor prognosis led to her passing on hospice care within weeks. IMPACT/DISCUSSION: Amyloidosis results from extracellular deposition of insoluble amyloid proteins in tissues and vital organs. Symptoms of AL amyloidosis are typically non-specific and include fatigue, weight loss, exertional dyspnea, orthostatic hypotension, and peripheral edema. Cardiac involvement (>75% of cases) manifests as restrictive cardiomyopathy, while kidney involvement (>60%) often presents as proteinuria. Other commonly affected organs include the liver (>50%), autonomic nervous system (20%), and peripheral nerves. The disease has a poor prognosis as 43% of patients die within the first year, and 25% die within six months, often from cardiac involvement. Diagnosis requires identifying both a plasma cell dyscrasia and amyloid deposits in tissue. Almost all patients exhibit abnormal free light chain levels or monoclonal proteins on serum or urine studies. Non-invasive tests, such as abdominal fat pad aspiration, are often diagnostic. Bone marrow biopsy is mandatory to exclude multiple myeloma and other plasma cell dyscrasias.

AL amyloidosis presents with non-specific symptoms, often leading to significant diagnostic delays. Awareness of its clinical manifestations among primary care and specialist physicians is crucial for timely recognition. Early diagnosis and intervention can improve patient outcomes by reducing delays and initiating prompt therapy. NAME THAT RASH! A TEXTBOOK CASE IN INTERNAL MEDICINE IN WHICH IN-BASKET MESSAGING SOMETIMES ISN'T ENOUGH. Stephanie B. Clauss. General Internal Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4272306) CASE: This is a case of a 45-year-old relatively healthy female with only past medical history of hyperlipidemia that reached out to her primary care physician (PCP) through in-basket messaging about a new rash on her hands. Initially she was given an antifungal but slowly began to experience more systemic symptoms such as muscle weakness. She arrived in the walk in clinic with concerns of facial swelling, nausea, headache, and worsening rash on the bilateral hands, elbows, and chest. On her physical exam she was found to have a raised erythematous rash on the elbows and knuckles as well as swelling and tenderness of her muscles. After exam and history it was decided an autoimmune work up was necessary. She came back a week later for follow up on her lab results and was found to have worsening symptoms on exam including 4/5 muscle strength in the proximal muscles of the upper and lower extremities. Her rash had worsened and she was found to have a heliotrope rash around the eyes and the shawl sign. Her labs were positive for an ANA of 1:40 with a speckled pattern as well as positive Sjogren's antibody. Her Creatinine Kinase level was found to be normal. Due to her worsening muscle weakness and long wait times for specialist referrals it was felt it would be best if she got evaluated in the ER and likely admitted for additional work up of possible dermatomyositis. Upon presentation to the ER the patient was admitted and evaluated by dermatology which did a punch biopsy and agreed with the likely diagnosis of dermatomyositis and recommended starting solumedrol. Unfortunately, the punch biopsy was inconclusive. Neurology also evaluated the patient and recommended serological testing as well as a muscle biopsy. They also recommended treatment with solumedrol and IVIG which the patient received. On discharge the patients muscle strength had significantly improved and she was discharged with prednisone, methotrexate, protonix, and bactrim prophylaxis. After discharge she followed up in the clinic and her muscle biopsy had resulted positive with classical findings of dermatomyositis and serological testing was positive for TIF 1 gamma with increased risk of malignancy. Complete malignancy work up was done and negative. IMPACT/DISCUSSION: Overall, this patient had a classic presentation in terms of dermatological findings and progressing muscle weakness for dermatomyositis. Her diagnosis was delayed due to pictures sent directly to the in-basket only of her hands and lack of complete history. In this case the in-basket messaging limited the context of the classic physical exam findings which led to delay of labs and ultimately treatment.

In conclusion primary care providers are often times overwhelmed by the in-basket and many times patients find it more convienent to just message the in-basket. It is important to always remember seeing a patient in person and getting a full history and physical can often times be a better option especially when it comes to more complex cases. NARCOLEPSY – OSA OVERLAP SYNDROME IN A PATIENT WITH CONGENITAL HEART DISEASE Caleb Max1; Chitra Lal2. 1Internal Medicine, Medical University of South Carolina, Charleston, SC; 2Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4267059) CASE: A 21-year-old female with narcolepsy with cataplexy, tetralogy of Fallot/pulmonary atresia (s/p RV to PA conduit/VSD closure) presented with worsening daytime sleepiness, morning fatigue, an Epworth Sleepiness Scale (ESS) score of 17, AM headaches, and snoring. Bedtime was at 11 pm, wake-up at 8 am, and sleep onset was within 15 minutes. She took low-sodium oxybate (3 mg at 11 pm, 1 am, and 4 am) and used methylphenidate 5 mg as needed. She was not on continuous positive airway pressure (CPAP), which she had briefly tried years prior. She denied symptoms of depression. Physical exam revealed a systolic murmur; her last echocardiogram showed normal LV, large RV, and RV dysfunction. An overnight PSG was ordered, with low-sodium oxybate adjusted to two doses before 2 am (9 mg total). PSG revealed mild OSA (AHI 6/h), and CPAP (5-8 cm H2O) was prescribed. After cardiology consultation, methylphenidate was discontinued. At follow-up, her ESS score improved to 12, and she declined additional wake-promoting medications, reporting improvement with the previous adjustments. IMPACT/DISCUSSION: Narcolepsy, a chronic sleep disorder, affects 1-2 per 4000 people (1). Management combines behavioral and pharmacologic approaches, as no disease-modifying therapies currently exist. Patients often experience fluctuating symptoms, making it essential to be able to adjust therapy while addressing confounding factors like untreated OSA. OSA treatment with CPAP is standard; however, unique challenges arise in patients with congenital heart disease (CHD). This patient, with pulmonary atresia s/p RV to PA conduit and RV dysfunction, highlights CPAP’s risks in CHD. CPAP can reduce cardiac filling pressure by negatively affecting the intrathoracic pressure gradient, which risks worsening RV function and can lead to RV overload (2). She previously tolerated up to 8 cm H2O informing her current therapy. Stimulants, which increase vascular resistance, can worsen RV dysfunction. Based on her cardiac history, echocardiogram findings, and cardiology consultation, stimulants were discontinued without worsening sleepiness after. Future treatments favor safer wake-promoting agents like modafinil or solriamfetol. Medication review is a cornerstone of effective prescribing, requiring providers to evaluate both compliance and usage patterns. This patient’s late-night dosing of low sodium oxybate likely contributed to excessive daytime sleepiness due to its sedative effects. Sodium oxybate can be divided into two doses, but the second should be taken at least 6 hours before wake time. Proper counseling on medication timing minimizes risks of sedation and accidents.

In managing narcolepsy, address untreated comorbidities, such as OSA, and optimize medication regimens. CHD patients present unique challenges when initiating therapies, such as CPAP or stimulants. A comprehensive, patient-centered strategy that accounts for comorbidities, therapy, and medication effects is essential for therapy in complex cases. NATURE VS NURTURE: A CASE OF SEVERE HYPERCHOLESTEROLEMIA IN A YOUNG ADULT Calla K. Khilnani, Rachel Engelberg, Allison Samuel. Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4270618) CASE: A 26-year-old female with a past medical history of small intestinal bacterial overgrowth (SIBO) presented to establish care. She had no known family history of high cholesterol or premature cardiovascular disease. She had a normal body weight (BMI 23.8 kg/m2) and unremarkable physical exam. Her only medication was cetirizine, taken for allergies. A screening, non-fasting lipid panel showed a total cholesterol of 398 mg/dL, with an LDL cholesterol of 306 mg/dL, HDL cholesterol of 82 mg/dL, and triglycerides of 51 mg/dL. A repeat, fasting lipid panel revealed a total cholesterol of 433 mg/dL, with an LDL of 356 mg/dL, HDL of 71 mg/dL, and triglycerides of 28 mg/dL. Her lipoprotein(a) and apolipoprotein B levels were 186.7 and 224 mg/dL respectively, indicating even greater cardiovascular risk. The patient’s thyroid stimulating hormone and hepatic function panel were within normal limits. Urinalysis was normal, and a spot urine protein was < 7. Hemoglobin A1c was 5.2%. Overall, her lipid profile, young age, and otherwise good health were concerning for a genetic cause of dyslipidemia such as familial hypercholesterolemia (FH). In-depth review of her lifestyle revealed that she had been adhering to a carnivorous diet comprised solely of meats, fish, and eggs, reporting that this diet relieved her SIBO symptoms of abdominal pain and bloating. The patient was started on a high-intensity statin and referred to cardiology for further workup. She is undergoing genetic testing and cholesterol production and absorption testing for any genetic or other metabolic contributions to her severe dyslipidemia. Of note, however, records were found from before her initiation of the carnivorous diet, at which time she had an LDL of 111 mg/dL. IMPACT/DISCUSSION: Based on the Dutch Lipid Clinic Network diagnostic criteria for FH, the patient would be classified as at least having “probable FH” due to the magnitude of her LDL elevation alone. However, her lack of family history and physical exam findings, such as xanthomata, made this diagnosis less likely. Even in patients with lab abnormalities of such an extreme magnitude, lifestyle factors should be examined as possible causes. This is especially true as fad diets such as the carnivorous diet become popularized for their supposed health benefits.

The differential diagnosis for severe hypercholesterolemia in an otherwise healthy young adult is broad and must be fully worked up to ensure adequate management. Lifestyle factors such as diet can have a significant effect on health that can resemble genetic causes of disease. NAVIGATING THE IMPERFECT DIABETES SCREENING TESTS FOR PATIENTS WITH SICKLE CELL DISEASE Tamara F. Godfrey. Internal Medicine, University of North Carolina System, Chapel Hill, NC. (Control ID #4271510) CASE: A 52 year old male with hemoglobin SS sickle cell disease, obstructive sleep apnea, and history of renal cell carcinoma s/p partial nephrectomy presented to hematology for routine care of his sickle cell disease. He had no signs or symptoms of diabetes or insulin resistance. Fructosamine was ordered for routine diabetes screening and was found to be elevated, therefore he was referred to Endocrinology and to establish care with a new PCP. At his Endocrinology appointment he had a normal 1 hour post-prandial blood glucose. He was given a continuous glucose monitor to wear for 10 days, which revealed some elevated blood glucose readings. A confirmatory two hour glucose tolerance test was performed, which revealed normal glucose. IMPACT/DISCUSSION: Hemoglobin A1c is not an accurate test in those with hemoglobinopathies. Fructosamine has been used by some providers as an alternative screening method however this is not a standardized test, and can be affected by conditions that alter albumin levels which are often abnormal in patients with sickle cell disease. This patient had been referred to Endocrinology because of an elevated fructosamine level. He had a normal glucose reading one hour after a meal (that included 2 tablespoons of honey), but had elevated readings while he was wearing a continuous glucose monitor. If he had not had the confirmatory glucose tolerance test he may have been incorrectly diagnosed with diabetes.

It is important to screen for diabetes melliltus in patients with sickle cell disease who meet criteria for screening based on the guidelines from the American Diabetes Association, however it remains complicated and currently there is no official guidance on how to optimally screen this population. The use of fasting and post-prandial glucose readings, whether via serum testing, point of care testing, or with continuous glucose monitors followed by confirmation with glucose tolerance testing should be considered in this population. NAVIGATING UNCERTAINTY: THE PROBLEM OF SCREENING IN PATIENTS WITH VARIANTS OF UNCERTAIN SIGNIFICANCE (VUS) IN TUMOR SUPPRESSORS Gabriel Haw, Susan M. Nikels. GIM, University of Colorado Denver, Aurora, CO. (Control ID #4270241) CASE: A 39 year old female presented to her PCP to discuss her family history notable for pancreatic cancer (age 55) in her father and breast cancer (54) in her paternal aunt. Genetic testing was sent, revealing a VUS in the gene PALB2, a tumor suppressor whose dysfunction is associated with breast and pancreatic cancer. She underwent routine screening for breast cancer with mammogram upon turning 40, without evidence of malignancy. Her family history qualified her for screening breast MRI. MRI 2.5 years later revealed a new 1cm mass in the right breast. Biopsy of this mass revealed DCIS, and patient underwent lumpectomy with concerning margins, followed by bilateral mastectomy. Surgical pathology revealed right DCIS, stage IA. VUS status was again confirmed given the time elapsed since first analysis. IMPACT/DISCUSSION: National Comprehensive Cancer Network guidelines for screening for patients with known tumor suppressor mutations are predicated on confirmation of pathogenicity. However, this is confounded by VUS, a category where there is not currently enough data to define the mutation as either benign or pathogenic. Patients with VUS present a problem for clinicians: they may either be screened as if their cancer risk reflects the general population, in which case opportunities for early diagnosis of potentially lethal malignancy may be missed. On the other hand, if they are treated as patients with pathogenic mutations, they may be subjected to over-treatment. The present uncertainty in established genetic knowledge means that the results of genetic testing alone may not be sufficient to guide clinical decision making. In these situations, attempting to analyze risk by type of neoplasm and age of diagnosis of family members may provide greater insight into an individual patient’s future risk of malignancy. However, using family history alone must be done with caution. This case also exemplifies the ways in which screening without genetics is imperfect, even though it led to an early diagnosis in this patient. Only one of the six predictive models used to estimate her risk (Tyrer-Cuzick v7) upgraded this patient into an advanced screening category, and only by a margin of 0.6% estimated lifetime breast cancer risk. If this patient had been born seven years earlier, and screened prior to the implementation of the v7 model, she would have likely not received enhanced screening.

Patients with a VUS in a tumor suppressor gene present a problem for those who wish to screen these patients. Family history in these cases may help guide decision-making, but history-based risk models are imperfect. Careful risk stratification must be implemented in these cases given the evolving nature of the field of clinical genetics. NEW SKIN LESIONS IN IMMUNOCOMPROMISED PATIENT ATTRIBUTED TO BACILLARY ANGIOMATOSIS Wesley Kong1; Sunny Lai2. 1Internal Medicine, Alameda Health System, Oakland, CA; 2Family Medicine, Alameda Health System, Oakland, CA. (Control ID #4273426) CASE: A 26-year-old man with untreated advanced HIV (CD4 95/7%) initially presents to the emergency department for disseminated skin lesions. His lesions first appeared 6 weeks earlier and are located to his scalp, face, mouth, torso, sole of his feet and genitals. Lesions are painful on palpation, non-pruritic, friable with minimal purulence secondary to picking. He initially presented to an ED 4 weeks earlier with labs showing HIV RNA 900, RPR titer >1:256, while receiving 1 dose of Bicillin for early syphilis. He later followed up at immunology clinic with pertinent labs showing HSV-2 PCR positive, VZV PCR negative, MRSA wound culture, MPOX negative. He was initially started on valtrex for HSV, Bactrim for MRSA in addition to tecovirimat, later discontinued following negative MPOX test. He re-presented for mostly stable diffuse exophytic violaceous nodules with friable components, concerning of bacillary angiomatosis, vs Kaposi Sarcoma vs. angiolymphoid hyperplasia, vs. cutaneous lymphoma in the setting of untreated HIV infection with CD4 count <100. Punch biopsies were sent for histopathology and tissue culture, plated on chocolate agar, and patient was started on empiric doxycycline. Pathologic tissue exam later revealed low concern for Kaposi sarcoma, favoring bacillary angiomatosis, pending further confirmation via serologic studies. IMPACT/DISCUSSION: Immunocompromised patients can have multiple concurrent infections. Bacillary angiomatosis skin manifestation are more commonly seen with low CD4 counts <100, may present variably, initially as a papulonodular rash with violaceous lesion, progressing into larger subcutaneous tumors, or vascular lesions, evolving into pedunculated friable lesions. Lesions can resemble Kaposi sarcoma, pyogenic granuloma, tuberculosis, coccidiomycosis, among others with possibility of concomitant disease, highlighting need to have a broad differential, as in the case above who presented with lesions of variable appearances that could represent different manifestations of bartonella vs concomitant processes such as KP. Biopsy is necessary for definitive diagnosis and to rule out alternative causes, with histopathology, PCR, culture, Warthin-Starry silver staining and blood culture/PCR to assist with diagnosis. Treatment depends on severity of illness, requiring a minimum 3-month antibiotic course.

Disseminated skin lesions often appear in immunocompromised patients and etiologies vary depending on CD4 counts, necessitating screening for HIV with CD4 counts to guide diagnosis. BA has variability in appearances which can be mistaken for Kaposi sarcoma. Various forms of lesions can also resemble pyogenic granuloma, cherry angioma, dermatofibroma, hemangioma, or lesions of mycobacteria, tuberculosis coccidiomycosis, cryptococcosis, histoplasma, or sporotrichosis Treat with minimum 3-month course of antibiotics with goal of clinical resolution without recurrence iso CD4 >200. NOT JUST A GUT FEELING: A MISSED DIAGNOSIS OF CELIAC ARTERY STENOSIS Taylor Caton, Jaime Fineman. Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #4270766) CASE: A 46-year-old man with a history of laparotomy for a gunshot wound in 2006, chronic pain on methadone, and mood disorder has been following with primary care for years of central abdominal pain, postprandial vomiting, dysphagia, and weight loss. He had seen multiple specialists since 2013 for these symptoms and had many studies performed: esophageal manometry, colonoscopy, endoscopies, ERCP, pH impedance, esophagram, whole gut scintigraphy, and multiple abdominal CTs. A 2018 CT showed annular pancreas; this led to the placement of a pancreatic duct stent which did not improve his symptoms. Gastric emptying study in 2021 showed functional obstruction in large bowel thought secondary to chronic opiate use, yet methadone was discontinued without symptomatic improvement. Fundoplication was performed in 2021 with mild improvement in vomiting but no effect on abdominal pain and weight loss. He was seen in resident clinic in 2023 with persistent symptoms leading to an extensive chart review, which noted abnormal CT findings not appreciated prior. A 2018 CT ordered by GI noted moderate stenosis of the proximal celiac axis, however this was in the body of the report rather than the impression, and the focus at that time was on the new diagnosis of annular pancreas. A surgeon ordered a CT in 2021 to look for a hernia, this also noted the stenosis, however the focus at this time was on the lack of hernia rather than the incidental finding of stenosis. Once these findings were recognized, the patient was referred to vascular surgery. He underwent a predictive celiac plexus block with complete resolution of his symptoms, followed by surgical ligament release in June 2024. Since surgery he has had complete symptom resolution. IMPACT/DISCUSSION: Celiac artery stenosis is an uncommon and difficult-to-diagnose condition due to nonspecific symptoms. Symptoms vary and can include postprandial abdominal pain, weight loss, nausea, vomiting, and diarrhea. Patients with this condition often undergo extensive evaluation; average duration of symptoms before diagnosis is 34 months. This case highlights the PCP’s role in coordination of care and the importance of following imaging results even when ordered by other clinicians. Specialists ordering studies may be focused on ruling in or out specific diagnoses (confirmation bias) and thus may miss unexpected yet important findings. Attribution bias also likely played a role in this case; clinicians were quick to attribute the patient’s pain to his chronic methadone use even when it did not improve with opiate avoidance.

Celiac artery stenosis is an uncommon explanation for chronic abdominal pain that can present with nausea, vomiting, and weight loss. To diagnose, clinicians must maintain a broad differential and avoid cognitive bias in their medical decision making. Primary care physicians must take care to review testing ordered by specialists, with special attention paid to incidental findings not addressed by the ordering provider. NOT YOUR AVERAGE SOB: PRIMARY WARM AUTOIMMUNE HEMOLYTIC ANEMIA Kaitlin Demarest1; Menaka Dhingra2; Deepa R. Nandiwada3. 1Internal Medicine, Penn Medicine, Philadelphia, PA; 2Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; 3General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4271695) CASE: We present a case of a 78-year-old man who presented with subacute shortness of breath and fatigue. For the month prior to presentation, he noted dyspnea on exertion. He needed to catch his breath after two blocks. His nails also began to turn yellow with exertion. He endorsed chest tightness, palpitations, lightheadedness. He denied cough, orthopnea, and wheezing. He has a history of prior tobacco use (quit 30 years ago), hyperlipidemia, and right bundle branch block. His father and grandfather had ischemic heart disease. He takes ezetimibe and vitamin D. On physical exam, there was no scleral icterus. Lungs were clear to auscultation bilaterally. He had a regular rate and rhythm. No lower extremity edema noted. Fingernails noted to be yellow. Initial differential based on patient risk factors included angina, heart failure, COPD, lung malignancy, pneumonia, and anemia. Initial testing: Labs were significant for hemoglobin 8.2 g/dL (from 13.5 g/dL nine months prior), white blood cell count 8.2, platelet count 227, an indirect hyperbilirubinemia, normal iron studies, elevated lactate dehydrogenase, undetectable haptoglobin, and elevated reticulocyte count. Chest x-ray was unremarkable. A stress test was ordered but not completed. Differential diagnosis included gastrointestinal bleed, hematologic malignancy, and hemolysis due to medication, infection, or autoimmune disease. Of note, last colonoscopy was normal in 2014. He did not describe any signs of bleeding. Subsequent lab testing: Blood parasites were negative. Blood smear notable for microspherocytes and nucleated red blood cells, without schistocytes or dacrocytes. Direct antiglobulin test was positive, consistent with warm autoimmune hemolytic anemia. He was referred to Hematology and underwent testing for autoimmune or lymphoproliferative disorders. Flow cytometry of peripheral blood was normal and SPEP showed no evidence of a paraprotein. Kappa:lambda free light chain ratio was in the normal range. Rheumatoid factor and ANA were within normal limits. He started prednisone 1 mg/kg/day and trimethoprim-sulfamethoxazole for pneumocystis prophylaxis. After three weeks, his hemoglobin increased to 10.6 g/dL and prednisone was tapered by 10 mg per week. IMPACT/DISCUSSION: This case illustrates the importance of testing for anemia in a patient with dyspnea on exertion despite cardiac and pulmonary risk factors. It also demonstrates the utility in a broad hemolysis work up in the setting of acute anemia, including those without known risk factors for autoimmune hemolytic anemia. It is critical to rule out underlying autoimmune or lymphoproliferative processes, although about half of cases are idiopathic.

Dyspnea on exertion, palpitations, and lightheadedness are common presenting symptoms of acute anemia. The most common causes of warm autoimmune hemolytic anemia are infection, malignancy, medications, and autoimmune disease. The first-line treatment for warm autoimmune hemolytic anemia is corticosteroids. OF TESTOSTERONE SUPPLEMENTATION AND AORTIC ARCH THROMBUS: A CASE REPORT Emmanuel Oundo. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4267110) CASE: Testosterone supplementation has increased in the US, with more healthy individuals taking supplementation. However, the side effects have not been as well described as with estrogens, and the incidence of thromboembolism and aortic arch thrombi is not well known in this population. A 51-year-old man, otherwise healthy, who had been taking testosterone twice weekly, DHEA, and pregnenolone for about 2 years for hypogonadism presents with a week of flu-like symptoms. He gave himself an intramuscular (IM) injection of ceftriaxone. A feeling of intense warmth and intense itching followed this. It was associated with dizziness, lightheadedness, weakness, and passing out multiple times at home. Because he was concerned about an allergic reaction, he gave himself an IM injection of 50 mg of Benadryl and came to the emergency department. Emergency medical services (EMS) noted isolated blood pressure elevation to the 200s but normalized by the time he developed at the emergency department. In the emergency department he was hemodynamically stable, troponin at 0.04, EKG in sinus tachycardia, and CTPA revealed 1.4 cm filling defect within the mid aortic arch most consistent with clot material. He was started on a heparin drip, which was later transitioned to apixaban, and he was discharged home with advice to discontinue the testosterone and DHEA supplementation. A hypercoagulability workup was done, including ANA, beta-2 microglobulin, homocystine levels, protein C, protein S, Antithrombin III, and factor V Leyden, all of which were negative. IMPACT/DISCUSSION: Testosterone replacement therapy (TRT) is increasingly prescribed for non-specific symptoms1. Testosterone has been associated with erythrocytosis (not seen in our patient), and this has been postulated to lead to thrombosis2. Indeed, Goldenberg et al evaluated 42 patients who had DVT and PE and were on testosterone. All the thromboses were venous, unlike in our patient. Arterial thromboses are seldom reported in literature3, and aortic thromboses are much less so.

Our case highlights the importance of considering arterial thromboembolism in patients on TRT, and the need to counsel such patients before recommending it. PAIN MASQUERADING AS HUNGER: AN UNEXPECTED DIAGNOSIS OF MALS IN PRIMARY CARE Tamar Mosulishvili1; Robert C. Lyman2. 1Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH; 2General Internal Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH. (Control ID #4231902) CASE: A 60-year-old woman with DMT1, ILD, and scleroderma-dermatomyositis, on hydroxychloroquine and prednisone, developed new gastrointestinal symptoms after starting mycophenolate mofetil (CellCept) month prior. She initially complained of burning discomfort radiating from the esophagus to the epigastrium and right side, without dysphagia or hematemesis. Despite discontinuing CellCept, symptoms persisted and worsened over time to include constant hunger, despite stable weight and adequate oral intake. She denied acid reflux, and H2 blockers and PPIs were ineffective. An upper endoscopy and H. pylori test were normal. Treatment trials included gabapentin (900mg daily), nortriptyline, desipramine, hyoscyamine, and dietary modifications, all providing minimal or no relief. Extensive workup, including thyroid function tests, iron studies, cortisol levels, leptin, ghrelin, gastric emptying scan, and CT angiogram, was unremarkable. Three months later, she presented with acute, severe epigastric “squeezing” pain. A CT abdomen/pelvis was normal. A follow-up exam revealed a new pulsatile epigastric mass, prompting vascular imaging. CT angiogram was normal, but a mesenteric duplex ultrasound showed celiac artery stenosis with characteristic respiratory variation: peak systolic velocity (PSV) of 410 cm/s, decreasing to 192 cm/s with deep inspiration, confirming MALS. She underwent robotic MALS release with neurolysis, with symptom relief. IMPACT/DISCUSSION: Median arcuate ligament syndrome (MALS) is a rare vascular condition where the median arcuate ligament compresses the celiac artery. Diagnosis can be challenging in patients with multiple comorbidities, as symptoms may mimic more common conditions or medication side effects. This case highlights the diagnostic challenges and the importance of choosing appropriate imaging in patients with atypical gastrointestinal symptoms. This case highlights the atypical presentation of MALS and the importance of a thorough examination. A pulsatile epigastric mass was key in prompting the correct vascular imaging. While CT angiography is the first-line imaging for mesenteric ischemia, it is often normal in MALS cases. Duplex ultrasound is the preferred imaging modality due to its ability to detect respiratory variations in celiac artery velocities, which are diagnostic of MALS.

MALS should be considered in patients with unexplained epigastric pain, especially post-prandial symptoms, even if initial imaging is normal. In patients with autoimmune conditions, the presentation may be atypical and treatment outcomes unpredictable. A systematic diagnostic approach, including duplex ultrasound and close post-surgical monitoring, is crucial for accurate diagnosis and management. PAROTID GLAND MASS-AN UNUSUAL CASE PRESENTATION OF B-CELL LYMPHOBLASTIC LYMPHOMA Noor Humayun, Laiba Masood, Muhammad A. Zia. Internal Medicine, Albany Medical Center, Albany, NY. (Control ID #4273023) CASE: A 23-year-old female with no significant medical history developed a painless, progressively enlarging right-sided facial swelling during the third trimester of her pregnancy. She had no associated intraoral swelling, fevers, chills, weight loss, night sweats, or other swellings. She was initially diagnosed with sialadenitis complicated by an abscess at urgent care,and was prescribed antibiotics, but her symptoms worsened over six months.She referred to an ENT specialist, examination revealed an 8x6 cm firm, mobile, non-tender swelling at the angle of her jaw, without intraoral extension or cervical adenopathy. A complete blood count and comprehensive metabolic panel were unremarkable. A core needle biopsy confirmed B-cell lymphoblastic lymphoma (B-LBL) with positive CD79, PAX5, CD10, TdT, and Bcl-2 markers. A PET scan revealed an FDG-avid mass in the right cheek and bilateral palatine tonsils but was otherwise unremarkable, indicating localized disease. Bone marrow biopsy and CSF analysis were negative. The patient underwent induction chemotherapy, achieving partial remission, and is now in the maintenance phase of treatment. IMPACT/DISCUSSION: Our case presents a unique manifestation of non-Hodgkin's lymphoma (NHL), specifically B-LBL, which accounts for only 2% of all NHL cases. The extranodal presentation in the parotid gland of a young adult without systemic or biochemical symptoms is an even rarer entity, comprising just 1-4% of all parotid tumors. This case expands the existing knowledge by documenting such an unusual presentation during pregnancy, highlighting the diagnostic challenges associated with localized disease.

-Our case reports an atypical presentation of B-LBL, emphasizing the importance of early recognition to prevent delays in diagnosis and improving patient outcomes. -Unique cases like this can guide future research, contributing to advancements in diagnostic strategies and better prognostic approaches. PEARLS AND PITFALLS FOR DIAGNOSING SERONEGATIVE ARTHRITIS IN PRIMARY CARE Michael E. McCarthy1; Paul O'Rourke2; Jane Abernethy3. 1Medicine, Johns Hopkins Medicine, Baltimore, MD; 2Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD; 3General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4270552) CASE: A nineteen-year-old female presents to an outpatient clinic with joint swelling. Patient reports seven years of intermittent episodes of painful joint swelling. Joints most affected are the hips, ankles, and toes, occasionally wrists and neck. Flares usually affect a single joint but can include as many as four joints in an asymmetric, bilateral distribution. Swelling is associated with morning stiffness and subjective fevers without known trauma. She was previously evaluated by orthopedic surgery and prescribed ibuprofen for presumed athletic injury without improvement. Review of systems is notable for daily cramping abdominal pains, unrelated to defecation, without diarrhea or constipation. Family history is notable for mother with aural psoriasis and brother with Crohn’s Disease. Exam is remarkable for swollen, erythematous, tender left ankle and multiple tender MTP joints of the left foot without dactylitis, absence of rash or nail changes, and benign abdominal exam. Labs revealed a sedimentation rate of 94 and C-reactive protein of 95, as well as unremarkable ANA, rheumatoid factor, anti-dsDNA antibody, anti-CCP antibody, tissue transglutaminase antibody, and endomysium antibody. She was diagnosed with seronegative inflammatory arthritis, with highest concern for IBD-associated or psoriatic as etiology. She was referred to rheumatology and gastroenterology for further evaluation. IMPACT/DISCUSSION: In this case, we encounter a young woman presenting with seven years of untreated, uncontrolled inflammatory arthritis with minimal workup by prior physicians. Inflammatory arthritis is a group of diseases defined by the presence of joint inflammation on exam or imaging. Etiologies are further sub-divided as those with stereotypical serological patterns and those without. Prompt diagnosis and treatment of inflammatory arthritis is essential to adequate symptom control, as uncontrolled disease leads to further joint damage and functional impairment. Diagnosis of seronegative arthritis is difficult; however, some investigators have proposed a tripartite diagnostic criterion of (1) imaging evidence of joint inflammation, (2) elevated inflammatory markers, and (3) negative rheumatoid factor and anti-CCP antibody. A thorough review of systems and family history are also key to diagnostic workup. For our patient, age, sex, and delay in presentation may impact future therapeutic success. Some evidence shows that inflammatory arthritis may be undertreated in female patients, however earlier age of onset is more favorable for future control.

Internists should consider inflammatory arthritis when any patient presents with joint pain or swelling and evaluate this concern with a thorough history, relevant physical exam, and appropriate diagnostics. PERNICIOUS ANEMIA MASQUERADING AS WEIGHT LOSS Franklin H. Lee1; Alain Greenwald1; Sumitha Raman2. 1School of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4273247) CASE: A 62-year-old female chef with a history of hypothyroidism, former tobacco use, and COPD presented as a new patient to our primary care clinic with 1-year of 44 pounds of unintentional weight loss. A review of systems was negative other than mild fatigue and early satiety disproportionate to her weight loss. She denied alcohol use, a special diet, or food insecurity. She had a recent normal mammogram but could not recall her last pap smear or colonoscopy; records from her last primary care doctor were limited to medical history, medications and labs. Physical exam was unremarkable, including normal abdominal and neurological exam. Initial tests revealed a normal TSH, new macrocytic anemia (Hgb 8.5 g/dL, MCV 114 fL) and elevated ESR and CRP. Subsequent tests included folate (normal), vitamin B12 (critically low at <50 pg/mL), and peripheral smear (normal). CT chest/abdomen/pelvis with contrast showed no malignancy. We initiated weekly IM cyanocobalamin, later transitioned to PO. Anti-intrinsic factor antibodies were elevated (248.3 AU/mL), confirming pernicious anemia (PA). An EGD and colonoscopy revealed moderate atrophic gastritis, negative H pylori, two tubular adenomas and no malignancy. After initiating B12 supplementation, her weight loss drastically improved and she gained 22 pounds in 5 months. She recalled that she had been diagnosed with PA in her 20s and treated with B12 which at some point was discontinued. She did not know that the treatment was lifelong. IMPACT/DISCUSSION: Pernicious anemia, a common cause of B12 deficiency, has a non-specific clinical presentation that leads to delays in diagnosis. Fatigue and neuropsychiatric symptoms (taught as core to B12 deficiency), are not always present. Our patient’s main symptom was severe unintentional weight loss, which led us to suspect malignancy. Even after PA was confirmed, we suspected gastric cancer as it is associated with PA. However, her weight loss was due to pernicious anemia alone and resolved with treatment. Our case demonstrates the diversity in presentation of PA and the importance of considering PA early when evaluating weight loss, to prevent irreversible complications. As supplements and vitamins become commonplace, their critical role in certain diagnoses might not be obvious to patients. Over the counter (OTC) vitamins are often omitted in medication lists, leading to missed treatment opportunities that are amplified by transitions in care. Our case highlights the importance of confirming patients' understanding of the duration of their treatment, and of ensuring that critical OTC vitamins are added to medication lists.

Pernicious anemia has a diverse clinical presentation that can include severe weight loss and might not include neuropsychiatric symptoms. Clinicians should consider PA in the evaluation of weight loss. OTC vitamins such as B12 should be included in medication lists when chronic therapy is essential, and patients’ understanding of the duration of therapy should be assessed. POLYMYALGIA RHEUMATICA WITH HAND AND FEET SWELLING? Niveda M. Rao, Jennifer DeConde, Jessica Chen. Internal Medicine, University of California San Diego, San Diego, CA. (Control ID #4271231) CASE: An 81-year-old male with history of hypertension, hyperlipidemia, urethral obstruction and prostate cancer presented to primary care physician with new onset bilateral symmetrical finger, dorsal hands, feet and ankle swelling for several weeks associated with malaise. He was unable to play guitar or make a fist. He also noticed increasing stiffness and pain in bilateral hips and shoulders, unable to play sports for several months. Patient denied trauma, fever, chills, rash, recent infection. He was a social smoker. Incidental prostate cancer was discovered seven months prior, currently under observation. Exam was unremarkable except for bilateral symmetrical fingers, dorsal hands wrists, toes, dorsal feet and ankle swelling. Hand x-rays have no erosive changes. Lab revealed CRP 4.75 (<0.5 mg/dL), ESR 50 (< 20 mm/hr), negative for ANA, RF, C3, C4, cyclic citrullinated peptide antibody (CCP), and CPK. A diagnosis of polymyalgia rheumatica (PMR) with remitting seronegative symmetrical synovitis with pitting edema (RS3PE) was made by rheumatology. Patient responded dramatically and quickly to 15 mg prednisone daily. IMPACT/DISCUSSION: Remitting Seronegative Symmetrical Synovitis with Pitting Edema (RS3PE) is a rare (∼0.09% incidence) rheumatic disease that was first described by Daniel McCarty in 1985. RS3PE primarily affects individuals over the age of 60, with higher occurrence in males (2:1). RS3PE is known for acute onset of symmetrical polyarthritis, typically involving the small joints of the hands and feet, associated with pitting edema of the dorsal hands and feet. RS3PE is a clinical diagnosis. The diagnostic criteria include bilateral pitting edema of both hands, sudden onset of polyarthritis, > 50 years of age, seronegative for rheumatoid factors. RS3PE generally has a favorable prognosis and responds rapidly to low-dose 15-20 mg corticosteroid therapy. RS3PE is associated with PMR, and patients can present with similar hip and shoulder girdle weakness and pain. These two entities, classified in the group of seronegative arthritis, can coexist (10-12% of cases), with RS3PE appearing as an initial or late manifestation of polymyalgia rheumatica. 10% of PMR patients may have giant cell arteritis (GCA), but RS3PE has not been associated with giant cell arteritis in some studies. RS3PE can be a paraneoplastic syndrome, associated with a higher risk of cancer (30%). It can be associated with solid adenocarcinomas (prostate, stomach, pancreas, lung, ovarian, colon), and hematologic malignancy (CLL, AML, non-Hodgkin’s lymphoma). Therefore, a diagnosis of RS3PE should be followed by a workup for occult malignancy. The two clinical characteristics suggestive of paraneoplastic RS3PE are systemic symptoms and the poor response to corticosteroid therapy.

1. Recognize that RS3PE is characterized by polyarthralgia and pitting edema. 2. Recognized RS3PE has a higher risk of cancer, requiring age appropriate cancer screening. POST-DENTAL TREATMENT CHOLESTATIC HEPATITIS: A CASE REPORT OF AMOXICILLIN/CLAVULANATE INDUCED LIVER INJURY Marlee Akerson1; Ronald Colson2. 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 #4271090) CASE: A 75-year-old female presented to her primary care provider with a 1-week history of painless jaundice, generalized pruritus and dark urine. She had no history of liver disease, alcohol abuse or recent international travel. Her past medical history includes osteoarthritis and microscopic colitis. She was taking calcium, zinc and Vitamin D, C, and B12 supplements only. Physical examination revealed jaundice with scleral icterus and diffuse excoriations. Abdominal examination was unremarkable with no palpable hepatosplenomegaly. Laboratory tests showed markedly elevated liver enzymes: AST 282 U/L, ALT 496 U/L, ALP 645 U/L, and total bilirubin 13.1 mg/dL. Autoimmune, infectious and inflammatory hepatitis labs were negative. Urinalysis and CBC were normal with the exception of high urine bilirubin. PT/INR was normal. Imaging studies including abdominal ultrasound and MRCP showed no biliary obstruction, dilation or structural abnormalities. A detailed medication history revealed that four weeks prior, she had completed a 10-day course of amoxicillin/clavulanate for a dental infection. Supportive care with antipruritic medications was initiated. Her liver tests gradually improved. One month later, her AST was 50, ALT 68, ALP 292, and total bilirubin 3.8. IMPACT/DISCUSSION: This case emphasizes the importance of considering drug-induced liver injury (DILI) as a diagnosis of exclusion in patients with painless jaundice and pruritus (even without clear hepatobiliary disease history). The presentation of painless jaundice, pruritus and dark urine resulted from cholestatic liver injury, causing bile salt and bilirubin accumulation. The clavulanate component is implicated in generating reactive metabolites, which trigger oxidative stress, mitochondrial dysfunction, and immune-mediated damage. HLA genetic variants, particularly alleles of DRB1, DRB5 and DQB1, increase susceptibility, leading to hypersensitivity reactions. These processes activate CD8+ T cells and natural killer cells, resulting in hepatocyte injury. Additionally, inflammatory cytokines amplify the immune response, contributing to cholestatic liver damage. This case demonstrates the necessity of thorough history in unexplained liver injury. Clinicians should recognize that common antibiotics like Amoxicillin/Clavulanate can cause DILI without other risk factors. Close monitoring of liver enzymes and prompt discontinuation of the offending agent are essential for management. If not identified early, persistent livery injury can progress to chronic cholestasis and even liver failure.

Amoxicillin/Clavulanate is a known cause of cholestatic hepatitis, presenting with painless jaundice and generalized pruritus Thorough medication history is crucial in evaluating unexplained liver injury, and clinicians should be aware of common medications causing drug-induced liver injury Prompt recognition and discontinuation of the offending agent, along with supportive care, are key management strategies for drug-induced liver injury POSTPARTUM HEPATITIS: A RECURRING MYSTERY Lisa M. Pinero, Rachel Engelberg, Allison Samuel. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272663) CASE: A 24-year-old woman with no significant medical history presented for follow-up after hospitalization for elevated liver function tests (LFTs). She had a week-long history of nausea, vomiting, and abdominal pain, two months postpartum after an uncomplicated pregnancy. On examination, she had abdominal tenderness and scleral icterus. Labs revealed a negative pregnancy test and elevated LFTs (ALT 593, AST 217, ALP 298, bilirubin 5.7). The differential diagnosis included viral infection, autoimmune disease, biliary obstruction, and drug-induced liver injury. Viral hepatitis panel was negative, and an abdominal ultrasound showed no gallstones or biliary obstruction. She denied autoimmune disease history. Within two weeks, LFTs normalized and symptoms resolved. Seven years later, she presented with right upper quadrant pain, vomiting, and elevated LFTs (ALT 817, AST 924, bilirubin 4.2, ALP 310). She had delivered her second child two weeks prior, with abdominal pain beginning in the second trimester and mild LFT elevation in the third. Viral and autoimmune workups were unremarkable, and LFTs improved with supportive care. She was discharged with close monitoring. LFTs normalized outpatient, and liver biopsy was deferred due to symptom resolution and normalized enzymes. The etiology of her recurrent postpartum hepatitis remained unclear, but there was concern for Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase (LCHAD) deficiency, linked to maternal acute fatty liver of pregnancy (AFLP). Given her desire for future pregnancies, an LCHAD test was ordered, pending at the time of submission. IMPACT/DISCUSSION: Identifying the cause of elevated LFTs postpartum requires distinguishing between pregnancy-related liver diseases, pre-existing conditions, and incidental liver diseases. Pregnancy-related liver diseases include HELLP syndrome, preeclampsia/eclampsia, intrahepatic cholestasis of pregnancy (ICP), and AFLP. ICP presents with pruritus and jaundice due to elevated bile acids. AFLP, typically occurring in the third trimester, can progress to liver failure with encephalopathy and coagulopathy. Though the patient did not display the full spectrum of AFLP, it remains a concern due to its severity. Management involves monitoring, follow-up with hepatology, genetic counseling, and supportive resources for high-risk pregnancies. LCHAD testing is done to identify enzyme deficiencies that lead to the accumulation of long-chain fatty acids, causing liver injury. Sparse studies show children born to mothers with AFLP may show signs of LCHAD deficiency, including hypoglycemia, hepatomegaly, lethargy, and feeding difficulties.

This case underscores the importance of a careful differential diagnosis in postpartum women with elevated LFTs, close monitoring in future pregnancies, and the value of genetic testing for conditions like LCHAD deficiency. PRIMARY DISSEMINATED CUTANEOUS BLASTOMYCOSIS IN AN IMMUNOCOMPETENT 39-YEAR-OLD MALE George Ibrahim. Internal Medicine, Cook County Health, Chicago, IL. (Control ID #4269691) CASE: A 39 year old male, with no known comorbidity, presented to our primary care clinic in a Midwest metropolitan center, for multiple progressive skin lesions on knee and temple for several months. Despite months of conservative management with bandaging, visits to outside clinics, and a 10 day course of antibiotics, the lesions continued to grow and bleed daily. Physical exam was remarkable for for 7 cm x 7 cm verrucous plaque on the right knee, with similar lesions the right temple of forehead, right thigh, and right wrist. Dermatology was called while the patient was in the clinic. Histopathologic examination of the lesions showed pseudoepitheliomatous hyperplasia with mixed inflammatory cell infiltrates and yeast forms. AFB stain was negative for microorganisms. Gomori methenamine silver staining revealed yeast forms, Fungal culture grew Blastomyces dermatitidis. The patient was then treated with itraconazole 200 mg twice daily for 3 months resulting in complete healing of all his lesions. IMPACT/DISCUSSION: Blastomycosis is most often reported in endemic regions, including areas surrounding the Mississippi and Ohio River valleys, Midwestern states and the Great Lakes. Primary cutaneous blastomycosis represents a minority of cases, as most infections result from inhalation of fungal spores, leading to pulmonary involvement. However, this patient’s lack of pulmonary involvement confounded his picture. The clinical manifestation of primary cutaneous blastomycosis often includes verrucous, ulcerative, or nodular lesions that mimic other infectious or neoplastic processes. Definitive diagnosis of Blastomyces dermatitidis requires direct visualization of the organism. Biopsy and histopathological examination of skin lesions often reveal pseudoepitheliomatous hyperplasia accompanied by neutrophilic abscesses. Delayed diagnosis can lead to progression of the lesion or potential dissemination, emphasizing the need for early biopsy and mycological studies in suspicious cases. Itraconazole is the preferred treatment for localized cutaneous blastomycosis, with therapy typically lasting 3 to 6 months. In this patient, early initiation of antifungal therapy led to significant clinical improvement. This case highlights the diagnostic challenge of primary cutaneous blastomycosis. It underscores the importance of obtaining a thorough environmental and occupational history when evaluating chronic skin lesions. Additionally, it demonstrates that immunocompetence does not preclude the occurrence of localized fungal infections, necessitating vigilance among clinicians.

This case highlights the diagnostic challenge of primary cutaneous blastomycosis. It underscores the importance of obtaining a thorough environmental and occupational history when evaluating chronic skin lesions. Additionally, it demonstrates that immunocompetence does not preclude the occurrence of localized fungal infections, necessitating vigilance among clinicians. PSORIASIFORM DRUG ERUPTION WITH A SURPRISING CULPRIT Erin Hollis, Deepa Chellappa. Internal Medicine, Lankenau Medical Center, Wynnewood, PA. (Control ID #4272427) CASE: A 67 year-old-male with a history of heart failure with recovered ejection fraction and chronic kidney disease presented to his primary care provider (PCP) for a two-week history of desquamating pruritic rash of his lips, trunk, and extremities following a routine colonoscopy. Several of his medications were held prior to the procedure, including aspirin, carvedilol, empagliflozin, rosuvastatin, sacubitril-valsartan, and spironolactone, and resumed thereafter. Labs showed an elevated absolute eosinophil count (1.46 K/uL) and elevated creatinine to 2.1 mg/dL from a baseline of 1.3 mg/dL. Two days after his outpatient visit, he developed lightheadedness and intermittent shortness of breath and presented to the hospital with worsening renal function and hypotension. The patient was admitted and evaluated by dermatology. Differential diagnosis included psoriasiform drug eruption, subacute atopic dermatitis, and drug reaction with eosinophilia and systemic symptoms (DRESS). The patient underwent punch biopsy; pathology showed spongiotic and psoriasiform epidermal changes with neutrophil exocytosis and dermal eosinophils and his clinical presentation was felt to be most consistent with drug-induced psoriasis. In addition to holding his medications, the patient was treated with topical corticosteroids with significant improvement in his rash. His guideline directed medical therapy for heart failure was resumed in a stepwise fashion. Upon resuming his valsartan, the patient developed recurrence of the rash. Valsartan was discontinued with immediate improvement, increasing suspicion that his angiotensin II receptor blocker (ARB) was the culprit. IMPACT/DISCUSSION: The most common medications implicated in psoriasis-like drug eruptions are beta blockers, nonsteroidal anti-inflammatories, anti-malarials, and certain antipsychotics. This presentation is more common in patients with pre-existing psoriasis, however, here we describe a case of a patient with no dermatologic history who presented with a psoriatic drug eruption secondary to an ARB. ARBs have rarely been described as triggering psoriatic drug reactions; of the commonly used antihypertensives, this reaction is more often seen with calcium channel blockers and beta blockers. Drug-induced psoriasis typically occurs up to 12 months after drug initiation, but in our patient, occurred after taking an ARB consistently for years and briefly holding the agent for planned procedure.

-Psoriasis should be considered as part of the differential for drug eruptions. Clinicians should be aware that drug-induced precipitation of psoriasis can occur in persons without a prior history. -Management involves swiftly discontinuing the causative agent and treating with a topical corticosteroid. PULLING DOUBLE TIME ON THE SECRETION LINE: DUAL ALDOSTERONE AND CORTISOL SECRETING UNILATERAL ADENOMA Chandler Richardson1; Andrew Costa2; Vivek Varughese1; Hibah Virk1; Ashley Mason1; Dominic J. Vacca1; Olivia Yessin1. 1Internal Medicine, Prisma Health Midlands, Columbia, SC; 2University of South Carolina, Columbia, SC. (Control ID #4271613) CASE: 36 y/o African American female with a past medical history of class III obesity with a BMI >50, motor vehicle accident, moderate hyperlipidemia, and hypertension with a family history of hypertension and heart attack in her father before the age of 40 years old who presented to the clinic with resistant hypertension. She was initially found to be hypertensive during pregnancy concerning preeclampsia and treated with nifedipine starting 7 years prior. Following her pregnancy and over the next 6 years, she was continued on blood pressure medicines including hydralazine, metoprolol, labetalol, HCTZ, and amlodipine. Upon presentation to the clinic at age 35 she was on amlodipine and HCTZ at maximum dosage with blood pressures remaining uncontrolled. Concern for secondary hypertension was raised and a renin-aldosterone ratio was ordered. Labs returned with a ratio of >50, plasma metanephrines were negative, and a CT scan of the abdomen showed a 2.1 cm left adrenal mass measuring 40-75 Hounsfield units. She was sent to interventional radiology for adrenal venous sampling with continuous cosyntropin infusion, which showed a positive lateralization and selectivity index for the left adrenal mass. It also showed a left adrenal cortisol secretion 10X greater than peripheral secretion during sampling which raised concern for unilateral concomitant Cushing's and Conn syndrome. She was counseled on surgical management which she was amenable to, but before scheduling surgery, she is going to undergo an Endocrinology evaluation for their recommendations for management. IMPACT/DISCUSSION: With the high prevalence of hypertension amongst the general population, it is easy to continue management and titrate medications without investigating why the condition exists. This case shows the importance of a proper workup for resistant hypertension, especially when patients meet the red flag criteria for secondary hypertension. It is also a good example of Hickam's Dictum and remembering that patients can have several diagnoses. It is important to evaluate all the data you receive so you don't miss something less common.

- Remember to complete the workup for secondary hypertension in patients who have red flag characteristics and don't brush off abnormal values just because a patient may be young. - Review all test values and imaging to find the reason behind the abnormality. This will lead to more accurate diagnoses when the initial suspicion doesn’t explain the whole presentation. RECOGNIZING AN UNDERDIAGNOSED DISEASE WITH MALIGNANT POTENTIAL: CLONAL CYTOPENIAS OF UNDETERMINED SIGNIFICANCE (CCUS) Christian M. Farag, Allison Samuel, Rachel Engelberg. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4270222) CASE: A 79-year-old male with a past medical history of type 2 diabetes and macular degeneration was incidentally found to have bi-lineage cytopenias of leukopenia and thrombocytopenia. The patient had no history of alcohol use, smoking, chemical exposures, liver disease, or use of myelosuppressive medications. Family history was notable for a sister who died from an unspecified leukemia at age ten. Physical exam was unremarkable without any evidence of bruising, lymphadenopathy, or hepatosplenomegaly. Initial labwork revealed a white blood cell (WBC) count of 3.6 with an absolute neutrophil count (ANC) of 1.7, a platelet count of 73, and a normal hemoglobin of 15.7. The patient was referred to hematology; subsequent nutritional and infectious workup was negative, and a bone marrow biopsy was conducted. Pathology demonstrated mild hypercellularity with maturing trilineage hematopoiesis with no increase in blasts. Next-generation sequencing (NGS) showed a low-level CBL mutation (CBL p.C384Y pathogenic variant at 5% variant allele fraction (VAF) consistent with a diagnosis of clonal cytopenia of uncertain significance (CCUS). The patient was scheduled with hematology follow up every three months to monitor for the development of subsequent hematological malignancy. IMPACT/DISCUSSION: This case highlights a clinically significant diagnosis of CCUS. CCUS is an under-recognized disease that is seen in 10-20% of all adults older than 60 years. This disease is defined by mutations with VAF of 0.02 or greater that are identified by NGS; and the patient’s risk profile is determined by both the patient’s VAF and the specific mutation identified. Depending on the disease-defining mutation’s risk profile, patients will have a 6-37% chance of progressing to acute leukemia or MDS within 2 years. TP53 is the highest risk mutation, while DNMT3A is the most commonly seen mutation; however the list of mutations is large and ever growing, highlighting the utility of sending a Myeloid Malignancy Gene panel in cytopenias of uncertain origin. Due to the malignant potential of this disease, it is essential that patients with unexplainable cytopenias be referred to hematology for NGS and followed closely for malignant transformation.

- CCUS is an under-recognized diagnosis in the primary care setting that carries a risk of malignant transformation - NGS is required for diagnosis and risk stratification - Patients should be referred to hematology for comprehensive genetic testing and subsequent monitoring due to the variable risk of malignant transformation RECURRENT ORAL ULCERS OF UNKNOWN ETIOLOGY Jessica Chen1; Miriam Hakim2; Armelia Sani1. 1Internal Medicine, University of California San Diego, San Diego, CA; 2Internal Medicine, University of California San Diego, La Jolla, CA. (Control ID #4270666) CASE: A 52-year-old Caucasian male with allergic rhinitis, hypogonadism, type 2 diabetes, and genital herpes presented with large, recurrent, and painful oral ulcers for the past several years, associated with mouth tingling, abdominal bloating, and fatigue. He denied diarrhea, food allergies, joint pain, or genital ulcers, and attributed his oral ulcers to possible oral exposure of genital herpes from his wife. However, his oral ulcers did not improve with repeated valacyclovir treatments. Repeated swabs (viral culture, herpes/varicella culture, and herpes simplex DFA) were negative. Exam was unrevealing as he did not have an active oral ulcer. SSA, SSB, RF, ferritin, vitamin B12, vitamin D, folate, IgE, and SPEP were normal. RAST food allergy and HIV tests were negative. A1c=6.3%, Cr=1.3, ANA=1:160. He never had an oral ulcer biopsy. Herpes simplex virus (HSV) 1 IgG was negative. HSV 2 IgG was positive. Both Tissue Transglutaminase (tTG) Antibody, IgA=42 (0-3 U/mL) and Endomysial Antibody, IgA titer=1:80 (<1:10) were highly positive, which indicated celiac disease. Once he started a gluten-free diet, his oral ulcers improved. IMPACT/DISCUSSION: Celiac disease (CD) is a chronic autoimmune disorder triggered by gluten exposure, commonly causing diarrhea, bloating, gas, constipation, and fatigue. Gluten mainly consists of wheat, rye, and barley. All CD tests require a gluten-containing diet to be accurate. The tTG-IgA test is positive in about 93% of patients on a gluten-containing diet. CD interferes with the absorption of vitamin B12, vitamin D, folate, iron, magnesium, zinc, calcium, and niacin. CD can present with extra-intestinal signs, including fatigue, iron deficiency anemia, folate or vitamin B12 deficiency, ALT elevation, oral ulcers, and dermatitis herpetiformis. CD can be associated with other autoimmune disorders, including type 1 diabetes mellitus and autoimmune thyroid disease. Recurrent oral ulcers can be separated by causes: traumatic, infectious, aphthous, allergic, autoimmune, oral dermatoses, drug-induced, and malignancy-induced ulceration. The two most common forms of acute recurrent oral ulcers are HSV-1 (cold sores) and aphthous ulcers (canker sores). These two may be distinguished based on their locations (lip vs oral mucosa). Oral ulcers can be further separated into solitary or multiple ulcers, acute or chronic/recurrent, and vesicular or bullous ulcers. Most types of multiple chronic oral ulcers are associated with disturbances of the immune system. Diagnosis often requires blood testing, culture, or biopsy. Although oral ulcers are not specific to CD, it is important to consider CD as a potential etiology within the patient’s clinical context.

1. Celiac disease can cause oral ulcers. 2. Recurrent oral ulcers can be caused by trauma, infection, allergy, autoimmune conditions, drugs, oral dermatoses, and malignancy. SEASONAL DYSPHAGIA: A CASE OF EOSINOPHILIC ESOPHAGITIS Stewart R. Malave. Internal Medicine, East Alabama Medical Center, Opelika, AL. (Control ID #4273551) CASE: A 28-year-old male with a PMHx of GERD, childhood asthma, allergic rhinitis, and atopic dermatitis presents to the clinic with dysphagia for solids and pills, which worsens during the fall and winter seasons. His acid reflux is well-controlled with famotidine and calcium carbonate. He denies chest pain, abdominal pain, N/V, weight loss, or other gastrointestinal symptoms. Laboratory tests, including CBC with differential, CMP, and thyroid panel, were unremarkable except for hyperlipidemia. A barium swallow was also unremarkable. Endoscopy with empiric dilation revealed minimal leukoplakia of the esophagus, irregular esophageal contractions, and a Forest Class 3 ulcer of the gastric antrum. Biopsies from the mid-esophagus showed esophagitis with eosinophilia (>50 eosinophils per high-power field), confirming the diagnosis of eosinophilic esophagitis (EoE). The patient was initially started on pantoprazole but experienced significant abdominal pain and food aversion, leading to discontinuation. He was then started on budesonide, which resulted in significant improvement. IMPACT/DISCUSSION: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease of the esophagus that affects approximately 34.4 per 100,000 individuals in Europe and North America, leading to esophageal eosinophilia and subsequent tissue remodeling and fibrosis. This can result in esophageal strictures and narrowing, contributing to clinical symptoms of esophageal dysfunction. The diagnosis of EoE requires both clinical symptoms and histologic evidence of eosinophil-predominant inflammation, defined as ≥15 eosinophils per high-power field on esophageal biopsy, with the exclusion of other causes. Management strategies include dietary modifications, pharmacologic therapy, and esophageal dilation. Dietary approaches are effective in reducing esophageal eosinophilia and improving symptoms. Pharmacologic therapy includes proton pump inhibitors (PPIs) and corticosteroids, which have shown efficacy in inducing histologic remission. Dupilumab, a monoclonal antibody, has also been approved for EoE treatment. Esophageal dilation is reserved for patients with significant esophageal narrowing or strictures. Regular follow-up with endoscopic and histologic assessments is necessary to monitor disease activity and adjust treatment as needed.

This case underscores the critical importance of obtaining a comprehensive medical history and considering a broad differential diagnosis for dysphagia. Our patient, with a significant allergic history, presented with dysphagia exacerbated by seasonal changes. This highlights the need to consider eosinophilic esophagitis (EoE) in patients with atopic conditions. The patient's case of EoE also emphasizes the importance of managing the condition with second- and third-line medications when first-line treatments are insufficient. Initial management with PPIs was poorly tolerated, necessitating the use of budesonide, which led to clinical improvement. SECONDARY HYPERTENSION AND ACUTE KIDNEY INJURY IN IGA NEPHROPATHY: A CASE REPORT Joeita F. Macfield1,2; William Mann1,2; Mustafa Saadi2; Maria Jamil2. 1College of Human Medicine, Michigan State University College of Human Medicine, East Lansing, MI; 2Department of Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4272548) CASE: A 24-year-old female presented with a two-year history of worsening hypertension. Elevated BP was first noted in May 2023 (134/91 mmHg), but no follow-up was pursued. Elevated BP was noted again in May 2024 (134/91 mmHg) and was attributed to stress. Laboratory evaluation revealed declining renal function (Cr 1.45 mg/dL, GFR 51 mL/min/1.73 m2, albumin 3.2 g/dL), attributed to dehydration. By September 2024, home BP readings ranged from 140/90 to 160/110 mmHg. Two months later, she had a BP of 188/124 mmHg at a PCP appointment. Labs showed significant renal dysfunction (BUN 36 mg/dL, Cr 3.64 mg/dL, GFR 17 mL/min/1.73 m2) and proteinuria (>300 mg/dL). Her PCP advised immediate emergency department evaluation for acute renal failure. In the ER, her BP measured 193/136 mmHg. Ultrasound revealed echogenic kidneys with left kidney enlargement. Despite the findings, she appeared euvolemic and well. Workup demonstrated nephrotic syndrome with marked proteinuria (>300 mg/dL), albumin/Cr ratio of 3517–5000 mg/g, hyperlipidemia (cholesterol 274 mg/dL, triglycerides 262 mg/dL), and hypoalbuminemia (3.2 g/dL). PT/PTT were normal. Kidney biopsy revealed mesangial expansion, glomerular sclerosis, interstitial fibrosis, and crescents. Immunofluorescence confirmed IgA deposition, while electron microscopy showed mesangial electron-dense deposits and foot process effacement. These findings were consistent with IgA nephropathy. The patient was discharged on labetalol, nifedipine, and losartan, with plans for close follow-up with primary care and transplant nephrology. Her past medical history was notable only for headaches and urinary tract infections. She denied alcohol, tobacco, or drug use. Relevant family history included hypertension in her father. IMPACT/DISCUSSION: Nephrotic syndrome typically presents with proteinuria, hypoalbuminemia, hyperlipidemia, and edema. However, this patient's lack of edema despite hypoalbuminemia and hyperlipidemia underscores the variability in clinical presentation. IgA nephropathy, characterized by IgA deposits in the glomeruli, often presents with gross hematuria in children but may manifest more subtly in adults. Early signs, such as microscopic hematuria and proteinuria, can be easily overlooked without routine screening. While hypertension is commonly associated with the condition, it is a nonspecific finding. The investigation of abnormal blood pressure alongside consistent urinalysis monitoring is critical for the timely detection of IgA nephropathy. This is important as persistent proteinuria and hematuria are key indicators of disease progression. Early diagnosis and intervention are crucial, given that up to 50% of patients with IgA nephropathy progress to end-stage renal disease within three decades. CONCLUSION:• Early intervention is critical in mitigating renal dysfunction progression in young patients with secondary hypertension • Secondary hypertension must be accompanied with comprehensive evaluation even in patients without typical risk factors SHADOWS OF SIGHT: MANAGING THE HALLUCINATIONS OF CHARLES BONNET SYNDROME (CBS) Shruthi Ilango, Diane L. Levine, Ayman Salem. Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4273198) CASE: A 60-year-old male presented to the clinic with new visual hallucinations that began shortly after undergoing surgery for bilateral tractional retinal detachment and cataract extraction with lens placement in the left eye. After the surgeries, he had significantly reduced vision in both eyes and could only see shadows and motion. He developed nightly visual hallucinations, which woke him up in a state of anxiety and panic, preventing him from falling back asleep. The hallucinations appeared as zombies and bats and later as large walls closing in, inducing a sense of claustrophobia. Depression screening was negative, but the Generalized Anxiety Disorder-7 questionnaire indicated moderate anxiety disorder. He was diagnosed with Charles Bonnet Syndrome (CBS) and educated on strategies to manage his hallucinations. Given his distress, he was prescribed a course of quetiapine. IMPACT/DISCUSSION: CBS is characterized by purely visual hallucinations, typically occurring in patients with impaired vision. The prevalence of CBS in patients with visual impairment varies greatly across studies. The content and setting of hallucinations also vary between patients. The widely accepted explanation for CBS is the deafferentation hypothesis, suggesting that decreased visual input leads to hyperexcitability of the visual cortex and visual hallucinations. Management of CBS includes behavioral and environmental changes; avoiding bright stimuli, looking away from the hallucination, and blinking may abort hallucinations. Additionally, managing stress and getting enough rest may help prevent flares. Studies have been largely inconclusive regarding the pharmacological treatment of CBS, so there is no definitive medication recommendation. However, if symptoms cause significant distress, a trial of medications like SSRIs or atypical antipsychotics may be beneficial. Our patient experienced significant emotional distress and sleep disturbance due to his hallucinations. Since he is expected to regain some vision as his eyes recover from surgery and behavioral changes alone were insufficient, a trial of pharmacological treatment for symptom relief was deemed appropriate. In cases where behavioral changes have been unhelpful or may not be possible, pharmacological treatment of the associated psychiatric symptoms may provide some relief. Recent approaches emphasize forewarning and pre-emptive questioning to identify CBS, followed by education and person-centered therapy with psychological counseling and caregiver support.

Purely visual hallucinations in patients with impaired vision and no other identifiable cause should be recognized as Charles Bonnet Syndrome. Patients should be adequately educated on behavioral strategies to manage CBS-related hallucinations. In cases of significant distress, pharmacological treatment may help alleviate associated psychiatric symptoms SILENT GENES, LOUD CONSEQUENCES Khalid Abu-Zeinah, Nouran Felo. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4273337) CASE: A 39-year-old male presented for clinical evaluation after being lost to follow-up for many years. He noted a family history significant for a “cardiac condition” which both his father and brother were being evaluated for. Additionally, a paternal uncle reportedly suffered from a cardiac-related death in his 30s. The patient himself had been asymptomatic and regularly performed high-intensity aerobic exercise without cardiac symptoms. His physical exam was unremarkable. Electrocardiography (ECG) did not demonstrate any evidence of left ventricular hypertrophy, but did demonstrate subtle T-wave inversion in leads V4-V6. A transthoracic echocardiogram (TTE) showed left ventricular septal hypertrophy measuring 15 mm, dynamic left ventricular outflow tract obstruction with a Doppler gradient of 29 mmHg, and systolic anterior motion of the mitral valve with trivial regurgitation. The findings were consistent with hypertrophic cardiomyopathy (HCM), rendering the importance of the patient’s family history and genetic predisposition. He was referred for genetic testing, which revealed the MYH7 c.4130C>T (p.Thr1377Met) pathogenic variant. This prompted subsequent referrals to Cardiology and Clinical Genetics for further evaluation, management recommendations, and counseling regarding implications. IMPACT/DISCUSSION: The MYH7 c.4130C>T (p.Thr1377Met) mutation encodes a sarcomere protein known as beta-myosin heavy chain protein critical to cardiac muscle contraction. This mutation is documented in HCM cohorts and demonstrates incomplete penetrance and variable expressivity, resulting in a broad phenotypic spectrum ranging from asymptomatic to sudden cardiac death (SCD) even within families (Wang et al., 2018). While the patient’s echocardiographic findings are concerning for HCM, his asymptomatic presentation highlights the importance of proactive genetic and echocardiographic screening in at-risk individuals. Ongoing surveillance with regular TTE and clinical examination is also crucial, as phenotype conversion can occur at various life stages. A meta-analysis has demonstrated that patients with MYH7 mutations classically have an earlier onset and more severe HCM compared to HCM patients without sarcomere mutations, with a mean age of onset around the fourth decade of life (Sedaghat-Hamedani et al., 2018). MYH7 mutations were also shown to confer a higher risk of SCD compared to other mutations found in HCM. Early detection and management of HCM in patients such as this one are critical to mitigate complications of HCM including heart failure, arrhythmias, and sudden cardiac death.

- Screening and genetic testing are crucial for individuals with a family history of HCM. - MYH7 pathogenic mutations are associated with variable clinical and phenotypic expression; early echocardiographic evaluation aids in timely diagnosis. - Regular follow-up is essential for genotype-positive individuals to monitor for phenotypic conversion and manage complications effectively. SPONTANEOUS NASAL CEREBROSPINAL FLUID LEAK: AN INSIDIOUS PRESENTATION OF A MEDICAL EMERGENCY Parin Thakkar1; Lubna Khawaja2. 1Internal Medicine, Baylor College of Medicine, Houston, TX; 2Section of General Medicine, Baylor College of Medicine, Sugar Land, TX. (Control ID #4267880) CASE: A 52 year old female with past medical history significant for hypertension, hypothyroidism, and renal cell carcinoma status post partial nephrectomy and now disease free, presented to the medicine clinic to re-establish care. The patient reported concerns of non-productive cough and rhinorrhea for the past 6 months. Her symptoms were present throughout the day with her cough most noticeable at night. She had trialed several over the counter nasal sprays sporadically including Afrin without relief. Following the discontinuation of Afrin and lisinopril and starting cetirizine, patient reported significant improvement in her cough. However, she continued to report persistent rhinorrhea now only noticeable while leaning forward. Further history revealed presence of occasional right sided headaches and double vision. She denied any history of head trauma or nasal procedures. Given increasing concerns for a more insidious process such as cerebrospinal (CSF) leak, nasal fluid was sent for analysis and was positive for beta-2 transferrin. Subsequent imaging was performed to localize the leak, which showed defect in the horizontal lamellae of the right cribriform plate, air-fluid level in the right sphenoid sinus, and a partially empty sella. Given these findings, she was urgently evaluated by neurosurgery and ENT and underwent successful endonasal repair with resolution in her symptoms. IMPACT/DISCUSSION: This case demonstrates an interesting case of spontaneous CSF rhinorrhea presenting insidiously in an outpatient setting. While initial workup pointed towards upper airway cough syndrome versus medication induced symptoms, further evaluation revealed the true diagnosis. Once discovered, this condition requires rapid evaluation by both neurosurgery and ENT given high risk of complications including meningitis. While CSF rhinorrhea can be caused by a variety of conditions and often associated with trauma, it can also occur spontaneously in up to 40% of cases. Of note, spontaneous CSF leaks have been shown to be associated with idiopathic intracranial hypertension (IIH). Some imaging findings associated with both IIH and spontaneous CSF leaks include pneumatization of the sphenoid sinus and an empty sella, both of which are seen in our patient. If IIH is confirmed, further treatment with acetazolamide or VP shunt may be required to reduce recurrence of CSF leak post-repair.

In summary, CSF rhinorrhea is a rare, yet important diagnosis to consider for a patient presenting with rhinorrhea especially if symptoms are worsening with leaning forward. Gold standard for diagnosis includes testing for beta-2-transferrin from nasal secretions, followed by imaging to localize the leak. In particular, leaks in the anterior skull base as seen with our patient is often considered higher risk due to proximity to sinuses and when untreated for longer periods, can significantly increase the risk of meningitis, thus necessitating urgent evaluation and treatment. SSRI DISCONTINUATION SYNDROME IN THE PRIMARY CARE SETTING Sharanya Iyer, Alison Koransky, Irene Rahman, Ari M. Fish. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4264915) CASE: A 65-year-old female with a past medical history of bipolar disorder and schizoaffective disorder began experiencing nausea, malaise, foul smelling urine and urinary frequency. She subsequently called her primary care physician (PCP), as she was concerned for a urinary tract infection, and empiric treatment was started. One day later, she went to the emergency department (ED). At that time, she had taken three doses of nitrofurantoin without any improvement in her symptoms. She had also begun experiencing intermittent substernal chest pain, lower back pain, nausea, one episode of non-bloody, non-bilious emesis, and one episode of diarrhea. Workup showed mild pyuria but was otherwise unrevealing. She was discharged with close PCP follow up, who she saw the next day. She noted worsening symptoms and new flank pain. Antibiotics were changed to cover pyelonephritis. The patient re-presented to the ED the following day. She was given IV fluids and Zofran. A CT scan of her abdomen and pelvis was unrevealing, and the patient was discharged. She then called her PCP three days later. In that time, she had spoken with her psychiatrist, who was located at an outside facility. The patient had self-discontinued her paroxetine prior to the onset of symptoms. She had discussed a plan to re-initiate paroxetine with her psychiatrist. At follow up with her PCP one month later, the patient’s symptoms had completely resolved. She was educated on the importance of discussing medication changes with her doctors. IMPACT/DISCUSSION: Selective serotonin re-uptake inhibitor (SSRI) withdrawal syndrome is a well-documented phenomenon, and can occur with discontinuation of any SSRI, often with nonspecific symptoms. The risk of withdrawal symptoms increases with female sex, younger age, having symptoms early in treatment, longer duration of use, and abrupt cessation. This vignette showcases the importance of considering SSRI discontinuation syndrome when patients on SSRIs present with nonspecific symptoms that do not resolve as expected with treatment or within the expected time course of more common illnesses. This case also highlights the importance of completing thorough medication reconciliations with patients. Medication reconciliation in the primary care setting can improve patient care by identifying discrepancies that can be clinically relevant. One study found that in a cohort of 327 patients, 51.1% of 2,167 identified medication discrepancies were deemed clinically significant. These were most often due to patients not taking a medication that was on their list. However, this case serves as an important reminder for clinicians to complete regular medication reconciliations with patients, especially when new or unexplainable symptoms present.

SSRI discontinuation syndrome can present with nonspecific symptoms such as nausea, malaise and diarrhea. Thorough medication reconciliations can help identify SSRI discontinuation by elucidating medication discrepancies. SYSTEMIC MASTOCYTOSIS: A RARE CAUSE OF FRAGILITY FRACTURE IN THE CONTEXT OF NORMAL PLAIN FILMS AND BONE MINERAL DENSITY Samuel M. Nelson1; Molly Conroy2. 1Spencer Fox Eccles School of Medicine, University of Utah Hospital, Salt Lake City, UT; 2Division of General Internal Medicine, University of Utah Health Hospitals and Clinics, Salt Lake City, UT. (Control ID #4271648) CASE: A 46-year-old female with past medical history of systemic mastocytosis (SM), pulmonary sarcoidosis, remote anorexia, and previous non-traumatic rib fracture presented to primary care for left hip pain. She recounted no inciting trauma nor symptoms of mast cell flair; physical exam was unremarkable apart from a limp. Pain persisted and she was seen by Sports Medicine the following week. Significant pain in left groin and lateral leg was noted during their physical exam with flexion, internal, and external rotation. There was tenderness to palpation on left greater trochanter. Lumbar spine MRI and X-ray pelvis revealed mild osteoarthritis but were otherwise unremarkable. A corticosteroid injection of the left hip was performed, which provided significant relief. Four weeks later, MRI pelvis was performed due to recurring pain and revealed an incomplete stress fracture of the left femoral neck/lesser trochanter without underlying marrow lesion. The decision was made to manage the fracture non-operatively. A month later, the patient reported a significant increase in pain following a low-energy fall from a chair and was directed to the ED. Orthopedics was consulted, and the fracture was repaired operatively. DEXA scan was performed two months post-operatively and showed normal bone mineral density (BMD), including left hip. IMPACT/DISCUSSION: Systemic mastocytosis (SM) is a relatively rare condition in the US (10 per 100,000 persons). However, those who are affected are known to be at risk of fragility fractures and osteoporosis. Risk factors for fractures in SM include a low femoral/hip BMD, older age at diagnosis, male gender, and alcohol intake. More common medical conditions that impact nutritional absorption, require high-dose steroids, or impact bone structure may also predispose to fragility fractures, even with normal BMD, as in the case of our patient. These conditions include diabetes mellitus, chronic kidney disease, rheumatoid arthritis, chronic liver disease, thyroid/parathyroid disease, and celiac disease. Non-displaced fractures that are the consequence of osteoporosis, systemic mastocytosis, or both may be small and difficult to detect via plain radiograph. Cases that lack the typical risk factors should be approached using the American College of Radiology Appropriateness Criteria for hip pain that uses MRI without contrast to identify occult fractures missed in up to 39% of plain imaging.

The selection of an appropriate imaging modality paired with a high index of suspicion increases the likelihood of identifying occult fragility fractures in patients with systemic mastocytosis that may occur in the absence of other risk factors and negative plain radiographs. TB OR NOT TB: AN UNUSUAL PRESENTATION OF ORAL TUBERCULOSIS Rita Malley1,3; Pouya Arefi3; Mayce Mansour2,3. 1Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Internal Medicine, Icahn School of Medicine at Mount Sinai, Brooklyn, NY; 3Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4271675) CASE: A 71 male with pure red cell aplasia requiring immunosuppression presented for evaluation of a painful tongue ulcer. He reported an ulcerated lesion at the lateral border of the tongue that started weeks after travel to Bangladesh. Exam was notable for poor dentition and was otherwise within normal limits. Prior to travel, quantiferon and HIV tests were negative. Months later, the patient was admitted with hypoxic respiratory failure. Workup revealed positive influenza A and fungitell; 3 AFB cultures were initially negative. He was treated with oseltamivir. CT chest revealed a RUL cavitary lesion and multiple parenchymal nodules. Gene Xpert samples from AFB cultures were positive for mycobacterium tuberculosis (MTB). Tongue lesion was biopsied; pathology was positive for non-necrotizing granulomas and AFB-positive rods, confirming diagnosis of pulmonary and tongue MTB. He started RIPE therapy for active MTB with improvement in his respiratory and oral symptoms. IMPACT/DISCUSSION: This patient’s presentation of a painful tongue ulcer with irregular borders and cavitary pulmonary nodules without associated lymphadenopathy consistent with secondary tuberculosis. His risk factors for MTB include immunosuppression and travel in Asia. The differential for oral ulcers includes infectious, inflammatory, and drug induced conditions. The initial workup for oral ulcers includes a comprehensive history focusing on symptoms, time course, and travel, sexual, and work history. If lesions do not respond to conservative management, increase in size, or persist for weeks, a biopsy should be obtained to evaluate for infectious, autoimmune and neoplastic conditions. Oral TB is rare and occurs at an incidence of 0.05% to 5% of all TB cases. TB ulcers are solitary lesions with irregular borders and central exudate that slowly increase in size. Primary TB ulcers occur as the first manifestation of TB through direct inoculation of the oral mucosa, with the highest prevalence in younger children. Secondary TB ulcers occur in systemic TB and are more common in older individuals/adults. Primary TB ulcers are typically non-painful and associated with lymphadenopathy, while secondary TB ulcers may be more painful and occur predominantly on the tongue and buccal mucosa. Diagnosing TB-related oral ulcers is challenging due to their non-specific symptoms and rarity. When suspected, biopsy should be performed to obtain a diagnosis. AFB culture of the ulcer may be obtained; however, sensitivity is low (7.8%). Histopathological analysis may reveal caseating granulomas with central necrosis. If initial biopsy is negative and clinical history is suggestive of TB, multiple biopsies may be required to confirm the diagnosis.

Oral TB is rare and typically presents as an ulcerated lesion with irregular margins that slowly increases in size. Secondary oral TB is more common among older adults and typically presents as a painful tongue lesion without associated lymphadenopathy. THE BURDEN OF PVCS Shaleen Thakur. Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4243882) CASE: Our patient is an 83-year-old male with persistent atrial fibrillation and recent ischemic stroke involving the right corona radiata while on therapeutic anticoagulation. His history included well-controlled hypertension and hyperlipidemia. When presenting following the cerebral infarct, his medications were apixaban 5 mg BID, lisinopril 20 mg daily, hydrochlorothiazide 12.5 mg daily and atorvastatin 40 mg daily. On examination his HR was 86/m with frequent extrasystoles, BP 130/60 mmHg, with no other abnormal findings. Notable lab data included Cr 1.18, LDL-C 84, A1c 5.8 and TSH 1.29. EKG showed rate-controlled atrial fibrillation with frequent PVC's. A TTE found LVEF 45-50%, severe left atrial dilatation and no significant valvular disease. The reduced EF coupled with frequent PVCs prompted a 7-day rhythm monitor that assessed the PVC burden at 35.93%. IMPACT/DISCUSSION: PVCs are a common rhythm disorder that are associated with a wide range of clinical manifestations from asymptomatic, as in our patient, to debilitating, and under certain conditions carry a risk of malignant ventricular tachyarrhythmias and sudden death. Patients should be asked regarding any symptoms (particularly syncope or symptoms consistent with ventricular tachycardia) or family history of early or sudden cardiac death. Their prevalence increases with age, taller height, myocardial disease and metabolic derangement. Modifiable factors include controlling hypertension, increasing physical activity and smoking cessation. Our patient was instructed to keep a log of blood pressure to ensure that no up-titration of antihypertensive regimen was necessary. Frequent PVCs are denoted as at least one PVC on the typical 25-second 12-lead EKG tracing; our patient had 10 polymorphic PVCs on the office EKG. The burden or frequency of PVC’s is associated with the degree of left ventricular dilatation and systolic dysfunction. A PVC burden of >10% prompts further evaluation, starting with a TTE to exclude structural heart disease and assess ventricular systolic function, as this extent of PVC burden can be associated with a reversible form of cardiomyopathy (dyssynchronopathy). First-line medical therapies are anti-arrhythmic medications, often given concurrently with a β-blocker. Our patient was prescribed amiodarone to reduce frequency of PVCs; it may also slow his ventricular response to atrial fibrillation and promote conversion to sinus rhythm. If medical therapy fails, catheter ablation should be considered, especially when the PVC burden exceeds 20-24%.

Frequent PVCs on a 12-lead EKG should prompt further work-up, particularly if the patient is symptomatic, has a family history of sudden cardiac death or left ventricular dysfunction. Further workup regarding high PVC burden should include TTE to evaluate for structural heart disease or ventricular dysfunction, ambulatory rhythm monitoring to determine the PVC burden and referral for cardiology consultation to guide further management. THE CLOT THICKENS: A NOSEBLEED EXPOSES MULTIPLE MYELOMA’S RETURN Rejowana Rouf. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273521) CASE: A 65-year-old male presented with a two-week history of recurrent nosebleeds and increasing fatigue. He denied recent trauma, nasal dryness, or anticoagulant use. His past medical history included multiple myeloma in remission after autologous stem cell transplantation two years prior. He denied fever, weight loss, or night sweats but noted mild headaches and blurred vision over the past week. Key History: Social History: Retired schoolteacher, non-smoker, occasional alcohol use, lives with spouse, no recent travel or sick contacts. Family History: Non-contributory. Medications: Lenalidomide maintenance therapy, no recent changes. Pertinent Physical Exam Findings: Vital signs: BP 140/90 mmHg, HR 88 bpm, afebrile. HEENT: Active anterior epistaxis (left nostril), mild conjunctival injection. Cardiovascular and respiratory exams: Normal. Neurological: Alert and oriented; no focal deficits. Abdomen: No hepatosplenomegaly. Musculoskeletal: No bone tenderness. Pertinent Diagnostic Studies: Hemoglobin: 10.0 g/dL (prior: 12.5 g/dL). Platelet count: 150 × 10^9/L. Leukocyte count: 6.7 Normal. Creatinine: 2.1 mg/dL (baseline: 1.5 mg/dL). Serum protein electrophoresis: Elevated monoclonal IgG (5.2 g/dL). Interventions and Clinical Course: Initial management included nasal tamponade for epistaxis control. Given elevated serum viscosity and a monoclonal protein spike, the patient was hospitalized for therapeutic plasma exchange. Bone marrow biopsy revealed 25% plasma cell infiltration, confirming relapsed multiple myeloma. Treatment was initiated with bortezomib, cyclophosphamide, and dexamethasone (VCD). The patient responded well, with resolution of hyperviscosity symptoms and stabilization of systemic disease. IMPACT/DISCUSSION: This case highlights the recognition of hyperviscosity syndrome as a life-threatening complication of monoclonal gammopathy, particularly in relapsed multiple myeloma. Recurrent mucosal bleeding, neurological symptoms, and visual changes should prompt systemic evaluation, especially in patients with plasma cell disorders. Hyperviscosity syndrome, occurring in 10–30% of patients with IgM monoclonal proteins and less frequently with IgG, disrupts microcirculation and can cause severe complications. Persistent nasal bleeding unresponsive to conservative treatment warrants systemic evaluation. This case underscores the importance of monitoring patients in remission for subtle signs of relapse. Early intervention with plasma exchange and disease-specific therapies like lenalidomide and dexamethasone in combination with either carfilzomib or elotuzumab significantly improves outcomes.

Hyperviscosity syndrome should be considered in monoclonal gammopathies with mucosal bleeding and neurological symptoms. Relapse of multiple myeloma must be suspected in patients with prior remission presenting with new systemic symptoms. Timely diagnosis and management of hyperviscosity syndrome prevent severe complications and optimize treatment outcomes. THE COLLAGEN CONNECTION: A SURPRISING CULPRIT BEHIND IRON DEFICIENCY Rita Malley1,2; Kenneth M. Fifer2,1. 1Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273360) CASE: A 35M with GERD and chronic anxiety presented for re-evaluation of iron deficiency anemia. The patient was initially diagnosed with GERD in 2015 after complaining of chest pain and hoarseness. He denied use of alcohol, NSAIDs, smoking, and recent travel. His only medication was sertraline, which was started in 2013. He had mild epigastric tenderness to palpation. He started twice daily PPI with improvement in GERD. Severe iron deficiency anemia (IDA) with Hgb 6.1 was identified a year later due to fatigue. EGD and colonoscopy were negative for celiac, ulcers, H pylori and polyps. He received IV iron and PPI was switched to H2 blocker. During workup for alopecia years later, IDA had recurred. Repeat endoscopy revealed gastric mucosal atrophy with normal duodenum and ileum, normal colonoscopy, negative H pylori and celiac testing. Biopsies showed collagenous gastritis (CG) in the antrum and fundus. Setraline was identified as the offending agent as he had taken this prior to the first episode of IDA. The medication was tapered off with resolution of anemia. IMPACT/DISCUSSION: CG is relatively rare, but important to consider given the widespread use of pharmacologic triggers, ie SSRIs, that can cause this condition. CG is more common in females and has a bimodal age distribution. In adults, CG is seen with small bowel and colonic inflammation; in children, inflammation tends to be localized to the stomach. Histologically, an infiltrate of plasma cells and lymphocytes, and thick bands of collagen (>10 μm) are seen immediately below the epithelial cells and do not extend to the lamina propria. Adults with CG often have comorbid autoimmune conditions, including collagenous colitis and duodenal lymphocytosis, suggesting an immune-mediated mechanism. The mechanism of IDA is thought to be related to malabsorption of iron from mucosal atrophy. Workup of IDA warrants exploration of possible causes; in young men, these include frequent blood donation, nutritional deficiencies, malabsorptive syndromes, and non-GI blood loss. Bidirectional endoscopy is recommended in all men and postmenopausal women who do not have other explanations for IDA, and should also be considered for premenopausal women. As in this patient, CG typically presents with anemia or upper abdominal discomfort. When evaluating causes, history should focus on pharmacologic triggers, substance use, recent infections, and risk factors for autoimmune conditions. Common pharmacologic triggers include NSAIDs, antibiotics and PPIs. SSRI-induced CG is less common but has been described in the literature. Discontinuation of the offending medication typically results in histologic and symptomatic resolution, though topically-targeted budesonide has been shown to improve CG in an open-label study.

The workup for CG includes a detailed history focusing on risk factors for autoimmune conditions and list of medications, including OTC substances. If related to a medication, discontinuing the agent results in improvement. THE DIAGNOSIS OF REMITTING SERONEGATIVE SYMMETRICAL SYNOVITIS WITH PITTING EDEMA IN A PATIENT WITH RECURRENT PROSTATE CANCER Juliana Lopez. Internal Medicine, St Luke's University Health Network, Bethlehem, PA. (Control ID #4229414) CASE: A 66-year-old male presents as an urgent new patient evaluation to rheumatology with new complaints of abrupt bilateral hand and foot swelling for six weeks with difficulty flexing fingers and toes. The swelling remained throughout the day without improvement with rest or activity. The patient was recently seen by his primary doctor who was initially concerned for gout and started him on colchicine with no improvements. After switching to prednisone, the patient had a complete resolution of the swelling in a few days. Unfortunately, shortly after the prednisone was completed, the hand and foot swelling re-occurred. During this time, the patient, who had a history of prostate cancer with resection, recently started radiation due to recurrence of his cancer. Physical exam revealed bilateral pitting edema of the hands and feet with swelling to the wrists and ankles. No rashes, joint tenderness or other deformities were noted. Outpatient labs showed a normal uric acid and negative ANA, CCP, and RF. Given the history of a robust response to prednisone and seronegative rheumatological work-up thus far, it was concluded that remitting seronegative symmetrical synovitis with pitting edema (RS3PE syndrome) was the likely diagnosis and the patient was started on a long prednisone taper over the next three months with reported resolution of his symptoms. The patient also continued to receive treatment for his prostate cancer. However, after a single missed prednisone dose, the patient's symptoms reoccurred. It was ultimately decided to add hydroxychloroquine 400 mg daily to act as a steroid sparing agent in addition to continuing prednisone 2.5 mg daily. IMPACT/DISCUSSION: This case illustrates the importance of correct diagnosis and treatment of a rare syndrome that could easily be missed in a primary care setting for other rheumatological conditions–gout in this case. The diagnosis of RS3PE is clinical and requires a good history and physical exam, as common rheumatological markers will be negative. In most cases, a prednisone taper is sufficient for treatment and remission of RS3PE. However, as in this case, patients who have ongoing cancer and RS3PE, may require the addition of hydroxychloroquine for disease management. It is also possible that the earlier diagnosis of RS3PE, which has a known association with cancer, could have led to the patient’s earlier referral for the treatment of his recurring prostate cancer.

RS3PE is a rare rheumatological condition involving abrupt onset small joint inflammation with a characteristic subcutaneous pitting edema of both hands and feet. The syndrome has been more associated in patients older than 50 and has some correlation with cancer diagnosis, but the true etiology of this syndrome remains uncertain with an estimated prevalence of 0.09%. Although rare, RS3PE should be included in the differential for any polyarthritis in order to avoid misdiagnoses and ensure patients are treated appropriately. THE EDEMA ENIGMA: SHEDDING LIGHT (CHAIN) ON A CASE OF HYPOPROTEINEMIA Joanne Huang1; Sarah A. Tilstra2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2Internal Medicine, University of Pittsburgh School of Medicine/Medical Center, Pittsburgh, PA. (Control ID #4273325) CASE: A 69yo male with Crohn’s disease s/p partial colectomy, iron deficiency anemia, HTN presented to clinic with bilateral lower extremity edema, loose stools, and mild dypnea on exertion. Denied cough, orthopnea, change in urine output. Recent TTE had shown normal cardiac function. Exam was unremarkable except 2+ pitting edema to knees bilaterally. Labs showed serum K of 2.9, low total serum protein 5.8g/dL, albumin 3.6g/dL, Ca 8.6, Cr 0.9 at baseline, and hemoglobin 10.7. LFTs, ESR and CRP, ferritin and serum iron were unremarkable. Potassium was repleted, amlodipine dose was decreased. No evidence of GI bleed or inflammation was noted on EGD and colonoscopy. Follow up labs were ordered, but never completed. 8 months later, patient returned with worsening edema and dyspnea on exertion. Exam now showed 3+ bilateral lower extremity pitting edema to thighs. Labs showed total serum protein 6.1g/dL, albumin 3.8 g/dL, and Cr 1.1, hemoglobin 11.7. Urine studies showed elevated urine albumin-Cr ratio of 95.3. Further studies revealed marked increase in 24hr urine protien-Cr ratio of 1680, low serum immunoglobulins, elevated free lambda light chain in the serum (1851mg/L) and urine (5348mg/L), serum kappa/lambda = 0.01 and Bence Jones protein band on UPEP identified to be monoclonal lambda light chain. Patient was urgently referred to hematology/oncology and promptly started on induction therapy for suspected lambda light chain multiple myeloma (LCMM) with impending renal failure. Bone marrow biopsy 2 months later showed 4% abnormal plasma cell population and PET CT revealed no osteolytic lesions. IMPACT/DISCUSSION: This is an atypical case of multiple myeloma (MM) with hypoproteinemia and normal serum albumin, calcium, creatinine; no bone pain or osteolytic lesions (present up to 79% at diagnosis). However, some initial findings point to LCMM. Hypoproteinemia is more common in LCMM due to higher rate of renal involvement with protein-losing nephropathy and smaller paraprotein. It is interesting that this patient had no significant rise in creatinine despite proteinuria. This pattern could be present in renal Fanconi syndrome as consequence of light chain proximal tubulopathy (LCPT). While this is more common with crystallin LCPT from kappa-restricted chain deposit, suspected case of non-crystallin LCPT from lambda light chain was noted in literature previously. In addition to SPEP with IEP, serum free light chain assay and UPEP with IEP should be ordered to distinguish LCMM, as serum M spike is often very low or absent in LCMM.

LCMM can present atypically to primary care, and is distinguished from other MMs by higher frequency of renal involvement and protein losing nephropathy. Providers must consider the differential for hypoproteinemia and consider evaluation for LCMM even when other distinguishing features of MM are absent. SPEP and UPEP with IEP, and serum and urine free light chain should be part of workup when dysproteinemia and renal protein loss is suspected. THE ELUSIVE AND EXTREMELY ELEVATED D-DIMER IN CLINIC Elizabeth Konon1; Melissa Griffith3; Laura Macke2. 1Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; 2General Internal Medicine, University of Colorado, Denver, CO; 3Rheumatology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4215261) CASE: A 66-year-old female with a history of seropositive rheumatoid arthritis presented to her primary care provider for evaluation of bilateral lower extremity edema and was found to have a newly elevated D-Dimer of 10,080 (reference range <500 ng/ml). Extensive workup for venous thromboembolism (VTE) including bilateral lower extremity ultrasound and CT pulmonary angiogram was negative. Laboratory workup was unremarkable including complete blood count, comprehensive metabolic panel, inflammatory markers, and labs for disseminated intravascular coagulation (DIC). Extensive workup for malignancy including colonoscopy, CT chest-abdomen-pelvis, transvaginal ultrasound, and PET/CT were unrevealing. Tumor markers were notable for a CA 19-9 of 654 (reference range 0-35 U/ml), CA 125 of 230 (reference range 0-35 U/ml), and CEA of 2.8 (reference range 0-3 ng/ml). Given the concern for ovarian malignancy, bilateral salpingectomy and partial omentectomy was performed. Histology showed a focal non-granulomatous necrotizing vasculitis involving the small arteries of the right fallopian tube and bilateral ovaries, consistent with polyarteritis nodosa (PAN). On follow up post-operatively, her D-Dimer down-trended to 4,070 ng/ml. Several months after the diagnosis, she passed away from surgical complications. IMPACT/DISCUSSION: A D-Dimer is a fibrin degradation product that has long been used as a marker for coagulation and fibrinolysis. Elevated levels should be investigated as they have been associated with increased mortality across many disease states. A prior study showed that in patients with extremely elevated D-Dimers (>5,000 ng/ml) the most common etiologies included VTE, malignancy, and infection, and patients with D-Dimers >15,000 ng/ml had a 75% mortality rate during 40-80 day follow-up1. DIC, cardiogenic syncope, trauma, and heart failure should also remain on the differential for an elevated D-Dimer. PAN is a necrotizing medium-vessel vasculitis that presents with systemic or localized organ involvement. Though rare, there have been case reports of elevated D-Dimers in various systemic vasculitides, but we found only one case report with an elevated D-Dimer in localized, cutaneous PAN. We present a case of a 66 year old female found to have a D-Dimer of >10,000 ug/ml during routine evaluation of lower extremity edema for VTE, eventually attributed to newly diagnosed PAN limited to her ovaries and right fallopian tube given her otherwise unrevealing workup, and the decrease in D-Dimer post-operatively.

1. Schafer K, Goldschmidt E, Oostra D, Fish J, Russell T, Lurie F. The clinical significance of ultra-high D-dimer levels. J Vasc Surg Venous Lymphat Disord. Jan 2022;10(1):8-13. doi:10.1016/j.jvsv.2021.06.011

A markedly elevated D-Dimer warrants further investigation given the high mortality risk. Vasculitis should remain on the differential for an elevated D-Dimer when more common etiologies have been ruled out. THE HARDEST PILL TO SWALLOW – DYSPHAGIA FROM A RARE SMOOTH MUSCLE TUMOR Anthony J. Mauro1; Brielle Spataro2. 1Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4271740) CASE: An 85-year-old woman presented to her primary care physician with difficulty swallowing large pills. She described that her daily 20mEq potassium chloride and 25/320mg hydrochlorothiazide/valsartan tablets would become stuck in her throat and needed water to get them down. She denied odynophagia, heartburn, and dysphagia with smaller pills, food, or liquids and did not smoke tobacco or drink alcohol. Her medical history included depression and anxiety, hypertension, atrial fibrillation, and hypothyroidism, all of which were controlled pharmacologically. Her medication list was otherwise noteworthy for 324mg daily ferrous sulfate. Physical exam was unremarkable. The potassium chloride was changed from a tablet to a powder formulation, and hydrochlorothiazide/valsartan was changed to two separate pills to limit size. This resolved her dysphagia, but an etiology was still unknown, warranting testing. She subsequently underwent barium esophagography two days after initial presentation, which identified a right-sided extrinsic mass impinging the esophagus at the level of the thoracic inlet. Head/neck CT five days later determined the mass to be 7 x 2.9 cm2, directly posterior to the trachea and displacing the esophagus to the left. Fibroma and leiomyoma were the likeliest diagnoses, but malignancy could not be ruled out. Endoscopic ultrasound with fine-needle biopsy was performed to rule out gastrointestinal stromal tumor; cytology showed atypical spindle cells without a specific cell of origin. Subsequent evaluation by otolaryngology and interventional radiology determined that the mass was likely of smooth muscle origin, though malignancy was unclear. Due to the morbidity of localized control in the tumor’s region, the conservative decision was made to monitor growth. IMPACT/DISCUSSION: Esophageal dysphagia to solids, but not liquids, is concerning for mechanical esophageal obstruction. Select causes include esophagitis and compression from intrinsic or extrinsic tumors. Pill esophagitis is a common cause, which can be due to use of potassium chloride and ferrous sulfate tablets. Barium swallow may be helpful to assess lumen compromise if there is suspicion of a proximal stricture, but esophagogastroduodenoscopy is the test of choice without such concern; prompt scheduling may expedite diagnosis and treatment of dysphagia. Smooth muscle tumors arising from deep soft tissue are immensely rare. Furthermore, when they present within deep soft tissue, they typically affect the extremities (leiomyoma) or retroperitoneum (leiomyosarcoma); thoracic inlet involvement is exceedingly rare. Thoracic inlet tumors may cause dysphagia via esophageal impingement, though they are most often asymptomatic.

The primary test for evaluating dysphagia is esophagogastroduodenoscopy. While incredibly rare, smooth muscle tumors may arise in the thoracic inlet; large tumors can cause dysphagia. THE HELIX HELPERS: ROLE OF INTERNISTS IN GENETIC MEDICINE Judy J. Wang2; Ying Liu1; Peggy B. Leung2. 1Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; 2Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4272435) CASE: A 44-year-old healthy woman initially presented for an annual physical following a mammogram revealing a BIRADS-4B retroareolar architectural distortion. After a negative biopsy, she expressed relief, citing nervousness due to her mother's breast cancer history. When initially questioned about family cancer history, she denied any additional cases. However, weeks later, she provided documentation revealing five family members with diverse cancer diagnoses across breast, gynecologic, and prostate cancers, prompting a referral to medical genetics for familial syndrome testing. IMPACT/DISCUSSION: Despite accelerating advances in genetic disease and management, genetic screening remains an unfamiliar topic amongst most primary care physicians. A 2024 survey of primary care providers showed that, while 98% acknowledged the importance of genetic testing to clinical care, only 32% felt confident in responding to questions related to this space. One way PCPs are equipped to engage is by obtaining detailed family histories, which may not only inform initial risk assessment but also tailor future testing needs. There are challenges associated with this. On the provider level, there is a lack of standardized and user-friendly tools integrated into the EHR that efficiently collect and interpret family history. On the patient level–as illustrated by this case–patients may be completely unaware of their own histories. Cultural differences can also impact their willingness to share such information. When applicable, internists should empower patients to navigate these challenges if more information can assist with clinical care. As cancer diagnoses among younger adults rise in recent years, knowing who and when to offer genetic testing becomes increasingly crucial. Current guidelines recommend a “family-history-based model” of testing, emphasizing key hereditary cancer features, such as multiple primary cancers, intergenerational cancer patterns, clustering of the same cancer, and family histories of unexplained early deaths or even early onset cardiovascular disease and dementia. Discussions around implementing a “population-wide screening model” are ongoing, but such a model may come with other ethical and cost-related considerations. The case demonstrates how proactive family history exploration can unveil potential hereditary cancer risks, transforming an routine annual physical into a crucial preventive intervention. It highlights the primary care physician's pivotal role in bridging genetic risk assessment and targeted screening, ultimately enabling personalized preventive care.

Primary care physicians can play a critical role in early identification and referral for genetic evaluation of hereditary syndromes. Collecting a comprehensive family history is a crucial first step to guide genetic screening in non-cancer patients. THE HIDDEN COSTS OF WEIGHT LOSS: SEVERE MALNUTRITION AND NEUROPATHY POST SLEEVE GASTRECTOMY Luisa Tsang. Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4266728) CASE: A 29-year-old woman with a history of a BMI 40-44 and treated latent syphilis who underwent sleeve gastrectomy in Mexico one year prior. She presented with hypovolemic shock, profound muscle weakness, neuropathy, visual hallucinations, and encephalopathy. Physical examination revealed severe muscle wasting, anasarca, intermittent upper extremity fasciculations, hyporeflexia, hyperpigmented rash on the neck, cheilosis, and glossitis. Initial laboratory workup showed deficiencies in zinc, folate, vitamins B12, D, B6, and copper, along with marked hypoalbuminemia, acute kidney injury, and hyperkalemia. MRI revealed changes consistent with metabolic encephalopathy, while EMG indicated diffuse peripheral axonal neuropathy. CT imaging and EGD findings were unremarkable except for postoperative changes consistent with the previous sleeve procedure. Upon further inquiry, the patient reported losing over 150 pounds in the last year, accompanied by a significant decrease in appetite and oral intake. She experienced progressive weakness and neuropathy, becoming bedbound over the last month. She had not been informed about the need for close post-operative follow-up and was given only a basic dietary recommendation sheet. During her extended hospital stay, the patient required nutritional supplementation via a feeding tube and developed re-feeding syndrome with transaminitis and electrolyte imbalances. She was discharged to an acute rehabilitation unit, where she has made progress but remains unable to walk unassisted due to ongoing weakness. IMPACT/DISCUSSION: This case underscores the critical importance of rigorous postoperative follow-up and comprehensive patient education following bariatric surgery, especially for patients undergoing procedures abroad. The patient's severe malnutrition and encephalopathy were direct consequences of unmanaged chronic complications from her sleeve gastrectomy. This case highlights the need for standardized follow-up protocols and greater awareness of potential long-term complications to prevent life-altering outcomes.

Effective postoperative care and nutritional management are essential for preventing severe complications in patients who have undergone bariatric surgery. This case emphasizes the importance of recognizing and addressing chronic complications early, particularly for patients returning to the U.S. after international surgeries. THE IRON-Y OF OVERLOAD: WHEN THE DIAGNOSIS OF HEMOCHROMATOSIS IS NOT SOLID Krittika Pant1; Cary Blum2. 1Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272406) CASE: A 39-year-old male with obesity, hypertension and diabetes presented to primary care after a knee injury. He reported going to an emergency department where an x-ray revealed chondrocalcinosis. Given the rarity of this finding in his age group, a workup for associated diseases, including hemochromatosis, was initiated. He was found to have iron overload, with transferrin saturation 49%, ferritin 750 ng/mL, iron 116 mcg/dL, and total iron binding capacity of 235 mcg/dL. Given concern for hemochromatosis, he was referred for HFE gene mutation testing, which was negative for the most common mutations (C282Y and H63D). Subsequent iron panels showed persistently elevated ferritin with a peak of 955 ng/ml and fluctuating transferrin saturation. Given ongoing concern for systemic iron overload, an MRI was obtained, confirming an elevated hepatic iron concentration of 2.03 mg/g, as well as severe hepatic steatosis with a fat fraction of 24%. His liver function tests remained normal. IMPACT/DISCUSSION: A diagnosis of non-HFE primary hemochromatosis was suspected at first due to elevated ferritin levels, a transferrin saturation level above 45%, evidence of hepatic iron overload on MRI, and negative testing for the two most common HFE gene mutations. Other clinical manifestations that raised suspicion for hemochromatosis include an episode of arthropathy and an early diagnosis of DM. However, given the presence of metabolic dysfunction-associated steatotic liver disease (MASLD), insulin resistance, and fluctuating iron saturation, dysmetabolic iron overload syndrome (DIOS) is the best unifying diagnosis for this patient. DIOS is characterized by a mild increase in hepatic or total body iron stores with no identifiable cause and is closely associated with MASLD and metabolic syndrome. Elevated iron markers are present in about one third of patients with MASLD and contribute to accelerated liver damage due to oxidative stress. The mechanism of iron overload in DIOS is thought to be related to hepcidin resistance, whereas in hemochromatosis, hepcidin is deficient. DIOS is a more common but less recognized cause of hyperferritinemia than hemochromatosis. In contrast to hemochromatosis, DIOS is characterized by normal to mildly elevated transferrin saturation, ferritin levels usually below 1000 ng/mL, iron deposition in the spleen seen on MRI and normal to elevated levels of hepcidin. There is not enough evidence at this time to support the use of phlebotomy or iron chelators for the treatment of DIOS, but iron metabolism remains a promising target for therapy in future studies. Currently, management should focus on treating the underlying MASLD and metabolic syndrome.

It is important to recognize DIOS, a common finding in patients with MASLD, which may result in accelerated damage to the liver. DIOS can be distinguished from primary hemochromatosis by its milder iron overload, normal to mildly elevated iron saturation, normal to high hepcidin, and normal HFE testing. THE POTENTIAL IMPACT OF MRNA COVID-19 VACCINATION ON CLL/SLL DISEASE DYNAMICS Anvitha Soundararajan, Sadia Amjad, Bhoomi Satani, Sandesh Murali. Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #4273309) CASE: A 61-year-old male patient with a past medical history of Type 2 Diabetes Mellitus and GERD developed ipsilateral axillary lymphadenopathy (LAD) following a second dose of COVID-19 vaccination (mRNA-1273). He subsequently developed contralateral axillary LAD and supraclavicular LAD. He assumed this LAD was secondary to the vaccine and did not seek medical attention for approximately 3 years. At the time of presentation to our clinic, he was also noted to have non tender occipital and cervical LAD. Throughout the course, his LAD had gradually increased in size but remained painless. He denied any B symptoms. CT neck and chest with IV contrast revealed multiple enlarged axillary, mediastinal, retroperitoneal, cecal, periportal, peripancreatic, and mesenteric lymph nodes. Biopsy of axillary lymph node was consistent with Chronic lymphocytic leukemia/small lymphocytic leukemia (Flow cytometry showed 67% population of mature B lineage cells with CD45+, CD5+, CD9+, CD20+, CD3+, CD 38 Partial positive, HLA-DR +). He was referred to an oncologist and he is undergoing a bone marrow biopsy as well as a PET scan. At this time, he is being evaluated for a stem cell transplant at a tertiary oncology institution. IMPACT/DISCUSSION: It is important to note that the mRNA COVID-19 vaccination often leads to a Hyperacute immunogenic response by induction of T and B cell function by the dendritic cells. It is possible that such a mechanism may induce rapid progression of underlying lymphomas. Upon review of literature, there have been 9 prior cases of non - hodgkin lymphoma reported following receiving the COVID-19 vaccine. This should incite both patients and providers to carefully observe for persistent lymphadenopathy following COVID-19 vaccination. Lymphadenopathy persisting for greater than 8 weeks after receiving the vaccination should undergo evaluation including imaging and biopsy.

mRNA COVID-19 vaccination has been implemented as a global health strategy to control the COVID-19 pandemic. It has been frequently associated with lymphadenopathy which typically resolves spontaneously. However, persistent lymphadenopathy should raise concern for other possible diagnoses such as CLL/SLL, a type of non-Hodgkin lymphoma, as seen in our patient. THE SKIN DETECTIVE : UNCOVERING PURELY CUTANEOUS ROSAI-DORFMAN-DESTOMBES DISEASE Mridula Sree Naagendran1; Olivia Steczko2; Wylie Hosmer1. 1Internal Medicine, UConn Health, Farmington, CT; 2PCIM, University of Connecticut School of Medicine, Farmington, CT. (Control ID #4229158) CASE: Healthy 37-year-old Caucasian female presented for evaluation of a left nasal dorsal lesion which has been present for approximately five years unchanged with time. She denied nasal pain, obstruction, epistaxis, fevers/chills, night sweats, or weight changes. Examination revealed a small raised erythematous nodule on the left nasal dorsum without lymphadenopathy.CBC with a differential was unremarkable. Chest x-ray was negative for mediastinal lymphadenopathy. Biopsy of lesion was notable for nodular-to-diffuse lymphoid infiltrate within dermis with lymphoid cells, plasma cells, epithelioid histiocyte aggregates, and emperipolesis of lymphocytes and plasma cells noted within many histiocytes. Immunohistochemical stains revealed infiltrate of CD3+ T-cells and CD20+ B-cells. CD30 highlighted scattered large lymphocytes and CD68 highlighted the histiocyte component consistent with RDD.She was treated with topical steroids with clinical improvement in her lesion. IMPACT/DISCUSSION: Rosai-Dorfman-Destombes disease (RDD) is a rare non-Langerhans cell histiocytosis with unknown etiology. Over 1000 cases have been reported since the development of the RDD registry by Foucar et al in 1990. Purely cutaneous RDD is rare, distinct variant of RDD,traditionally known for systemic presentations involving lymphadenopathy. Cutaneous RDD accounts for only 3% of systemic RDD cases . Cutaneous RDD poses both diagnostic challenges and clinical implications due to its rarity and often variable presentation which can mimic a spectrum of dermatologic conditions such as inflammatory, granulomatous or neoplastic disorders. When RDD is suspected, initial workups include CBC, CMP,quantitative immunoglobulin levels,CT neck, chest, abdomen, and pelvis. Autoimmune,lymphoproliferative process,HIV,hepatitis B, C should be ruled out. Histopathology remains central to diagnosis,showcasing hallmark findings of emperipolesis. Many cases of RDD are self-limiting requiring local treatments including topical steroids,surgical excision or systemic therapies when refractory. In Foucar et al's 1990 study, 7% of patients died due to direct complications of RDD. There is insufficient data to characterize prognosis of purely cutaneous RDD however careful differentiation from other systemic diseases is critical to avoid unnecessary systemic treatments.

Purely cutaneous RDD remains a rare and diagnostically challenging entity,often underrecognized due to its distinct presentation confined to the skin.This case emphasizes the necessity of heightened clinical suspicion and the role of comprehensive histopathological examination in distinguishing cutaneous RDD from other cutaneous infiltrating disorders.Our findings contribute to the growing body of evidence that RDD despite its rarity should be considered in differentials. Early and accurate diagnosis can prevent unnecessary treatments and guide clinicians toward tailored, patient-centered management strategies,underscoring its importance. THE TORMENTED TUMMY - A RARE CAUSE OF ABDOMINAL PAIN AND HEMOLYSIS Anjali Venkat1; Divya Venkat1; Laura J. Zimmermann2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Internal Medicine, Rush University, Chicago, IL. (Control ID #4271119) CASE: A 31-year-old woman with asymptomatic intermittent thrombocytopenia presented with a 6-month history of diffuse abdominal pain, constipation, nausea, and loss of appetite. Imaging was unremarkable and conservative treatment was ineffective. GI testing showed elevated TTG IgG and Gliadin IgG with normal fecal calprotectin. EGD revealed mild gastric inflammation but no evidence of celiac disease or H. pylori. A low FODMAP diet and PPI use led to mild improvement, but repeat fecal calprotectin increased leading to unremarkable colonoscopy. Over the next 2 months, she developed frequent emesis, gross hematuria, and scleral icterus. She was diagnosed with acute gastroenteritis at an urgent care with labs showing macrocytic anemia, leukopenia, thrombocytopenia, elevated creatinine, transaminitis, and hematuria. Blood smear revealed ovalocytes, schistocytes, teardrop cells, and macrocytosis prompting her PCP to refer her to hematology. Symptoms and lab trends initially improved, but with marked leukocytosis a month later. She was treated with oral Augmentin/Flagyl for presumed diverticulitis with some symptom remittance but then had recurrent ER visits with similar presentation. Outpatient hematology evaluation showed positive hemolytic parameters and paroxysmal nocturnal hemoglobinuria was confirmed by flow cytometry. Eculizumab infusions were started leading to symptom reduction. IMPACT/DISCUSSION: This case highlights the clinical impact of Paroxysmal Nocturnal Hemoglobinuria (PNH), a rare life-threatening condition marked by serious complications including intravascular hemolysis and thrombosis. PNH presents a diagnostic challenge, often with nonspecific symptoms, which can delay diagnosis. African Americans have the highest incidence (73%) compared to other racial groups, suggesting potential genetic or environmental modifiers in PNH risk. Patients with PNH have a 62-fold higher risk of thrombosis compared to the general population, with thrombosis to the liver and brain which underscore the need for early intervention in suspected cases to improve patient outcomes. PNH should be suspected in adults aged 30-40 who present with anemia and symptoms related to hemolysis and nitric oxide depletion, such as fatigue, gastrointestinal symptoms, and renal impairment. Bone marrow abnormalities and inadequate response to anemia treatments can also be indicators. Historically treated with transfusions and anticoagulation, PNH management has evolved with targeted therapies like eculizumab and ravulizumab which have reduced transfusion needs and thrombotic risks.

Thorough evaluation and ongoing research into the genetic, environmental, and clinical factors that affect PNH patients are essential. Clinicians should maintain a wide differential as many patients with unexplained abdominal pain are often disregarded with blanket diagnoses such as IBS or anxiety. TITLE: XYLAZINE-INDUCED NON-HEALING CHRONIC ULCER David Jimenez1; Tatiana Correa2; Lauren Meade1. 1Internal Medicine, Baystate Medical Center, Springfield, MA; 2internal medicine, Baystate Medical Center, Springfield, MA. (Control ID #4271088) CASE: A 39-year-old female patient with a past medical history of multiple abscesses, hepatitis C, and a person who uses intravenous heroin and cocaine presents to an academic health center with a right lower extremity ulcer that has been present since 2017. She was seen in the clinic for the first time in 2024. The patient had no systemic symptoms, and vital signs were stable. Laboratory tests showed no signs of infection. The patient underwent debridement in 2022 and subsequently received standard wound care treatment. A CT scan of the lower extremities revealed a large wound with superficial ulceration and infiltration of subcutaneous tissue along the anterolateral aspect of the right middle thigh. No organized fluid collection or soft tissue gas was seen, and there were no signs of acute osteomyelitis. The patient has never had a wound like this; however, she has had previous abscesses, which were treated and resolved appropriately. Pathology results from the wound biopsy revealed epidermal ulceration with underlying dense fibrosis and chronic inflammation. Histologic findings were nonspecific, and the etiology remained uncertain. Upon further questioning, the patient reported a history of xylazine use. Interestingly, the patient's mother, also a person who uses intravenous drugs, has also had bilateral chronic ulcers and uses IV substances. This information reduced the suspicion for other differential diagnoses, such as pyoderma gangrenosum and vasculitis ulcers, making xylazine-induced ulcers most likely. IMPACT/DISCUSSION: Xylazine is a recent drug often used in combination with opioids to enhance and prolong their effects; however, its long-term impacts remain poorly understood. It has been associated with non-healing chronic ulcers that are difficult to treat. These ulcers can appear at locations other than the injection site and do not typically cause systemic effects, such as sepsis. Suspicions of xylazine exposure should be maintained in patients with opioid use, mainly when they are present with skin ulcers. Diagnosis is challenging because xylazine is not included in routine toxicology testing, though specialized testing is available. It is also essential to rule out other causes, such as vasculitis or infection. Additionally, there are limited histopathological characteristics of xylazine due to the lack of extensive studies.

This case highlights the importance of considering xylazine as a potential factor in patients with chronic ulcers and a history of intravenous substance use in areas where its use is prevalent. TUNNEL VISION: ACUTE IDIOPATHIC UVEITIS WITH RETINAL DETACHMENT Marina Latif1; Lauren Peccoralo2. 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 #4270834) CASE: A 68-year-old male presented to clinic for follow-up with chief complaint of bilateral vision loss. His symptoms began with fever, photophobia, ophthalmalgia, and dizziness while traveling in South America and rapidly progressed to conjunctivitis and visual field contraction of both eyes. He experienced near full bilateral vision loss and after seeing multiple ophthalmologists was found to have bilateral uveitis with retinal detachment. Oral prednisone, atropine eye drops, and prednisone eye drops were started, and his vision gradually improved to near-baseline, at which point he presented for follow-up. He denied gastrointestinal symptoms, rashes, arthritic symptoms, or focal neurologic deficits. Extraocular physical exam was unremarkable. Preliminary external diagnostic work-up revealed a positive ANA, but CBC, CMP, ANCA screen, HLA-B27, Lyme disease, syphilis, tuberculosis, and sarcoidosis evaluation were unremarkable. IMPACT/DISCUSSION: Uveitis is inflammation of the uveal eye layer, containing the iris, ciliary body, and the choroid. Inflammation can target the anterior, intermediate, posterior, or entire uvea (panuveitis). Bilateral eye manifestations can occur such as this case of severe uveitis and retinal detachment, likely due to inflammation causing fluid build-up in the subretinal space. This case highlights the thorough history and work-up that general internists must consider for predisposing conditions. Though uveitis can be idiopathic, etiologies of uveitis include infections, systemic disorders such as sarcoidosis and spondyloarthropathies, or lymphoma. Internists should focus a review of systems and physical exam on ocular (photophobia, vision loss, pain, floaters, hypopyon, etc.) and extraocular manifestations (rash, respiratory symptoms, lymphadenopathy, arthralgias, fever, etc.) that could indicate a potential etiology. Diagnostic testing includes infectious disease serologies, autoimmune (e.g., lupus) work-up, and chest x-ray for sarcoidosis or tuberculosis. Without evaluation, patients with undiagnosed systemic conditions are at risk of recurrent uveitis and permanent vision loss. Patients with uveitis should be urgently seen by ophthalmology for a full exam, diagnosis, and treatment. Management of uveitis typically includes topical corticosteroids to reduce inflammation. Systemic corticosteroids may be used in severe, vision-threatening cases like those with retinal detachment and often require taper over several weeks to months.

While uveitis requires urgent ophthalmologic management to prevent severe complications, internists have an important role in diagnostic evaluation to assess for systemic conditions that can predispose to uveitis and require follow-up. UNMASKING CHRONIC FATIGUE SYNDROME: A DIAGNOSTIC CHALLENGE AFIFAH CHOUDHURY1,2; Zaber A. Rayan1. 1Latina Medical Office, PC, Brooklyn, NY; 2Internal Medicine, Bangladesh Medical College, Dhaka, Dhaka Division, Bangladesh. (Control ID #4273636) CASE: A 51-year-old male with a past medical history of diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease status post percutaneous coronary intervention (PCI), and anxiety presented with a three-year history of progressive fatigue and weakness. The patient reported a significant decline in his ability to perform daily activities and maintain work, despite receiving 12 doses of testosterone therapy. Comprehensive evaluation excluded alternative causes, including hypothyroidism, adrenal insufficiency, anemia, infections, and medication side effects. Extensive cardiac, endocrine, and psychiatric assessments were unremarkable. Based on the clinical presentation and exclusion of other conditions, the patient was diagnosed with CFS. IMPACT/DISCUSSION: Chronic fatigue syndrome (CFS), or myalgic encephalomyelitis (ME), is a debilitating condition characterized by persistent fatigue lasting at least six months that is not alleviated by rest. Diagnosing CFS is particularly challenging in patients with significant comorbidities, as symptoms often overlap with other medical conditions.This case illustrates the diagnostic complexity of CFS in the context of multiple comorbidities. The patient’s prolonged fatigue and lack of improvement with testosterone therapy highlight the importance of ruling out other potential causes. This also highlights the significant psycho-social impact CFS has on the quality of life. The patient reported significant improvement in fatigue and quality of life over a six-month follow-up period.

This case emphasizes the need for heightened awareness of CFS as a differential diagnosis in patients with persistent fatigue. A systematic, multidisciplinary approach is essential to improve outcomes and ensure appropriate care for patients with this underrecognized condition. UNTREATED HEPATITIS C VIRUS AND WORSENING INSULIN RESISTANCE Sharanya Iyer1; Alison Koransky1; Irene Rahman2; Anita Mahadevan3. 1Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Internal Medicine, Mount Sinai Health System, New York, NY; 3Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4270321) CASE: A 65-year-old female with a past medical history of hypertension and type 2 diabetes mellitus (DM) presented to the emergency room (ER) for altered mental status. At that time, she denied other symptoms, including urinary symptoms, fevers, or respiratory symptoms. Workup, including a CT head, was unremarkable. Her hemoglobin A1C (A1C) was 6.9%. At the time, her mental status improved without intervention and was attributed to psychosocial stress in the setting of significant life changes. Two months later, the patient established care at a hospital based ambulatory care practice, at which time her family endorsed continued cognitive decline, as well as weight loss, poor hygiene, worsening vision, and increased thirst. The patient’s family was unsure if she was taking any medications. Lab work revealed a significant increase in A1C to 12.8%, hyperglycemia, nephropathy, transaminitis, elevated hepatitis C (HCV) viral load and increased CA 19-9. Given her laboratory abnormalities, the patient was again sent to the ER and admitted for management of hyperglycemia. During admission, she was fluid resuscitated and started on an insulin regimen with repaglinide and metformin. On follow up with her hepatologist, the patient was started on HCV viral therapy. She was also started on empagliflozin by her primary care physician. Her A1C rapidly improved to 8.3%, and subsequent visits were complicated by hypoglycemia. The patient’s PCP subsequently discontinued insulin and repaglinide. The patient then saw endocrinology, and was started on linagliptin. The patient continued to tolerate her HCV therapy well, and on repeat check, had an HCV viral load of 0. IMPACT/DISCUSSION: HCV has an estimated global prevalence of 58 million per the World Health Organization in 2022; however, underreporting and underdiagnosis remain significant issues. Chronic HCV is a leading cause of liver disease including fibrosis, cirrhosis, and hepatocellular carcinoma. Insulin resistance (IR) is also commonly associated with HCV and can lead to the progression of DM. One study demonstrated that patients with HCV were at 11.5 times higher risk of developing DM in comparison to the general population. Other studies have estimated that the prevalence of DM in patients with chronic HCV infection is as high as 20-50%, which is higher than the reported prevalence of DM in patients with other liver diseases. Therefore, for patients with DM or predisposition to IR, treatment of HCV infection is crucial in improving disease control. As was demonstrated in this vignette, achieving good control of both DM and glucose levels can be significantly impaired by the presence of active HCV infection. Prompt initiation of antiviral therapy is crucial for these patients.

Hepatitis C infection is commonly associated with insulin resistance and progression of diabetes. Treatment of active hepatitis C is important in the treatment of patients with uncontrolled diabetes. UNVEILING THE HIDDEN: UNTANGLING DYSPNEA THROUGH DIAGNOSTIC SUBTLE CLUES Cody Hu1; Hugo Garcia2; Erica Santos1; Alexander Henze1; Michelle V. Conde3. 1Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; 2Radiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX; 3Internal Medicine, UTHSCSA, San Antonio, TX. (Control ID #4272601) CASE: A 72-year-old female with COPD Gold Group B presented with worsening dyspnea over months. In May 2023, lower extremity duplex ultrasound showed a nonocclusive thrombus in her right leg, with no clear clot risk factors. She was discharged on a long-term anticoagulation (AC). Rivaroxaban dose was reduced in Dec 2023 due to bruising. In March 2024, she presented to the ER for dyspnea. CT pulmonary angiogram (CTPA) excluded pulmonary embolism (PE) but revealed a dilated main pulmonary artery (3.4 cm). PFTs confirmed COPD. Her inhaler regimen was modified to include triple therapy, yet dyspnea persisted. In Oct 2024, a lung ventilation-perfusion (V/Q) scan showed heterogeneous decreased perfusion in bilateral lower lobes, concerning for chronic PE, though repeat CTPA remained negative. Transthoracic echocardiograms in Feb 2022 and July 2024 showed normal ventricular function, but incomplete tricuspid regurgitation jets prevented PAP calculation. She was then referred for right heart catheterization (RHC), which confirmed pulmonary hypertension, meeting diagnostic criteria for chronic thromboembolic pulmonary hypertension (CTEPH). AC therapy was switched to apixaban 5 mg twice daily, and she was referred to the PH clinic for further evaluation. IMPACT/DISCUSSION: CTEPH is a rare subtype of group 4 pulmonary hypertension, with a prevalence of 26-38 cases per million. Early diagnosis is essential as it is potentially curable with prompt intervention but often misdiagnosed due to its nonspecific presentation. The pathophysiology remains unclear. It is generally accepted as a complication of acute PE, though some research hypothesizes CTEPH arises from in situ thrombosis due to PH and endothelial dysfunction. This explains why patients can develop CTEPH without acute PE, as seen in our patient. Diagnosis is based on PH confirmed by RHC and perfusion defects on imaging, with V/Q scan as the gold standard. Literature supports V/Q’s high sensitivity for CTEPH at 90-100%. CTPA, while sensitive for acute PE, has lower sensitivity (around 60%) for CTEPH due to organized, fibrotic thrombi appearing as thin webs or subtle vascular irregularities rather than filling defects. In this patient, perfusion defects at the distal segmental level of bilateral lungs were likely imperceptible on CT. Medical management with indefinite AC therapy is indicated for CTEPH. Her worsening symptoms after halving AC therapy and minimal improvement with inhaler adjustments highlight the need to distinguish CTEPH from COPD progression, demonstrating the importance of accurate diagnosis.

Comprehensive review of imaging studies and clinical course is essential to diagnose CTEPH as symptoms may often be mimicked or masked by other processes. USEFULNESS OF BEDSIDE ULTRASOUND FOR SUSPECTED INTRA-ABDOMINAL INFECTION YUSUKE NISHIDA1; Yoshitomo Nishikawa1; Kayako Morikawa1; Kazuo Komamura1; Mitsunori Iwase2. 1Emergency Department, Toyota Kinen Byoin, Toyota, Aichi, Japan; 2Cardiology, Toyota Memorial Hospital, Toyota, Aichi, Japan. (Control ID #4273166) CASE: Suppurative pylephlebitis is a rare but life-threatening condition with a reported mortality rate of over 30%. Delayed intervention can result in bowel necrosis, liver abscess, and sepsis, often with fatal outcomes. Timely diagnosis and prompt initiation of treatment are critical. This report highlights a case in which abdominal ultrasound played a pivotal role in the diagnosis of suppurative pylephlebitis secondary to diverticulitis. An 84-year-old male with a history of hypertension and epilepsy presented with a three-day history of fever and limited mobility. There were no significant symptoms other than fever (Temp: 38.3C). Vital signs revealed hypotension (BP: 95/52 mmHg), tachycardia (HR: 139 bpm), and tachypnea (RR: 30 breaths/min). The wide pulse pressure despite hypotension suggests septic shock.The physical examination was unremarkable. Laboratory findings were consistent with marked inflammation (WBC: 19,500/μL; CRP: 33 mg/dL). Initial diagnostic considerations included diverticulitis, appendicitis, acute pancreatitis, and other intra-abdominal infections. Abdominal CT revealed fat stranding near the ascending colonic diverticula and superior mesenteric vein. An ultrasound was performed to further evaluate local inflammation, edema, and blood flow disturbances. Ultrasound did reveal a thrombus within the portal vein, raising a high probability of suppurative pylephlebitis. Contrast-enhanced CT confirmed extensive thrombi in the portal vein, superior mesenteric vein, and inferior mesenteric vein. The diagnosis was suppurative pylephlebitis secondary to diverticulitis. Immediate treatment with meropenem and heparin resulted in rapid improvement of inflammatory markers. Gastrointestinal endoscopy excluded malignancy. The patient recovered well and was discharged on day 31. IMPACT/DISCUSSION: Suppurative pylephlebitis is characterized by thrombotic inflammation of the portal vein or its tributaries. While it is often associated with cirrhosis, malignancy, or thrombophilic disorders (e.g., protein C or S deficiency, antiphospholipid syndrome), it may also result from intra-abdominal infections such as diverticulitis, appendicitis, or acute pancreatitis. The condition typically manifests without specific symptoms, presenting a diagnostic challenge. In this case, early identification of a portal vein thrombus by abdominal ultrasound allowed for prompt diagnosis and successful treatment.

Suppurative pylephlebitis remains a rare but serious complication of diverticulitis. Abdominal ultrasound is a valuable tool for early detection, allowing for timely intervention and improved patient outcomes. WARM AUTOIMMUNE HEMOLYTIC ANEMIA PRESENTING AS INCIDENTAL HYPERBILIRUBINEMIA Jenna Wettstein1; Whitney Lynch2. 1Medical School, Medical College of Wisconsin, Milwaukee, WI; 2University of Kentucky, Lexington, KY. (Control ID #4248726) CASE: 84 y/o male with HTN, HLD, afib, and celiac disease presented to establish care. Screening labs were obtained including LFTs with plan for statin titration. Results showed elevated total bilirubin level of 2.0mg/dL with normal AST, ALT, alk phos levels. A direct bilirubin level was 0.4mg/dL. Additional workup of indirect hyperbilirubinemia showed a hemoglobin 11.1g/dL, MCV 107.8fL, LDH 270U/L, and haptoglobin <10mg/dL. Blood smear was consistent with macrocytosis with concern for hemolysis. The patient was referred urgently to hematology with additional lab testing including an antibody screen and was diagnosed with WAIHI. He was started on prednisone 1mg/kg with PPI therapy and atovaquone for PCP prophylaxis due to a sulfa allergy. Flow cytometry wasn't suggestive of a lymphoproliferative disorder, and CT chest, abdomen, and pelvis were negative for lymphadenopathy or malignancy. A prednisone wean was initiated to 30mg daily but given ongoing hemolysis, the patient was initiated on Rituximab infusions with continuation of Prednisone ultimately weaned to 10mg daily. He completed a month long Rituximab course but ultimately developed symptomatic anemia with a hemoglobin of 8.0g/dL requiring hospitalization with administration of 2 units of packed red blood cells and high dose Solumedrol 500mg IV for 3 days. Bone marrow biopsy was normal. He was discharged on Prednisone 60mg/daily. Hemoglobin at discharge was 8.3g/dL and improved to 9.7g/dL at follow up. During that visit, he was started on Mycophenolate 500mg BID with initiation of Prednisone wean by 10mg daily per week. He had ongoing improvement in hemoglobin up to 13.4g/dL one month post-hospitalization. Labs remained stable for 7 months on Mycophenolate 500mg BID until hemolysis recurred. He was switched back to Rituximab infusions (completed 4 doses) with plan to monitor clinically and repeat labs to assess hemoglobin stability. Reinitiation of steroids was deferred due to side effects and stable hemoglobin. To date, hemoglobin remained stable at 10.8g/dL after a second round of 4 Rituximab infusions. IMPACT/DISCUSSION: Autoimmune hemolytic anemia is a disease where the body creates autoantibodies to attack one’s red blood cells. In warm autoimmune hemolytic anemia (WAIHI), these antibodies activate at body temperature. WAIHI can be associated with medications, lupus, or lymphoproliferative disorders and results in symptomatic and life-threatening anemia due to hemolysis. Patient's symptoms are related to the degree of anemia. Initial workup in asymptomatic patients is often precipitated by new-onset anemia. Other lab abnormalities include indirect hyperbilirubinemia, elevated LDH, and low haptoglobin.

This case illustrates the importance of pursuing additional workup of unexplained lab abnormalities given these abnormalities may precede symptoms or clinical progression. WAIHA specifically requires additional investigation to rule out potential causes that may have improved prognosis with early detection. WHAT DOES NOT KILL YOU, DOES NOT ALWAYS MAKE YOUR STRONGER: AN UNEXPECTED CAVITARY LUNG LESION Mohamad Saleh Alabdaljabar, Kathryn del Valle. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4246351) CASE: A 76-year-old male was admitted for expedited workup of a cavitary lung lesion that was found on a chest CT scan. His medical history is significant for metastatic papillary thyroid cancer (2021, treated with near total thyroidectomy and radioactive iodine 6 months prior to presentation). The patient has been following with endocrinology for his thyroid cancer. His annual CT showed a new 18 x 13 mm thick-walled cavitary lesion in the right apex with surrounding satellite micronodularity, a 5 mm cavitary nodule, and a few other smaller stable nodules. Given the radiographic appearance, infectious etiology was suspected, and he was admitted for expedited workup. Clinically, he was asymptomatic with reassuring physical exam. Laboratory studies were notable for: undetectable TSH and normal thyroglobulin levels. He had extensive infectious workup that was negative, including mycobacterial, fungal, and bacterial studies. On subsequent imaging approximately 8 weeks later, the lesion had increased in size to 35 x 25 mm. He underwent bronchoscopy with transbronchial biopsy which showed metastatic high-grade carcinoma consistent with dedifferentiation of patient's known papillary thyroid cancer to anaplastic thyroid cancer (ATC); this was positive for B-raf kinase (BRAF) 600E mutation, and he was started on targeted therapy with dabrafenib and trametinib. IMPACT/DISCUSSION: Many diseases can manifest in the form of cavitary lung lesions. These include infections, tumors, and autoimmune diseases, in addition to mimickers (e.g., cysts, infected bullae). Clinical assessment, including symptoms nature and duration, and radiological features are key to decide on next steps. Herein, the CT appearance of the lesion was suggestive of an infectious etiology (i.e., fungal, tuberculosis), but the lack of clinical symptoms argued against it. His oncological history raised suspension for malignancy. Thyroid cancer is rare (1% of all cancers), and <5% of thyroid cancer patients may have cellular dedifferentiation. As with this patient, undetectable TSH and low/normal thyroglobulin levels can be misleading and falsely reassuring. Dedifferentiated thyroid cancer also typically have more aggressive growth and metastasis rate and loss of iodide uptake ability, making their diagnosis and treatment more challenging. Approximately 20-50% of ATCs are BRAF 600E mutation positive and can be treated with targeted immunotherapy. Cancer recurrence and secondary malignancy are important entities to remember in cancer survivors, which can present in various ways.

Cavitary lung lesions may be caused by a wide variety of pathologies. It is important to have a broad differential diagnosis and tailor that based on the clinical and radiological assessment to guide management. WHEAT LIES BENEATH: ANEMIA AS THE FIRST SIGN OF CELIAC DISEASE Anita Mahadevan1; Cary Blum2. 1Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272573) CASE: A 29-year-old male with no past medical history presented to his PCP to establish care. Initial labs revealed iron deficiency anemia (IDA) with a hemoglobin (Hgb) of 9.9 g/dL, mean corpuscular value (MCV) 75.5 fL, transferrin saturation (TSat) 6% and ferritin 3 ng/mL. Review of systems was negative. Initial workup revealed normal IgA, strongly positive anti-tissue transglutaminase (tTG) IgA ten times the upper limit of normal and positive anti-gliadin IgA. He was referred to gastroenterology, who obtained genetic tests notable for a positive HLA-DQ2 allele. Esophagogastroduodenoscopy (EGD) demonstrated duodenal villous atrophy and crypt hyperplasia consistent with celiac disease (CD). Following diagnosis, he started a gluten-free diet with improvements in subjective strength and energy. Six months later, his Hgb was 15.6 g/dL(MCV 85 fL), ferritin 66 ng/mL, and iron supplementation was discontinued. His anti-tTG IgA had reduced by 50% after six months and by ten months was only weakly positive. IMPACT/DISCUSSION: While abdominal symptoms and low body weight are in the traditional illness script of CD, many patients are asymptomatic and/or diagnosed based on the presence of an extraintestinal manifestation such as iron deficiency anemia. The prevalence of CD among patients with asymptomatic IDA is reported to be between 2-6%, rising to 10-15% in patients with symptomatic IDA. Therefore, the finding of unexplained iron deficiency should trigger screening for CD, even in patients without GI symptoms. Initial screening for CD includes an IgA level and anti-tTG IgA titers with or without anti-gliadin and anti-endomysial IgA testing. A one-time initial IgA level is crucial because 2-3% of patients with CD also have IgA deficiency, which if present, reduces the sensitivity of anti-tTG IgA and should prompt an IgG-based assay. Anti-tTG IgA has a sensitivity of 85-92% and a specificity of 97-98%, positioning it as a useful first-line diagnostic test. Anti-endomysial IgA and anti-gliadin IgA testing have more limited applications given sensitivities of 74-90% and 60-80% respectively; however, both are highly specific. If serologies are positive, HLA genetic markers (DQ2 and DQ8) may be performed to help determine necessity of endoscopic biopsy. While biopsy is the gold-standard diagnostic test in CD, it may not be necessary in patients with positive antibodies, positive genetic testing, and compelling manifestations of the disease. Antibody serologies should be trended every 6 months to monitor disease activity.

Celiac disease is a potential etiology of iron deficiency anemia even in the absence of gastrointestinal symptoms. Testing for CD should be part of an initial IDA workup when no other cause is apparent. Anti-tTG IgA is the best initial test in patients without selective IgA deficiency and may be trended as a measure of disease activity. WHEN A COMMON WORK-UP FOR ASYMPTOMATIC TRANSAMINITIS REVEALS A RARE MASS: DISCOVERY OF A PANCREATIC NEUROENDOCRINE TUMOR AND A MULTIDISCIPLINARY APPROACH TO MANAGEMENT Katherine Kruse1; Rachel H. Kon2. 1Internal Medicine, University of Virginia, Charlottesville, VA; 2Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4271091) CASE: A 48-year-old male with a history of hypertension, hyperlipidemia, alcohol and tobacco use was found to have a mild transaminitis on routine labs. He was asymptomatic. A hepatic ultrasound was obtained with the expectation that this was metabolic-associated steatotic liver disease and surprisingly revealed an 11 cm epigastric mass and multiple vascular hepatic lesions. To better characterize the mass, a CT scan of the abdomen and pelvis was ordered and showed a pancreatic neoplasm with invasion into the spleen and possible liver metastasis. The differential for a mass like this includes pancreatic adenocarcinoma, pancreatic neuroendocrine tumor, pancreatic cyst or a tumor originating from a nearby organ including cholangiocarcinoma or gastrointestinal stromal tumor. Biopsy was needed to determine a diagnosis, and with assistance from gastroenterology, the patient underwent endoscopic ultrasound (EUS) and fine needle aspiration of the mass. Cytology revealed a grade 1, well-differentiated neuroendocrine tumor. A PET scan confirmed pancreatic NET with metastases to the spleen and liver. After discussion with surgery, oncology and gastroenterology, the patient was started on octreotide, a somatostatin analogue, to slow tumor growth until surgery. The patient ultimately underwent distal pancreatectomy, splenectomy, partial gastrectomy and hepatic subsegmentectomy with the intent to cure; however, a repeat CT scan post-surgery showed small areas of disease in the liver, so he has remained on a somatostatin analogue. Because of his splenectomy, he has required additional pneumococcal, H flu and meningococcal vaccines. Due to the pancreatectomy, his A1c increased from 5.5% to 6.9% within one year, and he was started on metformin. IMPACT/DISCUSSION: Although pancreatic NETs are rare, their incidence is increasing due to detection on imaging obtained for other reasons.1 Additionally, as this case shows, most pancreatic NETs are nonfunctioning and do not present with the classic hormonal symptoms commonly associated with NETs. Internists should consider pancreatic NET in an asymptomatic patient with an epigastric mass and work closely with a multidisciplinary team to obtain an EUS with biopsy, CT and PET imaging. Lastly, this case points out the importance of the primary care provider in ongoing management of vaccinations and diabetes in these patients.

The incidence of pancreatic NETs is increasing and the diagnosis should be considered in an asymptomatic patient with an epigastric mass. Surgical resection and somatostatin analogues can be used to cure or slow growth of NET. Splenectomy vaccines and A1c monitoring are necessary for many patients who have had surgical resection of pancreatic NET. 1. Sonbol MB, Mazza GL, Mi L, et al. Survival and Incidence Patterns of Pancreatic Neuroendocrine Tumors Over the Last 2 Decades: A SEER Database Analysis. Oncologist. 2022;27(7):573-578. doi:10.1093/oncolo/oyac049 WHEN A LAB BREAKS THE ROUTINE: THE A1C YOU CANNOT SEE Daniel Boctor2; Janet N. Chu1. 1Internal Medicine, University of California San Francisco, San Francisco, CA; 2Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4273080) CASE: A 63-year-old male with Type 2 diabetes mellitus, hyperlipidemia, and hypertension presented to primary care clinic to for routine follow up. He had no medical complaints, review of systems was negative, and vital signs and physical exam were unremarkable. Medications included metformin 1000 mg twice daily, lisinopril 20 mg daily, and atorvastatin 40 mg daily. A year prior, the hemoglobin A1C (A1C) was 6.2%. During the visit, a follow up A1C was ordered, and was 4.4%; the patient denied changes to diet, exercise habits, or metformin dose. Metformin was decreased to once daily dosing. Five months later, the A1C was undetectably low (less than 4%). Additional laboratory testing, including a complete blood count, showed a new normocytic anemia (hemoglobin of 9.8 g/dL from baseline > 13 g/dL). Peripheral blood smear showed normal platelets, 2-5 elliptocytes, 2-5 polychromasia. Iron studies showed a ferritin 129 ng/mL and 18% saturation. Reticulocyte count was 308 x 10^9 cells/L, total bilirubin 1.6 mg/dL (direct 0.5 mg/dL), haptoglobin undetectably low (<6 mg/dL), and LDH 397 U/L. The direct antiglobulin test (DAT) was positive. A computed tomography (CT) scan of the chest and abdomen showed mild splenomegaly with enlarged lymph nodes in the splenic hilum and periceliac chains. Additionally, a positron emission tomography (PET) CT demonstrated hypermetabolic bone marrow. Repeat laboratory testing showed worsening hemolysis and the patient was urgently admitted to the hospital for an expedited workup. A bone marrow biopsy and right cervical lymph node biopsy flow cytometry were completed; findings were consistent with a mature B-cell lymphoma. He was started on prednisone and subsequent labs showed a normalization of haptoglobin and LDH and improvement of hemoglobin back to baseline. He weaned off prednisone and completed a course of rituximab. IMPACT/DISCUSSION: Diabetes mellitus can be diagnosed based on two elevated levels of A1C, fasting plasma glucose, or oral glucose tolerance test. The advantages of using A1C testing include convenience (no need to fast) and reduced impact from day-to-day variations from nutrition or illness. The A1C reflects glucose bound to hemoglobin during the life span of the erythrocyte (about 120 days). Therefore, factors that impact hemoglobin concentrations or erythrocyte turnover can affect the accuracy of A1C. In this case, the erythrocytes were rapidly destroyed from an autoimmune hemolytic anemia (AIHA), resulting in a falsely low A1C. In 50-60% of cases, AIHA is caused by an infection, autoimmune disease, certain immunodeficiencies, or a lymphoproliferative disorder. In this case, autoantibodies from marginal cell lymphoma led to AIHA. This resulted in early destruction of erythrocytes leading to lower circulating erythrocytes.

The patient was otherwise asymptomatic and the abrupt drop in A1C was the first hint of a pathologic process; workup revealed an AIHA and he was ultimately diagnosed and treated for marginal zone lymphoma. WHEN ANTIFUNGAL THERAPY GOES AWRY: POSACONAZOLE-INDUCED HYPERTENSION AND HYPOKALEMIA IN A POST-HEMATOPOIETIC CELL TRANSPLANT PATIENT Jared Dashevsky1; 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 #4269867) CASE: A 47-year-old male with hepatosplenic T-cell lymphoma post-hematopoietic cell transplantation complicated by post-transplant relapse, GVHD of the upper gastrointestinal tract, IBD, and hypertension, presented with worsening hypertension and hypokalemia while on posaconazole for fungal prophylaxis. In the year prior to his presentation, the patient had an average blood pressure of 127/78 and average potassium of 4.09 mmol/L while taking amlodipine 5 mg and olmesartan 20 mg. By early 2024, the patient developed worsening hypokalemia (2.8 mmol/L) and weekly average blood pressure of 153/83 despite adjustments made to his antihypertensive therapy. Further workup then revealed suppressed renin (<1 ng/mL) and aldosterone levels (<1 ng/dL), raising concern for posaconazole-induced syndrome of apparent mineralocorticoid excess (AME). Posaconazole trough levels were 2.9 μg/mL, an increase from 1.4 μg/mL two years prior. Posaconazole was switched to isavuconazonium, with improvement in hypokalemia and weekly average blood pressure readings of around 130/80. IMPACT/DISCUSSION: Our patient’s presentation is consistent with posaconazole-induced AME. Posaconazole inhibits 11β-hydroxysteroid dehydrogenase type 2 (11βHSD2), which blocks the conversion of the metabolically-active cortisol to the inactive cortisone. Increased circulating cortisol results in hypertension, hypokalemia, and suppressed renin levels due to cortisol’s activity on the aldosterone receptor. However, in contrast with true hyperaldosteronism, aldosterone levels in AME are found to be low. The patient’s clinical course—marked by worsening hypertension, hypokalemia, suppressed renin and aldosterone, and improvement upon discontinuing posaconazole—strongly supports AME as the underlying cause and aligns with previously reported cases. Importantly, a posaconazole level of 2.9 μg/mL, at the threshold associated with AME, further supports this diagnosis. This case reinforces AME as a dose-dependent adverse effect linked to the azole antifungals posaconazole and itraconazole. Clinicians should monitor blood pressure, electrolytes, and drug levels closely in patients on these drugs. If AME is suspected, switching to an antifungal that does not inhibit 11β-HSD2, such as isavuconazonium, results in improvement.

1) Posaconzaole inhibits 11β-HSD2, a key enzyme in the aldosterone synthesis pathway, causing a buildup of the metabolite cortisol and ultimately resulting in clinical hyperaldosteronism despite a low aldosterone level. 2) Alternative therapies, such as isavuconazonium, should be considered in patients with AME who require ongoing antifungal therapy. WHEN BRUISES TELL THE TALE: METASTATIC PROSTATE CANCER PRESENTING AS HYPERFIBRINOLYTIC DIC Mary F. Ettori1; Ryan Truitte3; Anne Cioletti2. 1Internal Medicine, University of Utah Health Hospitals and Clinics, Salt Lake City, UT; 2Internal Medicine, University of Utah Health, Salt Lake City, UT; 3Internal medicine, University of Utah Health Huntsman Cancer Institute, Salt Lake City, UT. (Control ID #4272041) CASE: An 82-year-old male with a history of prostate adenocarcinoma (AC) treated with radiation therapy in 2021, type 2 diabetes mellitus, and remote coronary artery disease presented to his primary care physician for an annual physical. He reported an “itchy bite” on his right ankle and 24 hours of reddish urine. He recently stayed in a cabin in Idaho, denying insect bites or other exposures. Physical examination revealed swelling, induration, and erythema of the right ankle. Multiple large, atraumatic ecchymoses were noted on the right lateral calf, left anterior thigh, right ulnar wrist, and left palmar wrist, sparing the trunk and abdomen. Laboratory evaluation showed prolonged PT/INR (21.1 seconds), elevated PTT (45 seconds), thrombocytopenia (platelet count 90 k/uL), and stable mild anemia. These findings prompted urgent referral to the emergency department (ED). Further evaluation in the ED confirmed disseminated intravascular coagulation (DIC) with hyperfibrinolysis, gross hematuria, and a small nonocclusive thrombus in the right common iliac vein. PSA levels were markedly elevated at 31.8 ng/mL (previously 4.05 ng/mL nine months prior). PET/CT imaging revealed widespread metastatic disease involving pelvic and retroperitoneal lymph nodes and multiple bone lesions. A core needle biopsy confirmed Stage IVB prostate AC. Anti-androgen therapy with bicalutamide was initiated, resulting in rapid resolution of DIC. The patient was subsequently started on apixaban for the right iliac vein thrombus and referred for ongoing oncologic care. IMPACT/DISCUSSION: Disseminated intravascular coagulation is a complex and life-threatening syndrome characterized by systemic activation of coagulation pathways, causing simultaneous thrombosis and hemorrhage. Common causes include severe infections (39.8%), trauma (16.9%), and malignancy (6.8%). In malignancy-associated DIC, tumor-derived procoagulants, such as tissue factor and cancer procoagulant, drive excessive activation of coagulation pathways. Prostate cancer-associated DIC is rare and typically occurs in advanced disease stages, correlating with high tumor burden or aggressive tumor biology. In this case, unexplained bruising and hematuria led to the diagnosis of DIC, revealing advanced metastatic prostate cancer. The resolution of DIC following anti-androgen therapy highlights the critical role of hormonal manipulation in managing prostate cancer-related paraneoplastic syndromes. Despite treatment, the prognosis for malignancy-induced DIC remains poor, with reported median survival as low as 26 weeks.

This case emphasizes the importance of considering metastatic malignancy in patients with unexplained bleeding, bruising, or coagulopathy, especially those with a history of cancer. Early recognition and treatment of the underlying etiology are crucial in mitigating potentially fatal complications and guiding oncologic management. WHEN FLINTSTONES ARE NOT ENOUGH: AN UNUSUAL PRESENTATION OF PROTEIN-LOSING ENTEROPATHY (PLE) IN A PATIENT WITH NON-CIRRHOTIC PORTAL HYPERTENSION Olivia Ahearn, Karen Kimel-Scott. Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #4266829) CASE: A 28-year-old female with non-cirrhotic portal hypertension due to extensive splanchnic thromboses from an unspecified hypercoagulable state, complicated by ischemic small bowel requiring jejunal resection presented with abdominal pain, diarrhea, and persistently low albumin unexplained by malnutrition, proteinuria, or impaired protein synthesis. Prior endoscopy noted grade 1 esophageal varices and portal hypertensive gastropathy, and colonoscopy was unremarkable. She developed 3+ pitting edema in her lower extremities and anasarca and was treated with oral butmetanide. A 24-hour stool Alpha1AntiTripsyn was found to be elevated concerning for PLE. Specialized Dietician consult recommended frequent intake of high-protein, high-medium-chain triglycerides (MCT), and low-fat foods. Labs revealed low levels of transferrin, ceruloplasmin, zinc, copper, iron, and fat-soluble vitamins. She received IV copper, oral zinc and copper, vitamin A, D, and a multivitamin. Her portal hypertension led to hepatic fibrosis with decompensation including esophageal variceal bleeding, ascites, and hepatic encephalopathy. She started pancrelipase for pancreatic insufficiency. She has had exacerbations of volume overload refractory to oral diuretics due to hypoalbuminemia as well as persistent vitamin deficiencies after IV and oral repletion. Possible future treatments include outpatient albumin infusions, home parenteral nutrition, and evaluation for small bowel transplant. IMPACT/DISCUSSION: PLE is a rare condition that should be suspected in patients with hypoproteinemia unexplained by other causes. It is characterized by low levels of serum proteins with longer half-lives as well as protein-bound components. We report the case of a woman with non-cirrhotic portal hypertension found to have a PLE. This may be explained by intestinal lymphangiectasia and complicated by malabsorption from her jejunal resection. A review of the literature shows that patients should be maintained on a high-protein, high-MCT, and low-fat diet through protein supplements or MCT preparations including oils or powders. Recommended protein intake is 1.5-3 g/kg/day in adults. Essential long-chain polyunsaturated fatty acids must be supplemented. Serum levels of carrier proteins, trace elements, and fat-soluble vitamins should be obtained every three to six months. Our case illustrates the extensive monitoring and repletion required in patients with PLE to maintain appropriate nutrition.

PLE typically presents with deficiencies of serum proteins as well as iron, lipids, trace elements, and fat-soluble vitamins. Patients should be maintained on a high-protein, high-MCT, and low-fat diet, obtain 1.5-3 g/kg/day of daily protein, and ensure adequate intake of essential long-chain polyunsaturated fatty acids. WHEN HORMONES COLLIDE: THE IMPACT OF ORAL CONTRACEPTIVES ON LEVOTHYROXINE DOSING Chris Elsayad2; Annalise Cheshire1; Erica Lee2; Shah H. Ahmad2. 1American University of the Caribbean School of Medicine BV, Cupecoy, Sint Maarten (Dutch part); 2Internal Medicine, Nassau University Medical Center, East Meadow, NY. (Control ID #4272888) CASE: A 42-year-old female presented to the outpatient primary care clinic with a history of hypothyroidism, TI-RADS 4 thyroid nodules, menorrhagia, anemia, and prediabetes. She was clinically euthyroid, denying fatigue, weight gain, cold intolerance, dry skin, or cognitive slowing and was adherent to her levothyroxine of 50 micrograms daily. Recently, she discontinued her estrogen-containing oral contraceptive pill (OCP) and had a Mirena® intrauterine device (IUD) inserted. On examination, the patient was vitally stable. Her thyroid gland was neither visible nor palpable. Initial labs, drawn while the patient was on estrogen- containing OCPs, showed an elevated thyroid-stimulating hormone level of 6.29 mIU/L (reference: 0.55–4.78). Five weeks after transitioning to the Mirena® IUD, repeat labs demonstrated a TSH within normal limits (2.93 mIU/L). The patient’s management plan included follow-up with endocrinology, gynecology, and primary care. IMPACT/DISCUSSION: This case highlights the significant yet underexplored interaction between levothyroxine and estrogen-containing OCPs. Estrogen increases thyroid-binding globulin (TBG) production and reduces its clearance and while this mechanism is well-documented in pregnancy, its implications for OCP users are not widely studied, leaving a gap in clinical management guidelines. The normalization of TSH levels after transitioning to a non-estrogen-containing contraceptive supports the hypothesis that women on OCPs should be individually monitored and dose adjustments should occur for optimal outcomes. This case adds to the literature by emphasizing the need for targeted research, evidence-based guidelines, and interdisciplinary collaboration to improve care for the millions of women managing hypothyroidism and using hormonal contraception.

Thyroid Hormone Regulation and Estrogen Interaction: Estrogen-containing OCPs increase thyroid-binding globulin (TBG) levels, potentially leading to elevated TSH and necessitating higher levothyroxine doses in women with hypothyroidism. Regular thyroid function testing is essential during changes in hormonal contraception to ensure appropriate levothyroxine dosing and prevent subtherapeutic outcomes. Optimized management of hypothyroidism in women requires awareness of this interaction, collaboration across specialties, and research to establish clearer dosing guidelines. WHEN THE HEART SKIPS A BEAT: A CASE OF UNEXPLAINED CONDUCTION ABNORMALITIES Erica Comsti, Allison Samuel, Rachel Engelberg. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4270600) CASE: A 55-year-old female with a history of gestational hypertension (HTN) presented with 2 weeks of new palpitations, worsened by activity and relieved with rest. She denied chest pain, dyspnea, orthopnea, weight loss, heat intolerance, or irregular periods. She had no known history of cardiac or thyroid disease and was not on medications. Resting EKG showed a 2:1 second-degree atrioventricular (AV) nodal block. She was sent to the ED, where repeat EKG showed Mobitz II with 2:1 block and a heart rate in the 30s. The patient was asymptomatic, and her exam was otherwise unremarkable. Serial troponins and Lyme serologies were negative. Exercise treadmill testing (ETT) revealed progression to a 3:1 block, suggesting infranodal disease. The worsening block correlated with her worsening palpitations during exertion. Cardiac MRI showed mild left ventricular dilation but no other abnormalities. A pacemaker was placed and genetic work-up was planned after discharge, as no clear etiology of the block was identified. IMPACT/DISCUSSION: Palpitations can be non-specific, especially in otherwise healthy individuals. However, a high index of suspicion is essential in the context of new or worsening conduction abnormalities. Asymptomatic 2nd degree AV block is more common in older males with a history of myocardial infarction, heart failure, chronic HTN, and diabetes—none of which was present in this patient. The progression from 2:1 to 3:1 AV block during ETT underscores the importance of early detection and intervention to prevent further progression to complete heart block or sudden cardiac death. It is interesting that the work-up for an underlying disorder has been negative. Studies show that over 30% of unexplained high-grade heart block in middle-aged adults is due to cardiac sarcoidosis, while anywhere from 5-67% is due to genetic causes, most commonly mutations in the LMNA gene (though de novo mutations are exceedingly rare, with few cases reported). Despite the absence of a family history of cardiac disease, genetic testing is warranted to investigate potential hereditary causes that could impact future generations.

1. Internists should have a low threshold for pursuing diagnostic testing in patients with new 2nd degree AV block due to the risk of sudden cardiac death or arrhythmias. 2. Functional testing (e.g., ETT) may elucidate the severity of a conduction block and guide early intervention. 3. Genetic testing should be considered in patients with unexplained conduction abnormalities, even without a family history of cardiac disease. WHEN “CLASSIC FINDINGS” ARE WRONG: INTRAHEPATIC CHOLANGIOCARCINOMA INITIALLY MISDIAGNOSED AS HEPATOCELLULAR CARCINOMA Stephanie Arnouk1; Valerie Stark1; Anne Barnes2; Jillian S. Catalanotti1. 1Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Medicine, George Washington University Medical Faculty Associates, Washington, DC. (Control ID #4246225) CASE: A 71-year-old woman with hypertension, peripheral arterial disease and chronic kidney disease presented with poor appetite, abdominal discomfort, and a 13-pound unintentional weight loss over one year. Physical examination showed generalized upper abdominal tenderness. Initial lab results indicated normal liver and biliary chemistries, negative Hepatitis B and C tests, and baseline creatinine levels. Lumbar MRI performed for radiculopathy incidentally revealed hepatic lesions. Contrast-enhanced multiphase MRI showed multiple arterially hyper-enhancing hepatic masses with central washout, and an elevated alpha-fetoprotein (AFP) level of 1,145 ng/mL. PET scan suggested HCC. A tumor board diagnosed multifocal HCC based on imaging and AFP, recommending systemic chemotherapy without biopsy. Despite this recommendation, biopsy was performed, revealing adenocarcinoma and leading to a revised diagnosis of intrahepatic cholangiocarcinoma (iCCA). The patient began chemotherapy with cisplatin. Repeat PET imaging showed interim improvement with partial resolution of hepatic lesions and no evidence of distant metastases. IMPACT/DISCUSSION: Primary malignant liver tumors include hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and, very rarely, others. Intrahepatic CCA (iCCA) is rare, accounting for about 3% of all gastrointestinal tumors and 10% of primary liver tumors. Its incidence has increased dramatically in recent decades, with a projected rise of 55% from 2020 to 2024. iCCA has the poorest prognosis among primary liver tumors, with a 5-year survival rate ranging from 13-42%. It is often diagnosed at an advanced stage due to nonspecific symptoms like jaundice, abdominal pain, malaise, and weight loss. When a hepatic lesion appears heterogeneous or poorly demarcated, contrast-enhanced imaging is crucial to distinguish from normal liver tissue. Multiphase cross-sectional imaging with CT or MRI can be used to assess vascular characteristics. Typically, HCC shows arterial phase hyperenhancement followed by venous phase washout, whereas iCCA appears as a hypovascular mass with progressive peripheral enhancement, especially in the delayed phase. Such findings are considered “classic”, but these can lead to misdiagnosis. Consequently, biopsy may be necessary. Our patient’s lesions mimicked HCC, yet she lacked typical risk factors and elevated liver enzymes, which is atypical. She also lacked risk factors for iCCA, such as biliary sclerosis, inflammation, inflammatory bowel disease, cirrhosis, alcohol use, or hepatitis. While imaging often suffices for diagnosis, biopsy is essential when imaging and clinical history are inconsistent, as for our patient.

Primary hepatic malignancies (typically HCC or CCA) are often incidentally detected on imaging; the next diagnostic step includes contrast-enhanced multiphase CT or MRI. "Classic" imaging may be diagnostic, but consider biopsy when the clinical presentation is inconsistent. ZOSTER AND THE FOG: UNRAVELING CONFUSION IN A SHINGLES PATIENT Rohan Karanth, Nisha Viswanathan. Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4271234) CASE: A 49 year-old male with hypertension, type 2 diabetes on insulin, end stage renal disease on peritoneal dialysis (PD), and recent diagnosis of herpes zoster presented with gait instability, hallucinations, forgetfulness, and slowed speech for five days. Patient lives at home with his wife and has no pertinent family history. He was on valacyclovir 1 gram twice daily, as well as carvedilol, hydralazine, olmesartan, furosemide, insulin, sevelamer, and a Vitamin D supplement. On exam, he showed hemorrhagic erosions in the left V1 dermatome but no active zoster lesions. Neurologic exam showed slowed speech, but no focal neurological deficits. He was noted to have a peritoneal dialysis catheter without abdominal tenderness. Of note, the patient had been diagnosed with zoster three weeks prior to presentation. He was treated with fourteen days of oral antibiotics, as well as valacyclovir, without resolution of lesions. Ophthalmology had seen the patient five days prior to arrival and had found no ocular involvement, but they lengthened the course of his valacyclovir and increased his dosage. Labs were notable for hyponatremia (122) and hyperglycemia (276). MRI was attempted but aborted due to patient anxiety. Lumbar puncture showed normal protein, glucose and mild pleocytosis. Further CSF studies resulted, including HSV and VZV PCRs, which were negative. Toxicology was consulted as it was noted valacyclovir was dosed supra-therapeutically for the patient’s renal function. Toxicology noted the patient's presentation could be consistent with drug toxicity and recommended holding valacyclovir. Within 24 hours of holding valacyclovir, the patient had an improvement of symptoms. By the time of discharge four days later, the patient’s neurologic status had returned back to baseline, and his case was attributed to valacyclovir toxicity. IMPACT/DISCUSSION: Valacyclovir neurotoxicity is a rare but serious complication, particularly in patients with renal impairment. The risk of this complication is increased in patients on PD as clearance of the drug is reduced which can rapidly lead to supratherapeutic levels. Early recognition is imperative, making it important for clinicians to be aware of this side effect. This case adds to the limited literature on valacyclovir effects in PD patients. It also highlights the need for close review of prescribing practices in patients with renal impairment to improve patient safety. This is especially important in clinical environments where renal dosing is not commonly done, such as in this case.

-This case highlights the risks of valacyclovir neurotoxicity in PD patients and underscores the need for careful dose adjustments based on renal function. -Coordination of care between subspecialists can help prevent drug toxicities in patients with complex care needs. Clinical Vignette - Artificial Intelligence in Healthcare A PAGE-TURNING CLINICAL MYSTERY: UNCONTROLLED HYPERTENSION AFTER RENAL BIOPSY Karly Hampshire, Jeffrey Paer. Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY. (Control ID #4272404) CASE: A 31-year-old male with a history of untreated hypertension and CKD presented to an academic medical center with headache and hematuria. He was found to be hypertensive to 239/139 and with labs notable for a creatinine of 6.9 from 1.2 the previous year. His blood pressure was well controlled with captopril, spironolactone, and nifedipine. He then underwent a bedside renal biopsy. The biopsy had more bleeding than expected but post-procedure hemoglobin was stable. Overnight, he became hypertensive to 220s/120s with flank pain. Blood pressure was refractory to multiple agents. The overnight team asked the clinical artificial intelligence tool Open Evidence “What are causes of uncontrolled hypertension post renal biopsy?”. Open Evidence raised Page kidney, a phenomenon where external compression of the kidney by a subcapsular hematoma activates the renin-angiotensin-aldosterone system (RAAS). The patient was sent for an urgent CT abdomen pelvis, which showed a right renal subcapsular collection with impression of the renal parenchyma concerning for Page kidney. Patient was transferred to the MICU for management of hypertensive emergency. Blood pressure improved on a nicardipine drip. Several hours later, he was taken urgently to the IR suite for a renal artery angiogram. Patient was found to have a pseudoaneurysm, which was embolized. He eventually was initiated on dialysis and discharged. IMPACT/DISCUSSION: While most renal biopsies are uncomplicated, complications can include pain, bleeding, and hematuria. With only 100 cases reported in the literature, Page kidney is a rare diagnosis where external compression of the kidney leads to hypoperfusion, RAAS activation, and hypertension. Most commonly, it results from bleeding into the extracapsular space from blunt trauma or iatrogenic causes like renal biopsy or extracorporeal shockwave lithotripsy. Spontaneous cases have also been described. Diagnosis is made via renal ultrasound or CT. While Page kidney management is not standardized, in milder cases, medical management with RAAS blockade may be appropriate. However, if collections are large or hypertension is severe, invasive intervention with percutaneous or open drainage is warranted. While AI is not without its shortcomings, which have been described elsewhere, this case also highlights the utility of clinical artificial intelligence tools to broaden and refine differential diagnoses, especially for unusual presentations.

- Page kidney is a phenomenon where external compression of the renal parenchyma leads to activation of the renin-angiotensin-aldosterone system, resulting in systemic hypertension - Previously observed after blunt trauma, most cases of Page kidney are now noted after renal biopsy or other proceduralization - When applied responsibly, clinical artificial intelligence tools like Open Evidence can be powerful aids in patient care, broadening differential diagnoses, improving efficiency, and educating trainees ENHANCING TRANSITIONS OF CARE THROUGH AI AUTOMATION OF DISCHARGE SUMMARIES Alexander S. Chen1; Peggy B. Leung2. 1Internal Medicine, Weill Cornell Medicine, New York, NY; 2Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4271507) CASE: Ms. B is a 65 year old woman hospitalized three times in the last three months. After her first hospitalization for viral pneumonia, she was discharged to a subacute rehabilitation center (SAR) with an incorrect insulin dose leading to hypoglycemia and subsequent NSTEMI. Two-vessel disease was found and stents were placed. During her second discharge to a SAR,she noted worsening perineal tenderness, erythema, and fluctuance. She was readmitted a third time for soft tissue infection that progressed to necrotizing fasciitis requiring multiple surgical washouts. Her first discharge appointment was an evening add-on clinic at a primary care clinic. Her final discharge summary was notable for significant copy-pasted text, no medication changes (including no change to the patient’s SGLT2-inhibitor), and no cardiology follow-up one month after an NSTEMI. IMPACT/DISCUSSION: The discharge transition from hospital to outpatient care is a critical period in healthcare delivery, with profound patient safety implications. Poorly coordinated transitions result in increased readmissions, with one in five Medicare patients being re-hospitalized within 30 days of discharge and over $57 billion spent on avoidable readmissions. Discharge summaries (DS) are essential for communication across care settings but they are often delayed, incomplete, or contain erroneous information due to provider burden. There are several key components of discharge summaries that can lower readmission rates, including highlighting medication changes with rationales for changes, procedure and test results, follow-up appointments, and instructions to patients. Additional factors that reduce adverse events include enhanced readability and timeliness. Unfortunately, DS are delayed until after day of discharge over 50% of the time, primary diagnoses are incorrect (up to 55% of DS), discharge medication lists have inaccurate information 36% of the time, and 54% of DS include copy-pasted text that adversely affects readability. Artificial intelligence offers a transformative solution to these persistent challenges by improving documentation quality, timeliness, and by reducing provider burnout. By automating DS generation, AI can standardize critical components such as medication reconciliation, explicit follow-up appointment scheduling, structured communication of procedure outcomes, and flagging potential care coordination gaps. For Mrs. B, this AI tool could have flagged medication discrepancies, ensured appropriate cardiology follow-up, and generated a readable, accurate summary for her primary care physician.

AI-driven automation of discharge summaries has the potential to facilitate transitions of care by ensuring timely, accurate, and standardized discharge communication. By integrating this technology into existing EHR systems, healthcare systems can reduce clinician burden, improve care coordination, and lower readmission rates. Clinical Vignette - Career Development, Professionalism, and Wellness UNCOVERING THE SURPRISING BYSTANDER: A CASE OF DIZZINESS CAUSED BY THE POSTPARTUM THYROID Tamara F. Godfrey. Internal Medicine, University of North Carolina System, Chapel Hill, NC. (Control ID #4229652) CASE: A 39 year old G7P2143 female with HTN, endometriosis, and a remote history of PVCs presented to clinic with 2 days of episodic lightheadedness and dizziness that lasted 2 hours at a time. She had a few loose stools for 2 days but otherwise denied vertigo, hearing loss, nausea, diaphoresis, vision changes, chest pain, shortness of breath, palpitations, or fevers. She had been regularly breastfeeding her 2 month old but was drinking approximately 100 ounces water daily. Physical exam was unremarkable. EKG was normal, and labs were notable for normal CBC and CMP. Symptoms were thought to be due to dehydration so she was encouraged to increase hydration. She presented to the ED 2 days later for the same symptoms – EKG was normal, and labs were notable for normal troponin and CMP except potassium of 3.3 for which she was given IV supplementation. Ziopatch was later ordered by her PCP, which had unremarkable results. She presented to her PCP 5 weeks after the ED visit as the episodes had increased in frequency – they were occurring 3-4 times a week. She confirmed that there were no clear triggers, and there was no improvement after increasing fluid intake or reducing breastfeeding. She denied headaches, rashes, skin lesions, joint pain/swelling, new medications or supplements. Blood glucose and blood pressure were normal around the time of the episodes. Physical exam was unremarkable. Labs were notable for normal CBC/CMP/magnesium/D-dimer, low ferritin, low vitamin D, low TSH (0.026), normal free T4, and negative thyrotropin receptor antibody. She was prescribed iron and vitamin D supplementation. She presented to her PCP for follow up 4 weeks later, and the episodes had continued to increase in frequency. Labs were notable for high TSH (18.029), low free T4 (0.53), and high thyroid peroxidase antibody. She was started on levothyroxine, and on follow up 4 weeks later her symptoms had significantly improved. IMPACT/DISCUSSION: Her labs and time course of symptoms were consistent with postpartum thyroiditis. Postpartum thyroiditis is an autoimmune disorder that occurs in 3-8% of pregnancies. Patients typically start with a hyperthyroid state, which is followed by hypothyroidisim several weeks later. The presenting symptoms can vary depending on the phase of the disease - heat intolerance, fatigue, palpitations, irritability, and weight loss are a few symptoms associated with hyperthyroidism while cold intolerance, dry skin, and fatigue can be associated with hypothyroidism. Dizziness may not be considered as one of the classic symptoms of hyperthyroidism but can occur.

Thyroid disorders can cause a wide array of symptoms and should remain on the differential for patients presenting with lightheadedness and dizziness. The general internist should consider one’s peripartum status when asessing patients' symptoms, as during pregnancy and for several months after there are a variety of unique medical issues that can arise for patients due to significant physiological changes. Clinical Vignette - Geriatrics and Palliative Care ABIRATERONE AND ROSUVASTATIN-INDUCED SEVERE RENAL FAILURE IN VETERAN WITH METASTATIC CASTRATION SENSITIVE PROSTATE CANCER (MCSPC) Dileep K. Mandali. Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4273562) CASE: We present a case of 66-year-old veteran with PMHx of HLD, NIDDIM, HTN, and mCSPC just 3 months prior to presenting with worsening myalgias and dark-colored urine for few days, and was admitted for severe acute kidney injury (AKI) secondary to rhabdomyolysis. He was on rosuvastatin for several years without any complications, and he started abiraterone and prednisone ~1 month ago. On admission, his serum was Cr 11.7H with elevated CK 48,628. He also had elevated LFTs: AST 706, ALT 581, normal Alk Phos 63, Tbili 1.7H. During hospital course, he became anuric and anasarcic with significant scrotal edema and bilateral LE edema due to aggressive IVF for rhabdomyolysis, and failed lasix trial. As a result, he underwent hemodialysis (HD) and showed clinical improvement after discontinuing abiraterone and rosuvastatin. On discharge, he was placed under HD x3 per week MWF and was started on ~27 sessions of radiotherapy only. He continued prednisone. His serum Cr normalized in 3 months and outpatient HD had been concluded at that time. He resumed statin therapy, but his mCSPC treatment is still to be determined. IMPACT/DISCUSSION: Abiraterone is considered as a first-line treatment for metastatic castration sensitive prostate cancer (mCSPC) and castration-resistant prostate cancer (mCRPC). It is a selective and irreversible inhibitor of CYP17, blocking androgen synthesis in testes, adrenal glands, prostate gland, and tumor cells. Additionally, hypercholesteremia has been associated with high grade prostate cancer (Gleason 8-10). As such, statin therapy is common in patients, especially in geriatric population, that are predisposed to prostate cancer and has association with decreased incidence and aggressiveness of prostate cancer. In recent years, rhabdomyolysis slowly emerged as a major adverse event in patients on abiraterone, and it is linked to the concurrent use of specific statin therapy. We aimed to further explore this association in the context of our own case study and published literature.

The mechanism for the concurrent use of abiraterone and statin resulting in rhabdomyolysis is largely unknown. It is speculated that abiraterone may lead to rhabdomyolysis by inhibiting the hepatic uptake transporter OATP1B1, thereby increasing its plasma concentration which predisposes patients to muscle toxicity. Abiraterone may also raise plasma concentration of statins via competitive inhibition of CYP3A4 and CYPD2D6. Interestingly, few case reports that have been published on rhabdomyolysis due to concurrent use of abiraterone and statin, all but one included high-dose rosuvastatin, the other being simvastatin. This illustrates the need for routine monitoring of liver function tests to mitigate rhabdomyolysis risk. Further research is warranted to better establish correlation between abiraterone and different types and doses of statins in the setting of hepatotoxicity, and the need for alternatives to statin therapy. ADVANCE CARE PLANNING IN ADULT CONGENITAL HEART DISEASE (ACHD) Rhea Patil1; Jill Steiner2. 1Internal Medicine, University of Washington, Seattle, WA; 2Cardiology, University of Washington, Seattle, WA. (Control ID #4240513) CASE: A 33-year-old with complex single ventricle heart disease was hospitalized for decompensated heart failure. Persistent hypotension prompted transfer to the intensive care unit. After days of minimal improvement, Palliative Care was consulted. No advance care planning (ACP) documents were on file. The inpatient Palliative Care team expressed concern regarding the ongoing need for life-supporting interventions. The patient was surprised that they may not survive this hospitalization and that their prognosis was less than six months. With continued medical deterioration, their code status was changed to Do Not Resuscitate and they transitioned to Comfort Care. This hospitalization was this patient’s fifth for heart failure in nine years. They were referred to outpatient Palliative Care after their first hospitalization. However, they did not feel ready to engage with Palliative Care until they were hospitalized 3 more times and had progressive difficulty with symptom control, 7 years after the initial referral. Prior to the terminal hospitalization, the patient had 6 outpatient Palliative Care visits over 2 years. They shared frustration over their health, need for constant medical attention, and lack of autonomy. Despite these visits, the patient felt overwhelmed trying to synthesize their goals of care into the fields provided on ACP forms. Although their health declined to the point of severe debility, they wanted to remain Full Code and evaluate each medical intervention individually. IMPACT/DISCUSSION: This case illustrates the complexities of ACP for patients with ACHD. Timely ACP is integral to ACHD care given the expected morbidity and mortality. Patients usually have a long-term ACHD clinician, but an Internal Medicine physician is often directing care during acute medical events. ACP in ACHD is rarely performed prior to patients’ end-of-life. This patient’s perception of their health remained at odds with their medical team. Accurate prognostication in ACHD is difficult and patients often underestimate their illness severity. This and patients’ generally young age result in delays to ACP initiation. Furthermore, a recognized difficulty in ACHD and other young populations is that available ACP documents are targeted to an older population, who often have more experience with this topic. Thus, patients with ACHD may need more guidance to complete ACP documentation. This patient's outpatient Palliative Care physician focused on building rapport with them and gained insight into their values and care preferences. This rapport paved the way for them being amenable to meeting with the inpatient Palliative Care team during their terminal hospitalization.

ACP discussions in ACHD should be initiated early in the disease course, prior to the onset of severe illness and intensified based on clinical progression and patient readiness. Consider early referral to specialist Palliative Care as longitudinal relationships may be beneficial. BRITTLE BONES AND A BROKEN BACK: AN UNEXPECTED CAUSE OF CAUDA EQUINA SYNDROME Javier C. DeJesus Lugo1; Rachel Solomon2. 1Internal medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4273163) CASE: A 90-year-old woman with osteoporosis presented to clinic with 2 weeks of worsening leg pain and inability to ambulate. Before this, she was functionally independent and fully ambulatory. She denied any recent falls or trauma but noted the onset of pain in her left leg three days after stepping down heavily onto it. Several days later she went to an ER with left upper leg pain and impaired ambulation. Left hip/femur x-rays and lower extremity doppler were negative and she was discharged with pain control and referral to orthopedics where, four days later, she had a negative lumbar spine x-ray and was prescribed steroids. A week later in clinic, she could not rise to stand, bear weight, or ambulate; her son lifted her to the exam table and began carrying her to the bathroom at home. She denied bladder or bowel incontinence; but described ‘constipation.’ The pain had evolved to include both legs with radiation to her knees bilaterally and interrupted her sleep. MRI L-spine revealed an S2 vertebral body fracture with anterior subluxation, bilateral s2 nerve compression, and distended bladder. She was referred to the ED for cauda equina syndrome, underwent emergent spinal fusion, and made a full recovery IMPACT/DISCUSSION: Osteoporosis is common in older female patients and can increase the risk of fracture from less typical inciting events. In the case of our patient, stepping down heavily was sufficiently traumatic to cause vertebral compression fracture (VCF) and cauda equina syndrome. The diagnosis of a VCF requires a high index of suspicion. Accurately assessing functional status and functional status change in the geriatric patient is key to averting missed diagnoses. In this case, there may have been some delay in pursuing higher-level imaging due to misperception of baseline function. VCFs, the most common fractures in patients with osteoporosis, are associated with high rates of mortality and morbidity and cost to patients and the health care system. Most frequently occurring in the T8-L4 region, VCFs can be caused following strain (bending, coughing) or trauma (fall, lifting). While x-ray is the primary diagnostic modality, the false negative rate has been found to range from 15-50% missed on initial exam. Physicians should maintain a low threshold to pursue CT or MRI in high-risk patients whose symptoms progress or fail to improve. Urgently, but less typically, VCF can lead to cauda equina syndrome. Cauda equina syndrome presents with low back pain, radiculopathy, saddle anesthesia, and bowel or bladder incontinence. However, as was seen in our patient, it can also be associated with urinary and/or bowel retention. A neurosurgical emergency, cauda equina can rapidly progress to permanent debilitating neurological damage.

Osteoporosis causes increased vulnerability to VCF. Understanding a patient’s baseline function is essential to recognizing functional status change. Cauda equina syndrome is an uncommon but high-risk complication of VCF. LUNG GROWING INTESTINE? Bipneet Singh1; Palak Grover1; Gurleen Kaur2; Jahnavi Ethakota3; Sakshi Bai1; Merritt Bern1. 1Internal Medicine, Henry Ford Allegiance Health, Jackson, MI; 2IM, Government Medical College Amritsar, Amritsar, Punjab, India; 3internal medicine, Henry Ford Health System, Detroit, MI. (Control ID #4228870) CASE: A 76-year-old male patient presented with a one-month history of coughing spells, left-sided chest wall pain exacerbated by deep breaths, and worsening dyspnea, notably on exertion. Subsequent CT chest imaging revealed a small left-sided pleural effusion, prompting referral to a pulmonologist. Subsequent management included a left-sided thoracotomy, drainage of serosanguineous fluid, and biopsy of pleural nodules. Further diagnostic workup revealed cytological evidence of adenocarcinoma, prompting consultation with oncology. The positive immunostaining for CK7 and CDX2, along with negative staining for CK20, TTF-1, Calretinin, and D2-40, suggested a pattern consistent with potential primary sites such as the upper gastrointestinal tract. Enteric origin was further suggested by elevated levels of CEA and Ca19/9. PET scan confirmed malignancy in the left pleura and lung, with a likely metastatic lymph node without any gastrointestinal involvement. These findings prompted the diagnosis of enteric-type adenocarcinoma of the lung. Staging classified the cancer as Stage IVA. The patient underwent anti-cancer treatment with pembrolizumab, carboplatin, and pemetrexed. IMPACT/DISCUSSION: Pulmonary enteric adenocarcinoma(PEAC) has a higher propensity to invade the pleura and airways, with a rate of 38.5% and 46.2%, respectively, with our patient having significant involvement of pleural and subpleural tissues. The diagnosis of PEAC may benefit from laboratory testing for tumor biomarkers. A high CEA level was discovered in more than 65% of the patients in the available literature similar to our patient. This marker did not help differentiate PEAC from Metastatic colon cancer (MCC), despite having a high sensitivity and the ability to track the patient's clinical progress. The positive rates for CA19-9 and CA125 were comparatively lower, at 50%. The histopathological features include a tall or oval nucleus, high columnar cells grouped in irregular glandular lumens with central necrosis, brush borders, and irregular necrotic patches. Even though PEAC has unique pathological characteristics, histopathology alone was unable to fully differentiate it from lung MCC. When separating PEAC from normal lung adenocarcinoma and MCC, immunohistochemical markers are crucial. Immunohistochemical markers, including CK20, and CDX2, had far higher positive rates in PEAC than MCC. PEAC can be distinguished from MCC by its elevated CK7. Combining some tumor markers, like CK7+ and CDX2+, increased the sensitivity (71.3%) and specificity (82%) of differentiating PEAC from MCC The chemotherapy regimens for MCC were determined to be unsuitable for PEAC. A patient originally diagnosed with MCC was presented by Lin et al., where no response to MCC chemotherapy was noted.

PEAC can be easily confused with metastatic intestinal cancer, which has similar histology, molecular profile, and serum markers. The gastrointestinal tract needs to be evaluated to tailor the correct treatment. MAKING UP FOR LOST TIME: ADRESSING COMPLEX CARE NEEDS FOR A GERIATRIC PATIENT WITH NEWLY DIAGNOSED HIV Ari Gordon1; Fiorella Perez2; Sonica Bhatia2; John Weng1. 1Internal Medicine, The Mount Sinai Hospital, New York, NY; 2geriatrics, The Mount Sinai Hospital, New York, NY. (Control ID #4273487) CASE: A 78 year old patient with a history of hypertension, asthma, stroke, peripheral vascular disease, lung cancer with surgical resection 13 years ago, and multiple missed medical appointments over the last two years presented to the ED of a large academic hospital in the Northeast due to difficulty hearing. On exam she was found to have cerumen impaction, hypertensive urgency, significant weight loss, and cognitive decline. Given concerns for failure to thrive and possible malignancy recurrence, she was admitted to the hospital for further management. Social history: Retired. Son moved in with her 7 months ago due to safety concerns. Active smoker. Not sexually active. Hospital course: As a part of the workup for failure to thrive, she was tested and found positive for HIV with CD4 136, 7%; HIV viral load 5420. Other notable lab findings included thrombocytopenia and polyclonal hypergammaglobulinemia. Extensive workup for opportunistic infections was negative. After improvement of her mental status the patient was informed of her diagnosis. When asked if she knew anyone with HIV, the patient reported that she had a romantic partner who passed away in the 1990s due to AIDs-related illness but she was never personally tested. The patient consented to informing her children and including them in care discussions. Care conferences including the patient's physicians and a social worker specializing in HIV were held to educate the patient and her family on specific care needs given the new diagnosis. She was started on ART and bactrim for PCP prophylaxis and discharged with a plan for close outpatient follow-up. IMPACT/DISCUSSION: While only 10% of newly diagnosed HIV cases occur in older adults, geriatric patients have the highest rate of advanced disease (late-stage HIV/AIDS) at the time of diagnosis. The heightened inflammatory state of individuals with untreated HIV/AIDS can contribute to the progression of chronic illnesses but may go largely unnoticed or misattributed. Public policies tied with a common perception that geriatric patients are at a lower risk for HIV may be contributing to missed diagnoses. Geriatric patients with HIV are more likely to have comorbidities and complex care needs that necessitate a multi-disciplinary approach to care management. Including care-takers in medical management discussions can lead to better success with medication adherence and functional outcomes for patients.

Health comorbidities such as cognitive and functional decline can increase the risk of medication non-adherence and missed appointments in geriatric patients with HIV. This case highlights the utility of collaboration between patients, their support system, and all members of a patient's healthcare team to adress complex medical needs. This case also calls attention to potential consequences of the current U.S. HIV screening practices. Increased awareness and surveillance of HIV in geriatric populations may reduce time to diagnosis and improve patient outcomes. NAVIGATING THE CHALLENGES OF ACUTE AORTIC OCCLUSION IN AN ELDERLY PATIENT WITH MULTIPLE COMORBIDITIES: A CASE OF RAPID DETERIORATION DESPITE TIMELY INTERVENTION SAFAA KAMEL2,1; Zachary McSween2,1; Mahmudul Hassan2,1; Roxana E. Lazarescu3,2. 1Internal medicine, Wyckoff Heights Medical Center, New York, NY; 2School of Medicine , St. George's University, Brooklyn, NY; 3Medicine, Wyckoff Heights Medical Center, New York, NY. (Control ID #4271094) CASE: An 82-year-old female with a history of hypertension, diabetes, hyperlipidemia, atrial fibrillation, stroke, and recent severe anemia presented with acute shortness of breath. She had been discharged one week prior after treatment for GI bleeding and anemia, with temporary discontinuation of her anticoagulant, rivaroxaban, due to bleeding risk. On presentation, she was tachycardic (HR 150), hyperglycemic (474 mg/dL), and had elevated BNP (393 pg/mL), troponin (1,663.5 ng/L), and lactic acid (10 mmol/L). ECG showed atrial fibrillation with NSTEMI changes. Chest x-ray revealed cardiomegaly, and echocardiogram showed a dilated left atrium and low ejection fraction (30%). CT scan showed abdominal aortic occlusion with renal and splenic infarcts. Despite a multidisciplinary approach, including thromboembolectomy and ICU care, her condition worsened with rising troponins, CPK, and lactic acid. Goals of care were discussed, and the family opted for DNR status. She passed away after several hours of continued deterioration. IMPACT/DISCUSSION: This case highlights the critical diagnostic and therapeutic challenges in managing acute aortic occlusion (AAO) in elderly patients with multiple comorbidities. Key insights include the role of atrial fibrillation and interrupted anticoagulation in predisposing patients to thromboembolic events, as evidenced by the patient's sudden deterioration following temporary discontinuation of rivaroxaban [2]. The presentation underscores the variability in AAO manifestations and the importance of prompt imaging for diagnosis, as seen with the CT confirmation of abdominal aortic occlusion and organ infarcts [4]. Despite timely intervention with thromboembolectomy, the patient’s persistent metabolic derangements and multi-organ failure emphasize the high mortality risk associated with delayed diagnosis and complex comorbidities [4]. This case underscores the need for vigilant clinical suspicion, early detection, and a multidisciplinary approach to improve outcomes in high-risk populations. Further research should focus on optimizing management strategies for AAO in patients with significant underlying health issues [3]. -References will be provided upon request.

-High suspicion should be present in complex patients because AAO should be considered in elderly patients with multiple comorbidities, particularly those with atrial fibrillation and recent interruptions in anticoagulation therapy. -Timely intervention is critical, early diagnosis via CT imaging and prompt surgical revascularization are essential, though outcomes remain poor in high-risk populations. -Multidisciplinary approaches and collaborative care involving cardiology, vascular surgery, and critical care are crucial for managing AAO, but prognosis remains guarded despite intervention. NEUROLOGICAL AND URINARY COMPLICATIONS OF VARICELLA ZOSTER VIRUS IN AN OLDER ADULT: A CASE OF ENCEPHALOPATHY AND URINARY RETENTION Parul Pahal1; Helen Chen3; Keva Li2; Noelle Marie Javier3. 1Geriatric Medicine, Icahn School of Medicine at Mount Sinai Brookdale Department of Geriatrics and Palliative Medicine, New York, NY; 2Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY; 3Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272862) CASE: An 84-year-old Filipino female with hypertension, diabetes, Alzheimer’s dementia, and prior lacunar infarct presented with worsening headache, confusion, emesis, and gait instability. Two weeks earlier, she had been diagnosed with shingles (L2-L3 dermatomes) and treated with valacyclovir. On examination, she was confused but showed no focal deficits. Imaging ruled out acute ischemia but revealed a middle cerebral artery aneurysm. Laboratory tests indicated acute kidney injury (creatinine clearance 6.5 mL/min). Cerebrospinal fluid (CSF) analysis suggested viral meningitis, though VZV PCR was negative; VZV was confirmed via a skin swab. Treatment with intravenous acyclovir resolved her encephalopathy, and she transitioned to oral valacyclovir. Her cognitive status improved by day three. MRI revealed chronic microangiopathy and an old thalamic infarct. Persistent urinary retention required Foley catheter placement. After an unsuccessful voiding trial, she was discharged with a Foley catheter, a five-day course of valacyclovir, and follow-up recommendations for urodynamic studies and Shingrix vaccination. IMPACT/DISCUSSION: Varicella Zoster Virus (VZV), a reactivating DNA virus, may cause rare neurological complications, such as encephalitis and voiding dysfunction, particularly in older or immunocompromised individuals. This case highlights these uncommon manifestations in an older adult. VZV meningitis/encephalitis can lead to altered mental status weeks after rash onset. Negative CSF VZV PCR underscores the importance of correlating clinical findings and skin lesions for accurate diagnosis. Neurological complications from VZV arise due to viral inflammation of the dorsal root ganglia and adjacent structures, potentially causing meningitis or encephalitis and manifesting as cognitive changes, including confusion and altered mental status. In addition to neurological complications, urinary retention is a recognized complication of VZV, as seen in this case where the patient required discharge with a Foley catheter. VZV infection of L1-L2 or sacral dermatomes can disrupt neural pathways involved in bladder control, leading to voiding dysfunction. Prolonged urinary retention can result in encephalopathy due to uremia and metabolic disturbances, further worsening cognitive impairment. This case illustrates that altered mental status can stem from both VZV-related meningitis/encephalitis and secondary complications like urinary retention, emphasizing the need for a comprehensive diagnostic and management approach.

In conclusion, this case highlights the complications of Varicella Zoster Virus (VZV) in older adults, where meningitis/encephalitis and urinary retention can independently drive altered mental status. Timely recognition and a holistic management strategy are essential to address both primary and secondary effects of VZV, reduce cognitive decline, enhance patient safety, and support optimal recovery in this high-risk population. REDEFINING GERIATRICS: UTILIZING THE COMPREHENSIVE GERIATRIC ASSESSMENT TO IMPROVE CARE FOR A PERSON EXPERIENCING HOMELESSNESS Leanna Travis. Inernal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4270452) CASE: A 47-year-old man with a history of severe alcohol use disorder, anxiety, post-traumatic stress disorder (PTSD), and chronic homelessness. He was evaluated by his medical team on the street. The team utilized the Comprehensive Geriatric Assessment (CGA), that highlights the 5Ms to organize care. Mind: uncontrolled anxiety and PTSD from childhood adverse experiences driving alcohol use that led to complications including altercations and cognitive impairment. Mobility: recurrent falls due to intoxication and neurologic decline from alcohol use. Medications: lack of access to medications on the street and unforgiving side effects. Matters most: applying for housing and social security disability income with conflicting worries of isolation as housing often removed people from their primary street-dwelling community. Multi-complexity: due to cognitive deficits, substance use disorder and unstable housing, the patient had difficulty with independent activities of daily living including coordinating finances and attending medical appointments. Notable past family history included alcohol use disorder in his parents, both deceased. Medications include naltrexone, gabapentin, hydroxyzine, and thiamine. Physical exam revealing for cachexia, wide-based ataxic gait, slurred speech, tangential thoughts. Most recent CT head with global atrophy. IMPACT/DISCUSSION: Adults experiencing homelessness age at an accelerated rate compared to their age-matched, housed counterparts due to a complex intersection of adverse life-course experiences, environmental exposure, stress, poor quality sleep, and limited access to healthcare services leading to premature development of geriatric syndromes (JAMA 2022;10:1052). This case highlights premature aging in a 47-year-old patient with a history of chronic homelessness. Research has described this phenomenon, however, the clinical application of a geriatric framework in this population has been minimally explored. The CGA was utilized as it systematically identifies medical and psychosocial factors that lead to functional limitations for older adults (JAGS 2017;9:2115). Utilizing the CGA in the care of this patient helped the care team systematically identify functional decline, complex intersections of mood, memory and substance use disorder, and worries of isolation compounding a housing search. Internists should approach care for adults experiencing homelessness with a geriatric medicine mindset. In doing so, providers will acknowledge and identify needed variations in care compared to housed individuals, and combat systemic injustice in a population traditionally underserved by our medical institutions.

Recognize that adults who have experienced homelessness age faster than their housed counterparts and their care should be approached with a geriatric mindset. Utilize the Comprehensive Geriatric Assessment with people experiencing homelessness to organize concerns and to capture opportunities to improve functionality and quality of life. THE LONG TOENAIL SIGN AS A POTENTIAL INDICATOR OF UNMET STRUCTURAL AND SOCIAL DETERMINANTS OF HEALTH (SSDOH) NEEDS IN OLDER VETERANS: A CASE SERIES Michelle J. Berning1; Iris L. Wu1; Tyrone John P. Sumibcay2; Sherry A. Clement3; Ariela R. Orkaby3,4; Andrea W. Schwartz3,4. 1Department of Medicine, Brigham and Women's Hospital, Boston, MA; 2University of Hawai'i John A. Burns School of Medicine, Honolulu, HI; 3Geriatric Research Education and Clinical Center, VA Boston Health Care System Jamaica Plain Campus, Boston, MA; 4Division of Aging, Brigham and Women's Hospital, Boston, MA. (Control ID #4269478) CASE: Case 1:A 75-year-old man with history of AV block status post permanent pacemaker placement, vertigo, food insecurity with associated malnutrition, and housing instability presented from a local shelter with weakness, falls, and delusions. Laboratory findings revealed severe vitamin B12 and folate deficiencies, which were repleted. A foot examination revealed long, thickened, and pincered toenails with onychomycosis and “claw toes.” His toenails were cleaned and trimmed. He was discharged to a community residential care program with plans for podiatry and primary care follow-up. Case 2: An 84-year-old man with history of food insecurity with associated malnutrition, housing instability, and lack of contact with healthcare for 25 years presented with weight loss and weakness. He was found to have a moderately suspicious thyroid nodule, as well as a chronic left foot wound that was treated by podiatry. Foot examination showed very long (4.5cm on first digit), thickened, and brittle toenails with “ram’s horn nails” and calluses. His toenails were trimmed and he received shoes from prosthetics. He was discharged to a skilled nursing facility for rehabilitation with plans for fine needle aspiration of the thyroid nodule, podiatry, and social work follow-up. IMPACT/DISCUSSION: The long toenail sign (LTS) is characterized by long, often thickened, toenails with features such as “ram’s horn nails” and onychomycosis. The LTS may provide a unique window into the health and care needs of older adults.1 Here, we present two cases of older veterans with complex medical comorbidities, limited healthcare contact, and multiple unmet structural and social determinants of health (SSDOH) needs who were found to have the LTS. Resource deprivation in constellation with poor health and declining functional status may have driven the development of LTS in these patients, and the LTS could serve to alert clinicians to the patients’ increasing needs. To perform a comprehensive assessment of structural vulnerabilities in older adults, the SSDOH assessment can be done in parallel with the Geriatric 5Ms framework, which focuses on Mobility, Mentation, Medications, Multicomplexity, and What Matters Most.2

This case series highlights the potential role of the LTS physical exam finding in identifying older patients with declining health and unmet SSDOH needs. While often deferred, we encourage clinicians and trainees to incorporate the foot/toenail physical exam into their practices. If long toenails are identified, this should cue clinicians to investigate the underlying reasons and address unmet SSDOH needs to advocate for patients and promote health equity.

1. Orkaby AR, Schwartz AW. Toenails as the “Hemoglobin A1c” of Functional Independence—Beyond the Polished Wingtips. JAMA Intern Med. 2018;178(5):598-599. 2. Miller RK, Young M, Chippendale R, et al. Using the Geriatric 5Ms to teach structural and social determinants of health. J Am Geriatr Soc. 2023;71(12):3967-3972. UNINTENTIONAL WEIGHT LOSS: A COMMON COMPLAINT AND AN UNCOMMON DIAGNOSIS Robin Granberry, Zachary Blair, Kylie Cullinan. Internal Medicine, Division of Internal Medicine/ Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4272572) CASE: An 83-year-old male with a history of hypertension and coronary artery disease presented to clinic with an unintentional 15-pound weight loss and sinusitis. He was treated for allergic and bacterial sinusitis without relief. He noted new pleuritic chest pain controlled with acetaminophen. Labs demonstrated normal renal function, thyroid studies, A1C, and sinus electrocardiogram. ESR was mildly elevated to 48 mM/hr. One month later, he was admitted for dyspnea and chest pain. He was found to have pericarditis, a large pericardial effusion, pleural effusions, and a 2-centimeter upper lobe mass on chest CT. The effusions were exudative with negative cultures and no malignant cells on cytology. Creatinine was 2.0 mg/dL (baseline 1.0 mg/dL) without uremia. He was discharged home after pericardiocentesis with concern for malignancy. However, he was re-admitted with confusion, found to have a basal ganglia intracranial hemorrhage (ICH) and acute kidney injury (Cr 3.5 mg/dL). CBC showed anemia without eosinophilia; he had hematuria and proteinuria on urinalysis. Serology was positive for C-ANCA (1:80) and PR3-ANCAb (>8), and kidney biopsy demonstrated necrotizing, pauci-immune glomerulonephritis, confirming a diagnosis of granulomatosis with polyangiitis (GPA). He was initiated on rituximab and steroids with clinical improvement. IMPACT/DISCUSSION: Unintended weight loss in elderly patients often prompts evaluation for common etiologies such as malignancy, gastrointestinal disease, medication side effects, or social factors. However, autoimmune disorders, including vasculitis, account for 5-10% of cases but may be underrecognized, as in this case. GPA is an ANCA-associated vasculitis typically involving the upper and lower respiratory tracts and kidneys. This case highlights classic features of GPA: constitutional symptoms (weight loss), sinus involvement (present in >90% of cases), pulmonary nodules or cavitations, and glomerulonephritis. His ICH further flagged vasculitis, which can cause spontaneous nasal, intracranial, pulmonary, and gastrointestinal hemorrhages. Notably, his advanced age and pericardial involvement (seen in only 7% of cases) were atypical. Diagnosis requires clinical symptoms, ANCA serologies, and pathology from affected tissues. Delay in GPA diagnosis occurs in 60% of cases due to non-specific presentations and late consideration of vasculitis, delaying treatment. This case underscores the importance of broadened differentials for geriatric patients with weight loss that include autoimmune processes, like vasculitis.

In geriatric patients with weight loss, elevated inflammatory markers, multi-system symptoms, or spontaneous hemorrhage, vasculitis should be considered in the differential. Typical features of GPA are sinusitis, pulmonary disease, and glomerulonephritis. Clinical Vignette - Healthcare Delivery and Redesign A FRAGMENTED DIAGNOSIS Abigail Clark1; Danielle Jones2; David Krakow3. 1Internal Medicine and Psychaitry, Emory University Woodruff Health Sciences Center, Atlanta, GA; 2General Internal Medicine, Emory University School of Medicine, Atlanta, GA; 3medicine, Emory University, Atlanta, GA. (Control ID #4244540) CASE: A 58-year-old man presented to a tertiary hospital with 5 months of a dry cough and non-pruritic lower extremity rash. Since symptom onset, he had seen several specialists in multiple medical systems. Frustrated by not receiving a diagnosis, the patient sought an expedited workup. Vital signs and pulmonary exam were normal. The patient’s abdomen was diffusely tender without rebound. Skin exam revealed bilateral lower extremity purpura. Labs were notable for ALT 31 unit/L, AST 44 unit/L, alkaline phosphatase 739 unit/L, total bilirubin 1.5 mg/dL, GGT 227 unit/L, ESR 130 mm/hr, CRP 18 mg/L and undetectable C3 and C4. Liver MRI revealed mild hepatic steatosis and a normal gallbladder. CT of the chest demonstrated diffuse lymphadenopathy. Benign reactive lymph nodes were found on lung biopsy. Skin biopsy showed leukocytoclastic vasculitis. Liver biopsy demonstrated lymphoplasmacytic infiltration of IgG4-positive plasma cells. Serum IgG4 was 15 times the upper limit of normal. The patient was diagnosed with IgG4 related disease (IgG4-RD)—a rare immune-mediated fibroinflammatory disorder that causes tumor-like swelling of one or more organs due to the infiltration of IgG4-positive plasma cells. The patient was treated with prednisone and rituximab, referred for follow up with an IgG4-RD specialist and discharged 7 days after admission. IMPACT/DISCUSSION: Outpatient healthcare in the United States is characterized by care fragmentation—when a patient’s care is spread across many physicians and medical systems. Having multiple physicians may be appropriate, but may also lead to redundant diagnostics, avoidable hospitalizations and suboptimal care if physicians do not communicate effectively. Diagnosing rare diseases is made particularly challenging by fragmented care, as such diagnoses are often made through the direct collaboration of multiple sub-specialists. Our patient with IgG4-RD saw multiple providers in different healthcare systems, each of whom initiated a reasonable workup, but were unable communicate as a team. This led to a 5-month delay in diagnosis wherein the patient incurred potentially irreversible liver damage. Only after a costly hospitalization, when his physicians could collaboratively discuss his case, was a diagnosis made. The effect of our patient’s care fragmentation was compounded because he did not have a medical home, which is described as a healthcare delivery model in which a primary provider coordinates a patient’s care between multiple specialists. If our patient had a medical home, where a primary internist facilitated communication between his doctors, the medical and financial consequences of care fragmentation might have been mitigated or even avoided in this case.

This case demonstrates the risk of care fragmentation, particularly in delaying the diagnosis of rare diseases, and highlights the importance of ensuring all patients have a medical home to facilitate care coordination. CEREBRAL TOXOPLASMOSIS: A LIFE-THREATENING MANIFESTATION OF HIV/AIDS Isna Khaliq1; Justin J. Kim2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Infectious Diseases, Rush University Medical Center, Chicago, IL. (Control ID #4273100) CASE: A 51-year-old woman with no known medical history presented with new onset tonic-clonic seizures. She has had fevers and generalized weakness for several days, along with an unintentional weight loss of 20 pounds in two months. On exam, the patient was altered but otherwise clinically stable. MRI brain showed two heterogeneous peripherally enhancing necrotic lesions in left parietal and temporal lobes with surrounding vasogenic edema. She was empirically started on ceftriaxone, metronidazole, and IV ganciclovir. A full infectious work up was significant for a positive Human Immunodeficiency Virus (HIV) screen with a viral load of 188,977 copies/mL and a CD4 count of 16 cells/uL, and serum Toxoplasma IgG, raising the suspicion for cerebral toxoplasmosis. The Infectious Diseases team was consulted, empiric medications were stopped, and the patient was started on high dose trimethoprim-sulfamethoxazole (Bactrim). Her mental status improved over the next few days. A week later, she began taking Biktarvy, which was also well-tolerated. The PCR for Toxoplasma gondii from the CSF ultimately returned positive. We confirmed the patient’s social history after she became oriented. She was born in Benin, West Africa, and immigrated to Chicago in 2005. She and her partner have had multiple sexual partners. The patient was discharged with 6-weeks of Bactrim for cerebral toxoplasmosis. On a follow-up, she was doing well. She was subsequently swiched to a maintenance dose of Bactrim while continuing Biktarvy. IMPACT/DISCUSSION: Cerebral toxoplasmosis is a life-threatening infection in people living with HIV off therapy. The differential diagnosis most importantly includes lymphoma, though pyogenic abscess and tuberculosis can present similarly. Though this diagnosis of cerebral toxoplasmosis was supported with serology and CSF PCR, a brisk response to Bactrim is the best indicator of the correct diagnosis. Therefore, a high index of suspicion and prompt initiation of Bactrim are crucial for a favorable outcome. Patients with HIV/AIDS are at a high risk of being lost to follow-up. Studies indicate that up to 34% of HIV patients may lose contact with healthcare providers after their initial diagnosis. This issue is particularly pronounced among individuals of low socioeconomic status, those with low healthcare literacy, and immigrants. During our patient’s admission, we addressed social barriers to care and established a good rapport with her. Medications were delivered to the patient’s bedside before discharge, and we ensured a close follow-up with her at our HIV clinic to facilitate timely care.

This case underscores the importance of early diagnostic evaluations and interventions for patients with undiagnosed HIV. It also emphasizes the need to address socioeconomic barriers to healthcare for effective long-term management. The benefits of highly active antiretroviral therapy can only be realized if patients comply with their medication regimen and attend scheduled follow-up visits. MULTI-HOSPITAL CARE COORDINATION OF A COMPLEX CASE OF GI BLEED: A CASE REPORT Ameer Abdelrahman, Mahmoud Abdelwahab, Lucinda Dass, Deepika Suleria. Internal Medicine, Capital Health, Trenton, NJ. (Control ID #4273082) CASE: Angiodysplasia, the vascular malformation of dilated and tortuous arteries and veins, constitutes 50% of all small bowel bleeds. We present a 65-year-old female with peripheral artery disease (PAD), recent vascular surgery, gastritis and duodenal AVMs presented with sudden onset right toe pain and numbness. She was found to have restenosis of multiple arteries and underwent immediate intervention by vascular surgery. Labs were notable for hemoglobin (Hb) 7.2 on admission. CT scan head was negative for acute intracranial pathologies. While in recovery, she passed melanotic stools. The gastroenterology (GI) team discovered and treated a bleeding jejunal ulcer, and interventional radiology embolized the gastroduodenal artery and proximal jejunal artery. However, she continued to bleed, and due to the location of the bleed, both teams were unable to operate again. Eventually, general surgery was consulted for possible resection, but she was deemed a poor surgical candidate due to her multiple comorbidities. Efforts were made to reach out to other facilities with advanced GI techniques that would be less invasive. These facilities did not accept her, and she was eventually transferred to our sister hospital for evaluation by a pancreaticobiliary surgeon. She underwent exploratory laparotomy with resection of 20 cm of the jejunum and jejunal–jejunostomy; no ulcer was clearly seen. After the surgery, her Hb has been stable from 7.8-9.0. IMPACT/DISCUSSION: This case exemplifies the need for timely and synergistic collaboration between medical disciplines. The GI team, armed with advanced endoscopic tools and techniques, played a pivotal role in precisely locating the site of bleeding within the small bowel and labeled it for identification. Their expertise was complemented by the radiology team, who performed the embolization. While surgery did prevent future episodes of melena, a clear source was still not identified. Beyond the successful medical intervention, our case study highlights the importance of facilitating a safe patient transfer in a timely manner. The coordinated efforts of the multidisciplinary team ensured a smooth transition of the patient through various stages of care, from diagnosis to intervention and ultimately to recovery and discharge. We attempted to utilize resources in our community by contacting other regional hospitals with more advanced technologies. However, due to multiple comorbidities, she was deemed unstable for transfer.

In conclusion, our case presentation serves as an illuminating narrative of the transformative power embedded in collaborative, multidisciplinary healthcare. Combining the knowledge from GI, radiology, and surgery, we not only overcame a tough medical issue but also showed the crucial role of timely diagnosis, effective communication, and a shared commitment to patient well-being. THE INTERPROFESSIONAL APPROACH OF MEDICINE AND SOCIAL WORK FOR RECOGNIZING AND SUPPORTING SURVIVORS OF DOMESTIC VIOLENCE (DV) IN THE OUTPATIENT CLINIC Sofia S. Esquibies1; Christopher Dobbelstein2; Audrey Garcia2. 1School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 2University of Colorado Health, Aurora, CO. (Control ID #4271760) CASE: A 65-year-old woman presented as a same-day patient to a provider who was not her PCP with emotional distress related to her home situation. She was visibly distraught and reported physical, verbal, and emotional abuse from her 83-year-old husband with dementia. Together, we planned to connect her with a counselor and consulted our social worker. Unexpectedly, the social worker knew our patient and clarified that she has a history of histrionic personality disorder and emotionally charged visits, was falsely reporting her husband’s dementia, and had been abusing him for over a year. Once we better understood the situation and relationship, we were able to provide the correct resources for her and her husband, including referrals for couples counseling and information on pressing charges for the husband. IMPACT/DISCUSSION: This case highlights the complexity of detecting DV and importance of collaborating with social workers. Establishing a universal DV screening process that integrates social work and prioritizes patient-provider trust can be instrumental to the recognition and support of survivors during routine outpatient care. According to The National Intimate Partner and Sexual Violence Survey, about 1 in 2 women and 2 in 5 men in the United States have experienced contact sexual violence, physical violence, psychological aggression, and/or stalking from an intimate partner in their lifetime. It is acknowledged that these statistics are likely a reporting underestimate due to survivors' fear for their safety.1 Across multiple studies, DV screening instruments, like Hurt, Insult, Threaten, Scream (HITS), have demonstrated high diagnostic accuracy with sensitivities and specificities ranging from 65-87% and 80-95%, respectively.2 With incorporation of these tools and distinct evidence-based strategies for follow-through (referrals, resource call line), physicians and social workers felt more capable asking patients about their home situations and providing the appropriate resources for the patient they were treating.3 DV recognition methods improve survivor outcomes. However, intervention does not stop at identification. Follow-up is crucial, and social work plays a major role in identifying DV and providing continuity of care for survivors.4, 5 Both the patient and her husband frequently contact our social worker, allowing longitudinal care that is difficult for physicians to achieve. This continuity provided relevant history to our case that improved our assessment of the situation and changed our plan to fit both partners’ needs.

Interprofessionalism promotes better communication among disciplines and emphasis on patient-centered care to improve patient outcomes.6, 7 This case reveals the benefit of DV safety planning between medicine and social work to properly identify and treat survivors of DV in outpatient clinics, especially in complex cases. Clinical Vignette - Health Equity, Diversity, and Inclusion COMPASSIONATE RELEASE FROM A CARCERAL CATASTROPHE Kahsavyah B. Buckley2; Mark Spencer1. 1General Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2School Of Medicine, Emory University, Atlanta, GA. (Control ID #4270022) CASE: A 60-year-old male presented from a local jail with abdominal pain, dark urine, and emesis. His past medical history included remote alcohol use disorder. On physical examination, he had scleral icterus, jaundice, hepatomegaly, palmar erythema, and right upper quadrant (RUQ) tenderness. Laboratory findings included ALT 301 U/L, AST 382 U/L, INR 1.1, total bilirubin 3.6 mg/dL, alkaline phosphatase 571 U/L, and AFP >300,000 ng/mL. Imaging with abdominal ultrasound revealed hepatic cirrhosis and portal vein thrombosis, while abdominal CT demonstrated a ~19 cm liver mass occupying the right hepatic lobe with portal vein infiltration. The patient was diagnosed with advanced-stage hepatocellular carcinoma (HCC). Given the advanced disease, poor initial functional status, and rapid clinical decline, the primary team pursued compassionate release to provide the patient with the dignity of confronting his diagnosis without being shackled, under constant guard, or isolated from loved ones. He entered hospice care and passed away six weeks later. IMPACT/DISCUSSION: This case demonstrates the successful use of compassionate release in a non-carceral healthcare setting. Compassionate release is an term used to describe the early release of an incarcerated individual from a carceral institution typically due to a terminal condition with poor prognosis, or when the carceral system cannot meet a patients significant medical needs. Each year, thousands of individuals die in U.S. prisons and jails, many eligible for compassionate release. Unfortunately, limited physician knowledge and engagement in compassionate release processes results in both low application and approval rates. The incarcerated population is medically complex and has aged significantly, with nearly 30% now aged 50 or older. As the population continues to age, physicians in community-based hospitals will increasingly encounter incarcerated patients. This case provides an example, along with our flow chart and easy to follow guidelines, for how any student, resident, or attending can pursue compassionate release for a patient at their own institution.

Many physicians are unaware of what compassionate release entails or how to pursue it effectively. Without proper knowledge and structured approaches, opportunities to improve patients' lives through compassionate release are often missed. Our structured approach, including an easily interpretable flowchart adaptable to any hospital setting, aims to raise awareness and empower physicians to navigate the process. This includes answers to critical question such as when should I consider compassionate release, how would I pursue it, what would I include in a letter, and where can I turn for additional questions. Compassionate release ultimately upholds the dignity every human deserves—to die comfortably and, when possible, surrounded by loved ones. CORRECTIONAL CONTROL: STIGMA, DISPOSITION AND ADVOCACY Laura Pax1; Mark Spencer2. 1Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2General Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4271606) CASE: A 51-year-old male with HIV, schizophrenia, and housing instability presented to an urban ED in the Southeast with multiple soft tissue abscesses and was admitted for furunculosis. On exam, he was noted to have an ankle monitor and stated that he was no longer on probation. Ultimately, a skilled nursing facility (SNF) was recommended for safe discharge. However, when social workers noted the ankle monitor, indicating legal involvement, the medical team was told it would prevent him from being accepted at any facility. The explanation given was that he could pose a safety risk to others; therefore, no referrals were sent. After prolonged advocacy from the patient’s family and medical team, the ankle monitor was removed he was eventually discharged to a SNF after 64 days in the hospital. IMPACT/DISCUSSION: This patient’s delayed discharge and limited options were a collateral consequence of legal involvement. The legal system adversely impacts health in many ways. America’s carceral reach extends beyond mass incarceration, to correctional control through probation and parole. Our state in the Southeast has the highest rate of correctional control of any state, with 881 per 100,000 people are incarcerated, compared to 608 per 100,000 across the United States (Prison Policy Project, 2024). Collateral consequences are enforced through hundreds of legal barriers and informal policies that limit individuals' ability to thrive after conviction. Stigmatizing attitudes of providers towards those with legal involvement are barriers to obtaining comprehensive post-discharge care (Davis, 2022). As physicians, we must reevaluate the concept of “do no harm” when caring for patients impacted by the legal system. Action must be taken at all levels to address this disparity, including addressing personal biases and educating trainees on these health disparities. This includes addressing assumptions based in stigma, such as all legally involved people being violent. There must be clear policies in place regarding care for incarcerated patients. Interdisciplinary discussions are necessary to support disposition, and referral best practices must be organized. Physicians should also work with impacted community members to advocate for policy change, including the elimination of collateral consequences, to enact lasting change for those with a history of legal involvement.

This case exemplifies how criminal records, through collateral consequences, can dramatically impact a patient's ability to receive recommended discharge care. To advocate for our patients, we must address this stigma and increase awareness of the negative impacts of carceral control.

1. Davis D. Care of Justice-Involved Populations. Mo Med. 2022. May-Jun;119(3):208-212. MPID: 30635560. 2. Prison Policy Project. Incarceration Rates. 2024, published online. THE ROLE OF HEALTHCARE LITERACY IN DELAYED DIAGNOSIS AND MANAGEMENT OF OPPORTUNISTIC INFECTIONS IN ADVANCED HIV: A CASE REPORT Annie Taffaro1,2; Nicole Pancotto1,2; Jenny Lu3; Alice Huang1; Argavan Ansari1; Roxana E. Lazarescu4. 1Internal Medicine, Touro College of Osteopathic Medicine Harlem Campus, New York, NY; 2Internal Medicine, Wyckoff Heights Medical Center, New York, NY; 3Medicine, Touro College of Osteopathic Medicine Harlem Campus, New York, NY; 4Medicine, Wyckoff Heights Medical Center, New York, NY. (Control ID #4273279) CASE: A 27-year-old Spanish-speaking male with a recent HIV diagnosis developed multiple opportunistic infections within three months of diagnosis. He presented with weakness, weight loss, headache, and oral thrush. Original labs confirmed HIV with a viral load of 230,000+ and a CD4 count of 130 cells/μL. He was diagnosed with disseminated Mycobacterium avium complex (MAC), CMV retinitis, Cryptococcus neoformans, acute kidney injury and iron deficiency anemia at this time. Treatment for each infection was initiated along with antiretroviral therapy. After one month, he was discharged in stable condition. Follow-up continued to show declining CD4 count despite treatment. Three months after initial discharge, he was readmitted for severe headaches and lab results confirmed recurring cryptococcal meningitis. He was treated appropriately and was discharged on continuing ART. IMPACT/DISCUSSION: Cryptococcus neoformans is one of the most life-threatening opportunistic infections in patients with advanced HIV. However, its prevalence in the U.S. has decreased significantly since the introduction of antiretroviral therapy (ART). Current guidelines recommend screening for Cryptococcus in HIV-positive patients with a CD4 count <100 cells/μL. Yet, this case highlights a patient who experienced recurrent cryptococcal infection despite CD4 counts slightly above this threshold. This underscores the need for comprehensive care, especially for individuals in low socioeconomic neighborhoods and those facing language barriers. Effective HIV care in these settings requires addressing not only the disease but also the social and financial barriers to medication adherence and overall health outcomes. Poor healthcare literacy is a critical factor in the early diagnosis and management of HIV, influencing treatment adherence and long-term outcomes. In this case, the patient presented with three opportunistic infections, along with several undiagnosed issues, requiring extensive antifungal, antiviral, and prophylactic treatments. This delay was primarily due to healthcare disengagement, a limited understanding of HIV risks, and the stigma surrounding the disease. This case illustrates how healthcare barriers can delay diagnosis, worsen outcomes, and complicate management. Multidisciplinary interventions focused on patient education, stigma reduction, and resource provision are essential to reduce diagnostic delays and prevent severe HIV-related complications.

While the global prevalence of cryptococcal infections has declined due to ART, the disease remains a significant cause of morbidity and mortality in HIV patients, especially those with extreme immunosuppression and in low socioeconomic backgrounds. Efforts such as access to ART, education on signs and symptoms of opportunistic infections, and care in the patient's native language are key to reducing its impact. UNDOCUMENTED AND UNDERDIALYZED: AN IMMIGRANT'S STRUGGLE FOR LIFESAVING CARE Michaela Whitelaw1; Sarah G. Samaranayake1; Nicholas Wison2; Stephen Haff5; Venkatesan R. Krishnamoorthi4; Toby Terwilliger3. 1School of Medicine, Emory University School of Medicine, Atlanta, GA; 2Morehouse School of Medicine, Atlanta, GA; 3Medicine, Emory University School of Medicine, Atlanta, GA; 4Medicine, University of Chicago, Chicago, IL; 5Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4229023) CASE: Our patient came to the U.S. from Mexico when he was 2 years old, and Georgia is the only home he has known. He graduated high school and worked in construction until 2016 when he was the victim of intimate partner violence and suffered a spinal cord injury. He was left paraplegic with a neurogenic bladder which led to End Stage Renal Disease (ESRD) and nephrogenic ascites. Ineligible for publicly funded or subsidized health insurance due to his immigration status, he relied on a compassionate dialysis program provided by Atlanta hospitals. In the past year, he visited the emergency room over 100 times. His health is rapidly deteriorating, and his life consists of little more than waiting for his next trip to the hospital. IMPACT/DISCUSSION: Our patient is one of over 5,000 undocumented patients with ESRD in the US. With access to public health insurance, he could receive standard of care treatment including routine dialysis, peritoneal dialysis, and renal transplant. Instead, immigration policy and exclusionary public health eligibility resulted in high utilization of emergency services and a rapid decline in his health. Currently, publicly funded health insurance, such as Medicaid, Medicare, and Affordable Care Act (ACA) subsidies, excludes coverage to non-US citizens even though these individuals contribute billions in payroll taxes to fund these programs. Undocumented patients with ESRD are also ineligible for Medicare. At best, they may qualify for restrictive Emergency Medical Assistance (EMA) and rely on emergency dialysis when critically ill. To decrease costs and improve outcomes, 20 states extended EMA to include outpatient dialysis; Georgia has not. A pathway to citizenship and eligibility for public services remains out of reach for the 3.6 million undocumented immigrants brought to the US as children. In any legal pathway, undocumented individuals must return to their home country and make a “legal entry” back to the US before applying for status as a permanent resident or citizen – a journey that for many is unrealistic. Physician and other health care provider advocacy, however, has had an impact. Dr. Lilia Cervantes at University of Colorado successfully lobbied in 2020 for the state to offer routine dialysis for individuals whose immigration status only qualifies them for EMA. In 2015, advocates at Parkland Hospital in Dallas, Texas worked with local nonprofits to cover premiums for undocumented immigrants to buy private insurance plans.

Forty years shy of the average American life expectancy, our patient is nearing the end of his life. His death certificate may show he died from sequelae of chronic underdialysis. Yet his true cause of death will be the sociopolitical climate that dehumanized him and the healthcare system that denied him access to adequate care. As a profession, we must expand our vision of advocacy into the institutional, state, and federal policies that contribute to patients’ suffering. Immigration advocacy is patient advocacy. UNEXPECTED WEIGHT LOSS IN AN AFRICAN AMERICAN MALE Jessica Chen, Pearl Yu. Medicine, University of California San Diego, San Diego, CA. (Control ID #4267164) CASE: A 43 year-old African American male with no significant past medical history presented to community clinic for unexplained weight loss of 50 lbs in 8 months with mild increased in bowel movement and fatigue. Patient denied fever, chills, nausea, vomiting, abdominal pain, or recent travel. He admitted to remote history of alcohol abuse several years ago, but denied illicit drug use, testosterone use or smoking. Patient’s an amateur body builder and did not hold steady job. Patient was seen in two other community clinics for weight loss, with multiple HIV, drugs, and hepatitis tests ordered, and all were negative. However, TSH was never checked at previous clinic encounters at different clinics in preceding months. Physical exam revealed a dark skinned, well-muscled patient, heart rate was 95 with mild bilateral hand tremor. Lab showed TSH < 0.01. A diagnosis of hyperthyroidism was made, and patient responded to methimazole and propranolol treatment with weight gain of 30 lbs in 4 months and resolution of fatigue. IMPACT/DISCUSSION: In this patient, there was a clear showing of racial implicit bias in the work up of the weight loss in this African American patient. He had typical hyperthyroidism presentation of weight loss, increase bowel movement and fatigue in association with classic physical findings of hand tremor, borderline tachycardia. However, thyroid test was not considered in multiple previous encounters, but repeated HIV, hepatitis and drug tests were ordered. In the United States, people of color face disparities in the quality of care received, and health outcomes. There are many causes of rapid weight loss, which can be separate by categories. These include malignancy, endocrine abnormality (diabetes, hyperthyroidism, Addison’s disease), dementia, dental problem, mood disorder (depression, anxiety), cardiac issues (CHF, cardiomyopathy), malabsorption (Celiac disease, inflammatory bowel disease), dysphagia (achalasia), neurological difficulty (Parkinson, stroke, ALS), medication side effects (nausea, gastroparesis, early satiety), infection (tuberculosis, HIV/AIDS, parasites), drug/ETOH addiction, eating disorder, COPD, and infiltrative disorder (amyloidosis). Initial work up of weight loss should start with good history (HPI, social and family history) and physical, then basic labs. TSH should be included as initial lab assessment for unexplained weight loss disregard of ethnic background.

It is important for clinicians to be aware of possible implicit bias when treating minority patients. This case demonstrated stereotyping among health care providers resulted in misdiagnosis and delaying in treatment. It is important to advocate cultural competency training in medical school which help promotes unbiased provision of health care. Clinical Vignette - Hospital Medicine "STREPTOCOCCUS PNEUMONIAE CERVICAL SKIN ABSCESS IN A PCV-IMMUNIZED FEMALE WITH WALDENSTRöM'S MACROGLOBULINEMIA: EXPLORING THE ROLE OF OPSONIZATION FAILURE AND FUNCTIONAL ASPLENIA BEYOND THE SPECTRUM OF MALIGNANT B-CELL DISORDERS" Tanya Amal, Paul Johnson, Usman Bin Hameed, Ayesha Sharif. Royal Oak, Corewell Health, Royal Oak, MI. (Control ID #4273528) CASE: A 64-year-old female with recently diagnosed Waldenström's macroglobulinemia presented with pain and swelling in the neck. Three weeks prior, she had accidentally punctured her neck with her fingernail, leading to initial swelling. She visited the ER, but workup showed no acute infection. A contrast-enhanced CT scan revealed enlarged bilateral cervical lymph nodes. Over the next two weeks, the swelling became increasingly painful. On presentation, she had sharp, localized pain (10/10 intensity), tachycardia, and a 3x3 cm swelling on the right side of her neck, with redness, warmth, and tenderness. Laboratory results showed lymphocytic leukocytosis (WBC 31.5, lymphocyte 24.8%, neutrophil 6.1%). A repeat contrast-enhanced CT scan showed a 5x5 cm ring-enhancing lesion in the subclavicular space. Ultrasound-guided drainage with indwelling drain placement was performed, and cultures grew Streptococcus pneumoniae. The patient had been vaccinated with PCV13 and PPSV23 18 years ago. She was treated with IV ceftriaxone for 48 hours, followed by oral cephalexin for 14 days.She was discharged with the drain in place After infection resolution, she received repeat vaccinations with PCV, meningococcal, and Haemophilus influenzae vaccines. Notably, a previous PET scan showed marked splenomegaly with increased FDG uptake. IMPACT/DISCUSSION: Streptococcus pneumoniae, a common respiratory pathogen, can cause opportunistic cutaneous infections, particularly in patients with neutropenia or hyposplenism. Those with Waldenström's macroglobulinemia (WM) are at increased risk of sinopulmonary infections, pyelonephritis, and septicemia due to immune dysregulation from somatic mutations in the"V". "D" and "J/H' segments of immunoglobulin. These mutations impair affinity maturation and memory B-cell formation, leading to a suboptimal response to vaccinations against pathogens like Streptococcus pneumoniae, Staphylococcus aureus, and Varicella, similar to multiple myeloma. Severe infections with gram-positive organisms, including osteomyelitis and sepsis, have been reported in WM. Our patient, with splenomegaly but no signs of immunodeficiency or splenic sequestration, was treated with IV antibiotics and continuous drainage for 48 hours due to the risk of severe infection. She was revaccinated to dye functional hyposplenism and risk of recurrent infection

Recurrent infections in B-cell neoplasms with normal neutrophil counts remain poorly understood. Genetic immune dysregulation has not been proven in vivo. Abscess formation in vaccinated Waldenström's macroglobulinemia patients highlights impaired antibody response. Splenic involvement and opsonization defects, similar to multiple myeloma, may predispose to infections with encapsulated organisms. Ensuring infection resolution and determining optimal vaccination frequency is crucial. 47-YEAR-OLD WOMAN WITH AIDS AND BREVIBACTERIUM BACTEREMIA: A CASE REPORT. Andrew Maza, Anzi Salim, Maheswara Koppula. Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #4273176) CASE: A 47-year-old woman with a known past medical history of cerebral palsy, HIV on ART with poor compliance, hypertension, COPD, asthma, migraines, and stroke presented following a syncopal episode. The patient experienced a prodrome of nausea, sweating, dizziness, and a warm sensation. There was a questionable loss of consciousness, but the patient did not hit her head. Her initial work-up revealed significant leukopenia with a white blood cell count of 1,600 cells/μL. Other tests were unremarkable. These tests included a comprehensive metabolic panel, urinalysis, EKG, chest x-ray, CT head without contrast, MRI brain with and without contrast, and CT abdomen/pelvis with contrast. She was not on any medications that were likely causes of leukopenia. On physical exam, the patient was afebrile but met the criteria for systemic inflammatory response syndrome with a heart rate of 91 bpm in addition to her leukopenia. Blood pressure was 88/45 mmHg. Oral thrush was also noted on physical exam, but no other significant findings were observed. During her hospitalization, the patient’s viral panels and a lumbar puncture with CSF analysis and cultures were negative. Blood cultures were positive for gram-positive bacilli, later identified as a species of Brevibacterium. Notably, the patient’s CD4+ count was 1 cell/μL. For the bacteremia, the patient was treated with a two-week course of vancomycin, after which repeat blood cultures demonstrated resolution. She also received micafungin for oral thrush and trimethoprim-sulfamethoxazole for Pneumocystis carinii pneumonia primary prophylaxis. Mycobacterium avium complex prophylaxis was not indicated, as the patient had been restarted on her antiretroviral therapy following her previous non-compliance. IMPACT/DISCUSSION: Brevibacterium is a genus comprising over 50 species of non-motile, catalase-positive, aerobic, gram-positive bacilli. Long considered non-pathogenic, an increasing number of cases of infections, particularly bacteremia or endocarditis in immunocompromised patients, have been identified over the last 25 years. Risk factors typically associated with this uncommon pathogen are central catheter placement, chemotherapy, recipient stem cell transplant, and recipient solid organ transplant.

Even without the risk factors typically associated with opportunistic infection by Brevibacterium, immunocompromised patients may still be susceptible. Brevibacterium species have been found on human skin and are often believed to be the source of infection in immunocompromised patients following central catheter placement. This patient, however, exemplifies that Brevibacterium bacteremia may also originate from other sources, though it remains treatable with vancomycin. 7 HOSPITAL ADMISSIONS LATER: SECONDARY HYPERALDOSTERONISM RESULTING IN A BILATERAL NEPHRECTOMY Aya Hasan1; Benazir Khattri1; Saad Malik1; Victor C. Obuekwe1; Dipaben Patel1; Kishan P. Talagadadeevi2. 1Internal Medicine, Texas Health Resources, Arlington, TX; 2internal medicine, Texas Health Resources, Arlington, TX. (Control ID #4246646) CASE: A 20-year-old female with systemic lupus erythematosus, antiphospholipid syndrome, ESRD on peritoneal dialysis, failed renal transplant, lupus nephritis, and seizures presented with bilateral vision loss, seizure-like activity, along with nausea and vomiting that started 1 day prior. Due to concern of impending respiratory failure, the patient was intubated and admitted to the ICU. Her admission blood pressure was 233/155, she was placed on a nicardipine drip. Her relevant home medications included Keppra 500mg daily, amlodipine 10mg daily, labetalol 200mg twice daily, spironolactone 25mg twice daily, valsartan 25mg daily, and a 0.3mg clonidine patch weekly. The patient's mother stated she was compliant with medications. Per chart review, the patient had seven similar prior hospital admissions to different facilities in the past year, deemed secondary to “medication non-compliance.” EEG revealed epileptiform abnormalities; thus, the patient was resumed on Keppra. Brain MRI revealed findings consistent with posterior reversible encephalopathic syndrome; believed to be secondary to her elevated blood pressures. Due to concern of resistant hypertension, renin and aldosterone levels were ordered. Aldosterone was severely elevated at 155 ng/dL along with renin at 29.6 ng/ml/hr with an aldosterone renin ratio (ARR) of 5.24, indicating secondary hyperaldosteronism as the source of her uncontrolled hypertension. Of note, along with the nicardipine drip, she also required amlodipine 10mg, carvedilol 25mg bid, labetalol 300mg bid, and spironolactone 200mg daily to normalize her blood pressures. Her seizures ceased, repeat MRI revealed resolving of PRES, she was extubated, and a plan was made for a bilateral nephrectomy. Status post bilateral nephrectomy, the patient was titrated off the nicardipine drip , managed on oral medications and initiated on hemodialysis. The patient was discharged on amlodipine 10mg, spirinolactone100mg, labetalol 100mg bid, and doxazosin 4mg. IMPACT/DISCUSSION: Drug-resistant hypertension with hypertensive crisis is an indication for bilateral nephrectomy, this patient met criteria from her first admission. Several case reports have shown bilateral nephrectomies to be potential “rescue therapies," as well as improving the patient's quality of life. The resolution of this case highlights the vital concepts of thorough investigation and thoughtful history exploration that are central to medicine. This patient suffered many preventable admissions and complications due to the lack of an efficient and effective prior treatment plan.

Refractory hypertension is commonly seen in ESRD patients. Although commonly prescribed, oral medications in such cases merely act as a band-aid. It is essential to investigate the root cause and develop a plan of care to prevent numerous re-admissions. Medication noncompliance is easy to blame but resulted in an erroneous and painful course for our patient. Investigative analysis led to the proper and permanent resolution. A 21 YEAR-OLD MALE WITH HEADACHE AND FEVER, A STRAIGHTFORWARD CASE OF MENINGITIS? Linda Youn, Mirra Srinivasan, William Muniz. Internal Medicine, St. Bernards Medical Center, Jonesboro, AR. (Control ID #4271022) CASE: A twenty-one year old male presented with 2 days of flu-like symptoms, urinary retention and bilateral vision loss. Initial brain imaging was negative. Broad spectrum antibiotics and steroids were started due to concerns of meningitis. A tick panel performed due to the reported history of tick bite one month prior was negative. Meningitis/encephalitis panel and cytology for malignancy was negative. MRI of the total spine showed abnormal increased T2 signaling in the cervical and thoracic spine. MRI brain and orbits showed extensive WM signal abnormalities throughout central and periventricular white matter, and central pons. Neuromyelitis optica (NMO) IgG levels and aquaporin-4 (AQP4) antibodies were negative. Myelin oligodendrocyte glycoprotein (MOG) antibody was positive. Final diagnosis was myelin oligodendrocyte glycoprotein antibody syndrome (MOGAD). Patient was started on high-dose steroids and symptoms improved. IMPACT/DISCUSSION: Myelin oligodendrocyte glycoprotein antibody syndrome MOGAD is a relatively new demyelinating disease affecting the central nervous system. However, due to significant overlap in clinical presentation of MS and MOGAD and that MS is more common, the diagnosis of MOGAD can be missed initially. As in our case, due to presentation of myelitis and optic neuritis, the patient was thought to have MS. Although not specific, there are highly characteristic features of MOGAD which include unilateral or bilateral optic neuritis resulting in severe visual loss, acute disseminated encephalomyelitis (ADEM), and transverse myelitis. Recognizing atypical features and red flags that might suggest an alternative diagnosis is essential. The presence of MOG-IgG particularly at higher titers support the diagnosis of MOGAd although low-titer false-positive myelin oligodendrocyte glycoprotein (MOG)-IgG antibody results may occur. Conversely, the presence of cerebrospinal fluid oligoclonal bands supports a diagnosis of MS as they are absent in most patients with MOGAD. The evolution of T2 lesions is also a key differentiator as most MS lesions have residual signal abnormality while most MOGAD lesions resolve over time. Differentiating between the two disorders is important because maintenance therapy for MS and MOGAD are distinct. For example, MOGAD has shown poor response to disease-modifying therapies (DMTs) such as interferon-beta and glatiramer. Given that MS is more common worldwide than MOGAD, distinguishing MOGAD is important, particularly for patients with relapsing disease.

This case, along with previous reports, highlights an increasingly recognized MOGAD subgroup with initial clinical presentation suggestive of MS and later showing a disease course and therapeutic response compatible with MOGAD. Given the potential overlap of clinical phenotypes in patients with MS and those with MOGAD, we recommend MOG antibody testing in all patients with recurrent short-segment myelitis, conus medullaris, and those demonstrating steroid dependence. A BAFFLING CASE OF POLYMICROBIAL SECONDARY BACTERIAL PERITONITIS Bailee A. Cummings1; William Hahn1,2; William B. Rothwell3; Laura Rachal1,2. 1Internal Medicine, Tulane University, New Orleans, LA; 2Infectious Disease, Tulane University, New Orleans, LA; 3Internal Medicine & Pediatrics, Tulane University School of Medicine, New Orleans, LA. (Control ID #4270616) CASE: We report the case of a 55-year-old man with a past medical history of IV drug use and previously treated Hepatitis C who presented to the emergency room for progressively worsening abdominal pain. His initial hemoglobin was 5.0, and there was concern for hemoperitoneum due to abdominal fluid seen on FAST ultrasound. A subsequent CT angiogram was obtained which showed possible cirrhosis (new), large volume ascites, and a splenic abnormality concerning for developing abscess vs splenic infarction. Paracentesis was performed showing SAAG >1.1, LDH >3600, and fluid studies with neutrophilic predominance. Ascitic fluid cultures grew E. coli and Methicillin-sensitive S. aureus (MSSA). Blood cultures remained negative throughout hospital admission. Both a TTE and TEE were obtained, which were negative for endocarditis. Despite multiple paracentesis, the patient continued to accumulate fluid in his abdomen consistent with peritonitis, bringing up concern for bacterial seeding from a fluid collection in the spleen. CT A/P showed an evolving fluid collection in the spleen. Patient underwent splenic washout (noted to have 400 mL of purulent fluid) with drain placement, and ascites accumulation subsequently slowed significantly. Cultures of the splenic fluid grew MSSA. He completed a four-week course of IV antibiotics with resolution of the peritonitis on cultures. IMPACT/DISCUSSION: Due to the patient’s history of IVDU, it is thought that he may have had a transient MSSA bacteremia and endocarditis or endovascular disease. This may have caused the splenic infarct and subsequent abscess development, ultimately resulting in secondary bacterial peritonitis. The patient did not have a prior diagnosis of cirrhosis, and although his hepatitis C had been treated in the past, no other etiology for cirrhosis was identified. Secondary bacterial peritonitis (SecBP) is uncommon in that it causes <5% of all cases of peritonitis. Intra-abdominal abscesses should be considered as a possible etiology for SecBP with otherwise unknown causes. Polymicrobial peritonitis in and of itself is rare, and there were very few reports found in the literature of Staphylococcus aureus as a cause of peritonitis in patients not receiving peritoneal dialysis. While recurrent ascites and associated SBP is often seen in cirrhosis, as this was newly diagnosed cirrhosis, it remains unclear to what extent the patient’s presentation may have been related to his liver disease or precipitated by the splenic abscess.

Overall, there is significant morbidity and mortality associated with SecBP, so prompt source control is essential. It is also important to note that some patients who are treated for Hepatitis C may still have progression of fibrosis and development of cirrhosis. Furthermore, patients with a history of IVDU are at risk for bacteremia and endocarditis which could result in splenic involvement, even in the setting of negative blood cultures and echocardiography findings. ABERRATION OR TRANSFORMATION? BLAST-PHASE TRANSFORMATION OF POLYCYTHEMIA VERA IN A PATIENT WITH SEPSIS AND THROMBOCYTOPENIA Christian Hannah1; Rebeca Ortiz Worthington2. 1General Internal Medicine, The University of Chicago Medicine, Chicago, IL; 2General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4266883) CASE: A 79-year-old woman with polycythemia vera, chronic kidney disease stage 3, and congestive heart failure presented to an outside hospital with one week of back spasms, fever, chills, and productive cough. Medications included hydroxyurea, aspirin, benazepril, and rosuvastatin. She was febrile and tachycardic with CBC showing normal WBC and platelet counts, normal differential, and moderate macrocytic anemia. A chest x-ray revealed left lower lobe opacities and she was admitted and treated with antibiotics for community acquired pneumonia. An abdominal ultrasound for rising LFTs revealed splenomegaly. She then had worsening hypoxia requiring intubation and transfer to our ICU. She also developed pancytopenia which was attributed at the OSH and our ICU to hydroxyurea, which was held, and sepsis. Her leukopenia resolved, but after transfer to the wards the thrombocytopenia remained for over 14 days after stopping hydroxyurea. A repeat differential and blood smear revealed new blasts. Hematology was consulted and subsequent bone marrow biopsy showed 44% myeloid blasts consistent with blast-phase transformation of polycythemia vera. IMPACT/DISCUSSION: Polycythemia vera has a rate of transformation to acute myeloid leukemia (AML) of 5.5-18.7% over 15 years, with risk factors including advanced age, leukocytosis, and splenomegaly. Diagnosis is made with bone marrow biopsy showing ≥ 20% blasts. Treatment options include chemotherapy, targeted therapy, hypomethylating agents, or supportive care. In our case the patient likely had AML on presentation despite the differential not showing blasts, which increased her risk of developing severe sepsis. This was foreshadowed by her splenomegaly as well as pancytopenia and thrombocytopenia–two commonly encountered problems. Understanding the expected recovery timelines of these cell lines after resolution of sepsis and holding hydroxyurea was essential to making the diagnosis. Myelosuppression from hydroxyurea typically resolves rapidly within 15 days, and it is rare to have thrombocytopenia without leukopenia, something that our patient had. Thrombocytopenia in sepsis can persist anywhere from 10 days to several months. Additionally, since both the OSH and ICU attributed the pancytopenia to hydroxyurea there was significant anchoring bias that was perpetuated during handoffs. Splenomegaly was not explained by other acute conditions. Combining the absence of expected platelet recovery with the unexplained splenomegaly allowed us to overcome cognitive biases, create a new differential, and diagnose AML.

Blast-phase transformation of a myeloproliferative neoplasm is a rare but dangerous outcome of the condition; it should be suspected when there are persistent cytopenias, even with other potential causative etiologies. Understanding expected recovery timelines for various causes of cytopenias is a diagnostic key in cases with multiple acute causes. A BLURRY PICTURE: VISION LOSS DUE TO OPTIC PERINEURITIS Angela He1; Alexa Wilden2; Kristina Collins2; Sujata Bhushan3. 1Internal Medicine, The University of Texas Southwestern Medical Center Medical School, Dallas, TX; 2Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 3Section of General Internal Medicine, Dallas VA Medical Center, Dallas, , TX. (Control ID #4244919) CASE: A 42-year-old male with history of atrial fibrillation presented with persistent right eye pain for three weeks that progressed to vision loss after failing treatment for presumed bacterial conjunctivitis. He had worsening central visual loss and color vision with no history of trauma, infection, or personal/family history of autoimmune or neurological disorders. Exam showed normal vitals with a pale right fundus, blurred optic disc margins, acuity 20/100, and loss of color vision. His neurological exam was unremarkable. Initial CT head was concerning for optic neuritis (ON), prompting further imaging with MRI. This revealed severe right and mild left optic perineuritis (OPN), rather than ON. An extensive serum and cerebrospinal fluid workup for infectious and autoimmune causes was unrevealing. He was initiated on five days of IV steroids with significantly improved symptoms within 24 hours. With no identifiable underlying etiology, a diagnosis of idiopathic OPN was made and he was discharged on a prolonged steroid taper. IMPACT/DISCUSSION: Ophthalmic diseases account for up to 7% of internal medicine presentations and present a significant diagnostic challenge for many internists. Common eye pain conditions can be managed by internists, but it is crucial to identify conditions that require prompt referral. Our patient presented with painful acute vision loss, which demands timely evaluation. Acute vision loss can result from a variety of conditions, including ocular, neurovascular, and functional neurological disorders which were not considered early in this case. OPN is inflammation of the optic nerve sheath and presents as acute, unilateral, progressive visual decline and eye pain with movements which is confirmed with radiological imaging. Most cases are idiopathic, but it can be linked to systemic diseases such as Graves’ disease, GPA, SLE, RA and infections like syphilis, TB, and Lyme disease. It is also imperative to distinguish OPN from ON, which is a more common ocular disease. ON is associated with other types of systemic diseases, such as multiple sclerosis, neuromyelitis optica, post-vaccination syndromes and viral infections, and requires a different diagnostic workup and management. In OPN, early treatment with high-dose steroids followed by a slow taper is essential to prevent sustained vision loss, as delays in treatment often lead to poorer outcomes. Unlike ON, which may resolve spontaneously, OPN is unlikely to improve without intervention and tends to have a protracted and relapsing course.

This case underscores the importance of early consideration and recognition of OPN as a cause of acute painful vision loss, ensuring appropriate diagnostic work up and avoiding patient anxiety and irreversible vision damage. A BROKEN HEART IN MORE THAN ONE WAY A CASE OF TAKOTSUBO CARDIOMYOPATHY COMPLICATED BY SINUS NODE DYSFUNCTION Stefan Weston, Jesse Woodall, Kirsten Ferraro, Parth Patel, Zachary Spires. Internal Medicine, The University of Tennessee Medical Center, Knoxville, TN. (Control ID #4272479) CASE: A 79-year-old female presented with concern for NSTEMI following the development of left-sided chest pain with fatigue and nausea. Initial workup was significant for elevated high-sensitivity troponin T at 1963 and 1931 with concordant T wave inversion in the anterolateral leads. She was initiated on heparin and underwent left heart catheterization. Angiography only revealed non-obstructive coronary disease, but ventriculogram demonstrated apical wall hypokinesis consistent with Takotsubo cardiomyopathy. At this time, the decision was made to pursue medical management with goal-direct medical therapy (GDMT). However, she was only able to tolerate the addition of metoprolol prior to discharge due to concurrent renal failure. She re-presented to the hospital though following numerous syncopal episodes. She was found to be severely bradycardic with heart rates in the 30s and required ionotropic therapy to maintain perfusion despite the discontinuation of beta-blockade. IMPACT/DISCUSSION: Takotsubo cardiomyopathy (TCM) and broken heart syndrome are interchangeable terms used to describe the same phenomenon: transient left ventricular dysfunction due to stress. Regardless of the nomenclature, TCM is viewed as a mimicker of acute coronary syndrome (ACS). When patients present with signs and symptoms suggestive of ACS, angiographic evaluation of the coronary arteries is prompted. However, there is no evidence of coronary disease or plaque rupture in the setting of TCM. There is evidence of left ventricular dysfunction, but the regional wall motion abnormality often extends beyond the territory of a single coronary artery and occurs in a characteristic pattern with apical hypokinesis and basal hyperkinesis. Due to the overlap in clinical presentation with ACS, TCM is thought to be underdiagnosed. In part, this may contribute to the lack of knowledge pertaining to management. For instance, there is no guideline-specific treatment for TCM. Instead, the consensus is to manage the phenomenon in a similar fashion to heart failure with reduced ejection fraction (HFrEF) with GDMT +/- diuresis and address any complications accordingly. Complications of TCM are comparable to those of ACS. However, the development of sinoatrial (SA) node dysfunction is relatively uncommon. Per Syed et al, acute SA node dysfunction occurs only in 1.3% of TCM cases. Here, our patient demonstrated the classic clinical course attributed with TCM. Unfortunately, she was unable to tolerate the addition of GDMT due to renal failure and later developed symptomatic bradycardia. Per Sanders et al, structural and functional remodeling of the SA node is a known consequence of heart failure. Therefore, SA node dysfunction may develop in a similar fashion with TCM, particularly when GDMT is contraindicated.

Treatment for TCM involves GDMT +/- diuresis. SA node dysfunction is a rare complication of TCM. Failure to initiate GDMT may contribute to development of SA node dysfunction, but further research is required. A CASE OF ACUTE CARDIOMYOPATHY IN THE SETTING OF KNOWN SARCOIDOSIS RESULTING IN CARDIOGENIC SHOCK Jessica W. Mary1; Stephen A. Akinfenwa3; Muhammad M. Kamal1; Jasmine Varughese1; Kevin Watson2. 1Internal Medicine, UConn Health, Farmington, CT; 2Critical Care, Hartford HealthCare Corporation, Hartford, CT; 3Internal Medicine, University of Connecticut School of Medicine, Farmington, CT. (Control ID #4267387) CASE: 61 year old female with known pulmonary sarcoidosis who presented with difficulty breathing. Patient found to be volume overloaded and admitted for new systolic heart failure. Patient was admitted to the medical floor for transthoracic echo (TTE) and diuretics. Additionally, the patient had PE ruled out with CTA and infectious workup was negative. The patient was compliant with methotrexate therapy therefore worsening of pulmonary sarcoidosis was considered less likely. Patient had a strong family history of familial cardiomyopathy, in her mother, brother, and nephew. Patient’s respiratory status worsened, requiring transfer to the ICU for rescue bipap. Patient had TTE that showed new global hypokinesis, compared to normal echo one month prior. Patient required milrinone and nitroglycerin drips due to cardiogenic shock. Cardiac catheterization was performed, showing non-obstructive cardiomyopathy. Cardiac MRI was performed, suggestive of cardiac sarcoidosis. Cardiac PET scan did not show active inflammation of the cardiac tissues but did show extracardiac uptake of tracer consistent with systemic sarcoidosis. Patient stabilized from volume status and discharged with a life vest in place due to low EF. Due to lack of recovery of EF, the patient ultimately had ICD placed. IMPACT/DISCUSSION: Sarcoidosis is a rare granulomatous disorder that results in fibrosis of tissues. Cardiac involvement is present in only 2.3% of sarcoidosis cases. However, if present, fibrosis of the cardiac tissues can lead to severe cardiomyopathy and subsequent heart failure. Once fibrosed, this process is irreversible but further progression can be slowed with appropriate intervention. Definitive diagnosis of cardiac sarcoidosis is via biopsy. However, patients with biopsy proven extra-cardiac sarcoidosis can have advanced imaging with either cardiac MRI or PET scan to diagnose cardiac sarcoidosis and avoid cardiac biopsy. In this case, the patient had different findings between the two imaging studies. Familial cardiomyopathy, given the patient's family history, was considered and is diagnosed via genetic testing. Patient declined to have testing done but is currently undergoing work up for lung transplant.

In a patient with known sarcoidosis and new cardiomyopathy, cardiac sarcoidosis must be considered. Due to the risk for severe decompensation and cardiogenic shock in these cases, the providers must consider this on the differential in the appropriate clinical context. While rare, understanding of the underlying cause of acute cardiomyopathy allows for appropriate work up. Additionally, understanding which causes are possibly reversible or not for underlying cardiomyopathy and severe heart failure allow for appropriate planning around potentially necessary procedures including ICD placement. A CASE OF ADULT IGA VASCULITIS IN A 54-YEAR-OLD MALE WITH MULTISYSTEM DISEASE AND ALCOHOL USE DISORDER Sagar Chapagain. Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4273162) CASE: Background: IgA vasculitis is a rare small-vessel vasculitis that primarily affects children but can also occur in adults with multisystem involvement. It can be challenging to diagnose, especially in patients with multiple comorbidities. This case describes an adult patient with alcohol use disorder who developed IgA vasculitis during hospitalization for cardiogenic shock and other acute conditions. Case Presentation: A 54-year-old male with alcohol use disorder was admitted for cardiogenic shock, congestive heart failure, bilateral pulmonary emboli, and severe hyponatremia. On admission, he presented with petechial lesions on his lower extremities, which worsened into palpable purpura. Gross hematuria also raised suspicion for systemic vasculitis. Left heart catheterization (LHC) was negative for ischemic cardiomyopathy, with alcohol-related cardiomyopathy suspected. Further workup, including cardiac MRI, was pending. The patient’s rash and renal involvement, along with negative tests for infectious and iatrogenic causes, led to the diagnosis of IgA vasculitis. Differential Diagnosis: The differential diagnosis for leukocytoclastic vasculitis (LCV) in this case included IgA vasculitis, cryoglobulin vasculitis, immune complex-mediated vasculitis, and pauci-immune (ANCA) vasculitis. Given the clinical features, including the rash and hematuria, IgA vasculitis was suspected and confirmed. Diagnosis and Management: The diagnosis of IgA vasculitis was confirmed based on clinical presentation and histopathological findings. The patient was treated with corticosteroids and supportive care, while managing his heart failure, liver injury, and electrolyte abnormalities. IMPACT/DISCUSSION: This case highlights the diagnostic challenge of adult-onset IgA vasculitis, especially in patients with multiple comorbidities. The presence of petechial lesions on the lower extremities, which worsened over time, along with gross hematuria, raised suspicion for systemic vasculitis. The negative LHC for ischemic cardiomyopathy, combined with the patient's alcohol use history, supported the diagnosis of alcohol-related cardiomyopathy. Early recognition of IgA vasculitis in this complex clinical scenario allowed for timely treatment and improved management of his multisystem dysfunction.

IgA vasculitis should be considered in the differential diagnosis of adults with unexplained rash, systemic involvement, and renal manifestations such as hematuria, especially when other significant comorbidities exist. Timely diagnosis and intervention are essential to prevent complications and improve patient outcomes. A CASE OF AHUS WITH IDIOPATHIC INTRACRANIAL HYPERTENSION - A RARE COMPLICATION IN A RARE DISEASE Kaneez Zainab, Chelsey Petz. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4269897) CASE: A 29-year-old female with history of thrombotic thrombocytopenic purpura (TTP) presented to the hospital with abdominal pain and fever without diarrhea. Vitals showed BP 187/124 mmHg, HR 108 bpm and SpO2 96% on RA. She had anasarca on exam. Labs showed hemoglobin 8.9 gm/dL, platelets 80 K/cumm, WBC 16 K/cumm, creatinine 6.2 mg/dL and evidence of microangiopathic hemolytic anemia. Treatment for presumed hemolytic uremic syndrome (HUS)/TTP with steroids, plasma exchange, and dialysis had minimal benefit. She then developed seizures and headaches. Brain MRI showed Posterior Reversible Encephalopathy Syndrome (PRES), and lumbar puncture (LP) revealed high intracranial pressure (ICP) of 47 cm H2O. Chest and abdominal imaging were unremarkable and ADAMTS13 was normal. Kidney biopsy confirmed thrombotic microangiopathy. Genetic testing revealed a rare variant in CD46 and CFI genes. With these findings and lack of clinical evidence of Shiga toxin associated HUS, she was diagnosed with aHUS. Eculizumab was started, dialysis continued, and steroids were tapered. PLEX was discontinued after starting eculizumab. Despite improvement in her hemolysis labs, she had persistent headaches. A repeat LP showed an opening pressure of 38 cm H20 with normal fluid analysis, consistent with idiopathic intracranial hypertension (IIH). Acetazolamide/Topiramate were contraindicated due to a history of kidney stones, so she was started on nortriptyline for headaches. She was discharged on dialysis, weekly eculizumab and close follow up. IMPACT/DISCUSSION: Atypical hemolytic uremic syndrome (aHUS) is a rare disorder characterized by hemolytic anemia, thrombocytopenia and AKI. While typical HUS is caused by bacteria, aHUS could be genetically mediated or acquired. Most genes implicated in aHUS involve complement regulatory proteins, including Complement Factors H and I (CFH & CFI) and CD46. Thus, treatment of aHUS focuses on complement inhibition with eculizumab, while typical HUS is managed supportively. Our patient had a rare variant in both CD46 and CFI genes, and responded well to eculizumab therapy. While aHUS most commonly causes AKI, extrarenal manifestations occur in 20% of cases. Our patient developed seizures, headaches and elevated ICP. Her MRI showed PRES, which is a rare but recognized occurrence in aHUS. Her ICP remained elevated despite weeks of eculizumab therapy. We stipulated that without another cause for her ICP, she had developed IIH in association with her aHUS and PRES.

Atypical HUS is a complement-mediated process with high risk of morbidity and mortality despite advances in treatment. This case highlights the importance of prompt diagnosis and management of aHUS and its complications. Neurological manifestations occur in a small percentage of these cases, but may persist despite standard treatments like eculizumab, thus tailored approaches are needed to address them. Early identification can pave the way for better prognosis and quality of life in those affected by aHUS. A CASE OF A LIFE-THREATENING PACEMAKER POCKET HEMATOMA AFTER AGGRESSIVE THROMBOLYSIS AND ANTICOAGULATION OF A MASSIVE PULMONARY EMBOLISM Eshaan Parikh, Leanne Forman. Internal Medicine, Westchester Medical Center, Valhalla, NY. (Control ID #4273221) CASE: A 71-year-old female with a past medical history of pulmonary embolism (PE), deep vein thrombosis, 5 spontaneous pneumothoraces (status post talc pleurodesis), obesity, and hypertension presented to the hospital with progressively worsening exertional dyspnea. Physical exam and vitals were significant for bradycardia (heart rate 44 beats per minute) and a regular rhythm. Blood pressure was 144/54 mmHg. Thyroid-stimulating hormone and high-sensitivity troponin were within normal limits. An electrocardiogram revealed a Type II second-degree atrioventricular (AV) nodal block in a 2:1 pattern. Telemetry revealed a persistent second-degree AV block with periods of ventricular (wide QRS) escape rhythm with likely higher degree/complete AV block. A permanent pacemaker (PPM) was then placed. Her home Apixaban was held for 2 days before PPM placement and resumed afterwards. The next day, the patient became dyspneic, tachypneic, hypotensive, and hypoxic. Echocardiogram revealed a severely-dilated right ventricle with severely decreased systolic function and preserved apical contractility. She was then treated for a presumed massive PE with intravenous Alteplase and was transferred to another hospital for higher level of care. Chest computed tomography (CT) angiography scan confirmed an acute bilateral segmental and subsegmental PE. Ultrasound revealed a nonocclusive right posterior tibial vein thrombus. She was put on a high-dose heparin drip 24 hours after her last Alteplase dose. She later had non-fluctuant swelling and chest pain around her PPM site. CT chest revealed a large left chest wall hematoma with concern for a pacemaker pocket hematoma. An inferior vena cava (IVC) filter was then placed. She was switched to a low-dose heparin drip. Cardiothoracic surgery did not recommend hematoma evacuation. Her chest wall swelling and pain significantly improved with medical management. She was transitioned to Apixaban and discharged to rehab with vascular surgery follow-up for IVC filter retrieval. IMPACT/DISCUSSION: Holding the patient’s home Apixaban prior to PPM placement led to the emergence of a new PE which eventually caused hemodynamic instability. Thus, it is crucial to identify patients at higher risk of new thombosis when home anticoagulants are held for procedures. Furthermore, the decision to use Alteplase for treatment of the PE led to a unique superficial chest wall hematoma with risk of PPM displacement. Although there are documented cases of deep mediastinal bleeds after thrombolysis for PEs, there are little to no case reports in literature about superficial chest wall bleeds after thrombolysis for PEs. Despite having a life-threatening bleed, the patient was still grateful for receiving thrombolysis for her PE.

It is crucial to consider the complications of temporarily holding anticoagulation for procedures in patients at high risk of thombosis. The risks and benefits of aggressive thrombolysis should always be weighed against each other. A CASE OF A PULMONARY EMBOLISM UNMASKING IRON OVERLOAD WITH AN HFE H63D HETEROZYGOUS MUTATION Amrutha Sai Mittapalli1; Sophia Rokkas2; Zonera A. Ali2. 1Internal Medicine, Lankenau Medical Center, Wynnewood, PA; 2Hematology/Oncology, Lankenau Medical Center, Wynnewood, PA. (Control ID #4272448) CASE: A 22-year-old female with no past medical history presented to the ED after two near-syncopal episodes while walking. She was on the oral contraceptive pill but had no recent travel, surgeries, or prolonged immobility. Family history included pulmonary embolism (PE) with a prothrombin gene mutation in her father. Shortly after arrival in the ED, she had a cardiac arrest with pulseless electrical activity. CPR was initiated, and a bedside echocardiogram was concerning for right heart strain. Suspecting PE, Tenecteplase was administered. Subsequently, she was placed on ECMO and ROSC was achieved. CT angiogram revealed bilateral large PEs, right heart strain, and abdominal/pelvic ascites with high attenuation suggesting hemorrhage. Massive transfusion protocol and aminocaproic acid were started for peritoneal hemorrhage and IV heparin was initiated for PE. Doppler US of lower extremities did not show a deep vein thrombosis (DVT). Prothrombin and Factor V Leiden mutations, anticardiolipin, and beta-2 glycoprotein antibodies were negative. After three weeks, she was successfully decannulated from ECMO, and her anticoagulation was transitioned to apixaban. One week later, she developed bilateral lower extremity edema, and doppler US of lower extremities confirmed new bilateral DVTs. An echocardiogram demonstrated a right atrial thrombus. Subsequently, anticoagulation was transitioned to warfarin and she was discharged with hematology follow up. Two months after discharge, workup revealed a ferritin level of 878 ng/mL (11-250 ng/mL), serum iron of 138 μg/dL (35-150 μg/dL), iron saturation of 62% (15-45%), total iron-binding capacity of 221 μg/dL (270-460 μg/dL) and unsaturated iron-binding capacity of 83 μg/dL (180-360 μg/dL). HFE gene testing revealed one H63D pathogenic variant; C282Y was negative. These findings indicate the patient is likely a carrier of the HFE gene mutation, though a diagnosis of hereditary hemochromatosis cannot be ruled out. IMPACT/DISCUSSION: This case highlights the potential contribution of iron overload to hypercoagulability in a young patient with an HFE H63D mutation and laboratory findings suggesting iron overload (ferritin 878 ng/mL, iron saturation 62%). While a single copy of the H63D variant is typically of low penetrence, it can still lead to mild iron overload, contributing to oxidative stress, endothelial dysfunction, and platelet activation, which could increase risk of thrombotic events. The development of bilateral DVTs and atrial thrombus, while on apixaban, suggests an ongoing prothrombotic state. While oral contraceptive use likely contributed, this case emphasizes considering iron overload as a possible contributor to venous thrombosis.

This is a case of potential iron overload contributing to thrombosis, evidenced by elevated iron indices and an HFE hetrozygous mutation, in a patient who initially presented with a pulmonary embolism and subsequently developed further thrombosis while on apixaban. A CASE OF CEFEPIME NEUROTOXICITY PRESENTING AS APHASIA Julia M. Morales2; Salman Kazmi1; Jasmine Haydel1; Sathya Narasimhan2; Lubna Khawaja1. 1Internal Medicine, Baylor College of Medicine Margaret M and Albert B Alkek Department of Medicine, Houston, TX; 2Baylor College of Medicine, Houston, TX. (Control ID #4273423) CASE: A 46-year-old male with HIV not an HAART (CD4 count of 58, viral load of 1.6 million copies/mL), treated cryptococcal meningitis status post VP shunt placement, alcoholic cirrhosis (on lactulose and rifaximin), and CKDIIIb presented with 2 days of progressive altered mental status, aphasia and myoclonic jerking movements that began two days after being discharged on outpatient parenteral antibiotic therapy with cefepime and linezolid for a presumed bacterial meningitis of unknown etiology. On presentation the patient was ill appearing but hemodynamically stable. The physical exam was notable for facial flushing, scleral icterus, rhythmic horizontal nystagmus, and muscle rigidity with resistance to passive motion in all extremities. The patient was unresponsive, non-verbal, unable to follow commands and only opened eyes in response to stimulation. The remainder of the neurological exam was notable for diffuse jerking without myoclonus or asterixis. Initial laboratory results were notable for acute kidney injury on chronic kidney disease. Chest X-ray, series of VP shunt images and CT of the head were unremarkable. EEG showed diffuse slowing. Given his history and presentation there was early suspicion of cefepime toxicity. Cefepime was held. The patient became alert on day two of his admission and by day four he was back to his baseline. IMPACT/DISCUSSION: Cefepime is well known for its adverse neurological effects. Renal dysfunction and inflammation/acute illness predisposes patients to cefepime neurotoxicity by interrupting the blood brain barrier, allowing cefepime to transfix the central nervous system. Renal dysfunction confers a higher risk due to resultant higher serum cefepime concentrations due to impaired renal excretion. Cefepime neurotoxicity can present with altered mental status, reduced consciousness, myoclonus, agitation and seizures, with symptoms occurring approximately 4 days after drug initiation. Aphasia is another presenting symptom, although uncommon, and has only been found in 15% of reported cases. Evaluation via history and EEG can aid in diagnosis. Generalized periodic discharges with a triphasic wave pattern are the classic EEG findings associated with cefepime neurotoxicity. Management includes medication cessation, antiepileptics if needed and emergent hemodialysis in severe refractory cases. Improvement in mental status usually occurs within two days after drug discontinuation.

Cefepime neurotoxicity is not a rare occurrence, but aphasia as a presenting symptom is uncommon and something that we should be aware of. Cefepime neurotoxicity can occur even when cefepime is appropriately dosed and patients with renal dysfunction or acute illness/inflammation are at increased risk of developing cefepime neurotoxicity. Mainstay management includes medication cessation, supportive care and emergent hemodialysis in severe refractory cases. A CASE OF CHEMOTHERAPY-INDUCED HTN Cecile McGarvey, Shea Hubbard, Deepa Bhatnagar. Tulane University School of Medicine, New Orleans, LA. (Control ID #4273085) CASE: An 81y/o female presented with a 1-day history of generalized weakness, dizziness, and headache. She denied chest pain, shortness of breath, and any sudden-onset focal weakness, vision changes, or difficulty speaking. Her medical history was significant for HTN, DMII, prior DVT, CKD3, and stage IV ovarian cancer treated with eight rounds of chemotherapy (paclitaxel/carboplatin and bevacizumab). On admission, her vitals were notable for BP ranging from 180-192/76-88mmHg, tachycardia to 102 bpm, temp. of 98.2oF, RR 18, and spO2 of 95% on room air. Physical exam was unremarkable. Initial lab studies revealed WBC count of 12.0 x 109/L, Hgb/Hct of 8.4 g/dL/27.0%, and platelet count of 98 x 109/L– all consistent with recent chemotherapy treatment. High sensitivity troponins remained flat at 18ng/L and 16ng/L over a 3-hour period. BNP was elevated at 358pg/mL but consistent with the patient's baseline. UA remarkable for 3+ protein. CT PE was negative. The patient was admitted for hypertensive urgency despite adherence with her home amlodipine 10mg and metoprolol succinate 150mg. Upon admission, she was medically managed with hydralazine 25mg for systolic pressures >180mmHg. Her home amlodipine 10mg was continued, and the metoprolol was replaced by carvedilol 25mg. Furosemide 40mg daily and empagliflozin 10mg for proteinuria were started. The patient’s BPs improved but remained elevated with systolics >140mmHg despite medical management. IMPACT/DISCUSSION: This patient presented with treatment-resistant symptomatic HTN. With lab/imaging studies negative for an obvious cause and outpatient BPs well-controlled prior to onset of chemotherapy, this patient’s hypertensive urgency was likely induced by her treatment with bevacizumab. Her most recent course of chemotherapy was just 4 days prior to this admission. Bevacizumab is an anti-VEGF agent that can be used in the treatment of some solid tumors. Anti-VEGF agents prevent vasculature formation through inhibitory pathways involving nitric oxide. In this way, these agents can cause HTN by preventing physiological vasodilation by nitric oxide. Therapeutic medical management of bevacizumab-induced HTN includes trials of first-line antihypertensives with definitive treatment requiring discontinuation of bevacizumab. Despite treatment with three antihypertensives, the patient’s systolics remained >140mmHg. Our case demonstrates that medical treatment alone may not be sufficient without discontinuation of the inducing agent. This case also demonstrates the importance of regular BP monitoring for patients receiving anti-VEGF treatments.

This case illustrates how chemotherapy agents such as Bevacizumab can cause treatment-resistant hypertension. Patients taking anti-VEGF agents should routinely monitor their BP at home. A CASE OF DISSEMINATED COCCIDIOIDOMYCOSIS MASQUERADING AS METASTATIC CANCER Ivy Deane G. Manalo, Davida Flattery. Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4273405) CASE: A 37 year old otherwise healthy man presented with one month of back pain accompanied by 3 days of nausea, vomiting and abdominal pain. He denied associated fever/chills/night sweats, cough/hemoptysis, but endorsed subjective weight loss. He also denies any weakness, numbness of his extremities, or loss of bowel and bladder control. A CT scan of the abdomen and pelvis showed multifocal osteolytic lesions in T11 vertebral body with associated height loss, and a 5cm right anterolateral paravertebral mass, as well as multiple pulmonary micronodules, most concerning for metastatic malignancy vs infection, including Tuberculosis. Initial workup showed negative IGRA, HIV, HCV, HBV serologies. The patient underwent IR-guided biopsy of the paravertebral mass, which showed fungal spherules consistent with coccidioides organisms. Cultures of the biopsied material grew coccidioides. Other serologic test supporting the diagnosis was a high coccidioides complement fixation titer of 1:32. The patient was diagnosed with disseminated coccidioidomycosis and was started on indefinite Fluconazole therapy. He had significant improvement of back pain at 1 month follow-up. He continues to follow up regularly for surveillance. IMPACT/DISCUSSION: Coccidiomycosis, also known as Valley Fever, is an endemic fungal infection found in Southwestern United States, Mexico, and parts of Central and South America. Although it most commonly impacts the lungs, it has a wide variety of presentations that can mimic other infection or malignancy, which make diagnosis challenging. This case highlights the importance of maintaining a broad differential diagnosis in patients with osteolytic bone lesions, as well as the need for close follow-up of patients diagnosed with disseminated coccidioidomycosis.

Coccidiomycosis typically presents as a pulmonary infection, with extrapulmonary manifestations occurring in a minority of patients. Extrapulmonary involvement may affect all organ systems, but commonly disseminates to skin, soft tissues, and the central nervous system. Initially, our patient was suspected to have a metastatic malignancy, because of diffuse osteolytic bone lesions of vertebral spine and pulmonary micronodules, along with weight loss. The lack of pulmonary manifestations, and more concerns for underlying malignancy lead to low suspicion for cocci despite being in an endemic area. There have been a couple of cases of disseminated coccidioidomycosis mimicking malignancy, which can delay diagnosis given the challenges of obtaining histopathologic identification.Thankfully, our patient had a biopsy performed promptly during hospitalization, leading to a timely and accurate diagnosis. It is important to have close outpatient follow up for patients diagnosed with coccidioidomycosis since they require prolonged antifungal therapy with triazoles. A CASE OF DISSEMINATED MORAXELLA CATARRHALIS IN A PATIENT WITH ACUTE LEUKEMIA Sanjna L. Surya, Benjamin Gewurz. Brigham and Women's Hospital, Boston, MA. (Control ID #4271329) CASE: A 62-year-old male with type 2 diabetes presented with 2 months of generalized myalgias and lower back pain, fevers and drenching night sweats, and 1 day of expanding red lesions on both arms. He had severe pain of all extremities and inability to ambulate. He was febrile to 101F, tachycardic, normotensive, had lumbar spine point tenderness and several 5-10 cm red, warm, tender nodules on both forearms. Labs showed an ANC of 100 with 14% blasts, Hgb 6-7 g/dL, CRP 267 mg/L, ESR 87 mm/h, INR 1.4 and LDH 354 IU/L. CT and MRI showed a large anterior mediastinal mass, multiple intramuscular abscesses of both forearms, and evidence of lumbar spine septic arthritis and vertebral osteomyelitis. Echocardiogram showed no vegetations. Blood cultures grew Neisseria species in 3 of 4 bottles. Vancomycin and cefepime were initiated but the patient had soon developed a full-body petechial and purpuric rash. Peripheral blood flow cytometry and bone marrow biopsy suggested acute undifferentiated leukemia, likely early T-cell precursor ALL. He underwent a broad infectious work-up for persistent febrile neutropenia with serial blood cultures, serum bacterial and viral PCR and antibody tests, fungal markers, and urine gonorrhea testing which were negative. Nodule punch biopsy showed subcutaneous/deep dermal neutrophilic infiltrate with focal vasculitis suspicious for infection, favored to be septic vasculitis. Infectious stains and cultures were negative as were gram stain and cultures of a superficial arm lesion. 16S ribosomal sequencing of fluid from an arm lesion was sent which was positive for Moraxella catarrhalis. The patient defervesced by day 8, was transitioned to cefepime and then ceftriaxone monotherapy. Chemotherapy was initiated. At hospital discharge he was pain-free and skin lesions were resolved. He completed a 6-week course of levofloxacin. IMPACT/DISCUSSION: This case illustrates the utility of NGS in making a rare diagnosis. Moraxella is an important cause of sinusitis, otitis media, and respiratory infections in children and adults with COPD. Disseminated Moraxella catarrhalis is rare, primarily affects immunocompromised patients and can manifest with bacteremia, pneumonia, endocarditis, meningitis, septic arthritis, and/or a disseminated rash. Most affected patients are neutropenic and a petechial, purpuric, or nodular rash is reported in up to 25%. Cephalosporins or fluoroquinolones are effective. Notably, Moraxella catarrhalis was formerly named Neisseria catarrhalis and resembles Neisseria in culture, suggesting initial misidentification of the blood cultures.

Disseminated Moraxella catarrhalis is rare, primarily affects neutropenic adults and can affect many sites, with skin and soft tissue most commonly affected. It can be misidentified as Neisseria. NGS tests such as bacterial 16S ribosomal sequencing can aid diagnosis in patients with persistent fever and inconclusive conventional microbiology studies. A CASE OF DISSEMINATED MYCOBACTERIUM KANSASII IN A RENAL TRANSPLANT RECIPIENT: AN UNCOMMON DIAGNOSIS AIDED BY NEXT-GENERATION SEQUENCING OF MICROBIAL CELL-FREE DNA Stephanie Pintas1,2; Brian D. Young2; Omer E. Beaird2; Neveen S. El-Farra2. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4261114) CASE: A 48-year-old male renal transplant recipient with prior rectal abscess presented with a week of rectal pain and productive cough as well as several months of chills and unintentional weight loss. He had no dysuria or allograft pain. His immunosuppression regimen included tacrolimus, mycophenolate mofetil, and prednisone. Vital signs were notable for pyrexia to 38.2C and tachycardia. Admission labs demonstrated lymphopenia (150 cells/mm3), anemia (hemoglobin 10.3 g/dL), acute kidney injury (creatinine 5.47 mg/dL, baseline of 1.7 mg/dL), and mild pyuria (8 WBC/HPF) without hematuria. Bacterial blood and urine cultures were obtained. He was started on linezolid, cefepime, and metronidazole for presumed pneumonia and rectal abscess. CT chest demonstrated a right-upper lobe mass-like consolidation and hilar adenopathy. CT abdomen/pelvis was unrevealing, but MRI pelvis showed prostatitis with an abscess. Bacterial urine culture, STI testing, and serologic testing for typical fungal pathogens were all negative. A plasma-based, cell-free DNA assay sent on hospital day 4 detected Mycobacterium kansasii on hospital day 7 so rifabutin, ethambutol and azithromycin were promptly started. Acid-fast bacilli sputum cultures collected on hospital day 3 revealed M. kansasii 17 days after admission and urine AFB cultures also later grew M. kansasii. One month after initial presentation, the patient was readmitted for left lower extremity pain and MR angiography demonstrated pseudoaneurysms involving the superficial femoral artery and tibial-peroneal trunk. Histology of the resected lesions confirmed mycotic aneurysms with positive AFB stains and cultures. Isoniazid was added to his regimen for 3 months, and he completed treatment with rifabutin, ethambutol, and azithromycin with clinical stability. IMPACT/DISCUSSION: This is an atypical case of disseminated M. kansasii in a solid organ transplant recipient in which time to diagnosis and initiation of treatment was significantly reduced with use of a plasma-based microbial cell-free DNA assay compared to culture-based methods. Although pulmonary infection and dissemination are commonly reported with M. kansasii infections, prostatitis and mycotic aneurysms are rare. Diagnosis of non-tuberculous mycobacterial (NTM) infections is challenging and requires a combination of clinical, radiographic, and microbiologic criteria due to their non-specific and indolent presentations. Clinicians should consider mycobacterial infections in immunocompromised patients with suggestive pulmonary findings, but otherwise negative bacterial cultures as early diagnosis is key given the morbidity of these infections in this population.

- Solid organ transplant recipients are at risk for NTM infections, particularly in the first 12 months of transplantation. - Use of plasma-based microbial cell-free DNA assays allow for expedited diagnosis of NTM infections. - Prompt initiation of treatment decreases risk of complications from disseminated NTM infections. A CASE OF DOXYCYCLINE INDUCED STEVENS-JOHNSON SYNDROME Aram Aslanian, Samra Iqbal, Asim Ali, Sayma Yaqub, Ali Yusuf, Tarek Naguib. Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #4269866) CASE: A a 97-year-old female, with a background of rheumatoid arthritis, osteoarthritis, and chronic kidney disease (CKD) presented with a painful, itchy rash around her eyes, mouth, and anus, which had developed six days after starting doxycycline for a UTI. She had previously experienced a similar rash after using adalimumab, suggesting a propensity to drug-induced hypersensitivity reactions. Physical examination revealed an edematous, annular rash around her eyes and mouth, with erythema and skin fragility. Mucosal involvement was noted on the palate, consistent with Stevens-Johnson syndrome (SJS). Given her history and the timing of the rash onset, the diagnosis of drug-induced SJS was made. The rash was initially mild but worsened over the next few days, prompting hospitalization. The patient was started on methylprednisolone, which led to a rapid improvement in the rash. After 48 hours, the skin lesions began to subside, and she was switched to oral prednisone taper over the next week. IMPACT/DISCUSSION: Doxycycline, like other tetracyclines, is known for causing dermatologic adverse reactions, such as rash in sun-exposed areas. Doxycycline-induced SJS, although rare, represents a potentially fatal adverse drug reaction. It typically presents with widespread erythematous rashes, blistering, and mucosal involvement, affecting areas such as the mouth, eyes, and genital region. The pathophysiology of doxycycline-induced SJS is thought to involve an immune-mediated hypersensitivity response, where cytotoxic T cells target keratinocytes, leading to apoptosis and extensive necrosis of the epidermis. Elderly patients are particularly vulnerable to severe drug reactions due to factors such as possible polypharmacy, altered pharmacokinetics, and age-related changes in immune function. Additionally, comorbid conditions like CKD can complicate the diagnosis and management of drug-induced SJS. This patient’s age and underlying renal impairment likely increased her susceptibility to the adverse effects of doxycycline. In this case, the patient’s SJS improved rapidly with corticosteroid therapy, demonstrating the importance of early recognition and management. Discontinuation of the offending drug, in this case, doxycycline, is crucial to preventing further progression. Supportive care, including fluid management and pain control, is essential.

This case report illustrates the potential risk of SJS due to doxycycline, particularly in elderly patients with multiple comorbidities. Early recognition of drug-induced SJS and prompt discontinuation of the offending medication are essential to improving outcomes. Corticosteroid therapy can be effective in managing the symptoms, but careful monitoring is needed, especially in patients with pre-existing renal conditions. Care must be taken when prescribing doxycycline or any medication known to cause severe hypersensitivity reactions, particularly in older patients who may be more vulnerable to adverse drug reactions. A CASE OF ECTHYMA GANGRENOSUM IN A PATIENT WITH CUTANEOUS T-CELL LYMPHOMA PRESENTING WITH NEUTROPENIC FEVER Uzma Jafry1,2; Mohit Harsh2. 1Medical Student, Lake Erie College of Osteopathic Medicine, Erie, PA; 2Mercy Hospital Jefferson, Festus, MO. (Control ID #4273239) CASE: A 70 year old female with cutaneous T-Cell lymphoma on CHOP therapy presented to the emergency department with symptoms of fever, chills, lethargy, and development of skin lesions under her right breast. Initially, the lesions were painless and appeared as irregular vesicles on a purple, reddened base. Her initial vitals were unremarkable, and lab values were significant for a WBC of 1.1 K/uL, ANC of 0.32 k/uL, and lactic acidosis. Based on the clinical presentation, the patient was diagnosed with neutropenic fever and sepsis. She was started on broad spectrum antibiotics and infectious work up was initiated. The next day, the vesicles became painful and progressed to her right axilla and trunk. Blood cultures grew Pseudomonas aeruginosa in 2/2 bottles. The lesions started to drain; therefore, a Gram stain and VZV PCR were ordered. The Gram stain grew P. aeruginosa and VZV PCR was negative, ruling out shingles. Given the nature of her lesions, the Gram stain, and pseudomonas bacteremia, a diagnosis of ecthyma gangrenosum was made. The lesion growth, pain and neutropenia improved while on Cefepime. Subsequent blood cultures showed clearance of pseudomonas bacteremia. IMPACT/DISCUSSION: Neutropenic fever is a life-threatening condition with mortality rate as high as 15%. Guidelines recommend initiation of anti-pseudomonal antimicrobial therapy in patients presenting with neutropenic fever. Our case represents an excellent example of why anti-pseudomonal coverage is recommended. Our patient developed ecthyma gangrenosum, a rare cutaneous manifestation of pseudomonas bacteremia. The lesions were presumed to be a shingles infection due to the dermatomal distribution of painful vesicles in an immunocompromised individual. It is imperative for clinicians to keep a broad differential for cutaneous manifestations in patients presenting with neutropenic fever. When the bacteria enters the bloodstream, they quickly invade arteries leading to epidermal necrosis. The initial findings of ecthyma gangrenosum present as a painless round patch on a reddened base. The round patch progresses to a pustule with hemorrhagic vessels at its center. As the vesicle expands peripherally, it rapidly transforms into a gangrenous eschar surrounded by a red halo. The progression from a painless patch to a necrotic ulcer can occur within as little as 12 hours. Histologically, the lesions display epidermal necrosis along with vascular edema and neutrophilic predominance. The manifestation of echthyma gangrenosum in patients with sepsis is associated with a poor prognosis. The main cause of death is related to the immunocompromised state of these patients. Neutropenia serves as a crucial prognostic indicator for mortality.

Ecthyma gangrenosum is a rare but critical manifestation of pseudomonas bacteremia which requires prompt recognition and treatment by performing early diagnostic studies in immunocompromised patients presenting with neutropenic fever. A CASE OF GROUP B STREPTOCOCCUS INFECTION WITH A MISDIAGNOSIS OF INFLAMMATORY ARTHRITIS Fathima Alam1; Roshmita Bardhan2. 1Internal Medicine, Bon Secours Mercy Health, Cincinnati, OH; 2Internal Medicine, Mercy Health, Cincinnati, OH. (Control ID #4273415) CASE: A 59-year-old female with no significant past medical history presented with pain and swelling of her fifth digit metacarpophalangeal joint. She reported waking up with noticeable swelling and pain in the knuckle of her right long finger's metacarpophalangeal joint. Her symptoms continued to progress into the next morning, with noticeable redness, intense swelling, throbbing pain, and severe discomfort predominantly affecting her right long finger metacarpophalangeal joint, along with proximal and distal swelling of the entire finger. She denied any injury, punctures, fever, chills, or other systemic symptoms of infection. She was evaluated by her primary care provider, who presumed that the patient was experiencing an inflammatory response. Physical examination revealed soft tissue swelling, redness, and warmth predominantly affecting the right third metacarpophalangeal joint. She was started on a 40 mg prednisone taper; however, when her symptoms did not resolve after two days, she was switched to methylprednisolone, which she took for three days without any improvement in her symptoms. As her symptoms persisted, there was concern for a hand infection. Subsequently, an MRI was obtained, showing intense soft tissue edema, osseous edema, and effusion of the right third metacarpal joint. She was evaluated by orthopedic surgery and underwent an arthrocentesis, but aspiration was not successful. She was scheduled for surgery the next day for decompression, and the specimen was sent out for further review. She was found to have Group B Streptococcus bacteremia following uterine prolapse surgery, causing right-hand septic flexor tenosynovitis and osteomyelitis of her pelvis and spine, and she was treated with antibiotics for 12 weeks. IMPACT/DISCUSSION: This case highlights the diagnostic challenges and atypical presentation of Group B Streptococcus (GBS) bacteremia in an adult patient. GBS, predominantly associated with neonatal infections, is also a potential, though rare, cause of invasive infections in non-pregnant adults, particularly in those with underlying comorbidities such as diabetes, cancer, or immunosuppression. However, this patient had no significant past medical history or risk factors commonly associated with GBS infections, making the initial diagnosis challenging.

This case underscores the need for a broad differential diagnosis in cases of monoarticular arthritis, particularly when initial treatments fail. In adults presenting with atypical joint infections or swelling without a clear source of inflammation, GBS should be considered, especially in patients with recent surgical histories. Clinicians should remain vigilant for rare presentations of GBS in adults, as timely identification and appropriate treatment are essential to prevent dissemination and minimize patient morbidity. A CASE OF GROUP B STREPTOCOCCUS MENINGITIS REVEALING AN UNDERLYING DIAGNOSIS OF MULTIPLE MYELOMA Allison Kagerer, Michael Hovan, David T. Zhang. Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4272543) CASE: A middle-aged man with hypertension, type 2 diabetes, hidradenitis suppurativa, and prior smoking presented with one week of fevers, rigors, progressive myalgias, weakness, neck stiffness, and altered mental status. Given high suspicion for community-acquired meningitis, he was empirically covered with vancomycin, ceftriaxone, ampicillin, and acyclovir. A lumbar puncture was performed with cerebrospinal fluid cultures positive for penicillin-sensitive Streptococcus agalactiae/Group B streptococcal (GBS), with subsequent bacteremia with the same organism. His antibiotics were narrowed to penicillin to complete an 8-week course. Given the atypical organism of GBS, further investigation was performed to elucidate the source of the bacteremia and meningitis. Worsening upper back pain prompted an MRI of his spine which showed hyperintensity at the T6 vertebral body with associated compression fracture and a second soft tissue mass at the level of C1-C2, concerning for malignancy. Serum electrophoresis revealed a biclonal gammopathy. A positron emission tomography scan found multiple lytic lesions as well as moderate fluorodeoxyglucose uptake in the bilateral shoulders suggesting possible septic arthritis. Pathology from both a bone marrow and humeral biopsy were consistent with a plasma cell neoplasm, confirming the diagnosis of multiple myeloma. Orthopedic surgery also aspirated his shoulder joint with synovial fluid cultures positive for Streptococcus agalactiae. For his multiple myeloma, the patient underwent radiation and multiple rounds of chemotherapy with grade 1 complications. Given significant progression of disease, T cells were harvested with a plan to pursue CAR T-cell therapy. IMPACT/DISCUSSION: Our patient presented with classic meningitis symptoms of fever, neck stiffness, and altered mental status, and a lumbar puncture confirmed the diagnosis. Though GBS is not commonly thought of as an opportunistic organism outside of neonates or pregnant patients, our patient’s pre-disposing risk factors were poorly-controlled diabetes (hemoglobin A1c 11.2%) and obesity (body mass index 32.6 kg/m2). However, given that GBS makes up only 1% of meningitis organisms and the patient had imaging findings as described, there was reasonable concern he had an undiagnosed malignancy. The clinching diagnosis of multiple myeloma further explains his susceptibility to infection, with the hypogammaglobulinemia specifically increasing risk of bacterial infections during the first 3 months of diagnosis. Overall, GBS is a rare source of meningitis, with a significant case fatality rate of up to 1/3 of patients.

A middle-aged man presented with one week of fevers, altered mental status, and neck stiffness and was found to have Streptococcus agalactiae meningitis and bacteremia. Extensive workup revealed multiple myeloma which was treated with chemotherapy. A CASE OF HLH SECONDARY TO EBV-POSITIVE DLBCL: LESSONS TO BE LEARNED IN EARLY DIAGNOSIS AND TREATMENT Santoshi M. Kandalam, Anirban Ganguly, Meghana Rao. Internal Medicine , Tulane University, New Orleans, LA. (Control ID #4272742) CASE: A 64-year-old man presented with a productive cough, generalized weakness, nausea/vomiting, fever, and several months of unexplained weight loss and anemia. His vitals included a temperature of 101.2°F, BP of 98/64, and HR of 109. Exam findings included pale conjunctiva. Labs revealed anemia, hyponatremia, and liver dysfunction. Imaging showed hepatomegaly, splenomegaly, and liver masses. He was admitted to our hospital for a liver biopsy with IR, unavailable at the outside hospital (OSH). During his stay, a fine-needle aspiration of a lymph node was performed, and the team decided to wait for biopsy results before determining treatment. However, there were delays in obtaining liver and bone marrow biopsies and receiving results. The patient’s lab results worsened, with rising ferritin, hypertriglyceridemia, and persistent pancytopenia. Hematology/Oncology considered hemophagocytic lymphohistiocytosis (HLH) as a differential, but were concerned that starting treatment could obscure a potential underlying malignancy. By day 10, the patient’s ferritin had risen to >8000, AST to 127, triglycerides to 261, and hemoglobin dropped to 7.4. Soluble CD25 and CXCL9 were sent, and HLH treatment per the HLH-2004 protocol (etoposide, dexamethasone, cyclosporine, intrathecal methotrexate) was initiated. However, the patient suffered a cardiac arrest, was resuscitated, and was transitioned to comfort care on day 19. The liver biopsy later revealed Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL). IMPACT/DISCUSSION: HLH in adults is often secondary to malignancy or infection, which can delay diagnosis and treatment. Though HLH progression is rapid and early treatment is crucial, there is a perception that it is a diagnosis of exclusion, requiring identification of the underlying cause. In our case, the patient’s H-score was already elevated to 193 (80-88% probability of HLH) three days before transfer, meaning treatment ideally should have started immediately. This delay was compounded by factors such as weekend admissions, delayed biopsies, and unclear responsibility for care between hospitals. Furthermore, the recent transition of the community hospital to a teaching center led to scheduling issues and limited availability of specialist coverage and CT-guided procedures.

HLH is a rare condition in adults, more common in pediatrics, but recent data suggests it may be more prevalent in adults than previously thought. A Lancet study on adult HLH found high hospitalization costs ($54,800) and long lengths of stay (14.3 days), placing a substantial burden on the healthcare system. Pediatric hospitals may be better equipped to handle rare conditions like HLH, using standardized protocols and scoring systems. A standardized HLH protocol in adult settings could help mitigate delays in diagnosis and treatment, and further research into best practices for managing HLH and other rare conditions would benefit both patients and the healthcare system. A CASE OF HYPOMAGNESEMIA INDUCED CEREBELLAR EDEMA Roshmita Bardhan1; Fathima Alam3,2. 1Internal Medicine, Mercy Health, Cincinnati, OH; 2Internal medicine, The Jewish Hospital - Mercy Health, Cincinnati, OH; 3Internal Medicine, Bon Secours Mercy Health, Cincinnati, OH. (Control ID #4243349) CASE: In April 2024, a 61 year old male presented to the hospital with a 2 day history of increasing frequency of repeated episodes of dizziness that lasted for 15 to 20 seconds at a time, lightheadedness, slurred speech that was recognized earlier in the week by his co-workers and weakness in his bilateral upper arms. On admission, the patient was afebrile and was hypertensive to 154/97. Initial physical examination revealed a rightward leaning gait, 4 out of 5 strength in bilateral upper extremities and mild dysarthria. A Code stroke was called and the patient underwent a CT head and CTA head and neck, which came back negative.Labs revealed hypokalemia to 2.4, hypocalcemia to 5.6, and hypomagnesemia to 0.3. Aggressive electrolyte replacement was started. Medication list was reviewed and was notable for Losartan-Hydrochlorothiazide (Hyzaar), Amlodipine, and Omeprazole. Hyzaar was started a month prior to the patient’s presentation to the hospital by the patient’s primary care provider for high blood pressure. Brain MRI revealed increased T2/FLAIR in the bilateral cerebellar hemispheres with mild restricted diffuse activity secondary to suspected early hypoxia, along with mass effect with borderline tonsillar herniation. The patient was transferred to a comprehensive stroke center for further evaluation of mass. Repeat Brain MRI revealed bilateral cerebritis. Electrolyte abnormalities were initially thought to be from Hyzaar use, along with PPI use so they were held. However, he continued to require multiple IV electrolyte replacements. Given the significant improvement of clinical symptoms with electrolyte replacement with no signs of infection, the patient was diagnosed with hypomagnesemia-induced cerebellar syndrome. The patient was monitored closely by the neurology team, along with strict electrolyte replacement protocol. He was later discharged on oral electrolyte supplements. The patient was switched to Spironolactone, to increase potassium levels in the setting of hypertension. Omeprazole was changed to Famotidine. Outpatient instructions were given to follow up with neurology after discharge to confirm the resolution of cerebellar edema. IMPACT/DISCUSSION: The cerebellum plays a crucial role in motor control, coordination, and balance. Disturbances in magnesium levels can impact cerebellar function. When magnesium levels are low, it can lead to increased neuronal excitability with subsequent neuroinflammation. This inflammation results in edema, or swelling, in the cerebellum. Symptoms of cerebellar edema may include ataxia, dizziness, and balance issues.

In clinical settings, it is important to identify the underlying cause of hypomagnesemia. This can include factors such as malnutrition, gastrointestinal losses, or certain medications. Treatment typically involves magnesium supplementation, along with addressing the underlying cause to restore normal magnesium levels. A CASE OF KIKUCHI-FUJIMOTO DISEASE IN A YOUNG AFRICAN AMERICAN MAN Hoyoung Lee1; Shashank Suresh3; Michael Leonard2. 1Internal Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC; 2Infectious Disease, Atrium Health Carolinas Medical Center, Charlotte, NC; 3Rheumatology, Atrium Health Carolinas Medical Center, Charlotte, NC. (Control ID #4270311) CASE: A 20-year-old healthy African American man was hospitalized in June 2024 with headaches and papilledema. Vital signs and physical exam were normal. MRI of the orbits revealed bilateral optic perineuritis. A lumbar puncture (LP) was performed with a normal opening pressure (OP) and negative cerebrospinal fluid (CSF) viral panel and cultures. The CSF contained no neutrophils. The patient also reported months of cervical lymphadenopathy. A CT of the neck noted enlarged lymph nodes, and an ultrasound guided biopsy revealed histiocytic necrotizing lymphadenitis, findings that were noted to be seen in Kikuchi-Fujimoto disease (KFD). Autoimmune workup revealed an elevated ribonucleoprotein to 3.0 but normal antinuclear antibodies and anti-double stranded DNA. He was discharged after resolution of his symptoms with supportive measures. The patient was admitted again in December 2024 with headaches, fevers, photophobia, night sweats, and cervical lymphadenopathy with nuchal rigidity on exam. He was febrile to 102.4°F and started on empiric acyclovir for meningitis. CSF glucose and protein were normal, but LP revealed an elevated opening pressure of 45cmH2O. Of the 62 nucleated cells on CSF, 69% were neutrophils. CSF viral panel and tuberculosis CSF cultures were negative as were serum cytomegalovirus (CMV) and adenovirus polymerase chain reaction (PCR). Human immunodeficiency virus (HIV) serology was non-reactive. During his hospital course, he underwent repeat LPs; the first had an elevated OP of 37cmH2O and the second had a normal OP. He was started on intravenous methylprednisolone for presumed KFD flare and demonstrated a remarkable response with near resolution of his symptoms. He was discharged with a prolonged steroid taper. IMPACT/DISCUSSION: KFD most commonly presents with fevers and cervical lymphadenopathy and is more prevalent in young women than men. While the exact pathogenesis of KFD is unknown, there have been implications with viruses (e.g., EBV, CMV, and HIV) as well as associations with autoimmune conditions (e.g., systemic lupus erythematosus (SLE), mixed connective tissue disease, and scleroderma). It is diagnosed by lymph node biopsy, which reveals necrotic areas with histiocyte proliferation. It is mostly a self-limited disease that resolves in several months. Our patient is a rare example of the neuro-ophthalmologic manifestations of KFD. Within five months, he exhibited optic neuritis and aseptic meningitis, both known neurologic presentations of KFD. Other clinical features of KFD can include rashes, joint pain, and hepatosplenomegaly. Without an obvious infectious or autoimmune etiology, the inciting factor was unclear in our case. Further longitudinal observation would be warranted to monitor for disease recurrence or development of SLE.

● Consider KFD in the young adult with fevers, cervical lymphadenopathy, and neurologic symptoms ● Monitor patients with KFD for development of SLE and disease recurrence A CASE OF LACTOBACILLUS IN A PERINEPHRIC ABSCESS Anjali Gundeti1; Hillary Deveaux1; Jacob Barnhart3; Leon Hsueh1,2. 1Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; 2Infectious Disease, Advocate Christ Medical Center, Oak Lawn, IL; 3College of Osteopathic Medicine, Midwestern University - Downers Grove Campus, Downers Grove, IL. (Control ID #4270550) CASE: A 70-year-old female with type 2 diabetes (T2DM), hypercalcemia, and lactobacillus bacteremia 2 years prior, presented with 2 weeks of worsening right flank pain without dysuria, frequency, fevers, or chills. A week earlier, she was treated for a urinary tract infection with 3 days of nitrofurantoin. Vitals were unremarkable. She had right costovertebral angle tenderness. Labs showed WBC 11.7, hemoglobin 6.5, transferrin saturation 6%, glycohemoglobin(A1C) 6.3%. CT angiogram revealed a right renal 2cm staghorn calculus with hydronephrosis, and 13cm perinephric abscess. Ceftriaxone 2g IV was initiated with subsequent percutaneous nephrostomy drain placement. Abscess and urine cultures returned positive for lactobacillus species but non-viable for susceptibility studies. We escalated to piperacillin-tazobactam. Blood cultures remained negative. Sinogram showed abscess resolution on day 12. Bilateral deep vein thrombosis (DVTs) complicated her hospital course despite prophylaxis. She was discharged on 2 weeks of amoxicillin-clavulanate 875-125mg twice daily, with close ID and urology follow-up and recommendation for outpatient colonoscopy. IMPACT/DISCUSSION: Lactobacillus is commensal to the gastrointestinal and female genitourinary tracts. Bacteremia, endocarditis, and peritonitis have been documented. Risk factors include recent abdominal surgery and immunocompromised states (malignancy, ESRD, transplant, HIV, T2DM, cirrhosis, inflammatory bowel disease). A case of lactobacillus perinephric abscess has been published in a young, immunocompetent female following stenting for obstructing nephrolithiasis and there are a few published reports of pyelonephritis in immunocompromised hosts, most with nephrolithiasis. The patient’s A1C indicates well-controlled T2DM, thereby questioning an immunocompromised state. External infectious sources; yogurt consumption and probiotics were ruled out, as she rarely consumed yogurt. Her history of lactobacillus bacteremia begs the question of renal seeding with smouldering infection vs an underlying malignancy given the unexplained iron deficiency anemia and DVTs. Antibiotic choice and duration guidelines are sparse as lactobacillus species are tough to isolate with variable susceptibilities. Case reports have previously used ampicillin and piperacillin-tazobactam. Piperacillin-tazobactam was chosen for its historically exceptional coverage against lactobacillus and uncultured gram negative organisms that usually cause perinephric abscesses. Oral amoxicillin-clavulanate was chosen after abscess resolution for its broader coverage and decreased resistance rates compared to ampicillin. The duration of antibiotics and further imaging will depend on her clinical picture at follow-up and plans for definitive management by urology.

Lactobacillus is a commensal organism without standard guidelines for treatment due to limited published cases. We highlight the potential risk factors for infection and the reasoning for the choice of antibiotics. A CASE OF LATENT AUTOIMMUNE DIABETES OF ADULTS WITH PAST HISTORY OF NOONAN’S SYNDROME Ava Karnish1; Raya Tcheroyan2; Joseph Grogg2. 1Internal Medicine, Rowan University Cooper Medical School, Camden, NJ; 2Internal Medicine, Cooper University Health Care, Camden, NJ. (Control ID #4271536) CASE: A 33-year-old male with Noonan’s syndrome presented to an outside hospital for escalation of care in the setting of shock, diabetic ketoacidosis (DKA), and pneumonia. The patient experienced nausea, vomiting, and abdominal pain and was found to have glucose higher than 1700 mg/dL, pH of 6.9, potassium of 8.3 mEq/L, and Creatinine of 4.17 mg/dL. The patient was started on IV fluids, an insulin infusion, intubated for airway protection, and was transferred to Cooper. Chest CT showed multifocal pneumonia which was thought to be the cause of shock. On admission, an extensive workup for his diabetes was completed. His hemoglobin A1c was at 11%, Zinc transporter 8 antibodies were negative but his anti-glutamic acid decarboxylase GAD65 was found to be elevated to 12 IU/mL, normal being less than 5. The patient was subsequently diagnosed with LADA and started on a basal/bolus insulin regimen. The pneumonia was treated with antibiotics. Kidney function improved, electrolytes normalized, and urine output was adequate. The patient was later discharged and is currently being followed by endocrinology. IMPACT/DISCUSSION: This case highlights the importance of recognizing potential associations between genetic syndromes like Noonan Syndrome and other autoimmune conditions. According to the National Institutes of Health Autoimmune Disease Coordinating Committee Report, the general population in the US has a frequency of autoimmune disease development ranging from 5-8%. One study suggested that in a cohort of selected patients with Noonan Syndrome, the frequency of development of autoimmune disease was approximately 14%. While the precise mechanisms underlying this connection remain unclear, shared genetic pathways or dysregulation of immune responses may contribute to the co-occurrence of these conditions. In addition, patients with Noonan’s were found to have various autoantibodies contributing to that increased risk. Although there are no studies in the current literature that outline the correlation between Noonan Syndrome and LADA, it is widely accepted that LADA’s pathogenesis is rooted in cell-mediated autoimmunity. Documented cases of Noonan syndrome patients who also have Type I Diabetes Mellitus hint at a potential association between Noonan and the development of LADA, particularly among individuals with pre-existing autoantibodies to glutamic acid decarboxylase like our patient.

Management of autoimmune diabetes in patients with Noonan syndrome is challenging and requires a multidisciplinary approach. Physicians should keep a close eye for autoimmune complications in these patients, especially in those presenting with symptoms suggestive of possible diabetes mellitus. Early diagnosis and intervention are crucial in reducing the risks associated with uncontrolled hyperglycemia and in optimizing long-term outcomes. Further research is needed to understand the exact mechanism of association between these conditions to allow for a more targeted therapeutic approach. A CASE OF LYMPHOCYTIC COLITIS MASQUERADING AS CHRONIC INFLAMMATORY DIARRHEA Corey Haines1; Alejandro Aquino1; Diana Acosta Pozo1; Sophia Moon2; Giani Tah2; Fatimah O. Bello1. 1Internal Medicine, The University of Texas Rio Grande Valley School of Medicine, Edinburg, TX; 2The University of Texas Rio Grande Valley School of Medicine, Edinburg, TX. (Control ID #4273478) CASE: A 26-year-old male with no known past medical history presented to a hospital near the U.S.-Mexico border in southern Texas due to 2 weeks of worsening bloody diarrhea associated with tenesmus, fatigue, weight loss, blurry vision, and lower abdominal pain. For the past two years the patient had experienced intermittent monthly episodes of bloody diarrhea lasting several days. During these episodes the patient reported symptoms of bloating and abdominal cramping, most notably in the LLQ. He attempted to reduce the amount of spicy food and gluten in his diet as he these were triggers, however this did not relieve his symptoms. At no point did the patient experience non-bloody diarrhea, fever, arthralgias, eye pain, new onset rash, or nocturnal stools. The patient was not on any medications, did not use tobacco products or other substances, and drank alcohol rarely. Family history was negative for any GI pathology or cancer. The patient had never been evaluated by a gastroenterologist due to medical insurance cost barriers. On arrival to the ED the patient was found to be afebrile, HR 60, BP 128/57, RR 16, and SpO2 100% on room air. Physical exam was significant for ill-appearance, dry mucous membranes, delayed capillary refill, LLQ tenderness to palpation, and a +DRE. Initial labs included a normal metabolic panel, normal WBC count, Hgb 9.0 with MCV 64 and MCHC 27, normal inflammatory markers, and normal coags. Iron panel was suggestive of IDA with iron 16, ferritin 4.0, and TIBC 451. GI stool pathogen panel was positive for ETEC. An abdominal x-ray was unremarkable. The patient was fluid resuscitated and admitted for further workup. On the floors additional labs included negative IgA tissue transglutaminase Ab and a stool osm gap < 50. GI was consulted and performed endoscopy and colonoscopy with findings of suspected gastritis, grade II internal hemorrhoids, and a 9 mm sessile polyp which was removed via hot snare. Tissue samples were obtained from the gastric body, duodenum, and colon. Pathology was diagnostic of severe chronic gastritis positive for H. pylori and lymphocytic colitis. Post-procedure the patient was hemodynamically stable and able to be discharged with a single dose of azithromycin and GI follow-up. IMPACT/DISCUSSION: This case masquerades as acute worsening of chronic bloody diarrhea, however the patient had multiple pathologies contributing to a mixed clinical picture. Despite some symptoms of IBD (chronic bloddy diarrhea, blurry vision) other systemic involvement and supportive laboratory evidence was lacking. This case highlights how etiologies of chronic watery diarrhea can present as inflammatory diarrhea in the setting of a chronic lower GI bleed.

Microscopic colitis is an important differential to maintain for chronic bloody diarrhea despite its classic presentation as non-bloody diarrhea Work-up for chronic inflammatory diarrhea should include traditional lab testing as well as colonoscopic evaluation for co-existing GI bleed. A CASE OF MISTAKEN IDENTITY: ACCIDENTAL TRAUMA PROGRESSING TO NECROTIZING FASCIITIS OF THE FACE Laura Quillen1; Ryan Truitte2; Joshua LaBrin1. 1Internal Medicine, University of Utah Health, Salt Lake City, UT; 2Internal medicine, University of Utah Health Huntsman Cancer Institute, Salt Lake City, UT. (Control ID #4272358) CASE: A 65-year-old male presented with right facial pain and swelling following an assault in which he was wrongly targeted, an unfortunate victim of mistaken identity. Despite the trauma, he was afebrile and hemodynamically stable. Initial labs revealed a mildly elevated WBC of 11 but normal lactic acid at 2. Physical examination showed diffuse right facial swelling without crepitus. CT imaging showed significant right facial and periorbital edema but no abscess or gas. Ophthalmology and ENT recommended non-operative management. He was started on vancomycin and ampicillin-sulbactam for suspected facial cellulitis. One day later his symptoms worsened with increased pain and an inability to open both eyes. Although afebrile with stable vitals, his WBC rose to 18. Blood cultures grew group A Streptococcus. Repeat CT imaging identified new foci of gas, highly concerning for necrotizing fasciitis. The patient underwent urgent debridement of the right face in a joint procedure with ENT and ophthalmology. Following infectious disease consultation, antibiotics were adjusted to ceftriaxone and clindamycin. Clindamycin was discontinued after 48 hours, and doxycycline was added. The patient required multiple washouts over the next week. Over a week later, he underwent right cheek closure with a full-thickness skin graft to the right upper eyelid. He was discharged in stable condition with a two-week course of amoxicillin-clavulanate and doxycycline. IMPACT/DISCUSSION: Necrotizing fasciitis of the face is a rare, life-threatening condition often presenting with severe pain, swelling, crepitus, and systemic signs of infection. Early recognition is critical to minimize complications such as tissue loss, vision impairment, or systemic spread. Diagnosis is primarily clinical, supported by imaging findings and blood cultures to identify causative organisms. Risk factors include odontogenic, sinugenic, or peritonsillar infections, though trauma, as in this case, is also a recognized etiology. Management requires a multidisciplinary approach involving internists, surgeons, infectious disease specialists, and ophthalmologists. Aggressive debridement of necrotic tissue is essential, alongside broad-spectrum antibiotics. This case underscores the importance of early recognition, repeat imaging for clinical deterioration, and coordinated multidisciplinary care for optimal outcomes.

Recognizing the clinical presentation and diagnostic features of necrotizing fasciitis is essential for prompt management of this rare but life-threatening infection. Repeat imaging should be considered for clinical deterioration or new findings in patients with cellulitis and trauma history. Necrotizing fasciitis of the face requires multidisciplinary collaboration involving internists, surgeons, infectious disease experts, and ophthalmologists. Early specialist involvement is critical for managing surgical, antimicrobial, and supportive care needs, including fluid resuscitation and hemodynamic monitoring. A CASE OF MULTIPLE MYELOMA MANIFESTING AS SPINAL STENOSIS Richard Jin. Internal Medicine, Summa Health System, Akron, OH. (Control ID #4270330) CASE: Multiple myeloma is a relatively uncommon cancer representing 1% of all cancers in the US. A very rare subset of presentations, less than 5% of patients, present with symptoms of extradural spinal cord compression. A 44 year old female with 2 month history of spinal stenosis and low back pain presents to the emergency department with bilateral leg paresthesias and weakness. She is otherwise well with no other past medical history. Patient was seen by orthopedic surgery as an outpatient and was scheduled to undergo surgery to address her L5-S1 spinal stenosis. An outpatient MRI had also revealed abnormal epidural enhancement along the sacrum, with a planned biopsy to be performed in the operating room. However, the patient arrived at the emergency department after a fall at home, reporting severe pain and inability to stand. Decision was made to proceed with planned surgery while inpatient. Intraoperative biopsy of the epidural mass revealed a CD138+/lambda-restricted plasma cell process consistent with plasma cell myeloma. A subsequent bone marrow biopsy demonstrated 85% plasma cell infiltration, confirming a diagnosis of multiple myeloma based on the International Myeloma Working Group (IMWG) criteria. Cytogenetic testing (myeloma FISH panel) revealed multiple high-risk features, including del17p, t(14;16), and gain of 1q. The extent of myelomatous disease on presentation resulted in acute cord compression requiring multiple spinal decompression surgeries. Patient then underwent post-op radiation therapy, corticosteroid treatment, and aggressive induction myelomatous systemic therapy regimen consisting of daratumumab hyaluronidase-fihj. IMPACT/DISCUSSION: This case emphasizes the importance of considering multiple myeloma as a differential diagnosis in middle-aged patients presenting with unusual back pain and spinal stenosis, as the disease is more commonly associated with older adults. Early identification and treatment in younger patients may improve outcomes, highlighting the need for clinicians to maintain a high index of suspicion even in non-elderly populations presenting with persistent back pain. A combination of external beam radiation therapy and corticosteroids is typically the treatment of choice in multiple myeloma patients with spinal manifestations. Early studies that were conducted in small patient cohorts demonstrated that pain relief, quality of life, and motor function were improved in a sizable proportion of treated patients. Daratumumab was chosen for this patient due to the phase 3 PERSEUS trial that showed improved progression-free survival among transplant eligible patients with newly diagnosed multiple myeloma, and a higher sustained minimal residual disease (MRD) negative status.

This unique case demonstrates an atypical and aggressive presentation for multiple myeloma. Recognition of these symptoms is critical for broadening understanding of clinical presentation for earlier detection of multiple myeloma. A CASE OF MYCOBACTERIUM FORTUITUM INFECTION IN A SUBMANDIBULAR MASS Fathima Alam1; Roshmita Bardhan2. 1Internal Medicine, Bon Secours Mercy Health, Cincinnati, OH; 2Internal Medicine, Mercy Health, Cincinnati, OH. (Control ID #4273422) CASE: A 77-year-old female with a past medical history of chronic kidney disease status post diseased donor renal allograft twenty years back, maintained on tacrolimus and mycophenolic acid, hyperlipidemia, hypothyroidism, atrial fibrillation, dementia presents to the hospital for evaluation of a neck masses. Three months back, she was noted to have enlarged mobile and non-tender left posterior cervical lymph nodes. She was given azithromycin, but with no improvement. She had an excisional biopsy, which showed fibrous tissue with acute and chronic inflammation, focal abscess, fibrosis, and focal histiocytic response with giant cells, with no malignancy. She continued to have weight loss, loss of appetite, low-grade temperature of 100 Fahrenheit, and enlarging palpable lymphadenopathy. CT of the soft tissue of the neck showed bilateral cervical lymphadenopathy, left submental node 1.9 x 1.8 cm, and supraclavicular lymph node 1.3 x 1.2 cm. She was taken to the operating room, and a firm submandibular mass with a purulent abscess cavity was excised. Postoperatively admitted to the hospital and started on intravenous antibiotics. CT chest, abdomen, and pelvis ruled out underlying malignancy. Operative culture positive for Mycobacterium fortuitum complex (MF). She was discharged on ciprofloxacin, linezolid, and doxycycline. With antibiotic treatment, the lymphadenopathy started to improve, but unfortunately, due to her constitutional symptoms and progressive renal injury due to volume depletion, she continued to have worsening functional status. The family decided on a comfort approach, and she passed away. IMPACT/DISCUSSION: Mycobacterium fortuitum is an opportunistic pathogen that can be challenging to diagnose. It requires specific cultures and a longer duration of incubation to monitor for growth. Acid-fast staining combined with polymerase chain reaction is the most common method used to detect this infection. This case highlights an immunocompromised patient with lymphadenopathy and concern for an underlying malignancy, which was ruled out, with cultures subsequently positive for M. fortuitum. Few documented cases exist of lymph node involvement by non-tuberculous mycobacteria (NTMB), and it should be considered in the differential diagnosis for immunocompromised patients.

Mycobacterium fortuitum, acid-fast bacilli, is a nontuberculous mycobacterium (NTMB) found in the natural environment, including soil, dust, and tap water, across a wide geographical area. This opportunistic pathogen can cause infections by direct inoculation in the lungs, skin, soft tissues, bones, and rarely lymph nodes. It is important to consider non-tuberculous mycobacteria in immunocompromised patients so they can receive adequate treatment before the infection becomes too severe. A CASE OF OPTIC PERINEURITIS AS THE PRESENTING SYMPTOM OF SJOGREN'S SYNDROME Rasika Patil2; Victoria Mazo1; Luke Hong1. 1Neurology, University of South Florida Morsani College of Medicine, Tampa, FL; 2Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #4251381) CASE: A 53-year-old woman with coronary artery disease and family history of lupus presented with intermittent left-sided vision loss. She reported pain with extraocular movements and several episodes of transient vision loss lasting 5-10 minutes over a week. She was admitted for suspected optic neuritis. On exam, she had intact visual acuity without relative afferent pupillary defect or papilledema. Magnetic resonance imaging of the orbits revealed left-sided optic perineuritis. She was started on intravenous methylprednisolone empirically. Cerebrospinal fluid and serum studies were unremarkable aside from elevated Immunoglobulin G of 7.27 and positive anti-nuclear antibody, respectively. Rheumatology was consulted. Additional antibody testing was positive for anti-Sjogren’s-syndrome-related-antigen-A, anti-Sjogren’s-syndrome-related-antigen-B, and ribonucleoprotein. It was later revealed that she had a 20-year history of dry eyes and mouth that she attributed to taking diuretics. Given the above, the patient was diagnosed with SS. IMPACT/DISCUSSION: Sjogren’s syndrome is a progressive autoimmune condition affecting exocrine glands, often causing sicca symptoms including oral mucosal and ocular surface dryness. Neurologic sequelae are uncommon but difficult to quantify, with literature reporting these symptoms in anywhere between 10-60% of SS patients. With the most common neurologic manifestations being sensory polyneuropathies, few studies report optic neuritis as a presenting symptom of SS. Two retrospective cohort studies indicated only 6-16% of patients with primary Sjogren’s syndrome suffered from optic neuritis. One case report reported a patient with acute presentation of optic neuritis and no sicca symptoms whose management involved extensive investigation before SS was even suspected. Other literature notes variable presentation in cases of optic neuropathy including acute, chronic, and recurrent timelines as well as unilateral and bilateral presentations. Such variation highlights the importance of casting a wide differential and maintaining a high index of suspicion in cases of atypical vision loss to reduce delay in steroid initiation.

Although rare, optic neuritis can be a presenting symptom of underlying Sjogren’s syndrome. This case emphasizes the importance of considering autoimmune disorders as the culprit of optic perineuritis. Conversely, providers must be vigilant in asking about visual symptoms when managing patients with Sjogren’s syndrome to detect neurologic manifestations early. A CASE OF PANCREATOGENIC DIABETES MELLITUS (T3CDM) IN A MIDDLE-AGED FEMALE PRESENTING WITH SEVERE CACHEXIA FAHEMA NADIRA. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4271953) CASE: A 53-year-old female with a history of alcohol use disorder and smoking presented to the primary care office with severe unintentional weight loss (65% weight loss of usual body weight) in the setting of dull, mild, intermittent diffuse abdominal pain for the past year. Her physical exam was pertinent for temporal recession, profound muscle atrophy in her deltoids and quadriceps, and a scaphoid abdomen. Given her chief complaint of undifferentiated cachexia and abdominal pain with a history of alcohol use disorder, the initial work-up included labs and referral to gastroenterology for endoscopy. Labs revealed mild transaminitis, elevated glycosylated hemoglobin of 15.5, hyperglycemia, and urinalysis with marked glucosuria without ketones. Given the critical results, she was admitted to the hospital and started on a basal-bolus insulin regimen. MRCP confirmed sequelae of chronic pancreatitis with no malignancy seen. Follow-up labs were pertinent for negative autoantibodies, low c-peptide, and low glucagon. Her clinical course was complicated by labile blood sugars. IMPACT/DISCUSSION: T3cDM is classified by the American Diabetes Association as diabetes due to pancreatic exocrine damage commonly resulting from chronic pancreatitis. A review by Cui et al found T3cDM to account for 5–10% of Western diabetic populations.1 Although symptoms can overlap with T1DM or T2DM, distinguishing T3cDM is important, as the clinical presentation, underlying cause, diagnosis, and management strategies differ. In one study, up to 8% of patients with T3cDm were misclassified as Type 1 or Type 2, and 78.5% of patients reclassified as having T3cDM had a history of chronic pancreatitis.2 In T3cDM, the destruction of entire islets leads to loss of insulin and other islet-derived regulatory hormones resulting in low glucagon levels, which differs from Type 1 or Type 2 in which glucagon levels are normal or elevated. In this clinical vignette, the patient’s alcohol use and subsequent chronic pancreatitis symptoms predate her diabetes, consistent with T3cDM. The lack of counterregulatory glucagon can lead to labile glycemic control as seen in this patient’s clinical course. As a result, patients with T3cDM are more likely to experience complications and death due to treatment-related hypoglycemic events.3 Such risk was accounted for in our patient’s management plan by adjusting her insulin in small doses.

In this report, we present a case of a middle-aged female with T3cDM secondary to chronic pancreatitis, compounded by labile glycemic control. This case highlights the important diagnostic and management considerations for patients with T3cDM, as the risk factors, diagnosis, and management differ from those of Type 1 and Type 2 diabetes. A CASE OF PEMBROLIZUMAB-INDUCED MYOCARDITIS AND MYASTHENIC SYNDROME Ayman Haider, Keerthana Jayaseelan. Internal Medicine, Stony Brook University, Stony Brook, NY. (Control ID #4273416) CASE: An 84-year-old male with metastatic bladder cancer on pembrolizumab presented with generalized weakness, fatigue, and dyspnea. His symptoms began 3–4 weeks prior and worsened after his second Keytruda dose. Examination showed global weakness, right eye ptosis, and bilateral edema. Lab results indicated elevated troponin, NT-proBNP, CPK, ALT, and AST levels, and an EKG showed new bigeminy and right bundle branch block. Initially treated for NSTEMI, he was transferred to cardiac critical care due to suspected immune checkpoint inhibitor-induced myocarditis. Heart catheterizations showed non-obstructive disease. Oncology and neurology evaluated, suspecting myositis/myocarditis and myasthenic syndrome overlap. Treatment included prednisone, then methylprednisolone, but dyspnea worsened. Despite diuresis, respiratory distress persisted, and plasmapheresis was initiated. Troponin and BNP remained high, and repeat echocardiogram showed reduced ejection fraction. Advanced heart failure recommended pulse-dose steroids and mycophenolate. Steroids and plasmapheresis led to mild improvement in ventricular function, but respiratory status remained critical. A multidisciplinary team considered further immunosuppression options. Abatacept was administered, lowering troponin levels. The next step would have been to start Ruxolitinib but the patient developed hospital-acquired delirium and dysphagia. Unfortunately, with worsening mental status and increasing hypercapnia, the family chose comfort care, and the patient ultimately passed away. IMPACT/DISCUSSION: This case underscores the complexity of managing immune checkpoint inhibitor-induced myocarditis with overlapping myositis and myasthenic syndrome. It highlights the need for vigilance in patients receiving pembrolizumab, particularly when presenting with cardiovascular and neuromuscular symptoms. The clinical impact includes recognizing the challenge of treating steroid-refractory myocarditis, necessitating a multidisciplinary approach to explore alternative immunosuppressive therapies. Key teaching points include the importance of early identification, highlight the potential for rapid deterioration in cardiac and respiratory function, and the limitations of current treatment protocols for steroid-refractory cases of pembrolizumab induced myocarditis and myasthenia syndrome.

Early Recognition and Multidisciplinary Approach: General internists should be watchful for signs of immune checkpoint inhibitor-induced myocarditis and neuromuscular complications. Management of Steroid-Refractory Conditions: In cases of steroid-refractory myocarditis, internists need to collaborate early with cardiology, neurology, and oncology to manage these complex cases. Importance of Patient-Centered Decision Making: For patients with pembrolizumab-induced myocarditis, engaging them and their families in treatment decisions based on the best available evidence is crucial, ensuring transparency and active participation in their care. A CASE OF PERSISTENT AKI AND PULMONARY-RENAL SYNDROME Khalid Abu-Zeinah1; Lorraine Siebold2; SreeChandralekha Kruthiventi2; Paul Davis2; Sean Caples2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Mayo Clinic Minnesota, Rochester, MN. (Control ID #4270514) CASE: An 82-year-old male with a history of prostate cancer (in remission) presented to primary care with five days of diarrhea (attributed to gastroenteritis), poor oral intake, and oliguria. Labs revealed stage III AKI with creatinine of 17.1 (baseline of 1) and BUN of 188. He was admitted for AKI evaluation. CT abdomen showed a moderate, unilateral obstructive hydronephrosis with a 17 mm stone at the ureteropelvic junction. His AKI was initially attributed to pre-renal intravascular volume depletion due to diarrhea, with a lesser contribution from unilateral ureteral obstruction. He was IV fluid resuscitated and a ureteral stent was placed. Renal function did not significantly improve, and dialysis was eventually initiated. Anticoagulation was started for new atrial fibrillation (CHA2DS2-VASc 3). He subsequently developed acute hypoxic respiratory failure necessitating transfer to the ICU. Chest X-ray revealed bilateral infiltrates, raising concern for both hospital-acquired pneumonia and pulmonary edema. He exhibited hemoptysis, coffee ground emesis and passed melanotic stools. Serum hemoglobin, 11 g/dL on admission, was now 6.7 g/dL. Antibiotics were administered, and anticoagulation was held. An EGD showed no evidence of upper GI bleeding. Diagnostic bronchoscopy showed red blood in the distal airways, consistent with diffuse alveolar hemorrhage (DAH). Anti-GBM IgG antibodies were positive, and a renal biopsy demonstrated severe necrotizing and crescentic glomerulonephritis consistent with anti-GBM antibody disease. Treatment was initiated with plasma exchange, high-dose steroids, and cyclophosphamide. IMPACT/DISCUSSION: This case highlights the importance of maintaining a broad differential diagnosis for AKI, particularly in the face of disease that persists after addressing common causes such as volume depletion and obstructive uropathy. It also demonstrates the occult nature of hemoptysis and DAH, which can mimic more common conditions such as hydrostatic pulmonary edema, pneumonia and, when expectorated blood is ingested, GI blood loss. Anti-GBM disease is a rare condition with an incidence of 1 in a million and bimodal age distribution (Shiferaw et al., 2016). Reports suggest ureteral obstruction and hydronephrosis may trigger anti-GBM antibody production (Takeuchi et al 2015). Additionally, the patient’s coffee-ground vomitus and hemoglobin drop were thought to be due to an upper GI bleed. In this case, occult pulmonary hemorrhage with hematophagia resulted in the clinical appearance of an upper GI bleed.

- Persistent AKI despite addressing initial inciting factors warrants further evaluation - Diffuse alveolar hemorrhage can mimic other conditions like pulmonary edema or pneumonia - Occult pulmonary hemorrhage may be mistaken as a GI bleed if swallowed A CASE OF PERSISTENT HICCUPS UNMASKING METASTATIC LUNG ADENOCARCINOMA Asish Katta1; Seema Iyengar1; Grace P. Fomani1; Verena Sorial1; Saleh n. Jaafar2,3. 1School of Medicine, University of the Incarnate Word, San Antonio, TX; 2Medcare Associates, San Antonio, TX; 3Methodist Stone Oak Hospital, San Antonio, TX. (Control ID #4271457) CASE: A 68 year-old male with essential hypertension, hyperlipidemia, paroxysmal atrial fibrillation, asthma, and gastroesophageal reflux disease, without a history of cigarette smoking or family history of malignancy, presented with a concern of persistent hiccups, abdominal pain, and severe fatigue. The patient’s vital signs were unremarkable and he denied respiratory symptoms outstanding of his well-controlled asthma and family history of malignancy. The patient ALSO denied having respiratory symptoms outstanding of his well-controlled asthma. CT imaging revealed a juxtapleural nodule in the inferior lobe of the right lung, nodules in the right hepatic lobe, retroperitoneal and mesenteric lymphadenopathy, and peritoneal carcinomatosis with ascites. Further evaluation with core needle biopsy of the hepatic nodules revealed markers consistent with metastatic lung adenocarcinoma (CK8/18, CK7, napsin, TTF-1). Cytology confirmed stage IV progression with poor prognosis. The time from initial symptom presentation to confirmatory diagnosis was approximately one month. IMPACT/DISCUSSION: Lung cancer is the leading cause of cancer-related mortality with approximately 1.8 million deaths annually. Lung adenocarcinoma (LUAD) is the most common histologic subtype of lung cancer. While LUAD is associated with cigarette smoking, it is unique among lung cancer subtypes for its higher prevalence in non-smokers. Traditionally, LUAD presents as a peripheral mass with the potential to invade pleural tissue, causing symptoms such as cough, hemoptysis, pleuritic chest pain, and dyspnea. This presentation of symptomatic liver metastasis prior to manifestations of respiratory dysfunction is exceedingly rare. LUAD is often initially asymptomatic, and when symptomatic, tends to evoke respiratory manifestations. A lack of respiratory symptoms introduces diagnostic pitfalls of screening tests that do not consider atypical presentations. Furthermore, liver metastasis resulting in hepatic capsular distention can contribute to abdominal pain alongside peritoneal carcinomatosis. Although poorly documented in the literature, pleural irritation and phrenic nerve stimulation from a peripheral lung tumor can induce persistent hiccups. While seemingly unrelated to a pulmonary etiology, a combination of these symptoms can indicate advanced disease and should prompt clinicians to consider malignancy as a differential diagnosis.

This case underscores the importance of investigating unusual symptoms with cautious consideration of malignancy as a differential diagnosis to improve screening and disease outcomes. A CASE OF PHEOCHROMOCYTOMA MIMICKING SEPSIS AND COMPLICATED BY TAKOTSUBO CARDIOMYOPATHY IN A PATIENT WHO WAS DISCOVERED TO HAVE TYPE 1 NEUROFIBROMATOSIS Carlo Gabriel C. Casipit1; Bruce Adrian Casipit2. 1Internal Medicine, Jefferson Einstein Philadelphia Hospital, Philadelphia, PA; 2Loma Linda University, Loma Linda, CA. (Control ID #4271093) CASE: A 42-year-old female who recently immigrated to the US 3 months ago from Vietnam, with no reported medical history, presented to the hospital for elective orthopedic spinal surgery for cervical radiculopathy. Preoperatively, she denied any fever, headaches, dyspnea, chest pain, palpitations, or diaphoresis. Her vital signs and laboratory tests were unremarkable. Physical Examination showed congenital multiple hyperpigmented macules on her back. She has a family history of unrecalled “nerve problems”. She underwent successful surgery without intraoperative complications. However, on postoperative day 4, she developed a fever Temp 39C, with HR 130, BP 190/80. Laboratory tests showed WBC 28 (ref 4.5-10), Lactic acid 6(ref 0.5-1). Chest X-ray and Urinalysis were unremarkable. Blood and urine cultures were sent, and the patient was empirically treated with fluids, Ceftriaxone, and Vancomycin. 3 days after, she remained febrile Temp 39C, tachycardic HR 122, hypertensive BP 210/100, and developed dyspnea and bipedal edema, EKG was nonischemic, 2DEcho showed EF 40% with apical hypokinesis with basilar hyperkinesis, normal TSH and FT4, Urine Metanephrine 8618(ref 140-175). Abdominal MRI showed heterogenous enlargement of the left adrenal gland measuring 3x4 cm in diameter with normal right adrenal gland. A relative then brought the patient's medical records from Vietnam, which showed a confirmed history of neurofibromatosis type 1. She received Doxazosin and Propranolol. However, she developed cardiogenic shock, requiring brief inotropic support. Eventually, her HR and BP stabilized and she underwent left adrenalectomy with resolution of her symptoms and she was closely followed up as outpatient. IMPACT/DISCUSSION: Pheochromocytoma is a rare tumor of the adrenal medulla with an incidence of 1 per 100,000 population. It can occur in 0.1-5% of patients with Neurofibromatosis Type 1(NF1). Our patient presented with signs of cafe au lait spots and a family history of a "nerve problem" and was confirmed by records to have NF1. The hyperadrenergic state of pheochromocytoma causes increased interleukin-6, which results in fever and systemic inflammation mimicking sepsis, which has the potential for misdiagnosis. It also increases cardiac oxygen demand, which explains why Takotsubo Cardiomyopathy can be seen in 3-10% of patients with pheochromocytoma. This can present with sudden hypotension, which can be aggravated by aggressive antihypertensive medications given. However, previous studies supported that even with these complications, the prognosis remains good if detected and treated early.

Our case highlights the importance of consolidating history and physical examination, careful preoperative planning, and considering pheochromocytoma in at-risk patients presenting with sudden unexplained hypertension, heart failure, and sepsis-like syndrome in patients without any focus of infection, in order to provide early referrals, continuous patient education, and prompt treatment. A CASE OF PRIMARY MALIGNANT PERITONEAL MESOTHELIOMA Liz Betancourt1; Eli Sugarman1; Jennifer Wallace2. 1Internal Medicine, Ross University School of Medicine, Miami, FL; 2St. George's University, True Blue, Grenada. (Control ID #4271597) CASE: We present a case of a 47-year-old Hispanic male patient, with a past medical history of hypertension and diabetes mellitus type 2, who arrived at the emergency department with complaints of abdominal discomfort, distension, and constipation over 6 weeks. He denied any history of alcohol or drug use. He endorsed long-standing occupational exposure to the demolition of old buildings without a respirator. Blood tests demonstrated mild hypoalbuminemia (3.8 g/dL), but were otherwise insignificant. On physical exam, the patient was in evident discomfort. Lungs were clear to auscultation bilaterally, and patient was normotensive and normocardic. He had a protuberant and rigid abdomen with irregular contours; bowel sounds were quiet. Abdomen was diffusely tender to any palpation; pain was worse in the left lower quadrant. A nodular pattern was evident on palpation. Patient obtained an upper endoscopy and colonoscopy with results negative for any malignant pathology. Initial abdominal CT scan demonstrated nodular fat stranding of the omentum with several peritoneal confluent nodules and small volume ascites. The largest nodules were found in the left lower quadrant and within the pelvis, with the former measuring 1.4 cm and the latter 1.8 cm. No abdominopelvic lymphadenopathy was visualized. Chest cavity showed no nodularity of pleura. This led to an omental biopsy with tumor cells positive for AE1/AE3, calretinin, and WT-1. These findings support a diagnosis of epithelioid type malignant mesothelioma with peritoneum as the primary site. IMPACT/DISCUSSION: The case is of critical importance due to the unusual presentation of mesothelioma in the peritoneum. Peritoneal mesothelioma carries a differing clinical illustration from a typical pleural form. Some of the noted differences in clinical presentation include absence of dyspnea, chest pain, or appreciable pleural effusion. Literature on the condition is difficult to find due to the rarity of incidences; compounded by difficulties in diagnosis. It is understood that early interventions including surgery and chemotherapy are reported to have the optimal patient survival rates. An added feature to this case’s import is patient ethnicity. Literature on peritoneal mesothelioma describes Caucasian (75.2%), followed by Hispanics (13.5%), Black individuals (5.8%) and other (5.0%). The described patient is a Hispanic individual, making this report more consequential. This case illustrates the impact that rare and difficult to diagnose cancers can have on an individual. The patient had acute occupational exposures which exponentially increased his risk of developing mesothelioma.

Occupational exposure remains a key prognostic factor in diagnosis of any mesothelioma. While racial statistics may provide some insight into likely populations, low incidence in general may skew true results. Early recognition and intervention provided the most favorable outcomes for patients with peritoneal mesothelioma A CASE OF PROFOUND FATIGUE IN A PATIENT WITH LUNG ADENOCARCINOMA ON CHEMOTHERAPY Rafae Alam1; Hayalneh Gessessew2; Maya Patel2; Michael A. Gallagher2. 1School of Medicine, Emory University, Atlanta, GA; 2Internal Medicine, Emory University, Atlanta, GA. (Control ID #4272514) CASE: A 71-year-old man presented with 1 week of progressive fatigue and weakness. Upon arrival, he stated that he could not get out of bed, even to use the bathroom. Notably, he had undergone an infusion of carboplatin, pemetrexed, and pembrolizumab for treatment of lung adenocarcinoma 9 days before presenting. He attributed his symptoms to his most recent infusion. His vitals were unremarkable, and he appeared chronically ill and cachectic with dry mucous membranes. Laboratory testing revealed a TSH of 89 mIU/L, free T4 of 0.4 ng/dL, thyroglobulin antibody level of 427 IU/mL, and random cortisol level of 14 mcg/dL. Subsequent ACTH stimulation testing revealed a baseline cortisol level of 8.8 mcg/dL, with cortisol levels of 9.8 mcg/dL and 9.6 mcg/dL at 30 and 60 minutes post-ACTH administration, respectively, most consistent with primary adrenal insufficiency. Hydrocortisone and fludrocortisone were initiated to treat his primary adrenal insufficiency, and levothyroxine was initiated for his new-onset hypothyroidism. Treatment resulted in significant improvement of his symptoms, and he was able to return home on a stable dose of hydrocortisone, fludrocortisone, and levothyroxine. IMPACT/DISCUSSION: Fatigue and weakness are problems commonly encountered by practicing hospitalists. This case was found to be primary hypothyroidism and adrenal insufficiency. Common etiologies of these endocrinopathies include autoimmune, infectious, and malignant processes. However, in this case, the patient’s symptoms began shortly after his most recent chemotherapy infusion, suggesting that one of his cancer medications might be responsible. Pembrolizumab and other immune checkpoint inhibitors (ICIs) have been implicated in a number of endocrinopathies, including hypopituitarism, adrenocortical dysfunction, thyroid dysfunction, and type 1 diabetes mellitus. Adrenal insufficiency caused by ICI treatment is typically secondary and rarely primary. Hypothyroidism due to ICIs may also be secondary to hypopituitarism. However, the patient’s elevated TSH and poor adrenal response to the ACTH-stimulation test made hypopituitarism a less likely cause of his symptoms.

The patient’s symptoms and lab results were consistent with a new diagnosis of primary hypothyroidism and adrenal insufficiency, and prompt treatment resulted in a significant improvement in his symptoms and quality of life. His course demonstrated the importance of suspecting a variety of endocrinopathies in patients on ICI treatment for cancer, as the presenting symptoms of endocrinopathies can be difficult to distinguish from nonspecific symptoms in patients with advanced malignancy. Prompt diagnosis and treatment can lead to the prevention of the more serious consequences of immune-related adverse events, which include significantly reduced organ function and quality of life. A CASE OF PROGRESSIVE BILATERAL LOWER EXTREMITY WEAKNESS WITH LEPTOMENINGEAL ENHANCEMENT OF UNKNOWN ETIOLOGY Kathryn Addonizio1; Jennifer A. Trebilcock1; Kavya Sudireddy1; Geeda Maddaleni2. 1Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; 2Medicine, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4272990) CASE: A 74-year-old male with type 2 diabetes, neuropathy and lumbar spinal stenosis with radiculopathy presented to the ED for evaluation of months of waxing and waning progressive bilateral lower extremity weakness causing multiple falls. Initial CT head revealed an 11 mm acute hemorrhage of the superior vermis and right cerebellar hemisphere. CTA with no evidence of high flow vascular malformation near the hematoma. He was admitted to the Neurology service. MRI brain showed multiple small areas of enhancement concerning for leptomeningeal metastases with small hemorrhages. MRI spine showed avid leptomeningeal enhancement throughout the lumbar, thoracic, and cervical spine without intramedullary spinal cord enhancement. Given these findings, leptomeningeal neoplastic disease was favored; however, it was unclear where the primary neoplasm originated. CT torso revealed only a small lung nodule in the right lower lobe. Lumbar puncture demonstrated lymphocytic dominant pleocytosis with elevated protein and low glucose. Cytology was negative for malignancy. Infectious workup was negative. His weakness worsened and he became non-ambulatory. He developed a lower extremity DVT. Given high suspicion for leptomeningeal carcinomatosis, especially in the setting of thrombosis, he was transferred to the General Medicine-Oncology service ~hospital day 14 for further work up. Upon transfer, initial physical exam noted a suspicious asymmetric lesion on his left index finger nail. He disclosed prior trauma to the area and thought the skin changes were related to injury. On further questioning, he did notice the lesion had expanded over the last year. Dermatology was urgently consulted for biopsy. He had an IVC filter placed in lieu of anticoagulation for DVT to mitigate risk of intracranial hemorrhage. Skin biopsy was positive for pT2a acral lentiginous melanoma. While awaiting biopsy results, he also had a second lumbar puncture, with cytology confirming metastatic melanoma as etiology of leptomeningeal enhancement. IMPACT/DISCUSSION: Our patient was diagnosed with malignant acral melanoma with metastases to leptomeninges. Malignant melanoma has one of the highest incidences of leptomeningeal involvement among all solid tumors with rates as high as 10-15% of patients with advanced melanoma (1-2). However, it is extremely rare to have metastases to the leptomeninges in the absence of additional sites of metastasis. Retrospective analyses have found concurrent brain metastases in 60-85% of all patients with malignant melanoma with leptomeningeal involvement (3-7). Unfortunately, the presence of leptomeningeal involvement in melanoma conveys a poor prognosis with a mean overall survival of 3.5 months, despite treatment (3).

This case highlights a rare and highly advanced inpatient presentation of a common outpatient diagnosis, malignant melanoma. As generalists, it serves as a humbling reminder of the importance of a thorough physical exam in the pursuit of diagnostic accuracy. A CASE OF PSYCHROBACTER SANGUINIS BACTEREMIA: IMPLICATIONS OF EMERGING PATHOGENS FROM PERMAFROST MELTING AND CLIMATE CHANGE So Sato, Masaji Saijo, Shadia Constantine. Primary Center, Sapporo Tokushukai Hospital, Sapporo, Hokkaido, Japan. (Control ID #4272655) CASE: A 55-year-old man with a history of diabetes mellitus, depression, and alcoholic liver disease presented to the hospital with altered mental status. According to his family, he had been experiencing fever for the prior two weeks but had not sought medical attention. His social history was significant for alcohol use disorder, and his family history was noncontributory. He was not consistently taking prescribed medications. The patient appeared ill on examination, but his physical examination did not reveal a focal source of infection. Blood cultures on the second day of hospitalization identified gram-negative rods, later confirmed as Psychrobacter sanguinis and ESBL-producing Escherichia coli. Initial empiric therapy with ceftriaxone was adjusted to meropenem. Sensitivity testing for P. sanguinis could not be performed due to insufficient bacterial growth. Despite an extensive diagnostic workup, including chest X-ray, CT scans, and abdominal ultrasound, no localized infection was identified. The patient’s condition improved with continued meropenem therapy. His mental status normalized, and inflammatory markers trended downward. IMPACT/DISCUSSION: Psychrobacter sanguinis is a Gram-negative, aerobic bacterium adapted to cold environments like deep-sea habitats and permafrost. Human infections are rare but include bacteremia, meningitis, and wound infections. Its Gram-negative cell wall contributes to resistance against antimicrobial agents and environmental stresses. Risk factors include marine exposure, raw seafood consumption (a staple of the Japanese diet), nosocomial settings, and immunosuppression. Climate change accelerates permafrost thaw, releasing microorganisms that have been dormant for millennia. This raises concerns about re-emerging pathogens, as seen in the 2016 Siberian anthrax outbreak, where thaw exposed Bacillus anthracis spores, causing significant public health impacts. Given its cold habitat, P. sanguinis may emerge from thawing permafrost. While direct evidence is lacking, its ecology and increased human activities in Arctic regions suggest potential exposure pathways. The present case of P. sanguinis bacteremia emphasizes the need for awareness of such infections even outside typical environmental conditions. This case underscores the importance of integrating environmental awareness into clinical practice, particularly as climate change reshapes ecosystems.

Climate change and permafrost thawing may lead to emerging infections, requiring vigilance for rare pathogens. P. sanguinis infections highlight the importance of detailed patient history and tailored diagnostics. A CASE OF PURPLE URINE BAG SYNDROME Akash M. Gupte1; Sabbena Uppal2; Tori Chee2; Nili Gujadhur3. 1Internal Medicine, Nuvance Health, Lagrangeville, NY; 2Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 3medicine, Nuvance Health, Lagrangeville, NY. (Control ID #4261756) CASE: A 69-year-old male with history of type II diabetes, diabetic foot infections, end-stage renal disease on hemodialysis, Stage II colorectal carcinoma status post hemicolectomy and chemoradiation complicated by rectal stenosis and left ureteral stricture requiring a chronic left nephrostomy tube presented with malodorous and discolored urine. Urinalysis showed pyuria with pH of 6.0, and urine culture grew Klebsiella oxytoca and Proteus hauseri. He was prescribed Augmentin, and remained asymptomatic without systemic signs of infection on follow-up. IMPACT/DISCUSSION: Purple urine bag syndrome (PUBS) is a rare phenomenon with a distinct purple hue caused by indigo and indirubin pigments from bacterial metabolism of tryptophan reacting with catheter plastic. Predisposing factors for PUBS include bed-ridden state, slow gastrointestinal transit, end stage renal disease, chronic catheterization, and high bacterial load. Sulfatase or phosphatase-producing bacteria are implicated resulting in urine alkalinization which contributes to pigmentation and nephrolithiasis formation. PUBS is managed with catheter or tube exchange, diligent hygiene, and antibiotics. Common pathogens contributing to PUBS also produce biofilms which may result in continued purple urine despite appropriate antibiotic coverage.

We present a unique case of PUBS in a patient with chronic catheterization. Though alarming to patients, PUBS has a generally benign clinical course as seen in the above case presentation. However, clinicians should be aware that the syndrome is linked to recurrent UTI and improper care of catheters. A CASE OF RECURRENT PERICARDITIS IN THE SETTING OF CYSTIC FIBROSIS Madeline B. Zipperer1; Abigail Huetteman2; Aditya Grover1,2. 1Morsani College of Medicine, University of South Florida, Tampa, FL; 2Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #4271654) CASE: A 33-year-old male with cystic fibrosis (CF), pancreatic insufficiency, GERD, and pericarditis (7/2022, 4/2023) presented with 4 days of pleuritic chest pain with dyspnea and subjective fevers. His pain worsened with inspiration and lying flat, improved with leaning forward, and felt like his prior episodes of pericarditis. He was afebrile, vital signs were stable, and his physical exam was unremarkable with no friction rub appreciated. CMP and CBC were unremarkable. CRP and ESR were elevated. Lipase and serial hs-Troponin levels were within normal limits. EKG showed some ST-T wave changes unchanged from baseline. CXR, CTA, and TTE were unremarkable with no evidence of pericardial effusion. He was started on 650 mg Aspirin TID and 0.6 mg Colchicine BID and continued on 40 mg Protonix BID. His CRP and ESR down trended and his chest pain improved. He was discharged after 7 days on a regimen of 0.3 mg Colchicine BID and 650 mg Aspirin TID with instructions for Aspirin taper. IMPACT/DISCUSSION: The diagnosis of acute pericarditis is made based on the European Society of Cardiology guidelines and requires patients to meet 2 of 4 diagnostic criteria. Our patient presented with typical chest pain but did not have a friction rub, widespread ST elevations or PR depressions on EKG, or a pericardial effusion. However, patients with recurrent pericarditis may not meet clinical criteria and present with milder signs and symptoms of pericarditis. Findings like elevated inflammatory markers can aid in the diagnosis of recurrent pericarditis, as in the present case. Additionally, there are very few cases of pericarditis reported in patients with CF, with cases of constrictive pericarditis being the most commonly reported. Different mechanisms have been proposed that link CF to pericarditis (i.e., systemic inflammation, oxidative stress, association between CF-pancreatitis and pericarditis via the release of pancreatic enzymes), but further research is required to elucidate the exact mechanism. The use of corticosteroids during our patient’s initial episode of pericarditis may also have contributed to his presentation. During his initial episode of pericarditis, our patient was treated with Prednisone in addition to Aspirin and Colchicine. Data from the COPE trial reveals an increased risk of recurrent pericarditis associated with corticosteroid use during the treatment of acute pericarditis. Therefore, as prognosis for patients with CF continues to improve, it remains imperative to not only identify the etiology of complications of CF, but to optimize their treatment modalities.

Recurrent pericarditis may present with milder symptoms than acute pericarditis Recurrent pericarditis is a rare condition in patients with CF Further research is needed to understand the etiology of pericarditis in patients with CF A CASE OF SCAD (SPONTANEOUS CORONARY ARTERY DISSECTION) IN A YOUNG FEMALE WITH RECURRENT INTRACTABLE NAUSEA AND VOMITING Jimeka Pettes1; Emily Ceres2; Khalid Zakaria3. 1Medicine, Wayne State University School of Medicine, Detroit, MI; 2Michigan State University College of Human Medicine, East Lansing, MI; 3Henry Ford Health System, Detroit, MI. (Control ID #4273286) CASE: A 30-year-old Caucasian female with a history of intractable nausea and vomiting, endometriosis on hormonal therapy, and PTSD presented with recurrent severe nausea, vomiting, and new-onset chest pain. Her history included multiple hospitalizations for similar symptoms, thought to be related to marijuana use, gallbladder dysfunction (status-post cholecystectomy), or gastroparesis. In the past the patient had a positive gastric empyting study. Endoscopy was performed and showed no clear pathology, and her symptoms persisted. During hospitalization, she started having chest pain. Her electrocardiogram revealed ST-segment elevations and T-wave inversions in the inferior leads, prompting immediate cardiac evaluation. Troponin levels were markedly elevated. Coronary angiography confirmed SCAD involving three vessels. She was initiated on IV heparin therapy, which was discontinued after 24 hours due to resolution of chest pain and hemodynamic stability. She was discharged on carvedilol and antiplatelet therapy, with follow-up for repeat echocardiogram planned. Further evaluation revealed no significant underlying connective tissue disorder or vasculopathy. Her SCAD was attributed to hormonal therapy for endometriosis, physical stress from nausea and vomiting, and potential stress-induced cardiomyopathy, given her psychological history. IMPACT/DISCUSSION: This case highlights the importance of maintaining a high suspicion for life-threatening conditions like spontaneous coronary artery dissection (SCAD) in young patients. Particularly women, who present with atypical symptoms such as intractable nausea and vomiting. Hormonal therapy and physical stress from recurrent severe vomiting may have contributed to the pathogenesis in this patient. SCAD represents a diagnostic challenge in young females, particularly when co-existing with atypical symptoms such as recurrent intractable nausea and vomiting. This case emphasizes the need for multidisciplinary collaboration in evaluating young patients with chest pain. SCAD represents a diagnostic challenge in young females, requiring a holistic approach to patient care.

This case recognizes the need for increased awareness of SCAD in younger female patients presenting with atypical chest pain, especially in the context of hormonal therapy, physical stress, and psychological factors. Timely recognition and intervention can mitigate complications and improve outcomes. It also highlights the importance of addressing both physical and mental health factors to achieve a comprehensive care plan. A CASE OF SEVERE MALARIA IN A YOUNG MALE FROM SENEGAL FAHEMA NADIRA. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272016) CASE: 25-year-old Wolof-speaking male who recently arrived from Senegal with a remote history of malaria (unclear treatment, no hospitalization) presented to the emergency room with a three-day history of dull global headache, abdominal pain, vomiting, watery diarrhea, and hematuria. Upon arrival, he was noted to be diaphoretic, dehydrated, tachycardic and hypoglycemic. Labs were pertinent for severe thrombocytopenia with a platelet of 15, lactic acidosis, indirect hyperbilirubinemia, severe acute kidney injury (AKI), and parasite smear with 40% RBCs Plasmodium Falciparum. Given the considerable parasite burden, he was admitted to the hospital. After several hours, he became lethargic and minimally responsive, febrile to 104.1F, hypoxic, and found to be acutely anemic with a hemoglobin of 5.9. He was transferred to the intensive care unit (ICU) with a guarded prognosis. Thereafter, following the completion of two doses of IV artesunate, he had rapid improvement including resolution of fever, AKI, thrombocytopenia, and reduction in parasite burden to 11.2%. He was transitioned to oral artemether-lumefantrine for three days. Repeat parasite smear showed no parasitemia and he was discharged home. IMPACT/DISCUSSION: Malaria is a potentially serious and life-threatening mosquito-borne infectious disease caused by Plasmodium parasites, which affects red blood cells. Plasmodium falciparum remains the most dangerous species, responsible for the greatest number of severe cases and deaths. Less than 1% of cases are classified as ’severe malaria‘, defined as hyperparasitemia with signs of organ dysfunction. Such signs are the result of parasitized red blood cells adhering to the endothelial cells lining small blood vessels causing small infarcts, capillary leakage and massive intravascular hemolysis. This clinical vignette illustrates the potential of malaria to progress rapidly to life-threatening multi-organ dysfunction, in this case, becoming unresponsive and hypoxic within hours of presentation. Concurrently, the very quick response to Artemisinin-based combination therapy (ACT) resulted in clearance of parasitemia within 12-24 hours of ACT initiation.

In this report, we present a case of severe malaria in a young male, compounded by severe AKI, hypoglycemia and thrombocytopenia. The potential for rapid deterioration underscores the rationale of frequent clinical and laboratory assessments, and the rapid response to ACT highlights the importance of administering ACT promptly. A CASE OF SICKLE CELL DISEASE WITH PRESERVED HBF COMPLICATED BY BONE MARROW NECROSIS Charitha Karanam Ramapathy. Internal Medicine, University of Alabama at Montgomery, Montgomery, AL. (Control ID #4273594) CASE: A 53 year old African American female with hypertension came to the emergency department with fatigue and generalized body pains which is gradually worsening for the past 2 weeks. Family history is significant for sickle cell disease in sisters. Vitals were normal. On exam patient had bilateral lower extremity weakness. Labs on admission shows white cell count of 9.8 mm3, red cell count of 3.35million/mm3, hemoglobin 8.3g/dl, hematocrit 24.4L/L, platelet count 70 per litre, reticulocyte count 2.25%, bilirubin 1.2mg/dl, alkaline phosphatase 196 unit/L, ALT 82 unit/L, AST 102 unit/L, LDH is 2209 unit/L, haptoglobin is 60 mmhg. Bone marrow biopsy showed necrosis and patchy areas of intact hematopoiesis. Electrophoresis showed Hgb A1- 20.3%, Hgb A2-3.2%, Hgb S-58%, Hgb F-18.5%. Diagnosis of Sickle cell disease with preserved HbF was made and patient was started on hydroxyurea 500 mg and folic acid after which her symptoms improved. IMPACT/DISCUSSION: Sickle cell disease is a chronic and debilitating disease associated with recurrent vaso-occlusive crises, hemolytic anemia and end-organ damage from infarction. Red blood cells form sickle-shaped RBCs in deoxygenated state which has various manifestations in different organ systems. Some of the significant complications include acute chest syndrome, pulmonary hypertension, renal complications, avascular necrosis, heart failure, ulcers, intra-cranial hemorrhage, isolated neuropathies, transverse myelitis. The variability depends on the genetics with worse outcomes among homozygous sickle cell anemia (HbSS), followed by Hb SC, Hb SD and by Hb S-beta thalassemia. In neonates and fetus Fetal hemoglobin (HbF) is the predominant hemoglobin composed of two alpha-globin and two gamma-globin chains. HbF has been shown to inhibit the polymerization of HbS, thus preventing the sickling of red blood cells, which is a key contributor to the pathogenesis of SCD. Normally adult’s hemoglobin (HbA) replaces HbF, but in certain individuals, particularly those with SCD, HbF levels persist or be reactivated in response to anemia or hypoxia. In our patient, the persistence of HbF may be an important factor in modulating the clinical course of the disease with no episodes until the patient was 53 years old.

This case underscores the importance of understanding the clinical implications of preserved fetal hemoglobin in sickle cell disease. In this 53-year-old patient, the higher-than-expected levels of HbF may contribute to a relatively mild clinical course, reducing the frequency of complications associated with SCD. Ongoing research into gene therapy that enhance HbF production, combined with personalized management, holds promise for improving the quality of life, minimize infections and improve prognosis for patients with SCD. A CASE OF SLE-ASSOCIATED MACROPHAGE ACTIVATION SYNDROME: AN INTRIGUING ENTITY. Maryam Fatima1; Yasir Ahmed1; Yousaf Saeed3; Aditya Pawaskar2; Henda Bouali2; Rachel Lu-Do2. 1Internal Medicine, United Health Services Hospitals Inc, Binghamton, NY; 2Rheumatology, United Health Services Hospitals Inc, Vestal, NY; 3Quaid-e-Azam Medical College, Bahawalpur, Punjab, Pakistan. (Control ID #4273417) CASE: A 22-year-old male with no known comorbidities was evaluated for generalized weakness and progressively worsening fever over 3-4 weeks. The patient had hypotension and tachycardia at presentation and a discoid rash was seen the face and upper extremities. Laboratory (lab) workup showed low hemoglobin, leukopenia, and markedly elevated ferritin and LDH along with elevated transaminases, raising a concern for Hemophagocytic lymphohistiocytosis (HLH). Additionally, liver associated enzymes along with bilirubin were elevated. Pertinent labs are summarized in table 1. Additionally autoimmune workup showed a positive antinuclear antibody (ANA) 1:160, anti-Smith antibodies and RNP antibodies. Rheumatoid factor was positive in low titers with a negative anti-cyclic citrullinated peptide antibody (anti-CCP). Interleukin receptor antibody (IL-2) was positive at 1661.7. The bone marrow biopsy was reported as hypocellular, decreased M:E ratio, increased number of activated macrophages with hemophagocytosis of white blood cells and erythrocytes/erythroid precursors, supporting the diagnosis of HLH or macrophage activation syndrome (MAS). No dysplastic features or an increase in blasts was seen. Additionally, the patient had positive ANA, anti-Smith, RNP antibodies along with mallar rash, anemia, and leukopenia, supporting the diagnosis of SLE –associated HLH. Flow cytometry ruled out leukemia and other hematological malignancies but showed an increased number of macrophages and monocytes. Imaging studies were mostly unremarkable and the remaining serologic workup was within normal limits. The patient was initially treated with intravenous (IV) high-dose corticosteroids (Solu-Medrol 500 mg for three days) and intravenous immunoglobulins (IVIG) (20 g daily for three days). Hydroxychloroquine was also added, and cryoprecipitate was administered to manage fibrinogen levels. IMPACT/DISCUSSION: HLH is an under recognized life-threatening condition that requires prompt treatment and diagnosis. It can be primary or secondary (to infections, malignancies or rheumatologic disorders). The management of HLH typically involves corticosteroids and immunosuppressive agents, including etoposide in acutely ill patients. For refractory or recurrent HLH, treatments such as emapalumab, alemtuzumab, or ruxolitinib may be used. Allogeneic stem cell transplantation is considered for stable patients with persistent disease. The treatment of secondary HLH depends on the treatment of the primary disease and early diagnosis and treatment is critical for a better prognosis in HLH.

Prompt recognition and aggressive management are crucial for improving patient outcomes in primary or secondary HLH. The role of multidisciplinary consultation and supportive care, alongside targeted therapy, remains central to the management of HLH/MAS. A CASE OF SQUAMOUS CELL LUNG CANCER WITH EXCEPTIONAL METASTATIC SITES Aala Dweik1; Sundas Ali2; Khine s. Shan2; Matthew P. Salzberg2. 1Internal Medicine, Memorial Healthcare System, Hollywood, FL; 2Hematology/Oncology, Memorial Healthcare System, Hollywood, FL. (Control ID #4271725) CASE: A 72-year-old man with a history of HIV on Biktarvy and a 40-pack year smoking history presents to the ED for hemoptysis, shortness of breath, throat foreign body sensation and voice hoarseness for 2 days. Physical exam was unremarkable with normal vital signs. Labs showed hemoglobin 12 mg/dl, MCV 85.3 fL, and CD4+ count 16 cells/mm3. Two months earlier, a chest x-ray for similar symptoms revealed a widened superior mediastinum, suggesting a mass for which he followed up with Pulmonology. Chest CT showed a 5.9 x 3.9 x 5.7 cm mass in the right supra-hilar region extending to the mediastinum and obstructing the right upper lobe bronchus. Bronchoscopy was recommended but declined, thus PET scan was ordered showing a hypermetabolic mass with soft tissue deposits in the right supraspinatus muscle and the subcutaneous tissue of the right posterior thigh indicating metastasis. A tongue lesion with high uptake raised concern for synchronous head and neck cancer. On admission, imaging showed new peripheral nodules in the right middle lobe suggesting further metastasis. Brain MRI was negative for intracranial metastasis. Bronchoscopy and FNA of mediastinal lymph nodes confirmed metastatic squamous cell carcinoma and biopsy of the posterior thigh confirmed similar pathology. A final diagnosis of metastatic squamous cell carcinoma of the lung was made. Guardant ctDNA testing showed TP53 mutation, Caris testing showed PTEN mutation, and PD-L1 was negative. He began treatment with Carboplatin, Taxol, and Pembrolizumab. After 4 cycles, repeat PET scan showed improvement in the mediastinal mass and metastases, with resolution of the tongue lesion. He continues maintenance Pembrolizumab with stable disease after 16 cycles. IMPACT/DISCUSSION: Lung cancer is the leading cause of cancer deaths globally, with about 50% of cases metastatic at diagnosis. Non-small cell lung cancer (NSCLC) typically metastasizes to the brain, bones, liver, adrenal glands, and lymph nodes, while metastasis to the oral cavity and skeletal muscle is rare, comprising about 1% and 0.8% of cases, and is associated with poor prognosis. Diagnosis of rare metastatic sites, like soft tissue, requires biopsy, as clinical and radiologic findings cannot distinguish metastatic carcinoma from soft tissue sarcoma. In HIV-positive individuals, retroviral therapy has improved survival increasing non-AIDS-defining cancers (NADCs), which often present more aggressively. The patient was treated with Pembrolizumab, carboplatin, and paclitaxel, followed by maintenance pembrolizumab, based on the KEYNOTE-407 trial, which showed significant improvement in overall and progression-free survival with the addition of pembrolizumab to chemotherapy.

This case highlights a rare presentation of tongue, soft tissue, and muscle metastases in NSCLC, underscoring the rising prevalence of NADCs and the importance for metastases from NADC to be considered in the differential diagnosis of new lesions in the setting of underlying HIV infection. A CASE OF THE MISSING PETECHIA: NON-TRAUMATIC FAT EMBOLISM SYNDROME Elizabeth Terman1; Rafael Madero Marroquin2; Janet Chin2. 1Department of Medicine, The University of Chicago Medicine, Chicago, IL; 2Department of Medicine, Section of Hematology and Oncology, The University of Chicago Medicine, Chicago, IL. (Control ID #4267532) CASE: A 26 year old man with HbSB+ Sickle Cell Disease (SCD) was admitted with pain refractory to his home regimen. He received 1 unit of packed red blood cells and was then found to have infiltrates on chest x-ray, a new oxygen requirement, rising transaminases and troponins, and was positive for rhinovirus. He was transferred to the Intensive Care Unit for Acute Chest Syndrome (ACS) with concomitant hepatic sequestration and concern for type 2 non-ST elevation myocardial infarction. Emergent red cell exchange was initiated; hemoglobin S fraction decreased from 65% to 13%. While the patient’s respiratory status began to improve, his mental status continued to decline. He remained somnolent and developed worsening thrombocytopenia (platelet nadir: 56 103/uL) and ferritin >34,000 ng/mL. MRI brain showed findings concerning for Fat Embolism Syndrome (FES). Given patient’s continual poor mental status and down-trending labs, therapeutic plasma exchange was discussed. Ultimately, it was decided to carefully monitor; after 3 days, the patient’s mental status and respiratory status began to improve. Of note, the patient was positive for parvovirus B19 DNA. IMPACT/DISCUSSION: FES is a clinical syndrome with a classic triad – respiratory failure, petechial rash, and neurologic involvement – typically seen following long bone fracture. Non-traumatic FES occurs rarely and is thought to be related to bone marrow necrosis; there are rare cases of FES occurring as a consequence of sickle cell vaso-occlusive episodes. Despite homozygous HbSS traditionally being considered the more severe form of SCD, FES is more common in patients with HbSC and HbSB+ genotypes. One of the most notable lab findings can be ferritin elevated 100-times baseline, while the prototypical petechial rash can be the last part of the triad to develop and does not appear in two-thirds of cases. There is also an association between FES in patients with SCD and the presence of parvovirus B19 virus, as seen in our patient. Once one has suspicion for FES, urgent red cell exchange transfusion is indicated. In rare cases, therapeutic plasma cell exchange has been performed. Even with these measures, outcomes are poor and the disease is in many cases fatal. In this instance, we diagnosed FES in a patient who had already received red cell exchange, and his symptoms gradually improved over the course of several days with close monitoring.

The etiology of altered mental status is broad in patients with SCD experiencing a vaso-occlusive episode, including stroke, infection, and opioid-related sedation. Given that urgent exchange transfusion can be a life-saving intervention, it is critical to keep FES on the differential, particularly in patients with HbSC and HbSB+ genotypes, even without the presence of petechiae. A CASE OF THROMBOTIC THROMBOCYTOPENIC PURPURA IN A YOUNG FEMALE Rolando L. Cruz Ferrer, Tigran Kakhktsyan. Internal Medicine Residency Program, Capital Health, Trenton, NJ. (Control ID #4270462) CASE: We present a 28-year-old female with no medical history presented to the emergency department with neurologic symptoms of headache, dizziness, and arm paresthesia. Initial laboratory evaluation revealed severe anemia (hemoglobin 4.6 g/dL) profound thrombocytopenia (platelets 10,000/μL) and elevated creatinine of 1.17mg/dl. A peripheral blood smear showed positive schistocytes, indicating possible microangiopathic hemolysis, examination demonstrated hepatosplenomegaly with no signs of bleeding or ecchymosis. Given her presentation and laboratory findings, the diagnosis of TTP was made, followed by the placement of an indwelling catheter for plasmapheresis. The patient was transfused with three units of packed red blood cells (PRBCs) and two units of platelets. She completed six sessions of plasmapheresis, resulting in significant clinical improvements. Her hemoglobin levels gradually increased to 7.4 g/dL, while her platelet count improved to 224,000/μL by the end of her treatment course. ADAMTS13 enzyme activity was measured and found to be less than 2%, corroborating the diagnosis of TTP. The patient tolerated the treatment well without any complications during her hospital stay. The patient was discharged in stable condition, and follow-up appointments were scheduled with hematology to monitor her recovery and manage any long-term implications. IMPACT/DISCUSSION: Thrombotic thrombocytopenic purpura (TTP) is a rare condition marked by thrombotic microangiopathy (TMA) and low ADAMTS13 enzymatic activity, essential for regulating clotting via cleaving von Willebrand factor (vWF). In acute immune TTP (iTTP), a deficiency leads to excessive vWF aggregation and microthrombi formation, impairing organ function. Despite plasmapheresis, mortality rates remain 7–22%, with delayed diagnosis as a key issue, often complicated by symptoms overlapping with other disorders. Confirmatory tests for ADAMTS13 activity aren't readily available in many hospitals. Differentiating TTP from conditions like disseminated intravascular coagulation (DIC), hemolytic uremic syndrome (HUS), and heparin-induced thrombocytopenia (HIT) can be complex. A classic pentad of symptoms, thrombocytopenia, hemolytic anemia, neurological issues, fever, and renal compromise guides the diagnosis, though the PLASMIC score is recommended for early assessment. A 28-year-old female with a score of 7 showed a 72% likelihood of low ADAMTS13 activity, underscoring that TTP can occur without typical risk factors and stressing the need for rapid evaluation in emergencies.

Timely recognition of thrombotic thrombocytopenic purpura (TTP) is crucial in patients with unexplained thrombocytopenia and microangiopathic hemolytic anemia, as TTP can present variably, even without traditional risk factors. Immediate plasmapheresis should be initiated, even before ADAMTS13 activity testing, to prevent life-threatening complications. A CASE OF TUBERCULOSIS RECURRENCE AFTER ISONIAZID-BASED TREATMENT Benjamin Kieff, Sana Kamboj, Anna Kho. School of Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4270585) CASE: A 51-year-old male with a history of latent tuberculosis infection (LTBI), chronic anemia since childhood, 7-pack-year smoking history, and marijuana use presented to the emergency department for evaluation of chronic productive cough and subacute 30lb+ weight loss, night sweats, and chills. Fourteen months prior to presentation, he completed LTBI treatment with 3HP therapy (once weekly isoniazid + rifapentine therapy for twelve weeks), directly observed by his county public health department. Twelve months after treatment completion, he began developing a productive cough with hemoptysis. He underwent CXR at an outside ED, which showed patchy left upper and lower lung consolidation. He was diagnosed with multifocal pneumonia and discharged on azithromycin. Two months later, he presented to this hospital's ED with progressive cough and subacute night sweats and chills. CXR showed a left upper lobe consolidation and CT chest showed extensive left upper and lower lobe centrilobular consolidative opacities with a 3.4x2.3 cm cavitary component within the left upper lobe. CBC showed anemia and a normal white blood cell count. Iron studies suggested anemia of chronic disease. Differential diagnosis included recurrent TB vs malignancy, with pneumonia considered less likely due to the patient's normal WBC, his nonresponse to antibiotics, and his illness time-course. AFB sputum cultures and TB PCR confirmed the diagnosis of TB. The patient was treated with RIPE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) therapy, to be managed by his county public health department. IMPACT/DISCUSSION: The US National TB Surveillance System defines TB recurrence as verified TB in patients for whom 12 months have passed since the last clinical encounter for TB treatment. Recurrence of TB after completed LTBI treatment is exceedingly rare, with a recurrence rate of 0.3-0.6% more than 1 year after completion of isoniazid-based LTBI treatment. Among US-born patients, risk factors for recurrence include age 25–44 years at the time of initial diagnosis, substance use, and treatment for the initial episode having been managed by a health department. This patient had two of these risk factors. Thus, recurrent TB should have been considered on initial presentation. This case also provides insight into the relationship between anemia and TB infection. Anemia is a risk factor for TB, with the risk of TB infection over two times higher in anemic patients than in non-anemic patients. Additionally, nearly half (49.82%) of patients with TB develop anemia of chronic disease.

This case highlights the importance of ruling out recurrent TB in patients with previously treated LTBI who present with pulmonary and B symptoms. Additionally, this case highlights certain risk factors that predispose individuals to TB recurrence. Lastly, this case demonstrates the bidirectional relationship between anemia and TB: anemia increases the risk of acquiring TB, and TB infection increases the risk of developing anemia. A CASE OF VASOSPASM-INDUCED ST-ELEVATION MYOCARDIAL INFARCTION IN A 25-YEAR-OLD MALE PATIENT Tigran Kakhktsyan, talar acob. Internal Medicine, Capital Health, Trenton, NJ. (Control ID #4267005) CASE: A 25-year-old male with no prior medical history presented with acute left-sided chest pain radiating to the left shoulder and epigastric area. Describing the pain as 10/10, he noted sporadic episodes over the past year, not linked to physical activity, but this episode had worsened over two days and became constant. An ECG at his primary care provider's office showed ST-elevation, and a repeat ECG in the emergency department confirmed ST-elevations in leads II, III, aVF, and T-wave inversions in leads V4-V6, I, and aVL. Sublingual nitroglycerin significantly alleviated his chest pain. Initial labs showed a Troponin I level of 18.135 ng/mL, mildly elevated blood pressure at 135/82 mmHg, and a negative drug screen. A 2D echocardiogram displayed a normal-sized left ventricle with 50-55% ejection fraction and hypokinesis in the basal inferior and basal to mid inferolateral regions. CT angiography ruled out pulmonary embolism, and the patient had an elevated NT-proBNP level at 1985 pg/mL and Aspartate Aminotransferase at 91 U/L. Aspirin and a heparin infusion were initiated, along with 40 mg of atorvastatin. Cardiology consultation led to a cardiac catheterization which revealed no coronary artery disease. Diagnosed with ST-elevation inferior wall myocardial infarction due to prolonged vasospasm, the patient was discharged with a follow-up and medications including aspirin, atorvastatin, metoprolol, and nitroglycerin. IMPACT/DISCUSSION: Chest pain in emergency departments (EDs) ranges from benign to life-threatening conditions like acute coronary syndrome (ACS). Approximately 5-6 million U.S. ED visits annually involve chest pain, with 15-25% due to ACS. While STEMI and vasospasm-induced myocardial infarction are rare in young patients, they must be considered and ruled out. Demographic factors and cardiovascular risks—hypertension, dyslipidemia, diabetes, smoking—heighten ACS risk. Treatments vary, with STEMI requiring rapid diagnosis and intervention, and vasospastic angina managed with nitroglycerin and calcium channel blockers. Prompt and effective treatment is crucial for improving outcomes and reducing complications like heart failure.

While chest pain is often linked to benign causes, especially in younger adults without risk factors, it should never be dismissed lightly. Key takeaways for general internists include: Comprehensive Evaluation: Always take a detailed history and perform essential diagnostics like ECG and troponin levels to exclude or confirm acute coronary syndrome (ACS), even when coronary artery disease (CAD) seems unlikely. Consider Rare Causes: Conditions like STEMI and vasospasm-induced myocardial infarction are rare in young patients but vital to rule out. Immediate recognition and management are crucial. Prioritize Effective Management: Timely intervention for STEMI and appropriate use of nitroglycerin and calcium channel blockers for vasospastic angina are essential to improve outcomes and prevent complications. A CASE OF WERNICKE’S ENCEPHALOPATHY HIDDEN UNDER DELIRIUM TREMENS. Swetha Balaji1; Ajitha Virinchipuram Ganesan1; Evan J. Walsh2; George Freg1. 1Internal Medicine , NYMC GME at St Mary's General Hospital and St Clare's Health, Denville, NJ, US, Parsippany, NJ; 2Touro University, New York, NY. (Control ID #4272638) CASE: Following an assault, a 40-year-old man with diabetes mellitus (type II) and an alcohol use disorder presented with a laceration in his left brow. During the initial encounter, the patient reported intermittent dark stools over the past few months. The patient denied experiencing loss of consciousness, head trauma, dizziness, hematemesis, hematuria, abdominal pain, vomiting, dysuria, chest pain, fever, or chills. The patient had their last alcoholic beverage the day before admission. Upon admission, the patient's heart rate was 70 beats per minute, respiratory rate was 18 breaths per minute, blood pressure measured 124/64 mm Hg, and oxygen saturation was 99% on room air. The lab tests showed that the person's hemoglobin level was 9.3 g/dL, hematocrit was about 27%, platelet count was about 204 x 10^3/μL, AST was 237 U/L, ALT was 66 U/L, ALP was 194 U/L, bilirubin was 4.6 mg/dL, and the FOBT test was positive, and ethanol levels were 185 mg/dL. An upper endoscopy showed that the patient had LA Grade B reflux esophagitis, moderate portal hypertensive gastropathy, and antral gastritis. There was no active bleeding seen. Despite treatment with CIWA protocol, the patient advanced to delirium tremens and necessitated intubation. We started prednisolone due to the elevated Maddrey's score. We administered lactulose and rifaximin to prevent hepatic encephalopathy. The patient was eventually extubated, however, 2 days post-extubation, the patient suddenly became confused, agitated, and had ataxia. This led to the administration of IV thiamine to treat a possible Wernicke encephalopathy. Following this treatment regimen, his condition improved. Before discharge, he and his family received counseling regarding the significance of alcohol cessation, adherence to medication, and follow-up with addiction support services. IMPACT/DISCUSSION: Wernicke's encephalopathy (WE) is a clinical diagnosis, and only 16–33% of individuals have the characteristic triad of abnormal mentation, ataxia, and ophthalmoplegia, complicating the diagnosis, especially for chronic alcoholics. Confusion and ataxia may indicate alcohol withdrawal or hepatic encephalopathy. The absence of clinical suspicion and mild early signs makes diagnosis difficult. Magnetic resonance imaging can diagnose T2/Flair hyperintensities with restricted diffusion in the periaqueductal grey matter, dorsomedial thalami, third ventricle, or mammillary bodies with 53% sensitivity and 93% specificity. Thiamine testing is impractical and delays processing. Our case demonstrates that we should administer high-dose IV thiamine immediately due to rapid deterioration.

This particular case reinforces the importance of timely diagnosis and treatment of Wernicke's Encephalopathy, as well as the masking presentation that physicians ought to be aware of. A CASE PRESENTATION OF ATYPICAL GOUT Fathima Alam1; Roshmita Bardhan2. 1Internal Medicine, Bon Secours Mercy Health, Cincinnati, OH; 2Internal Medicine, Mercy Health, Cincinnati, OH. (Control ID #4252086) CASE: A 70-year-old African American male with a past medical history of right below-knee amputation, chronic kidney disease, heart failure with preserved ejection fraction, and type 2 diabetes mellitus presented with bilateral knee and elbow pain. The patient reported a sudden onset of knee and elbow pain that gradually worsened over the following weeks, resulting in an inability to ambulate. A week prior to symptom onset, he was hospitalized for heart failure exacerbation and reportedly had 50 lbs of fluid removed, leading to significant improvement in his swelling. He denied any alcohol use, trauma, fevers, tick bites, or recent sexual encounters. He had no personal or family history of gout, rheumatoid arthritis, or other autoimmune conditions. On physical examination, the patient had decreased range of motion in his right elbow and lower extremities but no tophi, erythema, effusion, or warmth on palpation. Laboratory results were notable for a sedimentation rate greater than 130, C-reactive protein of 186.5, total creatine kinase of 34, uric acid of 10.7, negative antinuclear antibody, and an elevated rheumatoid factor. X-ray of the left knee showed moderate degenerative changes with a small suprapatellar joint effusion, while X-ray of the right knee showed mild degenerative changes with a small suprapatellar joint effusion. Orthopedics was consulted for further evaluation, and aspiration of the left joint revealed monosodium urate crystals, confirming the diagnosis of gout. The patient was treated with prednisone and discharged on allopurinol with colchicine. IMPACT/DISCUSSION: Gout is an inflammatory condition characterized as a monosodium urate crystal deposition disease that presents with severe pain, redness, warmth, swelling, tophi, and disability, frequently affecting the first metatarsophalangeal joint. While gout is often easily recognized by its typical characteristics, our case presents an atypical manifestation of gout, with no visible physical exam findings or radiographic findings. This case highlights the importance of considering gout in a patient presenting with joint pain. Joint pain is a symptom that warrants further workup. You can have several different differentials with this symptom including osteoarthritis, gout, rheumatoid arthritis, and infection, to name a few. It is critical to consider gout due to increase risk of conditions of joint damage, hypertension, kidney disease, stroke, and heart disease.

It is important to differentiate the diagnosis of joint pain, especially when there are several differentials to investigate. Osteoarthritis, gout, rheumatoid arthritis, and joint infections can present similarly with joint pain. Our case highlights the importance of thoroughly analyzing physical findings and symptoms. Gout, for example, can present with no visible physical exam or radiographic findings but is essential to diagnose to prevent further damage to the patient. A CASE REPORT: RELAPSED ACUTE MYELOID LEUKEMIA (AML) IN A 51-YEAR-OLD MALE PRESENTING AS PARANEOPLASTIC GUILLAIN-BARRé SYNDROME (GBS) AND LEUKEMIA CUTIS (LC) Neha Chava, Tiffany Chu, Anisha Pareddy, Sajith Matthews. IM, Wayne State University School of Medicine, Detroit, MI. (Control ID #4272793) CASE: This is a case of a 51-year-old male in remission for intermediate risk of AML who presented with acute sensorimotor neuropathy distal to the bilateral wrists and ankles and expanding maculopapular rash. Workup of cerebrospinal fluid (CSF) via lumbar puncture showed leukemic cells signaling remission of AML and albumino- cytologic dissociation suggestive of paraneoplastic GBS. Skin biopsies also showed infiltration of AML into dermal layers. The patient was treated with further chemotherapy regimens of Giltertinib and intrathecal methotrexate for the relapse of AML which led to resolution of leukemia cutis by the end of admission. The patient also received six sessions of plasmapheresis to both treat the paraneoplastic GBS as well as treat infiltration of leukemic cells into CSF. After these sessions, the patient had significant improvement of weakness; however, he had continuing left foot drop. The patient was discharged to inpatient rehabilitation to rebuild strength and motor function and address debility due to paraneoplastic GBS. IMPACT/DISCUSSION: This case is an atypical presentation of relapsed AML. Additionally, bone marrow biopsies throughout admission showed complete morphological remission. The only indicators of relapse were CSF infiltration of leukemic cells and leukemia cutis. This patient was also not able to complete induction therapy for a full 7 days due to neutropenic colitis. There may be increased utility to obtaining a lumbar puncture in patients with high clinical suspicion of relapse and with factors that may contribute to increased risk of relapse such as not completing full induction chemotherapy. This case also highlights the importance as a primary team to coordinate multidisciplinary care between specialties such as hematology, oncology and neurology. This case is another example of an atypical presentation of AML which suggests relapse after complete remission shown on bone marrow biopsy. This shows the need for prompt and early recognition of physical exam findings suggesting relapse to initiate treatment early and improve outcomes.

● Relapsed AML may present as isolated CNS findings with or without concomitant skin involvement ● It is important as the primary team to efficiently coordinate care between multiple disciplines to prevent delays in care ● Early recognition of relapsed cancer is vital to improve outcomes in patients who develop debilitating conditions A CASE REPORT OF A SINGLE CHAMBER IMPLANTABLE CARDIOVERTER DEFIBRILLATOR ASSOCIATED SUPERIOR VENA CAVA SYNDROME Ashley Alex, Hibah Virk, Chandler Richardson, Jay Lucas. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4216191) CASE: A 46-year-old female with history of nonobstructive CAD, postpartum cardiomyopathy s/p ICD placement, ESRD on PD s/p renal transplant, TIA, type II DM, and HLD presented with one week of positional facial discomfort, headaches, and dizziness. She was afebrile, normotensive, and had SpO2 of 99% on room air. She had JVD and distended right-sided cutaneous neck veins. She had a regular rate and rhythm without murmurs, carotid bruit, or bilateral leg edema. Her lungs were clear to auscultation. A head and neck CTA showed a nearly occlusive thrombus in the superior vena cava (SVC) associated with the pacemaker lead wires from her implantable cardiac device (ICD). A CT chest showed prominent venous collaterals of the right hemithorax with a dilated right internal jugular vein and a chronically occluded left brachiocephalic vein. A TTE showed an EF greater 65% without thrombus or wall motion abnormalities. The patient's history, physical exam, and imaging studies were suggestive of ICD-lead-associated SVC syndrome. She was started on a high-intensity heparin drip, and general cardiology, electrophysiology and cardiothoracic surgery services were consulted. A plan was made to closely monitor her while she received adequate anticoagulation. As the patient remained hemodynamically stable, the decision was made to continue treatment with anticoagulation in the outpatient setting with follow-up imaging. IMPACT/DISCUSSION: Currently, there are no established treatment guidelines for cardiac device-related SVC syndrome. In this case, a treatment plan was developed with the electrophysiology, cardiothoracic surgery, and general cardiology teams. For a hemodynamically unstable patient, the plan involves explanting the ICD followed by stenting or venoplasty of the SVC and associated vasculature. The patient would then be closely monitored on an outpatient basis for persistently low ejection fraction (EF) or new-onset ventricular arrhythmias. If these conditions arise, the patient would be considered for leadless device implantation. If the patient remains hemodynamically stable, the treatment would include transitioning to Eliquis, with discharge and outpatient follow-up imaging and outpatient cardiology follow-up. If follow-up imaging reveals unresolved thrombus, the patient would undergo device explantation followed by consideration for leadless device placement. We propose a framework for medical and surgical management of cardiac device-related SVC syndrome through this case.

There is a rise in cases of SVC syndrome associated with catheters and cardiac implanted devices, such as hemodialysis catheters, peripherally inserted central lines, pacemakers, and ICDs. While there are no official guidelines addressing the treatment of device-related SVC syndrome, healthcare providers worldwide have developed effective frameworks for clinical management. This case highlights the sophisticated medical management strategies that were considered, leading to a successful treatment outcome. A CHILLING COMPLICATION: COLD AGGLUTININ HEMOLYTIC ANEMIA IN ADULT-ONSET STILL’S DISEASE Amanda Darzi, Jamie Therese Abad, Ali Ali. Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4273130) CASE: We present the case of a 39-year-old male with Adult-Onset Still's Disease (AOSD) who presented with recurrent hospitalizations for hemolysis and anemia. He was first diagnosed with AOSD based on migrating arthralgias, fevers, inflammatory knee effusions, erythematous rash, pericarditis, leukocytosis, transaminitis, and markedly elevated ferritin. He was treated with prednisone, methotrexate, and colchicine. After a period of medication nonadherence, he presented to the hospital with severe anemia, jaundice, and hypotension requiring vasopressor support. Laboratory evaluation showed hemoglobin 5.5 g/dL requiring multiple red blood cell transfusions, platelets 93 K/uL, LDH 3500 IU/L, haptoglobin < 30 mg/dL, reticulocyte 3.8%, fibrinogen 200 mg/dL, PT 18 sec, PTT 40 sec, normal C3 and C4, triglycerides 293 mg/dL, ferritin 973 ng/mL, positive Direct Antiglobulin Test (anti-complement positive, anti-IgG negative), peripheral blood smear with agglutination, suspicious for cold agglutinin hemolytic anemia (CAHA). The patient initially improved with pulse-dose steroids but later required Rituximab for worsening hemolysis. He was discharged on maintenance prednisone and followed outpatient with hematology and rheumatology with stable disease activity and hematologic parameters. Subsequent admissions demonstrated similar ongoing hemolytic episodes. Management included corticosteroids and supportive blood transfusions. Despite treatment, hemolysis persisted, prompting re-initiation of Rituximab. He was discharged with plans to treat underlying AOSD with an Interleukin-1 (IL-1) inhibitor, however, he was lost to follow-up. IMPACT/DISCUSSION: Common hematologic complications of AOSD include macrophage activation syndrome or hemophagocytic lymphohistiocytosis. This case highlights the rare and sparsely documented occurrence of CAHA as a manifestation of AOSD. Key teaching points include recognizing and managing atypical hematologic complications in AOSD. Traditional treatments involve systemic glucocorticoids, methotrexate, or biologics. However, limited data exists on the use of Rituximab in AOSD. This case demonstrates the successful application of Rituximab in treating AOSD complicated by recurrent CAHA. This case emphasizes the importance of a multidisciplinary approach involving hematology and rheumatology for addressing atypical complications. By documenting one of the few cases of recurrent CAHA in AOSD, this case provides a valuable reference for clinicians managing similar complex presentations.

Clinical assessment of hemolysis in patients with autoimmune disorders should include a thorough evaluation for atypical secondary causes, such as cold agglutinin disease for optimal treatment. Multidisciplinary collaboration between rheumatology and hematology is essential to optimize outcomes in patients with complex autoimmune and hematologic conditions like CAHA and AOSD. A COLD CASE OF AGGLUTININ SYNDROME IN THE SETTING OF DIFFUSE CD20+ LARGE B-CELL LYMPHOMA Adam Gumushian1; Collie Shaw1; Kelechukwu Megwa1; Katherine Treacy2; Ambica Chopra2; Ziad Ghneim1; Stephen Wagner1. 1Internal Medicine, Unity Health, Searcy, AR; 2Transitional Year Program, Unity Health, Searcy, AR. (Control ID #4272351) CASE: A 72-year-old man with a history of Type 2 diabetes, hyperlipidemia, and toxoplasmosis presented to the emergency department with worsening abdominal pain, fever, and fatigue. He had recently moved states and was awaiting cardiac clearance for hernia repair surgery, with an appointment scheduled the week after his admission. Initial evaluation revealed mild anemia, elevated BNP, and an abnormal CT abdomen showing bulky retroperitoneal lymphadenopathy and splenomegaly, suggesting a lymphoproliferative disorder. During his hospitalization, he developed episodic peripheral cyanosis of his nose, ears, and digits, later diagnosed as cold agglutinin syndrome (CAS), likely triggered by lymphadenopathy. After an inguinal lymph node biopsy, flow cytometry and immunohistochemical staining confirmed Diffuse Large B-Cell Lymphoma (DLBCL), positive for BCL2, CD20, and CD3. Newly diagnosed heart failure with reduced ejection fraction, sustained arrhythmias, and kidney failure complicated his clinical course, leading to metabolic encephalopathy, respiratory failure, and sepsis from an ESBL urinary tract infection. He also developed severe metabolic disturbances, including tumor lysis syndrome, hyperkalemia, hypercalcemia, and elevated uric acid, secondary to the aggressive nature of his lymphoma. DLBCL remained refractory to treatment due to compromised cardiac function, limiting chemotherapy options. Despite aggressive supportive care, his condition deteriorated. PET/CT staging was planned but never completed. After extensive discussions with the family regarding his poor prognosis, his code status was de-escalated, and comfort care was initiated. IMPACT/DISCUSSION: This case involves a unique pathophysiological presentation and management course. Delayed surveillance of the patient’s initial abdominal pain and inguinal mass, which was initially thought to be a hernia, led to a cascade of clinical delays. It remains unclear how long his lymphadenopathy had been progressing as he awaited follow-up with his out-of-state physician. CAS is a rare presentation in DLBCL, and his inpatient management required careful temperature control due to the potential risk of vasoproliferation if vasopressors were needed for cardiogenic shock. Differentiating systemic lymphadenopathy from infectious or reactive causes is essential in outpatient care. In this case, the patient faced months of misdiagnosis that delayed proper treatment, contributing to his deterioration. While an infectious etiology may have seemed unlikely, proper follow-up and surveillance were crucial to avoid this diagnostic error.

This case highlights the rarity of CAS in rapidly progressing DLBCL. The aggressive clinical course, compounded by multiorgan failure and sepsis, presented numerous challenges throughout his month-long hospitalization. His story underscores the importance of timely disease surveillance, the dangers of anchoring bias, and the risks of delayed diagnostics in managing critical conditions. A COMPLEX CASE OF HEPATORENAL SYNDROME IN A PATIENT WITH DECOMPENSATED MASH CIRRHOSIS AND SUSPECTED HEPATOCELLULAR CARCINOMA Molly Mehta, Susan Lopez, Yama Latif. Rush University Medical Center, Chicago, IL. (Control ID #4271492) CASE: Hepatorenal Syndrome (HRS) is a severe complication of advanced liver disease, characterized by renal dysfunction without intrinsic renal pathology, leading to significant morbidity and mortality. It often occurs with cirrhosis and ascites, complicating management. This case emphasizes the importance of timely intervention and comprehensive management in decompensated cirrhosis with HRS and suspected hepatocellular carcinoma (HCC). A 66-year-old female with recent diagnosis of MASH cirrhosis presented with worsening abdominal distension, bilateral lower extremity (BLE) edema, and shortness of breath. She had gained 50lbs in three weeks, indicating fluid retention. Her medical history included Type 2 diabetes, hypertension, and morbid obesity. On admission, her vital signs were BP 127/48, HR 93, and SpO2 93%. Physical exam revealed a firm, distended abdomen, tenderness, visible striae, 3+ BLE edema, and increased urinary frequency with minimal output, suggesting ascites and potential renal impairment. Neurological exam showed no signs of hepatic encephalopathy. Initial labs indicated hepatic dysfunction and potential renal impairment, including anemia, thrombocytopenia, hyponatremia, hypoalbuminemia, elevated liver enzymes, high bilirubin, and a mildly elevated INR. Creatinine was normal but worsened during hospitalization, leading to acute kidney injury (AKI). Despite aggressive treatment, including diuretics and albumin infusions, renal function deteriorated, requiring continuous renal replacement therapy (CRRT). Imaging revealed hepatic steatosis with a suspicious lesion, raising concern for HCC. Autoimmune and viral hepatitis panels were negative, and tumor markers were normal, except for elevated Des-gamma-carboxy prothrombin (DCP), concerning for HCC. The patient’s morbid obesity and suspected HCC limited her liver transplant candidacy. Despite interventions, her condition worsened, and she passed away. IMPACT/DISCUSSION: This case demonstrates the need for early intervention and comprehensive management of advanced liver disease. Early treatment, including albumin infusions and careful diuretic use, could have delayed the onset of HRS. Prognostic indicators, such as high bilirubin, low albumin, and elevated INR, highlighted her poor prognosis, with the suspected HCC further complicating her care. A multidisciplinary approach is crucial in managing HRS, involving hepatology, nephrology, and critical care to maintain renal perfusion. Regular HCC surveillance in cirrhotic patients is essential for improved outcomes. Primary care engagement in monitoring at-risk patients and implementing lifestyle changes, especially for comorbidities like obesity and diabetes, can positively affect long-term outcomes.

HRS is a life-threatening complication of liver disease, and early recognition is essential for improving patient outcomes. Comprehensive care, timely intervention, and a multidisciplinary approach are vital in managing cirrhotic patients with multiple comorbidities. A COMPLICATED CASE OF ACUTE HYPOXIC RESPIRATORY FAILURE SECONDARY TO A COMPLEX PLEURAL EFFUSION Andrew Wu. Hospital Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4242233) CASE: A 65 year old male with alcoholic cirrhosis presented for dyspnea. Over the past week he developed progressively worsening dyspnea and anasarca. He required 3 L of oxygen on presentation though his vitals were otherwise normal. CT Chest/Abdomen/Pelvis showed large right sided loculated pleural effusion and ascites. Serum lab work showed WBC 13.8 K/uL, total protein 6.9 g/dL and LD 376 U/L. Thoracentesis showed a milky fluid with 5207 neutrophils/mm3, protein 1.4 g/dL, LD 391 U/L, cholesterol 24 mg/dL and triglycerides 390 mg/dL. A chest tube was placed and antibiotics were started. Paracentesis showed 74 neutrophils/mm3 and triglycerides of 162 mg/dL. Octreotide and a low-fat diet were started for treatment of chylothorax. Workup for underlying causes such as malignancy or tuberculosis was negative. Whole body scintiography was negative for active chyle leak. Peritoneal venous shunt patency test was positive for hepatic hydrothorax (HH). Pleural fluid grew E.coli on hospital day 3 and he was diagnosed with spontaneous bacterial empyema (SBE). On day 7, a rapid response was called for hypotension secondary to excess chest tube output. His chest tube was subsequently clamped and then removed after tolerating water seal. He was not a liver transplant candidate due to ongoing alcohol use. He was instead referred to IR for TIPS and completed 4 weeks of antibiotics. IMPACT/DISCUSSION: Ultimately, this patient was diagnosed with hepatic hydrothorax complicated by transient idiopathic chylothorax and spontaneous bacterial empyema. HH is usually diagnosed clinically but due to this patient’s unclear presentation, a shunt patency test was utilized. A chylothorax is a pleural effusion that occurs when a disruption of the thoracic duct causes chyle to leak into the pleural space and is diagnosed with a triglyceride level of 110 mg/dL. Most cases are due to trauma though the differential is broad. Rarely they can occur due to cirrhotic chylothorax, a condition where chylous ascites translocates across the diaphragm. This was not the case in our patient as the ascitic fluid was not chylous (chylous ascites being diagnosed with triglycerides of 200 mg/dL) and his was ultimately thought to be idiopathic. Chylothorax can be treated initially with octreotide and a low-fat diet, while refractory cases can be treated with thoracic duct embolization. His pleural effusion was also complicated by SBE, a process that occurs with the spontaneous infection of HH. SBE is diagnosed with positive pleural cultures and 250 neutrophils/mm3. Ideally empyemas are drained for source control but given frequent fluid reaccumulation of his HH, this was not possible. Treatment of HH includes diuretics, TIPS and liver transplant. This was instead attempted for treatment along with antibiotics.

Chylothorax is diagnosed with triglyceride level over 110 mg/dL. HH can be confirmed with a shunt patency test. SBE is a complication of HH and is diagnosed with positive pleural cultures and 250 neutrophils/mm3. ACQUIRED HEMOPHILIA A FOLLOWING COVID-19 INFECTION Shalom Isaac2; Sangeetha Isaac1; Andrew Weil1. 1Hematology & Oncology, East Carolina University Brody School of Medicine, Greenville, NC; 2Palliative Medicine, Christian Medical College Vellore, Vellore, TN, India. (Control ID #4272759) CASE: A 69-year-old gentleman with a history of CHF, dilated cardiomyopathy, EF 40-45%, and recent history of COVID-19 infection 10 days ago, presented to an outside facility with exertional dyspnea. He was noted to have hemoglobin of 5.8 g/dL (baseline Hb 13-15 g/dL). During hospitalization, he developed spontaneous intramuscular hematoma over the right chest wall, right upper extremity, and right masseter muscle, and required 8 units of PRBC transfusion. Evaluation showed an elevated PTT of 140 s (Ref range 27.6-37s); PT/INR was normal warranting transfer to our tertiary center for hematology evaluation. Workup at our facility revealed PTT Mix 1:1 to be 70s (Ref range 25-37s). Factor assay showed Factor II 74%, V 91%, VII 103%, VIII <1%, IX 20%, X 59%, XI 29.8%, XII 3% (Ref range 50-150%). Factor VIII activity assay <1%; Factor VIII inhibitor level was 677 BU confirming AHA. Activity assay for factors IX, XI, and XII were normal. He was initiated on prednisone 1mg/kg/day and FEIBA (Factor Eight Inhibitor Bypass Activity) 100 units/kg every 12 hours for 4 doses. Cyclophosphamide was initiated at 50mg/day and increased to 100mg/day the following day. There was no extension of hematoma and hemoglobin remained stable. He was discharged on prednisone and cyclophosphamide. A week later, he was seen during an outpatient visit, Factor VIII inhibitors were present but had down trended to 288 BU, showing inadequate response to cyclophosphamide. Weekly Rituximab 375mg/sq meter was added to his treatment regimen. 2 weeks later, he suffered a cardiac arrest with successful resuscitation and admission to the critical care unit for management of septic shock and hemorrhagic shock. His hospitalization was complicated by clostridium difficile colitis, CMV viremia, and neutropenia. Though initially held, Rituximab and Cyclophosphamide were resumed due to active bleeding and worsening hematomas. Following a complicated hospitalization course, he succumbed to multiorgan failure. IMPACT/DISCUSSION: Acquired Hemophilia A (AHA) is a rare condition characterized by the development of inhibitory antibodies to Factor VIII. AHA is idiopathic in most cases; however, it could be associated with malignancies, infections, drugs, and autoimmune conditions. In recent years few cases of AHA following COVID-19 vaccination have been reported; but AHA following COVID-19 infection remains a rare occurrence. The immune dysregulation following COVID-19 infection has been suggested as a pathophysiology in the development of AHA in these patients. In our review of the literature, only very few cases of AHA have been reported following COVID-19 infection.

Given the rarity of this condition, a high index of clinical suspicion is needed. It is important for internists to be aware of this condition and approach a complex patient such as ours with this knowledge for timely diagnosis and appropriate intervention. ACQUIRED HEMOPHILIA A PRESENTING AS DIFFUSE ALVEOLAR HEMORRHAGE IN A PATIENT WITH SUSPECTED EHLERS-DANLOS SYDROME Amrutha Sai Mittapalli1; Sophia Rokkas2; Karthik Shankar2. 1Internal Medicine, Lankenau Medical Center, Wynnewood, PA; 2Hematology/Oncology, Lankenau Medical Center, Wynnewood, PA. (Control ID #4273197) CASE: A 42-year-old female with a history of asthma and migraines presented to the ED with multiple episodes of hemoptysis. Six months earlier, she had developed an uncomplicated nasal septum perforation. More recently, she experienced intermittent episodes of epistaxis that resolved spontaneously. On the day of presentation, she reported waking up with several episodes of hemoptysis, coughing up large clots (1–2 cm), but denied epistaxis. History revealed recent dental implants, easy bruising, and joint hypermobility, raising suspicion for an underlying connective tissue disorder like Ehlers-Danlos Syndrome (EDS). Lab results showed hemoglobin of 10.7 g/dL (reference: 11.8–15.7 g/dL) and aPTT of 47s (23–35s), with normal PT and INR. A CT angiogram of the chest revealed bilateral ground-glass opacities and CT angiogram of the neck showed normal vasculature. Bedside nasopharyngolaryngoscopy revealed a 2 cm central septal perforation with dried, stable scabbing and no active bleeding. Due to concerns for lung pathology, the patient was intubated and underwent bronchoscopy. Bronchoscopy with bronchoalveolar lavage confirmed diffuse alveolar hemorrhage (DAH). Further testing revealed CRP of 44, ESR of 38, Factor VIII activity of 13% (74–160%), Factor IX activity of 165% (60–160%), and Factor XI activity of 118% (60–160%). ANCA, MPO, PR3, ANA, rheumatoid factor, and anti-GBM, anti-cardiolipin, and beta-2 glycoprotein antibodies were negative. PTT mixing study did not correct after incubation, suggesting a coagulation inhibitor. Bethesda assay for Factor VIII inhibitor was elevated at 7 (<1), confirming an inhibitor. The patient was diagnosed with acquired hemophilia A(AHA) and treated with high-dose IV methylprednisolone for three days, resolving the bleeding. She is awaiting genetic testing for EDS. IMPACT/DISCUSSION: This case describes a 42 year old female presenting with DAH who was susequently diagnosed with AHA. Clinical features such as bruising, epistaxis, hypermobility, and multiple dental implants also raised suspicion for an underlying vascular EDS. AHA is a rare, life-threatening autoimmune condition caused by antibodies targeting clotting factor VIII, resulting in impaired coagulation and an increased risk of bleeding. Approximately 50% of AHA cases are associated with underlying conditions such as malignancies, infections, or connective tissue diseases. While EDS, particularly vascular EDS, is known for its bleeding complications due to vascular fragility, its association with AHA is not well documented.

This case highlights a rare presentation of acquired hemophilia A (AHA) in a patient with clinical features suggestive for an underlying vascular Ehlers-Danlos syndrome (EDS). Although both conditions can cause bleeding a direct association between them is not well established. ACUTE DYSTONIC REACTION AFTER ADMINISTRATION OF IV METOCLOPRAMIDE Jenna Glovsky2; Vikram Singh2,1; Rishab Srivastava2,1; Drew Rasmussen2,1; Christian Martin3; Kendal Flegenheimer1. 1Medicine, Banner - University Medical Center Tucson, Tucson, AZ; 2The University of Arizona College of Medicine Tucson, Tucson, AZ; 3Rocky Vista University College of Osteopathic Medicine, Parker, CO. (Control ID #4272729) CASE: A 43 year old female with recent sleeve gastrectomy and orthotopic liver transplant in the setting of autoimmune hepatitis presented to the hospital with 2 weeks of nausea, vomiting, and cough. CBC, CMP, and qualitative HCG were unremarkable. CT chest/abdomen/pelvis did not yield any intra-abdominal pathology. EGD performed showed only grade A esophagitis. On admission, she was started on PO metoclopramide 10 TID in an effort to manage her dysmotility. On day 3 of hospitalization, patient had difficulty tolerating PO intake, with IV metoclopramide given at 11:07 with no incident. At 17:31, it was administered with immediate development of jaw and lip tightening. Rapid response was called. On arrival, patient exhibited signs of trismus with inability to open her jaw and 10/10 pain. Acute dystonic reaction was diagnosed and IV diphenhydramine 50 mg was ordered stat. Upon administration, patient experienced complete resolution of trismus within 10 minutes. Metoclopramide was discontinued and she was discharged the following day with no clear residual effects. IMPACT/DISCUSSION: Metoclopramide is an antiemetic that antagonizes peripheral and central D2 receptors in the chemoreceptor trigger zone of the area postrema and is commonly used for management of nausea and gut dysmotility. Like other dopamine receptor antagonists, it has the known adverse effect of extrapyramidal reactions, of which acute dystonia is the most common. It can present as generalized or local hypertonicity, involuntary abnormal movements, tongue protrusion, torticollis, opisthotonus, or oculogyric crisis and is often misdiagnosed. Dystonic reactions with metoclopramide are rare, though occur more frequently when given IV due to greater absorption and quick onset of action. Notably, our patient had been on PO metoclopramide for several days without incident. Acute dystonic reactions can be alarming and deadly without prompt intervention. Diagnosis is made through physical exam and thorough history, including medication review. The pathophysiology of acute dystonia is not fully understood, but is thought to be related to excess striatal acetylcholine release in the setting of minimized dopamine inhibition. Treatment options, including benztropine and diphenhydramine typically exert anticholinergic effects, which rapidly resolve symptoms. We elected for IV diphenhydramine due to its immediate availability. This case highlights the importance of understanding severe adverse reactions to medications very commonly used in clinical practice.

Here we detail the case of a woman who experienced acute trismus after IV metoclopramide and was successfully diagnosed and treated for an acute dystonic reaction. A high index of suspicion and close monitoring for extrapyramidal reactions when prescribing metoclopramide, particularly the IV formulation, remain crucial for rapid diagnosis, treatment, and avoidance of adverse outcomes. ACUTE GASTRIC PERFORATION PRESENTING WITH ST SEGMENT ELEVATION IN AN ELDERLY MALE. Mohammad Rizwan Alam1; Sushil Rayamajhi1; Gary Batra2; Peter Fahim1; Anna Katja Maria Chesterman2; Shubham Sood2. 1Internal Medicine, University of Central Florida College of Medicine, Orlando, FL; 2internal medicine, UCF/HCA West Florida Hospotal, Pensacola, FL. (Control ID #4273352) CASE: A 61-year-old male with a history of alcoholic pancreatitis, gastric bypass surgery, tobacco and substance abuse, and right below-knee amputation presented to the Emergency Department (ED) with severe abdominal pain lasting for three days, associated with nausea, vomiting, and melena. He denied chest pain or shortness of breath. On arrival, the patient was hypotensive, with a blood pressure of 86/67 mmHg and a heart rate of 129 beats per minute. Physical examination revealed a distended abdomen with tenderness to palpation in the epigastric region, along with rebound tenderness and involuntary guarding. A 12-lead electrocardiogram (ECG) demonstrated 3–4 mm ST-segment elevations in the inferior leads and 2 mm ST-segment elevations in V5–V6, with reciprocal ST depressions in leads I and aVL, suggestive of an acute inferior wall myocardial infarction (MI). Due to concern for hemorrhagic shock, two units of packed red blood cells and intravenous crystalloids were administered emergently, resulting in stabilization of the blood pressure and heart rate. Initial lab work revealed a white blood cell count of 6.1k/μL, hemoglobin of 11.7 g/dL, and a lactic acid level of 7.6 mmol/L. Bedside echocardiography (echo) performed by a cardiologist revealed a left ventricular ejection fraction of 55–60% with no evidence of cardiac wall motion abnormalities. A subsequent ECG showed improvement in the ST elevations, with no pathological Q-waves. A bedside focused assessment with sonography for trauma showed free fluid in the abdominal cavity, prompting a CT scan of the abdomen and pelvis, which revealed a large volume of intraperitoneal ascites and pneumoperitoneum, suggesting a perforated viscus. Given these findings, it was determined that the ECG changes were likely associated with the perforated viscus. The patient underwent an emergent exploratory laparotomy, which revealed a perforated gastric ulcer in the excluded stomach. The ulcer was repaired, and the patient showed significant improvement postoperatively. A follow-up echocardiogram after surgery was unremarkable, and the patient was discharged on postoperative day 6. IMPACT/DISCUSSION: The etiology of ST-segment elevation in acute abdominal conditions is unclear. Several mechanisms have been proposed, including abdominal distension, which increases vagal tone and causes coronary vasoconstriction; irritation of the diaphragm, which can result in pericardial irritation or pseudo-pericarditis; or prolonged hypotension leading to coronary ischemia. Additionally, our case demonstrated the pivotal role of a multidisciplinary approach in diagnosing the underlying cause and expediting intervention. The integration of bedside point-of-care ultrasound was invaluable in identifying free fluid in the abdomen, guiding the decision to perform a CT scan, and prioritizing exploratory laparotomy over cardiac procedures.

This case highlights the importance of considering non-cardiac causes for STEMI-like ECG changes ACUTE KIDNEY INJURY FROM OBSTRUCTIVE UROPATHY: A CRUCIAL ALERT FOR BLADDER CANCER DETECTION Dhairya Salvi1; Pedro A. Pineiro De Jesus1; Mohammed Mohammed Ali2; Eli Diab3; Pranav Chalasani1; Parshva Salvi1; Basel Taha4. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2Internal medicine, Wayne State University School of Medicine, Detroit, MI; 3Internal Medicine, Wayne State University, Detroit, MI; 4Nephrology, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4273206) CASE: A 79-year-old male with a history of benign prostatic hyperplasia (BPH), hypertension, and hyperlipidemia, but no smoking history, presented to the emergency department (ED) with progressive weakness over several months, worsening in recent days. He reported poor appetite, urinary frequency, dysuria, and nausea. In the ED, he was hemodynamically stable, afebrile, and had normal oxygen saturation on room air. Labs showed elevated creatinine (3.88), BUN (101), glucose (189), and a positive urinalysis for WBCs, RBCs, and leukocyte esterase. Kidney ultrasound revealed bilateral hydronephrosis due to outlet obstruction. He was treated with IV fluids and antibiotics and admitted for further evaluation. A few weeks earlier, he had been evaluated at another hospital for similar complaints. Imaging showed bilateral moderate hydronephrosis and a creatinine level of 2.2. A Foley catheter was placed, but his creatinine levels did not improve, ruling out bladder outlet obstruction. He was discharged without the catheter and referred to a urologist. An outpatient cystoscopy identified a bladder polyp, but he did not schedule the recommended follow-up procedure. During this visit, a CT scan revealed severe bilateral hydronephrosis up to the ureterovesical junction (UVJ) and bladder wall thickening. The patient underwent cystoscopy, bilateral ureteral stent placement, and biopsies of an extensive bladder mass. Pathology confirmed a low-grade papillary urothelial neoplasm. He was discharged without complications and later underwent transurethral resection of the bladder tumor, with follow-up oncology care recommended. IMPACT/DISCUSSION: The patient's presentation with bilateral hydronephrosis and elevated creatinine, despite prior evaluations and Foley catheter placement, underscores the complexity of diagnosing AKI in the context of potential malignancy. When AKI is cancer-related, it represents about 10% of AKI cases in this population and is associated with higher mortality compared to AKI without obstructive nephropathy. While smoking is a known risk factor for transitional cell carcinoma (TCC), this case highlights that bladder cancer can occur even in patients without traditional risk factors. It emphasizes the interplay between urological and oncological pathologies and the importance of timely, comprehensive management to improve patient outcomes.

Consider bladder cancer in the differential diagnosis of AKI with hydronephrosis, even in patients without traditional risk factors like smoking. Early diagnostic interventions, including imaging, cystoscopy, and biopsy, are crucial for identifying malignancies in patients with obstructive nephropathy. ACUTE LIVER FAILURE SECONDARY TO AUTOIMMUNE HEPATITIS Christine Huynh, Olivia O'Keefe, Parker Woody, Matthew Glover. Internal Medicine, Dignity Health St. Rose, Las Vegas, NV. (Control ID #4271451) CASE: 60 year old female with medical history notable for atrial flutter on anticoagulation, COPD, POTS, and stiff person syndrome presented for shortness of breath and hematuria. She came from a different hospital for further management of cholelithiasis seen on ultrasound of the abdomen. Clinical Findings: Vital Signs: T 36.8C, HR 83, RR 16, 95% on RA Initial Labs: INR 2.10, Platelets 125K, Total Bilirubin 15.2, ALT 530, AST 944, Alkaline phosphatase 216. Repeat INR 6.66. Diagnostic Assessment: MRCP was negative for cholelithiasis. Presenting labs are indicative of acute liver failure. Iron studies are negative for iron overload. F-Actin IgG was 50, Smooth muscle Ab IgG was 1:160. The α-1-antitrypsin level was normal but she is of the M1Z phenotype. Hypergammaglobulinemia was present, the rest of the acute liver failure and autoimmune hepatitis workup were negative. Her liver biopsy showed mixed inflammatory infiltrates with prominent portal neutrophils as well as pigment laden macrophages and scattered plasma cells. There is concern for possibly advanced underlying fibrosis but evaluation is limited due to the presence of bridging necrosis. IMPACT/DISCUSSION: Although presenting with findings for cholelithiasis, it was important to recognize that the patient was in acute liver failure with her INR, platelet, and total bilirubin levels. We quickly pursued the work up for liver failure and then autoimmune hepatitis once F-Actin returned elevated. A liver biopsy was essential for further investigation. Histopathology generally shows abundant plasma cells in addition to necroinflammatory lesions (Beer et. al). The histopathology in addition to hypergammaglobulinemia with elevated F-Actin and Smooth muscle IgG, confirmed the diagnosis of autoimmune hepatitis. The MZ mutation in the AAT gene puts the individual at increased risk of advanced fibrosis and further failure (Liedtke et. al). The Z mutation causes misfolding of antitrypsin in the liver, resulting in normal quantities; however, accumulation of the protein in hepatocytes can lead to progressive disease and fibrosis from endoplasmic reticulum and mitochondrial injury (Wooddel et. al).

As soon as autoimmune hepatitis was suspected, the patient was empirically started on prednisone 60 mg daily. Labs from 1 month post discharge show an improvement of liver function tests. INR 1.12, PT 12.7 s, PTT 26.5 s. Total bilirubin 1.8, direct bilirubin 1.2, ALT 37, AST 47, and Alkaline phosphatase 109. The patient appeared clinically improved as well with resolution of jaundice and abdominal fluid wave. Although coagulation factors are much improved, the patient does appear to have continued bleeding diathesis. The patient remains on prednisone daily and has follow up with gastroenterology outpatient. Next steps include monitoring for remission, tapering glucocorticoids, and the consideration of immune modulator therapy. ACUTE PORTAL AND SPLENIC VEIN THROMBOSIS WITH PSEUDOHYPERKALEMIA IN A YOUNG MALE WITH ESSENTIAL THROMBOCYTHEMIA Simo Du, Subedi Pawina, Roha Saeed Memon, Ana Yasmin Caceres Lessa, Ibrahim Sange, Palaiodimos Leonidas. IM, New York City Health and Hospitals Jacobi, New York, NY. (Control ID #4267114) CASE: A 28-year-old Jamaican male with no significant medical history presented with acute back and lower abdominal pain for three days. He denied nausea, vomiting, diarrhea, or hematochezia. Laboratory evaluation revealed severe thrombocytosis (platelet count >1,000,000/μL). Imaging (CT and MRI) showed hepatosplenomegaly, portal and splenic vein thrombosis, and hypoperfusion of the right hepatic lobe. The patient received heparin infusion, later transitioned to enoxaparin, with improvement in symptoms and thrombosis resolution. Hematology consultation recommended a comprehensive hypercoagulability workup, including tests for antiphospholipid syndrome, lupus anticoagulant, antinuclear antibodies, and genetic mutations, all of which were negative except for a frameshift mutation in CALR exon 9. Bone marrow biopsy revealed hypercellular marrow with myeloid hyperplasia, atypical megakaryocytes, and reticulin fibrosis, consistent with pre-fibrotic myelofibrosis in ET. The patient was discharged on aspirin and apixaban, and started on hydroxyurea for cytoreduction outpatient. Platelet levels stabilized, and surveillance bone marrow biopsy was planned. During hospitalization, the patient also developed hyperkalemia (potassium 6 mEq/L) without symptoms or electrocardiographic changes. Plasma potassium levels were normal, confirming pseudohyperkalemia due to in vitro platelet lysis, a phenomenon linked to extreme thrombocytosis. Elevated lactate dehydrogenase (LDH >600 U/L) indicated high platelet turnover. IMPACT/DISCUSSION: Thrombosis in unusual sites, especially in young, healthy individuals, warrants thorough thrombophilia workup. Significant thrombocytosis with a negative hypercoagulability workup should prompt consideration of MPNs. Approximately 50–60% of ET cases are associated with the JAK2 V617F mutation, 15–30% with CALR mutations, and 1–5% with MPL mutations. In ET, extreme thrombocytosis can result in pseudohyperkalemia, caused by potassium release from activated platelets during clotting. Plasma potassium measurements, obtained in anticoagulated containers such as lithium heparinized tubes, are essential to avoid misdiagnosis and unnecessary treatment for hyperkalemia. Early recognition and treatment of ET, including cytoreduction and anticoagulation, improve outcomes, allowing most patients to achieve normal life expectancy.

Thrombosis in unusual anatomical sites in young individuals should prompt a comprehensive thrombophilia evaluation, including an assessment for rare conditions such as myeloproliferative neoplasms In the context of thrombocytosis and hyperkalemia, pseudohyperkalemia should be strongly considered, and plasma potassium levels measured using anticoagulated samples to avoid unnecessary treatments. ACUTE RESPIRATORY FAILURE AND CLUES TO AN ATYPICAL PRESENTATION OF ADRENAL INSUFFICIENCY Ruby Chien, Charlotte Crist, Sophia C. Levis, Parinaz Abiri. Internal Medicine, University of California Irvine, Irvine, CA. (Control ID #4272612) CASE: A 68 year old male with gastric adenocarcinoma and hepatocellular carcinoma presented with two weeks of coughing, dyspnea, lower extremity swelling, and generalized weakness, and was admitted for acute hypoxic respiratory failure. CT chest showed pulmonary congestion, atelectasis, and centrilobular consolidations, concerning for volume overload and aspiration pneumonia. Patient was started on antibiotics and a swallow evaluation was pursued, which demonstrated severe tongue and pharyngeal muscle weakness without any anatomic abnormalities. During hospitalization, he was also noted to have new urinary retention, severe constipation, tremors, intermittent hypoglycemia (though recurrently NPO), and eosinophilia. On hospital day 4, he was found to be unusually somnolent, prompting acute encephalopathy workup that was remarkable for a 10 am cortisol of 2 mcg/dL. Cosyntropin stimulation test showed cortisol levels of 1, 4, and 9 mcg/dL. Follow-up ACTH was < 1.5 pg/mL. Patient was started on stress dose steroids with a taper. Dysphagia improved after starting steroids, allowing him to advance his diet from pureed to chopped foods at time of discharge with return to regular textures post-hospitalization. All other symptoms similarly resolved within days of starting steroids. Notably, he had received Ipilimumab and Nivolumab 3 months prior to presentation, likely the underlying cause of his adrenal insufficiency (AI). Gastric adenocarcinoma treatment was ultimately changed to pembrolizumab on an outpatient basis. IMPACT/DISCUSSION: There is a rising incidence of immunotherapy use for cancer and rheumatologic disorders, and new side effects are being discovered, including endocrinopathies. AI is a rare complication of immune checkpoint inhibitors, but has been described in literature with a typical incidence of 5-7% and mean onset of ~3 months after initiation of therapy. Typical AI symptoms include hypotension, hypoglycemia, electrolyte derangements, muscle weakness, anorexia, and poor wound healing. This patient’s unique presentation demonstrated muscle involvement that extended beyond skeletal muscles of the extremities and appeared to include muscles of swallowing (dysphagia), bladder function (urinary retention), respiration (atelectasis from diaphragmatic weakness), and the gastrointestinal system (constipation), while missing the electrolyte or metabolic abnormalities typically seen in AI.

Our case describes an atypical presentation of adrenal insufficiency in the setting of recent administration of immune checkpoint inhibitors. In our patient's case, the absence of typical hemodynamic, metabolic, and electrolyte abnormalities of AI impacted the initial diagnosis of his multiple underlying presenting symptoms. Given the rising incidence of endocrinopathies as side effects of immunotherapy, it is imperative that clinicians are able to recognize atypical onsets of these complications. ACUTE UNILATERAL PTERYGOID ABSCESS & STEP PNEUMONIAE BACTEREMIA FROM COMPLICATED OBSTRUCTIVE SPHENOID SINUSITIS Raiza Fathima Nazeer Hussain3; QI SHI2; Prasanthi Limgala1; Roop S. Parlapalli2. 1Infectious Disease, Geisinger Community Medical Center, Scranton, PA; 2Hospitalist, Geisinger Community Medical Center, Scranton, PA; 3Geisinger Community Medical Center, Scranton, PA. (Control ID #4271662) CASE: 29-year-old male significant PMH of right TMJ dysfunction (TMD) presenting to the emergency department (ED) with chief complains of headache and fever for 1 week, radiated to the back of the head, associated with left jaw pain, aggrieved by chewing, and experiencing diarrhea with blood in stool. He came back from India one week ago after visiting family. Following with outpatient dentistry for Right TMD. On physical exam, Temp 100.8F, HR 107, left TMJ tenderness. Lab results show WBC 18.86 K. CT of head without contrast showed paranasal sinuses thickening and air fluid opacities in sphenoid sinus may represent changes of sinusitis. MRI showed opacification of left sphenoid sinus with air fluid level and multiloculated abscess within left lateral pterygoid muscle and left medial pterygoid myositis. Fiberoptic examination of nasopharynx was exanimated by ENT shown enlarged turbinates with mucopus. Non-obstructing adenoids with open choanae and non-obstructed eustachian tube orifices. The findings are concerning for complicated acute left sphenoid sinusitis. Blood cultures 4/4 were positive for Streptococcus pneumoniae. Infection disease, Neurology, OMFS, and ENT consulted. All other tests were unremarkable including X rays of bilateral TMJ. Patient was started on IV fluids & IV piperacillin-tazobactam initially, switched to IV Ceftriaxone and oral doxycycline. Patient symptoms improved and discharged to home with IV Ceftriaxone and oral metronidazole for 3 weeks and follow up with ENT as outpatient with MRI for elective Sphenoidectomy. IMPACT/DISCUSSION: Streptococcus pneumoniae is a common bacterial cause of sinusitis, including sphenoid sinusitis. Isolated sphenoid sinusitis is a rare but potentially serious infection due can cause pterygoid muscle abscess with possible devastating complications including cranial nerve involvement, brain abscess, meningitis, or sepsis. The lateral pterygoid muscle is a craniomandibular muscle that helps control TMJ, pterygoid abscesses can be like TMJ dysfunction. It is important to get an early diagnosis to prevent the abscess from spreading because the condition can progress quickly. Neuroimaging, such as a maxillofacial CT or MRI, are extremely useful in the diagnosis. Timely subspecialties consultation during hospitalization can help with earlier treatment initiation for such life-threatening complications.

Our case reported that infections of lateral pterygoid muscle secondary to acute sphenoid sinusitis can lead to sepsis due to streptococcus pneumoniae bacteremia as a life-threatening complication. A detailed clinical interview along with additional neuroimaging study, and interprofessional collaboration practice can timely provide in making an accurate diagnosis and treatment plan. A DIAGNOSTIC AND THERAPEUTIC CHALLENGE – ATYPICAL PRESENTATION OF DIABETIC GASTROPARESIS WITH SEVERE ABDOMINAL PAIN AND REFRACTORY NAUSEA Tammy Ly1; Frans Serpa1; Kristina Collins1; Ahmad Anshasi2. 1Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 2GIM, The University of Texas Southwestern Medical Center, Arlington, TX. (Control ID #4215363) CASE: A 35-year-old female with class I obesity and a recent diagnosis of type II diabetes mellitus (T2DM) presented with 6 weeks of severe abdominal pain, nausea, and frequent clear emesis. 2 weeks after symptom onset, she was diagnosed with cholelithiasis and underwent laparoscopic cholecystectomy. Symptoms recurred 2 days post-op, leading to an admission where she was diagnosed with H. pylori and uncontrolled T2DM (HbA1C 11.4), and discharged on quadruple therapy. 4 weeks later, she was re-admitted for refractory symptoms. Exam revealed diffuse abdominal tenderness without guarding, and labs showed baseline leukocytosis and thrombocytosis. Imaging, including abdominal CT, MRCP, and head CT, was unremarkable. The patient was initiated on metoclopramide, erythromycin, antiemetics, opioids, and insulin but remained intolerant to oral intake. Nutrition recommended enteral feeding via Dobhoff, but severe nausea led to feeding tube removal. Interim psychiatric evaluation diagnosed her with adjustment disorder. EGD showed esophagitis and gastritis without obstruction. Her pain persisted with concern for functional abdominal pain, prompting a GI consult. Gastric scintigraphy revealed 15% gastric emptying at 4 hours (normal >90%), confirming gastroparesis. Pyloric Botox injections were administered with improvement in symptoms. She was advised to maintain glycemic control and follow up outpatient. IMPACT/DISCUSSION: This case illustrates the complexity of managing diabetic gastroparesis, particularly when severe abdominal pain dominates the clinical picture. While gastroparesis is a known complication of long-standing diabetes, this patient’s presentation of severe gastroparesis along with newly diagnosed T2DM is atypical, challenging the usual progression of the disease. About one-third of patients dominantly experience severe abdominal pain. Management requires a multidisciplinary approach to ensure comprehensive nutritional support and medical care. Initial interventions include correcting fluid, electrolyte, and nutritional imbalances and achieving optimal glycemic control. Prokinetic therapy is essential, with metoclopramide as the first-line option, while antiemetics (e.g. 5-HT3 receptor antagonists) are used to control nausea/vomiting. Invasive interventions for patients with medically refractory gastroparesis are available but are constrained by limited robust evidence and long-term outcomes (e.g. gastric electrical stimulation, intra-pyloric botulinum toxin injections, pyloroplasty, partial gastrectomy, gastric peroral endoscopic myotomy).

Gastroparesis can present early in the course of diabetes and may manifest with severe, refractory symptoms. A multidisciplinary approach is crucial for comprehensive management. Advanced therapies like pyloric Botox injections can be therapeutic but require close follow-up for efficacy. The complexity of refractory gastroparesis underscores the need for further research and long-term studies to establish clear management guidelines. A DIAGNOSTIC CHALLENGE: HEPATOBILIARY MANIFESTATIONS IN A PATIENT WITH SICKLE CELL BETA-THALASSEMIA Melody Pi Yin Tu1; Hoe Yan Hor2; Arpita Jajoo3. 1Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, AZ; 2Division of Surgical Oncology and Endocrine Surgery, Mayo Clinic Arizona, Scottsdale, AZ; 3Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD. (Control ID #4242911) CASE: A 24-year-old male with sickle cell beta-thalassemia0 (S/β0) presented with 3 days of severe, sharp right upper quadrant (RUQ) pain, jaundice, and dark urine. He had experienced 2 to 3 pain crises monthly but had never had associated RUQ pain. He had no fever, nausea, vomiting, or shortness of breath and denied alcohol use. He had monthly blood transfusions but was unable to afford hydroxyurea. On examination, he was normotensive, tachycardic, and afebrile. Jaundice was observed with RUQ tenderness and a positive Murphy’s sign with no guarding, or hepatomegaly. The laboratory results revealed microcytic anemia, with hematocrit 29.7% and MCV 78.2 fL, and hemolysis, with reticulocyte count 9.6% and haptoglobin <3 mg/dL. Liver enzymes showed cholestasis with elevated total bilirubin 14.8 mg/dL, direct bilirubin 9.4 mg/dL, AST 218 U/L, ALT 367 U/L, ALP 367 U/L, and GGT 484 U/L. Chest X-ray was inconsistent with acute chest syndrome. Ultrasound showed a distended gallbladder with copious sludge and stones. He was admitted inpatient and treated with IV analgesics. MRCP showed gallbladder distention with biliary sludge and no choledocholithiasis. Acute hepatitis screening was negative, and the patient was managed symptomatically with close liver enzyme and coagulation cascade monitoring for fulminant hepatic complications. The patient’s clinical improvement with supportive care, as evidenced by down-trended liver enzymes and bilirubin with normal fibrinogen, supported a diagnosis of a sickle cell hepatic crisis. He was discharged home with close outpatient follow-up and recommended for an elective cholecystectomy. IMPACT/DISCUSSION: The hepatobiliary system is affected in 10 to 40% of patients with SCD. Patients with SCD may present with an acute syndrome characterized by RUQ pain and jaundice where acute sickle hepatic crisis, sickle cell intrahepatic cholestasis (SCIC), hepatic sequestration, acute hepatitis, and choledocholithiasis should be considered. Acute sickle hepatic crises are caused by focal sinusoidal obstruction, whereas SCIC is a rare but life-threatening variant of sickle cell hepatic crises due to disseminated vaso-occlusion in the sinusoids with hepatic ischemia. SCIC has a mortality rate up to 40% and requires urgent exchange transfusion, while sickle hepatic crises can be managed conservatively. Thus, diagnostic differentiation is crucial for timely care. Distinguishing features include development of striking jaundice with renal impairment, a bleeding diathesis, and increasing encephalopathy in SCIC. Hepatic sequestration presents as hepatomegaly and a falling hematocrit and requires exchange transfusion. Acute hepatitis and choledocholithiasis can be distinguished by serologies and MRCP biliary tree visualization, respectively.

This case demonstrates the importance of distinguishing the hepatobiliary manifestations in SCD presenting with RUQ pain and jaundice. Prompt diagnosis and appropriate management are essential to mitigate the risk of mortality. A DIAGNOSTIC DILEMMA: PRIMARY TESTICULAR LYMPHOMA MASQUERADING AS REFRACTORY EPIDIDYMITIS Caroline Horne1; Natalie J. Reed2; Nirja Sutaria1; Lindsey Whitesides3. 1Internal Medicine, Atrium Health, Charlotte, NC; 2Internal Medicine, Carolinas Medical Center, Charlotte, NC; 3Atrium Health Carolinas Medical Center, Charlotte, NC. (Control ID #4271704) CASE: A 79 year old male presented to the hospital for evaluation of acute worsening testicular pain/swelling that had been ongoing for 3 months. When symptoms first began three months prior, he was evaluated by Urology and diagnosed with epididymitis; however, he completed two courses of antibiotics without symptomatic improvement. Testicular and abdominal ultrasound exams in the outpatient setting at that time were largely unremarkable. A few days prior to presenting to the hospital, his primary care provider ordered a CT abdomen/pelvis to evaluate the ongoing pain which showed evidence of widely metastatic cancer of unknown primary involving the genitourinary system, adrenals, lymph nodes, liver, omentum, and expansion within the IVC/gonadal vein. These results prompted his current hospital presentation. A repeat testicular ultrasound in the emergency department showed findings consistent with epididymitis and orchitis. Initial labs were unrevealing, and vital signs were within normal range. Further lab evaluation revealed undetectable human chorionic gonadotropin, low testosterone (24), appropriately elevated luteinizing hormone (15.8), iron deficiency, elevated lactate dehydrogenase (1,112), and normal random serum protein electrophoresis, prostate specific antigen, alpha fetoprotein, follicle-stimulating hormone, folate, uric acid, phosphorous, and haptoglobin. MRI brain was normal. PET/CT showed FDG avidity at the right testis concerning for primary site of malignancy with extensive metastatic disease. CT guided biopsy of retroperitoneal lymphadenopathy revealed diffuse large B-cell lymphoma (DLBCL), non-germinal cell type, EBV negative, and Ki-67 proliferation index of 90%. The malignant hematology service was consulted, a port-a-cath was placed, and patient was initiated patient on R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) and intrathecal (IT) methotrexate (MTX). Lumbar puncture did not reveal evidence of clonal lymphoproliferative process. He was discharged 5 days after receiving initial chemotherapy and with close oncology follow up. IMPACT/DISCUSSION: This case highlights the importance of considering PTL in men > 60 years of age who present with scrotal pain, particularly if symptoms fail to improve on initial therapies, such as antibiotics, in order to avoid a delayed or missed diagnosis and delayed treatment of malignancy.

Primary testicular lymphoma (PTL) is a rare, clinically aggressive form of extra nodal lymphoma usually seen in the 6th decade of life, accounting for less than 5% of testicular malignancies and only 1-2% of non-Hodgkin lymphoma (NHL) cases. Testicular involvement of DLBCL is associated with adverse prognosis and increased risk for central nervous system (CNS) involvement, which alters the typical DLBCL treatment regimen due to the need to include IT MTX in addition to R-CHOP for CNS prophylaxis. A DIALYSIS DILEMMA- ACYCLOVIR NEUROTOXICITY IN A PATIENT WITH VARICELLA ENCEPHALITIS Medha Sharath4; Peter Thorne2; Don Bambino Geno Tai3; Thejaswi Poonacha1. 1Hospital Medicine, M Health Fairview University of Minnesota Medical Center East Bank, Minneapolis, MN; 2Division of Nephrology and Hypertension, University of Minnesota Medical School, Minneapolis, MN; 3Division of Infectious Diseases and International Medicine, University of Minnesota Medical School, Minneapolis, MN; 4Bangalore Medical College and Research Institute, Bengaluru, KA, India. (Control ID #4269061) CASE: A 71 year old female with end stage kidney disease(ESKD) on peritoneal dialysis(PD) was initially diagnosed with shingles at C5 dermatome and prescribed oral valacyclovir at 1 gram twice a day. However, two days later, she presented to our hospital with progressive confusion, hallucinations, and one episode of new-onset myoclonic seizure. She did not have any pre-existing seizure disorders and was not vaccinated against varicella zoster virus(VZV). Head CT and brain MRI were normal. EEG showed no epileptiform activity. Given her impaired renal function and neuropsychiatric manifestations, valacyclovir toxicity was suspected, and she was initiated on hemodialysis to promote clearance. A lumbar puncture was performed, demonstrating a CSF WBC count of 21 cells/microL with lymphocytosis, protein level of 104 and glucose level of 43 mg/dl. CSF PCR for VZV DNA was positive. She was diagnosed with VZV encephalitis and switched to IV acyclovir at 5mg/kg/day. She underwent 2 days of 4.5 hours hemodialysis after which she was transitioned back to PD following improvement in mental status. Despite initial improvement, her mental status deteriorated again to the point of obtundation. Repeat CTA head and neck and EEG were within normal limits. We resumed hemodialysis for six days; in view of sluggish blood flow and suboptimal clearance we simultaneously continued her home PD regimen. With this intensified clearance regimen and dose reduction of acyclovir to 2.5 mg/kg/day, the patient's neurological status returned to baseline. IMPACT/DISCUSSION: Acyclovir toxicity is a recognized cause of neurological complications, often attributed to the metabolite 9-carboxymethoxymethylguanine. For patients with ESKD on PD, the appropriate oral acyclovir dose is 500 mg every 24 hours. Despite accurate dosing of acyclovir, neurotoxicity is still possible and has increased incidence in patients with reduced renal function. Distinguishing between toxicity and encephalitis is also challenging due to overlapping neurological symptoms.The treatment of VZV encephalitis should be tailored as the morbidity and mortality can be high with undertreatment. This has to be weighed against potential adverse drug reactions from acyclovir. We chose to continue acyclovir therapy at a renally appropriate dosage to ensure complete treatment of VZV encephalitis while also pursuing an aggressive dialysis regimen to avoid recurrence of neurotoxic symptoms.

●It is crucial to administer accurate renal doses of acyclovir while treating VZV encephalitis in patients on peritoneal dialysis. ●Providers must be alert to neurotoxic symptoms in patients with impaired renal function, especially if they experience a worsening condition or lack of improvement during treatment. ●For patients on peritoneal dialysis, replacement or supplementation with hemodialysis may help alleviate toxicity symptoms by optimizing renal clearance. A DOUBLE HIT: MANAGING ACUTE PANCREATITIS FROM HYPERTRIGLYCERIDEMIA AND CHRONIC ALCOHOL ABUSE Camila Villacreses1; Chidozie Igbonagwam2; Amanda Rigdon1; Michael Sabina2; Luis Daniel Lugo Rosado2. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4272701) CASE: Chronic alcohol consumption accounts for 17–25% of acute pancreatitis cases globally, typically following over five years of significant alcohol abuse. Management generally involves goal-directed IV fluid therapy with moderately aggressive fluids during the first 24–48 hours. Hypertriglyceridemia-induced acute pancreatitis (HTG-AP), triggered by triglyceride levels >1,000–2,000 mg/dL, is managed with triglyceride-lowering therapies, but current guidelines lack clarity on first-line treatments. We report the case of a 31-year-old male with a history of alcohol abuse presenting with severe mid-epigastric pain and vomiting. He consumed one-fifth of tequila daily. Initial evaluation showed hypertension, leukocytosis, hyponatremia, elevated lipase (899 U/L), and acute kidney injury (AKI; creatinine >4 mg/dL). CT imaging revealed pancreatic edema and peripancreatic fluid. Initial treatment targeted alcohol-induced pancreatitis with CIWA protocol, NPO status, and aggressive fluid resuscitation, but his condition deteriorated, prompting measurement of triglycerides, which exceeded 1,000 mg/dL. HTG-AP management options included insulin or plasmapheresis. Given the patient’s age and lack of comorbidities as well as his clinical condition, insulin therapy was initiated. Triglycerides dropped by over 50% within 48 hours, resulting in symptom improvement and stabilization of AKI.Alcohol-induced pancreatitis requires CIWA protocol to prevent withdrawal complications and aggressive fluid resuscitation to stabilize vitals, kidney function, and BUN. HTG-AP also necessitates fluid resuscitation but focuses on reducing triglycerides to <500 mg/dL. While plasmapheresis offers rapid triglyceride reduction, its limitations include cost and resource demands. Insulin, by enhancing lipoprotein lipase (LPL) activity, is a cost-effective alternative. In this case, insulin alone reduced triglycerides effectively and resolved AKI, demonstrating the importance of individualized therapy. IMPACT/DISCUSSION: Alcohol-induced pancreatitis requires CIWA protocol to prevent withdrawal complications and aggressive fluid resuscitation to stabilize vitals, kidney function, and BUN. HTG-AP also necessitates fluid resuscitation but focuses on reducing triglycerides to <500 mg/dL. While plasmapheresis offers rapid triglyceride reduction, its limitations include cost and resource demands. Insulin, by enhancing lipoprotein lipase (LPL) activity, is a cost-effective alternative. In this case, insulin alone reduced triglycerides effectively and resolved AKI, demonstrating the importance of individualized therapy.

In HTG-AP without established first-line guidelines, minimally invasive treatments should be prioritized. Insulin therapy demonstrated efficacy in this patient, conveying the need for tailored, evidence-based management strategies. ADRENAL AILMENT AMIDST THE FUNGAL FURY: PRIMARY ADRENAL INSUFFICIENCY IN DISSEMINATED HISTOPLASMOSIS Fahiye Ali, William Muniz, Serena Thomas, Mirra Srinivasan, Chitharanjan Duvoor. Internal Medicine, St Bernards Healthcare, Jonesboro, AR. (Control ID #4271947) CASE: A 58-year-old male with a history of hypertension, psoriasis, biliary mass, and occupational exposure to cattle and poultry presented with recurrent episodic right upper quadrant abdominal pain, chills, and fatigue for several months. Lab results revealed a BUN of 42 mg/dL, creatinine (Cr) of 2.4 mg/dL, sodium of 119 mEq/L, and potassium of 5.4 mEq/L. During his hospital course, renal function continued to deteriorate, and hyponatremia and hyperkalemia worsened. A CT abdomen/pelvis revealed bilaterally enlarged adrenal glands. Given the patient's enlarged adrenals and history of chronic immunosuppression with adalimumab, adrenal insufficiency due to an underlying disseminated infectious process was suspected. A Cosyntropin stimulation test was conducted with a poor response of cortisol at 6. DHEA and 21 hydroxylase antibodies were negative. ACTH was elevated at 79. Thyroid function revealed hypothyroidism and was started on levothyroxine 50mcg as well as hydrocortisone 50mg and fludrocortisone. Adrenal biopsy revealed numerous histoplasma species. Patient was started on amphotericin B. Serum sodium and potassium began to normalize and hydrocortisone and fludrocortisone were tapered. Amphotericin B was transitioned to itraconazole and the patient was discharged with hydrocortisone 15mg qam and 10mg qpm as well as fludrocortisone 0.1mcg qam, with close follow up with endocrinology. IMPACT/DISCUSSION: Histoplasmosis is a fungal infection caused by Histoplasma capsulatum, commonly found in soil enriched with bat or bird droppings. It primarily affects the lungs but can disseminate to other organs, including the liver, spleen, bone marrow, and adrenal glands. The adrenal glands are a rare but important target of disseminated histoplasmosis, leading to adrenal insufficiency. Primary adrenal insufficiency occurs when the adrenal glands fail to produce sufficient cortisol and other steroid hormones, resulting in a life-threatening condition. While histoplasmosis presents typically as a pulmonary infection, it can disseminate hematogenously, leading to multiorgan involvement, including the adrenal glands. Involvement of the adrenals is relatively uncommon, but it can lead to primary adrenal insufficiency if the adrenal cortex is damaged. The pathophysiology involves fungal infiltration of the adrenals, which leads to gland destruction and impaired hormone production. The mechanism behind this enlargement is likely due to inflammation and granuloma formation within the adrenals, leading to functional impairment.This case highlights the role of histoplasmosis in causing primary adrenal insufficiency and the clinical findings of bilateral adrenal enlargement.

Early diagnosis and treatment of both fungal infection and adrenal insufficiency are critical in improving patient outcome. Clinicians should consider disseminated histoplasmosis as a potential cause of adrenal insufficiencies in patients with risk factors such as immunosuppression for fungal infections or in endemic areas. ADRENAL INSUFFICIENCY: A CASE REPRESENTING THE IMPORTANCE OF AI AS AN UNDERRECOGNIZED RISK FACTOR FOR DEVELOPMENT OF EUGLYCEMIC DKA Eva Schaible, William Ward. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4233420) CASE: The patient was a 45 y/o male with Multiple Endocrine Neoplasia Type 1 (MEN1), diagnosed at age 35 with prolactinoma and hyperparathyroidism, managed with Cabergoline and parathyroidectomy, respectively. Medical history also included Type 2 Diabetes, hypertension, hyperlipidemia, and obesity. Three years following MEN1 diagnosis, he developed an anterior mediastinal mass. It was surgically resected with positive margins, pathology revealing atypical carcinoid tumor. He patient underwent adjuvant chemoradiation. Years later, during the workup following a STEMI, he was diagnosed with Cushing’s Syndrome (CS) from ectopic ACTH production. Associated symptoms of edema, central obesity, dorsocervical fat pad, hair thinning, hypokalemia, insomnia, osteoporosis, and worsening of glycemic control. PET scan showed symmetric, physiologic uptake in the bilateral adrenal glands. There was also uptake in the supraclavicular lymph nodes suspicious for metastases. Supraclavicular lymph node biopsy confirmed metastatic neuroendocrine tumor. Given his severe CS, bilateral adrenalectomy was performed. Five weeks later the patient presented with fatigue, nausea, vomiting, and hypotension. He had been struggling with glucocorticoid withdrawal syndrome (GWS), but symptoms continued to worsen, and labs on admission confirmed euglycemic diabetic ketoacidosis (EDKA). This occurred in the setting of his adrenal insufficiency, and was likely exacerbated as well by his use of SGLT2 inhibitor. His condition improved significantly with stress-dose steroids and insulin therapy for EDKA. IMPACT/DISCUSSION: This patient has an atypical complication of MEN1, leading to severe CS. Severe CS can be life threatening due altered metabolism, causing hypertension, diabetes, and increased risk of cardiovascular disease (1). Other sequelae include osteoporosis, infection, and hypercoagulability (1). The necessary adrenalectomy led to adrenal insufficiency (AI), which carries its own risks. Adrenal crisis, characterized by hypotension, hyponatremia, hyperkalemia, hypoglycemia, and eosinophilia, is a life-threatening consequence of AI (2). AI also increases mortality from heart disease, infections, and malignancies (3). An important risk to recognize in AI is euglycemic DKA. Endogenous glucocorticoids inhibit ketogenesis and gluconeogenesis. During physiologic stress, blood glucose decreases and lipolysis is induced without glucocorticoids. Ketogenesis then occurs without the significant hyperglycemia typical of DKA (4). As such, providers need to have a high index of suspicion for EDKA in patients with AI, and should be cautious using SGLT-2 inhibitors in AI.

This represents a very rare case of post-surgical AI that was needed for the treatment of Cushing's Syndrome from an ACTH-producing tumor secondary to MEN1 syndrome. AI increases risk of mortality from multiple causes, with euglycemic DKA being an underrecognized,severe downstream complication. A DRESS IN THE TIME OF COVID Carson Oprysko1; Mridula Sree Naagendran2; Madura Saravanan3. 1Department of Medicine, University of Connecticut, Storrs, CT; 2Internal Medicine, UConn Health, Farmington, CT; 3Medicine, UConn Health, Farmington, CT. (Control ID #4273706) CASE: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug reaction that occurs in 1 in 10,000 drug exposures. Occurring 2 to 6 weeks after a drug exposure, it is characterized by fever, morbilliform rash, eosinophilia and organ dysfunction. Though the pathogenesis of DRESS syndrome is not completely understood, viral infections have been identified as a potential trigger. Although cases of influenza triggering DRESS syndrome have been described, COVID-19 infection has not yet been reported in literature. We present a patient who developed DRESS syndrome following COVID-19 infection. An 82 year old male with a past medical history of chronic kidney disease, chronic lymphocytic lymphoma and cerebellar ataxia presented to the emergency room with 3 days of fever, cough, and sore throat. On the day of presentation, he developed a diffuse morbilliform rash affecting the entirety of his body. He denied exposure to new environmental triggers. Two months prior to this admission he was started on a new medication, amantadine for cerebellar ataxia. On presentation, his blood pressure was 91/61 and he had a low grade fever. Physical examination showed a blanching morbilliform rash, involving his trunk, extremities, and face. Laboratory workup revealed a leukocytosis, and elevated absolute eosinophil count of 1.2/uL. Complete metabolic profile was significant for an elevated creatinine of 4.3mg/dL, an AST of 268/uL, ALT of 184/uL and alkaline phosphatase of 387/uL. COVID-19 PCR was positive. His clinical presentation was highly suggestive of DRESS syndrome as he also scored a 3 on the RegiSCAR scoring system. Amantadine was immediately discontinued. He was started on high dose steroids with gradual improvement in his rash, and organ dysfunction. He was discharged on prednisone with dermatology follow-up. In the outpatient setting, prednisone was tapered off. However, the patient developed recurrence of his morbilliform rash. A skin biopsy was done which revealed spongiosis, parakeratosis, and mixed inflammatory infiltrate consistent with a diagnosis of DRESS syndrome. IMPACT/DISCUSSION: Though the pathogenesis of DRESS syndrome is not completely understood, there are a number of factors, including drug, genetic, and viral dispositions, that are thought to play a role. Antigenic cross-reactivity and viral T-cell expansion lead to the widespread immune reaction that impacts multiple organ systems. In cases where viral triggers are a factor in the disease process, progression beyond drug cessation is often observed, a phenomenon that cannot be solely explained by drug-antigen driven expansion of T cells alone. This was observed in our case and implicates COVID-19 infection as a trigger in this patient's case.

DRESS syndrome is a life-threatening reaction to drug exposures leading to severe organ dysfunction. In some cases, viral antigenic cross-reactivity to a particular drug can trigger a widespread immune reaction and lead to DRESS syndrome A GAME OF VQ SCAN ROULETTE: THE RELIABILITY OF DIAGNOSING PULMONARY EMBOLISM Ashni D. Dudhia3; Anjum Dhamani1; Anthony J. Neira Lazaro2; Soumya Yemme3; Elizabeth Chandy3. 1Internal Medicine, Texas Health Resources, Arlington, TX; 2Internal Medicine - GME, Texas Health Resources, Arlington, TX; 3Internal Medicine, Texas Health Harris Methodist Hospital Hurst-Euless-Bedford, Bedford, TX. (Control ID #4271624) CASE: A 58-year-old Hawaiian gentleman presented with shortness of breath and chest discomfort. He described his discomfort as "cannot breathe deep enough". His PMH includes HTN, type II DM, CKD stage V and chronic hepatitis B. He has a 72 pack year smoking history and drinks alcohol occasionally. He is physically active and does not have any family or personal history of clots. He denied any recent travel history or hospitalizations. In the ED, a d-dimer level was obtained as PE was suspected. Lower extremity venous doppler was negative for DVT. CT angiogram was avoided given his CKD, VQ scan was performed instead which revealed several large, mismatched segmental defects in the left lower lobe, suggestive of pulmonary emboli. Heparin drip was started, and he was transitioned to Eliquis the next day. The patient did not have any risk factors so we were not sure why he would have a PE. A CTA would help to diagnose the PE definitively but with the risk of putting him in dialysis due to his CKD, we were hesitant. After an extensive discussion with patient by both nephrology and primary team, we decided to proceed with CTA. The risk of putting him into dialysis due to contrast nephropathy vs negative CTA which would eliminate the need for lifelong anticoagulation was explained in detail to both patient and his wife. With the patient approval CTA was done and negative for PE. Eliquis was discontinued and patient was discharged. IMPACT/DISCUSSION: This case depicts a clinical dilemma that we faced. In patients with CKD, d-dimer must be corrected based on eGFR. This eliminates unnecessary imaging, contrast exposure, and anticoagulation therapy. VQ scans are a valuable diagnostic tool in the diagnosis of a PE but should not be relied upon due to high false positive rates. It can pick up findings such as fluid-filled lung fissures as a perfusion defect as in our case. Studies show that a VQ scan is most accurately interpreted when compared with a CXR. Criteria to confirm a positive VQ scan include two or more defects seen, both being in the same location, and the defects being pleural based and wedge shaped. If positive, a CTA should follow. The combination of both tests greatly elevates accuracy of diagnosing PE in a patient with intermediate to high pretest probability. In a patient with low pretest probability, a PE, like in our patient, could have been ruled out with a renal function adjusted d-dimer.

Pulmonary embolism is a fatal condition that requires a high index of suspicion. A thorough evaluation is critical as this diagnosis carries a high morbidity and mortality. It is especially important in patients with comorbidities like CKD as it causes hesitation about performing a CT angiogram. This case highlighted an instance of how a VQ scan misdiagnosed a pulmonary embolism. A corrected d-dimer value and following the PIOPED algorithm would help direct accurate diagnosis and management of pulmonary embolism. A HIDDEN DIAGNOSIS– UNRAVELING THE MYSTERY OF BLADDER MASS AND FISTULA Jonathan D. Grube1,2; Kathleen Mattingly1,2; Heena Patel1,2; Tiffany Sculthorpe3; Franklin Hernandez1,2. 1Internal Medicine, University of Central Florida, Orlando, FL; 2HCA Healthcare Inc, Nashville, TN; 3VirtuaSOM Medical student, Rowan University, Glassboro, NJ. (Control ID #4270349) CASE: A 70-year-old male with a history of hypertension, hyperlipidemia, cerebrovascular accident, benign prostatic hyperplasia, anemia, atrial fibrillation, coronary artery disease presented with gross hematuria and abdominal pain. He had recently been discharged after treatment for a subdural hematoma and had a long-term Foley catheter placed due to subdural hematoma, removed the day before this admission. The patient was also being treated for a Pseudomonas-urinary tract infection from a prior visit. On presentation of this admission, he denied chest pain, shortness of breath, fever, or chills but reported abdominal pain and dysuria. Urology was consulted, and continuous bladder irrigation initiated. Initial CBC revealed anemia, Hgb 6.0, due to acute blood loss, and the patient was transfused with 4 units of packed red blood cells. Urinalysis showed a UTI with positive nitrates, leukocytes, and blood. Head CT confirmed a previous craniotomy with residual fluid in the subdural space. A bladder ultrasound suggested a diverticulum, and CT imaging revealed a fistula and two large masses, one near the bladder and another at the left iliac wing. The patient developed significant hematuria, requiring two additional blood transfusions. Initially, it was believed that these masses were sarcomas in nature. A biopsy confirmed multiple myeloma, supported by electrophoresis. Given the complexity, the patient was transferred to a tertiary care facility for further management following a multidisciplinary conference. IMPACT/DISCUSSION: Although multiple myeloma is a malignancy that involved the bone marrow and can be suspected in patient based on preliminary blood work. This disorder can also initially be diagnosed when it involves other organs, as term coined extramedullary disease. Bladder involvement is particularly rare, with only a handful of cases reported. According to the most updated diagnostic criteria for multiple myeloma, in addition to the classic CRAB criteria, diagnosis now requires evidence of clonal plasma cell proliferation either in the bone marrow or as a solitary plasmacytoma. However, diagnosing solitary plasmacytoma necessitates the absence of clonal plasma cells in the bone marrow, normal imaging studies, and no signs of end-organ damage. This patient presented with atypical features, including anemia due to acute blood loss, the absence of hypercalcemia and back pain, but with evidence of metastatic bone lesions. Further investigation through biopsy confirmed the diagnosis of atypical systemic multiple myeloma.

While atypical presentations of multiple myeloma are known, hematuria associated with a bladder mass and fistula is an uncommon manifestation. A comprehensive evaluation is crucial for diagnosing such unusual presentations, as these rare symptoms can easily be mistaken for other conditions. Considering a broad differential diagnosis ensures accurate identification of the underlying cause and facilitates appropriate treatment. A HIDDEN FUNGAL TRIGGER: A CASE OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Jamie Therese Abad, Kashmira Wani, Luis Gonzalez Mosquera, Jawad Sheqwara. Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4273136) CASE: A 76-year-old male with a Crohn’s disease on infliximab presented with fatigue and high-grade fevers. He denied sick contacts or recent travel. On presentation, he was febrile (102.5°F) but otherwise stable. Laboratory workup revealed anemia (hemoglobin 9.8 g/dL), thrombocytopenia (platelets 84 K/uL), acute kidney injury (Cr 1.89 mg/dL), elevated transaminases (AST 92 IU/L, ALT 113 IU/L, ALP 302 IU/L), hyperbilirubinemia (total 3.3 mg/dL), elevated C-reactive protein (8.5 mg/dL), negative HIV and blood cultures. Imaging showed bowel wall thickening consistent with Crohn’s and no biliary obstruction. Empiric antibiotics were started for presumed biliary infection. Persistent fevers led to endoscopic retrograde cholangiopancreatography, revealing choledocholithiasis, treated with sphincterotomy and stenting. Despite interventions, fevers persisted with rising bilirubin. A positive 1,3-beta-D-glucan assay prompted broader antibiotics. Peripheral smear showed immature precursors with poikilocytosis. Other notable findings included two-lineage cytopenias, hypertriglyceridemia (905mg/dL), hyperferritinemia (14,492 ng/mL), and low fibrinogen (157 mg/dL). Hematology raised concern for hemophagocytic lymphohistocytosis (HLH). Bone marrow biopsy revealed normocellular marrow with frequently seen hemophagocytosis. An H score of 235 and high Interleukin-2 receptor (CD25) (26,252.9 pg/mL) further supported the diagnosis. Steroids per HLH-94 protocol were initiated; etoposide was deferred due to liver and kidney dysfunction. Despite this, liver function worsened with mental status changes. Urine antigens for histoplasmosis were positive, with disseminated disease suspected as the HLH trigger. Amphotericin B was initiated but stopped due to renal dysfunction. His condition deteriorated, leading to eventual death. IMPACT/DISCUSSION: HLH is a rare, life-threatening syndrome characterized by immune hyperactivity leading to multi-organ failure. Secondary HLH is often triggered by infections, malignancy, or autoimmunity. Diagnosis requires high suspicion due to overlap with other conditions. Hallmark features include fever, cytopenias, hepatosplenomegaly, hyperferritinemia, and coagulopathy. This case illustrates HLH triggered by disseminated histoplasmosis in an immunocompromised host. Therapy led to partial improvement, but antifungal therapy complicated treatment, underscoring the balance needed in managing HLH and its triggers. This case adds to the literature by emphasizing the importance of recognizing histoplasmosis as a potential cause of HLH, even in non-endemic settings, and highlights the need for a high index of suspicion in patients with immune dysregulation.

- Persistent fever, cytopenias, hyperferritinemia, and organ dysfunction should raise suspicion for HLH. - Treatment for HLH secondary to opportunistic infections includes empiric antibiotics directed against the suspected organism and HLH specific chemotherapy. A HIGH-PRESSURE CASE OF IDIOPATHIC INTRACRANIAL HYPERTENSION AND DURAL VENOUS SINUS THROMBOSIS Samia Nadeem2; Hamza Khalid3; Yamna Jadoon1; Prarthna V. Bhardwaj2. 1University of California San Francisco, San Francisco, CA; 2Baystate Medical Center, Springfield, MA; 3Shifa College of Medicine, Islamabad, Islamabad Capital Territory, Pakistan. (Control ID #4273298) CASE: A 39-year-old female with a history of obesity and hidradenitis suppurativa for which she had recently completed a course of Minocycline, presented to the emergency department with a 3-day history of headaches and papilledema. The initial CT scan showed no acute intracranial abnormality and labs were unremarkable. A lumbar puncture showed increased opening pressures of 37 cmH2O. Empiric Acetazolamide was initiated due to concerns for idiopathic intracranial (IIH) but was discontinued after MRI showed extensive dural venous sinus thrombosis (DVST) affecting the right transverse and sigmoid sinus. It was thought that the DSVT was causing the increased ICP, and the patient was discharged with therapeutic Enoxaparin alone. In the following weeks, she continued to experience pulsating headaches and blurred vision. It appeared unlikely that the DSVT itself was the sole cause of increased intracranial pressure (ICP), as there was no tissue effect or edema on imaging and symptoms did not improve with decreased clot burden. Hypercoagulability workup was unrevealing. She was started back on Acetazolamide due to persistent symptoms of raised ICP requiring serial therapeutic lumbar punctures. Enoxaparin was discontinued after one month. Over the next few months, while undergoing evaluation for optic nerve sheath fenestration, magnetic resonance venography (MRV) revealed a new thrombus in the superior sagittal sinus. She was re-started on anticoagulation, along with Acetazolamide and Topiramate. Her symptoms resolved with this combination of anticoagulation and carbonic anhydrase inhibitors. IMPACT/DISCUSSION: Our patient presented with new onset papilledema and headaches, presumed to have IIH based on elevated CSF pressure and the presence of associated risk factors including female sex, obesity, and recent tetracycline use. Upon further workup, she was found to have DVST, thus refuting the diagnosis of IIH as it was no longer ‘idiopathic’ and was treated with systemic anticoagulation. Despite this, she continued to have florid papilledema and elevated ICP not explained solely by the DVST. Her symptoms were eventually controlled through a combination of anticoagulation, along with interventions used to target IIH including serial lumbar punctures and carbonic anhydrase inhibitors, indicating the presence of underlying IIH that was either exacerbated by the DVST or was a cause of it. It is plausible that IIH could alter flow patterns within the major venous sinuses, potentially causing increased stasis and, in turn, predisposing the formation of more blood clots.

This case highlights the challenges in diagnosing and managing raised ICP when both IIH and secondary causes, such as DSVT, are present. The successful management of symptoms with a combination of anticoagulation and carbonic anhydrase inhibitors underscores the importance of addressing both conditions concurrently and the need for further research to better understand the interplay between IIH and DVST pathophysiology. A HYPERINFLAMMATORY MYSTERY: UNRAVELING THE CAUSE OF FEVER, PANCYTOPENIA, AND SPLENOMEGALY IN ADVANCED HIV Timothy J. Libecap1; Rebecca Fine2; Cynthia R. Young3; Hirotaka Kato2. 1M.D./Ph.D. Program, University of Kentucky College of Medicine, Lexington, KY; 2Internal Medicine, University of Kentucky College of Medicine, Lexington, KY; 3Division of Infectious Diseases, University of Kentucky College of Medicine, Lexington, KY. (Control ID #4259770) CASE: A 48-year-old man with no past medical history was referred for elevated transaminases and 6 months of fatigue, intermittent fever, cough, and vomiting. On admission, he was tachycardic and his physical exam was notable for left upper quadrant abdominal tenderness. Initial labs demonstrated pancytopenia with WBC of 1,430 /μL, hemoglobin of 10 g/dL, and platelet count of 44,000 /μL as well as triglycerides of 2.63 mmol/L, AST of 111 U/L and ALT of 69 U/L with negative acute hepatitis panel. HIV-antibody testing was positive and CD4 was 7. CT demonstrated hepatic steatosis and splenomegaly. The patient was initiated on bictegravir/emtricitabine/tenofovir and pneumocystis prophylaxis with trimethoprim/sulfamethoxazole. On hospital day 5, opportunistic infectious workup revealed positive histoplasma antigen in blood and urine, for which he was initiated on liposomal amphotericin B. Ophthalmologic exam found bilateral ocular involvement. Further testing showed concerning signs for hemophagocytic lymphohistiocytosis (HLH) including elevated ferritin of 28,571 ng/mL and elevated s-IL2 of 5658 U/mL in the setting of recurrent fevers, cytopenia, and splenomegaly. A bone marrow biopsy demonstrated hypocellular marrow with budding yeast. The decision was made to continue treating the underlying causes, disseminated histoplasmosis and advanced HIV. After two weeks of amphotericin B, the patient had a CD4 of 221 on discharge and was prescribed itraconazole for one year. IMPACT/DISCUSSION: HLH is a rare but life-threatening hyperinflammatory state that can be triggered by infections. HLH has a severe prognosis and is easily obscured by primary infection thus requiring a high index of suspicion. For patients with advanced HIV, disseminated histoplasmosis is reportedly the most common cause of HLH. Our patient could be diagnosed with HLH by meeting the first five out of eight HLH-2004 diagnostic criteria, exhibiting the most common disease characteristics: fevers; splenomegaly; pancytopenia; ferritin ≥500 μg/L; sCD25R (s-IL2) ≥2400 U/mL; triglycerides ≥3 mmol/L; hemophagocytosis on biopsy; and low NK-cell activity. A bone marrow biopsy should be considered to evaluate treatment-altering causes of pancytopenia, such as hematologic malignancies or other opportunistic infections. Given the poor prognosis of disseminated histoplasmosis and HLH in patients with advanced HIV, it is important to consider the possibility of coexisting disease states when either one is present.

Disseminated histoplasmosis with HLH is a rare complication of advanced HIV that requires a high index of suspicion. While treatment for HLH often requires treating the underlying problem, bone marrow biopsy can help rule out additional causes of pancytopenia, affecting treatment course. ALL MIXED UP: HEPATITIS C STRIKES AGAIN. Ari R. Levine, Alexandra Arges. School of Medicine, Emory University, Atlanta, GA. (Control ID #4241625) CASE: A 43-year-old man presented with 2 weeks of fever, myalgias, bloody stools, and abdominal pain. Labs revealed elevated AST/ALT, ESR/CRP, WBC, and positive hepatitis C (HCV) antibodies. Acute infectious causes were ruled out, and elevated inflammatory markers suggested inflammatory diarrhea or autoimmune conditions. EGD and colonoscopy were negative. Further testing showed positive ANA, RNP, RF, and HCV RNA, suggesting an HCV-associated autoimmune process. Hematuria and neuropathic pain raised suspicion for mixed cryoglobulinemia secondary to HCV, supported by low C3/C4 and mesenteric edema on CT. Treatment was started with prednisone and gabapentin. Cryoglobulins came back positive on day 7, confirming mixed cryoglobulinemia secondary to HCV. Extensive effort was made to help this patient access HCV clinic treatment. IMPACT/DISCUSSION: Mixed cryoglobulinemia is an extrahepatic complication of HCV resulting in proteins that precipitate from a patient's serum or plasma at temperatures lower than 37°C. Reported prevalence in patients with HCV is between 40-65%. The most common presenting symptom is a purpuric rash. GI involvement, arthralgias, peripheral neuropathy, and glomerulonephritis can also be present. We present a case of HCV associated mixed cryoglobulinemia that manifested as fever of unknown origin with predominant GI symptoms and lacking a petechial rash. This case serves as a reminder to consider extrahepatic manifestations of HCV even in the absence of characteristic symptoms. Hepatitis C affects >70 million people globally. About 80% of acute hepatitis C cases are asymptomatic, while the rest show fever, fatigue, and GI symptoms. Up to two-thirds of cases have extra-hepatic manifestations, including cryoglobulinemia. Mixed cryoglobulinemia (types II and III) presents with polyclonal IgG and IgM with elevated rheumatoid factor (RF), and often with low C4 and normal C3. Meltzer’s triad of purpura, fatigue, and arthralgias appears in 80% of cases, with purpura being the most common symptom. Peripheral neuropathy is also seen. Renal involvement in mixed cryoglobulinemia shows a membranoproliferative glomerulonephritis detected through renal failure or nephritic syndrome. Management varies with severity, from antivirals in mild cases to IV steroids and plasma exchange for severe cases. Access remains a challenge for HCV treatment, with treatments lasting 8-12 weeks.

Hepatitis C is not typically associated with acute febrile illness, but mixed cryoglobulinemia should be considered if neuropathic pain, high inflammatory markers, positive RF, and cryoglobulins are present. ALLOPURINOL-INDUCED VASCULITIS: A RARE CULPRIT IN THE DIFFERENTIAL DIAGNOSIS OF SKIN LESIONS Aram Aslanian, Samra Iqbal, Ali Yusuf, Mohamed Sleem, Sayma Yaqub, Tarek Naguib. Internal Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, TX. (Control ID #4269128) CASE: A 71-year-old male, with history of atrial fibrillation, mechanical mitral valve replacement, chronic kidney disease (CKD) stage IIIb, and gout was admitted for progressively worsening leg swelling, pain, and the development of non-blanching pruritic rash over the course of a week. He reported being on allopurinol for gout management for the past three months, with recent use of pegloticase for refractory gout. His dose of allopurinol was increased 4 weeks prior to hospitalization. Wound cultures grew MRSA, and the patient was started on IV vancomycin. A punch biopsy of the rash revealed findings suggestive of vasculitis, with unremarkable complement, ANCA, and ANA levels, and immunofluorescence studies. Eosinophil count was elevated at 0.5 x10e3/mcL. Blood cultures were negative, and inflammatory markers were elevated but trended downward. Renal function improved with supportive care, fluid resuscitation, and discontinuation of allopurinol, with creatinine trending from 2.3 mg/dL on admission to baseline 1.4 mg/dL. The diagnosis of allopurinol-induced vasculitis and resultant acute kidney injury (AKI) were made clinically, based on the temporal relationship between drug use, onset of rash and renal impairment, and eosinophilia, with resolution upon discontinuation of the medication. IMPACT/DISCUSSION: Allopurinol, used for the management of gout and hyperuricemia, has been associated with skin eruptions, hypersensitivity reactions, and, less commonly, vasculitis. Vasculitis with resultant AKI is an uncommon but potentially serious adverse reaction that can complicate management of gout and hyperuricemia. The pathogenesis remains unclear, thought to be related to hypersensitivity reactions or immune-mediated mechanisms. The rash can present as erythematous macule, purpura, or petechiae, and may be accompanied by eosinophilia. In this case, the patient’s rash was initially thought to be related to his underlying cellulitis, but the progression of the skin lesions and their resolution after the discontinuation of allopurinol pointed to a drug-induced etiology. Skin biopsy with features of vasculitis, coupled with negative autoimmune markers further supported the diagnosis. The timing of the rash onset after the increase in allopurinol dosage, with improvement upon discontinuation of the medication, were key factors in diagnosing allopurinol-induced vasculitis.

This case underscores the importance of considering drug-induced vasculitis as a potential cause of new-onset dermatologic findings. Allopurinol, widely used for the treatment of gout, can lead to rare and potentially severe vasculitis presenting with skin and renal abnormalities. Prompt recognition and cessation of the offending drug are essential in preventing further complications. Clinicians should maintain a high index of suspicion for drug-induced vasculitis, particularly in patients with recent changes in medication regimens, to ensure timely diagnosis and appropriate management. ALL THAT COUGHS IS NOT ASTHMA: GASTRIC MALIGNANCY WITH PERICARDIAL EFFUSION PRESENTING AS CHRONIC COUGH Hannah Hoff, Lubna Khawaja, Stephanie Sherman. Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4272371) CASE: A previously healthy 52-year-old woman presented with nonproductive cough for 3 months. This was her fourth presentation for chronic cough. Trials of three oral antibiotics, an inhaled corticosteroid, an antihistamine, a cough suppressant, and a bronchodilator had been ineffective. Cough was worsened by lying flat and eating solid foods. She reported post-tussive dyspnea, chest pain, and emesis. There were no constitutional symptoms, hemoptysis, dysphagia, hoarseness, nausea, abdominal pain, orthopnea, or extremity swelling. She had no smoking history or recent travel. Her vital signs were normal, and she had normal cardiopulmonary and abdominal exams. She had jugular venous distention to 10 cm H2O and tender left neck lymphadenopathy. Labs were notable for iron deficiency anemia. Chest x-ray demonstrated new globular cardiomegaly, and electrocardiogram demonstrated normal sinus rhythm with subtle electrical alternans. Computed tomography revealed a pericardial effusion and diffuse lymphadenopathy. Echocardiography confirmed a moderate-sized, circumferential pericardial effusion and early signs of cardiac tamponade, requiring pericardiocentesis which moderately improved her cough. Cytology showed malignant cells, and endoscopy revealed a 3 cm signet ring cell gastric carcinoma. IMPACT/DISCUSSION: Chronic cough (>8 weeks) is frequently encountered in Internal Medicine, and common etiologies include asthma, gastroesophageal reflux disease, and upper airway cough syndrome1. After unsuccessfully trialing bronchodilators, antihistamines, decongestants, and inhaled corticosteroids, it is appropriate to pursue computed tomography, bronchoscopy, endoscopy, and/or echocardiography to evaluate rarer etiologies such as malignancy, interstitial lung disease, and cardiac causes1. Our patient’s cough was likely multifactorial, in part due to gastroesophageal reflux from the gastric cancer2. However, her cough improved after pericardiocentesis, suggesting that the cough may have been due to the pericardial effusion. Pericardial effusions commonly cause cough in children; prevalence may be as high as 60-70% in those with moderate effusions3,4. Cough is a rarer symptom in adults, though case reports do exist, and etiologies are both malignant and nonmalignant5-8. Cough is thought to result from the effusion compressing the nearby trachea and bronchi, increasing intrathoracic pressure, causing airway irritation and stimulation of tracheobronchial cough reflex receptors9. Theoretically, activity that exacerbates tracheobronchial compression (such as lying flat) could worsen cough and drainage of the effusion could improve cough, which may explain our patient’s unusual presentation.

This case highlighted a rare, but important, presentation of chronic cough that did not respond to classic treatments. Any such case should prompt further diagnostic testing to evaluate rarer malignant and cardiopulmonary etiologies of cough9. ALWAYS CHECK THE PTT, A CASE OF ACQUIRED HEMOPHILIA A Clifton F. Parrott1; Zachary Boggs2. 1Internal Medicine, University of Virginia, Charlottesville, VA; 2Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4272387) CASE: An 88-year-old woman with a history of hypertension and atrial fibrillation (not on anticoagulation) presented with persistent oral bleeding after tooth extraction one week prior. This was her third episode of bleeding since extraction. She had no personal history of abnormal bleeding or family history of bleeding disorders. Two months earlier, she had been admitted to a different hospital with a spontaneous retroperitoneal bleed and her blood thinner was discontinued as the suspected culprit. Neither a partial thromboplastin time (PTT) nor a prothrombin time (PT) was checked. On exam, she had acute bleeding from her extraction site and multiple bruises. Labs revealed a prolonged PTT of 130.7 seconds with a normal PT and platelet count. A mixing study showed no correction of PTT. Factor VIII activity was 1024 Bethesda units (BU)) confirming a diagnosis of Acquired Hemophilia A (AHA). Hematology was consulted and initiated recombinant factor VIII, however, did not stop her bleeding given her high titer. Bleeding was eventually controlled with recombinant activated factor VII and anti-inhibitor coagulant complex (factor VIII inhibitor bypassing activity (FEIBA). Imaging and autoimmune testing were negative for underlying etiology. Immunosuppression was initiated with prednisone and rituximab. Although her PTT and titers remained high, no further bleeding occurred. She was discharged with Hematology follow up with a plan to begin Emicuzumab outpatient, to be continued indefinitely due to her high titer. IMPACT/DISCUSSION: Acquired factor inhibitors are autoantibodies that inhibit clotting factor activity. AHA is the most common, inhibiting factor VIII, which affects 1-2 people per million annually. About 50% of cases are idiopathic, with the remainder linked to malignancy, autoimmune disease, or medications. Most patients present with bleeding events and a prolonged PTT. Diagnosis requires confirming a factor inhibitor via activity assays and mixing stidies. Only 12% of patients have titers >100 BU. Management includes hemostasis and inhibitor elimination. Bypassing agents, such as recombinant activated factor VII or FEIBA are preferred over factor VIII concentrate if inhibitor titer is >5BU to control bleeding. Inhibitor elimination requires immunosuppression, typically with glucocorticoids and either cyclophosphamide or rituxumab for high titers, or glucocorticoids alone for low titers (<5).

This case illustrates the importance of obtaining coagulation studies on patients with unexplained severe or persistent bleeding events. AHA is rare but should be considered when patients present with acute bleeding and an isolated, elevated PTT, even if on anticoagulation. A MISSED DIAGNOSIS OF M. TUBERCULOSIS-CAUSE AND EFFECTS Calie Brownlee1; Zuhair Ballas2. 1Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; 2Internal Medicine-Immunology, University of Iowa Health Care, Iowa City, IA. (Control ID #4268559) CASE: A 33-year-old male with no known past medical history, who immigrated from Haiti 6 months ago, presented with 3 days of sore throat, nausea, and fever. He had rapid respiratory decompensation requiring intubation. Initial evaluation revealed a fever of 38.8°C and diffuse skin rash. A pharyngeal swab was positive for Streptococcus species and a nasal swab was positive for Rhinovirus. Skin scrapings revealed diffuse Tinea corporis. Given the atypical symptoms for streptococcal pharyngitis or Rhinovirus, a broad infectious workup was performed, including tests for bacterial, viral, and parasitic infections, human immunodeficiency virus, Hepatitis, and QuantiFERON Gold (QFT-G) for tuberculosis, all of which were negative. Bronchoscopy with bronchoalveolar lavage (BAL) was performed, and samples were sent for smear, polymerase chain reaction (PCR), and culture. The acid-fast bacilli (AFB) smear and PCR for Mycobacteria were negative. The patient was treated with broad-spectrum antibiotics and antifungals, but his fever worsened, raising concern for cytokine storm. High-dose steroids and Anakinra were administered and his respiratory status improved, allowing extubation. After extubation, he intermittently refused further diagnostic studies. During this period, he was maintained on standard precautions. After 30 days, BAL culture grew Mycobacterium tuberculosis complex. PET/CT revealed uptake in retroperitoneal lymph nodes, prostate, and lungs. MRI brain revealed innumerable foci suggestive of tuberculomas. He was diagnosed with disseminated active tuberculosis, started RIPE therapy, placed under airborne precautions, and immunosuppressive therapy was discontinued. Investigation into the false-negative QFT-G test led to immunologic testing. His CD4 count at the time of the QFT-G was 70, below the threshold (100 –200) needed for an interpretable QFT-G (PMID: 23382842, PMID: 19156218). In addition, he had an absent response to IL-2 in lymphocyte transformation and NK cell activity, suggesting an underlying immune deficiency that could explain suboptimal secretion of interferon tested by the QFT-G. This also accounts for his diffuse Tinea corporis infection. Genetic testing to identify the defect was recommended; however, the patient declined. The likely explanation was a hypomorphic mutation in the common gamma chain of the IL-2 receptor, commonly associated with severe combined immunodeficiency. IMPACT/DISCUSSION: Due to reliance on negative QFT-G, AFB smear, and PCR, many healthcare staff and other patients were exposed to M. tuberculosis, and treatment was delayed for 30 days in a severely ill patient. Understanding the limitations of testing and recognizing factors that increase the likelihood of false-negative results is critical for patient and staff safety.

-M. tuberculosis testing has significant limitations, especially in immunodeficient patients -If there is suspicion for M. tuberculosis, precautions should be taken until infection is definitively ruled out A MULTIDISCIPLINARY APPROACH TO SYMPTOMATIC AORTIC REGURGITATION Andrew Kung3; Rafsan Ahmed2; Ming Zhong1. 1Cardiovascular Disease, Weill Cornell Medicine, New York, NY; 2Cardiovascular Disease, NewYork-Presbyterian Queens, Flushing, NY; 3Internal Medicine, NewYork-Presbyterian Queens, Flushing, NY. (Control ID #4270350) CASE: An 88-year-old male with hypertension presented to the emergency room with exertional left sided, non-radiating chest pain. He had bibasilar rales with 3+ pitting edema in the lower extremities. Labs revealed elevated high sensitivity troponin level of 136 ng/L, Cr 1.86 mg/dL, and proBNP of 60,000. Repeat 1-hour troponin level was 149 ng/L, peaking at 730 ng/L. Electrocardiogram showed normal sinus rhythm with T wave inversions in I, aVL, V4-6. Transthoracic echocardiogram (TTE) revealed an ejection fraction of 20-25%, global hypokinesis, and severe aortic regurgitation (AR). Cardiac catheterization showed three vessel disease with > 70% stenosis of the left anterior descending artery (LAD). Cardiac surgery was consulted for aortic valve replacement, while the patient was medically managed with hydralazine and bumetanide for afterload reduction and diuresis, respectively. Due to worsening creatinine levels and poor functional status, the patient was ineligible for surgical aortic valve replacement (sAVR), with an STS score of 38.4% for perioperative morbidity and mortality. After shared decision making, the patient pursued a transcatheter aortic valve replacement (TAVR) workup. Transesophageal echocardiogram (TEE) confirmed severe eccentric AR and cardiac CT reported an aortic valve calcium score of 293 Agaston units. The patient underwent a successful TAVR followed by staged percutaneous coronary intervention to the LAD. TTE confirmed a well-seated bioprosthetic valve with no significant AR and a 3-month follow up TTE noted a functional bioprosthetic aortic valve. IMPACT/DISCUSSION: TAVR has gained popularity as treatment for severe aortic stenosis (AS) over sAVR. The PARTNERS 2 trial demonstrated that TAVR was noninferior to sAVR with respect to all-cause mortality and disabling stroke at the two years. However, there is a lack of robust data on TAVR for AR. Poletti et al published the PANTHEON International Project which studied 201 patients that underwent off-label TAVRs for AR and found a 12.4% incidence of acute transcatheter valve embolization or migration; however, sample size was one of the limiting factors. While it is premature to assess long-term success of TAVR in our patient at 1-year, our patient’s three-month TTE was a promising finding along with a noticeable improved quality of life.

Off-label TAVRs for symptomatic severe AR appears to be an optimistic option for high-risk surgical candidates. While further research is needed to assess long term outcomes, an evaluation from a structural cardiologist may be beneficial. A MYSTERIOUS MYOSITIS Benjamin Caplan, Allison Samuel, Rachel Engelberg. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4269796) CASE: A 67-year-old Sri-Lankan female with a past medical history of Hashimoto’s thyroiditis, hypertension, and hyperlipidemia presented to the hospital with one month of diarrhea, diffuse weakness, and unintentional weight loss. Evaluation of her weakness was notable for bilateral proximal muscle and bulbar weakness on exam, as well as laboratory findings of sodium 135 (normal), TSH 1.9 (normal), CK 6.6 (normal), CRP 76.0 (elevated), positive ANA, positive anti-centromere antibody, negative anti-scl 70 antibody, negative Myasthenia Gravis antibodies, and negative EMG repetitive stimulation test. MRI femur demonstrated subacute diffuse myositis, clinically concerning for an inflammatory myositis, for which she was started on steroids, azathioprine, and IVIG. Development of new onset fevers in the following days prompted an infectious workup notable for a left upper lobe consolidation seen on CT Chest. Lung biopsy revealed necrotizing granulomatous inflammation with acid fast organisms consistent with active tuberculosis (TB). Treatment for TB was initiated with significant improvement of her muscle weakness, leading to a presumtive diagnosis of TB myositis. Further treatment with azathioprine and IVIG was held and steroids were tapered. A confirmatory muscle biopsy was deferred due to a combination of patient preference for minimizing proceduralizing and low suspicion for management-changing findings given improvement on appropriate tuberculosis therapy. IMPACT/DISCUSSION: This case highlights a rare cause of myositis. There is a broad differential diagnosis for both muscle weakness and myositis, which includes evaluation of metabolic, autoimmune, connective tissue, neurologic, iatrogenic, and infectious etiologies. Muscular TB is a rare cause of myositis, with fewer than 100 cases reported globally. It can be a challenging diagnosis due to its occult onset and atypical presentation, with less than half of these patients presenting with classic TB symptoms of night sweats, weight loss, and intermittent fever. Prompt treatment with appropriate tuberculosis therapy- rifampin, isoniazid, pyrazinamide, and ethambutol- has been shown to improve outcomes, and delayed treatment can leave patients vulnerable to the high mortality risk of TB. This case adds to the literature by reinforcing the identification and management of an atypical and dangerous cause of myositis. Muscular TB is an important diagnosis to consider in patients with muscle weakness, especially in cases without clearly identified etiology on initial testing.

When assessing novel myositis, it is important to keep muscular tuberculosis on the differential, especially in patients from endemic areas. Broad neurologic, infectious, and rheumatologic workups are important, and when suspicious for tuberculosis, prompt treatment is imperative. AN ASYMPTOMATIC RECURRING BREAST RASH: A RARE CASE OF ISOLATED CUTANEOUS ROSAI-DORFMAN DISEASE Nicholas Barnaba1; Sachi Singhal2; Sanjana Kalvehalli Kashinath3. 1Internal Medicine Residency, Temple University Hospital, Philadelphia, PA; 2Hematology/Oncology Fellowship, Temple University Hospital, Philadelphia, PA; 3Hematology, Temple University, Philadelphia, PA. (Control ID #4272791) CASE: A 70-year-old woman initially presented to her primary care office for 3 months of intermittent red-purple skin discoloration of her breast while showering. The area was nonpruritic and nontender, and resolved and re-appeared every few weeks. She denied any other skin changes, bleeding, or systemic symptoms. Mammography and ultrasound were unrevealing. Breast biopsy was negative for malignancy but revealed fibrous scarring with chronic perivascular lymphoplasmacytic infiltrate. The patient was also referred to dermatology clinic and skin biopsy was performed. This revealed a dense, nodular infiltrate of T-cells, B-cells, and plasma cells with positive immunohistochemistry markers S100, CD68, and CD 163, consistent with Rosai-Dorfman Disease (RDD). A thorough autoimmune and malignancy workup was performed to rule out underlying disease. ANA, CBC with differential, CMP, ESR, LDH, serum immunoglobulins, anti-phospholipid syndrome (APLS) panel, rheumatoid factor (RF), uric acid, and were all unremarkable. PET-CT showed focal uptake in the right breast and no evidence of lymphadenopathy. A diagnosis of isolated cutaneous RDD was made, and she was started on low-potency topical corticosteroids as needed. IMPACT/DISCUSSION: RDD, also known as sinus histiocytosis with massive lymphadenopathy (SHML) or Destombes–Rosai–Dorfman disease, is an uncommon benign disorder characterized by overproliferation of histiocytes. RDD typically presents as massive bilateral cervical lymphadenopathy. Up to 43% of patients with RDD present with extranodal disease, and of these patients, the skin is involved in 10%. Isolated cutaneous RDD is an exceedingly rare and challenging diagnosis. Skin lesions are slow-growing, usually painless, nonpruritic nodules, plaques, or papules with coloration varying from yellow to red to brown, and any skin site can be affected. More than 10% of patients with RDD have neoplasia- or immune-related RDD. Associations have been identified between RDD and Crohn’s disease, rheumatoid arthritis, lupus erythematosus, mycosis fungoides, and lymphoma. Therefore, thorough laboratory and imaging testing is necessary to rule out underlying disease processes. Several therapies have been reported as management options for cutaneous RDD, including topical and intralesional corticosteroids, cryotherapy, surgery, and in severe cases, chemotherapy. However, many cases such as this one demonstrate spontaneous resolution.

- Isolated cutaneous RDD poses a unique diagnostic and therapeutic challenge - Any unidentified relapsing-remitting rash should prompt further workup including a skin biopsy and dermatological evaluation - A new diagnosis of RDD should prompt a thorough evaluation for underlying autoimmune or malignant etiologies AN ATYPICAL CASE OF ACUTE ON CHRONIC DIARRHEA Irene Cofie. Internal Medicine, Washington University in St Louis, St Louis, MO. (Control ID #4232990) CASE: Chronic diarrhea, defined as experiencing loose, watery stools for more than 30 days, can cost $136 million to $524 million annually in the US. Common causes of chronic diarrhea include inflammatory disease, infection, and food or medication intolerance. This case illustrates a 77-year-old man with a past medical history of hypertension, type 2 diabetes, pacemaker placement, and atrial fibrillation s/p ablation on Eliquis who presented to an academic center with a five-week history of diarrhea. Associated symptoms included severe crampy abdominal pain, nausea, decreased oral intake with a 30-pound weight loss. He had initially been admitted to an outside hospital four weeks prior after developing orthostasis from acute diarrhea, notably with pasty black stools followed by frequent watery stools. Gastroenterologists evaluated the patient at the outside facility and were concerned about gastroenteritis or colitis as the cause of diarrhea. The patient received an extended course of IV antibiotics that helped his symptoms briefly. Upper endoscopy and colonoscopy were unrevealing. During his admission to the academic center, he continued to have diarrhea. He completed two CT angiographies of the abdomen and pelvis which showed acute long-segment ileitis. Infectious disease workup and repeat scopes were negative. Still, the patient received additional IV antibiotics due to leukocytosis and temporary relief from symptoms with treatment. On the anticipated day of discharge, the patient developed another episode of severe diarrhea. After contacting radiology to re-read the prior images, a superior mesenteric artery distal branch occlusion was identified as likely causing his diarrhea. General surgery was consulted, and repeat CT angiography showed an unstable thrombus in the thoracic descending artery. The patient was placed on a heparin drip, and antibiotic prophylaxis and was eventually taken for thoracic endovascular aortic repair. IMPACT/DISCUSSION: Initially, it was believed the patient had failed anticoagulation therapy with Eliquis which provoked the occlusion. Additional history revealed the patient had reduced his Eliquis for his atrial fibrillation from twice a day to daily due to a cost of $2,400 for a 3-month supply. After this revelation, the patient was discharged on Xarelto 20 mg once a day for $125.94 a month, through a special pharmacy program.

This case illustrates the importance of considering uncommon differentials for chronic diarrhea to reduce mortality and delay in care in an academic center, such as the case of a patient with an embolic superior mesenteric artery occlusion causing mesenteric ischemia and diarrhea. Additionally, completing a thorough history, including identifying disparities in obtaining adequate healthcare, such as financial barriers, can have life-saving implications. AN ATYPICAL OPHTHALMOLOGIC PRESENTATION OF DIFFUSE LARGE B-CELL LYMPHOMA WITH CAVERNOUS SINUS INVOLVEMENT Lyndon Huang, Grace Farris. Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4245993) CASE: A 73-year-old woman presented to the hospital with a right eye swelling, ptosis, diplopia and headache for several days. She reported an upper respiratory tract infection two weeks before admission. At her first evaluation, brain MRI and MRA were unremarkable, and she was discharged with a diagnosis of microvascular disease. Shortly after discharge, her symptoms worsened and she developed nausea, vomiting, and near-complete vision loss in her right eye and she was subsequently admitted. Physical exam on admission was notable for right-sided ptosis, complete ophthalmoplegia with mild proptosis in the right eye and facial pain. Repeat imaging revealed infiltrative soft tissue thickening in the right cavernous sinus extending into the orbital apex. Laboratory findings showed persistently elevated LDH (>3325 U/L), ESR of 71, and normal CRP. A lumbar puncture demonstrated mildly elevated protein (55 mg/dL) and normal glucose (71 mg/dL) without pleocytosis. Despite a comprehensive infectious workup, including fungal serologies, CSF cultures, and viral PCRs, no pathogens were identified. Neurosurgery was consulted for biopsy of the area of enhancement, but the location of enhancement abutted the carotid artery and extended to the cavernous sinus. A bone marrow biopsy was performed and revealed CD10-positive diffuse large B-cell lymphoma (DLBCL) thought to involve the blood, marrow, and right cavernous sinus. The patient was started on R-CHOP chemotherapy, rituximab, and radiation therapy targeting the cavernous sinus. After her first cycle, she had improvement in her vision and orbital pain. IMPACT/DISCUSSION: Cavernous sinus infiltrative disease is rare, with etiologies spanning infectious and non-infectious causes. Infectious culprits include invasive fungal infections (e.g., aspergillosis, mucormycosis), tuberculosis, and bacterial abscesses. Non-infectious causes include autoimmune disorders such as IgG4-related disease and sarcoidosis, inflammatory syndromes like Tolosa-Hunt syndrome, and malignancies such as lymphoma or metastatic disease. Among lymphomas, diffuse large B-cell lymphoma (DLBCL) is the most common type and is known for its aggressive behavior and potential to involve the central nervous system (CNS). Imaging findings, including infiltrative or mass-like lesions, can help narrow the differential diagnosis, though histopathologic confirmation remains crucial. In this case, histopathologic confirmation of DLBCL was achieved through a bone marrow biopsy, as the cavernous sinus lesion was inaccessible.

Diffuse large B-cell lymphoma is a rare but important consideration in patients with painful ophthalmoplegia and cavernous sinus disease. A systematic approach that integrates imaging, laboratory findings, and biopsy is crucial for accurate diagnosis. Early recognition and timely treatment with chemotherapy and radiation can significantly improve outcomes. ANCHORED IN ERROR: WHEN MISDIAGNOSED ACUTE PERICARDITIS HIDES A LETHAL TEAR Natalie Perez-Mendez1; Christian Pilot2; Frances Rodriguez2; Jeffrey Wilson1. 1Internal Medicine Residency, Florida Atlantic University, Boca Raton, FL; 2Emergency Medicine Residency, Florida Atlantic University, Boca Raton, FL. (Control ID #4272931) CASE: A 21-year-old man with no past medical or family history initially presented to urgent care with chief concerns of vomiting and fever for which supportive care was prescribed. One week later presented to our institution’s emergency department (ED) with progressive epigastric and chest pain radiating to back. Vitals normal except for sinus tachycardia. Laboratory results were normal except a leukocyte count of 13.5, hemoglobin of 11.9, troponin of 34, and ESR of 27. ECG at presentation showed diffuse ST-segment changes in all leads. Acute pericarditis diagnosed and he was started on colchicine and indomethacin. Second ECG performed for acute worsening of chest pain which revealed even more prominent diffuse ST-segment changes. TTE revealed pericardial effusion without tamponade physiology. Troponin trend with sharp rise and fall and patient continued to experience chest pain. Later on hospital day one, patient syncopized then suffered a cardiac arrest. Bedside pericardiocentesis yielded 1.4L of bloody output. Autopsy report illuminated cause of death was multiple vascular dissections, including aortic root dissection and splenic artery dissection, secondary to vEDS. Genetic testing showed heterozygous mutations in COL3A1 and LGI1 genes. IMPACT/DISCUSSION: EDS ecompasses a group of genetic connective tissue disorders with a subset of patients obtaining mutations encoding for vEDS, which may cause arterial and internal organ rupture. These patients require counseling about their prognosis, including need to seek prompt medical attention if they experience any sudden onset of pain or bleeding. Sadly, 80% of patients with vEDS experience a major adverse event by age 40(1), and median age of death is 51 years(2). Anchoring bias, causes over reliance on the first piece of information given, leading to filtering of new information through the framework initially made(3). As a result, perception is distorted and there is reluctance to change plans even if the situation calls for it. This often occurs subconsciously so clinicians must be aware it exists and take diagnostic time-outs, cognitive pauses that reassess data to ensure appropriate clinical decisions are being made(4), throughout a patient’s case in effort to identify if bias is impacting care. Despite hospital course revealing data that did not fit the diagnosis of acute pericarditis, anchoring on the initial diagnosis inhibited clinicians to pursue other causes of symptoms.

We describe a lethal case of vEDS misdiagnosed as acute pericarditis complicated by aortic dissection and cardiac tamponade. We highlight the need to consider a broad differential and reflect upon clinical decision-making when patient’s have evidence of decompensation despite appropriate management for the suspected diagnosis. AND THEN THERE WERE MANY… PLAQUES ON AN MRI: A UNIQUE CASE OF ADALIMUMAB CAUSING MULTIPLE SCLEROSIS-LIKE SYNDROME IN AN ELDERLY ADULT Gaayathri Krishnan, Ganesh Natarajan, Bridglal Ramkissoon. Internal Medicine, AdventHealth, Sebring, Sebring, FL. (Control ID #4230413) CASE: A 68-year-old woman presented to the ER with lower extremity weakness and tremors. She had experienced balance issues, unsteadiness, and difficulty walking for six weeks, along with speech and cognitive problems. No vision problems, numbness, or incontinence were reported. Her history included psoriasis treated with Adalimumab for the past 3 months, anxiety, and migraines. When she presented to the ER, symptoms had resolved. Examination revealed coordination and gait abnormalities with absent reflexes. Initial labs were mostly benign, except for thrombocytosis. CT brain showed no acute findings, and EKG showed prior septal infarct. Admitted for possible CVA; carotid ultrasound showed no significant stenosis. MRI of the brain revealed multiple lesions in periventricular and centrum semiovale areas with mild cerebral atrophy. Compared to an MRI 4 years back, new lesions were present. Further tests showed hyperlipidemia, Vitamin D deficiency, and normal inflammatory markers. Autoimmune and STD panels were negative. Vitamin B12 and thyroid levels were normal. CSF studies showed elevated RBC and protein, with beta 2 microglobulin and oligoclonal bands detected. This led to a provisional diagnosis of possible multiple sclerosis. IMPACT/DISCUSSION: Multiple Sclerosis (MS) is a chronic neurological condition that typically manifests in early adulthood, most commonly between ages 20 and 40. However, amidst the expected narrative, we encountered an intriguing anomaly: a patient, now approaching the seventh decade of life, who defies convention by presenting with features reminiscent of MS. Diagnosing MS is complex, involving clinical evaluation, imaging, and lab tests. The revised McDonald criteria have improved accuracy, yet diagnosing remains challenging due to MS's diverse symptoms. In this case, the patient’s symptoms align with typical MS patterns: progressive weakness, tremors, speech issues, and cognitive impairment. The absence of other causes supports a provisional MS diagnosis. Tests showing oligoclonal bands in the cerebrospinal fluid add weight to a demyelinating disorder. However, the patient’s late-onset MS led to investigating whether Adalimumab, a TNF-alpha antagonist used for her psoriasis, triggered these neurological symptoms. Adalimumab’s rare side effect, CNS demyelination, lacks a precise mechanism but might provoke an immune response targeting myelin-producing cells. While reports link Adalimumab to CNS demyelination, it’s uncertain if it’s coincidental or a consequence. This case emphasizes the need for vigilant monitoring of patients on Adalimumab, particularly when neurological symptoms arise. Early recognition and intervention are key, especially with atypical MS presentations in older adults.

In summary, this case stresses the intricate relationship between Adalimumab and possible CNS issues resembling MS. Vigilance in monitoring Adalimumab-treated patients and considering CNS demyelination in MS-like symptoms are essential. ANEURYSMAL SURPRISE: UNMASKING THE 12CM ABDOMINAL SURPRISE Amanda Sinderovsky1; William Simonds1; Aadhar Patil2. 1Internal Medicine, Jefferson Health - Northeast, Philadelphia, PA; 2Cardiology, Jefferson Health - Northeast, Philadelphia, PA. (Control ID #4272460) CASE: A 68-year-old male with past medical history hypertension, former tobacco use, recent diagnosis of T-cell lymphoma with lymphadenopathy and possible metastases was sent to the emergency department by his oncologist to expedite evaluation for chemotherapy initiation. One month prior, the patient was admitted to an outside hospital with shortness of breath. His symptoms resolved with antibiotics and respiratory support. At that time, he was also found to have new mediastinal and supraclavicular lymphadenopathy and hypodense liver masses. After discharge, preliminary results from lymph node biopsy returned concerning for T cell lymphoma, so the patient was sent to the hospital again for expedited workup. Throughout this most recent admission, the patient remained hemodynamically stable. Labs were significant for acute on chronic kidney injury, significant leukocytosis likely related to his lymphoma, elevated urate and LDH, causing concerns for tumor lysis syndrome. He was treated with rasburicase and allopurinol. The patient was incidentally found to have a 12cm infrarenal abdominal aortic aneurysm (AAA) on imaging, in addition to a palpable, pulsatile abdominal mass on physical examination. He denied abdominal, back, or flank pain. At the outside hospital one month prior, CT abdomen/pelvis had demonstrated 12cm AAA and vascular surgery was consulted. At that time, outpatient management and eventual endovascular repair was recommended, however the patient had not yet followed up. This admission, normotension goals were strictly put into place. Vascular surgery was again consulted, and the patient underwent endovascular repair of the aorta. He tolerated the procedure well and was instructed to follow with vascular surgery in one month for aortic duplex. He followed outpatient with oncology for treatment of his malignancy. IMPACT/DISCUSSION: AAA greater than 6cm have incredibly high annual risk of rupture, which increases exponentially with aneurysm size. This patient was also at even greater risk of rupture: he was planning to initiate chemotherapy, which may potentially disrupt the structure and function of the arterial wall, and was at risk for lymphomatous infiltration of the aortic wall due to the malignancy itself. This case was an extraordinary presentation of a relatively common disease. It highlights the importance of screening for abdominal aortic aneurysm and thorough physical examination, in addition to recognizing risk factors for rupture. By recognizing these risk factors, internal medicine doctors can better care for their patients while they are hospitalized, advocate for their patients, and collaborate effectively in a multidisciplinary team.

- Patients with large AAA require urgent vascular surgery evaluation, especially those with increased likelihood for morbidity and mortality - Both chemotherapy and malignancy itself can increase risk for AAA rupture - Closed-loop communication between specialty services is imperative for successful patient outcomes A NEW SPIN ON MALIGNANCY: RECOGNIZING OPSOCLONUS-MYOCLONUS SYNDROME AS A PARANEOPLASTIC PROCESS Simren Singh, George T. Kalapurakal, Parimal Sura. Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4237754) CASE: A 69-year-old male with past medical history of hypertension and daily tobacco use presented with intractable dizziness and vomiting for five days. He had worsening symptoms with positional changes, refractory to outpatient antihistamines. On physical exam, he had unstable gait and opsoclonus but intact deep tendon reflexes with no evidence of motor or sensory deficits, Romberg’s sign, or pronator drift. He had several head imaging studies including MRI Brain, MRA Head and Neck, and MRI of the Internal Auditory Canals showing chronic right basal ganglia infarct with no evidence of acute stroke. He had positive Mycoplasma pneumoniae IgM to 1.3 U/L. Otherwise, initial infectious workup, including HIV and cerebrospinal fluid analysis, was negative. He failed to improve with canalith repositioning maneuvers, antihistamines, anticholinergics and Gamma-Aminobutyric Acid (GABA) analogues. CT Chest/Abdomen/Pelvis showed rim-enhancing lesion in the right hepatic lobe and enlarged right iliac lymph node measuring 1.9 cm in the short axis. Prostate Specific Antigen (PSA) was elevated to 5.2 ng/mL and AFP elevated to 15 ng/mL. Subsequent CT-guided right external iliac lymph node biopsy revealed metastatic prostate adenocarcinoma. Paraneoplastic antibody panel was negative. The patient was started on Bicalutamide, intravenous Methylprednisolone and intravenous Immunoglobulin with gradual improvement in symptoms. IMPACT/DISCUSSION: Opsoclonus is an oculomotor dyskinesia characterized by rapid multidirectional eye movements. Opsoclonus has numerous etiologies, with paraneoplastic processes accounting for the majority. Common offenders include neuroblastomas in children and small cell lung cancer, breast cancer, or ovarian teratomas in adults. There have been limited case reports regarding opsoclonus in prostate cancer. It can often be accompanied by myoclonus resulting in Opsoclonus-Myoclonus Syndrome (OMS). The incidence is estimated to be 1 in 5 million. Both processes are proposed to be immune-mediated where the immune system, possibly through onco-neuronal antibodies, targets antigens shared by neurons and tumor cells. However, onco-neuronal antibodies are not found in all cases. Compared to other causes of opsoclonus, patients with paraneoplastic etiology have more relapses and worse outcomes, necessitating early and aggressive cancer treatment.

Opsoclonus and OMS are rare conditions that can have multiple etiologies, most commonly paraneoplastic. Evaluation should prompt broad workup with particular focus on malignancy evaluation. A negative workup should not preclude treatment initiation as onco-neuronal antibodies are not always found. AN EYE-OPENING CASE: CHLAMYDIA AS A CAUSE OF PRESEPTAL CELLULITIS Ryan W. Tatton1; Meenu Singh2. 1Internal Medicine, University of Utah Health, Salt Lake City, UT; 2Internal medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4273486) CASE: A 36-year-old female presented to the ED with six weeks of left eye redness, pain, and purulent drainage, along with dysuria and sore throat. Prior to presentation, the patient presented to urgent care where she received multiple courses of unspecified oral antibiotics without relief. She denied trauma or chemical exposure to the affected eye, involvement of the contralateral eye, arthralgia, rash, or other systemic signs and symptoms. Sexual history was notable for two male sexual partners and engagement in both oral and vaginal sex without barrier contraception. The patient was afebrile and hemodynamically stable. Examination demonstrated inability to open the left eye more than 50%, painful extraocular movements, edema of the left eyelids and surrounding soft tissue, and conjunctival injection with chemosis. Dilated eye exam did not show evidence of uveitis. Exam was otherwise unremarkable. Given concern for orbital cellulitis, CT imaging was obtained, demonstrating left preseptal orbital cellulitis without postseptal involvement and mild edema of the soft palate. The patient was started on ceftriaxone and vancomycin. Autoimmune workup was unremarkable. Broad infectious testing including HIV, syphilis, and gonorrhea was negative.The patient tested positive for Chlamydia thrachomatis by TMA at all sites tested, including urine, vaginal, conjunctival, and oropharyngeal samples. Antibiotics were switched to Doxycline, followed by brisk improvement. The patient was discharged with a one-week course of doxycycline and recommendation for partner therapy. At one-week follow-up she reported complete resolution of symptoms. IMPACT/DISCUSSION: Chlamydia trachomatis is the most common bacterial sexually transmitted infection. Chlamydia’s tropism for columnar epithelial cells gives it particular affinity for the conjunctiva and urogenital tract, though proctitis, perihepatitis, and reactive arthritis are other known syndromes. This case exhibits a patient with chlamydial preseptal orbital cellulitis, conjunctivitis, pharyngitis, cervicitis, and likely urethritis. There are only two other cases of chlamydial preseptal cellulitis reported in literature. Distinguishing orbital cellulitis from preseptal cellulitis is of urgent importance, as their clinical implications diverge significantly. Orbital cellulitis should be considered in any patient presenting with eyelid swelling and erythema, pain or diplopia with extraocular movements, chemosis, or proptosis. Differentiating orabital from preseptal cellulitis often requires either CT or MRI imaging. Usual bacterial causes in preseptal cellulitis are Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes.

Preseptal cellulitis must be promptly distinguished from orbital cellulitis. Chlamydia is a rare cause of preseptal cellulitis. It should be considered in those with risk factors for bacterial STI, extraoccular symptoms of Chlamydial disease, or disease not responding to empiric antibiotic therapy. ANGIOSARCOMA OF BONE PRESENTING AS CAUDA EQUINA SYNDROME Nicholas Barnaba1; Ho-Man Yeung2. 1Internal Medicine Residency, Temple University Hospital, Philadelphia, PA; 2Internal Medicine, Temple University Hospital, Philadelphia, PA. (Control ID #4272820) CASE: A 37-year-old male with obstructive sleep apnea, type 2 diabetes mellitus, hypertension, and recent kidney stones presented to the ED for difficulty voiding and worsening constipation. He endorsed perineal paresthesia with urination and defecation concerning for cauda equina syndrome. MRI pelvis and lumbar spine showed several enhancing bony lesions with encroachment upon the S2-S4 sacral foramina bilaterally and upon the sacral central canal. CT chest with and without contrast showed a few mildly enlarged mediastinal lymph nodes and a lytic lesion within the posterior aspect of the right fifth rib concerning for metastasis. MRI thoracic spine showed multiple hyperintense non-enhancing foci, favored to more likely represent atypical hemangiomas than metastases. Biopsy of the right fifth rib lesion showed a spindle cell neoplasm of unknown etiology, and subsequent biopsy of the sacral mass demonstrated spindle cell angiosarcoma of bone. FISH and NGS did not reveal any molecular targets. He was initiated on radiation therapy due to progressive neurologic symptoms and was started on palliative chemotherapy with paclitaxel with symptomatic improvement. IMPACT/DISCUSSION: Angiosarcoma arising from bone origin is extremely rare, and is associated with a very poor prognosis if not surgically resectable. Treatment typically entails chemotherapy and radiation, although literature is sparse for this disease entity. If angiosarcoma invades the pelvis or vertebrae, there is risk for cauda equina syndrome. Cauda equina syndrome occurs when the nerve roots of the cauda equina are compressed or damaged and can lead to saddle anesthesia, bowel and bladder dysfunction, and severe back pain, and it is considered a neurosurgical emergency. This case demonstrates a unique cause of cauda equina syndrome in a young patient found to have metastatic angiosarcoma of bone. Early identification of signs of cord compression and decompression is crucial to prevent permanent neurological deficits. Malignancy should be considered in any patient with signs of cord compression, regardless of demographic, and biopsy should be prioritized to aid diagnosis. Metastatic angiosarcoma is typically treated with chemotherapy and/or radiation and is typically quite aggressive with a 45% PFS rate in 4 months on paclitaxel. Finally, this patient also had evidence of atypical hemangiomas on thoracic spine imaging, which have been identified in rare cases as precursor lesions to angiosarcoma.

- Angiosarcoma of bone is a rare and aggressive cancer associated with poor prognosis, and hemangiomas have been identified as potential precursor lesions - Early identification and decompression are critical to preventing irreversible neurological damage in cauda equina syndrome - Malignancy should be considered in any patient presenting with signs of cord compression, regardless of age or other demographic factors A NOT SO COMMON SIDE EFFECT OF A COMMON MEDICATION: METFORMIN AND ITS RARE CHALLENGE Hinal Rathi1; Aesha Patel2; Alina Sehar3; John Fanning4. 1Internal Medicine, University of Alabama Huntsville Regional Campus, Huntsville , AL; 2Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; 3Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL; 4Internal Medicine, The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL. (Control ID #4271580) CASE: A 60-year-old male with CAD, aortic mechanical valve replacement on warfarin, and atypical migraines presented with sudden loss of peripheral vision in his right eye. While attempting to drive, he noticed he could not see his side or rearview mirrors. He denied headaches, facial drooping, nausea, vomiting, chest pain, shortness of breath, or seizure-like activity. He had recently started metformin for pre-diabetes. He denied smoking, alcohol, or drug use and only used reading glasses. Vital signs showed BP 168/73 mmHg. Labs revealed triglycerides of 264 mg/dL and an INR of 0.9. A stroke workup, including imaging, was negative. Ophthalmology attributed his symptoms to an ocular migraine. Despite compliance with Coumadin and dietary restrictions, his INR was subtherapeutic. Cardiology noted a possible interaction between metformin and warfarin. The patient was bridged with enoxaparin, advised to discontinue metformin, and referred to cardiology and a Coumadin clinic for follow-up. IMPACT/DISCUSSION: First developed in the 1940s as an anti-malarial agent, metformin received FDA approval in 1994 for treating Type II diabetes. Known for its safety and affordability, it is widely prescribed. Common contraindications include kidney failure due to the risk of lactic acidosis and gastrointestinal side effects like diarrhea. This case highlights a rare interaction between metformin and warfarin, resulting in a subtherapeutic INR in a patient with an aortic valve replacement. While the precise mechanism of this interaction remains unclear, it underscores the need to review possible interactions with warfarin. Given metformin’s accessibility and compliance benefits, its exclusion from treatment plans in warfarin patients presents challenges in managing comorbid conditions. Careful monitoring is essential to prevent complications in high-risk patients.

Prescribing new medications with warfarin requires thorough evaluation due to its numerous interactions. Regular INR monitoring is vital to ensure patient safety. A NOVEL PRESENTATION OF POEMS SYNDROME: A CALL FOR A UNIFIED DIAGNOSTIC CRITERIA Siddanth Singh2; Hiep Nguyen2; Tiffany Egbe2; Madhu Chiluveri2; Larry Frase1. 1Texas Oncology Longview Cancer Center, Longview, TX; 2Internal Medicine, CHRISTUS Health | Texas A&M University College of Medicine Internal Medicine Residency Program, Longview, TX. (Control ID #4271783) CASE: A 47-year-old woman with unknown past medical history presented with generalized weakness and left flank pain for the past two weeks. She reported an associated flank bruise and a dull aching abdominal discomfort, both of which have worsened in the past three days. In addition, she reported intermittent diffused, sharp pain on her legs bilaterally at night when she was in bed. Review of systems revealed tremors in the upper extremities, weakness in her lower extremities, nausea, vomiting, and bilateral leg swelling. Physical examination demonstrated icteric sclera, a low pitched ejection murmur, bibasilar rales, bilateral grade II pretibial edema, jaundice, hematoma on left flank, and a mild ataxic gait. CBC revealed severed pancytopenia across all blood lines including red blood cells, white blood cells, and platelets. CMP demonstrated high total protein level content of 10.8 gm/dL with low albumin of 1.7 gm/dL. Protein electrophoresis revealed markedly low Immunoglobulin M and G, elevated levels in β-globulin and γ-globulin, along with a remarkable high Immunoglobulin A of more than 7100 mg/dL. Transthoracic echocardiogram revealed severe pulmonary hypertension. Abdominal ultrasound was positive for hepatomegaly (Figure 2). CT abdomen and pelvis shows expansile lytic lesions involving the right posterolateral sixth concerning for metastatic disease (Figure 3). She was diagnosed with multiple myeloma. Oncology was consulted for treatment management. However, due to the patient’s lack of insurance, she was challenged for follow-up. IMPACT/DISCUSSION: According to the widely used criteria, by Dispenzieri, diagnosis of POEMS syndrome requires two mandatory criteria with fulfilling at least one major and one minor criterion. This patient met the major criteria of monoclonal plasma proliferation of IgA and sensory neuropathy consisted of paresthesia and neurogenic pain in the lower extremities. Although lytic lesions were present in our patient, she didn’t fit the other major criteria of “sclerotic” lesions. Meanwhile, she satisfied multiple minor criteria including organomegaly, extravascular volume overload, pulmonary hypertension, and skin change. Despite fully meeting the diagnosing criteria, the diversity of her clinical symptoms, which are missing in Dispenzieri criteria, should prompt for reconsideration of the diagnosing criteria.

As of today, there is no standardized definition for POEMS syndrome. Patients with the syndrome have been shown to display a broad variety of symptoms, many of which may exclude the pertinent mandatory or major criteria upon presentation according to Dispenzieri’s criteria. Even though this patient fully meet Dispenzieri’s criteria, she has many other symptoms which were not included in the current criteria. These “unincluded” symptoms, however, have been well documented in existing literature for POEMS syndrome. A more accurate and unified criteria would benefit many patients who present with atypical clinical presentations. ANTICOAGULATION CHALLENGES IN CIRRHOSIS Nirupama Devanathan, Sarah Khan, Julia Liberto, Seth Sweetser. Gastroenterology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271188) CASE: A 63-year-old man with hepatitis C related cirrhosis and thrombocytopenia presented to the emergency department with hematemesis and melena. He had a 10-year history of severe thrombocytopenia with platelet counts of 15,000 platelets/uL and was receiving eltrombopag 75 mg daily. Five years prior to presentation, he developed portal vein thrombosis and was initiated on rivaroxaban. On current presentation, he was resuscitated and started on octreotide, pantoprazole, and ceftriaxone. An upper endoscopy demonstrated large distal esophageal varices that were banded. Computed tomography (CT) of the abdomen and pelvis demonstrated a focal, non-occlusive thrombus at the portal confluence and thrombus in the splenic vein. Imaging from 3 months prior had demonstrated patent main portal and splenic veins. Due to the imaging findings, he was re-initiated on anticoagulation with enoxaparin. Bleeding recurred and he was transitioned to apixaban 2.5 mg twice daily with cessation of bleeding. Eltrombopag therapy was discontinued due to its thrombogenic potential and after discharge, anticoagulation was discontinued due to his increased risk of bleeding. IMPACT/DISCUSSION: This case highlights the difficulty posed by relative hypercoagulability, due to disturbances in factor production, and bleeding risk, related to thrombocytopenia and elevated portal pressures, in patients with cirrhosis. Portal vein thrombosis (PVT) also conversely increases bleeding risk due to elevation in pressure from venous occlusion. Optimal treatment with anticoagulation is often precluded by thrombocytopenia. Thrombopoietin agonist receptor agents have been studied primarily in the setting of optimizing platelet counts prior to procedures, but themselves have pro-thrombotic potential. Anti-coagulation recommendations for PVT are not definitive. Tentative data from meta-analyses indicate that anticoagulation is not necessarily contra-indicated following variceal bleeding, and in fact, may be protective in case of PVT. There is considerable variability in the recommendations for optimal anticoagulation, including heparin, low molecular weight heparin, or direct oral anticoagulant agents. Our case highlights the need for individualized and shared decision making in balanced prothrombotic and bleeding complications in such patients.

While some thrombopoietin receptor agonists have been investigated for treatment of thrombocytopenia in chronic liver disease, use is generally limited due to the risk of portal vein thrombosis and worsening portal gastropathy. Anticoagulation for portal vein thrombosis is recommended but may be limited by bleeding, especially in patients with platelets less than 50,000. ANTICOAGULATION MANAGEMENT IN A PATIENT WITH AN IVC THROMBUS WITH RECENT INTRACRANIAL HEMORRHAGE AND UNDERLYING AMYLOID ANGIOPATHY Keir MacKay1; Christopher A. Dinh1; Colin MacKay2. 1Hospital Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Indiana University School of Medicine, Indianapolis, IN. (Control ID #4243633) CASE: A 79-year-old male with cerebral amyloid angiopathy was admitted to the hospital due to the sudden onset of left-sided hemiparesis, sensory loss, neglect, and facial palsy. On neurological examination, his National Institutes of Health Stroke Scale score was 9, and a CT head scan revealed a substantial mixed-density hemorrhage in the right frontal lobe. He underwent a right frontal craniotomy for hematoma evacuation. Several days later, he developed an acute segmental pulmonary embolism (PE), which was managed with the placement of an IVC filter due to contraindications for anticoagulation. Prior to discharge, he experienced an episode of hypotension and syncope. A CT venogram of the abdomen and pelvis revealed a thrombus extending from the IVC filter through the iliofemoral vasculature to the right popliteal vein. Consultations were sought from vascular medicine, neurology, and vascular interventional radiology. The consensus was to initiate a trial of a low-intensity heparin nomogram, as the patient was not a candidate for lytic therapy nor for mechanical thromboembolectomy. The patient tolerated the heparin nomogram and was transitioned to enoxaparin two days later. He demonstrated significant functional improvement and could ambulate 300 feet without experiencing any pre-syncopal symptoms. Following discharge, he tolerated therapeutic enoxaparin for six weeks. He was then transitioned to apixaban to complete a total of three months of anticoagulation therapy. IMPACT/DISCUSSION: Cerebral amyloid angiopathy is characterized by the deposition of amyloid proteins in the walls of cerebral blood vessels, leading to an increased risk of intracranial hemorrhage. In cases of significant venous thromboembolism, balancing the increased bleeding risk and the necessity for anticoagulation creates a management dilemma. The decision to initiate anticoagulation in this patient was made after careful consideration and shared decision-making. The anticoagulation approach included a low-intensity heparin nomogram followed by a transition to enoxaparin for several weeks, with close monitoring for any hemorrhagic complications. Enoxaparin was favored due to the potential for rapid reversal if massive bleeding were to develop. He was then transitioned to apixaban. This stepwise approach to anticoagulation, coupled with close monitoring, allowed for the safe management of the patient's VTE.

- In cases of large venous thromboembolism, patients with amyloid angiopathy can undergo therapeutic anticoagulation with close monitoring. - Appropriately balancing the risk of thromboembolism and the potential for massive bleeding in patients with amyloid angiopathy is a unique challenge. - The patient's successful outcome demonstrates the potential for safe and effective anticoagulation in patients with amyloid angiopathy. ANTIPSYCHOTICS AND ISCHEMIC COLITIS: EXPANDING THE DIFFERENTIAL DIAGNOSIS Tiffani Najadifar1,2; Wasifuddin Syed1,2. 1Internal Medicine, Edward Via College of Osteopathic Medicine - Louisiana Campus, Monroe, LA; 2Internal Medicine, Willis-Knighton Medical Center, Shreveport, LA. (Control ID #4271555) CASE: A 40-year-old African American female with hypertension, seizure disorder, and a prior cerebrovascular accident presented to the emergency department with nausea, vomiting, and diarrhea. During admission, she developed hematochezia. Her medications included olanzapine at bedtime, initiated four months prior, along with antihypertensives and antiseizure medications. An abdominal CT scan showed moderate mural thickening throughout the colon, initially suggesting inflammatory bowel disease. A CT angiogram revealed patent superior and inferior mesenteric arteries but focal stenosis at the celiac trunk. A colonoscopy identified severe ischemic colitis (IC) with black eschar from the distal sigmoid colon to the splenic flexure. Biopsies confirmed IC with ulceration and necrosis. The recent initiation of olanzapine, a medication with anticholinergic properties, likely contributed to decreased colonic perfusion, explaining her symptoms. The patient was managed with broad-spectrum antibiotics, intravenous fluids, and bowel rest, leading to symptom resolution. IMPACT/DISCUSSION: This case highlights IC as a rare but serious adverse effect of atypical antipsychotics, particularly those with anticholinergic properties like olanzapine. IC pathophysiology involves transient hypoperfusion to the watershed regions of the colon, such as the splenic flexure and rectosigmoid junction. Anticholinergic agents exacerbate hypoperfusion by reducing gastrointestinal (GI) motility and causing vasoconstriction, which leads to progressive fecal accumulation. This increases intraluminal pressure, compromising intestinal perfusion and causing ischemia. Patients aged 60 years and older with pre-existing vascular conditions, such as atherosclerosis, are at an increased risk for ischemic injury. However, this case is notable because the patient is younger than the typical demographic and does not have significant vascular disease. Despite this, younger patients on antipsychotic therapy can also develop severe IC. The temporal link between olanzapine initiation and symptom onset suggests medication-induced IC may be under-recognized. Failing to recognize this association can delay diagnosis and lead to gangrenous ischemia, increasing morbidity and mortality. This underscores the critical need for thorough medication history reviews in IC patients, especially those on antipsychotics or other anticholinergic drugs, regardless of age or vascular history.

IC is a rare but serious complication of atypical antipsychotics like olanzapine. Medication-induced hypoperfusion combined with vascular pathology can predispose younger patients to severe ischemic injury. Clinicians should suspect drug-induced IC in patients with GI symptoms and recent antipsychotic use. Early recognition, medication discontinuation, and timely intervention are essential to prevent progression to gangrenous ischemia and reduce morbidity. Detailed medication histories and imaging are key to improving patient outcomes. ANTIVIRAL MYSTERY: A CASE OF BREAKTHROUGH HEPATITIS Eric J. Nolan1; Tricia Keller2. 1Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; 2College of Medicine, The Ohio State University College of Medicine, Columbus, OH. (Control ID #4271449) CASE: Our patient was a 20-year-old female who presented to the Emergency Department (ED) with fevers and labial irritation. Labial cellulitis was diagnosed, and she was discharged with cephalexin and trimethoprim-sulfamethoxazole. She presented to the ED a second time 4 days later with fever and labial vesicles. PCR confirmed HSV-1 infection, she was treated with valacyclovir and was discharged. She presented to the ED for the third time 6 days later, with ongoing fevers up to 102.8 degrees Fahrenheit and symptoms that progressed to difficulty ambulating, nausea, vomiting, diarrhea, and fatigue. Her labs were significant for an AST of 65 U/L, an ALT of 49 U/L, and a lactate of 1.7 mmol/L. Intravenous vancomycin, cefepime, and acyclovir were started and she was admitted. Abdominal computed tomography and lumbar puncture were without acute findings and included a negative cerebrospinal fluid HSV PCR. Serologies included negative viral hepatitis and human immunodeficiency virus studies. Her fever resolved 2 days into admission and intravenous acyclovir and antibiotics were discontinued. Labs trended up 4 days into admission and included: AST 574 U/L, ALT 426 U/L, and LDH 631 U/L. Despite these increases, the patient had no new fevers, her symptoms were improving, and bilirubin and alkaline phosphatase were not elevated. Liver failure was deemed unlikely, and she was discharged with close follow-up. Most likely etiologies were HSV hepatitis or drug-induced liver injury (DILI). Her symptoms resolved soon after discharge and her transaminases normalized over 6 weeks. IMPACT/DISCUSSION: HSV hepatitis is a rare and dangerous disease, associated with immunocompromised states, with a mortality rate approaching 90%1,2. Our patient appears to have developed HSV hepatitis despite being on treatment with valacyclovir and our review of the literature found no prior cases of HSV hepatitis occurring in a patient already on antivirals. Although the patient never had a liver biopsy to confirm, we believe this was the most likely cause due to her fevers starting before antibiotic administration and her bilirubin was normal. These suggest herpes hepatitis over DILI. She may have benefitted from her recent treatment with valacyclovir, experiencing clinical improvement early in her hospital course. Since HSV hepatitis is both rare and deadly, it is important to maintain a high degree of suspicion and treat early3. Full references not included due to character requirements. 1. PMCID: PMC7054783 2. PMCID: PMC6538099 3. PMCID: PMC7265941

1. HSV Hepatitis was thought to be most likely due to the fevers starting before antibiotic administration, high fevers, and normal bilirubin. This is the first case report of HSV hepatitis occurring despite prior use of antiviral medications. 2. She may have benefitted from early treatment with valacyclovir, lessening her clinical course. AN UNCOMMON CASE OF ACUTE PERICARDITIS: EXPLORING CARDIOTOXIC EFFECTS OF BINGE DRINKING ON HEART HEALTH Arshdeep Dhaliwal1; Changwoong Cho1; Tamara Goldberg2. 1Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Internal Medicine, Mount Sinai St. Lukes West, New York, NY. (Control ID #4270770) CASE: A 35-year-old male with a medical history of diabetes and alcohol use disorder presented to our hospital for alcohol detoxification. He reported consuming up to 1 liter of vodka daily, with his most recent binge-drinking episode on the day of admission. On the first day of hospitalization, he experienced an acute onset of sharp, squeezing retrosternal chest pain rated 8/10 in intensity. The pain was non-radiating, worsened by lying flat, and relieved by leaning forward. He reported similar episodes in the past, temporally associated with heavy alcohol use, lasting approximately 30 minutes. He denied any recent illness, fever, or symptoms suggestive of a viral infection. Physical examination was unremarkable. Electrocardiography (EKG) revealed diffuse ST-segment elevations with PR-segment depressions in most limb and precordial leads, along with ST depression and PR elevation in lead aVR, findings consistent with acute pericarditis. Laboratory tests showed no elevation in cardiac or inflammatory biomarkers. Transthoracic echocardiography demonstrated normal left ventricular ejection fraction, with no wall motion abnormalities or pericardial effusion. Based on the characteristic pericardial chest pain and EKG findings, a diagnosis of acute pericarditis was established. The patient was initiated on a regimen of ibuprofen taper and colchicine for three months, resulting in significant improvement in symptoms. IMPACT/DISCUSSION: Most cases of acute pericarditis are attributed to viral infections, autoimmune disorders, or uremia. Here, we present a unique case of acute pericarditis associated with binge drinking, an etiology that is not well-documented in the medical literature. While binge drinking is recognized as a risk factor for acute cardiac events, arrhythmias, autonomic dysfunction, and myocardial injury, these effects are thought to arise through mechanisms such as oxidative stress, immunological dysregulation, and direct myocardial toxicity. However, direct evidence linking binge drinking to acute pericarditis remains scarce1. In our case, the recurrent temporal association between binge drinking episodes and the clinical manifestations of pericarditis, coupled with symptom resolution following anti-inflammatory therapy, underscores the potential role of binge drinking as a precipitating factor. This case highlights the need for further investigation into this underexplored etiology of acute pericarditis, which may have implications for both diagnosis and prevention. Zagrosek A, Messroghli D, Schulz O, Dietz R, Schulz-Menger J. Effect of Binge Drinking on the Heart as Assessed by Cardiac Magnetic Resonance Imaging. JAMA. 2010;304(12):1328–1330. doi:10.1001/jama.2010.1343

This case highlights binge drinking as a potential but underrecognized cause of acute pericarditis. It underscores the importance of detailed history-taking in identifying atypical triggers and emphasizes the need for further research into alcohol-related cardiac inflammation. AN UNCOMMON CLINICAL PROGRESSION FROM PERIPARTUM CARDIOMYOPATHY TO LEFT VENTRICULAR NONCOMPACTION (LVNC) Giorgi Akhvlediani1; Suhani Dalal2; Tamar Bejanishvili2; Giorgi Maisuradze1,3. 1Department of Pulmonary and Critical Care Medicine, Tbilisi State Medical University, Tbilisi, Georgia; 2University Hospitals, Cleveland, OH; 3Clinical Oncology Tbilisi State Medical University, Tbilisi, Georgia. (Control ID #4247247) CASE: A 48-year-old woman, previously diagnosed with Peripartum Cardiomyopathy (PPCM) in 2016, presented for follow-up in 2023. Initially, her heart failure symptoms during the postpartum period were associated with a reduced left ventricular ejection fraction (LVEF) of 40-45%. She was treated with carvedilol, lisinopril, and spironolactone, improving LVEF to 60-65%. She remained stable, with no recurrence of heart failure exacerbation for several years. In early 2023, the patient experienced sudden blurry vision, and a retinal branch artery occlusion was diagnosed, strongly suspected to be of cardioembolic origin. An echocardiogram revealed significant left ventricular hypertrabeculation, prompting further investigation. A cardiac MRI confirmed LVNC, showing a non-compacted to compacted myocardium ratio of 3:1, primarily in the mid-to-apical segments of the left ventricle. Despite these findings, her LVEF remained at 64%. Anticoagulation with apixaban was started to reduce the risk of further thromboembolic events. Given the genetic implications of LVNC, she was advised to have her children undergo genetic screening. Since her diagnosis, the patient has adhered to her medication regimen and has attended regular follow-ups, including annual echocardiograms and cardiac MRIs, with no reported symptom progression. IMPACT/DISCUSSION: The incidence of LVNC is estimated at 8-12 cases per 1 million individuals annually. This case illustrates the diagnostic challenges associated with LVNC, particularly in the context of a patient with a prior diagnosis of PPCM. The thromboembolic event, manifested as a retinal artery occlusion, underscores the elevated risk of embolization in LVNC due to abnormal myocardial trabeculations, which result in turbulent blood flow. Timely initiation of anticoagulation therapy is essential to mitigate the risk of further embolic events. Cardiac MRI serves as the gold standard for diagnosing LVNC, offering superior resolution in assessing myocardial structure and accurately quantifying the non-compacted to compacted myocardium ratio. This imaging modality allows for clear visualization of the trabeculations and provides a more definitive diagnosis than echocardiography, which often lacks the sensitivity to detect this condition. MRI is also crucial for monitoring disease progression and identifying complications. Despite its rarity, LVNC is associated with significant clinical sequelae, including heart failure and arrhythmias. Furthermore, the genetic predisposition of LVNC necessitates screening of first-degree relatives, as early detection and intervention can significantly reduce the risk of adverse outcomes.

- LVNC should be considered in patients with a history of PPCM, particularly when new imaging abnormalities emerge - Anticoagulation therapy is essential in preventing embolic events in patients with LVNC - Cardiac MRI is the gold-standard modality for diagnosing LVNC and monitoring its progression over time AN UNCOMMON CULPRIT: BILIARY TRACT ANOMALIES AS A RISK FACTOR FOR ACUTE PANCREATITIS Misa Ito1; Aparna Venkatesan2; Hirotaka Kato3; Samuel Mardini3. 1MedPeds, University of Kentucky, Lexington, KY; 2Internal Medicine, University of Kentucky, Lexington, KY; 3Gastroenterology, University of Kentucky College of Medicine, Lexington, KY. (Control ID #4272512) CASE: A 44-year-old Asian woman with a history of recently diagnosed choledochal cyst presented to the emergency room with epigastric pain that started immediately after endoscopic retrograde cholangiopancreatography (ERCP). The patient had had a 5-month history of intermittent epigastric pain, and outpatient magnetic resonance cholangiopancreatography (MRCP) revealed fusiform dilation of the common bile duct (CBD) up to 15 mm, accompanied by an anomalous pancreaticobiliary junction with a long common channel, consistent with a type I choledochal cyst. ERCP demonstrated moderate focal dilation of the mid common duct to 12-15 mm, with smooth tapering to the ampulla. A long common channel was observed, with contrast filling the pancreatic duct during balloon occlusion of the CBD, just above the ampulla. On presentation, the patient was afebrile, and her physical examination was notable for epigastric tenderness. The initial workup showed lipase 2,880 U/L, normal bilirubin, and peripancreatic fat stranding, consistent with post-ERCP pancreatitis (PEP). On hospital day 2, the patient developed worsening transaminase levels and total bilirubin to 2.0 mg/dL, raising concerns for cholangitis. A right upper quadrant ultrasound was unremarkable. The patient’s acute symptoms resolved with a 7-day course of antibiotic treatment and supportive care. Given the increased risk of malignancy, elective surgical excision of the cyst with reconstruction using a Roux-en-Y hepaticojejunostomy (HJ) is planned. IMPACT/DISCUSSION: Choledochal cysts (CCs) are rare cystic dilations of the biliary tract associated with an increased risk of malignancy, pancreatitis, and cholangitis. Most cases (80%) are identified in children, but adult cases are increasingly recognized. Type I, which involves cystic dilation of the extrahepatic biliary duct, is the most common form among type I to V of Todani classifications and more commonly seen in females (4:1 ratios) and Asians as was our case. Abdominal pain is the most common presentation while the classic triad of abdominal pain, jaundice, and palpable abdominal mass is rare. CCs can cause pancreatitis, cholangitis, and other hepatobiliary infections due to reflux of pancreatic enzymes. The risk of PEP with CCs is not well studied, but MRCP is the preferred diagnostic test to avoid contaminating the biliary tree with the instrumentation. It might be reasonable to consider PEP prophylaxis (e.g., rectal indomethacine). Transformation into malignancy such cholangiocarcinoma is prevalent (7.5% to 30%). Complete resection of the cyst is recommended, with either Roux-en-Y HJ or Whipple procedure depending on the location/anatomy of the cyst.

CCs are increasingly diagnosed in the adult populations. Clinicians must be aware of the risk of malignant transformation, pancreatitis, and biliary infections and refer the patient to surgical oncology for resection and cancer surveillance. AN UNCOMMON TUMOR IN AN UNCOMMON LOCATION: METASTATIC RECTAL SQUAMOUS CELL CARCINOMA Paige Hammis2; Akshay Shah2; Nicole Rueb3; Marisa Echaniz1. 1Medicine, University of Colorado - Denver Health, Denver, CO; 2University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 3Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4273407) CASE: A 78-year-old male presented due to failure to thrive. He had stool incontinence, unintentional weight loss, and urinary retention. No shortness of breath, abdominal pain or constipation. Past medical history includes bipolar disorder, chronic encephalopathy, hypertension, and lupus. Notably, patient had a history of self-inflicted trauma to his rectum requiring surgical intervention years prior. No tobacco use. Family history was negative for malignancy. While admitted, he underwent an ultrasound for abnormal LFTs. It showed a hepatic lesion which prompted a CT abdomen/pelvis that demonstrated circumferential rectal thickening with perirectal lymph nodes/stranding, liver lesions, lung nodules, lytic bone lesions, and an irregular-shaped prostate. Rectal biopsy was positive for squamous cell carcinoma (SCC). Given primary SCC is rare, he underwent a liver biopsy to confirm this diagnosis -- pathology again revealed SCC. Initiation of chemotherapy was discussed with our patient and his family, who determined chemo was not within his goals of care. He was discharged to hospice. IMPACT/DISCUSSION: Primary rectal SCC is a rare malignancy that accounts for 0.3% of rectal cancers with average age being 63.1 Symptoms of rectal SCC are difficult to detect as they are non-specific. This patient’s urinary retention was likely due to his cancer; however, it was initially attributed to benign prostatic hyperplasia. His weight loss/stool incontinence was originally ascribed to his cognitive decline. This case is a reminder to keep a broad differential, and consider diagnoses, such as primary rectal SCC, when faced with non-specific symptoms. It has been hypothesized that rectal SCC is associated with processes that cause inflammation in the rectum, such as IBD or HPV.2 This patient’s history of rectal trauma with a foreign object requiring surgery could have contributed to chronic inflammation. Therefore, this case proposes another potential association with development of rectal SCC. It is important to keep this diagnosis in mind when seeing patients who may have a history of rectal trauma or other causes of inflammation, especially as rectal SCC is often diagnosed at an advanced stage due to clinicians’ unfamiliarity with the diagnosis.

Primary rectal SCC is a rare malignancy that is important to keep on the differential in patients with chronic inflammation of the rectum Presenting symptoms of primary rectal SCC are often non-specific, including weight loss, urinary retention, and stool incontinence, which makes it difficult to diagnose until advanced stages AN UNEXPECTED TURN: A CASE OF CAMPYLOBACTER DIARRHEA LEADING TO SEVERE COMPLICATIONS. Abdelrahman Yakout1; Suraj Modi2; Moyan Sun1; Henry Colorado1; Rahul Patel1; Noorine Plumber1; Cristina Vidal Carrion1; Chiugo Okoye1; Pa Ousman Sillah1; Sonu Gupta1. 1Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA; 2Augusta University, Athens, GA. (Control ID #4271792) CASE: A 61-year-old-male with a history of hypertension presented to the ER due to a pre-syncopal episode. The patient has been complaining of diarrhea for the past 10 days after consuming expired turkey lunchmeat but has been otherwise feeling well. On the day of presentation, he fell to the ground while he was getting out of bed and could not get up due to extreme weakness. In the ED his blood pressure fluctuated between 90/75 and 251/135, subsequently, a nicardipine drip was started. On physical exam, the patient had 1/5 bilateral lower limb weakness with absent reflexes and sensations up to the hip and complete loss of hand grip power. Given the history and presentation, suspicion for Guillan-Barré syndrome (GBS) was high. Neurology was consulted and the patient was started on 2g/kg of IVIG. The patient was admitted to the Neuro-IMC due to concerns of rapid progression of symptoms and potential respiratory involvement. On the night of admission, the patient became dyspneic with increased work of breathing and was transferred to the Neuro-ICU. By the following morning, he was unable to protect his airway and was emergently intubated. A stool PCR was positive for Campylobacter and the lumbar puncture was positive for GD1b antibodies with EMG showing severe sensory motor peripheral neuropathy. MRI of the brain and spine was non-revealing. After receiving 5 doses of IVIG the patient showed no signs of improvement with complete loss of all motor functions including eye movement. Eventually, a tracheostomy was performed, and plasmapheresis was started. He also developed constipation that progressed to ileus likely due to the autonomic dysregulation. The patient underwent a total of 6 plasmapheresis sessions followed by 3 additional doses of IVIG. He slowly started regaining facial and ocular movement, followed by head movement after a month of his admission. He was discharged to a rehabilitation center after 45 days of hospitalization. He continues to show slow but steady neurological improvement but remains quadriplegic and ventilator dependent to this day. IMPACT/DISCUSSION: Although GBS is a known sequela of Campylobacter infection, the rapid progression and severity of the symptoms in this patient highlights how quickly this condition can deteriorate, especially with respiratory involvement. The involvement of the autonomic nervous system with the fluctuation of blood pressure and ileus further complicates management and emphasizes the need for close monitoring in such cases.

1-Campylobacter infections can be complicated with GBS which can present with ascending paralysis, sensory deficit, and dysautonomia 2- Prompt identification of symptoms progression with appropriate triaging and low threshold for ICU admission and intubation. AN UNLIKELY UNIFYING DIAGNOSIS: GAS MENINGITIS Shereen Arco, Kathleen Glenn. Hospital Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4272465) CASE: A 74-year-old female with PMH of post-surgical lymphedema, T2DM, HTN, and hypothyroidism presented for a fall. On arrival, she was alert & oriented x 3, moving all extremities and hemodynamically stable with normal vital signs. After a negative trauma workup, she was admitted for hypoxia of unknown etiology. Review of systems was positive for pain to posterior neck (in c-collar), RUE and right ankle pain with movement. The patient denied cough, fevers, back pain, headache, recent illness, and sick contacts. Physical assessment was unremarkable except for a blister to right ankle and chronic lymphedema to the RUE. The patient explained she had fallen on her right side, lying on those prominences for several hours while awaiting help. Labs on admission were notable for UA with evidence of infection, no significant leukocytosis, and respiratory viral panel negative. On hospital day 2, a rapid response was called for acute onset confusion, eye twitching, increased hypoxia and one recorded fever. CT head, CTPE and EEG negative. Urine culture notably growing strep pyogenes, and patient received one dose ceftriaxone at that time. On hospital day 3, a rapid response was called again for confusion and hyperactivity in bed. Patient remained hemodynamically stable, afebrile, without leukocytosis but acutely altered, and an LP was performed. By end of day hospital day 3, CSF returned positive for Group-A-Streptococcus. By hospital day 4, the patient’s abrasion on her right ankle developed into a blistering rash with bullae. This was thought to be the source of her GAS infection, and an abscess was later found at the site of her rash. Blood cultures were obtained and remained negative throughout hospitalization although this is possibly due to being briefly treated with ceftriaxone prior to collection. After antibiotic treatment, the patient returned to her baseline and was discharged. IMPACT/DISCUSSION: The only finding in this case that fit the picture of bacterial meningitis was acute encephalopathy. In retrospect, her “sore neck from fall” in a c-collar could have been nuchal rigidity. Furthermore, her blood cultures returned negative but followed one dose of ceftriaxone. Even one dose of antibiotics prior to obtaining cultures may cause cultures to return without evidence of infection.

While a rare etiology (literature review states 1-4% of cases), GAS can cause bacterial meningitis. Lumbar punctures are overall safe procedures with backache and headache being the most significant reported adverse events. They are indicated urgently when concerned for infectious meningitis/encephalitis. In patients with altered mentation and no other etiology identified, it is reasonable to obtain an LP in the absence of infectious symptoms. Finally, small physical assessment notes, like an ankle blister, can help provide a unifying diagnosis. AN UNUSUAL CASE OF CEFTRIAXONE-ASSOCIATED AGRANULOCYTOSIS IN A WOMAN WITH COLON CARCINOMA Olivia Steczko1; Shruti Kumar1; Carson Oprysko1; Madura Saravanan2. 1PCIM, University of Connecticut School of Medicine, Farmington, CT; 2Hospital of Central Connecticut at New Britain, New Britain, CT. (Control ID #4270554) CASE: A 73-year old woman with history of pulmonary embolism on apixaban, COPD on baseline oxygen, hypertension, hyperlipidemia and multiple episodes of bloody stool over the last several years presented for 3 months of worsening shortness of breath. Her most recent episode of bloody stool was 1 week prior to admission. Studies on admission were remarkable for hemoglobin 8.3 g/dL, hematocrit 29.1%, WBC 10.1/μL, ANC (absolute neutrophil count) 9.63/μL, and reticulocytes 2.6%. She was admitted for symptomatic anemia and COPD exacerbation and initially started on IV vancomycin and steroids for the same. She received 1 unit of packed red blood cells. Blood cultures returned positive for streptococcus mitis and vancomycin was transitioned to 2g IV ceftriaxone daily. Echocardiograms did not show valvular vegetations. Upper and lower endoscopy revealed an infiltrative 5cm nonobstructing mass in the sigmoid colon which was resected during hospitalization and identified as adenocarcinoma with mucinous features and nodal metastases. She completed 14 days of ceftriaxone for streptococcus bacteremia. A day after she completed the antibiotic course, she developed leukopenia with WBC count of 2.8/μL. Over the next 3 days her leukopenia worsened with ANC nadir of 0.0 meeting criteria for agranulocytosis. Hematology-oncology was consulted and she was treated with 4 doses of G-CSF. WBC normalized 2 days following G-CSF therapy with ANC of 1.3 and she was discharged. Neither neutropenia nor agranulocytosis recurred within 2 years of follow up. IMPACT/DISCUSSION: Overall incidence of drug-induced neutropenia ranges from 2.4–15.4 cases/million. Non-chemotherapy drug-induced neutropenia is defined as ANC of <500/μL and agranulocytosis as ANC of zero. In our patient agranulocytosis developed shortly after a cumulative dose of 28g of ceftriaxone over 14 days. Cephalosporins have been implicated as a cause of agranulocytosis; however existing literature has described cases of ceftriaxone agranulocytosis in association with other therapies such as methotrexate, gentamicin, meropenem, or vancomycin, or with longer durations and higher cumulative doses. On average, mild neutropenia tends to occur in 5-15% of patients receiving ß-lactam antibiotics; with ceftriaxone, it tends to occur with a mean cumulative dose of 51g around day 21-22 of treatment. The exact mechanism of neutropenia is unclear but may involve immune-mediated mechanisms via haptens or inhibition of granulopoiesis. Treatment involves immediate cessation of ceftriaxone and support with G-CSF therapy. ß-lactam antibiotics are usually avoided in the future to minimize risk of cross-reactivity although reports have shown this may not be necessary. Close monitoring of CBC with differential is advised while on longer duration of therapy.

Ceftriaxone is a commonly used and well-tolerated antibiotic with a relatively safe side effect profile; however, it may rarely cause neutropenia. Prognosis is good and neutrophil counts recover with time. AN UNUSUAL CASE OF POLYMICROBIAL INFECTIVE ENDOCARDITIS PACEMAKER-ASSOCIATED INFECTIVE ENDOCARDITIS Rahul s. Tripathi, Valjean R. Bacot Davis, Matthew Pelletier, Alexander S. Kaiteris. Internal Medicine, Stony Brook University Hospital, Stony Brook, NY. (Control ID #4273380) CASE: This is a case of infective endocarditis after the initial presentation of pacemaker extravasation with overlying cellulitis. A large vegetation was identified by echocardiography attached to the pacemaker wire at the level of the tricuspid valve associated with tricuspid regurgitation. The patient is a 75-year-old male who presented to the emergency department with the chief complaint of skin breakdown and pacemaker exposure. The erosion was noted 4 days before presentation associated with serosanguinous discharge—no reported trauma, fever, chills, dizziness, or syncope. Medical history was significant for complete heart block. Examination at the time revealed pacemaker exposure at the left anterior mid-clavicular line with associated erythema,serosangous discharge, and skin breakdown. The site was warm to touch, although was non-tender. Initial laboratory findings were within normal limits. Pacemaker interrogation revealed normal thresholds. Atrial leads did not appear to be functioning at the time. A transesophageal echocardiogram revealed 0.98 X 0.55 cm vegetation attached to the pacer catheter at the level of the tricuspid valve with moderate tricuspid regurgitation. Cultures of pacemaker leads grew Staphylococcus Ludunesis and Staphylococcus epidermidis. Pacemaker leads were extracted and a subsequent leadless pacemaker was placed. Treated with ceftriaxone daily and vancomycin daily until cultures resulted. IMPACT/DISCUSSION: Here we present a case of infective endocarditis after initial hospital presentation for cellulitis with cardiac pacemaker skin breakthrough. A large mobile vegetation was seen by echocardiography attached to the pacemaker wire at the tricuspid valve with moderate tricuspid regurgitation. Wound culture was positive for Staphylococcus. Pacemaker culture of the ventricular lead grew Staphylococcus lugdunensis and Staphylococcus epidermidis. Culture of the atrial lead grew Staphylococcus epidermidis. The patient was treated with IV Ceftriaxone and vancomycin during hospitalization, and discharged with a peripherally inserted central catheter to complete 6 weeks of IV vancomycin with outpatient infectious disease follow-up. This unique case of likely polymicrobial Staphylococcus biofilm-mediated endocarditis offers insight into treatment strategies for complex Staphylococcus lugdunensis and Staphylococcus epidermidis endocarditis and reappraises challenges in treating polymicrobial infections and biofilm formation on cardiac devices.

This case demonstrates the importance of early and aggressive treatment of pacemaker associated endocarditis. This can lead to the eradication of biofilm formation on foreign indwelling devices and prevent further pacemaker extravasation and infection. Staphylococcus ludenesis is atypical coagulase-negative staphylococcus that can often lead to severe infection. Without early identification and aggressive management strategies, prognosis can often be poor. AN UNUSUAL CASE OF POST-POLYPECTOMY ANTICOAGULATION SYNDROME AFTER A ROUTINE COLONOSCOPY IN A COMMUNITY HOSPITAL Jason Truong1; Amruth A. Alluri2. 1Department of Medicine, Kansas City University, Kansas City, MO; 2Internal Medicine, American University of the Caribbean School of Medicine, Miami, FL. (Control ID #4273580) CASE: The patient is a 55-year old female who presented to a community hospital in the Pacific Northwest region with epigastric abdominal pain, fever, and tachycardia status-post routine colonoscopy. Medical history was significant for SLE, hypertension, hyperlipidemia, chronic thrombocytosis and an atrophic spleen. Home medications included lisinopril, atorvastatin, rituximab and hydroxychloroquine. Patient presented to the ED with moderate epigastric pain, fever, and tachycardia. Physical exam was unremarkable except for vague, dull epigastric pain. CBC showed mildly elevated WBC of 12 and chronic thrombocytosis. CMP showed significantly elevated transaminitis with a predominantly hepatocellular pattern with AST and ALT in the 400-500’s on admission. CT imaging of the abdomen and pelvis was unremarkable. Right upper quadrant ultrasound was unremarkable. Complete infectious workup including Hep A, B and C panels and HIV panel was normal. Autoimmune workup for possible autoimmune hepatitis was started. Upon consultation with gastroenterology, post-polypectomy electrocoagulation syndrome was proposed due to the acute nature of the abdominal pain within 1 hour after the colonoscopy. As a 10-mm transverse colon polyp was resected using a hot snare, this diagnosis was likely in the setting of the patient’s history of SLE. She was started on 1 L of IV LR and empiric ceftriaxone and metronidazole. She significantly improved within day 2 of admission with resolution of abdominal pain, tolerance of general diet and improved transaminases. Patient was discharged with oral ciprofloxacin and metronidazole to complete a seven-day course of treatment. Outpatient follow-up with gastroenterology and rheumatology was arranged to follow up on the elevated autoimmune antibodies. IMPACT/DISCUSSION: We present a case of post-polypectomy electrocoagulation syndrome in a middle-aged female with a history of autoimmune disease. Post-polypectomy electrocoagulation syndrome is relatively uncommon with a large multicenter study of 47,083 patients showing 34 patients developing post-polypectomy syndrome at a rate of 0.07 percent.. Risk factors include lesion size, shape and location, hypertension, and autoimmunity. The development of abdominal pain, fever, leukocytosis without bowel perforation immediately post-colonoscopy made the diagnosis very likely. The most likely etiology was peritoneal inflammation caused by electrocautery, with the patient’s autoimmunity predisposing for higher inflammation. Clinicians should consider this after colonoscopy to obviate the need for invasive surgery. Treatment is IV fluids, IV empiric antibiotics for 2-3 days with PO antibiotics to complete 7 days, and bowel rest or clear liquid diet until tolerance of general diet.

Post-polypectomy electrocoagulation syndrome can present acutely after a colonoscopy with the use of electrocautery. Prompt treatment with IV fluids and empiric IV antibiotics can resolve this issue without the need for invasive surgery. AN UNUSUAL CASE OF PYLEPHLEBITIS IN THE SETTING OF CLOSTRIDIUM DIFFICILE COLITIS Trevor J. Wyand2; Matthew Stagg2; Jay Park1; Matt Coster1. 1Hospital Medicine, Georgetown University, Washington, DC; 2Internal Medicine, MedStar Georgetown University Hospital, Washington, DC. (Control ID #4241429) CASE: A 52 year-old female with colon cancer status post right hemicolectomy, and on capecitabine, presented with acute onset of right-sided abdominal pain and diarrhea. She was afebrile, hemodynamically stable, and had no leukocytosis. CT of the abdomen and pelvis showed pylephlebitis - probable septic thrombus involving the right portal vein (PV), extrahepatic central PV, and diffusely involving the superior mesenteric vein (SMV) - in addition to findings of infectious colitis. A bedside ultrasound confirmed the diagnosis of a thrombus in the PV. Infectious disease was consulted and recommended ceftriaxone and metronidazole, which she would receive for four weeks. Stool testing was positive for toxigenic C. difficile antigen and she completed a course of oral vancomycin. The blood cultures remained negative. Hematology was consulted and she was started on therapeutic Enoxaparin. Follow-up CT revealed a significant decrease in SMV and PV thrombus with small, non-occlusive thrombi in the SMV, but noted chronic thrombosis in the right PV system. IMPACT/DISCUSSION: Pylephlebitis, or infectious thrombophlebitis of the PV, is a rare sequela of intra-abdominal infections with diverticulitis and appendicitis being the most common sites of infection. Bacteremia is often present, typically monomicrobial, though may also be polymicrobial with typical culprits being Escherichia coli, Streptococcus spp., and Bacteroides spp. Symptoms are typically vague, with abdominal pain, fever, diarrhea, and vomiting being the most common symptoms. The role for anticoagulation is not clear, but is typically recommended in patients with progression of thrombosis, persistent fever despite antibiotics, thrombosis extending beyond the main PV branch, or those with a hypercoagulable state. We present a case of pylephlebitis involving the right PV, extrahepatic central PV, and diffusely involving the SMV in the setting of colitis. This case is distinctive due to its association with C. difficile colitis likely resulting in a transient bacteremia and subsequent thrombophlebitis. A review of the literature showed that C. difficile has rarely been associated with bacteremia, pyogenic liver abscesses, and pylephlebitis. Furthermore, capecitabine being associated with enterocolitis posed a diagnostic challenge and whether this was contributory in this case would be difficult to determine. It also helped highlight that portal venous thrombosis can be detected with ultrasound with doppler or contrast-enhanced CT. This case emphasizes the importance of considering C. difficile colitis in the evaluation for extracolonic manifestations.

Rarely, Clostridium difficile colitis can have extracolonic manifestations, including bacteremia, pyogenic liver abscesses, and pylephlebitis. Infectious portal venous thrombosis can complicate intra-abdominal infections and can be detected on ultrasound with doppler or contrast-enhanced CT. AN UNUSUAL CAUSE OF LARGE VOLUME HEMATEMESIS: REFLUX ESOPHAGITIS Isha Bhutada1,2. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, James J Peters VA Medical Center, New York, NY. (Control ID #4273170) CASE: A 66-year-old male with a history of alcohol-associated decompensated cirrhosis (complicated by ascites and esophageal varices 2 years prior) presented with abdominal pain and massive hematemesis, requiring transfusions of multiple units of PRBCs. EGD was notable for Grade D esophagitis, but no other sources of an UGIB were identified, including esophageal varices or ulcerations. He was discharged with a PPI but was non-compliant at follow up. He stopped using alcohol. 10 weeks later, he presented with 1 day of abdominal pain, shortness of breath and multiple episodes of 300-600cc bright red hematemesis. He was tachycardic to 104 and hypotensive 97/60. Exam revealed a diffusely tender abdomen. Due to his history, he was started on an IV PPI, Octreotide, and empiric antibiotic. His Hgb was 5.3, requiring transfusion, after which it corrected to his baseline of 9. Labs: PT 17.1, INR 1.41, aPTT 33.5, and Plt 483. He declined EGD. He was discharged home after hemodynamically stable but died 2 weeks later. IMPACT/DISCUSSION: Esophagitis has been recognized as a cause of upper gastrointestinal bleeding, but there is limited literature documenting severe hematemesis secondary to esophagitis. While 8.1% of UGIB are associated with esophagitis, these are rarely large volume, as esophagitis is confined to the mucosa. In contrast, ulcers or pathologies directly affecting submucosal vasculature can cause more serious and rapid bleeding. Indeed, evidence suggests that bleeds secondary to esophagitis are associated with a lower transfusion requirement and rebleeding risk. Our patient presented with LA Grade D esophagitis. Given the severity of his esophagitis and his noncompliance with his PPI, it is possible that he developed esophageal ulcers after his EGD and prior to his second hospital presentation, as erosive esophagitis with prolonged acid exposure can develop into ulcers that can cause severe bleeding. However, there are few cases describing the speed of progression of erosive esophagitis to ulcerative disease. Without objective imaging data in the case of our patient, we are unable to further assess if this was the case. However, we must also consider other risk factors that may have predisposed him to present with hemorrhage. Interestingly, literature has suggested that UGIB can be more severe and result in longer hospital stays in esophagitis patients with cirrhosis than without. Non-variceal spontaneous bleeding has been reported as a cause of morbidity and mortality in patients with cirrhosis. Although the reason for this has not been ascertained, it is possible that coagulopathy in the setting of impaired liver function could contribute to increased bleeding risk in esophagitis patients with cirrhosis, as these patients have reduced levels of clotting factors and endogenous anticoagulants.

Ultimately, this case emphasizes the importance of recognizing esophagitis as a potential cause of large volume hematemesis, even in patients with decompensated cirrhosis. AN UNUSUAL CAUSE OF RECURRENT STROKE: A CASE OF CEREBRAL BETA AMYLOID ANGIITIS Thanmayi Parasu1; Taheea R. Ahmed2; Nazrul I. Chowdhury3. 1Student, The University of Texas Medical Branch at Galveston, Galveston, TX; 2Baylor Scott & White Health, Mckinney, TX; 3Banner Baywood Medical Center, Mesa, AZ. (Control ID #4271105) CASE: A 67-year-old male with hypertension and hypothyroidism was admitted in October 2022 with altered mental status (AMS) and required intubation. He was diagnosed with a cerebrovascular accident, and a patent foramen ovale (PFO) was found on transthoracic echocardiogram. Venous Doppler revealed deep vein thrombosis and the patient was discharged on aspirin, statin, and Eliquis. Two months later, he was readmitted for another ischemic stroke and seizure. Dual antiplatelet therapy and Keppra were initiated for seizure prophylaxis. However, he developed upper gastrointestinal bleeding from a duodenal ulcer, which was managed with cautery and epinephrine. Direct oral anticoagulant therapy was paused for two weeks, and proton pump inhibitors were prescribed. After neuro-rehabilitation, he remained stable until February 2023, when he was readmitted with AMS and seizure-like symptoms. On examination, he was disoriented, with left facial asymmetry and left-sided weakness. Labs revealed elevated WBC at 11.5 x 10^3/uL, creatinine of 2.6 mg/dL, and normal lactate with negative infectious and autoimmune workups. CT showed deep subcortical white matter hypodensities, and MRI revealed multiple areas of restricted diffusion, increased T2/FLAIR signal, and cortical enhancement. A lumbar puncture showed elevated CSF protein (234 mg/dL) and WBC (126 cells/μL), predominantly lymphocytes. A brain biopsy confirmed cerebral amyloid angiopathy-related inflammation (CAA-ri) with vasculitis. The patient was started on high-dose methylprednisolone and transferred to a tertiary center for cyclophosphamide and tapering prednisone. He showed significant neurological improvement and remained symptom-free by 2024. IMPACT/DISCUSSION: This case highlights the diagnostic difficulties of recurrent strokes in patients with PFO. Although paradoxical embolism through a PFO is a common cause of ischemic stroke, this patient's persistent symptoms despite anticoagulation prompted further investigation. CAA-ri, a rare but increasingly recognized cause of recurrent strokes and seizures in older adults, can mimic other neurological disorders, complicating diagnosis. In this case, brain biopsy confirmed the diagnosis of CAA-ri.

Immunosuppressive therapy is the primary treatment for CAA-ri and can lead to significant neurological recovery. Early diagnosis and treatment are crucial for favorable outcomes in recurrent neurological symptoms, as demonstrated by this patient’s recovery. The case also underscores the challenge of balancing stroke prevention with bleeding risks in anticoagulated patients. While paradoxical embolism is common in patients with PFO, rare conditions like CAA-ri must be considered when symptoms persist despite treatment. A thorough diagnostic workup and a multidisciplinary approach involving neurology, rheumatology, and cardiology are essential in managing complex cerebrovascular cases. AN UNUSUAL OUTCOME OF MYASTHENIC CRISIS Omaima Chaudhary1; Maimona Chaudhary2; Muhammad S. Zubair3; Erin McFadden1. 1Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA; 2Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; 3Medicine, Windsor University School of Medicine, Cayon, Saint Mary Cayon Parish, Saint Kitts and Nevis. (Control ID #4273233) CASE: Patient is a 69-year-old male with a history of hypertension, dyslipidemia, and gout who presented with one month of worsening dysphagia, hoarseness, and jaw locking. Vitals and labs were within normal limits. Esophagogastroduodenoscopy and barium swallow were unremarkable. Flexible laryngoscopy was also normal. Neurology was consulted who ordered magnetic resonance imaging (MRI) brain which was normal and a lumbar puncture (LP) which showed minimal cerebrospinal fluid protein elevation. Antibody workup for Miller-Fisher syndrome and myasthenia gravis (MG) was ordered. An empiric five-day course of intravenous immunoglobulin (IVIG) was started. Due to continued bulbar and respiratory weakness, electromyography was done which revealed neuromuscular junction transmission disorder. Acetylcholinesterase receptor antibodies were positive confirming MG so methylprednisolone and pyridostigmine were added. Respiratory distress continued to worsen, requiring BiPAP, and subsequent elective intubation. On day 2, a sedation vacation was initiated to assess his neurological status but the patient remained unresponsive, even after the discontinuation of all sedatives and despite arterial blood gas showing adequate oxygenation on adaptive support ventilation. Further workup with electroencephalography, repeat MRI brain, and LP failed to reveal a cause for his altered mental status. Plasmapheresis was initiated as a last resort but despite completing seven days, patient remained unresponsive. With no clear diagnosis, the patient's family opted for comfort measures, and he passed away peacefully. IMPACT/DISCUSSION: Myasthenic crisis (MC), defined as worsening myasthenia weakness requiring intubation, is a life-threatening exacerbation of myasthenia gravis (MG). It occurs in about 20% of MG patients within the first 2-3 years, but as seen in this case, can occur during the initial presentation. While typically caused by respiratory muscle weakness, it can also be due to bulbar weakness leading to airway collapse. Immediate intubation and mechanical ventilation are critical. Treatment involves either IVIG (2 g/kg over 2-5 days) or plasmapheresis (5 sessions over 7-10 days). Although there is limited data comparing the two, some studies show improvement with plasmapheresis in cases of IVIG failure. Response to treatment is typically seen within 2 days. High-dose prednisone and pyridostigmine can also be added. Most patients can be weaned off from mechanical ventilation and prognosis is generally favorable. The mortality rate is 5-12%, usually due to multi-organ failure due to sepsis or continued respiratory failure despite appropriate care. This is an unusual case where the patient's respiratory function recovered but he failed extubation due to deteriorating mental status and inability to protect his airway.

This case presents an unusual outcome of myasthenic crisis, where despite respiratory improvement, patient’s neurological function deteriorated. AN UNUSUAL PRESENTATION OF GRANULOMATOSIS WITH POLYANGIITIS WITH PRIMARY SKIN INVOLVEMENT Josiah P. Stryd1; Snigdha Reddy2. 1Student, Wayne State University School of Medicine, Detroit, MI; 2Nephrology, Henry Ford Health System, Detroit, MI. (Control ID #4270948) CASE: We present a case of a 60-year-old male who had recently been admitted for pleuritic chest pain and had been found to have a lung mass and multiple nodules with concerns for a malignancy diagnosis. He presented with a new onset bullous, hemorrhagic purpuric and petechiae to his bilateral hands, feet, lips, and nares. Notably, the patient had retiform purpura over the bilateral MCP, DIP, and PIP joints on the dorsal surface of the hand. His workup revealed a C-ANCA titer of 1:80 and proteinase-3 autoantibodies level of 116. Skin biopsy demonstrated bullous and leukocytoclastic vasculitis, leading to a diagnosis of granulomatosis with polyangiitis. Although C4 was notably low, cryoglobulin testing was negative. Bronchoscopy determined the lung mass and nodules to be secondary to GPA. Urine microscopy demonstrated microscopic hematuria with acanthocytes and preserved renal function. Following several days of steroids the patient began to have an improvement in his purpuric lesions. Rituximab infusions were initiated for definitive management. IMPACT/DISCUSSION: This case demonstrates the variation in presentation of GPA and the importance of keeping a broad differential inclusive of autoimmune diseases. The clinical triad of upper respiratory, lung, and kidney involvement was largely present in this case, but most notable were skin findings, which are only present in 34% of GPA cases. Skin findings in this case were markedly widespread in involvement and occurred in a symmetric pattern across the extremities. However, rather than anchoring on specific symptoms, this case benefited from keeping an open mind. Additionally, considering overlapping patterns of disease expression and effectively ruling out other manifestations of autoimmune disease such as cryoglobulinemia was important in this case. Treatment in this case was definitive and effective because it addressed the underlying pathophysiological process of GPA by interrupting autosensitization.

- As vasculitides have extremely varied presentations, it is important to avoid anchoring on a particular diagnosis and to maintain a broad differential - Regardless of presentation, treatment that addressed the underlying pathophysiology, as confirmed by serology, was effective in addressing the varied manifestations of GPA ANXIETY-INDUCED SPONTANEOUS PNEUMOMEDIASTINUM: A RARE CAUSE Rochelle A. Jayavendra1; Aman Saleemi1; Gagandeep Singh3; Bushra Shezhad4; Umer Javaid1; Zain Kulairi2. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI; 3internal medicine, Wayne State University School of Medicine, Detroit, MI; 4Transitional, Trinity Health Oakland Hospital, Pontiac, MI. (Control ID #4273174) CASE: A 29-year-old male with a past medical history of anxiety presented to the ED with complaints of chest pain. The patient reported experiencing symptoms of hyperventilation and heart palpitations upon waking up. Due to this, he had attempted to lie down to alleviate his symptoms, which later led to the onset of chest pain radiating to his anterior neck and excessive coughing. Upon evaluation in the ED, the patient was noted to be tachycardic, hyperventilating and restless. CT chest was completed which revealed pneumomediastinum with extension into the pericardium and lower neck. Follow-up CT angiography confirmed the presence of pneumomediastinum dissecting into the neck soft tissues. Further imaging including chest x-ray showed significant subcutaneous emphysema in the lower neck, while an esophagogram was unremarkable. Given that symptoms seemed to have been triggered by hyperventilation, secondary to anxiety, patient was administered Ativan which provided symptomatic relief. With his imaging findings and clinical presentation, the patient was admitted to the ICU with a diagnosis of spontaneous pneumomediastinum, likely precipitated by hyperventilation, after ruling out all causes. Conservative management with analgesia and rest was initiated, and psychiatry was consulted. The patient was discharged home on Zoloft to help manage his symptoms of anxiety. IMPACT/DISCUSSION: While pneumomediastinum is commonly associated with trauma, underlying lung diseases, connective tissue disorders, or iatrogenic causes, this case highlights the rare occurrence of spontaneous pneumomediastinum resulting from anxiety-induced hyperventilation. Though not widely documented, labored breathing can lead to barotrauma, where the imbalance in pressures causes damage to the surrounding tissues. The clinical significance of this case lies in recognizing the rare occurrence of pneumomediastinum as a complication of anxiety-induced hyperventilation. It emphasizes the importance of considering psychological factors when considering etiology of diagnosis, especially in those patients with unexplained chest pain or respiratory distress. This case illustrates the need for inclusion of addressing psychological factors and integrating them into evaluation. By expanding awareness of anxiety as a potential trigger for pneumomediastinum, this case contributes insights to clinical practice on stress-related physical manifestations, particularing in the absense of typical causes such as trauma or pulmonary disorders.

In conclusion, this case emphasizes the importance of recognizing anxiety as a potential cause of unusual physical manifestations like pneumomediastinum, especially in patients presenting with unexplained chest pain or dyspnea. Addressing the psychological root cause alongside physical symptoms, especially in the presence of history of psychological disorders, is critical and provides a holistic, integrated approach to care. AORTIC ROOT ABSCESS: A LIFE-THREATENING COMPLICATION OF UNDERLYING BICUSPID AORTIC VALVE Isna Khaliq1; Matthew DiMeglio2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Cardiology, Rush University Medical Center, Chicago, IL. (Control ID #4273429) CASE: A 23-year-old man, recently diagnosed with influenza A, presented with fevers and shortness of breath. Vitals were notable for hypoxia, and lab results were unremarkable. Chest X-ray showed a consolidation in the right middle lobe. The patient was admitted for acute hypoxic respiratory failure, and was started on empiric antibiotics and oseltamivir. Infectious workup revealed positive blood cultures with methicillin-sensitive Staphylococcus aureus (MSSA). Despite treatment with antibiotics, the patient continued to experience fevers and hypotension. A transthoracic echocardiogram indicated a normal ejection fraction but suggested possible bicuspid aortic valve (BAV), endocarditis, and mild aortic regurgitation. A transesophageal echocardiogram confirmed BAV and endocarditis and revealed a 2.4 cm x 1 cm heterogeneous echo density near the aortic root, suggestive of an abscess. Cardiothoracic surgery was consulted, and the patient underwent extensive debridement of the aortic root abscess, along with aortic root replacement via a modified Bentall procedure using a 25 mm St. Jude mechanical valve conduit and reimplantation of the coronary arteries. His postoperative course was complicated by acute blood loss anemia but was otherwise uneventful. The patient was started on warfarin and discharged with a six-week antibiotic regimen and outpatient follow-up. IMPACT/DISCUSSION: BAV is one of the most common types of congenital heart disease and affects ~ 1% of the population. It has several complications, such as aortic stenosis/regurgitation, endocarditis, aortic root dilation, aortic aneurysm, aortopathy, and dissection. Patients with BAV have a 2% to 5% incidence of infective endocarditis over 5 to 25 years, and BAV accounts for 25% to 30% of aortic valve endocarditis cases. BAV endocarditis necessitates cardiac surgery in 54% to 85% of cases and poses a high risk for perivalvular abscess. Aortic root abscess is a life-threatening complication of aortic endocarditis and a major cause of morbidity and mortality among these patients. An aortic root abscess should be considered in patients with persistent fevers and hemodynamic instability despite being on antibiotics. Early diagnosis and prompt surgical intervention, including abscess debridement and aortic valve replacement, are essential to prevent death. An untreated aortic root abscess can lead to severe complications like valvular dysfunction, cusp perforation, coronary flow obstruction, and arrhythmia. Even after surgery, the mortality risk for patients ranges from 12% to 30%.

This case highlights the life-threatening complications associated with a BAV in a young, healthy patient. Our patient had an underlying BAV, and the onset of his condition was triggered by a benign influenza infection, which subsequently led to bacterial pneumonia, bacteremia, endocarditis, and aortic root abscess. Surgical debridement of the abscess and valve reconstruction are vital for source control and infection treatment. A PAIN IN THE NECK: A CASE OF CAROTID ARTERITIS IN A PATIENT ON IMMUNOTHERAPY Samantha P. Beik1; Vasilii Bushunow2; Jeffrey M. Boby5; James Son3; John Rhee4; Janie Zhang4. 1Internal Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 2Internal Medicine, Division of Hematology and Oncology, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA; 3Internal Medicine, Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA; 4Internal Medicine, Division of Medical Oncology, University of Pittsburgh, Pittsburgh, PA; 5Government Medical College Kozhikode, Kozhikode, KL, India. (Control ID #4271669) CASE: A 60-year old man presented with 4 days of right-sided neck pain and fevers. He was receiving chemoimmunotherapy for stage 4 cholangiocarcinoma, including durvalumab, a PDL1 inhibitor, and granulocyte colony-stimulating factor (G-CSF). Exam revealed tenderness at the right carotid bulb. Lab studies included ESR of 62 mm/hr, CRP of 13.2 mg/dL, and normal rheumatoid factor, C3/C4, anticardiolipin antibodies, and ANA/ANCA. Neck CT showed circumferential wall thickening and perivascular fat stranding of the distal right common carotid artery, carotid bifurcation and proximal internal carotid. Infectious workup was unrevealing. Temporal artery biopsy showed mild intimal hyperplasia and focal adventitial inflammation, suspicious but not definitive for giant cell arteritis (GCA). We recommended steroids to treat an immunotherapy-related adverse event (irAE), but he declined. He received antibiotics and NSAIDs and symptoms improved. After discharge, he continued durvalumab without symptom recurrence. IMPACT/DISCUSSION: This case illustrates importance of thorough medication review in unusual presentations. ICI-induced large-vessel vasculitis is a rare irAE that our team recognized, but we were not familiar with the rarer side effect of arteritis from G-CSF. Thus, this did not enter our differential diagnosis. On average, 80% of vasculitis irAEs are related to anti-PD1/PDL1 ICIs. Large-vessel vasculitis, especially GCA, carries risk of vison loss or stroke. Importantly, biopsy findings can be variable in irAE vasculitis, with diagnosis often made from clinical findings only. Standard therapy for Grade III irAE - symptoms requiring hospitalization - is steroids and immunotherapy discontinuation. From hundreds of thousands of cancer patients receiving G-CSF, there exist several dozen vasculitis cases, an order of magnitude of .01%. Carotid vasculitis attributed to G-CSF is only reported twice. We suspect this case was related to G-CSF since the patient tolerated further durvalumab without issue. Shared decision-making incorporates beneficence and justice into clinical practice, representing an approach where clinicians share knowledge and evidence for treatment choices with patients who then develop informed preferences. Patients and clinicians then develop an evidence-based, patient-centered plan of care. In cholangiocarcinoma, adding durvalumab to gemcitabine and cisplatin significantly improves overall survival, motivating the patient's understandable reluctance to stop ICIs. Nonetheless, blindness or stroke from vasculitis could be devastating. We shared with the patient our uncertainty about his symptom etiology and thus prognosis of his vasculitis, which enabled him to incorporate his values into care decisions.

Rare conditions such as vasculitis require a broad differential diagnosis. For cancer patients, this includes oncologic therapy side effects. Management when risks and benefits are uncertain requires engaging patients in shared decision-making. A PARADOXICAL PRESENTATION OF STROKE AND HYPOXIA IN HHT Neil Kotta, Karthik Goli, Eduardo Ortiz, Jaime J. Rueda. Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4270882) CASE: A 20-year-old male with a history of nosebleeds presents to the ER with 2 days of left lower visual field loss and right temporal headache. In the ER, he was found to have an oxygen saturation of 84% on room air. A CXR, CT head, and TTE were ordered. Family history includes nosebleeds in patient’s mother, maternal aunt, uncle, and grandfather. Vitals show patient was hypertensive (143/73). Pertinent labs include hemoglobin/hematocrit of 20.3/61.1 and EPO < 2.3. Physical examination was normal except for above. Since the patient's hypoxia was without respiratory distress and did not improve completely with 10L nasal canula, a shunt was suspected. CT head without contrast showed right occipital intracranial hemorrhage, CXR showed triangular opacity in RLL, and a CT scan showed a 5.5 cm AVM in the RML. The TTE with bubble study showed a Grade 1 intrapulmonary shunt. Patient's polycythemia was secondary to chronic hypoxemia. Interventional radiology successfully embolized the AVM. Due to family history of nose bleeds and the large pulmonary AVM, a diagnosis of (Hereditary Hemorrhagic Telangiectasia (HHT) was suspected. Patient was heterozygous for the ENG gene which is associated with autosomal dominant HHT. IMPACT/DISCUSSION: HHT is a rare disorder characterized by telangiectasias and AVMs, with pulmonary AVMs forming right-to-left shunts that bypass pulmonary capillary filtration and gas exchange. This leads to hypoxia and increases risk for paradoxical embolism. This case illustrates the clinical impact of pulmonary AVMs, presenting as refractory hypoxia and an unusual hemorrhagic stroke in a young patient. It underscores the importance of considering pulmonary AVMs in young patient with hypoxia and acute neurological deficits of unclear origin. Key teaching points include recognizing HHT as the most common cause of pulmonary AVMs with estimated prevalence of 1 in 5000, understanding that paradoxical emboli in pulmonary AVMs can result in paradoxical strokes, and utilizing the Curacao criteria to diagnose HHT (spontaneous nosebleeds, telangiectasis, AVMs, and a family history of HHT). This case reinforces the importance of early detection and treatment of pulmonary AVMs via embolization - a gold standard to prevent paradoxical emboli and improve oxygenation. Furthermore, this case highlights that hemorrhagic complications can occur, a less frequently discussed outcome, adding to the existing literature on HHT.

Internists should be aware that hypoxemia without respiratory distress may be a sign of pulmonary AVMs and that they can also cause paradoxical emboli. Furthermore, diagnosis of HHT should be made by Curacao criteria. A PATH LESS TRAVELED: GROUP B STREPTOCOCCUS BACTEREMIA LEADING TO SEPTIC ARTHRITIS OF THE STERNOCLAVICULAR JOINT AFTER ELECTIVE TERMINATION Tomomi Miyazaki1; Kuya Wakayama1; Kazuki Ishikawa1; Fumio Hirano3; Koki Kikuchi2; Yuki Nishitani4; Tetsuya Hoshi1. 1General Internal Medicine, Teine Keijinkai Byoin, Sapporo, Hokkaido Prefecture, Japan; 2Infectious Diseases, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; 3Department of Rheumatology, Teine Keijinkai Byoin, Sapporo, Hokkaido Prefecture, Japan; 4Department of the Obstetrics and Gynecology, Teine Keijinkai Byoin, Sapporo, Hokkaido Prefecture, Japan. (Control ID #4272600) CASE: A healthy 41-year-old (G4P2) woman presented with fever and progressive left neck pain 11 days after an elective termination of pregnancy at 20 weeks. The procedure involved cervical dilation with laminaria sticks and uterine evacuation over four days. She initially developed fever and neck discomfort on the last day of the procedure, which progressed to localized sternoclavicular joint pain. On presentation, physical examination revealed localized swelling, tenderness, and restricted movement of the joint. Laboratory results showed WBC 9,800/μL, CRP 10.5 mg/dL, and normal liver and renal function. Contrast-enhanced CT revealed soft tissue swelling and opacity surrounding the joint without effusion on ultrasound, making aspiration unfeasible. Blood and vaginal cultures yielded Streptococcus agalactiae (GBS) despite negative GBS screening at 10 weeks of gestation. Intravenous cefazolin was initiated and later switched to penicillin G based on the culture results, leading to rapid improvement. Magnetic resonance imaging (MRI) during hospitalization revealed a high-intensity area spanning from the left medial clavicular head to the left upper part of the sternum on short tau inversion recovery (STIR) image, raising suspicion of osteomyelitis. This prompted a 6-week course of antibiotics, resulting in full recovery without residual dysfunction. IMPACT/DISCUSSION: This case highlights the rare presentation of sternoclavicular septic arthritis due to GBS bacteremia following elective termination. While GBS is primarily recognized as a neonatal pathogen, post-procedural adult infections are underappreciated. Early negative GBS screening does not exclude the possibility of late colonization, as colonization rates can range from 20-30%. Repeat screening closer to obstetric procedures may improve detection and reduce complications. Sternoclavicular septic arthritis itself is exceedingly rare, comprising less than 1% of all septic arthritis cases. The condition often presents subtly with localized pain and fever, particularly in post-procedural patients, and may easily be overlooked. In this case, localized tenderness and imaging findings prompted a timely diagnosis, which facilitated appropriate management and prevented further joint destruction. Prompt recognition and treatment of GBS infections are critical. Intravenous penicillin G remains the first-line therapy, providing effective bacterial clearance and excellent outcomes when administered early. This case underscores the importance of vigilance for GBS infections following obstetric interventions and highlights the need for tailored screening and management strategies to mitigate such complications.

Repeat GBS screening closer to obstetric procedures is essential to detect late colonization. Clinicians should consider sternoclavicular septic arthritis in patients who present with fever and localized joint pain following obstetric procedures. Early diagnosis and treatment for GBS prevent long-term complications. A PENNY FOR YOUR THOUGHTS: COPPER DEFICIENCY MYELOPATHY MASQUERADING AS GUILLAIN BARRE SYNDROME Natalie Albright1; Muling Lin2; Karima Benameur3. 1School of Medicine, Emory University, Atlanta, GA; 2Department of Internal Medicine, Emory University, Atlanta, GA; 3Department of Neurology, Emory University, Atlanta, GA. (Control ID #4272394) CASE: Case 1: 70-year-old female with history of esophageal cancer complicated by esophagectomy with gastrojejunostomy and chemotherapy-induced polyneuropathy presented with cardiac arrest at home. Neurology was consulted for “Guillain-Barre syndrome causing cardiac arrest”. The patient had a longstanding history of paresthesias below the ankles, worsening 6 months before admission to include ascending proximal leg numbness, weakness, and imbalance. Physical examination revealed normal strength in all extremities, absent sense of proprioception and vibration up to the knees, and hyper-reflexia. Imaging showed T2 hyperintensities without enhancement in the cervical dorsal columns. Laboratory findings revealed a macrocytic anemia (MCV 113.2 fL) with stomatocytes, low serum copper (35 ug/dL, normal 80-155), normal Zinc level, and low normal ceruloplasmin (20 mg/dL, normal 20-60). Cerebral spinal fluid had elevated protein (73, normal 15-45) without pleocytosis. All other serum and spinal fluid nutritional and inflammatory markers were normal. Case 2: 84-year-old female with history of congenital scoliosis and COVID with chronic Zinc supplementation presented with worsening ascending paresthesias and imbalance for 3 weeks. Physical examination revealed normal strength, decreased sensation and absent vibration and proprioception to the knees, with hyper-reflexia. Imaging revealed T2 hyperintensities in the cervical spine. Laboratory findings revealed a macrocytic anemia (MCV 104.3 fL), low copper (<10 ug/dL), high zinc (120.9 ug/dL, normal 60-120), and normal ceruloplasmin (13 mg/dL). IMPACT/DISCUSSION: Copper deficiency myelopathy is a rare complication of gastrointestinal surgeries, malabsorptive disorders, and excess zinc ingestion. Copper is primarily absorbed in the duodenum and stomach. Zinc impairs copper absorption primarily through the induction of intestinal metallothionein, a protein that binds copper and prevents its absorption. As a major copper transport protein and a ferroxidase, ceruloplasmin is integral to copper metabolism. In our patients, the placement of the jejunostomy distal to the stomach and duodenum, sites of copper absorption, and the Zinc supplementation, may have caused slowly progressive deficiencies. Copper deficiency myelopathy manifests with sensory ataxia, paresthesia, cytopenia, and dorsal column hyperintensity on MRI, and is often mistaken for subacute combined degeneration. This case series shows the importance of keeping a wide differential diagnosis to avoid anchoring bias, and being attuned to subtle signs on neurological examination pointing towards central rather than peripheral nervous system disorders, in our cases, hyper-reflexia, and keeping an eye on systemic manifestations such as hematological abnormalities, which may clue into the correct diagnosis.

Not all ascending numbness is Guillain-Barre Syndrome. Patients with a peripheral nervous system presentation having hyperreflexia should be thoroughly checked for myelopathy. A PERICARDIAL PUZZLE: A CASE OF IDIOPATHIC RECURRENT ACUTE PERICARDITIS Jamie Therese Abad1; Amanda Darzi1; Ali Ali2; Abigail Entz1. 1Internal Medicine, Henry Ford Hospital, Detroit, MI; 2Rheumatology, Henry Ford Hospital, Detroit, MI. (Control ID #4273527) CASE: A 29-year-old female with asthma and chronic, intermittent pleuritic chest pain presented with two days of positional chest pain five weeks postpartum after an uncomplicated, full-term spontaneous vaginal delivery. Her chest pain had previously been diagnosed as both acid reflux and anxiety. On initial presentation, she was afebrile and tachycardic at a rate of 130 beats per minute. Laboratory results showed leukocytosis (12.4 K/uL), along with elevated C-reactive protein (20 mg/dL) and erythrocyte sedimentation rate (128 mm/Hr). Electrocardiogram showed diffuse ST elevations. Point of care ultrasound revealed a small pericardial effusion. CT showed mild pericarditis. Persistent tachycardia prompted a formal echocardiogram, notable for a moderate-sized pericardial effusion with concern for tamponade, requiring pericardiocentesis with drainage of 200cc of serosanguinous fluid resulting in clinical improvement. Fluid analysis showed elevated LDH (1447 IU/L), low pH (7.27), and neutrophilic leukocytosis. Blood and pericardial fluid cultures were negative. She was discharged on colchicine and ibuprofen. One week later, she returned with recurrent symptoms and persistence of pericardial effusion on repeat CT imaging. Laboratory workup was notable for continued leukocytosis (17 K/uL), positive antiphospholipid and lupus anticoagulant antibodies. Serologies for anti-nuclear antibody, anti-double stranded DNA, rheumatoid factor, antineutrophil cytoplasmic autoantibody were negative. She was initiated on a prolonged prednisone taper, and she was later initiated on an Interleukin-1 (IL-1) inhibitor (anakinra) in the outpatient setting due to suspected autoimmune etiology. She had notable improvement in inflammatory markers and her disease activity has remained stable over time. IMPACT/DISCUSSION: Idiopathic recurrent acute pericarditis (IRAP) involves a complex interplay of infectious, autoimmune, and autoinflammatory mechanisms. Although pericarditis can have various triggers, in approximately 85% of cases, no specific cause is identified, and the condition is labeled "idiopathic," with reported recurrence rates of 20-50%. Persistent symptoms and refractory pericarditis despite standard treatment prompted an autoimmune evaluation, emphasizing the potential role of immunological and hormonal changes unique to the postpartum period. This case adds to the literature supporting the use of anakinra in refractory cases and highlights the importance of advanced diagnostics, autoimmune evaluation, and multidisciplinary care in managing IRAP.

Recognize pericarditis as a potential cause of chest pain and dyspnea, even in young otherwise healthy individuals. Consider IL-1 receptor inhibitors for treatment of pericarditis unresponsive to standard therapies. APRIL SHOWERS BRING MAY-THURNER FLOWERS: CONSIDERING MAY-THURNER SYNDROME IN ISCHEMIC STROKE OF THE YOUNG Evan Multala1; Christine Robbie2,3; Yasmeen H. Nabhani2; Robert Miller3. 1Neurology, Tulane University, New Orleans, LA; 2Internal Medicine, Tulane University School of Medicine, New Orleans, LA; 3Medicine, VA Southeast Louisiana Healthcare System, New Orleans, LA. (Control ID #4271772) CASE: A 26-year-old right handed female with a medical history of migraine headaches, PTSD, depression, and childhood febrile seizures, presented with left sided weakness, numbness, expressive and receptive aphasia. She was stroke-activated in the emergency department. CT head and CT angiogram were unremarkable, but MRI revealed a 3mm focus of acute ischemia in the left parietal lobe. Tenecteplase administration was declined by the patient and her symptoms resolved within several hours. Her home sumatriptan was discontinued in the setting of acute stroke. Regular workup for stroke was completed. Lab risk stratification with a lipid panel, HbA1C, TSH, RPR, and hypercoagulable workup were negative. Transthoracic echocardiogram with bubble study revealed a small atrial septal defect with adjacent aneurysm that was further characterized on transesophageal ultrasound. Ultrasound for DVT was negative, however, CT scan of the deep proximal veins of the pelvis was pertinent for a possible filling defect within the left common iliac vein (LCIV). This was confirmed by MRA and MRV of the pelvis which demonstrated mild to moderate luminal narrowing of the LCIV with compression of the overlying right common iliac artery against the lumbar spine, of which is seen in setting of May-Thurner Syndrome (MTS). She was discharged on aspirin and apixaban with scheduled follow up with Neurology and Cardiology. A loop recorder was placed for outpatient monitoring of her ASD, and she was instructed to discontinue triptan use and refrain from estrogen-containing medications. IMPACT/DISCUSSION: In this case, the combination of MTS, an ASD, and atrial-septal aneurysm created the perfect storm for turbulent blood flow leading to thrombus formation, which resulted in a paradoxical embolism ultimately causing an ischemic stroke. MTS is a variant noted in approximately 20% of the US population and as such accounts for DVT more frequently than it is included in differential diagnosis for DVT workup. ASD with aneurysm has also shown to increase the risk of recurrent stroke, and evaluation for closure by Cardiology is prudent. lliac vessel narrowing may also require stenting to prevent future thrombi. Additionally, in our patient and others with migraines, there is an increased prevalence of migraine headaches in patients with ASD, and closure has been shown to decrease symptom burden. As for our patient, an initial differential diagnosis of brainstem migraine or hemiplegic migraine was considered.

Ischemic strokes in adults less than 50 years of age account for 10% of all strokes, young women being at a disproportionately higher risk. The workup of stroke in the young often becomes difficult when routine risk factors, imaging modalities, and labs are unrevealing. In these cases, clinical suspicion for MTS is warranted and further investigations should be conducted. A RARE AND CHALLENGING CASE OF ACUTE JEJUNAL DIVERTICULITIS IN A HIGH-RISK PATIENT Samee Farooqi, Ahmad Mardini, Irfan Siddiqui. Internal Medicine, Advocate Christ Medical Center, Darien, IL. (Control ID #4270336) CASE: An 87-year-old male with a history of multiple myeloma on chemotherapy, coronary artery disease, and chronic kidney disease presented with abdominal pain, vomiting, and lethargy. His vital signs revealed a fever of 102.5°F, tachycardia, and hypertension. Labs showed a lactic acid level of 2.9 mmol/L, a white blood cell count of 4.0 K/mcL, and a hemoglobin of 8.4 g/dL. CT angiography revealed a 2.2 cm mesenteric mass in the left upper quadrant, raising concern for a diverticular abscess or carcinoid tumor. General surgery and oncology consultations concluded that the mass was small and well-circumscribed, making an abscess unlikely. The patient was started on intravenous piperacillin-tazobactam and intravenous fluids. During his hospitalization, he developed rectal bleeding with clots, requiring two units of blood transfusion. Gastroenterology was consulted, but no further intervention was pursued as the patient preferred limited treatment, and his hemoglobin stabilized. The hospital course was complicated by encephalopathy and persistent abdominal pain. A repeat CT scan revealed thick-walled jejunal diverticula (2.6 x 1.9 cm and 1.6 x 1.2 cm) with fat stranding, consistent with acute diverticulitis. An inflammatory mass (2.6 x 2.4 cm) in the jejunal mesentery, with a possible draining sinus tract and mild distortion of adjacent bowel loops, was noted. A small bowel follow-through confirmed a patent fistula but no obstruction. After consultation with general surgery and oncology, and considering the patient's high surgical risk, non-operative management was pursued. The patient’s condition improved with conservative treatment with resolution of inflammation on serial imaging, and he was discharged with outpatient follow-up. IMPACT/DISCUSSION: This case highlights the clinical challenges and decision-making involved in managing a rare case of acute jejunal diverticulitis in a high-risk patient. Despite the severity of his symptoms, the patient's comorbidities emphasized the importance of a conservative, non-operative approach in select cases. Additionally, this case contributes to the growing awareness that diverticulitis can affect the small bowel, not just the colon, a less common occurrence in clinical practice. Complications such as a patent fistula and an inflammatory mass further complicated management.

Key teaching points from this case include: 1. Conservative Management in High-Risk Patients: Despite severe diverticulitis, non-operative management was successful due to the patient's high surgical risk and multiple comorbidities. 2. Multidisciplinary Care: Collaboration among specialties was essential in determining the best treatment approach. A RARE CARDIAC CRISIS: VENTRICULAR FIBRILLATION AND CARDIAC ARREST IN LUPUS WITH END STAGE RENAL DISEASE AND ACUTE INFECTION Chana Bushee1; Hari Paudel2. 1Internal Medicine-Pediatrics, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; 2Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4272859) CASE: A 24-year-old female with systemic lupus erythematosus complicated by end-stage renal disease (ESRD) on hemodialysis presented with fever and erythema at her port site. Workup was consistent with cellulitis of her port and Staphylococcus aureus sepsis, for which she was started on broad-spectrum antibiotics. Her marginal hyperkalemia (potassium 6.0 mEq/L) without ECG changes was adequately medically treated and she remained hemodynamically stable, and the plan was to proceed with dialysis later that day. While awaiting hemodialysis, she abruptly developed ventricular tachycardia (VT), which rapidly progressed to ventricular fibrillation (VF) and subsequent cardiac arrest. Despite high-quality cardiopulmonary resuscitation, she was unable to be resuscitated and passed away. IMPACT/DISCUSSION: Systemic lupus erythematosus (SLE) is a rare autoimmune disorder that can affect multiple organ systems, including the heart, leading to significant morbidity and premature mortality. SLE is associated with an increased risk of premature cardiovascular disease development, myocarditis, and arrhythmias, for which early diagnosis and treatment are crucial. However, VT and VF are rarely seen in SLE, even in the context of acute infection. This case illustrates a rare and fatal presentation of ventricular arrhythmia in a patient with SLE and ESRD, presenting with an acute infection. In general, patients with ESRD can tolerate higher potassium levels, and hyperkalemia is not typically treated unless potassium exceeds 6 mEq/L, particularly when urgent hemodialysis is scheduled for potassium management. Although SLE is known to predispose individuals to structural and supraventricular arrhythmias, ventricular arrhythmias (VT and VF) are rarely described in the literature. The increased risk of arrhythmia is thought to be linked to generalized inflammation in SLE, which is exacerbated by the additional inflammatory burden of acute infection.

While the pathophysiology of ventricular arrhythmias in SLE is not well understood, known risk factors include QTc prolongation, which is common in SLE though not seen in this patient, and the effects of immunosuppressive medications. Given the potential for these devastating complications, clinicians should be vigilant for potential arrhythmias, even with potassium levels less than 6 mEq/L and be prepared for prompt management. A RARE CASE OF ATYPICAL VIRUS-ASSOCIATED MUCOCUTANEOUS ERUPTION WITH SEVERE OCULAR COMPLICATIONS IN AN IMMUNOSUPPRESSED PATIENT Spencer Asay1; Kavita Renduchintala2. 1Division of the Biological Sciences, University of Chicago Pritzker School of Medicine, Chicago, IL; 2Hospital Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4270075) CASE: A 45-year-old woman with systemic lupus erythematosus (SLE) and discoid lupus presented with eye pain and pruritic rash over her back. She denied other symptoms and new exposures. Home medications included hydroxychloroquine, methylprednisolone, and anifrolumab. Vitals were notable for tachycardia. Physical exam revealed bilateral, purulent conjunctival injection and erythema and urticaria over the back and posterior arms. Initial labs were notable only for a viral panel positive for coronavirus OC43. In subsequent days, the rash spread over much of her body and evolved into desquamative, vesiculobullous papules and plaques with ulceration of the oral mucosa and eyes. She was transferred to the burn ICU with a differential of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), bullous SLE (BSLE), and reactive infectious mucocutaneous eruption (RIME). Cyclosporine was initiated; however, skin biopsy by dermatology revealed neutrophilic subepidermal bullae with linear C3 on immunofluorescence (IF), weighing toward BSLE. Cyclosporine was discontinued for dapsone. On day 6, the patient's cutaneous disease stabilized, but, by day 8, she had developed corneal denudation requiring amniotic membrane transplant (AMT) by ophthalmology. Negative type VII collagen antibodies (anti-C7) on indirect IF ultimately ruled out BSLE. Dapsone was discontinued and steroids were tapered. On day 22, a second AMT was needed. By day 23, her cutaneous disease had improved and a diagnosis of virus-associated RIME was favored. IMPACT/DISCUSSION: This case highlights an unusual presentation of RIME in an immunosuppressed patient, featuring overlapping aspects of mucocutaneous disorders. While vesiculobullous rash and ocular involvement are common in RIME, BSLE, and SJS/TEN, extensive skin involvement is markedly infrequent in RIME, and corneal denudation is rare outside of SJS/TEN. Histopathology in RIME and BSLE often shows neutrophilic subepidermal bullae, while SJS/TEN is characterized by epidermal necrosis. Finally, linear C3 on direct IF is most characteristic of RIME, while BSLE and SJS/TEN are characterized by indirect IF with positive anti-C7 and negative IF findings, respectively. This unique case of RIME is among very few documenting severe ocular complications, broadening our understanding of variable presentations in immunosuppressed hosts. This case stresses the need for a broad differential diagnosis in such patients and underscores the importance of comprehensive workup and treatment with appropriate specialist consultation.

Mucocutaneous eruption in patients who are immunosuppressed or have underlying disease necessitates a broad differential and close monitoring for potential complications, including those less commonly observed. RIME should be considered along with entities like SJS/TEN and BSLE in immunosuppressed patients presenting with extensive cutaneous rash. A RARE CASE OF BRAIN METASTASES FROM UROTHELIAL CARCINOMA PRESENTING WITH MEMORY DISTURBANCES Roshan Afshan1,2; Javaria Tehzeeb3; Shueb Mohammed1. 1Internal Medicine, Detroit Medical Center, Detroit, MI; 2Internal Medicine, Wayne State University, Detroit, MI; 3Hematology Oncology, Barbara Ann Karmanos Cancer Institute, Detroit, MI. (Control ID #4272174) CASE: A 56-year-old male with a three-year history of urothelial carcinoma (UC) with lung metastases on maintenance avelumab presented to the clinic with a one-month history of progressive headaches, memory loss, and word-finding difficulty. Physical examination was significant for a GCS of 15, receptive aphasia, short-term memory loss, and sensory ataxia. CBC, CMP, and coagulation profile were unremarkable. MRI revealed a 5 cm mass in the left parietal lobe abutting the Wernicke’s area, associated with internal hemorrhage, surrounding vasogenic edema, and midline shift. CT was negative for any other metastasis. His previous chemotherapy treatment history included cisplatin, gemcitabine, and sacituzumab. The patient was admitted to the ICU and started on dexamethasone for vasogenic edema and levetiracetam for seizure prophylaxis. Neurosurgery was consulted for excisional biopsy, which was consistent with metastatic UC. Subsequently, he underwent gamma knife radiation as an outpatient, but a follow-up MRI showed worsening bulky brain metastases. Circulating tumor DNA (ctDNA) testing was positive. His case was discussed at the tumor board, and whole-brain radiation therapy was started inpatient, which he is tolerating well. The oncology team plans to begin enfortumab vedotin after discharge. IMPACT/DISCUSSION: Brain metastases (BMs) from urothelial carcinoma (UC) are extremely rare, with an estimated incidence of 1%. They often present as solitary intracranial lesions in the cerebral hemispheres, suspected to occur through hematogenous spread via Batson's plexus. They appear in the later stages of the disease and may cause new-onset neurological symptoms, including seizures, cognitive changes, headaches, and sensorimotor deficits. The management plan requires a multidisciplinary approach and depends on factors such as the patient's age, performance status, and number of metastases. Treatment includes a tailored combination of chemotherapy, immunotherapy, whole brain or stereotactic radiation, and surgery. The prognosis is poor, with a median survival of 2 to 4 months and a five-year-survival of around 8%. Due to the rare incidence of BMs, routine brain imaging is not part of UC surveillance, but providers should evaluate any new neurological symptoms with a head CT or MRI, as timely neurosurgical consultation can be life-saving.

Although rare, it is important to consider the possibility of distant metastases in UC. While insufficient evidence supports routine imaging for intracranial metastases, healthcare professionals should note the increasing incidence of CNS metastases. A RARE CASE OF CARDIAC DYSPHAGIA IN A PATIENT WITH A CHRONIC PERICARDIAL EFFUSION Amy Shuster, Matthew Dyer. University Hospitals, Geauga, OH. (Control ID #4273250) CASE: A 94-year-old female with a past medical history significant for paroxysmal atrial fibrillation, aortic stenosis, systolic heart failure, and a chronic pericardial effusion presented with complaints of intermittent dysphagia that had been ongoing for months. On arrival, labs were unremarkable despite a mildly elevated BNP at 396 pg/mL. CT chest, abdomen, and pelvis showed a large pericardial effusion worsened compared to prior and a moderate right sided pleural effusion. Cardiology and Pulmonology were consulted and the patient was transferred to a tertiary care center for pericardiocentesis. One liter of serous fluid was removed and she was treated empirically with Colchicine due to the presence of inflammatory cells. Repeat point of care ultrasound showed minimal effusion. A modified barium swallow was performed and revealed normal oral and pharyngeal phases but did show esophageal dysfunction evidenced by retention of barium. Her symptoms improved and she was discharged with close Cardiology follow up. IMPACT/DISCUSSION: Dysphagia is highly prevalent among the elderly population (2). It is important to understand that esophageal dysphagia can be caused by either dysmotility or a structural abnormality (3). Mechanical lesions that cause obstruction are mostly intrinsic, including strictures, rings, and tumors. Rarely will extrinsic compression of the esophagus occur but when it does, mediastinal masses and vascular compression are usually to blame (2). In regard to cardiac dysphagia, reports of left atrial enlargement (1) and any other disease state that alters the cardiac anatomy (3) has been known to contribute. However, very few cases of esophageal compression from a pericardial effusion have been reported (2). The patient in this particular case had a chronic pericardial effusion that enlarged in size causing her to experience ongoing dysphagia. This case highlights the importance of understanding that while a non-specific symptom, the presence of dysphagia may indicate a more serious complication (1).

In conclusion, cardiac dysphagia resulting from a pericardial effusion is a rare but important diagnosis. It is crucial to understand that while there are various causes of dysphagia in general, all dysphagia must not be attributed to GI related disorders. More careful consideration of patients presenting with the aforementioned symptoms is necessary in order to avoid missing a potentially fatal diagnosis. 1. Ipalawatte H, Ahl A, Takher J, Gower A. An Odd Presentation of Dysphagia Due to Pericardial Effusion. J Investig Med High Impact Case Rep. 2024 Jan-Dec;12:23247096241286364. doi: 10.1177/23247096241286364. PMID: 39403982; PMCID: PMC11483682. 2. Vats HS. Dysphagia from extrinsic compression of esophagus by pericardial effusion. Clin Med Res. 2008 Sep;6(2):78-9. doi: 10.3121/cmr.2008.780. Epub 2008 Jul 7. PMID: 18606977; PMCID: PMC2572552. 3. Chilukuri P, Odufalu F, Hachem C. Dysphagia. Mo Med. 2018 May-Jun;115(3):206-210. PMID: 30228723; PMCID: PMC6140149. A RARE CASE OF CIPROFLOXACIN ASSOCIATED ILIOPSOAS TENDON RUPTURE Farooq Chaudhary1; Asma Tameez Ud Din2; NAGARAMAKRISHNA Tangirala1. 1Internal Medicine, Unity Hospital, Rochester, NY; 2hematology, St Guys and Thomas, Webster NY, NY. (Control ID #4270518) CASE: 72-year-old female with a past medical history of hyperlipidemia, morbid obesity, obstructive sleep apnea, gastroesophageal reflux disease, chronic iron deficiency anemia, restless leg syndrome, history of provoked pulmonary embolism (completed anticoagulation 3 months ago), history of multiple orthopedic interventions on the right knee and femur with revisions due to prosthetic infections (on chronic suppressive antibiotics ciprofloxacin and cefadroxil for almost 4 months) presenting to the hospital because of 4-day history of left hip groin and lower abdominal pain. Patient reports that when she was getting out of the car she suddenly started feeling a popping sensation and since has been having trouble with any type of movement especially when she flexes her hip joint. Pain is predominantly localized around the left hip, severity 7 out of 10 and aching character. Patient did not report any fatigue, swelling or erythema at the joint, fever or chills, change in bowel or urinary habitus, appetite, nausea or vomiting and bleeding. Socially patient lives with her husband at home and is independent in all of her activities of daily living. Former smoker and occasionally drinks alcohol. On presentation to the ED, patient was vitally stable, afebrile. Pertinent exam revealed pain with active and passive range of motion at the hip, especially with flexion. Initial blood work was concerning for hemoglobin drop to 7.5 g/dL from her prior baseline of 9.9 g/dL, all other blood tests were within normal limits. X-ray of pelvis and left hip without evidence of fracture, only degenerative changes. Ultrasound ruled out any deep venous thrombosis. CT and later MRI of left femur showed left iliopsoas tendon rupture with fluid collection, likely hematoma. After discussion with infectious disease her chronic suppressive ciprofloxacin was discontinued as the tendon rupture was deemed fluoroquinolone associated. Orthopedics recommended conservative management and outpatient follow up. IMPACT/DISCUSSION: The United States Food and Drug Administration (USFDA) has published boxed warning for ciprofloxacin including tendinitis and tendon rupture. Even though Achilles tendon is the most commonly ruptured tendon, there have been case reports of tendinopathies in the gluteal, iliopsoas and triceps tendons. As per our literature review we were able to find only two case reports of ilipsoas tendon rupture associated with fluoroquinolone use, one with ciprofloxacin and another with levofloxacin use.

Fluoroquinolones-mediated tendinopathy commonly affects weight bearing joints which are subjected to greater mechanical force. Our case adds to the growing number of cases of iliopsoas tendon rupture due to fluoroquinolones. Iliopsoas rupture should be considered in patients presenting with hip pain where hip fracture has been excluded. A RARE CASE OF INFRARENAL AORTITIS SECONDARY TO CHRONIC Q FEVER Junaid Ebrahim. Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4273320) CASE: A 72-year-old male immigrant from Jamaica, with a past medical history of smoking > 20 pack years, presented with lower abdominal pain over the past two months. On evaluation, CTA abdomen showed infrarenal aortitis and dissection of the right common iliac artery extending to the proximal segment of the right external iliac artery. Autoimmune testing for various vasculitis and autoimmune conditions was negative, including a temporal artery biopsy for giant cell arteritis. Testing for infectious causes resulted in a positive syphilis screen. RPR syphilis was negative, but the FTA antibody level was weakly reactive. Treatment for Tertiary syphilis with Benzathine penicillin G was commenced after an L.P. that ruled out neurosyphilis. The patient returned to the hospital a few months later for treatment of his subdural hemorrhage, and a repeat CTA abdomen showed worsening aortitis despite completing treatment. He eventually underwent endovascular repair by vascular surgery. On gaining more history, we discovered that he grew up on a cattle farm in Jamaica. That prompted us to test for Coxiella, and surprisingly, serology showed phase 1 IGg antibody titer > 1: 4096 and phase 2 > 1: 2048, consistent with chronic Q fever. The echocardiogram was negative for endocarditis. We initiated treatment with doxycycline and hydroxychloroquine to complete 18 months. IMPACT/DISCUSSION: Infectious aortitis secondary to chronic Q fever is a potentially severe and fatal disorder with high rates of rupture that necessitates quick evaluation and treatment(Lopes, Almeida, Dias, Pinho, & Maciel, 2009). C. burnetti is a gram-negative bacteria, with its main reservoirs being cattle and sheep, and transmission is primarily through the inhalation of aerosolized bacteria (Eldin et al., 2017). Our patient likely had exposure growing up on a farm in Jamaica. In the Caribbean states like Jamaica data is sparse on Q fever, but in French Guiana incidence between 2010 and 2017 was around 25–30 cases per 100,000 inhabitants per year. (Thrill et al.2022) C. burnetti endocarditis and vascular infections most commonly occur in the setting of existing valvular disorders and vascular grafts. (Raoult, Million, Thuny, & Carrieri, 2011) Our patient did not have existing coronary disease or valvular pathology. Usually, serologic testing is used for diagnosis, where phase I IgG titers are typically >1:1024 and are generally higher than phase II IgG titers. PCR and IHC are alternatives. However, culture is not recommended due to difficulty and safety issues (Anderson et al., 2013). Treatment of chronic q fever involves doxycycline and hydroxychloroquine. In those with endocarditis or vascular infection, current guidelines suggest at least 18 months of treatment (Anderson et al., 2013).

Despite the low incidence, Coxiella should not be overlooked as a probable etiology of infrarenal infectious aortitis. Early treatment with an extended duration of antibiotics and monitoring for any relapses and surgical evaluation. A RARE CASE OF INTRACARDIAC MESOTHELIOMA Keauna Hilton1; David Lambert2. 1Department of Medicine, Washington University in St Louis School of Medicine, St. Louis, MO; 2Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4248595) CASE: A 42-year-old white male with history of idiopathic pericarditis presented with sharp chest pain. He was first diagnosed with pericarditis with a pericardial effusion 6 months prior to current presentation at an outside hospital and was started on indomethacin and colchicine. Prior pericardiocentesis was unrevealing for underlying etiology. On arrival, patient was afebrile and tachycardic to 115. Exam was notable for volume overload with 4+ pitting edema in bilateral lower extremities and decreased breath sounds on auscultation, making it difficult for him to ambulate or perform any activities of daily living. Laboratory workup, which included rheumatologic evaluation, were unremarkable. A cardiac MRI (cMRI) showed diffuse pericardial thickening as well as submyocardial enhancement consistent with myopericarditis. Transthoracic echocardiogram (TTE) performed demonstrated a loculated pericardial effusion and evidence of constrictive physiology. CTAP was notable for likely malignant pleural effusion and pleural thickening concerning for pleural and pericardial mesothelioma or lymphoma, and PET-CT verified these findings. He underwent diagnostic and therapeutic thoracentesis x2 with negative cultures and cytology, heart rate and respiratory rate did not significantly improve with large volume thoracentesis. Multiple TTEs were obtained to assess for cardiac tamponade and were negative. Chest x-ray continued to demonstrate reaccumulation of large, left pleural effusion. A biopsy of patient’s xyphoid nodule was performed, which resulted as epithelioid mesothelioma. Oncology requested optimization of pericardial and pleural effusions prior to initiating chemotherapy/radiation outpatient. Due to myocardial invasion, cardiac surgery felt operative risk was prohibitively high. He was ultimately transferred to oncology service to begin chemotherapy since surgical options were limited. He underwent chest tube and PleurX catheter placement and was later discharged to follow-up with oncology outpatient for chemotherapy/radiation. IMPACT/DISCUSSION: Thoracentesis with pleural fluid analysis is indicated for all patients with pleural effusion and suspected mesothelioma. However, sensitivity varies, and local invasion cannot be assessed, thus, it should be confirmed with a biopsy. Internists should be aware that this condition may lead to malignant pericardial effusion through involvement of the pericardium and myocardium. Because diagnosis is usually made at advanced stage, there should be an interdisciplinary approach to risks and benefits of treatment options between various care teams and the patient.

Intracardiac mesothelioma is an extremely rare and aggressive malignancy with prognosis being <1 year. Treatment options not well-established due to the rarity of the condition but include surgery, chemotherapy, and radiotherapy. Surgical resection may be considered in cases where the tumor is localized, although this is often not feasible due to the advanced stage at diagnosis. A RARE CASE OF LARYNGEAL SARCOIDOSIS PRESENTING AS AN ASTHMA EXACERBATION; A CASE REPORT William Muniz2; Fahiye Ali2; Santhosh Raja Thangaraj2; Paige I. Nappier2; Amirtharaj Dhanaraja1. 1Internal Medicine , St. Bernard's Medical Center, Jonesboro , AR; 2Internal Medicine Residency Program, St Bernards Healthcare, Jonesboro, AR. (Control ID #4271171) CASE: A 41-year-old female with a history of supraglottitis, chronic bronchitis, and sarcoidosis presented with exertional shortness of breath, speaking in short sentences with audible wheezing. Oxygen saturation was 88% on room air, improving to 98% with 2 liters of nasal cannula. She received Duoneb nebulizers, Solu-Medrol, magnesium, and normal saline. Due to multiple hospitalizations over the past six months, she was admitted to the ICU for presumed asthma exacerbation. Despite treatment, her shortness of breath persisted, and she reported intermittent hoarseness. A CT of the neck was negative for abscess or epiglottitis. ACE levels were 67 U/L, and an ENT consultation was obtained for suspected laryngeal sarcoidosis. A laryngeal biopsy revealed polypoid mucosal tissue with hyperkeratosis and mild inflammatory changes, while a lower lip biopsy confirmed periductular granulomatous inflammation with multinucleated giant cells, consistent with sarcoidosis. The patient showed improvement with intravenous steroids, and was discharged with a two-week prednisone taper. Follow-up was scheduled to monitor treatment response and evaluate for further management. IMPACT/DISCUSSION: Laryngeal sarcoidosis is a rare complication of systemic sarcoidosis that can mimic asthma exacerbations or upper airway infections. In this case, persistent shortness of breath, wheezing, and hoarseness despite standard asthma treatments raised suspicion for laryngeal involvement. Biopsies confirmed the diagnosis: the epiglottis showed polypoid mucosal tissue with hyperkeratosis and mild inflammation, while the lower lip biopsy revealed periductular granulomatous inflammation with multinucleated giant cells consistent with sarcoidosis. This case emphasizes the need to consider laryngeal sarcoidosis when respiratory symptoms persist despite treatment, particularly in patients with history of sarcoidosis. Biopsy and histology are critical for diagnosis, while corticosteroids remain first-line therapy. Long-term follow-up is essential to monitor for recurrence, with steroid-sparing agents like methotrexate or azathioprine as alternatives for refractory cases. Early recognition and a multidisciplinary approach with pulmonology and ENT specialists are key to improving outcomes.

● Laryngeal sarcoidosis is a chronic granulomatous condition of the larynx, occurring in less than 5% of sarcoidosis cases. ● This case highlights a rare presentation of laryngeal sarcoidosis initially misdiagnosed as recurrent asthma exacerbations. ● The clinical workup and management of laryngeal sarcoidosis, including diagnostic and therapeutic strategies, are discussed. A RARE CASE OF LISINOPRIL-INDUCED INTESTINAL ANGIOEDEMA MIMICKING ABDOMINAL PATHOLOGY Ghena Kasasbeh, Laith Qasarweh, Shanna Horne, Dakota J. Robertson. Internal medicine, Johnston Memorial Hospital, Abingdon, VA. (Control ID #4268671) CASE: A 42-year-old Caucasian female with hypertension, presented to the emergency department for severe cramping epigastric pain of two-day duration. The pain, which radiated to her back, was intermittent and not accompanied by nausea, vomiting, or changes in bowel movements. Six days prior, she had started lisinopril 40mg without any other recent medication or diet changes. She denied history of allergy or angioedema, but her father had discontinued lisinopril due to cough. Her physical examination was unremarkable. Labs showed an elevated CRP 28mg/L, ESR 35mm/hr, leukocytosis 12.6K/uL. However, lipase, lactate, GI PCR, coagulation panel, and hepatic panel were all normal. Abdominal CT revealed a long segment of submucosal edema with adjacent small bowel fat stranding and moderate ascites in cul-de-sac. These findings were consistent with intestinal angioedema. No abnormality of the pancreas or other organs appeared on CT. Subsequent C4 complement level 32 mg/dL, and C1 esterase inhibitor (84%) were normal. Treatment was conservative, and lisinopril was permanently discontinued. Her symptoms then improved and repeat imaging showed bowel edema resolution. IMPACT/DISCUSSION: Angioedema is a rare but potentially life-threatening side effect of angiotensin-converting enzyme inhibitors (ACEI). Though ACEI-induced angioedema (ACEIA) typically affects subcutaneous tissues, particularly in the face and airways, visceral involvement—especially in the gastrointestinal (GI) tract—is infrequent. Visceral ACEIA is a rare complication which can occur within days of starting treatment, with incidence of 0.07% in the first month and 0.2% over a year. This risk increases with higher doses and prolonged use, prior episodes of angioedema, or genetic factors. Accumulation of bradykinin—a potent vasodilator—leads to capillary extravasation and vasodilation. Visceral angioedema typically presents as abdominal pain, bloating, nausea, often leading to misdiagnosis as other GI conditions. A thorough clinical history, imaging (CT, ultrasound) findings, excluding other diagnoses, along with symptom resolution after omitting offending agent, confirm the diagnosis. As in our case, typical signs on imaging include dilated bowel loops, edematous mucosa, mesenteric fat stranding, and ascites. Normal complement levels exclude hereditary angioedema. While symptomatic treatment is key, tranexamic acid, fresh frozen plasma, or even C1 esterase can be beneficial. Although, mixed opinions surround their use in either ACEI or hereditary angioedema.

This case underscores the importance of considering ACEI-induced visceral angioedema in patients with unexplained gastrointestinal symptoms, particularly after recent initiation an ACE inhibitor. Due to its rarity along with nonspecific symptoms on presentation, ACEIA poses a diagnostic challenge. Prompt recognition through careful history and diagnostic imaging, along with discontinuation of the offending drug are crucial to prevent further complications. A RARE CASE OF METHAMPHETAMINE-INDUCED ACUTE RESPIRATORY DISTRESS SYNDROME Doga Kahramangil Baytar1; Kseniya Anishchenko1; Michael G. Risbano2. 1Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 2medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4273245) CASE: A 54-year-old female with a history of polysubstance use disorder presented with two weeks of progressive dyspnea and productive cough. On presentation, she was febrile, hemodynamically stable, with a new oxygen requirement of 5L. Social history was significant for recent incarceration, chronic daily alcohol use, and upon further questioning, methamphetamine inhalation 3 days prior to her presentation. Laboratory studies showed WBC 18.6 with 90% neutrophils. Chest CT revealed bilateral diffuse ground-glass opacities. She started on broad-spectrum antibiotics but her respiratory status rapidly deteriorated and she required intubation. The initial bronchoscopy was unremarkable. Repeat bronchoscopy after 14 days was positive for HSV-1, prompting initiation of acyclovir for 5 days. Comprehensive infectious workup and autoimmune studies were negative. Repeat chest CT revealed a cavitary right middle lobe nodule with potential hemorrhage and ground glass opacities alternating with mosaicism (crazy paving pattern) consistent with diffuse alveolar damage. A right lung wedge biopsy was obtained which showed diffuse alveolar damage with organizing pneumonia and organizing intravascular thrombi. Grocott stains, AFB stains, CMV, HSV1/2, adenovirus and COVID were negative. The pattern of lung injury was deemed secondary to drug-induced inhalational injury. Initiation of methylprednisolone 80mg BID resulted in significant improvement of oxygenation, allowing successful extubation after 14 days of mechanical ventilation. She is now stable and preparing for discharge. IMPACT/DISCUSSION: This case highlights a serious and rare case of ARDS due to inhaled methamphetamine use that required prolonged intubation and a long steroid course. Inhalation shortly before admission likely triggered severe inflammatory lung injury, mimicking infectious pneumonia. The HSV-1 positivity in BAL fluid likely represented opportunistic viral pneumonitis. Corticosteroids were critical in halting the progression of diffuse alveolar damage and promoting recovery. Prior literature has documented cases of pneumonitis, cryptogenic organizing pneumonia, and pneumomediastinum following methamphetamine use. Our patient's presentation and histopathologic findings of diffuse alveolar damage with organizing pneumonia align with these reports. Preclinical models suggest that methamphetamine induces inflammatory cascades in the lung via free radicals and early response cytokines, such as TNF-α and IL-6, which may explain the observed efficacy of steroids in our patient.

With increasing rates of illicit substance use, clinicians should maintain a high index of suspicion for inhalational injury in patients presenting with unexplained respiratory failure, particularly in those with known inhalational drug use. Early initiation of corticosteroids may be crucial in managing drug-induced lung injury. A RARE CASE OF MULTIPLE MYELOMA WITH EVANS SYNDROME Tiantian Zhang, Gary Batra, Mohammad Rizwan Alam, Yihong Ma, Anil Harrison. Internal Medicine, University of Central Florida, Pensacola, FL. (Control ID #4267659) CASE: A 76-year-old female with a history of nephrectomy for renal cell cancer and monoclonal gammopathy of undetermined significance presented with worsening anemia. She recently underwent esophagogastroduodenoscopy (EGD) and colonoscopy, both of which were unremarkable. Laboratory evaluation revealed pancytopenia. Despite receiving multiple blood transfusions, her anemia persisted, and her white blood cell and platelet counts continued to decline. Immunological workup showed significant findings, including an M spike at 3.5 g/dL on serum protein electrophoresis, serum IgG of 5143 mg/dL, and a high kappa/lambda light chain ratio. Bone marrow biopsy revealed 80% plasma cell infiltration, mildly hypercellular marrow with decreased hematopoiesis, and marked reticulin fibrosis. A diagnosis of multiple myeloma (MM) was confirmed, and treatment with weekly bortezomib was initiated. Despite therapy, the patient developed worsening shortness of breath, fatigue, and lightheadedness, necessitating hospitalization. Physical examination revealed pallor and dyspnea. Laboratory studies confirmed pancytopenia. Uric acid and lactate dehydrogenase levels were elevated, haptoglobin was low, and the direct antiglobulin test was positive for IgG. These findings were consistent with Evans syndrome (ES), characterized by autoimmune hemolytic anemia (AIHA), thrombocytopenia, and often associated with neutropenia. Further gastrointestinal evaluation (EGD and colonoscopy) remained unremarkable. The patient was treated with high-dose pulse steroids (dexamethasone 40 mg daily for 4 days) and multiple red blood cell (RBC) transfusions. Following treatment, her white blood cell count normalized, platelet levels improved, and hemoglobin stabilized without further need for transfusions. IMPACT/DISCUSSION: ES is classified as primary when no underlying etiology is identified and secondary when associated with conditions such as autoimmune diseases or immunodeficiency. ES, especially AIHA with pancytopenia in this case, in MM is extremely rare. This case broadens the spectrum of MM complications and highlights the importance of including MM in the differential diagnosis of pancytopenia in elderly patients. In this patient, no alternative etiologies, such as medication effects or other autoimmune disorders, were identified, and hemolysis due to transfusion was ruled out as pancytopenia preceded transfusions. Identifying whether ES is primary or secondary is essential, as management involves high-dose steroids, intravenous immunoglobulin, RBC transfusions, and treatment of the underlying disease if secondary. While ES is associated with higher mortality rates compared to isolated autoimmune cytopenia, improved awareness and management of pancytopenia in MM are critical for better outcomes.

1. ES is a rare complication of MM. 2. Management includes high-dose steroids and addressing the underlying disease if secondary. 3. Pancytopenia in malignancy patients should prompt evaluation for ES. A RARE CASE OF MULTI-VALVULAR, NATIVE VALVE ENDOCARDITIS CAUSED BY METHICILLIN-SENSITIVE STAPHYLOCOCCUS EPIDERMIDIS IN A CIRRHOTIC PATIENT Yasmin Araujo1; Rees Ridout1; Minh Q. Ho2. 1Internal Medicine, University of Central Florida College of Medicine, Orlando, FL; 2Infectious Disease, Orlando VA Healthcare System, Orlando, FL. (Control ID #4273175) CASE: A 67-year-old male with alcoholic cirrhosis (MELD score 28, Child-Pugh Class C), esophageal varices, and hypertension presented with five days of intermittent left-sided chest pain and one month of shortness of breath. He reported a facial rash one week prior to admission, and chills three days prior. On examination, he was in moderate distress but afebrile, with normal heart sounds and no murmurs. Initial workup revealed leukocytosis (20.3 cells/mm3), elevated lactic acid (2.57 mmol/L), transaminitis (ALT 113 U/L, AST 460 U/L), troponin (1750 ng/L), and BNP (3182.5 pg/mL). Imaging showed small pleural effusions and a hepatic infarct caused by a septic embolus. Blood cultures grew methicillin-sensitive Staphylococcus epidermidis (MSSE) in all four vials. A transthoracic echocardiogram identified severe multi-valvular endocarditis with vegetations on the aortic and mitral valves, an unusual presentation for coagulase-negative staphylococci (CoNS) in native valve endocarditis (NVE). Despite appropriate antibiotic therapy (cefazolin), the patient’s condition worsened, with new-onset acute kidney injury, encephalopathy, and multi-organ dysfunction. Surgical intervention was ruled out due to extensive comorbidities. The patient was transitioned to hospice care and passed four days later. IMPACT/DISCUSSION: Staphylococcus epidermidis is a common cause of prosthetic valve endocarditis but rarely implicated in NVE, especially in patients without traditional risk factors such as IV drug use or prosthetic devices. This case highlights the unique susceptibility of cirrhotic patients to NVE due to impaired immune function, which may facilitate hematogenous seeding of the valves. Cirrhosis, as seen in this patient, may have increased the risk of bacterial translocation from skin, predisposing him to severe systemic complications. The multi-valvular involvement observed in this case is uncommon for CoNS, which typically causes single-valve infections. The hepatic infarction was likely caused by septic emboli from valvular vegetations, a rare but severe complication of NVE. This highlights the potential danger of atypical endocarditis cirrhotic patients, who tend to see higher mortality rates and complications. Early recognition of S. epidermidis as a pathogen in cirrhotic patients presenting with atypical symptoms is critical. This case emphasizes the need for heightened clinical suspicion, especially when repeated positive blood cultures and systemic embolic phenomena are present. Aggressive antibiotic therapy and multidisciplinary collaboration are essential to manage these high-risk cases effectively.

Staphylococcus epidermidis is a less common cause of native valve endocarditis and may result in more severe disease and associated complications than typical infective endocarditis cases. Cirrhosis may increase susceptibility to this atypical presentation of infective endocarditis, warranting prompt diagnosis and aggressive treatment to improve outcomes for this high-risk population. A RARE CASE OF NIVOLUMAB-INDUCED CARDIAC TAMPONADE Emmanuel Oundo. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4237471) CASE: Introduction Immunotherapy is increasingly becoming a cornerstone in the treatment of various types of cancer. However, the full spectrum of its side effects is still being uncovered, including rare complications like pericarditis and pericardial effusion. Case Presentation: An 80-year-old man undergoing immunotherapy and external beam radiation therapy for metastatic lung cancer presented to the emergency department (ED) with acute onset chest pain, abdominal pain, and weakness. He had recently experienced an ST-elevation myocardial infarction (STEMI) and was discharged on aspirin, clopidogrel, and colchicine for a previously identified pericardial effusion. Apixaban for atrial fibrillation was discontinued upon admission to reduce the risk of hemopericardium. In the ED, his blood pressure was 80/60 mmHg, unresponsive to intravenous fluids, necessitating the initiation of a norepinephrine drip. Computed tomography (CT) of the chest revealed a large pericardial effusion. This was confirmed by point-of-care ultrasound (POCUS) and transthoracic echocardiography (TTE). Cardiology was consulted, and an urgent pericardiocentesis was performed, resulting in improvement in the patient’s blood pressure and pain. The pericardial fluid was hemorrhagic, and analysis indicated an exudative effusion without malignant cells. Both apixaban and nivolumab were discontinued, and a repeat TTE showed resolution of the effusion. The patient stabilized and was discharged home. IMPACT/DISCUSSION: Nivolumab, an immune checkpoint inhibitor, is an IgG4 antibody targeting the programmed death-1 (PD-1) receptor. Its side effect profile differs from conventional chemotherapy, as observed in trials comparing it to the microtublin inhibitor docetaxel. The side effects of immunotherapies typically result from the activation of the immune system and are thus termed immune-related adverse events (irAEs). Heinzerling et al. described side effects such as myocarditis, congestive heart failure, myocardial fibrosis, and pericarditis. Pericardial effusion due to nivolumab is rare, reported in only 0.69% of treated patients, as noted by Borghaei et al., with only a fraction of cases requiring pericardiocentesis. Since 2016, fewer than twenty cases have been reported in the literature. Some patients have required a pericardial window, and in cases like ours, discontinuation of nivolumab was necessary. This case was complicated by two factors. Firstly, the patient’s metastatic disease could have predisposed him to pericardial effusion, although cytology was negative for malignant cells. Secondly, Dressler syndrome, which can occur post-STEMI, was considered but was unlikely to be hemorrhagic, as observed in this case.

Our case underscores the importance of maintaining high vigilance for potential side effects of immune checkpoint inhibitors, which can significantly impact patient management. A RARE CASE OF NONTYPHOIDAL SALMONELLA INDUCED ACALCULOUS CHOLECYSTITIS IN THE SETTING OF ZOONOTIC EXPOSURE Christopher Mamone2; Amy Shuster1; Adam Kloha1. 1University Hospitals, Chardon, OH; 2Northeast Ohio Medical University, Rootstown, OH. (Control ID #4258949) CASE: A 44-year-old female presented to our medical facility with non-bloody diarrhea, mid-epigastric pain, and fevers. On arrival, she was febrile at 102.2 degrees Fahrenheit and had a leukocytosis of 17.3 x 103 u/L. CT abdomen and pelvis showed a mildly distended gallbladder and abdominal ultrasound revealed pericholecystic fluid without cholelithiasis. She was empirically started on Zosyn and general surgery was consulted. Initial plan was for laparoscopic cholecystectomy, however stool pathogen panel resulted positive for nontyphoidal Salmonella. The patient did endorse caring for chickens and recently cleaning a turtle enclosure. Antibiotics were deescalated to Ceftriaxone and Metronidazole, and surgical intervention was deferred due to improvement. She was discharged on a two-week course of Ciprofloxacin. IMPACT/DISCUSSION: This case presents a rare instance of nontyphoidal Salmonella-induced acute acalculous cholecystitis (AAC). Although nontyphoidal Salmonella commonly manifests as gastroenteritis, some cases can lead to rare complications such as AAC (1) and calculus cholecystitis (2), possibly via bacteremia or endotoxin-mediated bile stasis (3). The clinical presentation led to imaging and positive stool cultures confirmed the diagnosis of Salmonella infection. Effective antibiotic therapy in this case resulted in symptom resolution, however, in some cases surgical intervention can’t be avoided (4). This case highlights the importance of considering invasive nontyphoidal Salmonella infections in patients presenting with gastrointestinal symptoms and zoonotic exposure. Identifying these cases early can prevent delays in treatment. Additionally, public education on proper hygiene when handling animals is crucial to reducing zoonotic transmission.

This case highlights the potential for Salmonella-induced AAC in specific clinical settings. Timely diagnosis through imaging and stool cultures enables conservative management with targeted antibiotics, thus minimizing surgical interventions when possible and improving patient outcomes.

1. Ruiz-Rebollo ML, Sánchez-Antolín G, García-Pajares F, et al. Acalculous cholecystitis due to Salmonella enteritidis. World J Gastroenterol. 2008;14(41):6408-6409. doi:10.3748/wjg.14.6408 2. Juma F, Cave JJ, Gonzales H, Moore LSP. Non-typhoidal salmonellosis presenting as acute calculus cholecystitis. BMJ Case Rep. 2019;12(7):e230186. Published 2019 Jul 19. doi:10.1136/bcr-2019-230186 3. Zhao Y, Zhang L, Xing F, Zhang R, Huang J. Synchronous Acute Acalculous Cholecystitis and Appendicitis Due to Salmonella Group D: A Rare Case Report From China and Review of the Literature. Front Med (Lausanne). 2020;7:406. Published 2020 Aug 18. doi:10.3389/fmed.2020.00406 4. Commons, R., Dimitriou, J. and Campbell, I. (2008), Acalculous cholecystitis caused by Salmonella virchow. ANZ Journal of Surgery, 78: 514-514. https://doi-org.neomed.idm.oclc.org/10.1111/j.1445-2197.2008.04547.x A RARE CASE OF PURULENT PERICARDITIS CAUSED BY TOXIC SHOCK SYNDROME Aditya Maddali1; Danielle V. Lefebvre2; Ashley Wong3; Zahra Ukani4; Ashley Govi4. 1Internal Medicine, The George Washington University, Washington, DC; 2Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 3Internal Medicine, The George Washington University Department of Medicine, Washington, DC; 4Cardiology, The George Washington University Hospital, Washington, DC. (Control ID #4273135) CASE: We present a unique case of group A streptococcus (GAS) purulent pericarditis associated with toxic shock syndrome (TSS). A 61-year-old male with a medical history of rheumatoid arthritis presented with several days of severe pleuritic chest pain associated with cough, shortness of breath, and progressively worsening rash. Physical examination was significant for non-pruritic, non-painful erythematous rash involving his chest, ankles, and hands and with friction rub on cardiac auscultation. Vital signs within normal limits. EKG revealed ST elevations in leads V2-V6 and aVL, and TTE demonstrated a mild to moderate circumferential pericardial effusion with evidence of elevated pericardial pressures, with collapsible inferior vena cava consistent with low central venous pressure, but without wall motion abnormality. Laboratory results were significant for creatinine 3 mg/dL, blood urea nitrogen 70 mg/dL, lactate 2.8 mmol/L, white blood cell count 13 x 10^9/L, troponin < 0.012 ng/mL, and NT-proBNP 5,600 pg/mL. The patient was started on broad spectrum antibiotics but became hemodynamically unstable requiring transfer to the cardiac care unit. Repeat TTE revealed rapid expansion of the pericardial effusion with right ventricular diastolic collapse suggestive of tamponade physiology. Given anatomy of the effusion, pericardial window and drain were performed, draining 470 mL of purulent red fluid. Blood cultures tested positive for GAS. Patient was started on ceftriaxone, linezolid, and IV immunoglobins for treatment of toxic shock syndrome (TSS). Pericardial fluid cultures tested positive for GAS. Hospital course was further complicated by acute renal failure requiring continuous renal replacement therapy (CRRT). Pericardial drain was removed after 10 days and repeat TTE showed trivial pericardial effusion and normal biventricular systolic function. Although the patient hemodynamically stabilized, he continued to require CRRT and his prognosis continues to remain poor. IMPACT/DISCUSSION: Although rare, bacterial pericarditis can result in the buildup of purulent pericardial fluid. Rapid accumulation of pericardial fluid can result in cardiac tamponade and fatal obstructive shock. This is a rare case of GAS bacteremia resulting in TSS and bacterial seeding to the pericardium, precipitating cardiac tamponade. Prompt intervention with the creation of a pericardial window and with antibiotics were critical for achieving source control in the management of purulent pericarditis. Purulent pericarditis should be considered in patients presenting with signs of pericarditis and sepsis. This case highlights the importance of physical examination and early diagnostic testing such as TTE in the early diagnosis of purulent pericarditis.

We present a rare case of cardiac tamponade caused by purulent pericardial effusion in a patient with toxic shock syndrome We emphasize the importance of early diagnostic testing, and multimodality therapy in the management of purulent pericarditis A RARE CASE OF PURULENT PERICARDITIS IN THE ANTIBIOTIC ERA Isna Khaliq1; Steve Attanasio2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Cardiology, Rush University Medical Center, Chicago, IL. (Control ID #4273311) CASE: A 62-year-old woman with a history of diabetes mellitus presented with fevers and chills. Vital signs showed tachycardia. Labs indicated a white cell count of 15 K/uL. Chest X-ray revealed a left retrocardiac airspace opacity. A transthoracic echocardiogram (TTE) showed a moderate-sized pericardial effusion, and the patient was started on ibuprofen and colchicine to treat pericarditis. She experienced worsening chest pain and shortness of breath over the next week. A repeat TTE showed an enlarging pericardial effusion, raising tamponade concerns. The patient underwent pericardiocentesis, with removal of ~ 400 mL of grossly purulent fluid. Cultures from the pericardial fluid grew Streptococcus pneumoniae, and the patient was started on IV antibiotics. A follow-up TTE after 2 days showed enlargement of the pericardial effusion and evidence of restrictive physiology. A chest CT indicated a loculated left-sided pleural effusion. The patient underwent Video-Assisted Thoracoscopic Surgery and partial pericardiectomy. She continued to improve clinically over the next week. A follow-up TTE was without signs of restrictive pericarditis. The patient was discharged with a six-week course of oral antibiotics and a close outpatient follow-up. IMPACT/DISCUSSION: Purulent pericarditis is defined by the presence of gross pus in the pericardium or microscopic purulence (>20 leukocytes per oil immersion field). It is a life-threatening disease with a mortality rate of 20 – 30%. Restrictive and constrictive pericarditis occurs in up to 3.5% of cases and requires immediate surgical intervention. Without early treatment, the mortality rate approaches 100%, but timely intervention can reduce it to 40%. Purulent pericarditis is rare in the antibiotic era, with an incidence of less than 1% of all pericarditis cases. Due to its rarity, clinicians may find it difficult to consider this diagnosis, and it can easily be overlooked. The clinical presentation of purulent pericarditis varies significantly, often delaying diagnosis as symptoms are commonly attributed to viral pericarditis or other infections. Pericardial effusion associated with a respiratory infection, which shows no improvement with initial treatment, should raise concern for a bacterial cause. Our patient had Streptococcus pneumonia with contiguous spread, leading to empyema and purulent pericarditis. Close monitoring and a broad differential diagnosis helped us diagnose this rare condition. We then escalated the patient's care by obtaining expert opinions from specialists and facilitating timely surgical intervention. This case emphasizes the need for hospitalists to avoid anchoring bias by regularly reassessing initial diagnoses and seeking further evaluation if needed.

Our patient presented with purulent pericarditis, reminiscent of cases seen before the antibiotic era. Early recognition, thorough diagnostic workup, and intervention with source control and IV antibiotics are vital to prevent severe complications and death. A RARE CASE OF QUETIAPINE OVERDOSE MASQUERADING AS ST ELEVATION MYOCARDIAL INFARCTION Jiya Mulayamkuzhiyil1; Justeena Joseph1; Ivan Kharchenko1; Nadia Khan2; Waqas Khan3. 1Internal Medicine, Long Island Community Hospital, Patchogue, NY; 2Fatima Jinnah Medical University, Lahore, Punjab, Pakistan; 3Cardiology, Long Island Community Hospital, Patchogue, NY. (Control ID #4272780) CASE: A 34-year-old male with a history of opioid and tobacco use disorder presented to the ED after quetiapine overdose. He consumed 500mg of quetiapine as a sleep aid; subsequently he felt dizzy and fell. He denied chest pain, shortness of breath, palpitations, or diaphoresis. Family history was significant for premature coronary artery disease in his father with history of CABG at age 60. On exam, the patient's vitals were normal; he was alert and oriented and the remainder of physical exam was non-focal. Electrocardiogram (ECG) revealed normal sinus rhythm with ST segment elevation in leads I and aVL and ST-depression in inferior leads; QT-interval was 428. Labs demonstrated troponin 255 with no uptrend. Echocardiogram showed ejection fraction 60% with no evidence of pulmonary hypertension, pericardial effusion or wall motion abnormality.Given the ECG changes consistent with a possible ST-elevation myocardial infarction, patient was given Aspirin 325 mg and heparin drip and subsequently underwent cardiac catheterization which showed angiographically normal coronary arteries. A repeat ECG 24 hours later did not demonstrate any ST-segment changes consistent with Quetiapine induced ST segment elevation. IMPACT/DISCUSSION: Quetiapine is a second generation atypical antipsychotic used in the treatment of schizophrenia, acute manic episodes and major depressive disorder. The toxic effects of quetiapine include sinus tachycardia, QT prolongation, hypotension, respiratory depression, and anticholinergic delirium. Doses more than 3 g can cause coma. Only a handful of cases of Quetiapine induced inferolateral or diffuse ST segment elevation have been reported in literature so far, associated with concurrent myocarditis.There was one other reported case of Quetiapine overdose causing 3 mm ST elevation in lead I and II without evidence of myocarditis. This case creates awareness of the rare side effect of ST segment elevation in a patient with Quetiapine overdose which may mimic a myocardial infarction until a coronary angiogram proves otherwise.

*Quetiapine causing ST segment elevation has rarely been reported in literature and our case highlights the importance of clinician awareness of ST segment elevation in the setting of quetiapine overdose. *Awareness of this uncommon side effect is important while contemplating further diagnostic or therapeutic investigations due to ST elevation. A RARE CASE OF SIMULTANEOUS LYME DISEASE AND CAPNOCYTOPHAGA ENDOCARDITIS IN A PATIENT WITH CHRONIC ALCOHOL USE Kseniya Anishchenko1; Valentina Jaramillo-Restrepo2. 1Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 2New York University, New York, NY. (Control ID #4269698) CASE: The patient is a 45 yo M with past medical history notable for substance use disorder who presented to the hospital with one month of migraines, unsteady gait, and heavy night sweats. Social history was notable for active heavy alcohol use, with last IV substance use about 10 years before presentation. On examination, he had a 4/6 systolic murmur in the left upper sternal border. On admission WBC 47, ESR 73, CRP 12, and positive Lyme IgG/IgM and Western blot. TEE showed aortic valve mass, severe aortic regurgitation and perforation of non-coronary cusp. MRI brain showed small punctate areas of restricted diffusion in cortex as well as failure of T2 FLAIR suppression of frontal sulci concerning for meningitis. Two sets of blood cultures were negative. He underwent mechanical valve replacement which showed heavily diseased aortic valve with small abscess cavity at annulus of right coronary cusp. His 16s PCR was positive for Capnocytophaga canimorsus. He had difficulty with IV antibiotics at home and successfully completed 6 weeks of doxycycline and amoxicillin-clavulanic acid. Upon re-interrogation he endorsed a dog bite ~1 week prior to symptom onset and was counseled on safe handling of his pets. IMPACT/DISCUSSION: This case highlights a rare combination of newly diagnosed Lyme disease and sub-acute endocarditis from C. canimorsus. Initially, this patient’s presentation was thought to be secondary to disseminated Lyme disease after the Western blot returned positive. However, Lyme vegetations are rare with only seven isolated cases presented in literature and thus our multidisciplinary team treated broadly for bacterial causes. HACEK organisms are most implicated in culture-negative endocarditis, but in this case, the 16s PCR on aortic valve culture was positive for Capnocytophaga canimorsus. Capnocytophaga is a commensal bacterium in the saliva of dogs that causes wound infections and septic arthritis in human hosts, but in exceedingly rare cases can cause endocarditis. This patient was immunocompromised from chronic, heavy alcohol use. This case highlights the importance of comprehensive history-taking in patients with culture-negative endocarditis, including asking recent human, feline, or canine bites. It also highlights the potential dangers of anchoring bias, as the Lyme diagnosis was early in the hospital course and could have adversely impacted treatment decisions; to avoid this our patient was treated broadly with ceftriaxone and vancomycin while awaiting final PCR data. While C. canimorsus endocarditis remains a rare entity, using advanced techniques such as 16s RNA sequencing will likely identify more cases in the future and guide the creation of treatment paradigms.

Lyme disease can manifest as carditis but very rarely causes valvular vegetations, so any findings of endocarditis should raise suspicion of a separate entity. C. canimorsus is a rare cause of endocarditis but should be on the differential for patients with a history of animal bites. A RARE CASE OF SPINAL BROWN TUMOR IN A MIDDLE-AGED FEMALE WITH END-STAGE RENAL DISEASE ON HEMODIALYSIS FAHEMA NADIRA. Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4271965) CASE: A 47-year-old female with a history of advanced heart failure secondary to peripartum cardiomyopathy, anuric end-stage renal disease (ESRD) on hemodialysis with secondary hyperparathyroidism, nodular regenerative hyperplasia of the liver, currently undergoing evaluation for heart/liver/kidney transplant, presented to the emergency room with a two-week history of unremitting lower back pain with progressive bilateral leg weakness. Her neurological exam was pertinent for 4/5 strength in her right hip flexors, 3/5 strength in her right knee extensors, decreased sensation in the right lateral thigh, and a positive straight leg raise in her right leg. Labs were pertinent for grossly elevated parathyroid hormone (PTH) of 2,071, hypocalcemia, and hyperphosphatemia. MRI showed severe cord compression (SCC) due to the expansile lytic lesion at the level of L1 and she subsequently underwent emergent tumor resection via decompressive laminectomy. Histopathology was consistent with brown tumor (BT). Thereafter, she underwent a total parathyroidectomy, and post-operatively she was managed in the ICU for hungry bone syndrome. She was stabilized and discharged to inpatient rehabilitation. IMPACT/DISCUSSION: In ESRD, the low serum calcium and high serum phosphate levels stimulate PTH secretion (secondary hyperparathyroidism), which can result in a wide array of skeletal abnormalities including BT. A BT is a benign, locally destructive bone lesion that typically involves the mandible, ribs, pelvis, long bones, and rarely the spinal cord. A literature review by Tayfun et al found only 27 cases of spinal BT with only 5 cases of lumbar spine BT due to secondary hyperparathyroidism. Among the 27 cases, 20 underwent tumor resection, and among said cases, only 8 underwent parathyroidectomy. Therefore, this case report provides a rare learning opportunity for the clinical course of spinal BT. The symptoms of spinal BT depend on its location. In our patient, her symptoms of weak hip flexion, weak knee extension, sciatica, and sensory changes in the lateral thigh were consistent with radiculopathy at the level of L1. Management of BT mostly involves controlling phosphate levels and in rare cases, parathyroidectomy. In our patient, phosphate levels remained elevated despite restricted dietary phosphorus, high phosphate dialyzer, phosphate binders, vitamin D, oral calcium supplements and calcimimetics, and she developed life-threatening spinal SCC warranting an emergent parathyroidectomy.

In this report, we present a case of a middle-aged female with SCC secondary to a BT. This case underscores the importance of BT in the differential diagnosis of acute back pain in patients with longstanding secondary hyperparathyroidism in the setting of ESDR. A RARE CASE OF UPADACITINIB INDUCED LIVER INJURY Elona E. Poltiyelova1; Dovid Kotkes1; David C. Wolf2. 1Medicine, Westchester Medical Center, Valhalla, NY; 2Liver Transplant, Westchester Medical Center, Valhalla, NY. (Control ID #4271693) CASE: A 67 year-old woman with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC)-induced cirrhosis, was admitted for new onset jaundice. Several months prior, lab tests showed total bilirubin 1.9 mg/dL, AST 56 U/L, and ALT 37 U/L. Ten days prior, the patient began upadacitinib 45 mg daily to treat a UC flare. Her other medications included carvedilol and hydralazine, which she has been taking for years. She denied the use of any herbal supplements. Within days of starting the upadacitinib, the patient developed new onset jaundice and abdominal swelling. She stopped upadacitinib after five days. Labs on admission showed total bilirubin 23.3 mg/dL, direct bilirubin 17.4 mg/dL, alk phosphatase 140 U/L, AST 116 U/L, and ALT 145 U/L. Testing for hepatitis A, B, C, acetaminophen, antimitochondrial antibody, ANA and ASMA were negative. Immunoglobulin levels were elevated. MRI showed cirrhosis with moderate ascites. The liver biopsy showed features of PSC, including duct loss and biliary cirrhosis. The biopsy also demonstrated mild steatosis, as well as marked cholestasis and inflammation, suggesting possible drug-induced liver injury (DILI). After other potential causes of liver injury were ruled out, it is postulated that the patient had upadacitinib-induced acute-on-chronic liver injury. Given the severity of her liver injury and a MELD score of 26, she was listed as a candidate for liver transplantation. Over the next three months, liver function improved. Lab testing performed three months after showed total bilirubin 4.2 mg/dl, AST 82 U/L and ALT 32 U/L. IMPACT/DISCUSSION: DILI is a diagnosis of exclusion and the most common cause of acute liver failure in the U.S. Our case report describes a patient with UC who developed DILI after initiating treatment with upadacitinib. To our knowledge, this is the first reported case of clinically significant DILI associated with upadacitinib use. The patient’s preexisting liver disease may have predisposed her to having severe liver dysfunction. Upadacitinib is a selective JAK inhibitor that primarily targets JAK-1. Upadacitinib has been shown to cause mild elevation in transaminases. However, there were no reports of serious cases of liver injury. The R ratio was calculated to be 3.1, demonstrating a mixed hepatocellular and cholestatic pattern of injury. The patient’s biopsy also aligned with a mixed pattern. The RUCAM score was 9, indicating that hepatotoxicity secondary to upadacitinib was “highly probable”. The exact mechanism by which upadacitinib may cause liver injury is not understood. JAK inhibitors modulate multiple cytokine signaling pathways involved in immune regulation and inflammation. It is possible that alterations in these pathways could lead to hepatotoxicity.

It is essential for clinicians to be aware of severe DILI as a rare, but potential side effect of upadacitinib treatment. As the use of JAK inhibitors in IBD management continues to expand, vigilance for hepatic adverse events remains crucial. A RARE CASE OF WARFARIN-INDUCED ACUTE LIVER INJURY IN A PATIENT WITH COMPLEX COMORBIDITIES Greeshma James1; Ajitha Virinchipuram Ganesan1; Mohana Priya Manoharan1; Bolivia C. Fernandes2; Joseph Defrank3. 1Internal Medicine , NYMC GME at St Mary's General Hospital and St Clare's Health, Denville, NJ, US, Parsippany, NJ; 2Internal Medicine, NYMC at St. Mary's General Hospital and Saint Clare's Health, Parsippany, NJ; 3Saint Clare's Health System, Denville, NJ. (Control ID #4272676) CASE: A 67-year-old male with ischemic cardiomyopathy with ejection fraction 40%, diabetes mellitus type 2, chronic kidney disease stage 3a was sent to emergency due to abnormal blood work. He was admitted 2 weeks prior for new-onset atrial fibrillation with rapid ventricular response and acute heart failure exacerbation. He was successfully cardioverted. With a CHADs-VASc score of 5; he was discharged on anticoagulation bridging to warfarin 5 mg. Within a week, he presented due to elevated liver enzymes and INR. The patient’s only new change in medication was the addition of warfarin. His home medications included aspirin, lipitor, torsemide, metoprolol, vitamin D3, fish oil. He denied dietary changes or alcohol use. No potential triggers were found within the last week. He was in atrial fibrillation with HR 60 and normotensive. Physical examination was unremarkable. Laboratory values showed AST 1469 u/L, ALT 1800 u/L, total bilirubin 2.4 mg/dl, alkaline phosphatase 79 u/L, albumin 3.3 g/dl, INR 9.65. Hepatitis panel including hepatitis A, B, C, D, urine drug screen, and ANCA profile were negative. Acetaminophen levels were within normal limits. Abdominal imaging with doppler ruled out Budd-Chiari syndrome. The Roussel Uclaf Causality Assessment Method score was 8, which denoted the probable likelihood of warfarin causing drug-induced liver injury (DILI). Given that warfarin was the only change, it was withheld. Atorvastatin and fenofibrate, were stopped due to transaminitis. He received oral vitamin K. Next day, the patient’s AST 403 u/L, ALT 848 u/L, and INR 2.19 improved. He was also given the option to rechallenge with warfarin and monitor, but given the risks, the family opted to start apixaban. He was switched from warfarin to apixaban 5 mg twice daily. His outpatient lab work 3 days post-discharge revealed improved AST, ALT, total bilirubin 1.8 mg/dl, and a normal alkaline phosphatase. IMPACT/DISCUSSION: The patient had an asymptomatic, acutely severe hepatocellular pattern of injury. After ruling out the most common etiologies of acute transaminitis, DILI or hypoperfusion were considered, although no profound hypotension had occurred since admission. Therefore, warfarin was the most likely cause of liver injury, which markedly improved within 10 days of withdrawal of the agent. Warfarin’s association with liver injury, although rare, has been reported in the past. Possible mechanisms of warfarin-induced liver injury from animal studies include oxidative stress, immune-mediated reactions, and direct hepatotoxicity. Although the patient was predominantly asymptomatic, the superimposed effect of warfarin exaggerated the PT-INR values and, hence, the MELD scores.

While warfarin-induced liver damage seems to be rare, this case highlights the importance of being aware of the potentially uncommon hepatotoxicity of the drug. More studies are needed to identify better the risk factors for warfarin-induced liver issues to improve the care of susceptible individuals. A RARE CONVERGENCE: WERNICKE'S ENCEPHALOPATHY INDUCED BY CANNABIS HYPEREMESIS SYNDROME Lynnee Vaught1; Karen Kimel-Scott2. 1Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; 2General Medicine, UNC Chapel Hill, Durham, NC. (Control ID #4272311) CASE: A 25 year-old woman with past medical history of lupus, chronic constipation, CMV colitis complicated by sigmoid perforation requiring sigmoidectomy and ostomy reversal 2 years prior, presented to the emergency department with refractory nausea and vomiting. Her nausea and non-bilious, non-bloody emesis started 3 months prior to presentation. She had 4 episodes of emesis per day with decreased oral intake and weight loss. She had a bowel movement every 3 days during the same time period. Vital signs were notable for tachycardia to 110. BMI 30. Exam included focal patch of hair loss over right anterior scalp and soft, nondistended abdomen with tenderness to palpation diffusely. Lab work included mildly elevated lipase at 137, and venous lactic acid was elevated to 3. Her CTAP revealed large bowel-containing left ventral hernia without obstruction. She was admitted for inpatient management. She received 1 Liter of Lactated Ringers with normalization of heart rate and lactic acid. She was not eating due to the nausea, so she was started on maintenance fluids with Dextrose 5% and 0.45% Normal Saline. The next morning, on physical exam, she was confused with new nystagmus. MRI was obtained and revealed DWI and T2 FLAIR signal abnormality along the medial thalami bilaterally consistent with acute Wernike encephalopathy (WE). She was treated with IV thiamine, and confusion improved quickly. Her nausea and vomiting resolved. We discovered that her emesis started the same time that she had started smoking marijuana daily. This case is a presentation of malnutrition due to cannabis hyperemesis causing Wenike Encephalopathy exacerbated by Dextrose 5%. IMPACT/DISCUSSION: This case highlights the importance of recognizing patient populations who are vulnerable to thiamine and other vitamin deficiencies. Cannabis hyperemesis syndrome (CHS) is a common etiology of refractory nausea and vomiting. If chronic, these patients are susceptible to thiamine deficiency. Clinicians should have a high suspicion for thiamine deficiency in patients with decreased oral intake and vomiting and should avoid dextrose containing fluids until thiamine supplementation has been given or thiamine deficiency has been ruled out.

Chronic vomiting and inadequate nutrition, both common in CHS, can lead to thiamine deficiency. In this case, the patient’s repeated vomiting likely contributed to thiamine depletion, making them vulnerable to developing WE when exposed to dextrose. This case highlights the need to consider thiamine supplementation in any patient with chronic vomiting, particularly with a history of chronic cannabis use. A RARE PRESENTATION OF GUILLAIN-BARRé SYNDROME Tingfei Hu1; Isna Khaliq2; Arti A. Narsinghani2. 1Medicine, Rush University Rush Medical College, Chicago, IL; 2Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4273369) CASE: An 18-year-old female presented to the ER with 2 weeks of bilateral ascending leg weakness, which progressed to saddle anesthesia, bladder incontinence, and fingertip numbness. She reported an upper respiratory infection with fever 2 months earlier. On presentation, vitals and routine laboratory were unremarkable. Physical exam revealed sensory ataxia, diminished reflexes, and sensory deficits in the lower extremities. Motor strength and cranial nerves I-XII were normal. Infectious testing showed Epstein-Barr virus (EBV) mononucleosis and negative metabolic workup. Further workup ruled out spinal inflammation and multiple sclerosis with unremarkable MRI brain and spinal cord, normal WBC, and absence of oligoclonal bands. Subsequent elevated CSF proteins raised concern for Guillain-Barré Syndrome (GBS). Acute demyelinating polyneuropathy was supported by the electromyography and nerve conduction study (EMG/NCS), demonstrating abnormal motor function of the left limbs. The patient’s symptoms significantly improved after 4 days of immunoglobulin therapy. She completed physical/occupational therapy evaluations and was discharged to follow-up with her neurologist and primary care provider. IMPACT/DISCUSSION: GBS is an acute immune-mediated peripheral neuropathy that typically presents with bilateral ascending paralysis. It occurs 1-3 weeks post respiratory/gastrointestinal infection, with rare associations with EBV. One subtype is Acute Inflammatory Demyelinating Polyneuropathy (AIDP), which involves autoantibodies against myelin and is characterized by motor weakness and prolonged conduction velocities. Another variant, Acute Motor and Sensory Axonal Neuropathy (AMSAN), targets motor and sensory axonal membranes, causing motor and sensory deficits with normal EMG/NCS. Our case highlights an atypical presentation of GBS. Unilateral sensory deficits and bladder incontinence initially suggested spinal cord lesion or multiple sclerosis. But elevated CSF protein and preceding viral illness shifted the differential to GBS. The AMSAN subtype of GBS was considered given the sensory deficit, but abnormal EMG/NCS was more indicative of AIDP. Ultimately, clinical intuition and evidence-based investigation identified AIDP as the most probable diagnosis. GBS primarily presents with motor deficits, with <10 purely sensory cases documented to our knowledge. This suggests a motor-sensory continuum, with our patient leaning toward the atypical sensory end. Thus, our patient’s symptoms were initially misattributed to a functional etiology. However, by keeping an open mind, clinicians were able to re-evaluate their assumptions, incorporate new findings, and refine their diagnoses. Our case illustrates the importance of practice-based learning and the need to refine current GBS diagnostic criteria to better accommodate atypical manifestations.

This unusual case of GBS highlights the need of an open-minded, flexible, and evidence-based approach to diagnosing rare and complex conditions. A RARE PRESENTATION OF MANTLE CELL LYMPHOMA Ommara Jabbar1; Alba L. Caceres Munoz2; Anunaya Aashish3; Scott Keeney3. 1Internal medicine, Texas Health Resources, Arlington, TX; 2Internal Medicine, Texas Health Resources University, Arlington, TX; 3GME, Internal medicine residency program, THR HEB/Denton, Texas Health Resources, Arlington, TX. (Control ID #4273326) CASE: 75-year-old man with PMH of HTN, medication noncompliance, and malignant melanoma presented to the ED with 1 day of slurred speech, weakness, and mechanical fall. ROS was positive for subjective fever for 1 day and lower back pain for 3 weeks. The Stroke Protocol was activated due to slurred speech and weakness. CT head and MRI w/o con showed no evidence of acute stroke. NIHSS was 1. CXR and UA were unremarkable. Hypercalcemia was noted at 11.8. Initial management with IVF, Calcitonin, Lasix, and Pamidronate and clear downtrend of Ca was seen. AKI in the setting of poor oral intake was noted and Cr plateaued at 2.2. Anemia was noted with Hg 11.8. Workup for Multiple myeloma was ordered. SPEP with immunofixation showed IgG kappa paraprotein. Markedly elevated kappa and lambda light chains with normal ratio seen. Findings were not strongly suggestive of Multiple Myeloma. Although, patient’s symptoms were improving with correction of hypercalcemia, further workup was ordered, which revealed CT A/P findings of multifocal lymphadenopathy diffusely with splenomegaly, Vitamin D3 1,25-OH level at 98.8 and PTH <4. A lymph node biopsy revealed mantle cell lymphoma. As hypercalcemia improved, patient's mentation and speech also improved. The patient started chemotherapy. IMPACT/DISCUSSION: Mantle cell Lymphoma is a rare subtype of Non Hodgkins lymphoma, with an annual incidence of 4-8 cases per million. Amongst its presentations, it can uncommonly present with hypercalcemia, in about 8.5% of the patients, making it a very rare combination. Patients may present with neurological symptoms, which frequently prompts stroke workup. We present a case of a patient with stroke-like symptoms, in whom stroke was r/o and his symptoms were attributed to mild hypercalcemia. Further workup revealed the patient had Mantle cell lymphoma. His hypercalcemia and associated symptoms improved with initiation of treatment. Even if the hypercalcemia can potentially be explained by conditions like dehydration, renal failure, poor intake etc., a high index of suspicion should be maintained for more significant underlying pathologies, like Multiple myeloma or more rarely Mantle cell lymphoma as in our patient. The incidence of patients reported to have hypercalcemia is about 30% of patients with multiple myeloma and 60% of patients with T-cell NHL due to osteolytic processes or PTHrP hypersecretion. In contrast, hypercalcemia seen in patients with B-cell NHL, such as mantle cell lymphoma, is mainly attributed to elevated calcitriol.

Hypercalcemia occurs in only approximately 7-8.5% of patients with B-cell NHL, like Mantle cell lymphoma and may present with stroke-like symptoms. Investigate other causes when slurred speech and weakness occur without focal deficits, as these symptoms alone are unlikely to indicate a stroke. The assessment of serum PTHrP and 1,25(OH)2D3 can assist in both diagnosis and management. A RARE PRESENTATION OF VASCULITIS SECONDARY TO ADULTERATED COCAINE Martin G. Yu. Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4269957) CASE: A 65-year-old male with a history of polysubstance use disorder (PSUD), including cocaine use, presented with hemoptysis, shortness of breath (SOB), night sweats, fatigue, and unintentional weight loss. He had a prior transient ischemic attack (TIA) and was previously hospitalized for acute kidney injury (AKI) and hypertensive emergency, both thought to be related to cocaine use. On admission, his vital signs revealed hypertension and hypoxia, requiring high-flow nasal cannula (HFNC) oxygen therapy. Physical examination showed rhonchi and wheezing bilaterally. Chest imaging revealed bilateral patchy consolidations suggestive of diffuse alveolar hemorrhage (DAH). Laboratory results indicated a creatinine level of 7.7 mg/dL, microscopic hematuria, and a protein-to-creatinine ratio (UPCR) >3g. His p-ANCA was positive (1:640), with low MPO and negative GBM antibodies. Urine toxicology confirmed recent cocaine use. A renal biopsy revealed crescentic necrotizing glomerulonephritis, focal sclerosing membranous glomerulonephritis, and interstitial fibrosis with arteriosclerosis, consistent with levamisole-induced vasculitis. Given the rapid deterioration of renal function, he was started on hemodialysis (HD) during his inpatient stay. The patient was treated with intravenous methylprednisolone and then transitioned to a prednisone taper. Despite a negative levamisole screen (likely due to rapid clearance of the drug), the clinical picture was suspected to be due to levamisole-induced vasculitis. He was later diagnosed with pulmonary-renal syndrome secondary to microscopic polyangiitis and started on rituximab for ongoing management. IMPACT/DISCUSSION: Cocaine is a widely abused recreational drug, often mixed with harmful substances. One such adulterant is levamisole, a veterinary anti-parasitic agent found in approximately 70% of street cocaine, which can lead to severe life-threatening complications. Levamisole-induced vasculitis is a well-documented complication of cocaine adulteration, often presenting with severe skin, renal, and pulmonary involvement. While kidney failure and pulmonary hemorrhage are rare, they can be life-threatening complications that clinicians must consider in patients with cocaine use. The p-ANCA positivity observed in this case is consistent with levamisole-induced vasculitis but does not match the classic presentation of ANCA-associated vasculitis. Treatment typically involves removal of the offending agent and administration of glucocorticoids, with rituximab added in severe cases.

Clinicians should remain vigilant for levamisole-induced vasculitis in patients with polysubstance use, as the immunologic effects of levamisole can persist even after the drug is cleared from the system. A RARE TRAVEL RELATED CASE OF SEPSIS AND PNEUMONIA FROM BURKHOLDERIA THAILANDENSIS Mohamed Mansour1; Pranav Chalasani2; Kopal Kotak1; Kyle W. Gifford1; Palpasa Bhui2; Ayushi Garg3; Emad Shehada2. 1Internal Medicine Residency Program, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 3INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI. (Control ID #4271639) CASE: A 54-year-old Filipino male with a history of nonischemic cardiomyopathy (EF 20–25%), atrial fibrillation with an AICD, and diabetes mellitus presented with a two-week history of fever, chills, diarrhea, cough, shortness of breath, and 15-20 pounds of weight loss. He resides part-time in the Philippines, where he works on a farm, and returned to Michigan a week prior after symptoms persisted despite antibiotics prescribed for typhoid fever, diagnosed by his physician based on a positive typhoid IgM. On admission, his vitals included a blood pressure of 103/79 mmHg, pulse of 99 bpm, respiratory rate of 20 breaths per minute, temperature of 100.4°F, and oxygen saturation of 98% on room air. He was alert, oriented, and diaphoretic, with scattered bilateral rhonchi but intact air entry. A chest X-ray revealed multifocal opacities consistent with an infectious process. Initial treatment included piperacillin-tazobactam and doxycycline per infectious disease recommendations. Sputum culture grew 3+ respiratory flora, and blood cultures at 24 hours showed no growth. Legionella urine antigen was negative. On day 2, a rapid response revealed fever, tachycardia, and hypoxemia (BP 147/77, HR 120, temp of 102 F, SpO2 97% on 5 L), consistent with severe sepsis and acute respiratory failure from multilobar pneumonia. Labs done during the rapid showed: Lactate 12.1, WBC 10.1, and Blood cultures later grew gram-negative bacilli resembling Burkholderia thailandensis from the aerobic vial, confirming the source of sepsis, with no growth observed in the anaerobic vial after five days. The patient stabilized after tailored therapy for B. thailandensis. IMPACT/DISCUSSION: This case highlights the need to consider rare tropical pathogens like Burkholderia thailandensis in patients with sepsis and respiratory failure after travel to endemic regions. B. thailandensis is a soil- and water-dwelling gram-negative bacillus closely related to Burkholderia pseudomallei, the causative agent of melioidosis. Melioidosis can present with a variety of clinical manifestations, including acute pneumonia with septicemia, carrying high mortality despite aggressive treatment. Blood cultures revealing B. thailandensis were critical in guiding appropriate therapy, as the pathogen exhibits intrinsic resistance to certain antibiotics, including piperacillin-tazobactam, which was part of the initial regimen.

A thorough travel and exposure history is essential for identifying rare infections such as Burkholderia thailandensis. Early diagnosis and tailored antibiotic therapy are crucial for improving outcomes in rare cases of tropical sepsis. A RAT-ICAL CASE OF ENDOCARDITIS Jacqueline M. Ziegman, Kathryn Leyens. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4272502) CASE: A 28-year-old male with no significant past medical history presented to the emergency department with an acute onset severe frontal headache. Imaging showed a right frontal infarct and right parietal subarachnoid hemorrhage. Prior to this, the patient had three months of fevers, fatigue, and night sweats which transiently improved following a short course of azithromycin. He helped his partner in caring for several pet rats but denied recent bites. Digital subtraction angiography revealed a 1.9 mm left posterior cerebral artery mycotic aneurysm. Transthoracic and transesophageal echocardiogram identified small atrial-sided mitral valve vegetations with destruction of the leaflets and resulting severe eccentric mitral regurgitation. Blood cultures and antibody testing for Bartonella, Coxiella, Brucella, and HIV were negative. He was empirically treated with vancomycin, ceftriaxone, and doxycycline given the animal exposures. He underwent mitral valve ring annuloplasty. Surgical pathology of the vegetations was culture negative, but 16s rRNA testing identified Streptobacillus moniliformis. IMPACT/DISCUSSION: Rat bite fever is typically caused by Streptobacillus moniliformis, a microaerophilic, pleomorphic, gram-negative bacillus. It is harbored in the nasopharynx and oropharynx of rats and is transmitted through rat bites or consumption of contaminated food. Infection with this organism typically manifests with fevers, rash, and arthralgias, but more severe complications can occur including endocarditis, pneumonia, osteomyelitis, meningitis, septic arthritis, and vasculitis. Endocarditis is a rare complication with mortality rates estimated around 50%. This organism can cause ruinous valvular damage, necessitating early diagnosis. Most cases occur in patients with pre-existing valvular damage, and embolic sequelae are infrequent. While S. moniliformis can be cultured from blood or tissue samples, it is difficult to isolate and often requires 16s rRNA sequencing. Treatment is guided by anecdotal reporting and has traditionally been penicillin. Ultimately, this case highlights the necessity of thorough history taking in patients with vague symptoms as well as the importance of early recognition to prevent catastrophic complications.

Rat bite fever should be on the differential for patients presenting with vague symptoms including fever, rash, and arthralgias with rat exposure. Endocarditis is a rare but often fatal complication requiring prompt diagnosis and management. S. moniliformis is particularly challenging to culture and usually requires PCR analysis for diagnosis. AREN'T YOU TOO OLD FOR THIS?: THROMBUS FORMATION SECONDARY TO INFECTIVE ENDOCARDITIS IN A 3-YEAR-OLD LEADLESS PACEMAKER Chandler Richardson1; Vivek Varughese1; Logan Carlyle1; Dominic J. Vacca1; Olivia Yessin1; James Pollock1; Carra Lyons2; Patryk Czyzewski1. 1Internal Medicine, Prisma Health Midlands, Columbia, SC; 2Internal Medicine, University of South Carolina School of Medicine Columbia, Columbia, SC. (Control ID #4271563) CASE: An 82-year-old male presented to the emergency department for malaise and weakness. He was SIRS positive with tachycardia (heart rate >90) and tachypnea (respiratory rate >20). Initial evaluation including a CT angiogram of the chest showed several areas of density in the upper lung fields concerning for septic emboli vs multilobar pneumonia. Radiology also noted a possible mass at the base of the LPM in the right ventricle on the CT scan concerning for thrombus surrounding his 3-year-old leadless pacemaker. ECHO was performed and showed a mobile echogenic mass in his right ventricle at the base of the LPM measuring 1.94cm x 2.69cm. Cardiology was consulted to perform TEE which could not be completed due to respiratory decompensation during the procedure. Blood cultures returned positive for MSSA and Pseudomonas and he was treated with cefazolin, cefepime, and rifampin. Cardiothoracic surgery was consulted for surgical assessment and it was determined that he was not a surgical candidate based on his increased mortality risk. They instead recommended attempting percutaneous suction removal of the thrombus and LPM with the AngioVac system (AngioDynamics, NY, USA) After successful thrombus debulking, the LPM remained attached to the ventricular wall despite repeated efforts to break it loose and remove it with the AngioVac (AngioDynamics, NY, USA). Ultimately the patient and his family decided against continued intervention and the patient died on comfort care a few days later. IMPACT/DISCUSSION: LPMs have a lower risk of device-related infections, but data on the management of LPMs greater than 1 year after implantation is still limited. Some studies have explored transvenous extraction methods like snaring for LPM removal, but removal becomes more complex when LPMs become encapsulated in cardiac tissue or have thrombi attached to them. Commonly, the next step in management would be removal through open heart surgery, however, a typical LPM patient is too frail to undergo such invasive procedures. There are cases of AngioVac (AngioDynamics, NY, USA) use in several different instances including the removal of a thrombus and an LPM less than 1 year after placement, but it has had mixed success rates.

It is important to have a good understanding of what complications are possible after any procedure no matter how small the risk so you know what to look out for and can get specialists involved early. Also, understanding what interventions are available in these instances can help guide your conversations with patients and families to set their expectations accordingly early in the disease course. ARTERY OF PERCHERON INFARCTION AND PATENT FORAMEN OVALE: AN ATYPICAL PRESENTATION OF STROKE IN A YOUNG PATIENT Anthony M. Perez Santos1; Gordon White2; Harrison Koss1; Michelle Cheung1; Micah Chaiprakorb1; Arie Szeinfeld1; Osama Elsammani1. 1Internal Medicine, HCA Florida JFK Hospital, Atlantis, FL; 2Internal Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4272582) CASE: A 35-year-old woman with no significant medical history was brought to the emergency department by her husband after being found unresponsive and foaming in the mouth. Patient medications included oral contraceptives and over-the-counter analgesics for headaches. Her husband found her unresponsive at 11:00 AM after she had gone to bed at 20:00. The patient could not recall any events before hospitalization and denied substance abuse or recent travel. In the emergency department, the patient was alert and oriented, primarily complaining of double vision. No seizures, loss of bowel or bladder control, or other neurological symptoms were reported. Physical examination revealed a visual field defect with left lateral and bilateral downward gaze, which was more pronounced on the left, and diplopia. Serial CT scans per stroke protocol, were unremarkable. Magnetic resonance imaging (MRI) with and without contrast revealed acute bilateral thalamic strokes and the presence of an artery of Percheron (AOP). Further investigations revealed a small but significant patent foramen ovale (PFO) on echocardiography. Due to the high risk of recurrent stroke in patients with PFO-associated cryptogenic stroke, PFO closure was performed. After the procedure, the patient was started on antiplatelet therapy and scheduled for regular follow-up to monitor her neurological recovery. IMPACT/DISCUSSION: The AOP is a rare anatomical variant where a single arterial trunk from the proximal posterior cerebral artery supplies the bilateral paramedian thalami and rostral midbrain. Occlusion results in bilateral thalamic infarctions, presenting with neurological symptoms such as altered consciousness, oculomotor disturbances, cognitive disturbances, and potentially coma. Diagnosis is challenging and typically relies on MRI to identify bilateral thalamic infarcts indicative of AOP occlusion. In contrast, patent foramen ovale (PFO) can act as a conduit for paradoxical emboli, leading to cryptogenic strokes. The American Heart Association and American Stroke Association guidelines note that PFO increases the risk of cryptogenic stroke, especially in younger individuals and those with specific anatomical features like atrial septal aneurysm. Although both AOP occlusion and PFO can cause strokes, they are distinct conditions with different pathophysiological mechanisms, and the presence of a PFO is not required for an AOP stroke to occur.

The present case illustrates a complex scenario involving a young female patient with bilateral thalamic strokes resulting from an artery of Percheron occlusion, potentially associated with a patent foramen ovale (PFO). The patient's clinical presentation, characterized by an abrupt onset of neurological symptoms including unresponsiveness and diplopia, is indicative of acute stroke. The identification of an artery of Percheron underscores the significance of considering this rare anatomical variant in cases of unexplained bilateral thalamic strokes. A SEVERE NUTRITIONAL DEFICIENCY MASQUERADING AS BONE MARROW FAILURE Danielle Uibel1; Faiqa Amin1; Sumukh Arun Kumar2; Madhulika Urella2. 1Internal Medicine, Bayhealth Medical Center, Dover, DE; 2Hematology and Medical Oncology, Bayhealth Medical Center, Dover, DE. (Control ID #4273508) CASE: We present a 36 year old female with past medical history of iron deficiency anemia requiring weekly transfusions who presented with fatigue. Initial workup notable for macrocytic anemia and hemolysis with elevated LD, fibrinogen, and D-Dimer, undetectable haptoglobin, hyperbilirubinemia, severe thrombocytopenia and leukopenia. Differential showed elevated metamyelocytes and myelocytes. Peripheral smear demonstrated hypersegmented neutrophils. Reticulocytes levels were notably low. Iron studies revealed modestly elevated ferritin. Flow cytometry showed a small population of circulating myeloblasts and abnormal myeloid maturation. The patient was found to have a severely low B12 level. She was treated with subcutaneous B12 daily for seven days, then weekly for four weeks, then monthly, with adequate recovery of B12 levels and resolution of pancytopenia. She was discharged with outpatient follow up and later diagnosed with pernicious anemia. IMPACT/DISCUSSION: Vitamin B12 is a key component of DNA synthesis and its deficiency results in impaired hematopoiesis and megaloblastic anemia. Deficiency is common, and is usually seen in those with poor oral intake, dietary restrictions, and/or and digestive diseases. Unlike iron deficiency anemia, B12 deficiency does not result from blood loss or heavy menstruation. This patient was previously diagnosed with iron deficiency anemia secondary to heavy menses requiring weekly transfusions. She had been told that her B12 levels were low in the past but was never treated. It is likely that this patient’s underlying pernicious anemia and resulting B12 deficiency were the driving force of her anemia given the speed of her hematologic recovery once B12 was repleted. It is reasonable to assume that earlier identification and repletion could have prevented numerous blood transfusions and their associated risks. This patient also presented with overt hemolysis and pancytopenia, which is atypical for macrocytic anemia. In severe B12 deficiency, ineffective erythropoiesis can lead to intramedullary hemolysis and peripheral hemolysis. Reticulocyte count is paradoxically low despite the pancytopenia and hemolysis secondary to the lack of functional erythropoiesis. Her undiagnosed pernicious anemia prevented absorption of B12 causing severe depletion with inadequate bone marrow compensation.

Severe B12 deficiency results in altered hematopoiesis and can present with significant pancytopenia and paradoxically low reticulocyte count due to bone marrow depletion which appears similar to myelodysplastic syndromes. Intramedullary hemolysis is a possible side effect of severe B12 deficiency and can present with significantly elevated levels of LD, fibrinogen, and D-dimer and low haptoglobin. It is possible that patients may have a diagnosis of iron deficiency anemia when their anemia is driven by another cause, such as pernicious anemia. As such it is important to complete a full workup of those presenting with symptomatic anemia including B12. A SOCCER FIELD BADASS: A MINOR ABRASION LEADS TO A DISTANT ABSCESS Youssef Samaha1,2; Bibhuti Adhikari3. 1Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; 2Neuro-Oncology, Harvard Medical School, Boston, MA; 3Internal Medicine, Elmhurst Hospital Center, Queens , NY. (Control ID #4273602) CASE: A 20-year-old man presented with right lower quadrant abdominal pain, fever, and chills one week after sustaining a skin abrasion on his right knee while playing soccer. He had no significant medical history and denied intravenous drug use, recent hospitalizations, or dental work. On exam, he was tachycardic, hypotensive, and had tenderness in the right medial thigh, but no visible signs of infection at the abrasion site. His right hip range of motion was significantly restricted due to severe pain. Labs showed an elevated C-reactive protein (CRP) of 152.9 mg/L. A CT scan of the pelvis and right leg was normal. Blood cultures grew methicillin-sensitive Staphylococcus aureus (MSSA), and he was started on IV piperacillin/tazobactam and vancomycin, which were later switched to cefazolin after identification of the pathogen. Despite normal CT imaging, an MRI was performed due to lack of clinical improvement and revealed a 6 x 2 cm abscess in the right obturator externus muscle. The abscess was initially deemed too small for drainage, but repeat imaging showed an increase in size, prompting percutaneous drainage of 15 mL of sanguino-purulent fluid, which also grew MSSA. Blood cultures cleared after 5 days, and the patient was discharged on a single dose of dalbavancin 1500 mg due to insurance issues preventing home IV antibiotic administration. IMPACT/DISCUSSION: Small skin abrasions can lead to MSSA bacteremia, which may progress to complications like sepsis and metastatic infection. Clinicians should be vigilant for these consequences, including abscess formation in the deep tissues. Abscesses in the obturator externus muscle are rare and difficult to diagnose due to nonspecific symptoms. In this case, the abscess was not seen on the CT, but was noted on the MRI. This underscores the role of MRI in identifying deep soft tissue infections that may be missed on CT, especially in cases where clinical suspicion remains high despite negative imaging findings. Dalbavancin, a long-acting lipoglycopeptide with potent MSSA activity, was chosen in this case to facilitate the transition from inpatient to outpatient care. Its use was necessary due to insurance-related barriers to administering home IV antibiotics. Although dalbavancin is not first-line therapy for MSSA bacteremia, its long half-life and effectiveness in maintaining therapeutic drug levels during the tail-end of the treatment course make it a useful option for patients who face logistical or compliance challenges with prolonged IV antibiotic regimens. In this case, dalbavancin helped avoid the need for a central line and frequent infusions, offering an alternative to standard IV therapy and contributing to the patient's successful recovery.

This case underscores the importance of MRI in diagnosing deep tissue abscesses and the role of dalbavancin in managing MSSA infections when home IV antibiotics are not feasible. A STICKY SITUATION: ACUTE PERICARDITIS SECONDARY TO CYANOACRYLATE GLUE FOLLOWING GASTRIC VARICEAL OBTURATION Nader James Al-Shakarchi, Orly P. Ran Sapir. Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271751) CASE: A 55-year-old female with a past medical history of pancreatic neuroendocrine tumor (NET) complicated by gastric varices presented from an outside hospital with hematemesis. Outside esophagogastroduodenoscopy (EGD) revealed grade 1 gastric varices without evidence of active bleeding and the patient was transferred to a tertiary centre. On arrival, the patient was hemodynamically stable, afebrile, and saturating appropriately on room air. Laboratory evaluation revealed hemoglobin 7.4 g/dL. The patient was started on IV Pantoprazole and IV Octreotide. A preoperative CT pancreas angiogram revealed known NET with involvement of the spleen, stomach, jejunum, colon, splenic vein and gastrosplenic varices. Repeat EGD demonstrated gastric varices with high-risk stigmata, prompting glueing of the varices with cyanoacrylate glue to achieve hemostasis. Postprocedure the patient reported significant pleuritic chest pain relieved by leaning forwards. Physical examination revealed a new pericardial rub and ECG demonstrated diffuse PR depressions. Inflammatory markers were mildly elevated with CRP 10.6 mg/L and ESR 31 mm/hr. CT Chest angiogram demonstrated new radiopaque material in the pericardium. Transthoracic echocardiogram (TTE) revealed no evidence of constructive physiology and limited visualization of foreign material in the pericardium. Esophagram showed no evidence of perforation or fistula and telemetry monitoring revealed sinus rhythm. Following cardiology and cardiovascular surgery consultations, the patient was started on colchicine 0.6 mg BID and 30 mg prednisone daily with a gradual taper. Repeat TTE after 48 hours showed no evidence of overt constriction. The patient was subsequently discharged with close outpatient cardiology follow-up and repeat TTE and ECG within 1 week. IMPACT/DISCUSSION: Only one other case has been reported in the literature of acute pericarditis in the setting of cyanoacrylate glue in the pericardium. Foreign material in the pericardium typically requires surgical management in the presence of symptoms, but clinical context should take precedence. Potential sequelae include constrictive pericarditis, cardiac tamponade, decompensated heart failure, and septic pericarditis. If conservative management is pursued, prompt treatment of pericarditis, telemetry and serial TTE are essential. Indeed, NSAIDs are contraindicated in the setting of gastrointestinal bleeding and steroids carry a high risk of recurrence. However, patients with foreign material in the pericardium are at high risk of decompensation and are usually treated more aggressively with a prolonged steroid taper. If symptoms remain refractory to medical management, pericardiectomy remains an option but may be technically challenging due to the adhesive properties of cyanoacrylate glue.

Pericarditis should be considered in postprocedure patients with positional and pleuritic chest pain. Foreign material in the pericardium requires multidisciplinary consultation and careful monitoring. A SURPRISING CAUSE OF ALTERED MENTAL STATUS IN A YOUNG WOMAN Melissa A. Hynds2; Lee Meluban2; Parth K. Shah2; Mytra Haerizadeh1,2. 1Columbia University, New York, NY; 2Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. (Control ID #4273044) CASE: A 27-year-old woman with a history of depression, menorrhagia, chronic lower back pain, and obesity was brought in by EMS with altered mental status. The patient is a PhD student and her boyfriend activated EMS for altered mental status. On arrival to the emergency department, the patient reported that she had attended a school event where she had had a few drinks. Her boyfriend clarified that this event actually took place five years prior. On initial assessment, her vital signs were stable. She was alert but oriented to self only. Exam was notable for a bizarre affect and bidirectional nystagmus. Initial labs were notable for an acute kidney injury and anion gap metabolic acidosis with positive ketones. Workup was negative for salicylates, acetaminophen, lithium, ethanol, methanol and ethylene glycol. Her fingerstick was 289 md/dL. Urine drug and pregnancy test were negative. CT head showed mild brain atrophy inconsistent with the patient's age. She was administered diazepam, high dose thiamine, dextrose, and started on an insulin drip, and transferred to the ICU. The insulin drip resulted in anion gap closure and she was transferred to the medicine floor. The patient then reported a prior alcohol use history of up to 10-12 drinks at events multiple times per week, though she had been limiting her use recently due to brain fog. Her mental status slowly improved but she continued to display confabulation, ataxia, and short-term memory loss, in addition to end-gaze nystagmus. Neurology was consulted. MRI brain showed hyperintensities in the mamillary bodies and thalamic nuclei bilaterally consistent with Wernicke-Korsakoff Syndrome (WKS). Her PETH levels were significantly elevated consistent with heavy alcohol use. She was followed with CIWA protocol although she showed no signs of withdrawal while admitted. The patient and her family were counseled that the patient was likely in the Korsakoff's phase of illness, and that full recovery of memory deficits may be unlikely. She was discharged with neurology and psychiatry follow up. IMPACT/DISCUSSION: Our patient presented with the traditional WKS triad of confusion, oculomotor dysfunction, and ataxia, as well as an anion gap metabolic acidosis. A prior 2007 case series reported four cases of Wernicke’s encephalopathy which presented with a primary anion gap metabolic acidosis and accompanying respiratory alkalosis speculated to be a distinctive acid-base pattern associated with thiamine deficiency.1 As most young adults with heavy alcohol ingestion do not develop WKS, greater awareness and discernment of conditions that may predispose and/or suggest WKS is warranted.

Recognition of WKS in younger adults is critical to preventing irreversible neurological deficits in patients. Further investigation as to the clinical variability and susceptibility to development of WKS in young adults is warranted. A TALE OF MEGALOBLASTIC MADNESS Cody Hu1; Erin Kaser1; Aymen Baig2; Aaron Owens1. 1Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX; 2Internal Medicine, The University of Texas Health Science Center at San Antonio Department of Medicine, San Antonio, TX. (Control ID #4272606) CASE: A 37-year-old female with no medical history presented for lab abnormalities. Initial blood work revealed a hemoglobin of 5.1 g/dL, a MCV and MCH unable to be calculated, and normal WBC and platelet counts. She denied melena, hematochezia, and reported menorrhagia requiring up to 20 pads/day for 10 days/month. She was transfused and initial workup with iron studies, ferritin, and a transvaginal ultrasound were unrevealing. Upon further history, the patient endorsed paranoid auditory hallucinations. Her brother reported the patient “fell apart” when their patients passed away two years prior. At this time, the patient quit her job and gave up her children. She sent peculiar messages such as, “Our parents are still alive - where are you hiding them?”. The patient stopped showering routinely. Two days after admission, her blood work was remarkable for pancytopenia and normal MCV and MCH levels. Her lactate dehydrogenase was elevated at 2017 U/L, and her haptoglobin was less than 10 mg/dL. Peripheral blood smear was normal. Nutritional labs were notable for a significantly low vitamin B12 level at 56 pg/mL. Daily high-dose cobalamin intramuscular injection was initiated. Her intrinsic factor (IF) antibody returned positive. She was formally diagnosed with PA that would require lifelong cobalamin supplement. After a month of treatment, the patient reported no further episodes of hallucinations, and her pancytopenia was resolving. IMPACT/DISCUSSION: PA is an autoimmune disorder that causes vitamin B12 deficiency. The symptoms of PA encompass neuropsychiatric and hematologic abnormalities. Hematological manifestations of cobalamin deficiency inversely correlate with neuropsychiatric impairment. Co-existence of severe hematologic and neuropsychiatric symptoms, as seen in our patient, is atypical. The gold standard of diagnosing PA is based on detecting IF deficiency. Our patient presented for anemia, and iron deficiency anemia was a top consideration given her menstrual history. It is important to remain broad and fully explore all etiologies of a disease. PA requires parenteral B12 for correction of hematologic abnormalities. With timely intervention, some neuropsychiatric symptoms can be reversed.

PA is a type of megaloblastic anemia due to a lack of IF resulting in vitamin B12 deficiency. It is often insidious to be diagnosed due its wide variety of symptoms and subtle presentations. A TALE OF OVERLAPPING AUTOIMMUNE SEROLOGIES: DIAGNOSING HYDRALAZINE-INDUCED ANCA VASCULITIS (AAV) ASSOCIATED WITH ISOLATED PULMONARY INVOLVEMENT. Pratikshya Thapa1; Ankita Dharmendran2. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Anesthesiology, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4270883) CASE: A 57-year-old Caucasian male with hypertension, severe diastolic dysfunction, and end-stage renal disease on dialysis presented with shortness of breath, cough, and fatigue. He was tachypneic and hypoxic (82%), with bilateral lung crackles and peripheral edema. Lab results showed normal WBC count, elevated ESR >140, CRP 126, and serum creatinine 4.24 mg/dL. Urinalysis showed 200 mg/dL protein and 50-100 RBCs/HPF. Imaging revealed bilateral pleural effusions and patchy ground-glass infiltrates. Despite emergent dialysis and thoracentesis, the patient had only mild relief. Pleural fluid analysis showed an exudative pattern with reactive mesothelial cells in cytology. Autoimmune workup revealed high antinuclear antibodies (1:1280), anti-dsDNA (1:80), P-ANCA 1:1280, MPO 73, PR3 108, and anti-histone antibodies (>7), raising suspicion for drug-induced ANCA vasculitis due to hydralazine, which he had taken since 2015. A renal biopsy confirmed diabetic glomerulosclerosis. After discontinuing hydralazine and initiating high-dose corticosteroids, the patient rapidly improved and was discharged with a steroid taper and follow-up with rheumatology and pulmonology. IMPACT/DISCUSSION: AAV involves necrotizing inflammation of small blood vessels, often presenting with fever, malaise, arthralgias, and myalgias, potentially leading to organ failure. Hydralazine, an Antihypertensive since 1951, can induce AAV via neutrophil accumulation and autoantibody production. Risk factors include cumulative doses >100 g, prolonged use, female sex, and certain genetic traits. Diagnosis involves ANCA antibody testing and renal biopsy, often revealing pauci-immune glomerulonephritis. Notably, as seen in studies by Kumar et al. and Battisha et al., serological features may overlap with systemic lupus erythematosus (SLE), with ANCA-positive patients also exhibiting ANA, anti-dsDNA, and anti-histone antibodies. In our patient, overlapping serologies were noted without SLE signs, and renal biopsy ruled out lupus nephritis, hinting at chronic hydralazine-induced AAV. While there is no standardized therapy, treatment often involves immunosuppressive steroids and/or cytotoxic agents. Our patient improved with tailored high-dose therapy followed by a gradual prednisone taper, underscoring the necessity for individualized treatment strategies.

This case illustrates the challenges in diagnosing hydralazine-induced AAV affecting the lungs/pleura, especially with comorbidities like renal /cardiac failure and overlapping autoimmune serology. A thorough medication review, comprehensive autoimmune workup, and biopsy are essential. Prompt hydralazine discontinuation and high-dose corticosteroids are crucial. Further research into alternative heart failure/antihypertensive medications is recommended. A TALE OF TWO FLARES: CASE OF GPA AND SLE IN IGA DEFICIENCY Archana Regmi1; Swarnima Rijal1; Alexa Constantakos1; Fawad Ahmed2; Luis Sanchez2. 1Internal Medicine residency, AdventHealth Orlando, Orlando, FL; 2nephrology, AdventHealth Orlando, Orlando, FL. (Control ID #4271700) CASE: A twenty-nine-year-old male with past medical history of necrotizing glomerulonephritis secondary to Granulomatosis with Polyangiitis (GPA) diagnosed when he was 13 years old presented to the hospital with involuntary weight loss and fatigue for two weeks. Patient had been previously treated with Cyclophosphamide and Rituximab and Azathioprine for maintenance. He did not experience any relapses after achieving remission though he developed an acquired hypogammaglobinemia after rituximab for which he received IVIG until the age of 21. On presentation serum creatinine was at baseline. Urine analysis was relevant for microscopic hematuria. Urine random protein/creatinine was 450 mg/g. C3 was 91mg/dl (88-201mg/dl) and C4 was 3mg/dl (15-45 mg/dl). Proteinase 3 antibody was 113IU/ml (negative <2 IU/ml) ANA was positive (1:1280), and anti-ds DNA was more than 300. Anti-smith RNA Ab was positive. IgA level was <10 (70-400mg/dl), IgG 1725 (700-1600mg/dl), and IgM 49 (40-230 mg/dl). Patient underwent kidney biopsy which showed focal glomerulonephritis consistent with Class III lupus nephritis. The patient was started on hydroxychloroquine, steroids and mycophenolic acid, which were continued at discharge. IMPACT/DISCUSSION: Primary or acquired immunoglobulin A (IgA) deficiency has been linked to an increased susceptibility to infections, allergies, and autoimmune conditions. We report a unique case of a 29-year-old male with a history of granulomatosis with polyangiitis who subsequently developed lupus nephritis in the context of IgA deficiency. IgA deficiency whether primary or secondary can be associated with development of autoimmune conditions. Patients with IgA deficiency have an 8-fold higher prevalence of Systemic Lupus Erythematosus (SLE) compared to the general population. Decrease in mucosal protection in IgA deficiency with increased GI permeability and cross reactivity of antigen and molecular mimicry may be responsible for autoimmune conditions. Although Rituximab and Cyclophosphamide have been linked to hypogammaglobulinemia that can persist even after discontinuation of treatment, IgA level is less affected. In our case, the early-onset diagnosis GPA, which has a rare incidence of 1 in 1,000,000 among pediatric patients, and the persistent lack of IgA reconstitution despite recovery of other immunoglobulins, suggest that this patient likely had a primary rather than acquired immunodeficiency, predisposing him to the development two distinct autoimmune diseases with different treatment approaches.

This case highlights the complex interplay between immunodeficiency, treatments, and evolving autoimmune conditions. It underscores the importance of broadening differentials as well as thorough diagnostic evaluation cementing the importance of repeating biopsy when clinical suspicion for disease is high. A TALE OF TWO ORGANS Sara Hatoum1; Heather N. Simpson2. 1Internal Medicine, Medical University of South Carolina, Charleston, SC; 2Gastroenterology, Medical University of South Carolina, Charleston, SC. (Control ID #4270694) CASE: The patient is a 49-year-old female with alcohol use disorder who presented to an academic medical center for 2 months of nausea, vomiting, and abdominal pain. Her physical exam was notable for abdominal distention without tenderness. Labs included WBC 28 K, alkaline phosphatase 583 U/L, AST 191 U/L, ALT 108 U/L, and total bilirubin 1.6. Amylase and lipase were normal. CT abdomen showed steatohepatitis, bilateral pleural effusions, and a cystic lesion in the pancreatic head. MRCP showed walled-off necrosis in the pancreatic head, irregularly dilated pancreatic duct, and pancreatic atrophy. Liver biopsy revealed acute alcoholic hepatitis. Shortly after admission, the patient became hypoxic. She had interval increase of the left sided pleural effusion which was now moderate-to-large. Thoracentesis was performed and fluid studies were consistent with an exudative effusion. The patient completed a 7-day course of IV antibiotics for possible parapneumonic effusion, however her respiratory status did not improve. A chest tube was placed with additional fluid studies sent including an amylase level which was 5,536 U/L. This raised suspicion for a pancreatic pleural fistula. ERCP confirmed a large fistula from the tail of the pancreas communicating with the pleural space. There was a stricture in the head of the pancreas, which was dilated to 4 mm and a stent was deployed across the stricture, terminating in the tail of the pancreas. Her chest tube output was reduced following stent placement. A few days afterward, the patient became febrile, and imaging demonstrated a left-sided, small, loculated pleural effusion. Repeat pleural fluid studies were consistent with an empyema with an amylase level <3. The patient was treated with TPA dornase and debridement antibiotic solution was instilled into the pleural space. She was discharged on oral antibiotics to complete a 6 week course. Unfortunately, she passed away one month later. IMPACT/DISCUSSION: Pancreatic pleural fistula (PPF) is a rare complication of pancreatitis, occurring in 0.4% of all cases. It can occur in both acute and chronic pancreatitis with alcohol use being the usual culprit. The most common presenting symptom is dyspnea, while symptoms typically associated with pancreatitis, such as abdominal pain, are less common. MRCP is the imaging modality of choice to identify PPF, detecting up to 80% of cases [1]. MRCP did not detect the fistula in this case, which made the diagnosis more challenging. This patient’s risk factors included signs of chronic pancreatitis on imaging as well as history of heavy alcohol use. [1] Ali, Tauseef MD*; Srinivasan, Nandakumar MD*; Le, Vu MD*; Chimpiri, A. Rao FRCR†; Tierney, William M. MD*. Pancreaticopleural Fistula. Pancreas 38(1):p e26-e31, January 2009. | DOI: 10.1097/MPA.0b013e3181870ad5

Amylase rich pleural fluid should raise concern for a pancreatic source in the right clinical setting. This complication is rare and difficult to diagnose without a high index of suspicion. ATAXIA AND DYSARTHRIA ASSOCIATED WITH A RECURRENT REVERSIBLE LESION IN THE SPLENIUM OF THE CORPUS CALLOSUM Dylan Grote1,2; Tyler Tepfenhart1,2; Blake Oliaro1,2; Yizhong Wu1,2; Sindhoora Koneru3. 1Internal Medicine, Baylor Scott and White Central Texas, Temple, TX; 2College of Medicine, Texas A&M University, Round Rock, TX; 3University of the Incarnate Word, San Antonio, TX. (Control ID #4251027) CASE: A 59-year-old male, with past medical history of hypertension, anxiety, depression, thiamine deficiency, and hyperparathyroidism status post parathyroidectomy, presented with a five hour history of dysarthria and ataxia. A CT head showed no acute abnormalities. Workup revealed hyponatremia consistent with SIADH. Infectious workup, autoimmune panels, and lumbar puncture were negative. An MRI of the head, neck, and spine was significant for restricted diffusion within the central splenium of the corpus callosum. The patient had presented six months prior with chest pressure, dysarthria, confusion, and dyspnea. A MRI brain showed non-specific signal changes, believed to be an ischemic stroke to the splenium of the corpus callosum. The patient’s symptoms resolved within a week but reoccurred two months later. Further workup, including lumbar puncture was unremarkable. Repeat MRI brain showed the previously identified splenial lesion had resolved. The patient’s symptoms resolved within two days. Four months later, the patient again presented the hospital with the currently described symptoms. IMPACT/DISCUSSION: The first description of a reversible lesion in the splenium of the corpus callosum was published by Tada et al. in 2004, and referred to the clinical and radiographic findings as “clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS).” The most common causes are epileptic, infection, metabolism related conditions, high altitude edema, or a combination of other rare etiologies. Patients present with cognitive impairment, seizures, acute urinary retention, and delirium. Less commonly, patients can present with motor deterioration, coma, ataxia, dysarthria, and visual disturbance. Symptoms typically resolve in days to weeks, and patients are left without residual deficits. The etiology of MERS in our patient’s case is unknown, but may be related to his hyponatremia. Hyponatremia can lead to cerebral edema with clinical features similar to MERS. Alternatively, it may be a consequence of the disease process, with inflammation leading to IL-6 mediated release of vasopressin, resulting in SIADH. Other hypotheses of the pathophysiology of MERS include intramyelinic axonal edema, inflammatory or cytotoxic infiltrates, immune system activation, and oxidative stress. No obvious cause for SIADH was identified during our workup, and we did not measure serum or CSF levels of IL-6, which have been found to be elevated in previously reported cases of MERS.

Although MERS is increasingly recognized, recurrent episodes are rarely reported, with only one adult and two pediatric cases documented to our knowledge. As the etiology and pathophysiology of MERS has yet to be elucidated, it remains largely a clinical diagnosis. Management involves ruling out other emergent neurological conditions, addressing hyponatremia, and supportive care. ATAXIA AND NYSTAGMUS: THE UNEXPECTED PATH TO A HODGKIN'S LYMPHOMA DIAGNOSIS Santhosh Raja Thangaraj1; Mirra Srinivasan2; Ishita Gupta4; Linda Youn3; Amirtharaj Dhanaraja2. 1Internal Medicine Residency Program, St Bernards Healthcare, Jonesboro, AR; 2Internal Medicine, St. Bernards Medical Center, Jonesboro, AR; 3Internal Medicine, St. Bernards Hospital, Jonesboro, AR; 4Internal Medicine, St. Bernard's Medical Center, Jonesboro, AR. (Control ID #4271078) CASE: A 29 year-old M with no significant medical history presented with complaints of nystagmus and ataxia. Initial neurological evaluation failed to identify a primary central nervous system cause and both infections and immunological workup was unremarkable. Diagnostic workup was expanded due to persistence of symptoms leading to a CT scan of the chest, abdomen, and pelvis, which revealed multiple enlarged lymph nodes. Concurrently, a bone marrow biopsy was performed due to pancytopenia, revealing classic hodgkin lymphoma with mixed cellularity. This culminated in the diagnosis of paraneoplastic cerebellar degeneration (PCD) associated with undiagnosed Hodgkin’s lymphoma (HL). The patient was subsequently started on ABVD (Adriamycin, bleomycin sulfate, vinblastine sulfate, and dacarbazine). After the first cycle of chemotherapy, the patient's nystagmus and ataxia had almost completely resolved and his vision returned to normal. IMPACT/DISCUSSION: Given the patient's symptoms of fever, bicytopenia, and an elevated ferritin level (>10,000), hemophagocytic lymphohistiocytosis (HLH) was also considered in the differential diagnosis. While HLH could have potentially triggered the patient's neurological symptoms, MRI of the head did not reveal any lesions, hyperintensities, or atrophy, making HLH less likely to be the primary cause of his neurological manifestations. PCD is a rare neurological disorder caused by autoimmune response to tumor cells, most commonly associated with lung cancer, gynecologic and breast cancer and HL. The anti-Tr antibody, which is specific to PCD associated with HL, was negative in our patient. However, approximately 50% of patients with suspected PCD test positive for antineuronal antibodies in either serum or cerebrospinal fluid (CSF). In addition, anti-mGluR5, anti-GlyR, and anti-Ma2 antibodies have known relation to PCD associated with HL and were not tested for in our patient. Given the resolution of the patient's neurological symptoms following the initiation of chemotherapy, it is evident that his symptoms were likely a paraneoplastic manifestation of HL. The purpose of presenting this case is to raise awareness among clinicians about the rare neurological manifestations of hematologic malignancies. PCD are associated with late stages of HL and high risk phenotype due to rapid progression of symptoms. Thus, early recognition and diagnosis of such symptoms can lead to timely treatment and significantly improve patient outcomes.

This extremely rare presentation of HL stresses the importance of considering broad differentials when evaluating neurological presentations as they can signal another underlying disease. Whether the ataxia was a paraneoplastic symptom of HL or it was caused by an unknown pathophysiology remains unclear. Given the paucity of literature, more molecular and laboratory research on the biochemistry of HL is needed to help guide treatment strategies and developing new targeted anti-cancer drugs. A TOAST TO THE CORPUS CALLOSUM: UNCORKING MARCHIAFAVA-BIGNAMI DISEASE Abigail Immanuel1; Stephen A. Akinfenwa1; Ginikachukwu Agudosi1; Olurotimi Adekolu2. 1Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Hartford HealthCare Medical Group, Hartford, CT. (Control ID #4271656) CASE: Marchiafava-Bignami disease is marked by necrosis or demyelination of the corpus callosum resulting in altered mental status, dysarthria, and spasticity. It is thought that malnutrition and chronic alcohol use play a role in its pathogenesis. Here, we discuss the case of a patient who presented with acute encephalopathy, felt to be in the setting of Marchiafava-Bignami disease. The patient was a 40-year-old female with a history of type 1 diabetes mellitus and chronic pancreatitis who was brought to the emergency department after being found unresponsive. The patient was at her wedding the night prior to presentation where she consumed 3-4 alcoholic beverages with minimal food consumption. The morning after her wedding, her husband found her asleep in bed with emesis around her mouth, prompting him to call EMS who noted a blood glucose of 53 that improved with dextrose administration. In the ED, she was hypoxemic and was unable to track with the eyes, follow commands, or communicate verbally. The patient also exhibited seizure-like activity manifesting as contractions of all extremities and staring in one direction, which improved with lorazepam. Due to concerns for airway protection and worsening hypoxemia, she was intubated. Initial labs showed mild leukocytosis, glucose of 168 mg/dL, ethanol level of 53 mg/dL, lactic acid of 2.5 mmol/L, ammonia 79 umol/L, normal electrolytes, normal thyroid, hepatic, and renal function, and negative urine toxicology. Venous blood gas was remarkable for pO2 48 with normal pCO2 and bicarbonate. The patient was admitted to the intensive care unit and was evaluated by neurology with a CT head negative for an acute intracranial pathology and CTA head/neck, negative for stenosis or large artery occlusion. Long-term electroencephalography, lumbar puncture, NMDA receptor panel, and heavy metal testing were also unremarkable. The key to uncovering her diagnosis was an MRI of the brain with contrast that showed lesions of the corpus callosum and bilateral parietal white matter. Given these findings, her presentation was felt to be in the setting of Marchiafava Bignami disease. She was started on high-dose thiamine and folic acid along with amantadine to promote wakefulness with eventual improvement in mental status. IMPACT/DISCUSSION: Marchiafava-Bignami disease is defined by lesions of the corpus callosum that can be seen on a contrast-enhanced brain MRI. Symptoms are nonspecific and include altered mental status, spasms, and dysarthria. Treatment includes high-dose intravenous thiamine and nutritional support. Prognosis varies with some eventually recovering while others become comatose.

This case provides a framework on the evaluation of altered mental status, a relatively common chief complaint. In instances of altered mental status and nonspecific neurologic symptoms of unclear etiology, Marchiafava-Bignami disease is a rare but noteworthy entity that should be considered in patients with a history of alcohol use or malnutrition. A TRIPLE CHALLENGE: CMV AND ULCERATIVE COLITIS IN AN HIV-POSITIVE PATIENT Meumbur P. Kpughur-Tule1,2; Carly Hubers3,1; saba asif1,2; Ngumimi Kpughur-Tule1,2; Kendall Conway2,1; Alexander M. Satei4,2; prritha chitagi1,2. 1Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI; 2Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 3Student , Wayne State University School of Medicine, Detroit, MI; 4Radiology, Trinity Health Oakland Hospital, Pontiac, MI. (Control ID #4244690) CASE: A 44-year-old male with ulcerative colitis (UC) on Stelara missed doses due to insurance issues. He presented with 20 episodes of bloody diarrhea daily for 4 weeks, significant weight loss of 35 pounds, nausea, vomiting, and left lower quadrant pain. His prior treatments included Humira, discontinued for drug-induced psoriasis, and intermittent prednisone. His last gastroenterology follow-up was over a year before presentation. On admission, the patient was hemodynamically stable. Labs showed elevated WBC (18.5), CRP (23.9), and platelets (671). Stool studies, including C. difficile and Ova & Parasites, were negative. CT imaging revealed coloproctitis. Initial management included IV Solu-Medrol, ceftriaxone, Flagyl, and supportive care. Despite receiving Stelara during hospitalization, symptoms persisted. Sigmoidoscopy revealed severe sigmoid disease with pseudopolyps, friable tissue, and deep ulcerations sparing the rectum. Biopsies confirmed severe UC-related inflammation. Additional workup, prompted by immunosuppression and worsening symptoms, revealed serum cytomegalovirus (CMV) > 20,000 and newly diagnosed HIV with a CD4 count of 256. Infectious disease was consulted, and the patient was started on IV ganciclovir for CMV colitis and Biktarvy for antiretroviral therapy. During a 28-day hospital stay, he received IV ganciclovir for 21 days, transitioned to oral valacyclovir, and started Rinvoq for UC. His bowel movements improved to 4 non-bloody stools daily. He was discharged on Biktarvy, oral prednisone, and follow-up with gastroenterology, infectious disease, and colorectal surgery. IMPACT/DISCUSSION: Co-occurrence of CMV colitis and UC in a newly diagnosed HIV-positive patient is rare and presents a diagnostic and therapeutic challenge. HIV suppresses immune pathways critical to UC, while CMV colitis is more common in immunocompromised individuals, complicating the clinical picture. This case illustrates the overlap of these conditions, leading to severe symptoms and increased complications. Immunosuppression from undiagnosed HIV and UC therapy likely exacerbated CMV colitis. Differentiating between a UC flare and CMV colitis is challenging, requiring endoscopic biopsy and histopathology. CMV colitis necessitates antiviral treatment, while UC often requires immunosuppression, creating a therapeutic dilemma. Here, IV ganciclovir led to symptom improvement despite ongoing immunosuppression for UC.

Careful immune monitoring was critical as CMV colitis management unmasked UC and prevented complications like colonic perforation or toxic megacolon. This case highlights the need to consider CMV infection in refractory UC, especially in immunosuppressed patients. Early recognition and treatment are essential to improve outcomes. ATYPICAL BABESIOSIS IN A NON-ENDEMIC SETTING: FROM DELAYED DIAGNOSIS TO EXCHANGE TRANSFUSION Fadi Zaiem1; Edgar Amavizca1; Christine Firth2; Ibrahim Qaqish2; Vipul Ganatra2. 1Internal medicine , Creighton university, Phoenix Arizona, Mesa, AZ; 2Internal Medicine, St Joseph's Hospital and Medical Center, Phoenix, AZ. (Control ID #4273623) CASE: A 68-year-old male with a history of coronary artery disease presented with a 3-day history of fever, chills, night sweats, weight loss and fatigue. He reported bruising on his upper extremities and a left forearm injury from a thorne while hiking 4 days prior to admission. He reported recent travel to Florida, Colorado, and Arizona. On presentation, his vital signs and physical exam were unremarkable. Initial workup was significant for platelets: 23 × 10/μL, creatinine: 1.36 mg/dL, total bilirubin: 1.9 mg/dL, direct bilirubin 0.7 mg/dl, ALT: 51 U/L, AST: 90 U/L, and CT imaging showed splenomegaly. Mononucleosis test was positive. He initially received supportive therapy and empiric cefepime for forearm cellulitis. Over the next 3 days, he deteriorated significantly, developing confusion, persistent high fever (up to 40°C), worsening thrombocytopenia 18 × 10/μL, leukopenia 2.4 × 10/μL, and worsening transaminitis ALT: 125 U/L, AST: 196 U/L. Dengue and Lyme tested positive later, however blood cultures, pan-CT for malignancy screening, bone marrow biopsy, and tests for malaria, and ADAMTS13 activity (88%) were negative. On day five, a peripheral smear revealed intracellular and extracellular Babesia parasites, which were confirmed by Babesia PCR and serology testing. Due to severe symptoms and high parasitemia the patient was started on azithromycin and atovaquone and transferred to a facility with exchange transfusion capabilities. IMPACT/DISCUSSION: This is a unique case, as our patient does not have the typical babesiosis risk factors, such as asplenia, immunocompromise, endemic travel, or blood transfusion history. It highlights the importance of keeping a broad differential and considering babesiosis in febrile patients with thrombocytopenia, particularly when common infectious etiologies have been excluded or do not explain the entire clinical picture. Delayed diagnosis leads to significant complications, including fulminant disease and multi-organ dysfunction, which occur in 5-19% of cases. In severe parasitemia (>10%), RBCs exchange transfusion is a rapid therapeutic intervention for reducing the parasite load, alongside appropriate antimicrobial therapy. In our case, clinical deterioration and high parasitemia necessitated exchange transfusion.

This case highlights the necessity for prompt recognition and treatment of Babesiosis, especially with atypical geographic presentation and vague symptoms. Maintaining a high index of suspicion for vector-borne diseases even in non-endemic regions is crucial. Additionally, the clinical deterioration observed in this case necessitated advanced therapeutic measures, demonstrating the importance of rapid and intensive intervention in severe presentations. Furthermore, this case underscores the critical need for effective coordination of care among a multidisciplinary team, including specialists in infectious disease, and hematology to manage complex presentations and ensure optimal patient outcomes. ATYPICAL BELL’S PALSY WITH COEXISTING HEMIPLEGIC MIGRAINE: A DIAGNOSTIC CHALLENGE Zoya Khan1; Lyudmila Sarder1; Jennifer Trube2; Kayla Hernandez1. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4272159) CASE: A 40-year-old female with a history of migraines presented with right-sided facial numbness and droop for one day, as well as right upper and right lower extremity weakness, accompanied by a headache that was ongoing for two days. On presentation, her neurologic examination was significant for loss of the right nasolabial fold, and right facial droop with sparing of the forehead muscles. Motor strength was 4 out of 5 in the right upper and right lower extremity. Non-contrast computed tomography (CT) of the head, CT angiogram of the head and neck, CT cerebral perfusion and magnetic resonance imaging (MRI) of the brain were negative for acute pathology. Due to her persistent headache, she was treated with NSAIDs, resulting in improvement of her right sided weakness. Her facial droop persisted and she was diagnosed with atypical Bell’s palsy, with her facial symptoms resolving after initiation of oral steroids. She was discharged on hospital day 3 with no neurologic deficits. IMPACT/DISCUSSION: Bell’s palsy is a peripheral nerve disorder that typically causes complete, unilateral facial paralysis. In rare cases, it can present atypically due to a partial lesion at the distal facial nerve, located between the deep and superficial lobes of the parotid gland near the pes anserinus. This spares the temporal branch to the frontalis muscle, resulting in lower facial paralysis with preserved forehead movement. When atypical, Bell’s palsy can create a complex clinical presentation, particularly when combined with hemiplegic migraines; a subtype of migraines characterized by reversible hemiparesis. Managing both conditions independently suggests the presence of concomitant pathologies. Although this overlap is uncommon, its occurrence presents the diagnostic challenge of recognizing coexisting disorders.

The coexistence of atypical Bell’s palsy and hemiplegic migraines presents a rare but diagnostically challenging scenario requiring careful evaluation. Recognizing these overlapping conditions stresses the importance of considering multiple pathologies in complex presentations, allowing us to guide accurate diagnosis and management. ATYPICAL PRESENTATION OF AEROCOCCUS URINAE-INDUCED INFECTIVE ENDOCARDITIS Samuel Ramos Garcia2,3; David Moodie1; Priscilla Phan2,3; Juan Pablo Meruvia Garron2,3; Richard Henriquez2,4; Edward W. Drehs4. 1Collegue of Medicine, University of Central Florida, Orlando, FL; 2University of Central Florida College of Medicine, Orlando, FL; 3Internal Medicine, University of Central Florida HCA Healthcare GME, Greater Orlando, Orlando, FL; 4Orlando VA Healthcare System, Orlando, FL. (Control ID #4271601) CASE: A 55-year-old man with a past medical history of obstructive sleep apnea, asthma, non-insulin-dependent diabetes mellitus, and hypertension presented with worsening dyspnea and chest pain over three days. Despite treatment for suspected pneumonia in the outpatient setting, symptoms persisted. Upon arrival to the emergency room, the patient demonstrated evidence of sepsis, and exhibited bilateral multifocal pneumonia on imaging. Broad spectrum antibiotics, including Vancomycin, Piperacillin/Tazobactam, and Azithromycin for treatment of multifocal pneumonia were started. Blood cultures grew gram-positive cocci, and echocardiography revealed a vegetation on the aortic valve with severe regurgitation. Aerococcus urinae was isolated, and the patient underwent urgent aortic valve replacement. IMPACT/DISCUSSION: Aerococcus urinae (A. urinae) is a gram-positive coccus that constitutes less than 1% of symptomatic urinary tract infections. Though primarily associated with urinary tract infections, A. urinae is also an extremely rare cause of infective endocarditis (IE) with a prevalence of 3 per 1 million, and fewer than 50 cases have been reported in the literature. Comorbid genitourinary infections, male sex, and advanced age are noted risk factors. This case consists of A. urinae-induced IE complicated by acute severe aortic regurgitation. A. urinae, often linked to urinary tract abnormalities, can cause severe infections with serious complications including IE, as noted by this patient with no history of urinary tract infection (UTI). The persistence of symptoms despite treatment and the identification of gram-positive cocci in blood cultures prompted further investigation with echocardiography, ultimately revealing the underlying IE and its underlying structural heart disease. There are no established treatment protocols for A. urinae-induced IE; however, researchers have demonstrated promising results with a 4-week course of IV Penicillin monotherapy. Broad-spectrum antibiotics, particularly beta-lactams and aminoglycosides, have also shown efficacy.

This case highlights the rare but serious nature of A. urinae-induced infective endocarditis (IE), emphasizing the importance of vigilance in evaluating gram-positive bacteremia with early use of echocardiography to identify potential endocardial involvement. It also contributes to the growing body of literature on the clinical presentation of A. urinae IE, underscoring the need for further studies to develop standardized treatment protocols and enhance understanding of the disease's clinical course. ATYPICAL PRESENTATION OF AUTOIMMUNE PANCREATITIS MASQUERADING AS MALIGNANCY Panida Charnvitayapong, Yoanna Benitez, Michelle Cheung, Bebika Subedi. Internal Medicine, Unversity of Miami/HCA JFK Medical Center, Palm City, FL. (Control ID #4270619) CASE: A 56-year-old male with a medical history of hypertension and hyperlipidemia presented with worsening right upper quadrant abdominal pain radiating to the back, jaundice, and a 20lb weight loss over about six weeks. He denied systemic symptoms and any changes in stool or urine. Initial labs were significant for elevated LFTs and bilirubin. Imaging findings, including bile duct dilation, gallbladder sludge, and a questionable pancreatic head mass, initially suggested malignancy. ERCP showed a severe distal CBD stricture, leading to biliary sphincterotomy, stent placement, and sludge removal. The patient was transferred to our facility to evaluate further abnormal labs and plans for EUS with biopsy. EUS showed pancreatic parenchymal abnormalities consisting of lobularity in the entire pancreas. Lab workup, including IgG subclass 4, was elevated at 396, and CEA and CA 19-9 were negative. Biopsy results appeared to have findings consistent with autoimmune pancreatitis (AIP). IMPACT/DISCUSSION: AIP is a rare autoimmune form of chronic pancreatitis characterized by inflammation and pancreatic duct strictures with lymphocyte and plasma cell infiltration in the pancreas. Clinically, AIP often presents with nonspecific symptoms such as abdominal pain, obstructive jaundice, and weight loss, which overlap with the presentation of pancreatic malignancy. While classified into two primary types, a third type is emerging. Type 1, also known as lymphoplasmacytic sclerosing pancreatitis, manifests as part of IgG4-related disease (e.g., Sjogren syndrome, primary sclerosing cholangitis) and typically affects men in their 60s-70s. Type 2, more localized and pancreas-specific, is frequently linked to other autoimmune disorders, such as inflammatory bowel disease. The newly recognized type 3, or immunotherapy-triggered AIP, occurs in patients on immune checkpoint inhibitors (e.g., anti-PD-1 and anti-CTLA4). Diagnosis relies on imaging, serologic markers, and histological confirmation. Imaging features, such as a "sausage-shaped" pancreas indicating a diffusely enlarged pancreas with loss of nodularity and elevated IgG4 levels (>280 mg/dL), are highly specific but not always present, as the patient's history and imaging were inconsistent with AIP. Treatment for AIP involves corticosteroids, with immunosuppressive agents like rituximab for refractory cases. Management strategies vary depending on the subtype, with supportive care (intravenous fluids and pain control) playing a key role in immunotherapy-triggered AIP.

Autoimmune pancreatitis is a distinct form of chronic pancreatitis with different subtypes that are difficult to distinguish clinically, relying on histological confirmation. Not only can its nonspecific symptoms be misdiagnosed as pancreatic cancer, but the recurrent bouts of acute pancreatitis can lead to significant morbidity and mortality. Therefore, prompt diagnosis and treatment are essential in improving clinical outcomes and avoiding unnecessary invasive interventions. ATYPICAL PRESENTATION OF CHRONIC PANCREATITIS SECONDARY TO SPHINCTER OF ODDI DYSFUNCTION Paige J. Awtrey. Medicine, Wayne State University, Detroit, MI. (Control ID #4270542) CASE: 86-year-old female presented with a one-day history of RUQ pain. Labs significant for lipase elevated to 74 IUnits/L. No history of alcoholism, gallstones or pancreatitis. Abdominal CT revealed mild biliary and pancreatic ductal dilatation with gallbladder distention confirmed by MRCP. Neither imaging modality visualized specific obstructive etiology. Subsequent HIDA confirmed cystic duct patency with delay in common bile duct uptake, indicating partial obstruction or Sphincter of Oddi Dysfunction. ERCP revealed a bulging major papilla and dilated pancreatic duct with narrowing at the genu of the pancreas. Notably, the pancreatic duct in the body and tail had a chain of lakes appearance with common bile duct dilatation, a finding typical of chronic pancreatitis. Needle knife sphincterotomy was attempted in which the surgical team was unable to cannulate the common bile duct. Repeat ERCP was planned to rule out stones versus stricture in which the surgical team accessed the common bile duct but did not visualize gallstones or gallbladder abnormalities. Considering the intermittent nature of the obstruction, the results are suspicious for the presence of Sphincter of Oddi Dysfunction. IMPACT/DISCUSSION: Sphincter of Oddi Dysfunction (SOD) is difficult to diagnose due to the intermittent nature of the obstruction. Despite its diagnostic difficulty, the incidence rate has increased from 2.4 to 12.8 per 100,000 between 2010-2019 demonstrating the need for consideration of SOD in chronic pancreatitis. Due to the extended diagnostic time course of Sphincter of Oddi Dysfunction, patients often display symptoms of chronic pancreatitis at the time of initial diagnosis. Imaging yields the cause of pancreatitis in 70%-90% of cases therefore, Sphincter of Oddi Dysfunction should be considered in cases of recurrent pancreatitis with negative imaging.

-Sphincter of Oddi Dysfunction is difficult to diagnose due to the intermittent nature of the common bile duct obstruction and often causes chronic pancreatic changes before the diagnosis is made. -Imaging and clinical evaluation will yield the cause of recurrent pancreatitis in the majority of cases. In the remaining cases, Sphincter of Oddi Dysfunction should be thoroughly investigated. ATYPICAL PRESENTATION OF HSV ESOPHAGITIS IN A PATIENT WITH AIDS Adlin Lawrence1,3; Paul Stolarov2; Joane Titus1,3; Felix A. Zayas Rodriguez1; Nima Hosseinian1,3. 1HCA healthcare GME, University of Central Florida, Greater Orlando, FL; 2College of Medicine, University of Central Florida, Orlando, FL; 3Department of Internal Medicine, College of Medicine, University of Central Florida, Orlando, FL. (Control ID #4270359) CASE: A 25-year-old woman presented with worsening dyspnea, a productive cough, and odynophagia. Her examination revealed oral thrush and mucosal ulcers. Initial workup confirmed a new diagnosis of HIV with AIDS (CD4 count: 24 cells/μL). Based on her symptoms and the presence of oral thrush, Candida esophagitis was suspected, and fluconazole therapy was initiated. However, her odynophagia persisted. Upper endoscopy revealed erosive gastritis and deep, punched-out ulcers in the distal esophagus, suggestive of CMV esophagitis. CMV IgG levels (>8) supported chronic CMV infection, and ganciclovir was started. Biopsy results, however, identified HSV as the cause of her esophagitis, leading to a switch in therapy to acyclovir. This case demonstrates the diagnostic challenges of overlapping clinical and endoscopic features among Candida, CMV, and HSV esophagitis in patients with advanced HIV/AIDS. The delay in accurate diagnosis due to atypical endoscopic findings underscores the need for biopsy confirmation to guide appropriate treatment. IMPACT/DISCUSSION: Esophagitis is a common complication in patients with AIDS, with Candida, CMV, and HSV as the primary etiologies. While Candida esophagitis can often be managed empirically, CMV and HSV require pathogen-specific therapies guided by confirmatory diagnostic tests. Endoscopic findings alone cannot reliably differentiate between CMV and HSV esophagitis. For instance, CMV is associated with deep, linear ulcers, whereas HSV often presents with vesicular or punched-out lesions. However, studies have shown that these distinctions are not absolute, and biopsy remains the gold standard for diagnosis1. Jung et al. emphasized that biopsy sensitivity rates for distinguishing CMV and HSV esophagitis exceed 90%, significantly improving diagnostic accuracy2. In this case, atypical endoscopic findings of HSV delayed the correct diagnosis. Similar delays have been reported in the literature, where empirical treatment based on endoscopy alone led to suboptimal outcomes3. Early biopsy and histopathological analysis are critical, particularly in immunocompromised patients, to guide therapy and improve clinical outcomes.

Biopsy is essential for accurate diagnosis in patients with overlapping features of Candida, CMV, and HSV esophagitis. Atypical presentations of HSV esophagitis require high clinical suspicion and histopathological confirmation. Early diagnosis and appropriate antiviral therapy are crucial to improving outcomes in immunocompromised patients.

1. Kataria R, D’Cruze L, Lal T, et al. An Unusual Presentation of Herpes Esophagitis in an Immunocompromised Individual. Cureus. 2021;13(6):e15845. 2. Jung KH, Choi J, Gong EJ, et al. Can endoscopists differentiate cytomegalovirus esophagitis from herpes simplex virus esophagitis based on gross endoscopic findings? Medicine. 2019;98(23):e15845. 3. Mönkemüller KE, Wilcox CM. Diagnosis and treatment of esophagitis in AIDS. Compr Ther. 2000;26(3):163–8. AUTOIMMUNE INSULIN SYNDROME IN A HISPANIC OLDER WOMAN Alan Villarreal Rizzo, Kevin Stanko. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271716) CASE: The patient is a 71-year-old Hispanic female from El Salvador admitted to the Hospital Medicine Service after experiencing 20 days of intermittent episodes of lightheadedness, diaphoresis, tremors, and fatigue. Her medical comorbidities are notable for hyperlipidemia, ocular herpes simplex virus, gastritis, and non-toxic goiter. Before admission, she underwent an outpatient work-up and was found to be hypoglycemic under non-supervised fasting with random blood glucose in the 30s mg/dL and an HbA1c of 6.2%. She was placed on a continuous glucose monitor which showed nocturnal hypoglycemia. CT scan of the abdomen did not show any pancreatic masses. Given a concern for possible autoimmunity, she was given a 7-day course of prednisone which did not improve her symptoms. During the admission, further work-up including a 72-hour supervised fast showed – Glucose: 41 mg/dL, Insulin: 12,400 mcIU/mL, C-peptide: 27 ng/mL, Insulin: C-peptide: 9.5 molar ratio, Proinsulin 38 pmol/L, Insulin antibodies 171 nmol/L, Insulin free 31 mcIU/mL, Insulin bound >17000 mcIU/mL. These results were suggestive of insulin autoimmune syndrome (IAS). She was treated conservatively with nocturnal tube feeding and frequent daily eating to prevent symptomatic hypoglycemia. A percutaneous endoscopic jejunostomy (PEJ) tube was placed for overnight feedings to maintain normoglycemia. The patient’s blood glucose remained stable, and she was discharged with outpatient nutrition follow-up. IMPACT/DISCUSSION: IAS is a rare condition, mostly reported among the Japanese population with an estimated prevalence of 1-2 cases per million people per year. An insulin-C peptide ratio >1 and a high bound insulin are considered diagnostic. The etiology of this disease involves the development of autoantibodies against endogenous insulin, though the exact cause remains unclear and may be linked to genetic predisposition, certain medications, or autoimmune disorders. IAS is a self-limited disease, and most reported cases resolve within six months to one year. The treatment options may vary from conservative measures such as dietary modifications to avoid hypoglycemic episodes to steroids or other immunosuppressants with refractory cases. The presentation of IAS in a Hispanic woman with no known risk factors is very unusual, but highlights the importance of considering IAS in the differential once other causes of hypoglycemia such as exogenous insulin use, sulfonylurea use, and insulinoma are ruled out.

IAS is a rare condition that manifests as recurrent hypoglycemic episodes, even overnight. The disease is usually self-limited, and the first-line treatment is dietary modifications including tube feeding to prevent hypoglycemic episodes until expected resolution within 6 months to 1 year. AUTOIMMUNE MYELOFIBROSIS AS A RARE LUPUS COMPLICATION: A CASE REPORT Sujit Prasad1; Ahsun R. Siddiqi2; Mehdi B. Swaid2; Donald M. Rozzell2. 1School of Medicine, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Henry Ford Health System, Detroit, MI. (Control ID #4273116) CASE: A 32-year-old African American female with SLE and lupus nephritis managed with mycophenolic acid and hydroxychloroquine presented with severe fatigue, generalized weakness, anemia, and thrombocytopenia. She was also taking warfarin due to her recent diagnosis of right sigmoid sinus thrombosis. Initial labs showed hemoglobin 7.5 g/dL and platelet count 104 x 109/L, dropping to 67x 109/L within 3 days. A bone marrow biopsy revealed autoimmune myelofibrosis, and her hemoglobin further dropped to 3.6 g/dL, prompting transfusion of five units of packed red blood cells. Peripheral blood smear showed very rare schistocytes. A Coombs test was positive 2+, anti-IgG 1+ and anti-C3d 1+, suggesting autoimmune hemolysis. High-dose prednisone (100 mg daily) was initiated, significantly improving hemoglobin levels from 3.6 g/dL to 8.2 g/dL. Warfarin was withheld in the setting of bleeding and a supratherapeutic INR of 5.5. Mycophenolic acid was increased to 720 mg twice daily and Hydroxychloroquine was maintained at 200 mg daily. Platelet recovery was less robust, improving modestly from 67 × 109/L to 79 × 109/L. The patient’s condition stabilized, and she was discharged with plans for continued monitoring and management. IMPACT/DISCUSSION: AIMF is a rare but significant complication of SLE, involving immune-mediated bone marrow fibrosis and severe cytopenias. This case highlights acute anemia and thrombocytopenia in AIMF, particularly in the context of SLE. The dramatic hemoglobin drop post-biopsy, despite minimal bleeding, highlights the need to consider AIMF in SLE patients with unexplained cytopenias. It is also important to distinguish between primary myelofibrosis and AIMF. Autoimmune myelofibrosis is typically seen in younger individuals with a median age of 29 years whereas primary myelofibrosis patients have a median age of 66 years. Additionally, AIMF has no association with JAK2 mutations and splenomegaly is less common than primary myelofibrosis. This case is further distinguished by the patient’s complex medication adjustments, which balanced management of SLE, lupus nephritis, and venous thrombosis alongside treatment of AIMF. The robust response of anemia to corticosteroids aligns with prior reports of AIMF being highly steroid-responsive. However, the modest platelet recovery underscores the variability in hematological responses and the potential for residual bone marrow dysfunction. Patients who do not receive an early diagnosis may experience a poor response to treatment. For patients who do not respond well to first-line treatment, transformation to acute leukemia may occur.

Early diagnosis and treatment with corticosteroids are critical for reversing cytopenias and preventing further complications. The continuation of immunosuppressive therapy and anticoagulation alongside steroids reflects the importance of individualized treatment plans in AIMF cases with coexisting SLE complications. AUTONOMIC OVERLOAD: THE COMPOUNDED CHALLENGES OF EHLERS-DANLOS SYNDROME SUPERIMPOSED ON POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME Emma R. Weiland1; Jennifer Trube2; Zoya Khan1; Kayla Hernandez1; Jacob Jernigan1. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4273018) CASE: A 32-year-old female with Postural Orthostatic Tachycardia Syndrome (POTS), Ehlers-Danlos Syndrome (EDS), and atrial flutter status post multiple cardiac ablations presented to the emergency department with a chief complaint of palpitations. She struggled with refractory POTS symptoms for over 10 years, despite numerous treatment attempts. Under the care of an electrophysiologist, she was informed that no further management options were available and that she would need to seek specialist care. Her condition progressively worsened, severely impairing her quality of life. She was unable to carry her child or even get out of bed due to debilitating symptoms. Previously, she had tried and failed multiple medications, including metoprolol, propranolol, pyridostigmine, diltiazem, verapamil, and ivabradine, as well as several ablation procedures. An AV node ablation with a permanent pacemaker was suggested as a potential solution, but this was deemed less than ideal due to the need for approximately seven device replacements over her lifetime, increasing her risk of infections and complications. She was discharged without further inpatient procedures and advised to follow up with her electrophysiologist to discuss additional management options. IMPACT/DISCUSSION: POTS and EDS often co-occur, sharing overlapping features that affect the autonomic nervous system. POTS primarily disrupts blood flow and heart rate regulation, impairing the body's normal response to standing. EDS impacts collagen, which is a key structural component of skin, ligaments, blood vessels, and bones. There is a well-recognized connection between POTS and EDS, particularly in cases of hypermobile EDS (hEDS). Both conditions contribute to autonomic dysfunction—POTS through heart rate and blood pressure abnormalities, and EDS through connective tissue defects around blood vessels and nerves. The combined effects of both disorders lead to increased vascular and postural instability. For example, the joint hypermobility in EDS can make it difficult to maintain an upright posture, exacerbating symptoms like dizziness, tachycardia, and fainting seen in POTS. This results in a greater symptom burden and significantly reduces quality of life, as daily activities become increasingly difficult to manage.

The relationship between POTS and EDS is complex, with overlapping features that complicate both diagnosis and treatment. Both conditions involve autonomic dysfunction and vascular instability, with EDS exacerbating POTS symptoms. When co-occurring, they severely impact a patient's quality of life, requiring comprehensive management that addresses both autonomic and connective tissue issues. This case highlights how individuals with EDS may experience a severe, refractory form of POTS, emphasizing the need for further research. Alternative or more invasive treatments, such as pacemaker placement, should be explored to improve quality of life and potentially provide a cure for patients with refractory symptoms. A VIRUS PULLING WOOL OVER OUR EYES: A TYPICAL PRESENTATION OF ORF VIRUS MIMICKING OSTEOMYELITIS Megan E. Cavrak, Paola Zinser Peniche, Tanya Nikiforova. General Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4271298) CASE: A 56-year-old farmer with history of gastroesophageal reflux disease, sleep apnea, and depression presented to the ED with a lobulated left thumb wound that had been present for three weeks after contact with an ill sheep on her farm, as well as fever, headache, and myalgias. She had been treated outpatient with a variety of antibiotics, none of which resolved the skin lesion, and she continued to have intermittent constitutional symptoms. Initial labs revealed mildly elevated C-reactive protein (1.1) and no leukocytosis (WBC 5,900). MRI reported likely cellulitis and osteomyelitis of her left first proximal phalanx. In consultation with infectious diseases and orthopedic surgery, it was determined that the lesion was due to Orf virus based on its appearance and the patient’s occupational history. The post-mortem veterinary report of the sheep revealed the presence of multiple common cattle-related bacteria, including Pasteurella multocida, Mycoplasma species, and Streptococcus entericus. Lumbar puncture and laboratory tests for other zoonotic infections were negative. The patient's timing of symptom onset, lack of pneumonia symptoms, and absence of CNS and bloodstream involvement made Orf virus more likely than the bacteria identified on autopsy. The patient was discharged without antibiotics with the presumptive diagnosis of Orf virus. IMPACT/DISCUSSION: Orf virus, or contagious pustular dermatitis or ecthyma contagiosum, is a Parapoxvirus zoonotic infection that infects people who handle sheep and goats, the natural hosts of the virus. The main symptom of infection are lesions that can vary in type (vesicles, papules, nodules) and location (lips and mouth in animals and hands and fingers in humans). As in our case, the diagnosis is usually made through history and physical examination alone. Though available, biopsy and molecular testing are usually not needed. In healthy people, the disease usually spontaneously resolves in three to six weeks. No specific treatment is necessary, however, there have been reports of imiquimod, cidofovir, curettage, shave excision, cryotherapy, and electrocautery improving symptoms. Antibiotics are not indicated for treatment. Orf virus is unique in that it can infect previously exposed humans repeatedly. Immune evasion is possible with virulence factors and because of this, the whole, inactivated version of the virus has been researched as a type of immunomodulating drug.

Orf virus is an important consideration for those with appropriate risk factors, including people who work with sheep and goats (farmers, veterinarians, shepherds, butchers, and wool shearers). It can be confused with other skin infections such as cellulitis or osteomyelitis. Patients with the virus should be monitored without antibiotics and treated conservatively. A WAITING GAME: THE RISKY BUSINESS OF REPAIRING A FRIABLE SEPTUM Michael Sabina1; Jennifer Trube2; Shrinand Shah1; Anas Bizanti3. 1Internal Medicine - GME, Lakeland Regional Medical Center Inc, Lakeland, FL; 2GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 3IM, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4271671) CASE: An 83-year-old female presented with two days of chest pain, dizziness, and diaphoresis; ECG confirmed an inferior STEMI. Emergent PCI with stenting to the LAD revealed a VSD, and surgical repair was deemed too risky. Despite delaying percutaneous closure for seven days to allow tissue stabilization, the procedure failed due to friable myocardial tissue, leading to hemodynamic collapse and death despite resuscitative efforts. IMPACT/DISCUSSION: Ventricular septal defects (VSDs) result from rupture of the infarcted interventricular septum, requiring complex management decisions between percutaneous intervention and surgical repair. The friable myocardial tissue surrounding the defect heightens the risk and challenges of achieving successful closure. Current guidelines suggest emergent surgical repair for most cases. However, early repair (within 7 days post-MI) is associated with a high mortality rate, primarily due to the fragile and necrotic myocardial tissue. Delaying repair beyond 7 days can reduce mortality rates, potentially allowing the damaged myocardium to stabilize through the deposition of new collagen and healing processes.

This case questions the guideline recommendations for emergent or early VSD repair post-MI, suggesting that in stable patients, a longer waiting period than currently advised might be necessary to allow sufficient tissue healing. A WHIPPLE IN TIME: CULTURE-NEGATIVE ENDOCARDITIS AS A MANIFESTATION OF WHIPPLE'S DISEASE McCall Simon, Sejal Batra, Lisa Silvotti, Andrew Hamarich. Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4273332) CASE: A 74-year-old male with a past medical history of heart failure with preserved ejection fraction presented with progressively worsening shortness of breath. Patient denied gastrointestinal symptoms on presentation. Given concerns for decompensated heart failure in the setting of a volume overload state, patient was started on aggressive diuresis. A transthoracic echocardiogram was performed to assess progression of his cardiac disease and revealed a mobile echo density on the aortic valve. Transesophageal echocardiogram demonstrated a 1.8-centimeter vegetation on the right coronary cusp. An infectious workup was initiated to identify possible causes of endocarditis. Blood cultures remained negative after 5 days. Serum PCR returned positive for Tropheryma whippeli. He underwent aortic valve replacement, and surgical pathology was positive for T. whippeli. Antibiotic therapy was initiated with ceftriaxone for two weeks followed by trimethoprim-sulfamethoxazole. IMPACT/DISCUSSION: Tropheryma whippeli is the causative organism for Whipple’s Disease. While ubiquitous in the environment, this intracellular bacterium causes a rare gastrointestinal disease. Classic symptoms include arthralgias followed by diarrhea, weight loss, and abdominal pain. In rare cases, T. whippeli infection develops as culture-negative endocarditis. Symptoms may include fever, malaise, night sweats, and abdominal pain, although their presence can be highly variable. Associated complications include heart failure, conduction abnormalities, and valve regurgitation, and frequently these are the only presenting symptoms. The most common exam finding is a new cardiac murmur. Remarkably, T. whippeli-associated endocarditis frequently lacks the symptoms of classic Whipple’s Disease. Despite its indolent presentation, studies show that T. whippeli is responsible for between 2% and 6.3% of biopsy-proven endocarditis, making it the 4th leading cause of endocarditis and the leading cause of culture-negative endocarditis. The vague symptoms, slow progression of disease, and overall rarity contribute to difficulty with diagnosing Whipple’s endocarditis. The lack of symptoms typical of endocarditis complicates assessment, and the lack of gastrointestinal symptoms obscures it in the diagnostic framework. In our case, the patient had acute decompensated heart failure with no infectious symptoms. Duke criteria was negative on initial workup, and blood cultures were negative. It was the presence of small, fibrotic vegetations on the aortic valve on echocardiogram which prompted the PCR testing that yielded the final diagnosis. Further history from the patient after PCR confirmation led to the illumination of chronic diarrhea and weight-loss.

This case demonstrates the importance of complete workup for new exacerbation of heart failure. Thorough assessment, including echocardiogram, and an open diagnostic framework led to an accurate diagnosis of an occult condition. BALANCING THE ELEMENTS: A MULTIDISCIPLINARY APPROACH TO HYPERNATREMIA AND LEUCINE CLEARANCE IN MAPLE SYRUP URINE DISEASE Leenah Abojaib, Arianna N. Rahimian, Ali Kashkouli. Medical School, Emory University, Atlanta, GA. (Control ID #4271581) CASE: A 59-year-old male with a history of maple syrup urine disease (MSUD) was admitted with altered mental status and severe hypernatremia, possibly exacerbated by poor oral intake and medication non-adherence. He was intubated for airway protection and initially treated with 10% dextrose (D10) fluids and intralipids to provide nutritional support and shunt away from protein catabolism. Genetics, nephrology, and neurology teams were consulted for hypernatremia management and monitoring for cerebral edema. High dose continuous renal replacement therapy (CRRT) was initiated to remove excess leucine and ammonia, while sodium levels were gradually corrected over 48 hours from 166 to 144 mEq at a rate of 12 mEq/day with close monitoring. IMPACT/DISCUSSION: Maple syrup urine disease (MSUD) is a rare metabolic disorder characterized by accumulation of leucine, isoleucine, and valine. Acute decompensations following increased dietary protein or illness result in altered mental status, elevated leucine levels, and occasionally hyperammonemia. Additionally, metabolic abnormalities must be closely monitored, and hyponatremia due to fluid shifts is common. We highlight a rare case of hypernatremia in a metabolic decompensation of MSUD and the complexities of its management. The use of CRRT was crucial to removing excess leucine and ammonia, both toxic metabolites. Previous cases of hypernatremia showed that rapid correction is associated with lower mortality. However, our patient’s sodium level was significantly higher than the average level from other published cases, and elevated leucine complicated his case further—high leucine loads in MSUD decompensations predispose patients to osmotic shifts leading to cerebral edema and elevated intracranial pressure (ICP). The hypernatremia was therefore corrected more slowly to limit any further risk of ICP elevation. Close collaboration between nephrology, neurology, genetics, and critical care teams ensured a comprehensive approach to managing the patient's complex metabolic and electrolyte imbalances.

Prompt recognition of metabolic decompensation in patients with MSUD is critical, especially patients presenting with altered mental status, electrolyte abnormalities, and poor oral intake. Hypernatremia in critically ill patients, particularly those with MSUD, should be managed with caution. Despite prior case reports, rapid correction of severe hypernatremia may exacerbate elevated ICP in these patients, so a gradual decrease in sodium levels (no more than 12 mEq/day) is recommended. Successful management of patients with rare metabolic disorders requires a coordinated, multidisciplinary approach involving nephrology for electrolyte management, genetics for metabolic crisis guidance, neurology for altered mental status, and critical care for ongoing complications. BARK WORSE THAN ITS BITE: PET SCAN BELIES BENIGN CAUSE Tanuja A. Prakash1,2; Aparna A. Rathnam2; Harleen Sidhu2; Thanushiree Sivalingam2; Alberto Busmail Haylock2; Mya Hnin Lwin3. 1Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; 3Internal Medicine , Mount Sinai Health System, New York, NY. (Control ID #4273581) CASE: A 61-year-old woman with a history of RA (on methotrexate and adalimumab) and latent TB (previously treated with rifampin in 2023), presented with a three-month history of cough and shortness of breath. Imaging revealed bilateral pleural effusions and hypodense lesions in the spleen. Thoracentesis was performed; pleural fluid analysis revealed a lymphocytic exudative effusion. ADA in the pleural fluid was 45U/L (0-30U/L). The differential diagnosis at this stage included malignant pleural effusion, tuberculosis, and RA-related pleural disease. AFB testing on three sputum samples was negative. PET-CT scan demonstrated multiple metabolically active foci in the spleen, along with increased uptake in the omentum, peritoneum, and bilateral pleura, which raised concern for metastatic malignancy of unknown origin. During the four-week hospitalization, the patient required three thoracenteses for rapidly accumulating pleural effusions. A pleuroscopy with pleurodesis was done, and pleural biopsies revealed granulomatous inflammation with foci of punctate necrosis. Acid-fast culture of both the pleural fluid and biopsy specimen was positive for Mycobacterium tuberculosis. The patient was started on RIPE therapy (rifampin, isoniazid, pyrazinamide, and ethambutol) and was discharged with follow-up in the TB clinic. IMPACT/DISCUSSION: Malignancy and TB are at the top of the differential for lymphocyte-predominant exudative pleural effusions, and both conditions share clinical and radiological similarities. While FDG PET scans are useful for detecting primary malignancies and distant metastases, they are not definitive in distinguishing between malignancy and TB. This is due to FDG uptake being elevated in both malignant and inflammatory cells, and overlapping Standardized Uptake Value (SUV) ranges make PET scans unreliable for differentiating between the two conditions. Therefore a biopsy of the affected tissue remains essential for confirming the diagnosis. In our case, the patient had bilateral pleural effusions, three negative AFB sputum samples, and a PET-CT scan showing increased uptake in the pleura, omentum, and spleen, with an SUV max of 12.9 further supporting the suspicion of malignancy. However, pleural biopsies revealed necrotizing granulomatous inflammation, ultimately confirming the diagnosis of TB. This case highlights the diagnostic challenge in distinguishing between TB and malignancy, leading to potential delays in the recognition and treatment of these life-threatening conditions.

Latent TB reactivates to active TB in 10% of cases within two to five years of initial infection. TB associated with anti-TNF inhibitors is predominantly extrapulmonary, with disseminated TB occuring in 25% of the patients. Given the increased risk of TB in patients receiving treatment with TNF-alpha inhibitors, shared decision-making should be a key part of management when initiating such treatments, ensuring that patients are appropriately screened and monitored for TB reactivation. BARRIERS TO CARE: AN UNUSUAL TUMOR IN AN ECONOMICALLY DISADVANTAGED PATIENT Amber Roberts1; Daniel Lee2. 1Internal Medicine, University of Virginia, Charlottesville, VA; 2School of Medicine, University of Virginia, Charlottesville, VA. (Control ID #4273303) CASE: A 49-year-old male presented with dyspnea and facial pain in the setting of an enlarging facial mass. When the patient first noticed the mass 1 year prior, imaging showed a 4.5cmx4.5cmx4.3cm right maxillary mass which biopsy revealed to be a benign dentinogenic ghost cell tumor. He was tentatively scheduled for surgical resection several times but intervention was consistently delayed due to the patient’s financial status and housing instability. Meanwhile, the tumor continued to grow rapidly and had a malignant transformation to a ghost cell odontogenic carcinoma (GCOC) per biopsy obtained 2 months prior to this presentation. The patient was still not scheduled for surgery at this time. CT imaging on admission showed a tumor size of 14.9cmx13.3cmx17.9cm with extension into the right orbit and oral cavity causing nasopharyngeal airway compression. Given the extent of the tumor, a multidisciplinary team was assembled to consider possible interventions. GCOC is extremely rare, accounting for 0.23% of all odontogenic tumors, which are rare in themselves, constituting <1% of all oral tumors. The only definitive therapy for a tumor such as this one is surgical resection. If the window for surgical resection is missed, as was the case in our patient, then radiation and chemotherapy can be considered, though it is not a long term management plan. Given our patient’s tumor had reached a surgically unresectable size, he underwent systemic chemotherapy with Nirogacestat (an oral gamma secretase inhibitor) and radiation (total dose of 50Gy over 25 fractions) in hopes of controlling his symptoms (pain and dyspnea) while also reducing the tumor size to allow for surgical resection. The patient luckily had ~30% reduction in size and he continues to take Nirogacestat while awaiting his now scheduled tumor resection and free flap reconstruction. IMPACT/DISCUSSION: The planned resection of the patient’s tumor was eventually scheduled more than a year after it was first identified. GCOC is known to progress very rapidly, with only one management option, however the concerns that the patient would not be able to afford surgery lead to the eventual inability for him to be able to obtain it. If he had better access to social support and expedited financial assistance, he may have been able to undergo surgical resection sooner, possibly prior to the malignant transformation, thereby greatly improving his prognosis.

Given that GCOC is very aggressive, early surgical resection is the first line of treatment. Therefore, it is critical to address any obstacles that may delay this intervention. If the patient is deemed inoperable, other options are possible, but the efficacy of radiation therapy, chemotherapy, immunotherapy, and targeted therapy is uncertain, and the lack of reported cases renders it difficult to select a therapeutic agent, making it all the more important to support the patient in key social aspects to make surgical resection a quickly accessible option. BCG-‘OH NO’-SIS: A RARE CAUSE OF ACUTE INTERSTITIAL NEPHRITIS AND MYCOBACTERIUM SEPTICEMIA Samantha Parks, Pranav Shah. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4271955) CASE: An 84-year-old male with bladder cancer status post mitomycin-C and 5 cycles of intravesical Bacillus Calmette-Guérin (BCG) therapy presented with lethargy, anorexia, and weight loss 6 weeks after his last BCG treatment. He had no urinary symptoms. On examination, he was afebrile, hypotensive (90/58 mmHg), and tachycardic (105/minute). Admission blood tests were notable for creatinine 2.57 mg/dL (baseline 2), corrected calcium 13 mg/dL, thrombocytopenia (65 k/mm3), normal thyroid studies, and normal liver function tests. Urinalysis was positive for elevated protein at 50 mg/dL, but otherwise negative for blood, nitrates, leukocyte esterase, and casts. A CT abdomen and pelvis demonstrated new splenomegaly, mild ascites, no abnormal liver morphology, no adenopathy, and multifocal lytic lesions. His creatinine continued to rise, peaking at 5.17 mg/dL and he underwent a renal biopsy that demonstrated non-caseating granulomatous interstitial nephritis. His blood cultures ultimately returned positive for acid fast bacilli suspected to be mycobacterium bovis secondary to recent intravesical BCG therapy. He was started on rifampin, INH, ethambutol, and prednisolone 40 mg daily with gradual improvement in his renal function back to baseline. A subsequent renal biopsy performed 7 months later was without evidence of granulomatous interstitial nephritis. IMPACT/DISCUSSION: BCG-osis occurs following systemic absorption of BCG into the bloodstream. This case report describes a patient who developed BCG-osis manifesting as an acute kidney injury following intravesical BCG therapy for bladder cancer. It highlights a rare but serious complication associated with BCG immunotherapy for bladder cancer – acute interstitial nephritis. Other complications include granulomatous prostatitis, arthritis, granulomatous hepatitis, pneumonitis, involvement of bone marrow, and possibly severe sepsis with multiorgan failure. BCG renal granulomas occur in approximately 0.1% of individuals undergoing intravesical BCG instillation. These masses are difficult to distinguish from other malignancies and therefore should be included in the differential diagnosis in all patients presenting with a renal mass with a history of intravesical BCG treatment. Renal biopsy, as demonstrated in our patient, plays a key role in determining treatment. There is currently no standard guideline for treatment of BCG-osis but the recommendation is empiric initiation of steroids in conjunction with RIPE therapy (except pyrazinamide which has proven ineffective against this bacterium). RIPE therapy should be continued for 3–6 months, while steroid treatment should be gradually tapered after patients demonstrate a clinical response.

1. BCG renal granulomas should be considered in any patient with a history of intravesical BCG treatment that presents with an AKI and/or renal mass. 2. Treatment consists of steroids plus RIPE therapy (except pyrazinamide). BENEATH THE SURFACE: ACUTE JOINT PAIN AND SOFT TISSUE SWELLING AS INITIAL CLUES IN PRIMARY MYELOFIBROSIS Joyce Chen1; Jordan Selep2; Carol Gergis1; James M. Cheung3; Austin M. Cohen2; Cyrus Adams-Mardi1; Katherine Tsavaris2. 1Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Internal Medicine, The George Washington University, Washington, DC; 3SUNY Upstate Medical University, Syracuse, NY. (Control ID #4272626) CASE: A 47-year-old female with no known past medical history presented with sudden onset right ankle swelling for one day that began during a transcontinental flight, subsequently limiting her ability to ambulate. Her physical exam was notable for a swollen ankle tender to light palpation on both the lateral and medial malleoli. Other symptoms included chronic abdominal discomfort and a 2-kilogram weight loss. She had not seen a doctor for many years. Labs were notable for a white blood cell count (WBC) of 30x10E3/uL with left shift and rare blasts and a platelet count of 127x10E3/uL. She was started on clindamycin by the emergency department for cellulitis. During admission, further workup was completed with an abdominal ultrasound showing hepatosplenomegaly, a doppler ultrasound negative for deep vein thrombosis, and labs notable for an elevated uric acid. Blood and urine cultures resulted without growth. Bone marrow biopsy was later completed with findings consistent with primary myelofibrosis, JAK2 positive. The patient was started on ruxolitinib outpatient. IMPACT/DISCUSSION: Given our patient’s presentation of an acute onset swollen painful ankle with an elevated WBC count, it is reasonable to assume a diagnosis of infectious etiology. However, it is important to consider other diagnoses, such as gout, deep vein thrombosis, myeloproliferative disorders, or other rheumatologic disorders, such as lupus or rheumatoid arthritis. The patient’s leukocytosis to 30x10E3/uL with immature blood cells seen on the smear is characteristic of both infection and malignancy. Given negative infectious workup and reported weight loss, bone marrow biopsy was a logical next step to investigate malignant causes of leukocytosis. If anchoring had been more prevalent in this case, bone marrow biopsy may have been delayed, further delaying definitive diagnosis and treatment. For this patient, her presentation of gout as a manifestation of myeloproliferative disorder is consistent with hyperuricemia caused by rapid cell turnover. Avoiding anchoring and maintaining hematologic malignancies on the differential for patients with these symptoms can improve diagnostic accuracy and treatment.

It is important to consider a broad differential in the setting of leukocytosis with joint pain and nonspecific symptoms. Underlying causes of hyperuricemia in gout should be further investigated in patients with abnormal lab tests. BEVACIZUMAB INDUCED HYPOTHYROIDISM MIMICKING CEREBROVASCULAR EVENT IN STAGE IV OVARIAN CARCINOMA Tanya Amal, David Connolly, Usman Bin Hameed, Tucker Billups, Ayesha Sharif. Royal Oak, Corewell Health, Royal Oak, MI. (Control ID #4272481) CASE: A 75-year-old female presented with transient dysarthria lasting 1.5 hours, fatigue, and memory deficits for 6 months. Vital signs showed hypertensive urgency (220/110 mm Hg), controlled with IV labetalol and nifedipine. A non-contrast CT scan of the head was negative for acute stroke. Her medical history included stage IV serous epithelial ovarian cancer, treated with total hysterectomy, bilateral salpingo-oophorectomy, and chemotherapy. She had recurrent metastasis to the colon and had been on bevacizumab for 4 months after treatment failure with cisplatin, gemcitabine, and olaparib. The patient reported increasing word-finding difficulties, confusion, and cold intolerance for the past 3 months. She also had intermittent elevated blood pressure (SBP around 150 mm Hg), attributed to bevacizumab. Lab work showed thrombocytopenia (platelets 71k/uL), macrocytic anemia (MCV 105 fl, Hb 9.8 g/dl), elevated LDH (432 U/L), and haptoglobin (66 mg/dl), with no schistocytes. Kidney function was impaired (creatinine 1.42 mg/dl, BUN 27 mg/dl) with proteinuria. A thyroid panel revealed severe hypothyroidism (TSH 79 mcIU/ml, free T4 <0.4 ng/dl, free T3 <1.5 pg/dl), and hypercholesterolemia (LDL 229 mg/dL). MRI ruled out acute stroke but showed chronic white matter changes. She was diagnosed with severe hypothyroidism and started on levothyroxine, resulting in symptom improvement. IMPACT/DISCUSSION: VEGF inhibitors like Bevacizumab can cause thyroid dysfunction, ranging from hypothyroidism to thyrotoxicosis. VEGF and its receptors are expressed on thyroid follicular cells and regulated by TSH. VEGF also affects microvascular density, potentially reducing blood supply and causing thyroid tissue ischemia. This mechanism may explain hypertension and thrombocytopenia observed in Bevacizumab-treated patients. In the IMBrave trial, 15-19% of patients on Bevacizumab and Alemtuzumab for hepatocellular carcinoma developed thyroid dysfunction after 3.5 months. In this case, the initial diagnosis was cerebrovascular event or vascular dementia, given her age, hypercoagulable state from malignancy, and white matter changes. However, improvement with thyroid supplementation, along with lab findings of macrocytic anemia, hyperlipidemia, and negative thyroid peroxidase antibodies, suggested Bevacizumab-induced thyroid dysfunction. Hypertension and thrombocytopenia were likely due to microvascular dysfunction, and transient dysarthria likely resulted from a transient ischemic attack in the context of hypertension and hyperlipidemia.

Patients treated with VEGF inhibitors like Bevacizumab should be monitored early for symptoms of microvascular dysfunction (hypertension, thrombocytopenia) and endocrine issues (fatigue, memory deficits). As side effects often correlate with treatment response, management includes endocrine supplementation and addressing hypertension and thrombocytopenia. BEYOND BLOOD PRESSURE THE UNDERDIAGNOSED BURDEN OF CONN’S SYNDROME FNU Kalpana1; Rana H. Asif2. 1Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 2Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4273461) CASE: A male in his 30s with a history of T7 paraplegia, recurrent urinary tract infections, colostomy, chronic hypokalemia, and resistant hypertension presented with myoclonic jerks, nausea, and diaphoresis. His home regimen included multiple antihypertensive agents. On arrival, his blood pressure was 225/111 mmHg, temperature 103.2°F, and initial labs showed potassium 2.0 mmol/L, WBC 13.4 K/μL, high-sensitivity troponin 561 ng/L, creatine kinase 2,700 U/L, and venous blood gas pH 7.6 with lactate 2.6 mmol/L. Nicardipine infusion was started for BP control. The workup revealed moderate left ventricular hypertrophy, mild aortic regurgitation on TTE, and negative bilateral renal duplex. Notably, chart review identified a prior elevated aldosterone-renin ratio (ARR) from nine months earlier, prompting further imaging. A CT and MRI revealed a 9x7 mm right adrenal nodule suggestive of an adenoma. Spironolactone was up-titrated to 75 mg twice daily, carvedilol 25 mg twice daily was added, and potassium supplementation was initiated, achieving BP and potassium normalization. The patient declined further adrenal evaluation or surgery but was discharged on a revised antihypertensive regimen with follow-up plans in nephrology, cardiology, and primary care. IMPACT/DISCUSSION: This case highlights the importance of early recognition and evaluation of resistant hypertension with hypokalemia, a hallmark of primary aldosteronism (PA). PA is the most common cause of secondary hypertension, affecting up to 20% of resistant cases, yet it remains underdiagnosed, leading to preventable cardiovascular complications. Screening with the aldosterone-renin ratio (ARR) is crucial but requires proper timing and medication adjustments for accuracy. This patient’s delayed diagnosis underscores the need for heightened clinical suspicion and prompt follow-up on abnormal findings. Treatment with mineralocorticoid receptor antagonists, such as spironolactone, can significantly improve outcomes, while adrenalectomy offers curative potential for unilateral adenomas. Barriers such as clinical inertia and patient preferences can delay care. Enhanced clinician awareness, patient education, and adherence to screening guidelines are vital to reducing delays and preventing complications like stroke and myocardial infarction.

Resistant hypertension with hypokalemia should prompt urgent evaluation for primary aldosteronism to prevent diagnostic delays and associated complications. Early and thorough investigation, guided by established screening protocols and accurate interpretation of the ARR, can mitigate adverse outcomes and improve patient care. This case reinforces the importance of a multidisciplinary approach to managing resistant hypertension, emphasizing patient-centered care and timely initiation of targeted therapy. BEYOND BORDERS: THE GLOBAL DIAGNOSTIC CHALLENGE OF NECROTIZING WOUNDS Tanvi Kongara, Aditya Desai, Shreya Ahuja, Bryn Rubin, Jadranko Corak. Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4271719) CASE: A 40-year-old man, with no known medical history who recently emigrated from Cuba in early 2024, presented with five weeks of necrotic, gangrenous ulcers on his bilateral lower and upper extremities and ear helices. There was no improvement despite trialing Pentoxifylline twice for lower extremity claudication given in Cuba. In fact, after the second trial, he developed small, raised lesions on his elbows and feet. These lesions rapidly progressed into open ulcers spreading bilaterally across his legs, arms, and ears. Despite empiric trials of antibiotics and systemic steroids, the skin lesions continued to deteriorate, and he developed bilateral leg neuropathy, Laboratory tests showed elevated CRP and ESR, positive autoantibodies (RF, ANA, cardiolipin IgM, beta-2 glycoprotein IgM, Lupus Anticoagulant), and a positive QuantiFERON Gold test. Wound cultures isolated E. coli and MRSA thereby complicating the diagnosis. Imaging studies demonstrated periarteritis and focal vascular occlusion, but radiology and vascular assessments deemed the finding a normal anatomical variant. Skin biopsy showed extensive hemorrhage, necrosis, and rod-shaped organisms on Gram stain and positive AFB stains, indicating an infectious cause, complicating the diagnosis of vasculitis. Advanced microbial testing with Karius (analyzes microbial cell-free DNA in the blood) and tissue PCR identified Mycobacterium lepromatosis as the causative agent suggesting the primary culprit for skin changes. IMPACT/DISCUSSION: The patient was diagnosed with Lucio phenomenon, a form of necrotizing vasculitis associated with diffuse lepromatous leprosy. He met diagnostic criteria of skin ulceration, vascular thrombosis, and blood vessel invasion by leprosy bacilli [1]. Positive cardiolipin and beta-2 glycoprotein antibodies further supported this diagnosis. Lucio’s phenomenon is difficult to diagnose outside endemic areas due to its similarity to other autoimmune and rheumatologic conditions, such as SLE and APLS. Delaying treatment can result in extensive skin necrosis, secondary infections, and fatal complications. Treatment included antibiotics for multibacillary leprosy and systemic steroids to prevent Lepra reaction flares. While WHO guidelines recommend multidrug therapy (MDT) with rifampin, dapsone, and clofazimine, studies suggest an alternative RMM regimen (rifampin, moxifloxacin, minocycline) with better adherence and outcomes [2]. The National Hansen’s Disease Program supports the RMM regimen as a viable treatment option. Lifelong anticoagulation was recommended due to antiphospholipid antibodies and thrombosis risk.

1. Clinicians should be aware of atypical leprosy presentations, particularly those that mimic autoimmune diseases. 2. Recent studies show that regimens like monthly RMM offer better safety and adherence than traditional treatments. 3. Bedaquiline, an antimicrobial used for multidrug-resistant tuberculosis, shows promising evidence for treatment of multibacillary leprosy [3]. BEYOND THE HEART: A RENAL MANIFESTATION OF BARTONELLA ENDOCARDITIS Radhika Patel, Indira Chervu. Internal Medicine, Wellstar Kennestone Regional Medical Center, Marietta, GA. (Control ID #4272499) CASE: A 72-year-old male with coronary artery disease, diabetes, hypertension, and valvular heart disease with aortic valve replacement presented with intermittent fevers for one month with associated weakness, weight loss, and night sweats. Initial lab data indicative of pancytopenia; WBC 2.4, HgB 9.0, PLT 84 and acute kidney injury. Recent outpatient bone marrow biopsy results negative. Due to laboratory findings, the patient was started on empiric antibiotics with piperacillin-tazobactam and doxycycline. The initial transthoracic echocardiogram showed moderately dilated left atrium with preserved EF 55-60% and no mobile vegetations appreciated; these findings were then supported by a transesophageal echocardiogram. Imaging suggestive of unchanged low-density lesions on the R kidney likely renal cysts, and nonspecific perinephric stranding. Additional renal work up was positive for ANA and rheumatoid factor prompting a renal biopsy was obtained; pt was then discharged with outpatient follow up due to improvement in clinical status. During the two-week hospital follow up, the patient was sent for hospital admission for worsening kidney function. Kidney biopsy revealed focal necrotizing and sclerosing glomerulonephritis with early segmental cellular crescent formation and focal glomerular tuft fibrinoid necrosis with concern for renal findings associated with Bartonella endocarditis. Blood cultures remained negative. A new echocardiogram performed showing severe calcifications on prosthetic aortic valve and a large echo density was noted on the aortic leaflet. Due to acute deterioration in clinical status, the patient was transitioned to comfort measures. Autopsy report revealed fibrinous calcified aortic valve tissue; Cat scratch, and Warthin Starry antibody stained was positive for Bartonella henslae. IMPACT/DISCUSSION: Bartonella endocarditis, also known as cat-scratch disease continues to be a serious condition that is difficult to identify and often leads to delay in treatment. Bartonella henslae is noted to be the most common culprit species seen in immunocompromised individuals or valvular heart disease. The presentation often includes nonspecific symptoms such fever and malaise. Many times, the classic findings are not obvious on initial work up and can lead to delay in care. Necrotizing glomerulonephritis is associated with Bartonella endocarditis and serves as a clue to the underlying infection. Histopathology of necrotizing glomerulonephritis will show focal crescentic necrotizing formations with immune complex depositions, most commonly IgA, IgG, and IgM. A high index of suspicion is needed to ensure early detection and initiation of targeted treatment.

Understanding the pathophysiology of the disease process and the identifying uncommon presentations on other organ systems due to Bartonella can provide early detection, guidance on performing tests and imaging, and early initiation of treatment. BEYOND THE KIDNEYS: A RARE CASE OF CALCIPHYLAXIS IN END-STAGE LIVER DISEASE Matthew Genelin, Sarah Anstett, Alexis Jacobson. Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4272400) CASE: A 41 year-old female with alcohol-induced cirrhosis and frequent admissions for decompensated cirrhosis was admitted to a tertiary care center for worsening abdominal distension and skin rash. On admission, the patient was noted to have ascites and a diffuse, necrotizing, desquamating rash on the bilateral thighs, proximal arms, axilla, abdomen, and back. Dermatology was consulted and performed a biopsy of the skin lesions which revealed vascular calcium deposition in the subcutis consistent with a diagnosis of calciphylaxis. The patient had normal electrolytes, including a protein-corrected calcium of 9.0mg/dL, ionized-calcium of 4.5mg/dL, creatinine 0.80mg/dL, and a low albumin of 1.9g/dL. She had normal renal function, negative hepatitis C serology, negative cryoglobulins, and no history of warfarin exposure as an alternate explanation for calciphylaxis. The patient was started on sodium thiosulfate therapy, topical antibiotics, and received aggressive wound care. The patient developed recurrent severe anion-gap metabolic acidosis related to sodium thiosulfate infusions and thus therapy was discontinued. Unfortunately, despite treatment, her skin lesions continued to progress. The patient declined cognitively and physically and the decision was made to transfer to hospice. The patient died 4 days after discharge. IMPACT/DISCUSSION: Calciphylaxis is a severe dermatologic disease most commonly seen in patients with end-stage renal disease (ESRD). We report a rare case of calciphylaxis in a young woman without evidence of renal disease to raise awareness of other possible presentations. The pathogenesis of calciphylaxis without ESRD is poorly understood but may be related to hypoproteinemia, hypercalcemia, hyperphosphatemia, and impaired wound healing. Interestingly, despite correction for hypoalbuminemia from hepatic dysfunction, our patient had normal calcium and phosphorus leads us to believe her primary etiology for calciphylaxis was alcoholic cirrhosis. In both cases, calciphylaxis is a poor prognostic sign and carries a high morbidity and mortality. Given our limited understanding of the pathogenesis outside of renal disease, treatment options are poorly understood but include supportive care and consideration for liver transplant.

Calciphylaxis is a dermatologic disease typically related to ESRD, however as we illustrate, it may rarely be seen in other end-organ illnesses like decompensated alcoholic cirrhosis. In patients with cirrhosis and rash, consideration of an atypical presentation of calciphylaxis may allow for quicker diagnosis and treatment. Our case highlights a rare case of biopsy-proven calciphylaxis in the setting of alcoholic cirrhosis that clinicians may reference when managing this life-threatening illness. BILATERAL THALAMIC INFARCTION DUE TO A RARE ANATOMICAL VARIANT Omaima Chaudhary1; Maimona Chaudhary2; Muhammad S. Zubair3; Erin McFadden1. 1Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA; 2Internal Medicine, Wright Center for Graduate Medical Education, Scranton, PA; 3Medicine, Windsor University School of Medicine, Cayon, Saint Mary Cayon Parish, Saint Kitts and Nevis. (Control ID #4273155) CASE: Patient is a 67-year-old female with history of hypertension, prediabetes, lower back pain, hyperplastic adrenal gland, and alcohol use disorder who presented with increased somnolence and difficulty being aroused. Patient has recently been discharged after an episode of witnessed seizure which was thought to be due to alcohol withdrawal. Patient had also been extremely fatigued for the past few months. She was hemodynamically stable. Labs showed no abnormalities. Urinary drug screen, salicylate, and acetaminophen levels were all normal. Electrocardiography was unremarkable. Computed tomography (CT) head was negative for acute findings. The next morning, patient had visible bilateral ptosis with loss of extraocular movement. Magnetic resonance imaging (MRI) brain revealed acute infarct of bilateral thalami. Neurology was consulted and she was managed with aspirin and clopidogrel. Over the next couple of days, patient showed significant improvement in the ptosis on the right side with residual left-sided ptosis and gradual improvement in extraocular movements bilaterally. She was discharged to a rehabilitation facility and made a complete recovery. IMPACT/DISCUSSION: Multiple vascular anatomical variants supply the thalamus. The most common is two paramedian arteries (PA) arising from each posterior cerebral artery (PCA) to feed their respective thalamus. A rare variant, seen in 4-12% of the population, is where one PCA gives rise to a single trunk, called the artery of Percheron (AOP), that then bifurcates into two PAs, each supplying a thalamus. Among ischemic strokes, pure thalamic strokes make up only 3-4%, and even rarer are bilateral thalamic strokes, which account for 0.1-0.4% of all ischemic strokes and can only happen due to AOP occlusion. Clinical features of AOP strokes are variable but are typically described in seven patterns: mental status changes (somnolence, stupor), memory impairment, speech changes, ocular movement abnormalities, motor deficits, cerebellar signs (ataxia, dysmetria), and nonspecific symptoms (tremors, seizures). Therefore, AOP infarct should be a differential diagnosis in patients with altered mental status and somnolence. As CT findings are typically normal, diagnosis of AOP ischemic strokes is typically made with MRI brain, specifically FLAIR and diffusion-weighted. AOP occlusions present a diagnostic challenge due to the small vessel size leading to difficulty localizing on imaging, hence many cases remain undiagnosed. When appropriately diagnosed, AOP infarct follows the same thrombolysis guidelines as other ischemic strokes. Mechanical thrombectomy however is rarely an option, due to the small diameter of the artery. The prognosis tends to be favorable for both recovery and mortality given the diagnosis is made.

AOP infarcts are not only rare, but they also provide a diagnostic challenge, as seen in this patient, who first presented with seizures and then just increased somnolence. BILE IN THE CHEST: A CALL FOR RAPID INTERVENTION Charita Kunta1; Wanna Zhang2; Madeline Cook2. 1Rush University Rush Medical College, Chicago, IL; 2Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4272124) CASE: A 77-year-old male with past medical history of hypertension, hyperlipidemia, stroke, subarachnoid hemorrhage, and obstructive hydrocephalus status post ventriculoperitoneal shunt (VPS) placement presented with altered mental status and fever. A CT head showed worsening hydrocephalus. VPS was aspirated, fluid was non-infectious. Patient was empirically treated with vancomycin and zosyn for presumed sepsis. His clinical condition deteriorated and blood cultures indicated bacteremia. CT Abdomen and Pelvis showed liver abscess and Abdominal Ultrasound showed acute cholecystitis. Chest x-ray (CXR) at this time was concerning for volume overload with pulmonary edema and bilateral pleural effusions. He underwent drainage of the hepatic fluid collection and percutaneous cholecystostomy tube placement. He was treated with broad spectrum antibiotics for acute cholecystitis and bacteremia. He underwent neurosurgical intervention for hydrocephalus. He continued to be hypoxic. CXR revealed interval increase of Right pleural effusion. He was diuresed, but subsequent imaging revealed persistent right pleural effusion. Thoracentesis was done. Pleural fluid studies showed exudative effusion with elevated bilirubin in the pleural fluid, consistent with bilothorax. The fluid was not fully evacuated as he could not tolerate the procedure, leading to an interdisciplinary discussion between cardiothoracic surgery, pulmonology, and primary internal medicine team on whether the patient needed intervention for this asymptomatic bilothorax. Ultimately, intervention was advised to due to concern for infection. Patient underwent placement of chest tube and was ultimately discharged after chest tube removal on six weeks of Augmentin. IMPACT/DISCUSSION: Common disease processes such as acute cholecystitis can have atypical and severe clinical manifestations that require timely diagnosis and treatment. Bilothorax is defined as the presence of bile in the pleural space. While the etiologies of bilothorax can be varied, the main presumption of the mechanism of bilious pleural effusion includes small perforations in the diaphragm that lead to the fenestration of these contents into the pleural space [1]. Bilothorax may also be an iatrogenic complication after surgical manipulation of hepatobiliary structures or after blunt force trauma to the chest [2]. The diagnosis of bilothorax is made when the fluid-to-serum bilirubin ratio is greater than 1.0. This requires a high index of clinical suspicion as pleural fluid bilirubin is not routinely checked. Early fluid drainage and prompt administration of broad-spectrum antibiotics are crucial for management [3] to prevent subsequent infection and progression to empyema and sepsis.

Bilothorax may arise as a complication of hepatobiliary tract surgery. Fluid studies including bilirubin are vital to diagnose the condition. Once confirmed, bilothorax requires drainage to prevent secondary infection and subsequent sepsis. BIOPSY UNHELPFUL, PATIENT HISTORY FOR THE WIN: A CASE OF BRUCELLOSIS AORTITIS Anusha Amaravathi2; Jennifer A. Corbelli1. 1Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA; 2Internal medicine, UPMC, Pittsburgh, PA. (Control ID #4272765) CASE: A 46-year-old man with history of seronegative inflammatory arthritis presented with abdominal pain, and penile discharge. He spoke Nepali and all history was obtained by phone through a certified interpreter. He was well-appearing with mild tenderness to palpation in bilateral lower quadrants and frank penile discharge. Labs were notable for ESR 57, CRP 2.2 and UA with 223 WBC and many bacteria. CT angiogram was obtained due to abdominal pain and elevated inflammatory markers. Results showed soft tissue encasing a segment of abdominal aorta concerning for aortitis vs retroperitoneal fibrosis. Infectious disease and rheumatology were consulted. The differential included HIV, TB, syphilis as well as Takayasu arteritis, giant cell arteritis and Reiter’s syndrome. Penile fluid cultures grew E. Coli for which he completed 6 days of antibiotics. Blood cultures and TTE were negative. Further history revealed that the patient had consumed unpasteurized milk in Bhutan and used to live in a farm. Brucella serologies showed inconclusive results, with positive IgG and negative IgM. Due to ongoing diagnostic uncertainty, periaortic FNA was performed but was non-diagnostic. Although the confirmatory Brucella standard tube agglutination was negative, the infectious disease team ultimately recommended treatment of Brucella aortitis with doxycycline and rifampin for 6 weeks. He followed up after discharge by which time his abdominal pain had resolved. IMPACT/DISCUSSION: We describe a case of aortitis after likely Brucella exposure. Brucella is known to cause osteoarticular and genitourinary disease.1 In the setting of aortitis and seronegative inflammatory arthritis, a broad differential including autoimmune and infectious sources was considered. After obtaining further details of the patient’s history, despite his inconclusive Brucella results, Brucella was felt to be the most likely diagnosis and his symptoms resolved after treatment. This case emphasizes the importance of taking a thorough social history as it is important to recognize the risk factors for Brucellosis such as living near farm animals and consuming unpasteurized milk. It also demonstrates a rare Brucellosis presentation as compared to the more common symptoms of fevers, myalgias and fatigue. (1Siem, European J Vascular and Endovascular Surg 2022)

When considering a differential for aortitis with negative blood cultures, it is important to obtain a thorough social history and consider Brucella in individuals with risk factors such as interactions with farm animals and consumption of unpasteurized milk. Diagnostic workup can be made by more than fourfold increase in Brucella antibody titer or by antibody titer greater than 1: 160 via standard agglutination test. Treatment is doxycycline plus streptomycin or rifampin. BLOOD LOSS ANEMIA IN AORTIC STENOSIS Landry Cowles1; Calen Frolkis2,1; Andrew Wakeling2,1; Sorrel Lokkesmoe2,1. 1School of Medicine, Case Western Reserve University, Cleveland, OH; 2The MetroHealth System, Cleveland, OH. (Control ID #4242265) CASE: An 82-year-old woman was admitted for anemia. She endorsed fatigue, melena, and dyspnea on exertion. Physical exam was pertinent for tachycardia, pale complexion, good capillary refill, and a harsh mid-systolic murmur with absent S2. Past medical history was significant for aortic stenosis (AS), hypertension, and three hospitalizations in the past month for anemia in the setting of an obscure gastrointestinal (GI) bleed initially found during preoperative medical clearance for transcatheter aortic valve replacement (TAVR). Medications included aspirin, amlodipine, and furosemide. There was no relevant family or social history. Labs revealed a normocytic, hypoproliferative anemia with a Hemoglobin (Hgb) of 5.3. Hemolysis and coagulopathy workup was negative. Blood transfusion corrected her hemoglobin. EGD and colonoscopy were unrevealing. Records review yielded a pill enteroscopy in 2009 that showed arteriovenous malformations (AVMs) in the ileum. A repeat pill enteroscopy showed fresh blood in the terminal ileum though no source of bleed (notable for suboptimal bowel prep). Push enteroscopy showed no evidence of bleeding. The patient remained stable and was discharged. TAVR was completed a month later with Hgb maintained >12 since. IMPACT/DISCUSSION: AS is associated with acquired von Willebrand Syndrome (AVWS) due to turbulent flow through a stenotic valve causing breakdown of large von Willebrand factor (VWF) multimers. AVWS is suspected to interfere with inhibition of angiogenesis and delivery of factor VIII. Often, this results in blood loss anemia, most commonly from a GI source. Heyde syndrome (HS) is the clinical triad of AS, GI bleeding, and AVWS. Sources of GI bleeds in HS can be existing conditions (e.g. congenital AVMs) or acquired angiodysplasias. Regardless of the source of GI bleed, the danger is multifactorial. Acquired vWS can cause life threatening bleeding, or consequent anemia can precipitate complications such as heart failure exacerbations or myocardial ischemia. GI bleeding and AS can coexist incidentally in the elderly, so HS is likely underdiagnosed. However, HS has an excellent prognosis in individuals definitively managed with TAVR with cessation of GI bleeding in a majority of patients. Delays in diagnosis increase risk for mortality and longer hospitalizations. Thus, initial evaluation of patients with a clinical picture of GI bleed and AS should include CoAg studies and PFA. Interdisciplinary collaboration, with cardiology and gastroenterology especially, is necessary to evaluate severity and manage the often complicated perioperative course in HS.

This case illustrates the importance of early detection of a patient fitting the clinical picture of HS. Clinicians should have a clinical suspicion for HS in elderly patients with AS and/or GI bleeding, especially from obscure sites. Management of HS includes interdisciplinary collaboration and valve replacement. BLOOD TO THE BONE: EPISTAXIS LEADING TO OSTEOMYELITIS Zarif Kazi1; Marlon E. Rivera Boadla1; Bettina Zou1; Ahmad Bhaiyat3; Edward K. Chapick2. 1Internal Medicine, Maimonides Medical Center, New York, NY; 2Infectious Disease, Maimonides Medical Center, New York, NY; 3St. George's University, St. George, Grenada. (Control ID #4270202) CASE: A 75-year-old female with atrial fibrillation being treated with apixaban presented from a skilled nursing facility with three weeks of worsening back pain. She was recently discharged from another hospital where she presented with major epistaxis requiring nasal packing to control. The hospital course was complicated by MRSA bacteremia secondary to nasal packing which was treated with intravenous vancomycin for 6 weeks. The patient was discharged four weeks and completed antibiotics two weeks prior to this admission. An MRI showed evidence of discitis and osteomyelitis at L2-L3, and lumbar disc sampling resulted in cultures growing MRSA. Patient was discharged to rehab facility with IV antibiotics. IMPACT/DISCUSSION: Epistaxis is a known complication in patients on anticoagulation therapy, with nasal packing being a common intervention. However, nasal packing can predispose patients to secondary infections such as bacteremia. The moist and enclosed environment created by the nasal packing can serve as a nidus for bacterial growth, leading to local and systemic infections. In this patient, the nasal packing contributed to the development of MRSA bacteremia. The subsequent development of osteomyelitis in the lumbar spine (L2-L3) highlights a severe and rare complication of bacteremia. This case highlights the need for careful monitoring and management of patients on anticoagulation therapy who develop epistaxis. Physicians must be vigilant for symptoms of osteomyelitis in patients with known risk factors such as the use of nasal packing. Osteomyelitis can present in various anatomical locations, each with distinct clinical manifestations. In the vertebral column, it typically presents with localized back pain, tenderness, and sometimes fever or neurological deficits due to spinal cord compression. Although it is rare for osteomyelitis to occur secondary to nasal packing use, this case underscores the need to be vigilant in patients with increased risk of nasal packing use such as those on anticoagulation.

Nasal packing, though frequently used to manage epistaxis, can lead to severe systemic infections, including MRSA bacteremia and osteomyelitis. A thorough history of recent interventions, including nasal packing, can provide critical diagnostic clues. General internists should remain vigilant for atypical presentations of infection following nasal packing, especially in high-risk patients such as those on anticoagulation therapy. Close follow-up and prompt recognition of systemic signs of infection can mitigate severe outcomes, emphasizing the importance of an interdisciplinary approach in managing these patients. BLUE WITH BENZOCAINE Faizan Rahim, Katelyn Garza, Neil Patterson, David Alter. Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4223373) CASE: 64 year old male with past medical history of Liver cirrhosis, Alcohol abuse, Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Peripheral Artery Disease, Heart Failure with Preserved Ejection Fraction, Small Cell Lung Cancer with metastasis who presented to the hospital for a respiratory viral illness with an underlying superimposed bacterial pneumonia. His hospital course was complicated by a lower GI bleed and patient underwent a colonoscopy which showed hemorrhoids and an anorectal ulcer. Subsequently, he was taken to the operating room for suture ligation of the anorectal ulcer. After the patient returned from the operating room, he was found to have an increase in his oxygen (O2) requirement from 1L to 4L via nasal cannula. Patient continued to have an oxygen saturation (SpO2) between 85-87% on 4L of O2. On physical exam, he appeared in no acute distress. He remained alert and oriented x 4. Lung auscultation was significant for decreased breath sounds on bilateral lower bases. Skin exam was remarkable for blue appearing lips, pale nail beds, and discoloration or paleness of the skin. Medications received during the procedure were reviewed. Patient reeived anesthetics with bupivacaine with epinephrine injection and topical benzocaine 20 % hemorrhoidal ointment which were administered at the rectal site. An ABG with co-oximetry was ordered which showed methemoglobin levels greater than 28%. Chest X-ray showed unchanged bilateral pleural effusions and right sided pulmonary infiltrates with associated atelectasis or consolidations. Patient was given a dose of Intravenous (IV) methylene blue 100mg. Repeat ABG after 1 hour showed a methemoglobin level of 9.4%. However, given patient’s persistent physical exam findings of cyanosis another dose of 1mg/kg of IV methylene blue was administered. On physical exam, his discoloration of the skin and lips improved significantly. Patient’s O2 requirements also down trended from 4L of O2 to baseline 2L of O2. IMPACT/DISCUSSION: Studies have shown that the incidence of methemoglobinemia as a result of topical anesthetic use is a rare side effect. Incidence rates are approximately 3.5 out of every 10,000 cases. In this case, the absorption of topical benzocaine in the bloodstream and its reduced hepatic clearance setting of liver cirrhosis led to methemoglobinemia. A common pitfall in such cases is to measure clinical improvement by improvement in partial pressure of oxygen or arterial oxygen saturation. These readings may be normal or falsely elevated despite elevated methemoglobin levels.

It is important to recognize acute toxic methemoglobinemia early in its course. Evidence of cyanosis with elevated methemoglobin levels are diagnostic of this condition. It is considered a medical emergency and management comprises of discontinuing offending agents and escalating supportive care such as IV access, hydration or ventilator support for hypoxemia. BRACHIAL PLEXOPATHY SECONDARY TO ANAPLASTIC THYROID CARCINOMA Keri Angers1; Renieh Nabaty2; Abigail Entz3. 1School of Medicine, Wayne State University, Detroit, MI; 2Internal Medicine, Henry Ford Health System, Detroit, MI; 3Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4270116) CASE: A 68-year-old female with past medical history of cervical, uterine, and colorectal cancer status post respective treatments was diagnosed with papillary thyroid cancer and underwent total thyroidectomy with left neck dissection in late 2023. Radio ablative iodine treatment was completed in early 2024. Five months following radio ablation, the patient presented to her primary physician with acute neck and left shoulder pain associated with numbness and weakness. Symptoms subsequently progressed to complete loss of range of motion of her left shoulder. CT neck revealed an ill-defined necrotic soft tissue mass in the left neck extending posteriorly into the anterior scalene, surrounding the common carotid almost to the bifurcation, and abutting the transverse processes of C5-C7 with cortical erosions. Lab work demonstrated elevated CRP (21.2 mg/dL) and ESR (65mm/Hr). Due to intermittent dysphagia, a flexible laryngoscopy was obtained which showed a medialized left arytenoid, likely from mass effect. MRI results revealed a large infiltrative left neck mass involving the left brachial plexus, neck musculature, and cervical vasculature. Osseous tumor infiltration of the cervical spine and epidural space, without mass effect on the spinal cord. Unfortunately, biopsy of the area revealed anaplastic thyroid carcinoma. Genetic testing revealed a BRAF mutation. Aligning with patient care goals, she transitioned to hospice care. IMPACT/DISCUSSION: Breast cancer, lymphoma, lung cancer, and head and neck tumors are the most common causes of neoplastic brachial plexopathy. This remains a rare complication of malignancy with only 0.43% of cancer patients being affected; Breast and lung metastasis make up 32% and 37% of these cases respectively. There is limited literature discussing brachial plexopathy secondary to papillary thyroid cancer and no current literature, to our knowledge, of anaplastic thyroid cancer-induced brachial plexopathy. This case highlights a rare cause of brachial plexopathy with a clinical presentation atypical for thyroid cancer. This emphasizes the need for clinicians to be aware of rare complications following thyroidectomy in conjunction with patient history. The transformation of papillary thyroid cancer to anaplastic thyroid cancer is rare, yet genetic mutations are hypothesized to be a main driver. Approximately 20% of patients diagnosed with anaplastic thyroid cancer have a history of well-differentiated thyroid cancer. This case highlights the significance of identifying potential genetic drivers of cancer as this can prime clinicians to stay alert to rare clinical presentations.

Recognize rare causes of brachial plexopathy and symptom presentation Consider genetic drivers in patients with extensive cancer history BRAIN ABSCESS IN A 27-YEAR-OLD: CONSEQUENCES OF A DELAYED DIAGNOSIS Jennifer Mansour2; Jonathon M. Monroe3; Nidhi H. Patel1; Shub Agrawal1. 1Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2Medical Education, Emory University School of Medicine, Atlanta, GA; 3Medical Scientist Training Program, Emory University School of Medicine, Atlanta, GA. (Control ID #4273291) CASE: A 27-year-old male with a history of recurrent pneumonia and chronic sinusitis presented to the ED for new-onset seizures. Initial head CT identified vasogenic edema in the right frontal lobe and mucosal thickening within the maxillary sinuses. MRI demonstrated a peripherally enhancing lesion with irregular enhancement and extensive surrounding edema. Empiric antibiotics were initiated, and Neurosurgery performed a stereotactic brain biopsy. Initial biopsy studies were negative. Post-operative MRI redemonstrated the lesion, and the patient underwent a second craniotomy during which purulent material was removed. Anaerobic, fungal, and tissue cultures resulted negative. Further testing revealed a low/undetectable level of immunoglobulins for which the patient was started on IVIG. Genetic testing found a variant Bruton tyrosine kinase gene diagnostic of XLA. IMPACT/DISCUSSION: X-linked agammaglobulinemia (XLA) is an inherited primary immunodeficiency that results in impaired B cell development, low or absent antibody levels, and recurrent bacterial infections. Most commonly, XLA results in recurrent respiratory tract infections, which lead to chronic lung damage, a key predictor of morbidity and mortality in XLA. The respiratory, gastrointestinal, and neurologic systems are frequently affected. Despite recurrent pneumonia, our patient’s diagnosis of XLA was delayed. In late 2019, five years prior, he was found to have hypogammaglobinemia while hospitalized for pneumonia. After his last known primary care visit in late 2020, he was lost to follow-up – unable to be diagnosed or treated. Subsequently, he presented to the ED seven times for respiratory tract infections and abscesses without further work-up prior to the current hospitalization. Several structural and socioeconomic barriers contributed to his delayed diagnosis. XLA is difficult to diagnose and manage due to low awareness, limited access to genetic testing, and restricted availability of immunoglobulin. For 60% of patients diagnosed with XLA, the initiation of diagnostic testing occurs during or after admission for a severe infection. Excessive costs further limit care access in countries lacking comprehensive government healthcare coverage3. Our patient was uninsured and unaware of his diagnosis of hypogammaglobulinemia, despite his positive testing.

A high index of suspicion for XLA among internists is critical to improving early diagnosis of XLA, therefore reducing patients’ risk of developing long-term complications of recurrent infections. Patients may still experience complications and infections while on immunoglobulin replacement therapy, but it has been shown to reduce early mortality. Physicians should consider early immunoglobulin testing in patients with a history of recurrent infections and close outpatient follow-up to expedite diagnosis. BREAK BONE FUO IN SICKLE CELL ANEMIA Marcus W. Moses. Internal Medicine, Emory University, Atlanta, GA. (Control ID #4273215) CASE: A 20-year-old woman with sickle cell disease (SCD) complicated by avascular necrosis of the hip presented with an acute onset of bilateral lower extremity pain consistent with prior pain crises. On presentation, she was afebrile with a normal exam and labs that were notable for WBC 15.2, Hgb 11.9 (her baseline), platelets 349, total bilirubin 1.4, LDH 252, and reticulocyte count 3.08%. A morphine PCA pump, multimodal pain regimen, and IV fluids were initiated. Within the next 24 hours, she developed intermittent fevers and tachycardia with an LDH increase to 2,490. By hospital day 4, her cell counts began to drop: hemoglobin was 7.8, platelets were 52, and reticulocyte was 2%. CXR, UA, respiratory viral panel, HIV, blood cultures, doppler US, and CT PE were negative. Parvovirus, CMV, and EBV were pending. Hematology recommended to initiate EPO, to transfuse platelets and pRBCs, and to order bilateral tibia/fibula MRIs. MRI was notable for heterogeneous marrow abnormalities suggestive of acute bone infarcts. At this point, it was believed the infarcts were the primary driver for her persistent fevers though it would not support the anemia and thrombocytopenia. On hospital day 8, parvovirus B19 was detected via PCR and IVIG 1g/kg was administered for 2 days. Shortly thereafter, her fevers resolved with improvement in thrombocytopenia and anemia. On repeat parvovirus testing, PCR was undetectable signifying viral clearance. On hospital day 15, the patient was discharged in stable condition with cell counts and functional status near baseline. IMPACT/DISCUSSION: SCD affects approximately 100,000 people in the U.S. and given the possible immunocompromised state due to functional asplenia, the evidence of fever in SCD requires prompt diagnostic evaluation. Though this patient presented with a typical crisis, her clinical status quickly deteriorated into a transient aplastic crisis with ensuing anemia, thrombocytopenia, reticulocytopenia, and bone infarcts. Since general internists typically are the first point of contact, it is imperative to have a broad understanding of common SCD complications. Parvovirus B19 frequently causes red cell aplasia in SCD (30-67% of patients) due to erythropoiesis arrest and without appropriate intervention can result in splenic or hepatic sequestration, acute chest syndrome, meningoencephalitis, and stroke. IVIG therapy led to parvovirus B19 clearance, resolution of symptoms, and improvement in aplastic crisis.

SCD can present with a diverse array of symptoms with the potential to develop into life-threatening complications. Parvovirus B19 is commonly associated with SCD resulting in the interruption of erythropoiesis leading to aplastic anemia. Early expert consultation and proactive management are recommended to reduce the risk of severe complications. BREAKING THE BLOCK WITH INTRAVENOUS ANTIBIOTICS- NO PACEMAKER NEEDED Mohammad Hazique3; Sameer Lohana2; Shanmukha Priya Peddireddy1. 1Internal Medicine, Nuvance Health, Lagrangeville, NY; 2Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 3Internal Medicine, Vassar College, Poughkeepsie, NY. (Control ID #4273394) CASE: A 60-year-old male fisherman with a known history of Lyme disease presented to the emergency department complaining of persistent dizziness and lightheadedness over the past few days. He denied chest pain, palpitations, or syncope. His medical history was significant for tick exposure due to his occupation. On examination, his vital signs were stable, but his pulse was markedly bradycardic. An initial electrocardiogram (EKG) revealed a third-degree atrioventricular (AV) block with 4-second sinus pauses, necessitating further investigation. Laboratory studies confirmed a positive Lyme disease serology with elevated IgM and IgG antibodies, and the SILC (Suspicious Index in Lyme Carditis) score was calculated to be seven, indicating a high probability of Lyme carditis (LC). An echocardiogram showed preserved left ventricular ejection fraction (>55%), no evidence of valvular disease, ruling out structural cardiac abnormalities as the cause of the conduction disturbance. IMPACT/DISCUSSION: Lyme disease is a tick-borne infection caused by Borrelia burgdorferi, and Lyme carditis (LC) is a rare but significant manifestation, often presenting as a conduction abnormality such as first-, second-, or third-degree AV block. The clinical presentation of LC can range from mild, transient symptoms to severe, life-threatening complications. If untreated, the cardiac manifestations may progress to irreversible damage or require invasive management, such as pacemaker implantation. This case highlights the importance of recognizing LC in patients with unexplained heart block and a history of tick exposure. The patient’s EKG findings and serological results strongly suggested LC. Intravenous Ceftriaxone was initiated promptly, targeting the spirochete infection. Western blot analysis confirmed the diagnosis. Within three days of initiating antibiotic therapy, the patient’s AV block began to resolve, and follow-up EKGs demonstrated significant improvement. A treadmill stress test performed during recovery showed a positive chronotropic response, ruling out intrinsic conduction system disease and obviating the need for a permanent pacemaker. The patient completed a 21-day course of intravenous antibiotics with symptom resolution and follow-up EKG with normal sinus rhythm.

This case underscores the critical need to consider reversible causes of heart block, particularly in patients with a history of Lyme disease or tick exposure. Lyme carditis, though uncommon, can cause significant conduction disturbances, including complete heart block. Early recognition and prompt initiation of antibiotic therapy can lead to dramatic improvement, prevent permanent cardiac damage, and avoid unnecessary invasive procedures like pacemaker implantation. Clinicians should maintain a high index of suspicion for LC in endemic areas and utilize diagnostic tools such as the SILC score and serological testing to guide management effectively. Early intervention remains key to favorable outcomes in Lyme carditis. BREAKING THE BULLA: A CASE OF ECTHYMA IN AN IMMUNOCOMPETENT HOST Nicole C. Nowak2; Melissa Gunchenko1; Michelle Sweet1. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Rush University Rush Medical College, Chicago, IL. (Control ID #4271001) CASE: A 24-year-old male with no significant past medical history presented with painful, blistering lesions of the left lower extremity (LLE) that progressed to erythematous and tense bullae over seven days. On arrival, he was afebrile and hemodynamically stable. Physical exam of the edematous LLE revealed a 3x3 cm intact bulla with a necrotic rim (Figure 1), a 1x1 cm ruptured bulla with yellow crusting and serous drainage (Figure 2), and a negative Nikolsky sign. Empiric ceftriaxone and vancomycin were started for suspected cellulitis. Laboratory studies revealed a WBC 9.69 K/uL. Bulla fluid culture grew methicillin-resistant Staphylococcus aureus (MRSA). CT of the LLE showed a superficial hypodense lesion on the medial proximal LLE, but no signs of osteomyelitis or deep tissue involvement. LLE vascular duplex ultrasound showed no evidence of deep vein thrombosis. After consultation with the dermatology and infectious disease teams, the lesions were determined to be ecthyma. The patient was transitioned to oral doxycycline on discharge for a total seven-day course. A decolonization regimen, consisting of intranasal mupirocin and chlorhexidine gluconate baths, was repeated monthly for six months. IMPACT/DISCUSSION: This case highlights an atypical presentation of ecthyma in an immunocompetent individual and emphasizes the challenge of diagnosing skin lesions. The initial presentation of a weeping, yellow-crusted bullous lesion raised concern for bullous impetigo, but its progression to an erythematous lesion with a hemorrhagic, necrotic ring suggested ecthyma. Given the absence of central necrotic ulceration, ecthyma gangrenosum (EG) was considered less likely. Ecthyma and impetigo are caused by S. aureus and S. pyogenes; however, they differ in depth and presentation. Bullous impetigo is a superficial infection with flaccid bullae filled with clear or yellow fluid that are prone to rupture, leaving a varnish-like crust. Nonbullous and bullous impetigo can progress to ecthyma if left untreated. Ecthyma initially presents as vesicles that progress into ulcerative lesions with a thick, adherent crust, surrounded by raised erythematous margins and extending into the dermis layer. Similar to ecthyma, EG involves the dermis layer and is classically seen in immunocompromised patients. However, it is typically caused by P. aeruginosa and is often associated with systemic symptoms. EG presents as erythematous and violaceous macules that quickly evolve into necrotic-ulcerative eschars. Treatment of EG involves anti-pseudomonal antibiotics, with surgical debridement reserved for severe cases.

- A high index of suspicion for ecthyma should be maintained in patients with ulcerated, crusted lesions even in the absence of immunosuppression. - A multidisciplinary team is essential in diagnosing complex skin infections and ensuring optimal patient outcomes. BREAKING THE OBSTRUCTION-POLYURIA CYCLE: A CASE OF NEPHROGENIC DIABETES INSIPIDUS IN A PATIENT WITH SEVERE CHRONIC OBSTRUCTIVE UROPATHY-INDUCED ANTIDIURETIC HORMONE RESISTANCE Carlo Gabriel C. Casipit1; Bruce Adrian Casipit2. 1Internal Medicine, Jefferson Einstein Philadelphia Hospital, Philadelphia, PA; 2Loma Linda University, Loma Linda, CA. (Control ID #4270481) CASE: A 61-year-old male presented to the hospital with a 10-day history of frequent, large-volume urine approximately 3L in 24 hours, associated with excessive thirst. He has hypertension and is on Amlodipine, Benign Prostatic Hyperplasia currently on Tamsulosin. He denied any fever, vomiting, abdominal pain, constipation, diarrhea, flank pain, paresthesia, dysuria, or hematuria. Vital signs were only remarkable for hypertension with BP 150/90. The Physical Examination showed dry skin and oral mucosa, a distended urinary bladder, and an enlarged prostate. Diagnostic tests showed Na 156 (ref 135-145), K 3.5(ref 3-5), Ca 8(ref 8-10), Creatinine 1.67 from baseline 1.29 (ref 0.5-1.5), Glucose 97(ref 70-140), HbA1C 5.4(ref <5.7),Serum osmolality 325(ref 275-295), Urine Osmolality 106 (ref 500-850),Urinalysis was unremarkable. CT head showed no abnormality. Endocrinology was consulted, fluid restriction and empiric treatment with Desmopressin were suggested. However, 4 hours later, there was no significant increase in urine osmolality or reduction in urine volume. Abdominal ultrasound revealed chronic severe bilateral hydronephrosis, markedly thickened bladder, and enlarged smooth prostate. A Foley catheter was placed and his serum sodium, urine output, and urine osmolality gradually improved over the course of 1 week. He was then diagnosed with acquired nephrogenic diabetes insipidus and overflow incontinence in the setting of severe chronic urinary obstruction. He was started on a Thiazide diuretic, and continued on Tamsulosin. He was then discharged with close follow-up with Nephrology for monitoring and Urology for urosurgical planning. IMPACT/DISCUSSION: Nephrogenic Diabetes Insipidus (NDI) is a defect in the concentrating ability of the kidneys due to Antidiuretic Hormone (ADH) resistance. Most NDI cases are inherited but can be acquired due to medications or rarely obstructive uropathy. The urinary system remodeling associated with chronic obstructive uropathy impairs tubular ADH receptors, disrupting water reabsorption and resulting in NDI. Interestingly, severe NDI-induced polyuria worsens the urinary system remodeling, resulting in ureteral dilatation, impaired bladder contractility, and further distal collecting tubular destruction, aggravating the obstruction and NDI cycle. Although certain medications, such as Thiazides, were shown to improve symptoms, the definitive treatment remains to be treating the cause and relieving the urinary obstruction.

Our case discussed the importance of ruling out obstructive uropathy, a common yet treatable condition, in any patient with clinical evidence of Diabetes Insipidus and how critical it is to promptly address the cause of the urinary obstruction in order to mitigate the obstruction-polyuria cycle. BREAKING THE SCRIPT: UNMASKING RHEUMATOID MENINGITIS IN A STROKE MIMIC Megan P. Connor2; Yan Zhou2; Kimberly A. Indovina1; Mojtaba M. Abnos3. 1Denver Health Main Campus, Denver, CO; 2University of Colorado System, Denver, CO; 3Kansas City University, Kansas City, MO. (Control ID #4269915) CASE: An 83-yo woman with longstanding rheumatoid arthritis (RA), well-controlled on a tumor necrosis factor (TNF) inhibitor, presented with acute-onset right focal neurological deficits (FND), fever, and headache for 6 hours. On exam, she appeared well, was hemodynamically stable, and had right-sided weakness. She had no cranial nerve deficits, meningeal signs, or synovitis.1 Computed tomography of the head revealed nonspecific increased hyper-attenuation of the left frontal subarachnoid spaces. Magnetic resonance imaging (MRI) of the brain revealed increased enhancement along the left-sided meninges with concomitant hazy T1 signal and subtle restricted diffusion. Cerebrospinal fluid (CSF) studies revealed white blood cells (WBC) 15 /μL, protein 129 mg/dL, and glucose 48 mg/dL, with negative West Nile antibody, cryptococcal antigen, and PCR panel of common meningitis pathogens. Serum protein electrophoresis was normal, and peripheral flow cytometry negative. C-reactive protein was 62 mg/L, rheumatoid factor > 4096 IU/mL, and anti-cyclic citrullinated peptide 149 U. The differential diagnosis was broad, including stroke, bacterial or viral meningitis, RA meningitis, malignancy, and amyloidosis. The patient was given broad-spectrum antibiotics and steroids empirically for bacterial meningitis, though we suspected a non-infectious etiology. The next day, in consultation with rheumatology and neurology, we made the clinical diagnosis of rheumatoid meningitis. As she was too high-risk for brain biopsy for definitive diagnosis, she was empirically treated with methylprednisolone 250 mg IV daily for 3 days with rapid improvement. Antibiotics were discontinued after 2 days of negative cultures. Her symptoms resolved and strength returned to baseline prior to discharge. IMPACT/DISCUSSION: Rheumatoid meningitis is a rare and severe complication of RA. It is typically seen in patients with longstanding RA and is associated with TNF inhibitor use. Clinical manifestations may include transient FND, headaches, and psychiatric symptoms. On imaging, the leptomeninges are predominantly affected. CSF studies mimic aseptic meningitis, with elevated WBC and protein, variable glucose, and negative Gram stain. The diagnostic gold standard is brain biopsy. Treatment involves high-dose corticosteroids, usually followed by rituximab, and most patients recover fully. This patient presented with stroke-like symptoms but without radiographic evidence of stroke. While CSF studies suggested bacterial meningitis, she was not septic and appeared well. Her longstanding RA and unique MRI finding of focal left frontal leptomeningeal enhancement provided clues to the correct diagnosis.

Rheumatoid meningitis can mimic both stroke and infectious meningitis and should be considered in patients with RA presenting with neurologic signs and symptoms. 1. Villa, Eduardo et al. “Rheumatoid meningitis: A systematic review and meta-analysis.” European journal of neurology vol. 28,9 (2021): 3201-3210. BREAKING THE SEAL: MANAGING POST EPIDURAL STEROID INJECTION COMPLICATIONS Sejal Batra, McCall Simon, Ravindra Bhati. Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4272253) CASE: A 78-year-old female with a history of giant cell arteritis and chronic low back pain presented to the ED with altered mental status and severe headache. On presentation, she was afebrile, tachycardic, and hypertensive. Initial labs showed significant leukocytosis (35.7 thou/cmm) with neutrophilic predominance, normal ESR (3), and elevated CRP (73.4). On exam she exhibited nonsensical speech, dizziness, and blurred vision without any focal neurological deficits. Notably, the patient had undergone lumbar epidural steroid injection (ESI) the day prior for chronic low back pain management. CT head showed multiple foci of gas within the subarachnoid spaces, and MRI Brain showed abnormal proteinaceous fluid layers in the occipital recesses. Given the findings of pneumocephalus and concerns for meningitis, a lumbar puncture was performed and revealed high protein and low glucose levels. Patient was started on empiric vancomycin, ampicillin, ceftriaxone, and acyclovir. CSF cultures and PCR later returned negative. Patient’s headache and mentation improved significantly by Day 3, and she was transitioned to ceftriaxone. She was discharged on Day 8 and completed 14 days of antibiotics. IMPACT/DISCUSSION: ESI is a relatively safe procedure used to treat patients with radicular back pain. Complications are rare, with major events occurring at an exceptionally low rate of 0.011%. These include inadvertent dural puncture (IDP), infection, and hematoma. In this case, the patient developed both pneumocephalus and meningitis following ESI. Pneumocephalus, a rare complication of IDP, can lead to severe meningeal irritation and rapid-onset headache. Additionally, the steroids used in ESI can enter the canal and cause chemical irritation of the meninges. Distinguishing between bacterial and chemical meningitis in such patients is clinically challenging due to overlapping symptoms and CSF findings. CSF analysis can help differentiate the two, as bacterial meningitis showing elevated protein, low glucose, and neutrophilic pleocytosis while chemical meningitis typically has mild protein elevation, normal or mildly low glucose, and lymphocytic or mixed pleocytosis. In this case, the rapid improvement of symptoms, negative CSF cultures and PCR, and absence of fever supported the diagnosis of chemical meningitis. However, timely initiation of empiric antibiotics is crucial in such cases given the potential severity of untreated bacterial meningitis.

This case underscores the importance of recognizing rare complications of ESI, such as IDP and pneumocephalus and their potential to cause chemical meningitis. Differentiating between bacterial and chemical meningitis is often challenging, requiring careful consideration of clinical presentation, imaging findings, and CSF analysis. As the occurrence of chemical meningitis is vanishingly rare, and the risks associated with untreated bacterial meningitis are high, it is important to presumptively treat with appropriate antibiotics. BREATHLESS BEGINNINGS: A CASE REPORT OF ALS PRESENTING AS PROGRESSIVE DYSPNEA Andrew Bihl1; Ahmad Anshasi2. 1Internal MEdicine, The University of Texas Southwestern Medical Center, Dallas, TX; 2GIM, The University of Texas Southwestern Medical Center, Arlington, TX. (Control ID #4267868) CASE: 69-year-old male with a history of prostate cancer and DM presented to an academic hospital with progressive, exertional dyspnea and tachypnea. These symptoms progressed until tachypnea was present at rest. Review of systems revealed orthopnea, 50 lbs unintentional weight loss, decreased appetite, intermittent blurry vision, tremors, and micrographia. He owned a construction company but denied any occupational exposures. He reported rare cigar smoking and consumed 4-5 drinks per week. Family history was notable for a father with Parkinson’s Disease. Prior to this presentation, he had been to multiple physicians without a formal diagnosis. Negative outpatient workup included a CXR, CT chest, MR brain, TTE, nuclear stress test, and PET CT. He was encouraged to present to an academic center. Examination showed clear lungs with subcostal retractions. RR was 24 with SpO2 98% on room air with no subjective dyspnea. A neurologic exam showed 4/5 strength in bilateral proximal muscles of the hip girdle and was otherwise 5/5. Strength exam caused increased dyspnea. Coarse fasciculations were noted to the muscles of the chest wall and the tongue. Lateral deviation of the right eye was seen on upward gaze and 3 beats of horizontal nystagmus were noted in the left eye on leftward gaze. The patient was diffusely hyper-reflexic with 3+ DTRs. Labs were notable for a compensated respiratory acidosis with pCO2=66.4 and HCO3=37 with pH 7.36. A neuromuscular etiology was suspected and neurology was consulted. EMG was performed and showed “an axonal motor neurogenic process with widespread fasciculations and active denervation...consistent with the clinical diagnosis of ALS”. The patient was started on riluzole and discharged on nocturnal BPAP. He continues to follow regularly with neurology and pulmonary. IMPACT/DISCUSSION: This patient's abnormal neurologic examination coupled with poor ventilation suggested a neuromuscular etiology which led to the diagnosis of amyotrophic lateral sclerosis (ALS). While ALS is a relatively rare disorder with an annual incidence of 1-2 cases per 100,000 people in the US, the cumulative lifetime risk may be as high as 1 in 400. This means that even primary care providers are likely to see at least one case of ALS during their career based on average patient panel size. For this reason, it is paramount that all internists be aware of the typical presentation of ALS to prevent delays in diagnosis (which often takes up to a year after the onset of symptoms). While this patient did have the classic signs of combined upper (hyperreflexia) and lower (weakness, fasciculations) motor neuron dysfunction, the presence of early diaphragmatic weakness is rare with only ~3% of patients having this at the time of diagnosis.

This case serves as a reminder that dyspnea is a common symptom of neuromuscular disorders. While most dyspnea is cardiopulmonary in nature, the differential is broad and a specific diagnosis is often not apparent by history and physical exam alone. BREATHLESS ON DAPTOMYCIN: UNVEILING EOSINOPHILIC PNEUMONITIS AFTER TREATMENT FOR PROSTHETIC JOINT INFECTION Sidratul Baizeed, Luke Ciminera, Wali Kamran, Jeffery A. Debuque. Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4271667) CASE: A 74-year-old male with a recent right hip prosthetic joint infection (PJI) caused by Enterococcus faecalis, treated with daptomycin, presented to an outpatient Infectious Disease (ID) followup with a 5-day history of productive cough. Three weeks earlier, he underwent right total hip revision surgery and was discharged on a 6-week course of daptomycin. At the outpatient ID follow-up, elevated C-reactive protein of 201 milligrams per liter (mg/L) prompted referral to the emergency department, where imaging revealed new patchy bilateral pulmonary infiltrates with ground glass opacities. Labs showed a mild leukocytosis of 11,500 cells per microliter of blood (cells/μL) with eosinophilia of 1.1%. Suspecting daptomycin-associated eosinophilic pneumonitis (DAEP), ID recommended discontinuing daptomycin. Bronchoscopy with bronchoalveolar lavage (BAL) confirmed DAEP with eosinophilia (40% and 69% in sampled lobes). Daptomycin was replaced with intravenous (IV) ampicillin, and a prednisone taper was initiated, leading to clinical and radiological improvement. IMPACT/DISCUSSION: Daptomycin-associated eosinophilic pneumonitis (DAEP) is a rare but serious complication characterized by subacute respiratory symptoms, bilateral pulmonary infiltrates, and eosinophilia. Diagnosis requires a high index of suspicion and can be confirmed by BAL showing over 25% eosinophils. Treatment involves discontinuing daptomycin and initiating corticosteroids. This case underscores the need to balance daptomycin’s benefits with its potential risks and highlights the importance of clinician awareness of this rare condition, especially as daptomycin is being utilized more frequently in clinical practice for MRSA skin and joint infections.

A high index of suspicion is required to make the diagnosis of DAEP. It should be considered in patients presenting with respiratory symptoms, eosinophilia, and new pulmonary infiltrates while on daptomycin therapy. Diagnosis is supported by bronchoscopy with BAL showing over 25% eosinophils. Prompt discontinuation of daptomycin and initiation of corticosteroids are essential for optimal recovery. BRINGING UP A SORE SUBJECT: DIABETIC MYONECROSIS AS A RARE COMPLICATION OF A COMMON DISEASE Affan M. Ahmed2; Ravi Patel1; Colin Ly1; Leslie Cler1. 1Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; 2Internal Medicine , Methodist Health System, Dallas, TX. (Control ID #4273390) CASE: We present a case of a 43-year-old male with a history of uncontrolled type-II diabetes mellitus, who was admitted with complaints of unilateral thigh and bilateral knee pain for several days. Upon admission, there were concerns of possible septic arthritis or gout affecting the knees, but joint aspiration yielded unremarkable findings. The patient's A1c was noted to be 11.4. Given the individual's pre-existing diabetic complications and the subacute presentation of anterior thigh pain in the setting of uncontrolled diabetes with swelling, an MRI was performed. This revealed patchy abnormal signals within the thigh muscles and a focal abnormal region within the rectus femoris muscle, raising clinical suspicion for myonecrosis. A muscle biopsy confirmed the clinical diagnosis, showing significant coagulative myonecrosis with scant mixed interstitial inflammation and arteriolosclerosis. The patient was started on 81 mg of aspirin daily and encouraged to refrain from strenuous activity. Additionally, the individual's insulin regimen was adjusted to improve glycemic control. IMPACT/DISCUSSION: As a rare debilitating condition, diabetic myonecrosis typically involves muscle pain and swelling, often affecting the anterior thigh, calf, or posterior thigh, and developing over days to weeks. Workup for this condition often includes ruling out other potential causes, such as septic arthritis, gout, or various myopathies. Imaging with MRI and muscle biopsy are essential for confirming the diagnosis, which shows characteristic findings of muscle necrosis with vascular occlusion. Management of diabetic myonecrosis is limited, as there are no current established guidelines. However, strict glycemic control is necessary to prevent further muscle necrosis. Long-term recommendations include low-dose aspirin and NSAIDs, although a significant proportion of patients may also have pre-existing diabetic kidney disease. Surgical intervention is not advised for this condition.

Diabetic myonecrosis, a rare and debilitating complication of diabetes, is believed to stem from arterial and capillary occlusion leading to muscle necrosis. While the number of documented cases is limited, this condition represents one of the many serious vascular complications that can arise from uncontrolled diabetes.While the presentation and management of diabetic myonecrosis are relatively understudied, this case highlights the importance of recognizing this rare complication of diabetes and the need for further research to develop evidence-based treatment strategies. BRUGADA SYNDROME: AICD AND MEDICATION REGIMEN: A CASE REPORT Kathleen Mattingly1,2; Jonathan D. Grube1,2; Marcelo Farias2,1; Tiffany Sculthorpe3; Franklin Hernandez1,2. 1Internal Medicine, University of Central Florida, Orlando, FL; 2HCA Healthcare Inc, Nashville, TN; 3VirtuaSOM Medical student, Rowan University, Glassboro, NJ. (Control ID #4270347) CASE: A 31-year-old male with a history of Brugada syndrome, diagnosed at age 18 and implanted with an automatic implantable cardioverter-defibrillator (AICD) at that time, presented to the Emergency Department with left-sided chest pain, triggering his AICD. The patient reported engaging in strenuous exertion during sexual intercourse and drinking three beers on the day of the event. He also reported starting to get a respiratory infection and was currently taking cold medicine to relieved remaining symptoms. An electrocardiogram (EKG) showed a classical Type 1 Brugada pattern, and AICD interrogation revealed ventricular tachycardia/flutter, which triggered a shock. The patient was started on quinidine (324 mg BID) to prevent VT storm, and after three days, his EKG normalized. Months later, the patient returned with chest pain again, reporting that he had discontinued quinidine due to intolerance and financial constraints, once again was noted to have the classical Brugada findings on EKG. He underwent echocardiogram and heath catheterization which revealed no abnormalities. Quinidine was restarted, and his EKG improved over several days. However, due to ongoing intolerance, the patient was switched to disopyramide (100 mg BID). He was discharged in stable condition with recommendations for continued cardiology follow-up. IMPACT/DISCUSSION: Brugada syndrome, first described in the 1990s, is a significant cause of sudden cardiac death, accounting for up to 10% of cases. Characteristic EKG findings include the "spike and dome" pattern, which occurs in the absence of structural heart disease. These abnormalities are due to repolarization heterogeneity in the right ventricular outflow tract. The condition is primarily caused by mutations in myocardial ion channel genes, especially the SCN5A gene, which encodes the sodium channel alpha subunit. Brugada syndrome is more prevalent in individuals of Asian descent and often presents with a family history of sudden cardiac death, with 25% of affected patients having a familial history. Genetic testing for family members is recommended due to the high familial correlation. Brugada syndrome has a male predominance, and studies suggest a link between testosterone levels and worse outcomes. The cornerstone of treatment is the placement of an AICD, which has proven efficacy in preventing sudden cardiac death. Anti-arrhythmic agents such as quinidine are also used to manage patients, especially those with persistent symptoms despite AICD placement. Quinidine is particularly effective in preventing arrhythmic storms, defined as three or more sustained episodes of ventricular tachycardia within 24 hours.

The management of Brugada syndrome requires a multifaceted approach, including accurate diagnosis, AICD placement, and the strategic use of anti-arrhythmic medications. Regular cardiology follow-up and EKG monitoring are essential to ensure optimal outcomes and long-term patient care in individuals with Brugada syndrome. BURNING QUESTIONS: AN UNEXPLAINED FEVER SUCCESSFULLY TREATED WITH BACLOFEN Suzanna E. Coyne1; Isna Khaliq2; Susan Lopez2. 1Rush Medical College, Rush University Rush Medical College, Chicago, IL; 2Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4272771) CASE: A 27-year-old male with sickle cell disease presented with four days of fevers (Tmax 105°F), chills, hip pain and shortness of breath. Initial vitals were unremarkable. Labs were notable for leukocytosis (WBC 10.9), chronic anemia (Hg 11), hyperbilirubinemia (Tbili4.3), mild transaminitis (AST 96), and evidence of active hemolysis. Acute chest was excluded by x-ray and he was admitted for presumed sickle cell vaso-occlusive crisis. By day 3, his pain resolved but he was febrile to 104.1°F. His unexplained fevers without pain crisis symptoms required further investigation. Through x-rays, ultrasounds, CT and MRI scans osteomyelitis, thrombosis and embolism were ruled out. Other sources of infection remained a possibility, but extensive testing was unrevealing. He received empiric treatments of levaquin, doxycycline and vancomycin without improvement. Due to the patient’s recent strep pharyngitis, the diagnostic criteria for rheumatic fever was considered but not met. Ultimately, after thorough evaluation for rheumatologic or infectious cause of fevers, no etiology was ever identified. Despite acetaminophen and NSAIDs, patient’s fevers, chills, diaphoresis and rigors intensified. The patient began to show signs of hemodynamic instability with tachycardia and hypotension during high fevers. His initial neutrophilic leukocytosis (76.9%) shifted to severe lymphocytic predominance (66%) with monocytosis (12%) and worsened anemia (Hg 7.3) without evidence of bleeding. Given the significant rise in cell lines and acute phase reactants, concern for an underlying hematologic etiology arose. The patient underwent bone marrow biopsy, which was unremarkable. A PET CT revealed hepatomegaly, of which workup is going. Although the CT head was negative, we considered a central cause for the fevers. We started baclofen 5 mg three times a day as empiric treatment for central fevers. After 72 hours with no improvement, we increased to 10 mg thrice daily and saw a resolution of fevers within 24 hours. The patient was discharged home where he continued taking baclofen, with no reported breakthrough fevers. IMPACT/DISCUSSION: Central fever is a diagnosis of exclusion, classically seen in severe neurotrauma. Our patient’s confounding hemolysis, unexplained transaminitis, leukocytosis and the absence of trauma are atypical for central fever. However, given his persistent clinical symptoms resistant to antipyretics and risk of hemodynamic instability, empiric therapy for central fevers was appropriate. We chose baclofen, which inhibits excitatory glutamate release by binding GABA-B receptors in the brain, for its favorable side effect profile compared to propranolol and bromocriptine.

● Extensive testing may not identify a cause of fevers ● Severe fevers that are symptomatic and hemodynamically compromising should be worked up and treated ● Consider central fever treatments in atypical cases refractory to antipyretics CAMPED OUT IN THE ABDOMEN Joanna Krupp, Grace Y. Zhang, Bradley A. Sharpe. Medicine, UCSF, San Francisco, CA. (Control ID #4272898) CASE: A 52-year-old woman with a history of metastatic duodenal gastrointestinal stromal tumor (GIST) status post Whipple (2019) and hepatectomy (2022) and chronic hepatitis B presented with several days of epigastric pain, nausea, and diarrhea. She was on imatinib and entecavir. She began to have non-bloody diarrhea four days prior to presentation with associated anorexia. She subsequently developed progressive epigastric pain and nausea. On admission, she had epigastric tenderness, her lipase was > 1200 U/L, and a computed tomography (CT) scan of the abdomen showed pancreatic tail fat stranding consistent with acute pancreatitis. Regarding the etiology of her pancreatitis, her liver function tests and lipid panel were normal. CT of the abdomen showed no gallstones, pancreaticojejunal anastomotic strictures, or new metastatic lesions. She did not use alcohol and took no medications that cause pancreatitis. Stool PCR, which was sent because of the diarrhea, was positive for Campylobacter jejuni. She was treated with pain control, intravenous fluids, and azithromycin with resolution of her abdominal pain within 24 hours. Given her otherwise negative workup, her acute pancreatitis was presumed to be caused by C. jejuni gastroenteritis. IMPACT/DISCUSSION: General internists frequently care for patients with acute pancreatitis and seek to determine the underlying etiology. Gallstones and alcohol are the most common causes. Infections are a rare cause of acute pancreatitis, accounting for less than 5% of cases. Viruses are the most common infectious cause (e.g. hepatitis viruses, coxsackie). Salmonella spp. and leptospirosis are the most commonly implicated bacteria. Review of the literature reveals 20 reported cases to date of C. jejuni gastroenteritis with co-occurring pancreatitis. In a study of 188 patients with C jejuni enteritis, 6% developed pancreatitis. This typically presents with fever, nausea, vomiting, abdominal pain, and diarrhea. Campylobacter-associated pancreatitis has been successfully managed with supportive care and symptom management. Severe cases of C jejuni enteritis or those at risk of severe disease (ie. immunocompromised) can be treated with antibiotics, though the impact of antibiotics is unknown. Suggested mechanisms by which Campylobacter, an enteroinvasive pathogen, causes pancreatitis include direct biliary, lymphatic, or hematogenous invasion, or obstruction of the ampulla of Vater by local inflammation. Alternatively, pancreatitis may an immune phenomenon similar to the reactive arthritis associated with Campylobacter.

Infectious gastroenteritis as a trigger for acute pancreatitis should be considered in patients presenting with pancreatitis and an acute diarrheal illness. Campylobacter jejuni is a rare but recognized cause. Though typically managed with supportive care alone, antibiotics should be considered in patients presenting with severe disease or immunocompromise. CANCER GOT MY WORLD SPINNING Palak Grover1; Bipneet Singh1; Gurleen Kaur2; Muhammad R. Malik1; Devin Malik1. 1Internal Medicine, Henry Ford Allegiance Health, Jackson, MI; 2IM, Government Medical College Amritsar, Amritsar, Punjab, India. (Control ID #4268725) CASE: 61 year old male with recently diagnosed peritoneal carcinomatosis presented with dizziness, vertigo and nausea. On admission CT and MRI head were non remarkable. On physical examination, the patient had conjugate vertical gaze palsy. This was followed by a battery of tests including vitamin B-12, thiamine, copper, and finally a lumbar puncture all of which were non remarkable. Prior to the hospitalisation patient had undergone a biopsy for peritoneal carcinomatosis which resulted negative for CK20, CDX2, S100, P40, TTF1, PSA, NKX 3.1, MOC 31, NKX3.1, Ber-Ep4, With more common pathologies ruled out, HemOnc team requested a more robust panel for staining which ultimately yielded positivity for Pancytokeratin AE1/AE3, CK7, calretinin, CK5/6, WT1, D2-40, hence confirming the diagnosis of peritoneal mesothelioma with epitheoid features. A carboplatin based paliative chemotherapy was discussed but patient's major concern remained the initial presenting symptoms. Then paraneoplastic panel was run on the cerebrospinal fluid. His anti-Ma2 antibodies were positive indicating a paraneoplastic syndrome as the cause of the vertical gaze palsy. So prior to his chemotherapy, a treatment with IVIG was initiated for paraneoplatic cerebellar symptoms. IMPACT/DISCUSSION: Paraneoplastic neurologic syndromes are immune mediated symptoms which could affect any part of the nervous system. Symptoms include encephalitis, myelitis, subacute cerebellar degeneration, myasthenia gravis or lambert eaton syndrome etc. Currently, the most widely used definite diagnostic criteria includes a classical syndrome and cancer developing within 5 years of a neurological disorder’s diagnosis or non-classical syndrome resolving or significantly improving after cancer treatment or a non-classical syndrome with onconeural antibodies and cancer developing within 5 years of a neurological disorder’s diagnosis or a neurological syndrome with well-characterized onconeural antibodies and no cancer. Anti-Ma2 antibody are notorius for involving the CNS. It is more common in men with germ cell tumors but varied association and diverse symptoms have been reported. In a small study on hispanic poulation, isolated cerebellar symptoms were seen but absence of MRI evidence of the same was unlikely. Moreover presence of such antibodies with mesothelioma has only been reported once in literature. In general, anti-Ma2 antibody-positive PNS is subacute, if untreated turns irreversible and can be expected to improve by approximately 30% after tumor removal and immunosuppressive therapy. IVIG, corticosteroid and even plasma exchange play a key role if initiated early.

- Peritoneal mesothelioma is rare, association with Anti Ma antibodies even though rarer, likely occurs in paucity of diagnosed cases. Hence any patient with the diagnosis and neurological symptoms should be worked up for paraneoplastic syndrome. - Early initiation of treatment with IVIG can prevent the disease from being irreversible CAN WE RULE OUT SEPTIC ARTHRITIS IN NATIVE HIPS WITH “DRY” FINDINGS ON IMAGING AND ARTHROCENTESIS? Xiaomei Meng. Hospital Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4272624) CASE: A 69-year-old male with chronic hips osteoarthritis (OA) was presented to the ED with worsening hip pain, after he slipped and fell on his buttocks and back 3 weeks ago. CT showed severe lumbar spinal stenosis and severe OA in both hips without effusion. ESR was 22mm/hr, CRP at 181mg/L (normal range <20), normal WBC and Lactate at 4.4 which was back to normal level quickly without intervene. All other labs were unremarkable, and he was admitted for pain control. His condition remained well and afebrile until 4 days later, when he became lethargic with WBC at 20K/μL, lactate at 2.9mmol/L, total bilirubin at 5.7mg/dL, Creatinine up to 2.1mg/dl, CRP significantly increased to 404mg/L, and ESR at 50mm/hr. CT head/chest/abdomen and MRI hips were both unremarkable except severe OA in both hips. Urgent bilateral hips aspiration turns out to be dry tap, which requires saline injected into the joints for sample obtain which culture showed Streptococcus dysgalactiae. Surgery took him for hip irrigation and debridement and found “very scant amount of purulence upon entering the joint capsule”. Hospitalization was complicated with respiratory failure requiring intubation, renal failure requiring hemodialysis, Psoas hematoma, and persistent encephalopathy slowly improving. His ambulatory function and mentation slowly improved 2 weeks after surgery. IMPACT/DISCUSSION: This report describes an unusual presentation with painful hips without signs of joint effusion on physical exam, CT, MRI, and “dry tap” on joint aspiration, as well as a normal WBC count and being afebrile. All the above makes diagnosis of septic arthritis least likely. The only unexplainable work-up is severely elevated CRP, which made his initial admission VS discharge debatable. Septic arthritis has been considered as an urgent surgical indication to avoid permanent damage and disability. Sometimes it is hard to tell infection based on clinical findings; so, imaging looking for joint effusion, or other signs of infection have been used frequently to screen patients for joint aspiration. A “dry” joint in a native hip usually rules out septic arthritis in practice. Recently, a 10 year retrospective study including 215 patients with dry-tap hip aspiration showed that most patients with native hip who underwent joint aspiration with a dry tap were not infected. Both ESR and CRP being normal can rule out septic arthritis.

“Dry” septic arthritis in native hips is rare and not as well-known as in Periprosthetic hips. If septic arthritis of the native hips is suspected clinically, even if there is no evidence of joint effusion clinically or on imaging (CT, MRI) or aspiration, significant elevated CRP and ESR are indicators supporting septic arthritis. If both CRP and ESR are negative, it may help to rule out Septic arthritis. CAN’T CATCH A BREATH: RESPIRATORY DEPRESSION WITH RESPIRATORY ALKALOSIS IN CIRRHOSIS Preksha Kukreja1; Ronnye Rutledge2. 1Medicine, Emory University, Atlanta, GA; 2Internal Medicine, Emory University, Atlanta, GA. (Control ID #4242068) CASE: A 49-year-old female with a history of decompensated cirrhosis presented to the ED for right upper quadrant abdominal pain and was found to have choledocholithiasis on ultrasound. Cholecystectomy was unfavorable given her MELD Na score of 22. Instead, ERCP was pursued with sphincterotomy and placement of a pancreatic pigtail stent . Following the ERCP, the patient continued to endorse worsening abdominal pain, coffee ground emesis, melena and developed a direct hyperbilirubinemia to 5.3 mg/dL On post-procedure day 4, she began to display mild confusion and asterixis concerning for hepatic encephalopathy. Her course was further complicated by unexplained episodes of bradypnea to 10 breaths/min. ABG revealed a of pH 7.53, pCO2 21 mm Hg, bicarbonate 21 mEq/L and pO2 116 mm Hg, consistent with respiratory alkalosis (with potential concurrent metabolic alkalosis) and inappropriate compensation. Given worsening mental status, patient was transferred to the ICU for respiratory monitoring. The cause of her bradypnea was never determined though there was some concern that intermittent use of IV opioids for pain control during her hospital stay may have contributed to her state. However, this was dismissed when she continued to remain bradypneic despite discontinuation of IV opioids. IMPACT/DISCUSSION: Respiratory alkalosis is the most well-established acid-base disorder in liver dysfunction, one that is traditionally accompanied by normal or increased respiratory rate. Patients with liver failure often have decreased lung compliance, indicating restrictive patterns due to increased intra-abdominal pressure caused by ascites. Furthermore, dynamic airway collapse has also been noted, contributing to arterial hypoxemia. These findings support development of dyspnea, leading to compensatory hyperventilation in these patients. Another theory posits that hyperammonemia in hepatic encephalopathy may directly activate respiratory centers in the brain, leading to hyperventilation. Lastly, a correlation has also been established between elevated estrogen and progesterone levels (from impaired hepatic metabolism) and increased ventilatory rate. However, the bradypnea that this patient developed did not lead to hypercapnia, likely due to the effect of the primary respiratory process of hyperammonemia. This case demonstrates that even with respiratory rate suppression, patients with liver failure can increase their tidal volumes to develop profound pH derangements.

In conclusion, metabolic and respiratory abnormalities in cirrhosis can be driven by multifactorial causes, all of which have not been well elucidated. Ultimately, it is imperative to consider pH derangements independent of respiratory status when assessing for acid-base disorders. CARBAMAZEPINE INDUCED DRESS AND DILI: A RARE CASE Alice Treuth, Taylor E. Smith. School of Medicine, Emory University, Atlanta, GA. (Control ID #4270400) CASE: We describe a 26 year-old female with history of trigeminal neuralgia who presented to the emergency department with three days of nausea and a diffuse erythematous rash in the setting of increased carbamazepine use. For relief of uncontrolled facial pain, the patient increased her dose of carbamazepine from 300 BID to 900mg BID for three days. On day three of this regimen, she began to have nausea, shortness of breath and new onset chest pain; at this time, she returned to her 600mg carbamazepine daily dose. Four days later, she presented to the emergency department with a maculopapular erythematous rash. On exam, she was afebrile, normotensive and had a blanching rash on the trunk and bilateral upper/lower extremities, without scleral icterus or neurologic deficits. She was found to have an AST of 392, ALT of 515, ALP of 158 as well as eosinophilia. She was subsequently diagnosed with Drug Induced Liver Injury (DILI) and Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). The patient’s condition was managed with fluids, systemic steroids, and cessation of carbamazepine. Upon discharge, the patient was started on an extended course of corticosteroids, with close follow up with dermatology and neurology for a new regimen for her trigeminal neuralgia. IMPACT/DISCUSSION: To our knowledge, no previous case studies in the literature have demonstrated simultaneous DRESS Syndrome and DILI presentations in a patient using carbamazepine, and studies on combined DRESS Syndrome and DILI are sparse. Carbamazepine has been clearly linked to DRESS Syndrome and DILI independently; carbamazepine has also been associated with combined DRESS-DILI in a retrospective review study, though no case reports have been outlined in detail. The insight gleaned from this case may help reduce future presentations of DRESS-DILI due to anti-convulsant overuse. Patients must be educated on the risks of carbamazepine, including the risks of supratherapeutic levels. In patients taking carbamazepine for trigeminal neuralgia, such as in this case, education also must include that increasing carbamazepine dose will not lead to an increase in pain control. Furthermore, the approach of self-management could have reduced this patient’s risk for this life-threatening condition; especially in cases of chronic conditions, patient education should include teaching on self-management of medications. This case stresses the importance of adequate patient education, outlines appropriate treatment algorithms as well as reiterates the fatal side effect profile of anti-convulsant medications.

Combined DRESS-DILI is a rare but life-threatening side effect of carbamazepine. Adequate patient education is essential prior to starting patients on medications with severely adverse risk profiles. CARCINOMA OF UNKNOWN PRIMARY, AN ANTIQUATED DIAGNOSIS Linda Youn1; Amber Kuta3,2. 1Internal Medicine, St. Bernards Hospital, Jonesboro, AR; 2Internal Medicine Residency Program, St Bernard's Medical Center, Jonesboro, AR; 3hospice and palliative medicine, University of Texas at Tyler, Tyler, TX. (Control ID #4269715) CASE: 62 year old male with history of Guillian-Barre who presented with gastrointestinal bleed and unintended weight loss. CT abdomen/pelvis showed nonspecific retroperitoneal lymphadenopathy and biopsy of an aortocaval lymph node showed poorly differentiated carcinoma. Extensive work-up including an EGD and colonoscopy were negative. MRI showed right-sided prostate mass, however, immunostaining was negative for PSA. Additionally, PET/CT showed adenopathy around the diaphragm and multiple sites of bony metastasis not seen on bone scan. Beta-hCG and AFP were also negative. Work-up for plasma cell dyscrasia was also negative. Patient was initially started on treatment with carboplatin and paclitaxel for carcinoma of unknown primary. However, molecular testing resulted with a genomic probability score of 98% probability of renal cell carcinoma. PD-L1 was also highly expressed, however, history of guillain-barre syndrome precluded the patient from receiving nivolumab. Patient was started on cabozantinib. IMPACT/DISCUSSION: Carcinoma of unknown primary (CUP) is a rare diagnosis in which malignant cells have metastasized but the primary location cannot be determined. CUP accounts for 2% of all invasive cancers. CUP is the fourth most common cause of cancer death. Median survival time is 4.5 months. After diagnosis of CUP, patients are classified pathologically into adenocarcinoma, squamous cell carcinoma, neuroendocrine carcinoma, and poorly differentiated tumors. Treatment for metastatic carcinomas are based on the primary site. However, by definition CUP has unknown primary thus, standard treatment has been empiric chemotherapy and diagnosis of CUP has had poor prognosis. In recent years, immunohistochemical staining (IHC) and molecular cancer classifier assays (MCCAs) have improved evaluation of CUP and can help predict tissue of origin in absence of an anatomic primary site. Site specific treatment has been made possible due to improved accuracy in predicting tissue of origin. Currently targeted therapies are strongly recommended when a genetic alteration has a strongly associated primary and is considered standard of care. Also, high expression of PD-L1 in CUP is associated with better response rate and longer survival in patients who received nivolumab monotherapy.

Further clinical investigation is needed to elucidate the impact on outcomes of molecular testing driven management of CUP patients. Eventually with improved understanding in utilization of molecular testing in cancer diagnosis and treatment, CUP may become obsolete. CARDIAC ANGIOSARCOMA: AN ABRUPT DEMISE Meghan Stevenson. Internal Medicine Residency Program, St. Bernards Medical Center, Jonesboro, AR. (Control ID #4271547) CASE: We present the case of a 47-year-old African American male with no known cardiac or oncologic history who was evaluated for a pericardial effusion. Presenting symptoms included chest pain, dyspnea, and abdominal pain. Initial imaging included a transthoracic echocardiogram (TTE) which identified a small circumferential pericardial effusion with maximum pericardial separation of 1.3 cm, as well as early tamponade. The ejection fraction (EF) was noted to be 55-60% with no wall motion abnormalities. The patient subsequently underwent pericardiocentesis and follow up imaging showed a small pericardial effusion without evidence of cardiac tamponade. Shortly after he developed a pleural effusion which required a thoracentesis. The patient tolerated all interventions adequately and he was eventually discharged home. Nearly four months later he returned with complaints of hemoptysis, chest pain, and dyspnea. A repeat TTE identified a solid mass within the right atrium which measured 2.5 cm x 1.4 cm. The mass was adherent to the lateral wall of the atrium near the annulus of the tricuspid valve. An abdomen and pelvis computed tomography was obtained and showed a large mass involving the right atrium and right lung in addition to lesions in the liver and spleen. A biopsy of a liver lesion revealed neoplastic cells that had expression of vimentin, dim expression of CD31and strong expression of CD34. These findings were consistent with cardiac angiosarcoma. Unfortunately, surgical excision of the mass was deemed unfeasible due to the extensive involvement of surrounding structures. The patient declined chemotherapy and his condition continued to decline until he eventually expired. IMPACT/DISCUSSION: Cardiac angiosarcomas are primary cardiac tumors known for their aggressive nature. The most common presenting symptom is dyspnea which can be attributed to blood flow obstruction in the heart. Additional presentations include pericardial effusion and cardiac tamponade, both of which were seen in this case. Initial imaging did not show any evidence of a tumor. In less than four months the patient returned with worsening symptoms and was ultimately diagnosed with a cardiac angiosarcoma with widespread metastasis. While ideal treatment is surgical removal of the tumor, it is limited by factors such as degree of surrounding infiltration and overall size. In this case the angiosarcoma progressed too rapidly and the mass was unable to be excised.

The diagnosis of cardiac angiosarcomas can be elusive. Although there was no evidence of tumor on initial imaging, a thorough workup was appropriate to determine the etiology of the patient’s cardiac tamponade. While it is unknown whether closer follow up would have yielded a different outcome, it remains crucial to investigate seemingly idiopathic pathologies. Early detection of underlying malignancy is vital to improve patient outcomes. CARDIAC IMPLICATIONS OF SUSPECTED PARATHYROID HYPERPLASIA- BRADYCARDIA IN PRIMARY HYPERPARATHYROIDISM Arie Szeinfeld, Yarden O. Goldman Gollan, Muhammad Rehan, Yoanna Benitez, Anthony M. Perez Santos. Internal Medicine, HCA Florida JFK Hospital, Atlantis, FL. (Control ID #4272674) CASE: Primary hyperparathyroidism (PHPT) has been associated with several non-specific musculoskeletal, genitourinary, and gastrointestinal manifestations including weakness, renal stones, constipation and others. Cardiac manifestations of PHPT, however, are not well documented. We present a rare case of symptomatic bradycardia due to hypercalcemia secondary to PHPT in the setting of suspected parathyroid hyperplasia. 24-year-old male with a history of schizophrenia, depression and polysubstance abuse presented after a near-syncopal episode from a drug rehabilitation facility, where he was admitted for fentanyl use. He reported sudden onset lightheadedness without loss of consciousness. He admitted to decreased oral intake for the past few days and working outside in the hot sun. Upon presentation, heart rate was 30-35 beats per minute and blood pressure was 117/60 mmHg. Initial workup revealed a serum calcium level of 12.9. He was treated with IV normal saline without improvement. Calcium levels rebounded as high as 13.4. Further workup revealed a parathyroid hormone level of 325.8 pg/mL (normal range 10-66pg/mL). Thyroid ultrasound revealed several small hypoechoic lesions, some as large as 2x2 cm in the right lobe. Nuclear medicine sestamibi scan demonstrated no scintigraphic evidence of parathyroid adenoma, but was unable to rule out diffuse hyperplasia. Parathyroidectomy was recommended but patient deferred surgical interventions and opted for medical management. He was treated with calcitonin and cinacalcet with dose optimization. Blood calcium levels and heart rate improved significantly and the patient was discharged with close outpatient follow-up. IMPACT/DISCUSSION: Common presenting symptoms of hypercalcemia classically include polydipsia, polyuria, nocturia, nausea, abdominal pain, constipation, mental status changes, and nephrolithiasis. Bradycardia is an even rarer presentation of PHPT with a mechanism that is not fully understood, but may be secondary to sinus node dysfunction or calcification of the sinus node. PHPT is the third most common endocrine disorder after diabetes and thyroid disorders. In this patient, no parathyroid adenoma was identified on nuclear medicine sestamibi scan. Parathyroid solitary adenoma is responsible for 80-85% of PHPT, while diffuse parathyroid hyperplasia, suspected in this case, accounts for 15-20%. PHPT is most commonly diagnosed asymptomatically on routine lab screenings. Parathyroidectomy is the definitive treatment. On further chart review, this patient’s calcium had been asymptomatically elevated on his previous ED visit in 2021 at 10.8. Due to the mild nature of his hypercalcemia and patient’s desire to return home at that time, further workup was not pursued.

This case demonstrates a rare presentation of bradycardia secondary to PHPT in the setting of suspected parathyroid hyperplasia and underscores the importance of working up electrolyte deficiencies with a broad differential and close follow-up. CARDIAC TAMPONADE: TB OR NOT TB, THAT IS THE QUESTION Barbara C. Okeke1; Ciri Chandana Pocha1; Lanerica Rogers1; Amber Stefanski1; Chien-Jung Lin2,1. 1Internal Medicine, St. Louis University Hospital, St. Louis, MO; 2Cardiology, St. Louis University Hospital, St. Louis, MO. (Control ID #4271784) CASE: Cardiac tamponade (CT) is caused by various etiologies including trauma, infection, autoimmune, cardiac, toxic, and malignancy. CT caused by multiple concurrent infectious causes is rare. A 40-year-old man who immigrated from India with no medical history, presented with progressive shortness of breath, night sweats, intermittent fevers, weight loss over a 3-month period, and a cough. On presentation, patient was diaphoretic with a respiratory rate of 40 breaths/min and heart rate up to 115 beats/min. A computed tomography chest pulmonary embolus scan showed no pulmonary embolus but demonstrated a large right pleural effusion, moderate pericardial effusion, a right lower lobe lung nodule, nodular peritoneal thickening and infiltration of the omentum, necrotic retroperitoneal lymphadenopathy, and pathologic mediastinal lymphadenopathy. Pleural effusion analysis showed lymphocytic predominance with pH 7.57, total cell counts 1079 with 17% neutrophils, 55% lymphocytes, glucose 75 mg/dL, lactate dehydrogenase 634 u/L, protein 4.4g/dL, red blood cells 12x106 per liter, and elevated adenosine deaminase at 48 U/L. Subsequent, pleural biopsy revealed necrotizing granulomas. Given presentation, an extensive Tuberculosis (TB) workup was done but initially unremarkable. Subsequent cancer workup for a primary malignancy was also unrevealing. Though the QuantiFERON-gold test and initial sputum cultures were negative, the clinical suspicion of TB remained, prompting a consult to Infection Diseases for culture-negative TB. Following this, the patient began to deteriorate, becoming febrile up to 102.3 F, tachycardic to the 160s beats/min, and was in acute respiratory distress. While an initial echocardiogram showed no signs of tamponade physiology, a repeat ordered as respiratory status worsened showed partial right sided chamber collapse and significant respiratory variation in ventricular filling. IMPACT/DISCUSSION: Pericardiocentesis was completed along with right heart catheterization that showed near equalization of intracardiac pressures. Pericardial effusion was hemorrhagic and lymphocytic predominant and with the current negative TB workup, we expanded the differential for other infectious causes. Ultimately, tularensis IgM serologies were positive and subsequent MTB-PCR came back positive 6 weeks after initial admission.

While management of this patient’s pericardial effusion and CT were appropriate, this patient underwent extensive workup for various etiologies due to anchoring. Although tularemia is an extremely rare cause of pericardial effusion, the presence of necrotizing granulomas on histopathology in this patient was highly specific. While Tularemia in the setting of immunodepression has been identified as a cause for pericardial effusions, there is no current literature of a Tularemia and Tuberculosis co-infection causing CT. This case highlights the importance of expanding a differential diagnosis especially when a delay in management can be consequential. CARDIOVERSION-INDUCED CARDIOGENIC SHOCK IN ATRIAL FIBRILLATION WITH HFREF: A CASE REPORT Sameer Lohana1; Mohammad Hazique1; FNU Kalpana2; Kamran Haleem3. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 3Cardiology, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4245731) CASE: A 49-year-old male with Heart Failure with reduced ejection fraction (EF <30%) and a history of atrial fibrillation with rapid ventricular response who developed cardiogenic shock following synchronized electrical cardioversion (ECV). The patient had a history of mechanical mitral valve replacement, and a cardiac resynchronization therapy-defibrillator (CRT-D) implantation. He presented with worsening fatigue, palpitations, and hypotension. Initial management with IV amiodarone failed to control his ventricular rate. ECV successfully restored sinus rhythm but was followed by rapid clinical deterioration, including hemodynamic instability, anuria, and cold extremities. Bedside echocardiography revealed severe diminished cardiac wall movement. Despite aggressive interventions, including vasopressors, inotropes, and consideration of mechanical circulatory support, the patient succumbed to refractory cardiogenic shock and ventricular fibrillation arrest. IMPACT/DISCUSSION: This case highlights the complexities of rhythm management in patients with heart failure with reduced ejection fraction (HFrEF). While ECV is an essential rhythm control strategy in atrial fibrillation, its use in this patient highlights the risks of myocardial stunning and cardiogenic shock, particularly in those with impaired left ventricular function and other high-risk factors, including mechanical valves, prolonged QT interval, and supratherapeutic anticoagulation. The transient reduction in myocardial contractility post-cardioversion, known as myocardial stunning, may have precipitated rapid hemodynamic compromise in this vulnerable patient. Several key risk factors contributed to this outcome: Severe LV Dysfunction: Severely reduced Ejection fraction is associated with poor tolerance to hemodynamic stress, increasing susceptibility to adverse outcomes post-cardioversion. AF-RVR: The elevated heart rate likely exacerbated myocardial oxygen demand and worsened LV remodeling, further impairing cardiac reserve. Prolonged QTc: Increased vulnerability to ventricular arrhythmias during and after ECV. Mechanical Valves: Complex anticoagulation management added bleeding risk while increasing procedural challenges. This case highlights the importance of pre-procedural stabilization, including rate control and optimization of anticoagulation, to minimize risks associated with cardioversion. Alternative strategies, such as catheter ablation or the early use of mechanical circulatory support, may offer safer outcomes for high-risk patients.

Cardioversion-induced cardiogenic shock is a rare but severe complication in patients with advanced HFrEF. This case emphasizes the critical need for individualized management approaches to balance the benefits of rhythm control against potential hemodynamic instability. Enhanced pre-procedural planning, early recognition of high-risk features, and alternative rhythm management strategies are essential to optimize outcomes in this vulnerable population. CASE PRESENTATION AND MANAGEMENT OF PORTAL CAVERNOMA CHOLANGIOPATHY Bradley Karmo2; Sophia V. Gandarillas1; chris matti1; Abigail Entz2. 1MD, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4254193) CASE: A 32-year-old female presented with acute, projectile hematemesis, melena, and sharp right upper quadrant abdominal pain (9/10). She had no prior medical history aside from menorrhagia and oligomenorrhea, and denied smoking, alcohol, or drug use. Lab results showed AST 29, ALT 21, alkaline phosphatase 60, hemoglobin 9.4, PT 23.7, and INR 2.13. An EGD revealed multiple grade 3-4 varices which were banded. CT imaging showed severe dilation of intrahepatic biliary ducts, massive splenomegaly,, extensive portal vein (PV) thrombosis, and an enhancing mass-like structure circumferentially surrounding the common hepatic duct. Findings were suspicious for portal cavernoma cholangiopathy (PCC). Laparoscopy confirmed splenomegaly, 1L ascites, and a cystic mass around the common bile duct. Splenic angiography demonstrated a splenic artery aneurysm, which was treated with coil embolization. Hypercoagulable workup indicated a JAK2 mutation, decreased protein C and S, elevated cardiolipin antibodies, and decreased antithrombin III activity, indicating a complex hypercoagulable state and potential antiphospholipid syndrome. IMPACT/DISCUSSION: Portal Cavernoma Cholangiopathy (PCC) results from chronic portal vein thrombosis (PVT), leading to the formation of collateral veins, which compress surrounding structures, causing biliary or hepatic duct compression. PCC may lead to complications like liver fibrosis or secondary biliary cirrhosis, causing liver failure if left untreated. The patient presented with gastrointestinal bleeding due to portal hypertension, highlighting the latent nature of PVT. The patient's hypercoagulable state was due to a combination of genetic (JAK2 mutation), acquired, and autoimmune factors, leading to an increased thrombosis risk. First-line treatment for PVT is anticoagulation with unfractionated or low molecular weight heparin to improve vessel patency and reduce disease progression. Despite the initial bleeding risk, long-term anticoagulation outweighs the short-term risks, and treatment may be transitioned to oral anticoagulants. Variceal bleeding may be managed with non-selective beta blockers or variceal ligation. Splenic artery embolization (SAE) was performed to reduce portal hypertension, splenomegaly, and variceal bleeding risk. Early identification and management of the hypercoagulable state could have prevented PVT and its complications.

Early Recognition of Hypercoagulable States: Unexplained thrombosis in atypical sites should prompt evaluation for underlying hypercoagulable conditions to prevent severe complications like PCC. Balance of Anticoagulation: In patients with both thrombosis and bleeding, anticoagulation decisions must weigh risks and benefits. Long-term anticoagulation is crucial despite initial bleeding risks. Multidisciplinary Approach: Effective management of portalhypertension requires a combination of interventions. Collaboration across specialties is key to optimizing outcomes in complex conditions like PCC. CASE REPORT: 58-YEAR-OLD FEMALE WITH SPLENIC INFARCTION AND HEMATOMA SECONDARY TO NEWLY-DIAGNOSED JAK2 V617F-POSITIVE POLYCYTHEMIA VERA. Khadyoth S. Nanneboyina1; Luming Chen2; Alan Tran3; Keshav Poddar1. 1Internal Medicine, Methodist Health System, Dallas, TX; 2Anesthesiology, The University of Texas Southwestern Medical Center, Dallas, TX; 3The University of Texas Southwestern Medical Center Medical School, Dallas, TX. (Control ID #4269529) CASE: A 58-year-old female with PMH of HTN and prior pancreatitis presented with left-sided abdominal pain. Initial workup was significant for WBC 25.6 (x10^3/uL), Hgb 19.6 g/dL, platelets 407 (x10^3/uL), neutrophils 85.7%, and lymphocytes 7%. CT imaging showed splenic lesions suggestive of evolving hematomas or infarcts. Further evaluation for persistent erythrocytosis showed a positive JAK2 V617F mutation and subnormal erythropoietin level consistent with polycythemia vera (PV). The patient was classified as high-risk given the presence of thrombotic complications and started on daily low-dose aspirin and hydroxyurea. She was also scheduled for outpatient therapeutic phlebotomy to maintain hematocrit <45%. Anticoagulation was deferred due to the presence of evolving hematomas on imaging. Pegylated interferon-α (peg-IFNα) was also deferred due to the patient’s low potential for pregnancy. IMPACT/DISCUSSION: PV is a chronic myeloproliferative neoplasm characterized by the proliferation of mature myeloid cells. It is associated with Janus kinase-2 (JAK2) oncogene mutation resulting in unregulated proliferation of red blood cells. Manifestation of PV are primarily due to hyperviscosity of the blood from increased red blood cell mass. The most common symptoms include headaches, vision changes, pruritis (classically called “aquagenic” pruritis), erythromelalgia, splenic discomfort, splenomegaly, arterial/venous clots, and bleeding. Complications include progression of disease (post-PV myelofibrosis, myelodysplastic neoplasms, acute myeloid leukemia), bleeding, and thrombotic events. Thrombotic complications are the leading cause of death in PV. In all patients with PV, the mainstay of treatment involves reduction of RBC mass through phlebotomy, aspirin, and/or cytoreductive therapy. First-line cytoreductive therapies include hydroxyurea and peg-IFNα. Second-line therapies for hydroxyurea-resistant/-intolerant patients include ruxolitinib (JAK1/2 inhibitor) and busulfan (alkylating agent). The RESPONSE/RESPONSE-2 and MAJIC-PV trials demonstrated that ruxolitinib was superior in controlling hematocrit, decreasing spleen volume, and symptom control in hydroxyurea-resistant/-intolerant PV patient. Busulfan is typically given in older patients (> 60 years) who do not respond appropriately to hydroxyurea and peg-IFNα; however, it is not used often due to various adverse effects. Concerns about the leukemogenic effects of busulfan have also been raised but evidence is evolving. Several new medications are being investigated as potential future treatments for PV including rusfertide (hepcidin mimetic), idasanutlin (MDM2 antagonist), and givinostat (histone deacytelase inhibitor).

1. The mainstay of PV treatment is phlebotomy, aspirin, and/or cytoreductive therapy. 2. First-line cytoreductive therapies are hydroxyurea and peg-IFNα. Second-line therapies are ruxolitinib and busulfan. 3. New medications currently being investigated including rusfertide, idasanutlin, and givinostat. CASE REPORT OF SUSPECTED PROZONE PHENOMENON IN A PATIENT WITH MALIGNANT SYPHILIS Sydney Roston, Justin Carrington, John Roth, Reid P. Schlesinger, Nathaniel E. Davis, Omar Abu Saleh. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4269887) CASE: A 31-year-old male with untreated HIV, diagnosed a year prior, presented with a 2-month history of non-healing ulcers on his face and shoulder, bilateral palmar erythema, body aches, bilateral shin pain, fatigue, and fevers. CD4 count was 385 cells/μL and HIV RNA viral load was 255,000 copies/mL. The differential diagnosis for his skin lesions and constitutional symptoms included infectious and non-infectious etiologies. Serum studies and lesion swabs excluded endemic mycoses, bartonella, cryptococcus, Coccidioides, tick-borne illnesses, syphilis, extrapulmonary tuberculosis, HSV, VZV, and monkeypox. Initial syphilis testing, including rapid plasma reagin (RPR) and IgG titer, was negative. Rheumatologic causes such as vasculitis and cryoglobulinemia were also excluded. Undiagnosed inflammatory bowel disease with extraintestinal manifestations was considered, however colonoscopy findings were unremarkable. Finally, the lesions were not characteristic of cutaneous T-cell lymphoma or Kaposi sarcoma in the context of untreated HIV. Repeat biopsy of the ulcers identified spirochetes, confirming secondary syphilis despite initial negative syphilis testing. A prozone reaction was suspected, and serial serum dilutions subsequently revealed a positive syphilis IgG. CSF studies ruled out neurosyphilis. The patient received 3 doses of intramuscular benzathine penicillin G for malignant syphilis (a severe form of secondary syphilis), in addition to antiretroviral therapy with bictegravir, emtricitabine, and tenofovir alafenamide and referral to an HIV clinic for multidisciplinary care. IMPACT/DISCUSSION: This case demonstrates the prozone phenomenon which occurs when laboratory positivity depends on an optimal ratio of antibody to antigen, yielding a false-negative result when one is present in excess. In this patient, serial dilution of the sample unmasked a true positive result. This is increasingly recognized in co-infections with syphilis and HIV, as B-cell hyperactivity results in overproduction of antibodies. A key takeaway is the importance of interpreting diagnostic tests within the broader clinical context and identifying scenarios that yield false-positive or false-negative results. Navigating these diagnostic complexities requires collaboration among physicians and laboratory personnel. Another critical lesson is holistic patient care, addressing both medical and psychosocial needs. Referral to the HIV clinic ensured counseling from a pharmacist, an infectious disease specialist, a social worker, and a mental health specialist. All patients with new diagnoses of HIV and other chronic illnesses should be connected to community resources for comprehensive care.

We present a case of a patient with untreated HIV diagnosed with syphilis despite initially negative serum studies. This case represents the importance of interpreting tests within the patient’s clinical context and ensuring that psychosocial resources are provided for optimal long-term outcomes. CAUGHT IN A RED AND BLUE SQUEEZE: A PLAQUE-FREE CORONARY CRISIS Zoya Khan1; SOPHIA A. VOZZA1; Jennifer Trube2; Michael Sabina1; Anas Bizanti1. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4271107) CASE: A 44-year-old female newly diagnosed with hypertension, presented with a syncopal episode with preceding diaphoresis after taking her first dose of Nifedipine. In the Emergency Department, she was found to be in atrial fibrillation with rapid ventricular response (RVR). Troponin-I was elevated at 55 ng/L. She spontaneously converted to normal sinus rhythm, and subsequently underwent a coronary computed tomography angiogram (CCTA) of the coronary arteries, which showed an anomalous right coronary artery (RCA) originating from the left cusp, compressed between the pulmonary artery and aorta, without atherosclerotic disease. Surgical consultation was sought for intervention. IMPACT/DISCUSSION: Anomalous origin of the right coronary artery (RCA) is a rare congenital condition that can lead to myocardial ischemia due to external compression, rather than obstructive coronary artery disease. The use of Nifedipine may have precipitated symptoms through a myocardial steal phenomenon, particularly if the collateral vessels were compensating for the anomalous RCA, therefore exacerbating the obstruction. Surgical correction options, including coronary artery unroofing or vessel bypass were considered due to high-grade narrowing along its inter-arterial course.

Anomalous coronary arteries can be compressed by surrounding structures and can mimic myocardial infarctions, even without the presence of atherosclerotic disease. Therefore, it should be considered in the differential for myocardial ischemia. CEFEPIME INDUCE NEUTROPENIC FEVER RARE SIDE EFFECT IN 25 YEAR OLD: A CASE REPORT. Jonathan D. Grube1,2; Kathleen Mattingly1,2; Heena Patel1,2; Mehak Sachdeva1,2. 1Internal Medicine, University of Central Florida, Orlando, FL; 2Internal Medicine, HCA Healthcare Inc, Nashville, TN. (Control ID #4270348) CASE: This report presents a rare case of cefepime-induced neutropenic fever in a 25-year-old male with a history of frontal lobe arteriovenous malformation (AVM), status post surgical resection, and meningitis. The patient had no prior hematologic abnormalities. His previous admission was for new-onset seizures and severe headaches lasting 3 months. CT imaging revealed a left frontal lobe AVM, which was resected via craniotomy. Post-operatively, he developed leukocytosis (32,000) with associated fever. A repeat head CT showed an enlarging subgaleal fluid collection, and a lumbar puncture (LP) revealed >2000 WBCs (83% neutrophils), hypoglycorrhachia, and a gram stain showing PMNs, suspicious for meningitis. The patient underwent a second surgery for wound cultures, washout, and bone flap removal. Wound cultures grew Klebsiella, which was sensitive to cefepime. He was discharged with a plan for 6 weeks of outpatient cefepime therapy (2g q8hrs). During this admission, the patient presented with chills and a high-grade fever on day 3 of cefepime therapy, additionally was hypotensive and tachycardic which responded with fluid bolus. Laboratory tests revealed neutropenia with an absolute neutrophil count of 350, significantly lower than baseline. Infectious Disease and Neurosurgery teams were consulted for further infectious work up. After an active discussion, cefepime was replaced with meropenem. By day two of admission, the patient’s symptoms began improving. Neurosurgery removed staples from his scalp and confirmed the MRI findings were consistent with post-surgical changes. A repeat LP showed improved results compared to the prior admission, ruling out infection. The patient was stable for discharge on outpatient ertapenem 1g. IMPACT/DISCUSSION: This case highlights the potential for hematologic side effects in patients on prolonged cefepime therapy. Cefepime, a fourth-generation cephalosporin, is widely used for serious infections but can rarely cause neutropenia and subsequent neutropenic fever. The incidence of neutropenia with beta-lactam antibiotics is approximately 10% within the first two weeks of use. Neutropenic fever specifically due to cefepime is rare, with an estimated incidence of about 1%. The exact mechanism remains unclear but is believed to involve an idiosyncratic immune-mediated response that suppresses bone marrow production of neutrophils.

While cefepime is generally well-tolerated, it can, in rare cases, cause neutropenic fever. Clinicians should be vigilant for unexplained neutropenia with fever during cefepime therapy. In such cases, discontinuation of the drug and initiation of supportive care is essential to prevent severe complications. When prescribing long-term cefepime therapy, it is important to weigh the benefits against the potential risks, including the rare but serious side effect of neutropenia. CENTRAL DIABETES INSIPIDUS: AN UNCOMMON INITIAL PRESENTATION OF METASTATIC CANCER Nirja Sutaria1; Alexis LeMone2; Alena Sidwell1; Jessica L. McCutcheon3. 1Internal Medicine, Atrium Health, Charlotte, NC; 2Wake Forest University School of Medicine, Winston-Salem, NC; 3Department of Internal Medicine, Atrium Health, Charlotte, NC. (Control ID #4271764) CASE: An 81-year-old female presented with a month-long history of abdominal pain, nausea and vomiting. A CT scan revealed dilation of the common bile duct, intrahepatic bile ducts, and pancreatic ducts, without evidence of malignancy. When placed NPO for her endoscopic retrograde cholangiopancreatography with stent placement, she developed hypernatremia (serum sodium rose from 136 to 150 mEq/L) with polydipsia and polyuria. Urine osmolality was low at 87 mOsm/kg (500-850 mOsm/kg) and serum osmolality was elevated at 310 mOsm/kg (275-290 mOsm/kg). Despite unreliable urine output measurement, DI was suspected. However, due to her poor oral intake and calculated free water deficit, hypernatremia was initially attributed to dehydration. The patient received D5W, which corrected the hypernatremia. However, her serum sodium rose again to 151 mEq/L despite adequate oral intake, and she continued to experience severe thirst. Repeat urine osmolality remained low at 86 mOsm/kg. Desmopressin was administered, normalizing both serum sodium and urine osmolality, confirming central DI. Further evaluation of pituitary function revealed central hypothyroidism, for which thyroid hormone replacement was initiated. Although MRI was contraindicated due to a spinal stimulator, a head CT showed thickening of the pituitary stalk. Differential diagnoses included lymphocytic hypophysitis, metastatic disease, leukemia/lymphoma, and neurosarcoidosis. To further evaluate the cause of central DI, a PET scan was performed, revealing widespread metastatic disease, including involvement of the liver, likely accounting for the patient’s biliary symptoms. A bone biopsy confirmed adenosquamous carcinoma of mammary origin. Consultations with oncology, rheumatology, and endocrinology confirmed that the patient’s central DI and hypothyroidism were secondary to metastatic breast cancer involving the pituitary gland. IMPACT/DISCUSSION: Pituitary metastatic disease, though rare, should be considered in patients with new-onset central DI, especially in older individuals. The posterior pituitary lobe and infundibulum are more prone to metastatic involvement due to their vascular supply, with breast and lung cancers being the most common sources. Diagnosis is often associated with poor prognosis, and a comprehensive evaluation of the hypothalamic-pituitary axis is crucial. Clinicians should also be aware of "masked DI" in cases of panhypopituitarism, which can obscure the diagnosis.

- Central diabetes insipidus is a rare but challenging diagnosis with many potential causes - While uncommon, posterior pituitary metastatic disease should be considered, particularly in older patients - Early recognition and thorough workup are essential for identifying the underlying etiology and guiding appropriate management CERVICAL CANCER RECURRENCE MIMICKING A PSOAS MUSCLE ABSCESS: A CASE OF MALIGNANT PSOAS SYNDROME Kathryn Thompson1; Joo Jung2; Anna Kho1; Ashley Urrutia1. 1Medicine, Emory University School of Medicine, Atlanta, GA; 2Dermatology, Augusta University, Augusta, GA. (Control ID #4271174) CASE: A 56-year-old female with a history of stage IB cervical cancer status-post radical hysterectomy and bilateral salpingo-oophorectomy nine years prior presented with an 11-month history of lower back and right hip pain. She had a few mechanical falls that precipitated the pain, but her pain progressively worsened. On exam, she had tenderness to palpation of the right hip and thoracic/lumbar paraspinal muscles, but her neurologic exam was intact. An MRI lumbar spine/pelvis demonstrated extensive edema and a complex fluid collection in the right psoas muscle which prompted three inpatient admissions for work-up and pain management. Labs revealed negative human immunodeficiency virus antibody screen, interferon-gamma release assay, Bartonella and Brucella antibodies, Q fever antibodies, Echinococcus antibody, Histoplasma urine antigen, Blastomycoses antibody, Cryptococcal antigen, 1-3 beta-D glucan assay, and rapid plasma reagin. Fine needle aspirate (FNA) of the psoas collection yielded negative bacterial, acid-fast bacilli, fungal, and anaerobic cultures. Cytology of the psoas collection revealed metastatic squamous cell carcinoma (SCC) during her third admission. CT of the abdomen and pelvis demonstrated two ill-defined hepatic lesions, but CT of the chest and MRI of the brain did not show evidence of malignancy. A liver biopsy confirmed metastatic SCC. To identify the primary malignancy, she had a vaginal cuff Papanicolaou (Pap) smear, flexible fiberoptic endoscopy of the oropharynx, and esophagogastroduodenoscopy. All her tests returned negative and ruled out SCC other than her Pap smear which had a low-grade squamous intraepithelial lesion of the collected cells. Although her Pap smear didn’t capture malignant cells, her primary malignancy was attributed to a recurrence of cervical cancer, and she was diagnosed with malignant psoas syndrome (MPS). IMPACT/DISCUSSION: The appearance of a fluid collection with adjacent vertebral involvement on imaging was highly suggestive of a psoas abscess as the etiology of the patient’s pain. However, given cultures from an FNA were negative on three occasions, the other etiology of the psoas collection to consider was malignancy. Ultimately, cytology confirmed that diagnosis. Since there is limited literature on characteristic imaging findings of MPS, obtaining cytology of a psoas fluid collection is imperative to make the diagnosis of MPS as demonstrated in this case.

MPS is a rare form of metastatic disease to the psoas muscle that causes significant pain and can be difficult to diagnose and treat due to the advanced nature of the malignancy and invasion of the muscle. In a patient with multiple admissions for intractable pain and a psoas fluid collection, one should consider the diagnosis of MPS, especially in a patient with a history of cancer, where cytology is needed to make the diagnosis. CHALLENGES AND INCIDENCE OF APIXABAN FAILURE IN SECONDARY PREVENTION OF DEEP VEIN THROMBOSIS IN CHRONIC MYELOMONOCYTIC LEUKEMIA Dana Dhami, Christopher Solowiej Singh, Anna Schwab, Heather Murray. Internal Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4272350) CASE: This is the case of a 44-year-old female with a past medical history of pulmonary embolism 5 months prior to admission who is currently on apixaban therapy, morbid obesity, seizure disorder, and type 2 diabetes mellitus who presented with progressive dyspnea. She stated she had progressively worsening shortness of breath the night before admission. The patient also endorsed associated chest pain, palpitations, and dizziness. She stated that she had been compliant with her medications including her apixaban. The patient reported that she had not followed up with her hematologist-oncologist as she had been having difficulty arranging transportation to the clinic. She also denied any recent history of travel, and reported that she was up to date on age-appropriate cancer screenings. A CTA chest with contrast demonstrated bilateral pulmonary emboli, left greater than right, with evidence of right heart strain. Lab work demonstrated a hemoglobin of 9.3, and troponin of 1.93. Review of lab work from prior admissions revealed a prior bone marrow biopsy and next-generation sequencing with findings meeting criteria for chronic myelomonocytic leukemia, of the hypoproliferative subtype. The patient underwent mechanical thrombectomy and was ultimately discharged with coumadin due to concerns of treatment failure with apixaban. IMPACT/DISCUSSION: The incidence of treatment failure for deep vein thrombosis (DVT) in patients with malignancy receiving apixaban (Eliquis) is a critical area of study, given the unique challenges posed by cancer-associated thrombosis. Apixaban is a direct oral anticoagulant (DOAC) that is commonly used for the prevention and treatment of DVT and pulmonary embolism (PE). In the context of malignancy, patients are at a higher risk for both thrombosis and bleeding, complicating anticoagulation therapy. Studies have indicated that while DOACs, including apixaban, are effective in the general population, the treatment failure rate in cancer patients can be higher due to the hypercoagulable state induced by malignancy and its treatments. In clinical trials, apixaban has shown a lower recurrence rate of venous thromboembolism (VTE) compared to low molecular weight heparin (LMWH) in cancer patients. However, real-world data suggest that the incidence of treatment failure, defined as recurrent DVT or PE, while on apixaban can still be notable in this population. This failure rate is influenced by factors such as the type and stage of cancer, patient comorbidities, and concurrent cancer therapies. Studies have reported recurrence rates ranging from 3%-7% in cancer patients on apixaban, which underscores the need for careful patient selection and monitoring.

In summary, while apixaban is a promising anticoagulant for treating DVT in patients with malignancy, treatment failure is a concern due to the complex interplay between cancer and coagulation. Continuous research and tailored therapeutic strategies are essential to optimize outcomes in this high-risk group CHALLENGING CHEST PAIN: ACUTE CORONARY SYNDROME AND THE HIDDEN IMPACT OF ANOMALOUS CORONARY ARTERIES Satvika Nimmagadda1; Saad Ghumman2. 1Edward Via College of Osteopathic Medicine, Blacksburg, VA; 2Ballad Health CVA Heart Institute, Bristol, TN. (Control ID #4271801) CASE: A 42-year-old male with coronary artery disease and a history of prior stenting presented to the emergency department with new-onset, typical anginal chest pain radiating to the left arm. He denied associated symptoms such as shortness of breath, diaphoresis, or nausea. On presentation, he was hemodynamically stable and EKG was equivocal. However, serum troponin was elevated at 0.24 ng/mL, consistent with a Type 1 NSTEMI. Initial management included aspirin, sublingual nitroglycerin, and a heparin drip per acute coronary syndrome (ACS) protocol. Coronary angiography revealed an anomalous left circumflex artery (LCx) originating from the right coronary cusp and a 100% complete in-stent thrombosis in the obtuse marginal (OM) branch of the anomalous LCx. Percutaneous coronary intervention (PCI) was performed using an AL 0.75 guide catheter and Sion Blue guidewire. Intravascular ultrasound helped guide optimal stent placement. A 3.0 × 18 mm drug-eluting stent was deployed followed by successful revascularization. Post-dilation with a noncompliant balloon ensured proper stent expansion and integrity. The patient’s subsequent hospital course was chest pain-free and he was discharged the next day. IMPACT/DISCUSSION: This case highlights the diagnostic and therapeutic challenges associated with coronary artery anomalies (CAAs). The prevalence of CAAs is approximately 1% in the adult population, with the most common anomalies involving the origin of major epicardial coronary arteries. CAAs are often asymptomatic, but may become clinically significant in specific contexts, such as stent thrombosis or atherosclerosis. This case demonstrates the intricate interplay between anomalous coronary anatomy and stent-related complications. The left circumflex artery's origin from the right coronary cusp presented technical challenges during the intervention and altered hemodynamics, increasing shear stress and turbulence, which predisposed the patient to in-stent thrombosis. This underscores the potential for CAAs to exacerbate ischemic complications when compounded by pre-existing coronary artery disease and prior stenting. The anomalous origin also influences the distribution of myocardial perfusion, potentially creating zones of ischemia that are not aligned with conventional coronary territories. These factors require increased vigilance for recurrent ischemia and a multidisciplinary approach, combining advanced imaging, interventional techniques, and aggressive medical therapy to reduce the risk of restenosis, thrombosis, and adverse cardiac events.

Management of ACS in the setting of catastrophic in-stent thrombosis in an anomalous coronary artery requires prompt recognition, advanced imaging for identification, and tailored interventional strategies. While often incidental, CAAs can significantly impact ischemic events. Secondary prevention measures are crucial for improving long-term outcomes in patients with complex coronary anatomy. CHEMOTHORAX AND ATRIAL FIBRILLATION: MULTIDISCIPLINARY MANAGEMENT OF MISPLACED PORT-A-CATH IN A LUNG CANCER Charu Hasini Vasa, Antonio De Gorodo Arzamendi, Yasitha Kakarlapudi, Aminadab Godina Flores, Jose Bejarano. Internal Medicine, DHR Health, Edinburg, TX. (Control ID #4272523) CASE: Chemothorax caused by a misplaced Port-A-Cath is an exceedingly rare complication of chemotherapy, with limited cases reported in the oncology literature. A 79-year-old woman with primary adenocarcinoma of the right lower lobe, status post-lobectomy, presented with fever, fatigue, and respiratory symptoms during chemotherapy. Initial evaluation revealed leukocytosis (WBC: 25000/uL), anemia (hemoglobin: 6.6 g/dL), and right middle lobe pneumonia with pleural effusion. Empirical antibiotics were initiated for healthcare-associated pneumonia (HAP) and urinary tract infection (UTI). Given these findings, further diagnostic workup included thoracentesis, which removed 1,400 mL of milky pleural fluid. Fluid analysis revealed triglycerides of 392 mg/dL, giving an impression of chylothorax. Further fluoroscopic imaging subsequently demonstrated extravasation of contrast into the pleural cavity from a misplaced Port-A-Cath, presumed to have caused chemothorax during prior carboplatin and pemetrexed infusion. The catheter was surgically removed, and a second thoracentesis drained 1,450 mL of yellowish fluid. Endoscopy identified a 3 cm non-bleeding gastric ulcer as the source of anemia, which improved after transfusion. Concurrent new-onset atrial fibrillation (AF) with rapid ventricular response (HR: 145 bpm) was managed with metoprolol and amiodarone. A multidisciplinary team including pulmonology, cardiology, oncology, and surgery coordinated care. IMPACT/DISCUSSION: This case adds to the limited literature on chemothorax due to misplaced central catheters in chemotherapy patients, reinforcing the need for heightened vigilance. The diagnostic process involved a combination of imaging, fluid analysis, and clinical expertise, while the management required prompt surgical intervention and medical optimization. This case highlights the critical importance of maintaining a high index of suspicion for uncommon complications, such as chemothorax, when evaluating complex clinical presentations involving the use of central lines. Moreover, the diagnostic and management principles demonstrated here are essential in oncology and serve as a blueprint for addressing catheter-related complications in critical care and hospital medicine settings. It emphasizes the importance of timely diagnostic evaluation, coordinated specialty input, and patient-centered care in improving outcomes.

- Misplaced central catheters can lead to rare but severe complications, such as chemothorax, necessitating early recognition and intervention. - Multidisciplinary collaboration ensures comprehensive management of complex complications, optimizing patient outcomes across diverse healthcare contexts. - This case underscores the need for vigilance in catheter placement and monitoring, especially in oncology patients undergoing chemotherapy. CHEYNE STOKES BREATHING PATTERN IN HIGH-DEGREE ATRIOVENTRICULAR BLOCK Aditya Maddali2; Joyce Chen1; Carol Gergis1; Margot Valme2; fatima Pasha2; Lyndsey Turbow1; Luis Cerna Urrutia3; Joel Nations4. 1Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Internal Medicine, The George Washington University, Washington, DC; 3Cardiology, The George Washington University Hospital, Washington, DC; 4Washington DC VA Medical Center, Washington, DC. (Control ID #4273190) CASE: An 85-year-old male with past medical history of hypertension, hyperlipidemia, Mobitz Type I atrioventricular (AV) block and left bundle branch block presented with a one-week history of recurrent syncope associated with dyspnea and syncopal episode on the day of presentation. On presentation, the patient’s heart rate ranged from 30s to 60s on telemetry monitor, and he was noted to have plethysmograph alternating between deep, heavy breaths and shallow rapid breaths consistent with Cheyne-Stokes during episodes of bradycardia. EKG completed in the emergency room demonstrated second-degree heart block with 2:1 and 3:1 conduction ratios and new right bundle branch block. At rest however, the patient remained asymptomatic. While the patient was being triaged, atropine was considered for management given symptomatic bradycardia, but was advised against by Cardiology consult services. After pacemaker placement, the patient’s symptoms and associated Cheyne-Stokes breathing resolved. The patient was discharged in stable condition with cardiology follow-up for continued monitoring. IMPACT/DISCUSSION: Cheyne-Stokes respirations have been noted in patients with arrhythmias and commonly found in patients with heart failure. The association with arrhythmias and heart block is thought to be secondary to vagus nerve activity. As the vagal nerve is activated by the deep, slow breaths exhibited in the Cheyne-Stokes pattern and exerts a negative chronotropic effect on cardiac conduction, vagal nerve stimulation can be associated with variable conduction block. Primary management of second-degree AV block with variable conduction and intermittent complete heart block is pacemaker placement. While atropine is a common treatment for bradycardia, it is not effective in Mobitz type II and third-degree AV blocks. This is because it primarily promotes sinoatrial (SA) node function and the ventricles in advanced heart blocks are unable to reliably respond to SA node activation. While atropine can have an effect on the AV node, its effect is not significant. In this case, our patient underwent pacemaker placement shortly after admission, and his Cheyne-Stokes breathing patterns subsequently resolved.

While Cheyne Stokes breathing patterns may be observed in both heart failure and stroke, it may also be present in high-degree heart block. Atropine is not useful in the treatment of Mobitz type II and third-degree AV block given its isolated effect on the sinoatrial node. Pacemaker placement is the definitive therapy for certain types of heart block and can result in resolution of Cheyne stokes breathing pattern. CHOLEDOCHOLIATHIASIS - A COMPLICATION 16 YEARS FOLLOWING CHOLECYSTECTOMY Rochelle A. Jayavendra1; Aman Saleemi1; Kopal Kotak1; Yash Patel2; Zain Kulairi1. 1Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI; 2Internal Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4273205) CASE: A 75-year-old male with a past medical history of type 2 diabetes mellitus and cholelithiasis status-post cholecystectomy (2008) presented to the ED with complaints of colicky postprandial abdominal pain for 5 days. At the time, the patient had endorsed periumbilical pain which intermittently radiated to the epigastric region, which had been progressively worsening, prompting him to the ED. He denied any radiation of pain, nausea, emesis, melena or hematochezia, or history of hepatitis. Patient had also denied any tobacco, alcohol or recreational drug use. He had also reported that he completed a colonoscopy earlier in the year, which was unremarkable. Upon evaluation, the patient was hemodynamically stable. Labs on admission were remarkable for ALT 1000, AST 773, ALP 208, total bilirubin 2 and direct bilirubin of 2.20. Abdominal ultrasound only showed a surgically absent gallbladder and common duct measuring 8 mm, normal for a post-cholecystectomy patient. However, due to symptoms, additional imaging of CT abdomen was completed, revealing 5mm calculus along the distal common bile duct consistent with choledocholithiasis, with possible biliary ductal dilatation. At that time, patient was admitted for further management, and ERCP was conducted with papillotomy and balloon sweep. Following the procedure, the patient reported relief of symptoms and discharged home. IMPACT/DISCUSSION: The gallbladder is the main location for gallstone formation, however in cases involving patients status-post cholecystectomy, the bile duct often becomes an alternative location for gallstones. While the documented median time for common bile duct stones to occur after laparoscopic cholecystectomy is 4 years, this case presents a patient with CBD stones 16 years post-surgery, highlighting the importance of considering choledocholithiasis in the differential diagnosis of abdominal pain, even in the presence of a cholecystectomy. After cholecystectomy, bile flow is continuous; prone to causing bile stasis and sludge. In addition, biliary strictures, bile duct injury, and migration of surgical clipping all pose risks leading to CBD stone formation. Furthermore, multiple imaging modalities may be required to rule out gallstone formation, like in this case where ultrasound yielded unremarkable results, which were later presented on CT. Therefore, it is important to recognize that this delayed presentation emphasizes the need for ongoing clinical vigilance and appropriate imaging, such as ERCP, to ensure timely diagnosis and prevent complications like cholangitis or pancreatitis in this patient population.

This case presents a rare instance of choledocholithiasis occurring years after cholecystectomy. It highlights the importance of including choledocholithiasis in the differential diagnosis, even long after the surgery, and illustrates the need for timely intervention to prevent complications and decrease mortality risk. CHRONIC DYSPNEA AND COUGH IN AN ELDERLY WOMAN: A DIAGNOSTIC CHALLENGE OF PARTIALLY STEROID AND DIURETIC RESPONSIVE HIATAL HERNIA-INDUCED LEFT ATRIAL COMPRESSION Abdullah Khalid1; Saurav Kini2. 1Medicine, Tufts Medical Center, Boston, MA; 2Internal Medicine, Tufts Medical Center, Boston, MA. (Control ID #4273278) CASE: An 82-year-old woman chronic smoker with a history of asthma, chronic bronchitis, hypertension, atrial fibrillation, and known large paraesophageal hiatal hernia presented with a cough and progressive dyspnea on exertion over several months. Despite multiple outpatient evaluations for presumed asthma exacerbations treated with short courses of steroids, her symptoms recurred upon cessation of therapy. Outpatient CT imaging revealed diffuse mosaic attenuation with ground-glass opacities suggestive of pulmonary edema and tree-in-bud nodular opacities possibly indicative of infection/inflammation. Given pulmonary edema findings, she was trialed on furosemide also with only partial improvement. On presentation, her oxygen saturation was 91% on room air, dropping to 84% with ambulation. A CT pulmonary angiogram was negative for embolism but re-demonstrated large paraesophageal hiatal hernia. Transthoracic echocardiography showed normal left ventricular ejection fraction but revealed a small left atrium with significant extrinsic compression. It was postulated that the hiatal hernia was causing left atrial compression, leading to pulmonary edema due to obstruction of pulmonary venous drainage, and pleuritis. After respiratory optimization, the patient underwent outpatient elective surgical repair of the paraesophageal hernia. Postoperatively, she experienced marked improvement in her cough and dyspnea on exertion. IMPACT/DISCUSSION: Hiatal hernia-induced left atrial compression is a recognized but uncommon cause of dyspnea. This case underscores the diagnostic challenge in patients with multiple comorbidities, where symptoms may be mistakenly attributed to more common conditions like asthma or heart failure. The patient's transient response to steroids and diuretics further complicated the clinical picture, delaying the definitive diagnosis. This case highlights the importance of considering structural abnormalities, such as large hiatal hernias, in the differential diagnosis of unexplained dyspnea, especially when initial treatments yield only temporary relief.

- Hiatal hernia-induced left atrial compression should be considered in patients with unexplained dyspnea and known large hiatal hernias, even if symptoms temporarily respond to diuretics and steroids. - Comprehensive diagnostic evaluation, including CT and TTE, are crucial in identifying extrinsic cardiac compression. Early recognition and surgical intervention can lead to significant symptomatic improvement in such cases. CLINICAL AND ETHICAL CHALLENGES SURROUNDING CULTURAL PSYCHIATRIC DISORDERS: A CASE OF ATAQUE DE NERVIOS WITH OVERLAPPING DISSOCIATIVE SYMPTOMS Karla Chamorro Garcia, Jacob Riegler. Internal Medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #4272378) CASE: A 56-year-old woman from Brazil with a history of major depressive disorder and fibromyalgia presented to the emergency room three days after two episodes of sudden onset memory loss and confusion. These events lasted for approximately 4 hours each and were associated with lack of perception of her surroundings, nonsensical speech, and intermittent foaming at the mouth without tonic-clonic movements or bladder incontinence. The patient then developed persistent memory lapses and was unable to recognize her own daughter. Prior to these episodes the patient was fully independent and had not demonstrated any issues with memory. In the emergency department, a CTA head and neck as well as an MRI brain were normal. The patient was admitted for the possibility of seizure disorder versus encephalitis. EEG was within normal limits. On interview, the patient was noted to have normal speech content and a linear thought process with clear comprehension. During the interview, the patient received a video call from her daughter, she was unable to identify her. Further investigation revealed that the patient had several “out of body” feelings after these episodes and that this occurred immediately following arguments with the daughter that she was unable to identify. Psychiatry was consulted and found that the cultural dissociative disorder Ataque de Nervios was the most likely diagnosis given the episodes of somatization with dissociative symptoms. She was discharged and her dissociative symptoms have completely resolved with mood stabilizing medications and supportive psychotherapy. IMPACT/DISCUSSION: Ataque de Nervios is a cultural disorder seen mostly in patients of Hispanic or Latin American descent that presents similar to panic disorder with exaggerated somatization of symptoms during the episode. It may have a dissociative component that is generally linked to the main stressor. This case illustrates the nuance in diagnosing cultural disorders such as Ataque de Nervios, as it can be difficult to distinguish from unwitnessed seizures with post-ictal state, encephalitis, and other psychiatric illnesses. The key features of this patient are the selective inability to recognize her daughter who she had an argument with and otherwise intact cognition. Cultural diagnoses can be ethically challenging as culturally ascribing symptoms can be prone to bias. However, it is also important to recognize cultural differences in psychatric diseases in the psychosocial model of care. This should be seen as a diagnosis of exclusion after a thorough neurologic and psychiatric examination to reduce bias in evaluation.

Ataque de Nervios often presents with exaggerated somatization following an acute stressor and may have prolonged dissociative symptoms that are particular to the stressor Ataque de Nervios may be challenging to distinguish from a post-ictal state, acute stress reaction, or even encephalitis when persistent. Therefore, it should be considered a diagnosis of exclusion. CLINICAL CASE REVIEW OF CEFEPIME-INDUCED DRESS SYNDROME Kashvi Patel1; Aminatta Mitchell2; Matthew Emery1. 1Internal Medicine, The Ohio State University, Columbus, OH; 2Des Moines University, Des Moines, IA. (Control ID #4267147) CASE: A 29-year-old male with no significant past medical history presented with night sweats, 60 pound unintentional weight loss, fevers, and weakness for 1-2 months. Physical examination was remarkable for abdominal tenderness and splenomegaly. Labs were notable for pancytopenia (white blood cell count 1.5 x109/L, hemoglobin 12.5 g/dL, platelets 8 x109/L). CT abdomen and pelvis demonstrated moderate to severe splenomegaly. Patient was started on cefepime for concern for infectious etiology. Despite being on cefepime, he had a recurrence of fevers up to 38.2°C. Extensive infectious work-up was negative, including hepatitis panel, HIV, Epstein-Barr virus, parvovirus, cytomegalovirus, tuberculosis, histoplasma/blastomyces, babesia, and bartonella. Thus, the patient was transitioned to doxycycline for possible unidentified tick borne illness. Off cefepime, his fevers resolved. A bone marrow biopsy was performed to rule out malignancy which showed normocellular bone marrow. Rheumatology work-up was significant for elevated angiotensin-converting enzyme and 1-25 dihydroxyvitamin D3, with concern for sarcoidosis. A day after cefepime was discontinued, the patient developed an erythematous maculopapular rash across his trunk which spread to his neck and extremities. It was non-painful and pruritic in nature. Dermatology was consulted for concern for DRESS, likely secondary to cefepime use. He was started on IV steroids and transitioned to an oral prednisone taper. On discharge, he was afebrile and his rash had resolved. Per follow-up with rheumatology, he was continued on prednisone for presumed sarcoidosis. IMPACT/DISCUSSION: Drug rash with eosinophilia and systemic symptoms syndrome (DRESS) is a distinct drug reaction characterized by a prolonged latency period followed by fever, rash, lymphadenopathy, and other systemic manifestations (1). DRESS accounts for approximately 10-20% of cutaneous drug reactions (1). We report a case with an atypical offending agent: cefepime. There is limited literature on cephalosporin drug therapy leading to DRESS syndrome. The reported cases of cephalosporin-induced DRESS syndrome have largely been third-generation antibiotics of this class. The significance of this case is the atypical offending agent precipitating DRESS syndrome in an otherwise healthy young adult male. Clinicians will benefit from this finding, given the novelty of this scenario. The latency period for DRESS ranges from 2-6 weeks before symptom manifestation (1), and we highlight a case with earlier cutaneous manifestations. This shortened latent period also informs clinicians of the spectrum of symptom onset in DRESS syndrome. 1. Fiszenson-Albala F, et al. A 6-month prospective survey of cutaneous drug reactions in a hospital setting.

- The prevalence of cefepime use in the hospital setting requires clinicians to be acutely aware of the possible side effects. - This is a unique case of cefepime as a causative agent of DRESS, with an atypical time course of symptom onset. CLOT, CYST, AND CANCER: NAVIGATING A COMPLEX PULMONARY EMBOLISM CASE Allison Reichl1; Agnieszka Gryguc-Saxanoff2. 1Internal Medicine, University of California Los Angeles, Los Angeles, CA; 2Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4270389) CASE: A 74-year-old female with a history of a right lung nodule and 7cm liver cyst presented for acute dyspnea. On exam, her heart rate was 110, blood pressure 129/86, and she required 3L oxygen. Imaging revealed large volume bilateral pulmonary emboli. Labs showed a hsTrop of 1122ng/L and BNP of 537 pg/mL. Stat echo revealed right-heart strain. She underwent partial thrombectomy and was started on heparin. On hospital day 3, her hemoglobin dropped from 11.2 to 8.0 g/dL and she reported abdominal pain. Abdominal CTA showed no active bleeding but revealed an occlusive thrombus in the inferior vena cava (IVC) extending to the renal and iliac veins. Her hepatic cyst had grown to 16cm, causing mass effect on the IVC. There was concern that cyst drainage could precipitate transit of the thrombus, so the patient first underwent catheter-directed thrombolysis of the IVC clot. Four days later, she underwent repeat IVC thrombectomy and finally cyst drainage. Cultures and cytology from the drained cyst were negative, and echinococcus IgE was normal. The patient was discharged on enoxaparin. One month later, a biopsy of the lung nodule confirmed non-small cell lung cancer (NSCLC). A PET scan showed FDG-avidity in the hilar lymph nodes and liver segment 8 concerning for metastatic disease. The surgery team recommended biopsy of the segment 8 liver lesion and the wall of the segment 6 drained cyst. The segment 8 lesion was metastatic NSCLC, while the cyst was ultimately benign. Cancer pathology revealed an EGFR exon 19 deletion and the patient was started on Osimertinib 80mg daily, 3 months after her initial presentation. IMPACT/DISCUSSION: IVC thrombus from compression by a cystic liver lesion is exceedingly rare, with fewer than 10 cases reported in the literature. No consensus exists on managing such thrombi, but in this case, anticoagulation, mechanical thrombectomy, and catheter-directed thrombolysis were all required. Liver cystic lesions can be benign, malignant, traumatic, or infectious. In symptomatic patients with large cysts, therapeutic approaches include needle aspiration, surgical cyst deroofing, internal cystojejunostomy, or liver resection. No standard treatment exists, and management is individualized. Ultimately, multiple factors including hypercoagulability in the setting of NSCLC combined with stasis from IVC compression resulted in this patient’s large volume IVC thrombus and pulmonary emboli.

-Pulmonary embolism often points to an underlying condition that requires further investigation. -When direct compression contributes to thrombosis, thrombus extraction may be necessary before relieving the mass effect, depending on clot migration risk. -Hepatic cystic lesions are rare, with asymptomatic lesions usually requiring no intervention. Management of large cysts is individualized. CLOTS WITH A CAUSE - THE MYSTERY OF RECURRENT PULMONARY EMBOLISMS Joanna Kilbane Myers, Steven Hopkins, Jacob Hernandez. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4269049) CASE: A 44-year-old woman with medical history of epilepsy, hypertension, active tobacco use and recent diagnosis of recurrent pulmonary embolisms with equivocal APLS workup, presents with dyspnea and nonproductive cough for 3 days. Associated symptoms include pleuritic chest pain and body aches. She denies recent travel. She reports strict adherence to her anti-seizure medications, however is not sure of her adherence to enoxaparin. Presenting vitals were as follows: afebrile, HR 75, BP 100/71, RR 18, SpO2 98% on RA. Only positive physical exam finding was trace bilateral lower extremity edema. Initial diagnostic evaluation notable for WBC 9.8, Hgb 14.2, Cr 1.1, BNP 32, hs-trop 32, lactate 1.6, UA with positive protein 600, positive COVID-19 viral swab. CTA revealed segmental and subsegmental pulmonary embolisms (PEs) in the right lower lobe, and segmental PEs in the right middle and upper lobes with no evidence of RV strain. Moderate bilateral pleural effusions and bilateral axillary lymphadenopathy were also seen. Providers had high concern for malignancy as the etiology for recurrent PEs and lymphadenopathy. Pulmonology team recommended a lymph node biopsy which revealed no evidence of cancer, but more concern for infectious vs. autoimmune etiology. Further testing revealed ESR (>130), CRP (29), nephrotic range proteinuria (4.5g in 24hr collection) and elevated ANA 1:1280 nuclear, homogenous pattern, elevated values of Anti-DsDNA 154, Anti-Smith 1.8, Anti-SSA 1.9, and Anti-Chromatin 7.3. Complement levels were normal. Renal biopsy revealed membranous nephropathy stage II and III out of IV. MRI brain and lumbar puncture to evaluate for lupus cerebritis were unrevealing. She was diagnosed with systemic lupus erythematosus (SLE) and started treatment with hydroxychloroquine and methylprednisolone. IMPACT/DISCUSSION: SLE can affect any part of the body. A high degree of clinical suspicion is critical with new SLE because many patients may present with nonspecific signs and symptoms. Classic presenting features can include fatigue, arthritis, arthralgias, rashes, fever, edema, and more. A less common presenting feature is venous thromboembolism. Patients with SLE are at higher risk of thromboembolism than the general population, even those patients who are lupus anticoagulant or antiphospholipid antibody negative. Of note, SLE hematologic effects more often include thrombocytopenia, anemia and lymphopenia. This patient’s main feature that led to her SLE diagnosis was recurrent pulmonary embolisms. Active SLE is also associated with lymph node enlargement. A hypercoagulable state and lymphadenopathy led to an extensive malignancy workup prior to an autoimmune workup, which delayed her SLE diagnosis.

SLE can present in a wide variety of ways, with nonspecific symptoms. Although recurrent thromboses and lymphadenopathy are less common presenting features of SLE, these symptoms should alert the general internist to consider autoimmune conditions such as SLE on the differential. CMV COLITIS COMPLICATED BY A STRICTURE IN AN IMMUNOCOMPETENT ADULT David Pinto1; Kelsy N. Larios2; Inderpreet Saini1. 1Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4271722) CASE: A 72-year-old woman with hypertension presented with a 3-week history of right lower quadrant (RLQ) abdominal pain, nausea, low-grade fevers, hematochezia, dizziness, and fatigue. Two weeks earlier, she was evaluated at another hospital, where a CT scan suggested ascending colonic malignancy; a biopsy was negative, and she missed follow-up. In the ED, CT imaging showed colonic wall thickening (4 cm) and labs notable for anemia (Hb 8.7). Colonoscopy revealed an ulcerated ascending colonic stricture and a smaller descending colonic ulcer; biopsies were performed. Differential diagnoses included ischemic colitis, infections, IBD, or malignancy. A CT angiogram ruled out ischemia, and infectious workup was initially negative. On day six, pathology revealed CMV IgG in the colonic biopsy. Serologic testing confirmed CMV DNA, while HIV screening was negative. The patient received IV ganciclovir and was discharged on 3 week-course of oral valganciclovir. IMPACT/DISCUSSION: We present a case of CMV colitis in an immunocompetent patient, highlighting the importance of maintaining a broad differential diagnosis for abdominal pain with colonic findings. CMV infection typically occurs in immunocompromised individuals, but rarely, can present in immunocompetent patients, contributing to a delayed diagnosis. The patient’s hematochezia and colonic wall thickening on CT raised concerns for malignancy. Our initial differential diagnosis included ischemic colitis, IBD, and infectious colitis. A notable discovery was a colonic stricture on colonoscopy, a rare finding in CMV colitis. This emphasizes the need to consider CMV colitis when malignancy is suspected but unconfirmed. A similar case involved a 58-year-old male with RLQ pain, imaging revealing colonic wall thickening and luminal narrowing, leading to a presumptive colon carcinoma diagnosis. The patient underwent surgical resection however, histopathology later revealed CMV pseudotumor. Another case involved a 77-year-old male with cirrhosis and a liver transplant, whose ulcerated stricture was found to be CMV colitis. Similar to our patient, he was treated with IV ganciclovir followed by oral valganciclovir. Socioeconomic and ethnic factors may influence susceptibility to CMV. Studies suggest higher CMV infection rates among Latino and Black populations, potentially contributing to disparities in outcomes. In this case, our patient's Latina ethnicity and Spanish-speaking background may have added barriers to timely diagnosis, highlighting the importance of addressing language and cultural factors in healthcare delivery.

Our case emphasizes the importance of maintaining a broad differential and using endoscopic evaluation with histological analysis to rule out infections. Early CMV colitis diagnosis can prevent unnecessary surgery and complications. Socioeconomic and racial factors, including higher infection rates among Latino and Black populations, and language barriers may contribute to delays in diagnosis and care. CMV IN IMMUNOSUPPRESSED LUPUS PATIENTS REFLECTING DIAGNOSTIC VIGILANCE Joseph Reitano2; Melanie Prestidge1. 1Hospital Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Medicine, The Ohio State University College of Medicine, Columbus, OH. (Control ID #4271352) CASE: A 23-year-old male with SLE and class V lupus nephritis presented with fevers, abdominal pain, and dark urine. He had been diagnosed with strep pharyngitis 5 days earlier with positive rapid antigen testing and started on amoxicillin. Due to odynophagia, he had 2 days of non-compliance of his SLE medication (mycophenolate mofetil and hydroxychloroquine) before his symptoms began. He also reports throat pain, myalgias, and fatigue. Vitals were largely unremarkable, except recurrent fevers (Tmax: 101.8). On exam, he had left flank pain/tenderness and vague, diffuse abdominal tenderness. Labs showed unremarkable CBC and chemistry, positive dsDNA and ANA, nephrotic range proteinuria, and >25 RBC on UA. Kidney biopsy showed class V lupus nephritis. He was diagnosed with a lupus nephritis flare and treated with IVIg x5 days. IV Obinutuzumab was added for better SLE control. Despite resolution all URI symptoms and completing antibiotics, he continued to have persistent daily spiking fevers and vague abdominal discomfort. Labs showed mildly elevated LFTs. Ferritin (641), CRP (45.3), and ESR (53) were notable. Abdominal imaging showed hepatosplenomegaly, a small hepatic granuloma, and a splenic wedge infarction. EBV, AMA, ASMA, fungal panels, and STI testing were all negative. UA, CXR, and blood cultures were unremarkable. Ultimately, CMV PCR, IgG, and IgM were found to be positive. The patient was treated with valganciclovir. Fevers resolved during his hospital stay and his abdominal discomfort improved. He was discharged on valganciclovir until full CMV clearance. IMPACT/DISCUSSION: CMV infects ~60% of adults, manifesting as clinically silent or as a mononucleosis syndrome. Patients who are immunocompromised, however, are at an increased risk of complications from viremia, such as hepatitis, retinitis, esophagitis, or encephalitis. In predisposed patients, there must be a high clinical suspicion for CMV, even with rather straightforward clinical presentations. This patient presented with a lupus nephritis flare and a presumed strep pharyngitis infection. Although our patient had fully completed treatment, some clinical symptoms remained, requiring diagnostic vigilance for potential causes. Lupus flares are known to cause prolonged fevers, myalgias, and fatigue; however, they are unlikely to cause elevation of inflammatory markers, especially CRP. Additionally, mycophenolate mofetil, a known immunosuppressant, increases his likelihood of opportunistic infections. In this case, diagnosing and treating his CMV and lupus flare was imperative to prevent clinical worsening, serious complications, and disease recurrence of CMV viremia.

CMV is an ubiquitous virus that must always be considered in at-risk patients. Providers must have a high index of suspicion for CMV in at-risk patients, regardless of clinical symptomatology. COEXISTENCE OF IGA NEPHROPATHY AND THROMBOTIC MICROSCOPIC ANGIOPATHY IN AN ADULT MALE WITH CFHR5 GENE MUTATION Manasa Handady, Sumona Banerjee, Reema Gowda, Kunal Malhotra. Nephrology, Saint Louis University School of Medicine, St. Louis, MO. (Control ID #4269333) CASE: A 67-year-old male with a history of diabetes, coronary artery disease status post coronary artery bypass grafting, heart failure with reduced ejection fraction (51%), and atrial fibrillation on apixaban presented as a transfer from an outside hospital with an acute kidney injury, suspected to be due to acute interstitial nephritis from oxacillin. He was switched to cefazolin at the outside hospital and given 1g methylprednisolone before transfer, but this was stopped to establish an accurate diagnosis by obtaining a kidney biopsy. Initial labs showed an elevated creatinine of 6.49 mg/dL from a baseline of 0.8 mg/dL. C3 and C4 were within normal limits, and the urine eosinophil smear was negative. The patient was initiated on intermittent hemodialysis as his labs demonstrated several electrolyte imbalances in the setting of anuria. On kidney biopsy, he was found to have coexisting TMA, IgA nephropathy, and diffuse endocapillary proliferative glomerulonephritis. Further labs to work up his TMA showed a normal LDH of 234 units/L, elevated D-dimer at 10.37 mcg/mL, and an increased fibrinogen at 511 mg/dL. Further gene panel testing revealed a heterozygous missense variant in exon 7 of the CFHR5 gene, associated with TMA/aHUS. Our patient was initiated on 80 mg daily prednisone to be continued for 1 month and then re-evaluated. He was scheduled for outpatient dialysis due to anuria and close outpatient follow-up with a nephrologist upon discharge. IMPACT/DISCUSSION: This case involves an adult male with no prior history of kidney disease who presented with anuria. His kidney biopsy demonstrated coexisting IgA nephropathy, glomerulonephritis, and thrombotic microscopic angiopathy (TMA). The patient was subsequently found to have a CFHR5 gene mutation. The complement factor H-related 5 gene (CFHR5) regulates the immune system. Variations in this gene, as seen in this patient, have been associated with C3 glomerulonephritis (C3GN) and hemolytic uremic syndrome (HUS). This case highlights the importance of obtaining a kidney biopsy in such atypical cases, in order to establish an accurate diagnosis and initiate an effective treatment plan. Genetic testing can also be obtained if the underlying cause remains unestablished.

Rare genetic variants in the CFHR5 gene have been associated with an increased genetic susceptibility to IgAN. It should be suspected in cases of unconventional presentation of AKI or glomerulonephritis. A kidney biopsy should be done in such cases to establish the correct diagnosis and treatment plan. COLD PLUNGE: SEVERE COLD AGGLUTININ HEMOLYTIC ANEMIA IN A HEALTHY YOUNG FEMALE Benjamin Kofoed. Medicine, Emory University, Atlanta, GA. (Control ID #4271035) CASE: A previously healthy 25-year-old female presented to the Emergency Department with abdominal pain and jaundice. She reported one week of congestion, headaches, and lethargy which progressed to one day of right upper quadrant abdominal pain, jaundice, and subjective fever. She endorsed dark-colored urine. She denied postprandial pain, nausea, or bowel habit changes. She denied Raynaud’s or other skin changes. Her medical history was significant only for prior cholecystectomy. She had a copper IUD but took no medications. She was sexually active with one longtime male partner. On exam, the patient was lethargic but not in distress. Temperature was 37C, heart rate 142, blood pressure 102/56, respiratory rate 29, and oxygen saturation 95%. She had scleral icterus, tachypnea, sinus tachycardia, a nontender abdomen, diffuse jaundice, and significant pallor. There was no peripheral cyanosis or livedo reticularis. White blood cell count was 19,600 cells/μL, hemoglobin 3.1 gm/dL, and platelets 244,000 cells/μL. Agglutination was noted. Total bilirubin was 7.1 mg/dL (direct 2.7, indirect 4.4). LDH was 1,593 U/L and haptoglobin was undetectable. Direct Antiglobulin Test (DAT) showed positive C3 but negative IgG. Cold agglutinin titer was 1:256 (<1:32). Further evaluation revealed positive EBV IgM with PCR at 200,000 IU/mL. The patient was diagnosed with severe, EBV-mediated cold agglutinin hemolytic anemia (CAD). She was transfused, closely monitored in the intensive care unit, and recovered without complication. IMPACT/DISCUSSION: This case highlights a classic but dramatic presentation of CAD, a rare cause of autoimmune-mediated hemolysis. CAD is thought to represent 15% of all AIHA. Classic laboratory findings include positive DAT, specifically with C3 (74%) +/- IgG (25%).[i] Diagnosis is confirmed with cold agglutinin assay. 50-70% of cases are due to an underlying process, and internists should be comfortable considering infectious, autoimmune, and malignant causes. EBV is considered a classic infectious precipitant, and cold agglutinins are detected frequently in those with acute EBV mononucleosis.[ii] Management includes specialized transfusion procedures, supportive care, and plasma exchange or rituximab in severe disease. [i] Swiecicki PL, Hegerova LT, Gertz MA. Cold agglutinin disease. Blood. 2013;122(7):1114-1121. doi:10.1182/blood-2013-02-474437 [ii] Rosenfield RE, Schmidt PJ, Calvo RC, McGinniss MH. Anti-I, a frequent cold agglutinin in infectious mononucleosis. Vox Sanguinis. 1965;10(5):631-634. doi:10.1111/j.1423-0410.1965.tb01418.x

- Suspect CAD in patients with Coombs-positive, anti-C3 hemolytic anemia. - Identify common causes of secondary CAD and patient risk factors to guide evaluation. - Management is typically supportive, though severe cases require close Blood Bank and Hematology involvement. COMPLICATIONS OF GEMCITABINE THERAPY: SYSTEMIC CAPILLARY LEAK SYNDROME IN T-CELL LYMPHOMA Paola T. Farah, Nikita Piryani, Pooja B. Patel. Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4272906) CASE: An 82-year-old female with a significant PMH for T-cell lymphoma on gemcitabine, hyperlipidemia, HTN, asthma, HF with preserved ejection fraction (HFpEF, 56-59% EF), and anasarca, presented with erythema of the LUE, chest wall, and abd, with associated SOB, worsening LE edema, and cough. Her vitals were normal except for an O2 sat of 89% on room air. Exam revealed decreased air movement bilaterally, along with erythema and warmth of the left chest wall and abdomen, extending to her arm and back. Her LUE was edematous without crepitus, and motor and sensory functions were intact, with adequate perfusion. Initial labs indicated elevated B-type natriuretic peptide (BNP) (7329 pg/mL), elevated creatinine (1.85 mg/dL), and mild hypoalbuminemia (3.3 g/dL). Chest X-ray showed cardiomegaly, pulmonary vascular congestion, and interstitial opacities. Troponin levels (30 ng/L) were elevated without ST elevations on electrocardiogram (EKG), and venous Doppler ruled out DVT. She received nebulizers and magnesium, leading to symptomatic improvement, but her sat improved with supplemental O2. Ceftriaxone was included for suspected erysipelas and furosemide for HF management. The pt was admitted with a dx of erysipelas, AKI, and acute decompensated HF. Despite aggressive diuretic therapy, signs of fluid overload persisted, prompting suspicion of chemotherapy-induced systemic capillary leak syndrome (SCLS). Nifedipine was discontinued, and a computed tomography (CT) scan of the chest revealed borderline cardiomegaly, consolidations at lung bases suggestive of atelectasis, small pleural effusions, and scattered ground glass opacities. Diuretics were stopped, and normal saline was initiated alongside dexamethasone to manage capillary leak and stabilize renal function. Renal function returned to baseline and she tolerated furosemide. The pt's hospital stay was also complicated by atrial flutter. Negative findings on US and ventilation/perfusion (VQ) scan ruled out PE, although the pts risk profile necessitated empirical anticoagulation. Rate control was achieved with metoprolol. Concurrently, worsening anemia required one-unit packed red blood cell transfusion to stabilize hemoglobin levels. Dexamethasone was discontinued upon discharge and she was weaned off supplemental O2. After discharge, the pt continued rehab and cephalexin. IMPACT/DISCUSSION: SCLS is an extremely rare complication of gemcitabine therapy with an incidence rate of less than 1%. Gemcitabine's active metabolites damage capillary endothelial cells' mitochondria, producing excessive ROS and disrupting cellular function. There is no cure for SCLS and gemcitabine therapy should be promptly stopped and treated with steroids. In our case, the pt's hypervolemia, normal EF, hypoalbuminemia, and history of gemcitabine prompted suspicion of SCLS.

Increasing awareness of SCLS among patients receiving gemcitabine therapy is crucial and should be considered in the evaluation of anasarca that cannot be explained by organ failure. COMPREHENSIVE MANAGEMENT OF IDIOPATHIC VENTRICULAR FIBRILLATION (IVF) IN A YOUNG PATIENT WITH SUBCUTANEOUS ICD Giorgi Akhvlediani1; Suhani Dalal2; Tamar Bejanishvili2; Giorgi Maisuradze1,3. 1Pulmonary and Critical Care, Tbilisi State Medical University, Tbilisi, Tbilisi , Georgia; 2Internal Medicine, University Hospitals, Cleveland, OH; 3Clinical Oncology Tbilisi State Medical University, Tbilisi, Georgia. (Control ID #4267023) CASE: A 33-year-old female with no past medical history initially presented at age 24 with a syncopal episode attributed to dehydration. Subsequently, she suffered a cardiac arrest due to ventricular fibrillation (VF) and successfully achieved the return of spontaneous circulation after CPR and defibrillation. The cardiac evaluation revealed no structural or valvular abnormalities and a subcutaneous ICD (subQ ICD) was implanted. Over time, she experienced multiple shocks from the subQ ICD for life-threatening arrhythmias as documented during device interrogations. Following these episodes, genetic testing was performed but yielded negative results. An ablation attempt was made but was unsuccessful, as no arrhythmias could be induced under anesthesia. Holter monitoring later revealed frequent premature ventricular contractions (PVCs) and additional episodes of non-sustained VT. Her treatment regimen included flecainide and nadolol. Despite therapy, the patient continued to report worsening of palpitations. The cardiology team plans ongoing monitoring with the Holter device and regular ICD interrogations. Future management considerations include another attempt at ablation if her arrhythmia burden persists. IMPACT/DISCUSSION: This case underscores the diagnostic complexity of idiopathic ventricular fibrillation, a rare condition predominantly observed in young adults without structural heart disease or identifiable genetic abnormalities. Our patient meets the diagnostic criteria for IVF, including the absence of structural abnormalities, negative genetic testing, and recurrent VF events. The recurrent VF and associated arrhythmias, despite optimal antiarrhythmic therapy and the presence of a subcutaneous implantable subQ ICD, highlight the challenges in managing this condition. The subQ ICD effectively prevents sudden cardiac death but is limited in controlling recurrent arrhythmias, often resulting in patient distress and diminished quality of life. Furthermore, the failure of genetic testing and prior ablation attempts underscores the need for advanced electrophysiological evaluations and innovative therapeutic approaches. Ongoing monitoring through ICD interrogations and ambulatory devices remains integral to optimizing long-term management. Future considerations, including repeat ablation attempts and further refinement of antiarrhythmic therapy, are essential in reducing the burden of arrhythmias and improving patient outcomes.

- Idiopathic ventricular arrhythmias present significant diagnostic and therapeutic challenges, requiring advanced electrophysiological evaluation and individualized management strategies. Optimized antiarrhythmic therapy, repeat ablation attempts and multidisciplinary care are essential to improving outcomes and quality of life in this high-risk patient population - Subcutaneous ICDs prevent sudden cardiac death but pose challenges like frequent shocks, requiring individualized management CONCOMITANT POLYCYTHEMIA VERA AND DIFFUSE LARGE B-CELL LYMPHOMA COMPLICATED BY GASTROSPLENIC FISTULA Bibek Saha1; Jenny Jia Ling Cao1; Allison A. Reinhardt1; Alex P. Danielson1; Victoria Kalinoski-Dubose1; William Mundell2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Hospital Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4272623) CASE: A 72-year-old male with a history of polycythemia vera (PV) presented due to left upper quadrant (LUQ) abdominal pain for 3 months, and recent imaging findings of a splenic mass with possible gastrosplenic fistula (GSF). He also reported 30lb weight loss, early satiety, poor appetite, and fatigue during this time. Three months prior to presentation, for his symptoms, he underwent CT A/P which revealed a 10.7X9.7X13.6cm splenic mass; hematoma, malignancy, or an abscess were considered. A PET-CT performed 3 months later revealed a hypermetabolic large necrotic splenic lesion with extensive lymphadenopathy which was suspicious for malignancy. There was also concern for possible GSF but this was uncertain on the noncontrast CT prompting hospital admission for further workup. He denied fever, chills, night sweats, nausea, emesis, bleeding or easy bruising, blood in the stool, and a family history of cancer or bleeding disorders. Vital signs were normal. Abdominal exam revealed splenomegaly with palpable masses as well as LUQ abdominal pain. Labs revealed microcytic anemia with a hemoglobin of 9.5 (previously 10-11), thrombocytosis (422; previously in the 400s), and leukocytosis (18.1; neutrophils 15.36, lymphocytes 0.84). Liver chemistries were elevated. CT angiogram A/P revealed a large centrally necrotic process in the spleen filled with gas and fluid and a new GSF without active bleeding. Hematology and surgery were consulted for possible primary splenic lymphoma (PSL) complicated by GSF. Given concerns for eventual massive upper gastrointestinal bleeding (UGIB), the patient underwent prompt splenectomy, gastrectomy, and distal pancreatectomy due to dense adherence to the pancreas. Bone marrow biopsy was negative for lymphoma involvement. Surgical pathology showed diffuse large B-cell lymphoma (DLBCL) prompting treatment with rituximab, steroids, and chemotherapy. On outpatient PET-CT 3 months after admission, there was resolution of the lymphadenopathy. IMPACT/DISCUSSION: Hematologic malignancies contribute to 20.2% of all malignancy-related hospitalizations. We however present a unique case, the first to our knowledge, with two hematologic malignancies, one of which was newly diagnosed, that was complicated by GSF formation. The differential for the splenic mass initially consisted of abscess, hematoma, second primary malignancy including lymphoma, and PV associated splenomegaly or splenic infarctions. Biopsy was avoided given the high risk for hemorrhage. However, given the new GSF, decreased hemoglobin, and risk for massive UGIB, prompt management was warranted.

●PSL should be in the differential for a splenic mass regardless of whether the patient has a prior hematologic malignancy ●Management of PSL should be prompt especially if complicated by a GSF CONCURRENT PERICARDIAL, PLEURAL, AND ASCITIC EFFUSIONS: A RARE MANIFESTATION OF SEVERE HYPOTHYROIDISM Adeoluwa Adewuyi, HanSol Park, Miriam Nji, Hardeep Singh, Gurleen Kaur. Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4231291) CASE: A male in his 70s presented with progressive dyspnea, abdominal distension, and bilateral lower extremity edema. Past medical history included smoking and hemorrhoids. Initial evaluation revealed bradycardia (HR 40s) and hypoxia (O2 sat 80s). Echocardiogram and CT imaging showed significant pericardial effusion without tamponade, bilateral pleural effusions, and abdominopelvic ascites. Physical exam noted periorbital edema, hoarse voice, cold extremities, and 3+ bilateral lower extremity edema. Labs revealed markedly elevated TSH (66.931 mIU/L), low free T4 (<0.10 ng/dL), and pancytopenia. Treatment included IV levothyroxine, initially 76 mcg daily, later increased to 100 mcg. Due to persistent symptoms, the patient underwent robotic-assisted pericardial window procedure, draining 700 mL each of pericardial and left pleural fluid. Paracentesis removed 3.3 L of ascitic fluid. Fluid analyses showed exudative characteristics for pericardial fluid and SAAG of 1.0 for ascitic fluid. The patient improved significantly and was discharged on oral levothyroxine. IMPACT/DISCUSSION: This case presents a rare triad of concurrent pericardial, pleural, and ascitic effusions secondary to severe hypothyroidism, with only one similar case previously documented. The exudative nature of the pericardial fluid and low SAAG of the ascitic fluid differ from some previous reports, highlighting variability in hypothyroidism-induced effusions. The need for surgical intervention for pericardial effusion management is uncommon in hypothyroidism-related cases, emphasizing the importance of individualized treatment strategies. The presence of pancytopenia further underscores the systemic effects of profound thyroid hormone deficiency. This case contributes to the literature by demonstrating the diverse and potentially severe manifestations of hypothyroidism, emphasizing the need for early recognition and appropriate management to potentially avert invasive procedures.

Severe hypothyroidism can present with rare complications requiring surgical intervention, necessitating a high index of suspicion and prompt thyroid function testing. Hypothyroidism-induced effusions may exhibit variable fluid characteristics, challenging conventional diagnostic criteria. Consider hypothyroidism in patients presenting with unexplained multiple serous effusions, even without typical symptoms. CRACKING THE CASE: AMYLOIDOSIS MEETS CRYOGLOBULINEMIA Youssef Samaha1,2; Alberto Busmail Haylock1; Angelica Singh1. 1Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; 2Neuro-Oncology, Harvard Medical School, Boston, MA. (Control ID #4273585) CASE: A 61-year-old woman presented with worsening bilateral lower extremity swelling and shortness of breath for 2 weeks. She had a history of AL amyloidosis, which was diagnosed nine years prior with bone marrow and kidney biopsies showing plasma cell dyscrasia, MPGN, and amyloid deposits. Treatment included CyBorD (cyclophosphamide, bortezomib, dexamethasone), melphalan, and autologous stem cell transplant, followed by maintenance therapy with lenalidomide for 4 years due to persistent amyloid burden. Two years later, she presented with fluid overload, and a repeat kidney biopsy showed glomerular capillary thrombi positive for IgG and kappa, suggesting cryoglobulinemia. Outpatient cryoglobulinemia workup was scheduled, but the patient was lost to follow-up. Two years later, a bone marrow biopsy revealed no evidence of amyloid deposits, although monoclonal gammopathy remained detectable. The current admission was the third over six weeks due to edema, weight gain, and shortness of breath, which were attributed to nephrotic syndrome and suspected MPGN secondary to cryoglobulinemia. However, the test for cryoglobulins was repeatedly negative. Laboratory findings on this admission included creatinine of 1.36 mg/dL (baseline 0.9 mg/dL), urine protein/creatinine ratio of 5.6 (normal 0.0-0.2), and albumin 2.6 g/dL. A further workup revealed low C3 and C4 (72 and <1 mg/dL, respectively), and Rheumatoid Factor of 264 IU/mL (normal 0-13 IU/mL). Cryoglobulins were again negative. Immunofixation showed IgM kappa and weak IgG kappa bands, suggestive of plasma cell dyscrasia. Given low complements, high rheumatoid factor, the presence of plasma cell dyscrasia, and prior renal biopsy results, a diagnosis of cryoglobulinemia was made. The patient was treated with a tapering course of prednisone and diuretics with improvement in symptoms. In retrospect, the collection technique for cryoglobulins appeared to be faulty as the specimens were always collected and kept at room temperature. IMPACT/DISCUSSION: Monoclonal gammopathy can cause both AL amyloidosis and cryoglobulinemia, though it is rare for a patient to have both conditions simultaneously. In AL amyloidosis, misfolded light chains form amyloid deposits, while in cryoglobulinemia, monoclonal immunoglobulins precipitate at low temperatures, causing vascular inflammation and renal damage. Persistent monoclonal protein production drives cryoglobulin formation, contributing to MPGN and systemic symptoms. A key challenge in diagnosing cryoglobulinemia was the repeated negative cryoglobulin tests, likely due to technical issues with specimen collection and handling. Proper temperature management is essential for accurate testing, and a negative result does not rule out cryoglobulinemia when pre-test probability is high.

In conclusion, this case underscores the importance of proper sample handling in diagnosing cryoglobulinemia and the need for a high index of suspicion in patients with monoclonal gammopathy and systemic symptoms. CRITICAL DO2 AND THE UNDERLYING ETIOLOGY OF DYSPNEA AND TACHYCARDIA IN A MAN PRESENTING WITH ANEMIA Tim Long1; Shoshana J. Herzig2. 1Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2Medicine, Beth Israel Deaconess Medical Center, Brookline, MA. (Control ID #4273437) CASE: A 73-year-old man with PMHx of HTN and recently diagnosed iron and vitamin B12 deficiency anemia presented to a New England academic hospital with progressive dyspnea on exertion and bilateral lower extremity. He denied any dark or bloody stools, chest pain, palpitations, or orthopnea. The patient was tachycardic in the ED with otherwise normal vitals and physical exam was notable for symmetric 3+ lower extremity pitting edema and clear lungs. Initial labs were notable for anemia with a hemoglobin of 7.1 (from 8.9 three months prior), ProBNP of 1341 and D-dimer of 1273. Bilateral lower extremity ultrasound was without evidence of DVT and CXR was without acute cardiopulmonary process. The patient was admitted and underwent Colonoscopy and EGD without any evidence of bleeding. A TTE was obtained which demonstrated normal cardiac function. Despite some improvement in his dyspnea as his hemoglobin corrected with red blood cell transfusions, he remained tachycardic. Inflammatory markers were elevated with CRP of 253 and LDH 312. Cross-sectional imaging was obtained, which demonstrated a large primary neoplasm most consistent with clear cell type renal cell carcinoma (ccRCC) in the left kidney with a large tumor thrombus filling the whole left renal vein and also involving the IVC, as well as liver and pulmonary lesions. Subsequent bronchoscopic lymph node biopsy confirmed the suspicion of metastatic RCC. IMPACT/DISCUSSION: When hemoglobin declines, tissue oxygen delivery (DO2) is initially able to be maintained by increasing the oxygen extraction ratio from a baseline of 25% to a maximum of 60-70%. This allows for preservation of oxygen consumption down to a hemoglobin concentration of approximately 8.0 g/dL. Assuming there is no intravascular depletion, cardiac compensation can preserve DO2 down to a hemoglobin of 5.0 before tissue hypoxia and lactic acidosis will ensue. This threshold is called the Critical DO2 and given our patient’s preserved cardiac function, his symptoms could not be explained by his anemia of 7.1 alone. ccRCC has been shown to lead to dysregulated erythropoietin synthesis and function, which results in anemia. Furthermore, the tumor thrombus which had invaded his IVC provides a mechanical explanation for his lower extremity swelling. His worsening dyspnea on exertion are likely reflective a chronic hyperinflammatory state with possible mechanical contribution from his lung metastasis.

The threshold where oxygen delivery fails to meet the tissue oxygen requirements is referred to as the Critical DO2. In patients with preserved cardiac function, the critical DO2 threshold typically occurs around a hemoglobin of 5-6 g/dL. Despite our patient presenting with dyspnea and tachycardia in the setting of worsening anemia, the concept of Critical DO2 helped us understand that his presenting hemoglobin of 7.1 g/dL alone likely did not explain his symptoms, prompting further investigation and resulting in a new diagnosis of metastatic renal cell carcinoma. CRITICAL ROLE OF DIETARY CONTROL IN MANAGING HYPERTRIGLYCERIDEMIA-INDUCED PANCREATITIS Own D. Khraisat1; Ellen Choi1; Yu-Han Chen2; Dipal R. Patel3. 1Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ; 2Internal Medicine, Englewood Health, Englewood, NJ; 3Dept of Medicine, Englewood Health, Englewood, NJ. (Control ID #4217690) CASE: A 40-year-old man with a history of hypertriglyceridemia (HTG), familial hypercholesterolemia, hypertension, depression, and PTSD presented to the emergency room with worsening epigastric pain over 3 days. He had poorly controlled dyslipidemia and was only on niacin. His lipid panel showed triglycerides (TG) at 3754 mg/dL and cholesterol at 704 mg/dL. Upon arrival, the patient was hemodynamically stable and afebrile. Laboratory results indicated TG at 2721 mg/dL, cholesterol at 606 mg/dL, HDL at 22 mg/dL, LDL at 138 mg/dL, and elevated lipase at 613 U/L. A CT scan revealed hepatic steatosis and signs consistent with acute pancreatitis (AP), leading to a diagnosis of hypertriglyceridemia-induced pancreatitis (HTGP). The treatment plan included intravenous fluids and an insulin drip at 0.1 units/kg/hr, with dextrose infusions to maintain normoglycemia. The patient continued his home niacin at 1000 mg daily and was started on rosuvastatin 40 mg and gemfibrozil 600 mg. A nutritionist recommended a low-fat diet after the resolution of pain. However, TG levels remained high. Niacin was increased to 1500 mg, and gemfibrozil was switched to fenofibrate 145 mg, yet TG persisted around 1800 mg/dL. It was discovered that the patient was non-compliant with his prescribed diet, bringing fatty foods from outside the hospital. After enforcing dietary compliance, his TG levels significantly improved, dropping to less than 1000 mg/dL within 2 days. IMPACT/DISCUSSION: Hypertriglyceridemia is a recognized but rare cause of AP, with an incidence of 2-4%. Elevated TG levels correlate with increased risk and severity of AP, with levels above 1000 mg/dL commonly linked to its onset. Timely identification of HTG is crucial for effective treatment. Management for HTGP follows established protocols for AP, focusing on reducing TG levels. Interventions may include plasmapheresis, insulin therapy, heparin infusion, and hemofiltration. Monitoring blood glucose during insulin therapy is vital to prevent hypoglycemia. Treatment should continue until TG levels fall below 500 mg/dL. Once oral intake is tolerated, fibrates are recommended as the first-line lipid-lowering therapy. In our case, the patient required glucose pushes and infusion to maintain normoglycemia, which posed a challenge in continuing the insulin drip to lower TG levels. Additionally, there is often a strong focus on medication management overlooking the possibility of dietary non-compliance. This patient’s TG levels dropped significantly once the diet was restricted. Preventing relapse of HTGP requires a low saturated fat diet, weight loss, alcohol avoidance, and management of diabetes and carbohydrates intake to control TG levels.

In conclusion, effective management of HTGP involves timely diagnosis, aggressive treatment to lower TG, and long-term strategies focused on dietary modifications and lifestyle changes. Addressing dietary non-compliance is critical for achieving optimal patient outcomes and preventing recurrence of HTGP. CRYPTOCOCCAL MENINGITIS PRESENTING AS RETROGRADE AMNESIA IN AN IMMUNOCOMPETENT INDIVIDUAL Zaid Nour2; Joshua Ross1; Peter S. Zhang1. 1Department of Medicine, New York University Grossman School of Medicine, New York, NY; 2Education, Faculty and Academic Affairs, New York University Grossman School of Medicine, New York, NY. (Control ID #4272960) CASE: A 54-year-old shelter-domiciled male with a history of Hepatitis C and polysubstance use presented to the ED with multiple recent falls and retrograde memory loss. He reported getting lost en route to his methadone clinic over the past week but otherwise had no other constitutional symptoms. He exhibited word finding difficulty and stated he lived in an apartment but could not provide further details. He struggled to recall major life details, such as who his parents were or where they resided and expressed frustration with his memory loss. Collateral from his case manager of two years confirmed a deviation from baseline mental status over the prior few weeks. The patient, a Hungarian immigrant of 20 years, described a vague work history as a “printer” and had a remote history of intravenous cocaine use until one month prior. On initial assessment, vitals were unremarkable; he was afebrile. On exam, he appeared disheveled. He had no meningismus, but was noted to have mild left CN VI palsy, hyperreflexia, jaw jerk, and bilateral Hoffman's sign. He demonstrated an unsteady narrow gait with loss of postural reflexes. CT of his brain revealed mild ventriculomegaly, and MRI brain revealed leptomeningeal enhancement. He underwent a lumbar puncture which was significant for a normal opening pressure of 22cmH2O, elevated CSF protein (313mg/dL), and lymphocytic pleocytosis (131 cells/mcL); BioFire meningitis PCR panel was negative for usual pathogens, including for Cryptococcus neoformans. Given the initial concern for CNS tuberculosis, empiric treatment with RIPE protocol was initiated. Other laboratory and imaging evaluations, including HIV, TSH, vitamin levels, drug screen, empiric cultures, and chest imaging, were all unremarkable. The next day, Cryptococcus antigen titer returned positive (1:320). RIPE therapy was discontinued, and the patient was started on cryptococcal induction therapy with Amphotericin and Flucytosine. After 2 months of follow-up, his Cryptococcus antigen titer steadily improved (1:40) with corresponding improvement in his mental status. On his most recent assessment, he is noted to be alert and oriented, with resolution of his memory deficits. IMPACT/DISCUSSION: Cryptococcal meningitis (CM), most commonly seen in immunocompromised individuals, is increasingly seen in immunocompetent patients. Despite this patient’s immunocompetent state, he likely had other risk factors for CM (using intravenous drugs and living in shelters). Further, our case also demonstrates the limitations of routinely used laboratory tests, such as meningitis PCR panels and India Ink staining. Overall, our case highlights the need to have a higher clinical suspicion of fungal meningitis in the undifferentiated patient with encephalopathy, regardless of immunocompetency.

Cryptococus can present in immune competent individuals Treatment requires vigilance in monitoring symptoms CRYPTOCOCCUS IN THE SHADOWS: A LINGERING FOE AFTER TONGUE CANCER THERAPY Rakesh Reddy Likki1; Shanmukha Priya Peddireddy2; Sri V. Banda1. 1Internal medicine, Nuvance Health, Lagrangeville, NY; 2Internal Medicine, Nuvance Health, Lagrangeville, NY. (Control ID #4272565) CASE: A 49-year-old male with a history of invasive squamous cell carcinoma (SCC) of the tongue, treated with cisplatin-based chemoradiation in 4/23, presented with a 1-2 week history of malaise, altered mental status, hallucinations, and poor oral intake. His medical history included jaw osteonecrosis (post-debridement 12/23), active smoking and alcohol use disorder. The patient had neglected medical care for the past year. On admission, he was febrile, hypotensive, and displayed signs of dehydration and malnutrition. Labs revealed severe anemia, thrombocytopenia, and elevated creatinine. Imaging revealed bilateral pleural effusions and right lung ground-glass opacities. The patient was admitted to the ICU with sepsis due to community-acquired pneumonia, complicated by acute renal failure and metabolic encephalopathy. Initial management included broad-spectrum antibiotics, intravenous fluids, blood transfusions, and vasopressor support. Blood cultures grew Cryptococcus neoformans, and cerebrospinal fluid (CSF) analysis confirmed cryptococcal meningitis. Antifungal therapy with amphotericin B and flucytosine was initiated. Despite aggressive management, his clinical course deteriorated with worsening respiratory failure, progressive encephalopathy, and multi-organ failure. The family decided to transition to comfort care, and the patient subsequently passed away. IMPACT/DISCUSSION: This case illustrates the complexity of managing opportunistic infections in patients with significant immunosuppression due to malignancy and its treatment. The patient’s history of chemoradiation, coupled with malnutrition, active smoking, and alcohol use disorder, heightened his susceptibility to Cryptococcus neoformans infection. The delayed presentation, attributed to healthcare neglect, contributed to advanced disease at the time of diagnosis, complicating management efforts. Early recognition of cryptococcal meningitis through CSF analysis enabled the initiation of targeted antifungal therapy. However, the patient’s critical condition, compounded by multi-organ failure, ultimately led to a fatal outcome. This case highlights the role of multiple predisposing factors in the development of opportunistic infections. Chemoradiation-induced immunosuppression, combined with poor nutritional status and comorbid substance use, created an environment conducive to severe infections. It underscores the importance of maintaining vigilance for fungal infections in high-risk populations.

This report emphasizes the need for early diagnosis and management of opportunistic infections in immunosuppressed patients. Addressing barriers to care, such as healthcare neglect and comorbid conditions, is critical in improving outcomes. Furthermore, integrating palliative care into the treatment plan for patients with limited prognoses ensures a comprehensive approach to care. Multidisciplinary management and preventive strategies are crucial to mitigate the risk of severe infections in vulnerable populations. CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS AS THE HERALD OF SYSTEMIC LUPUS ERYTHEMATOSUS Monique Fagan. Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4270397) CASE: A 47-year-old female with no significant past medical history presented with a one-week history of rash of the bilateral ankles and thighs. It was described as red/purple, non-pruritic, painless and symmetrical. She had no ill contacts, prior history of similar rash or environmental changes. Examination revealed palpable purpura affecting both lower extremities. The rash then spontaneously resolved. Two months later, she developed intermittent polyarthralgia. An initial limited autoimmune workup showed negative ANA by IF, anti-CCP and RF. Later, she was hospitalized with symptomatic anemia and recurrence of a similar rash. Workup revealed: Hemoglobin 5.3 mg/dL, ESR >140mm/hr, CRP 2.7, positive anti-dsDNA at 12.0 IU/mL (later negative by Crithidia), positive ANA (>1:80), with otherwise negative ENA panel. CT C-Spine and Chest showed diffuse lymphadenopathy. Punch biopsy of her skin lesions revealed leukocytoclastic vasculitis (LCV) and axillary lymph node biopsy showed B/T cell reactive changes. Further investigation revealed decreased complement levels (C3: 36, C4: <8, total <14 (mg/dL). Later, she had an acute kidney injury, elevated protein:creatinine ratio (1634) and 24-hour urine protein level of 1,125 mg resulting in a renal biopsy that showed diffuse class IV lupus nephritis. At this point, she was diagnosed with Systemic Lupus Erythematosus (SLE) and treated with Methylprednisolone, Mycophenolate and Hydroxychloroquine with remission of lupus nephritis. IMPACT/DISCUSSION: Mucocutaneous lesions are a known feature of SLE, however cutaneous LCV is less common as an initial presentation. Cutaneous LCV may delay the diagnosis of SLE, especially in the absence of other lupus-specific symptoms and signs. In this case, the onset of cutaneous LCV preceded her official diagnosis by 11 months. In addition, the delayed seropositivity despite the presence of palpable purpura, lymphadenopathy and arthralgia proved to be a diagnostic challenge. The EULAR/ACR criteria requires a positive ANA as an entry criterion for the diagnosis of SLE, therefore she did not initially meet criteria. In addition, LCV is not explicitly listed as a possible mucocutaneous lesion of SLE. Eventually, she met criteria with transient seropositivity and additional features such as lupus nephritis. In patients presenting with unexplained LCV, it is crucial to consider systemic autoimmune diseases, including SLE, as part of the differential diagnosis. Prompt recognition and treatment are crucial to prevent complications, particularly in patients with other systemic symptoms.

Recognizing LCV as a potential cutaneous manifestation allows for timely diagnosis and initiation of therapy, which can improve patient outcomes and prevent complications. Patients presenting with cutaneous LCV shoud be closely monitored for development of SLE. Diagnostic criteria is essential, however, the heterogeneity in presentation of SLE requires vigilance and full consideration of the clinical picture as in this case. CYTOMEGALOVIRUS ANTERIOR UVEITIS WITH DENDRITIC KERATITIS: A RARE EYE DUO THAT LIKES TO KEEP THINGS INTERESTING! Shanmukha Priya Peddireddy1; Sean Nichols4; mathew schear2; Hector Ojeda-Martinez3. 1Internal Medicine, Nuvance Health, Lagrangeville, NY; 2Ophthalmology, Nuvance Health, Lagrangeville, NY; 3Infectious disease, Nuvance Health, Lagrangeville, NY; 4Nuvance Health, Lagrangeville, NY. (Control ID #4272470) CASE: A 61-year-old immunocompetent Caucasian male with a history of recurrent uveitis and secondary glaucoma presented with cloudy vision, ocular pain, redness, and swelling in his left eye. Initially diagnosed with viral keratitis by a retinal specialist, the patient was referred to an ophthalmology clinic for further evaluation.On slit-lamp examination, findings included 1+ conjunctival injection, moderate corneal edema, and temporal pseudo-dendrite lesions with negative staining. Based on these findings, an initial diagnosis of herpes simplex virus (HSV)-related iritis was made, and treatment with valacyclovir and topical steroids was initiated. Despite this regimen, the patient’s symptoms persisted. A follow-up examination revealed sectoral retinal atrophy with a distinctive moth-eaten appearance superiorly, along with ongoing uveitis. This prompted a referral to a uveitis specialist. Anterior chamber paracentesis and PCR testing were performed, which confirmed cytomegalovirus (CMV) infection. Treatment was initiated with valganciclovir and topical steroids. This led to the resolution of dendritic lesions and quiescence in the anterior chamber upon follow-up. However, attempts to taper valganciclovir resulted in symptom recurrence necessitating maintenance therapy with 450 mg twice daily. IMPACT/DISCUSSION: This case highlights the diagnostic challenges associated with viral uveitis in immunocompetent individuals. The patient’s initial presentation, featuring dendritic-like lesions and presumed HSV etiology, did not respond to standard antiviral therapy. Persistent symptoms and the presence of sectoral retinal atrophy necessitated further evaluation, leading to a diagnosis of CMV uveitis. CMV is an uncommon cause of uveitis in immunocompetent individuals but can result in significant ocular complications. Unlike HSV, CMV may present with pseudo-dendritic lesions and distinctive sectoral retinal atrophy. PCR testing of the anterior chamber fluid was instrumental in confirming the diagnosis, emphasizing the importance of molecular diagnostics in atypical or refractory cases. The reliance on valganciclovir for symptom control underscores the chronic nature of CMV uveitis and the potential need for long-term suppressive therapy. This case demonstrates the necessity of a broad differential diagnosis and the role of advanced diagnostic tools in managing complex ocular conditions.

This case underscores the diagnostic challenges posed by CMV uveitis, particularly in immunocompetent individuals with atypical presentations. The presence of dendritic-like lesions, a feature typically associated with HSV, initially complicated the diagnosis. However, persistent symptoms, retinal atrophy, and PCR testing ultimately confirmed CMV as the causative pathogen. This case highlights the importance of considering CMV in the differential diagnosis of recurrent or refractory anterior uveitis and demonstrates the critical role of molecular diagnostics in achieving accurate diagnoses. DAPTOMYCIN INDUCED RHABDOMYOLYSIS - A RARE ENTITY Rochelle A. Jayavendra1; Aman Saleemi2; Zain Kulairi3. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Wayne State University, Detroit, MI; 3Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4273232) CASE: A 33-year-old male with a past medical history of CKD Stage G5, type 2 diabetes mellitus and hypertension presented to the ED with complaints of purulent drainage from right foot, fever and chills over 1 week. Upon evaluation in the ED, patient had a temperature of 101.2. Labs were remarkable for BUN 34, creatinine 5.6, WBC 15.2, hemoglobin 7.7 and albumin 2.1. On exam, patient was noted to have ulcerations to the first and fifth metatarsophalangeal joints with foul smelling discharge. Right foot x-ray showed soft tissue emphysema surrounding the left first digit of the right foot, and cortical disruption visualized from the base of the proximal phalanx of the fifth digit. He was admitted with sepsis secondary to infection from underlying diabetic foot ulcer. The patient was treated via incision and drainage and open amputation of right fifth digit. Given this, patient was started on Flagyl and cefepime. However, both antibiotics were discontinued, with blood cultures positive for MRSA, where daptomycin was initiated. On day 2 of treatment, the patient began to complain of generalized weakness, fatigue and worsening creatinine to 6.6. At that time CK levels were >22000 unit/L. With concerns for daptomycin induced rhabdomyolysis, antibiotics were transitioned to linezolid. Results for urine myoglobin showed 14375 ng/mL, confirming diagnosis. Patient was treated with aggressive IV fluid administration and electrolyte correction. Following this, CPK continued to downtrend and creatinine level returned to baseline and patient was discharged to IPR. IMPACT/DISCUSSION: Daptomycin-induced rhabdomyolysis is a rare, adverse reaction resulting from daptomycin use, especially in high-risk populations such as those with renal failure, concomitant statin use, and patients on high doses of daptomycin. Daptomycin, a lipopeptide antibiotic, works by calcium-dependent insertion into the bacterial membrane, leading to membrane depolarization. While it is not clearly understood how daptomycin induces rhabdomyolysis, it is proposed that the mechanism lies behind the disruption of calcium within the skeletal muscle versus mitochondrial dysfunction. Regardless, early detection of rhabdomyolysis is critical in preventing severe outcomes, such as electrolyte imbalances and renal failure from the breakdown of muscles cells and release of potential toxic substances. Monitoring of CK levels and clinical symptoms during daptomycin therapy, particularly in high-risk populations, is recommended. Additionally, future research can be focused on the mechanism leading to daptomycin induced rhabdomyolysis and formulation for guidelines regarding early detection and contraindications for use.

In conclusion, daptomycin therapy should be used in caution, specifically in patients with underlying renal dysfunction and those receiving high doses of daptomycin. Monitoring CK levels in high-risk populations is recommended to prevent complications including worsening renal function and electrolyte imbalances. DEADLY DESCENT: A RARE CASE OF CARDIAC TAMPONADE FROM ACTINOMYCES ODONTOLYTICUS, STREPTOCOCCUS CONSTELLATUS, AND STREPTOCOCCUS INTERMEDIUS IN IMMUNOCOMPETENT HOST Usman Bin Hameed, Mujtaba Moazzam, Tanya Amal, Florian Bukovec. Internal Medicine, Corewell Health, Royal Oak, MI. (Control ID #4272401) CASE: A 39-year-old male presented with sharp chest pain radiating to his back, shortness of breath, chills, nausea, and vomiting. He had a recent two-week dental infection treated with Augmentin, but his symptoms worsened to include left neck pain, malaise, and intermittent chest pain. He denied drug use, travel, or TB exposure. Exam showed poor dentition and mild left anterior cervical tenderness. Vitals: BP 102/71 mmHg, HR 113 bpm, RR 21/min. Labs: WBC 43.3 x10^9/L (70% neutrophils), CRP 266.3 mg/L, negative troponins. EKG showed ST elevations and PR depressions in several leads. CT showed pericardial effusion, mediastinal adenopathy, and gas pockets indicating descending necrotizing mediastinitis (DNM). A bedside POCUS revealed a large pericardial effusion with tamponade physiology including right atrial and right ventricular collapse with a distended IVC. Emergent pericardiocentesis drained 350 mL of purulent fluid. Analysis showed 1.1 million cells/μL (70% neutrophils), protein 4.9 g/dL, LDH >4500 U/L, and glucose <5 mg/dL. Initial treatment included vancomycin and piperacillin-tazobactam, later narrowed to ampicillin-sulbactam. Pericardial fluid cultures identified S. constellatus, S. intermedius, and A. odontolyticus. A CT scan of the mandible revealed damaged teeth with periapical lucencies. The patient was discharged on Ertapenem for 4 weeks with close monitoring for the development of constrictive pericarditis. IMPACT/DISCUSSION: Purulent pericardial effusion accounts for approximately 1% of pericarditis cases and carries a mortality rate of up to 40% without timely intervention. This case is the first documented instance of Actinomyces odontolyticus, Streptococcus constellatus, and Streptococcus intermedius causing pericardial tamponade secondary to DNM. EKG findings of diffuse ST elevations with PR depression and POCUS evidence of pericardial effusion confirmed pericarditis. A recent dental infection, along with imaging findings of mediastinal gas pockets and periapical lucencies, strongly supported the diagnosis of DNM, a rare but severe odontogenic complication. DNM spreads rapidly through fascial planes, with mortality exceeding 50% if untreated, highlighting the importance of early recognition. Emergent pericardiocentesis drained 350 mL of purulent fluid, alleviating tamponade and providing a diagnostic sample confirming polymicrobial infection. Prompt broad-spectrum antibiotics, later narrowed to ampicillin-sulbactam, were critical in managing the infection. Constrictive pericarditis develops in 20–30% of purulent effusion cases, underscoring the need for vigilant follow-up.

This case underscores the importance of early recognition with POCUS in diagnosing pericardial effusion with tamponade physiology, considering rare oral flora in purulent pericarditis. Timely pericardiocentesis and antibiotics are vital to prevent cardiac tamponade, septic shock, and constrictive pericarditis. DECODING DUAL DIAGNOSIS: PSYCHOGENIC NON-EPILEPTIC SEIZURE AND EPILEPSY IN CHALLENGING CLINICAL PRESENTATIONS Hufsa Khan1; Marwah Shuaib1; Niharika Chandna2; Peter Caldwell1. 1The George Washington University School of Medicine and Health Sciences, Washington, DC; 2University of Virginia, Charlottesville, VA. (Control ID #4228675) CASE: A 27-year-old woman with systemic lupus erythematosus (SLE) and history of a single seizure episode presented with acute altered mental status. The patient was initially disoriented and nonverbal, able to open eyes but unable to track, intermittently responding to commands. She eventually deteriorated, becoming obtunded and later comatose. Her NIH Stroke scale was 2 and no focal deficits were noted during her hospitalization. MRI findings revealed mild-to-moderate brain atrophy with patchy periventricular and subcortical hyperintensities, suggesting an inflammatory process. After ruling out meningoencephalitis with a lumbar puncture, she was diagnosed with Neuropsychiatric SLE (NPSLE), later complicated by multiple unprovoked seizure-like episodes. Three 24-hour video electroencephalograms (vEEGs) were negative for epileptic activity despite the presence of postictal states and tongue lacerations. Her treatment for lupus cerebritis led to improvements in mental status and neurological symptoms, although seizure-like activities persisted. Despite repeated negative EEGs, the patient was started on Levetiracetam 500 mg alongside 1mg Lorazepam as needed. Notably, the patient retained memory of one episode, and experienced two panic attacks suggesting concomitant psychogenic non-epileptic seizures (PNES) and anxiety. These PNES events occurred after administration of Levetiracetam, supporting the possibility of a dual diagnosis. IMPACT/DISCUSSION: Our patient had experienced both PNES events with negative EEG and clinically apparent seizures. Her events continued even after her NPSLE responded to treatment. This prompted a multidisciplinary evaluation of the best management of her seizure-like episodes. Ultimately, the Neurology team decided her clinical symptoms of epileptogenic seizures that continued despite NPSLE treatment warranted AED therapy. Administration of levetiracetam stopped the patient’s clinical features of true seizures including tongue biting and postictal states, but PNES-suggesting events continued. We also acknowledged that the trauma and anxiety of her acute illness likely played a role in PNES events, and she was started on escitalopram.

The dual diagnosis of PNES and epilepsy is vital in patients with altered mental status and limited histories. EEGs aid in differentiating these conditions, yet their temporal limitations make clinical judgment essential. Hospitalists should adopt a multidisciplinary approach for complex cases like NPSLE, coordinating with neurology, psychiatry, and rheumatology to ensure comprehensive care. When high clinical suspicion supports a dual diagnosis, antiepileptic drugs may be initiated with consult support. Additionally, addressing the psychological aspects, reducing trauma and anxiety, and integrating holistic and collaborative care can significantly enhance patient outcomes in these challenging cases. DEFYING THE ODDS: EFFECTIVE CPR ACHIEVES REMARKABLE NEUROLOGIC PRESERVATION AFTER PROLONGED CARDIAC ARREST Joshua Tsai1; Juan Rivera-Martinez1; Mason Grimm1; SOPHIA A. VOZZA1; Hemantkumar Raval2. 1GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2Pulmonary & Critical Care, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4273458) CASE: Cardiopulmonary resuscitation (CPR) is a critical intervention in cardiac arrest management, essential for maintaining circulation and oxygenation to avert irreversible brain damage. This case report highlights the impact of high-quality CPR on neurological outcomes, even after extended resuscitation. A 45-year-old sedentary female with multiple sclerosis (MS) and morbid obesity with a BMI of 53 presented with gastrointestinal and dyspnea symptoms post-immunotherapy. Imaging identified bilateral lower lobe pulmonary embolisms and a saddle embolus with significant thrombus burden and right heart strain. During suction thrombectomy, the patient experienced pulseless electrical activity (PEA) arrest. Manual CPR was immediately initiated, and the patient was intubated 12 minutes later. Due to the patient’s body habitus, robotic compressions could not be performed. Sustained return of spontaneous circulation (ROSC) was achieved after 70 minutes, despite transient ROSC episodes. Throughout the resuscitation, she received 13 doses of epinephrine and 4 doses of sodium bicarbonate. Following the event, the patient required hemodialysis due to renal deterioration but stabilized hemodynamically five days later. She regained cognitive capacity and full motor function within 10 days, leading to discharge after a 28-day hospitalization. IMPACT/DISCUSSION: The optimal duration of CPR in adults remains debated. A 2024 meta-analysis indicated a significant decrease in favorable neurological outcomes beyond 15 minutes of CPR. Effective CPR entails compressions at a depth of at least 2 inches at a rate of 100 to 120 compressions per minute, full chest recoil, minimal interruptions, and proper team coordination. Despite typically poor outcomes associated with prolonged CPR, this case illustrates that timely and effective resuscitative efforts can result in complete neurological recovery even after 70 minutes of CPR. A retrospective cohort study in 2024 found the probability of favorable outcomes beyond 32 minutes of CPR to be less than one percent, highlighting the exceptional nature of this case.

This case report attenuates the importance of high-quality CPR in achieving positive neurological outcomes, challenging conventional beliefs about prolonged resuscitation prognoses. It reinforces the need for rigorous adherence to CPR guidelines, ongoing education, and training for medical providers. The remarkable recovery of this patient emphasizes the potential for favorable outcomes with persistent and effective resuscitative efforts. Further research is warranted to refine CPR duration guidelines and explore factors contributing to improved patient outcomes. Studies investigating predictive factors for favorable neurological outcomes and the efficacy of mechanical compression devices are planned. DELAYED PRESENTATION OF CHOLEDOCHOLITHIASIS EIGHT YEARS POST-CHOLECYSTECTOMY WITH INITIALLY NEGATIVE DIAGNOSTIC FINDINGS Wasiq Rashid. Morsani College of Medicine, University of South Florida, Tampa, FL. (Control ID #4268597) CASE: A 41-year-old male with cholecystectomy 8 years ago presented to our emergency department (ED) with acute, severe epigastric pain radiating to the back along with nausea and non-bilious vomiting. Earlier that day, he had been discharged from a different ED with only supportive/symptomatic management after initial laboratory tests, including bilirubin and liver function tests (LFTs), were within normal limits, and computed tomography (CT) of the chest, abdomen, and pelvis showed no acute findings. At our ED, he now had worsening of symptoms, elevated LFTs (ALT 283, AST 375) and neutrophilic leukocytosis. Social history was unremarkable with no tobacco, alcohol, or illicit drug use. Past medical history included only the prior cholecystectomy. He was not on any medications at presentation. Physical exam revealed severe epigastric pain with light palpation, but negative Murphy sign or rebound tenderness. Abdominal ultrasound (US) and repeat CT abdomen revealed no pertinent biliary or pancreatic findings. Blood cultures revealed E. coli and K. pneumoniae bacteremia, and patient received appropriate antibiotics. Despite this, severe symptoms persisted. A magnetic resonance cholangiopancreatography (MRCP) was pursued, which revealed a filling defect in the distal common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, which confirmed choledocholithiasis. The stone was removed via balloon extraction, and the patient improved rapidly after the procedure. IMPACT/DISCUSSION: Choledocholithiasis is rare in patients post-cholecystectomy with an incidence of around 0.4%, and a vast majority of cases occur within 3 years following the procedure. Pathophysiology can include retained stones within a gallbladder remnant, sphincter of Oddi dysfunction, or migration of surgical clips. Diagnostic workup typically includes clinical suspicion (acute epigastric or right upper quadrant pain, jaundice), elevated biliary, liver, and pancreatic labs, and abdominal imaging (US or CT). In the event of high clinical suspicion yet negative imaging results, MRCP is a sensitive follow-up test. First-line intervention includes ERCP with stone removal, which typically resolves symptoms with low recurrence rates. This case contributes uniquely to existing literature by demonstrating an instance of choledocholithiasis despite exceedingly low pre- and post-test probabilities on initial workup, highlighting the importance of clinical vigilance when objective findings do not align with symptomatic presentation. Additionally, this case reinforces the need for a systematic approach in diagnosing biliary disease and emphasizes the utility of MRCP and ERCP in managing complex cases.

- Choledocholithiasis can present many years post-cholecystectomy and may not always be detected on initial labs or imaging. - Clinicians should remain vigilant for occult biliary disease in similar cases and consider further workup if clinical suspicion does not align with initial objective results. DELAYED UNMASKING: A LATE-ONSET CASE OF DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS) SYNDROME Malik Alqawasmi, Jacob Imber. School of Medicine, University of New Mexico School of Medicine, Albuquerque, NM. (Control ID #4269339) CASE: A 47-year-old female with a history of chronic severe anemia (uterine fibroid), IVC thrombus (on apixaban), recent COVID-19 infection (treated with Remdesivir), and prolonged hospitalization for MSSA bacteremia with skin abscesses and septic arthritis (treated with IV antibiotics) was readmitted 4 days after discharge for a pruritic rash covering 60% of her body. Symptoms began near discharge, initially attributed to dryness. On readmission, she was afebrile, tachycardic, and had an edematous face with faint pink scaly papules coalescing into plaques across her trunk, extremities, and face. Labs showed worsened leukocytosis, new eosinophilia, elevated creatinine (0.43→1.05 mg/dL), and elevated alkaline phosphatase (187 units/L). Drug exposures included cefazolin, vancomycin, piperacillin-tazobactam, and Remdesivir, with a family history of drug reactions (e.g., sulfa allergy) suggesting genetic predisposition. Punch biopsy revealed spongiotic and vacuolar interface dermatitis with eosinophils and neutrophilic pustules, consistent with a drug eruption. A RegiSCAR score of 6 classified her as a “definite” case of DRESS syndrome. All antibiotics were discontinued. Dermatology and infectious disease consultations recommended high-dose IV methylprednisolone and topical triamcinolone. Anasarca improved with IV furosemide, and creatinine normalized within 5 days. The rash resolved gradually, and she was discharged on a four-week prednisone taper, PJP prophylaxis (TMP-SMX), and GI protection (pantoprazole). Follow-up with dermatology and repeat labs were scheduled. IMPACT/DISCUSSION: DRESS syndrome is a severe, delayed hypersensitivity reaction that typically occurs 2–8 weeks after exposure to certain medications, such as anticonvulsants, antibiotics, and antivirals. This patient’s presentation, with a delayed onset after antimicrobial use, (cefazolin seems the most likely culprit), highlights the diagnostic challenges. The lack of specific histologic findings and reliance on clinical criteria such as the RegiSCAR score are helpful for diagnosis. Management involves immediate withdrawal of the offending agent, corticosteroids, and supportive care, including monitoring for organ involvement. Prompt recognition and intervention can prevent severe outcomes, including organ failure and long-term sequelae.

This case underscores the complexities of diagnosing and managing DRESS syndrome, particularly with delayed onset and multiple potential drug culprits. Early suspicion, identification, and treatment are critical to minimizing morbidity. Ongoing patient education, drug avoidance, and follow-up are key to preventing recurrence and ensuring long-term health. DEVELOPMENT OF DAPTOMYCIN RESISTANCE DURING TREATMENT OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA Ross Hardin1,4; Ali Hassoun3; Addison Hardin2; Hinal Rathi5. 1Internal Medicine, UAB Health System, Huntsville, AL; 2Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL; 3Infectious Disease, Huntsville Hospital Health System, Huntsville, AL; 4Huntsville Hospital Health System, Huntsville, AL; 5Internal Medicine, University of Alabama Huntsville Regional Campus, Huntsville , AL. (Control ID #4267743) CASE: A 48-year-old male with end-stage renal disease (ESRD) on hemodialysis, cervical spinal stenosis post-laminectomy, and paraplegia presented with worsening lower back pain for two weeks. He arrived with altered mental status from his outpatient hemodialysis center and was unable to complete his dialysis due to pain. The patient had multiple admissions over the previous year, including a month prior, when he was discharged on daptomycin for pressure-related sacral wounds and bacteremia caused by multi-drug resistant (MDR) MRSA sensitive to daptomycin. Despite extensive workup, no infection source other than sacral wounds was identified at that time. On examination, the patient appeared ill and intermittently responsive. His sacral region showed multiple ulcerations without exposed bony prominences. He was hypotensive. Laboratory findings revealed leukocytosis and elevated CRP levels. A CT scan of the abdomen and pelvis showed evidence of osteomyelitis and discitis at L2-4, which an MRI of the lumbar spine confirmed. Blood and wound cultures were obtained, and daptomycin and ceftazidime were started. A CT-guided biopsy of the lumbar vertebrae confirmed the presence of MDR MRSA, now resistant to daptomycin. The antibiotics were adjusted from daptomycin to telavancin. A transesophageal echocardiogram (TEE) revealed echo-dense vegetations on the patient's Ash Split catheter, which was replaced, leading to negative subsequent blood cultures. Despite this, the patient remained critically ill, and serial lumbar MRIs showed the development of an epidural phlegmon. Neurosurgery recommended continuing IV antibiotics for lumbar osteomyelitis and discitis without performing surgical intervention due to the absence of epidural abscess formation. IMPACT/DISCUSSION: This case illustrates the challenges of identifying and controlling infection sources in patients with sepsis and bacteremia. Inadequate source control can lead to reinfection and the development of antibiotic resistance. Previous workups failed to reveal the infection source, and the patient was discharged on IV daptomycin. Without proper source control, the MDR MRSA formed resistance to daptomycin, an exceptionally rare occurrence but has been seen in cases where a deeply rooted infection cannot be managed surgically. Another key takeaway is the importance of considering the entire spinal column as a potential infection site in patients with a history of invasive spinal procedures. The patient's prior cervical surgery warranted additional MRI evaluation of the cervical and thoracic spine, but the lumbar region remained unassessed. Invasive spinal procedures increase the risk of infections along the entire spinal column.

This case highlights the vital role of adequate source control in managing active infections. Without prompt removal of the infection nidus, patients remain highly susceptible to life-threatening infections and the development of antibiotic resistance despite prolonged IV antibiotic treatment. DIABETIC KETOACIDOSIS ASSOCIATED WITH CAPIVASERTIB FOR TREATMENT OF METASTATIC BREAST CANCER Kabeer Ali, Natalie Shaykh, Michael Yanoschik, Christopher Izzo, Alexander Den Boef, Tiffany Scotto, Pramod Reddy. Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, FL. (Control ID #4272469) CASE: A 65-year-old female with a past medical history of hypertension, heart failure, type II diabetes mellitus, and metastatic breast cancer presented to the emergency room after noticing her blood sugars were elevated at home. She was discharged from the hospital two weeks prior for symptomatic hyperglycemia, which started five days after starting a new breast cancer therapy, capiversatib. The patient visited her oncologist recently, through shared decision-making, decided to restart capiversatib for a second time. Initial labs revealed blood glucose of 751 mg/dL, serum pH of 7.18, serum osmolality of 315 mOsm/kg H2O, and wide anion gap metabolic acidosis with bicarbonate 13 mmol/L and anion gap of 22 mmol/L. The patient was eventually started on an insulin drip at 0.1 units/kg/hour and admitted to the medical intensive care unit where she required over twelve hundred units of intravenous insulin to reverse her diabetic ketoacidosis. The patient required intravenous insulin therapy, totaling over 1200 units, for three days before being able to convert to subcutaneous insulin. Remarkably, once she was no longer in a keto-acidotic state, she had little to no insulin requirement. Ultimately, the patient decided to pursue hospice care given the progression of her cancer, decrease in functional status following repeated hospitalizations, and failure to tolerate multiple lines of therapy, including capiversatib. She passed away peacefully two months later. IMPACT/DISCUSSION: This patient’s presentation is consistent with diabetic ketoacidosis related to capivasertib use. Capivasertib is a selective ATP-competitive pan-AKT kinase inhibitor. Inhibition of AKT disrupts insulin signaling, leading to decreased glucose uptake by cells and increased hepatic gluconeogenesis, thereby causing hyperglycemia. Following the first hospitalization for hyperglycemia, the patient was advised to discontinue capivasertib and follow up with her oncologist for an alternative treatment. However, through shared decision-making with her oncologist, she was re-started on capivasertib along with sliding scale insulin five days before presenting again with hyperglycemia, this time in diabetic ketoacidosis. The dosing of capivasertib makes things more complicated; consisting of four consecutive days of therapy, with three days without the drug. This may result in short periods of hyperglycemia where a patient’s insulin requirements may sharply increase, requiring titration of insulin doses. This may be difficult for patients who are not very astute with self-monitoring of glucose levels or comfortable with self-adjusting insulin dosages.

Capiversatib use, a breakthrough targeted therapy for metastatic breast cancer, can cause acute insulin resistance. Both clinicians and patients should be aware of this potential complication, which can result in an intensive care unit admission and present significant morbidity. DIABETIC KETOACIDOSIS PRESENTING AS SEVERE HYPERTRIGLYCERIDEMIA TRIGGERED BY INTERMITTENT FASTING AND A KETOGENIC DIET Laura Hohenstein1; Ashwin Kumar1; Edgar Naut2. 1Medical School, University of Connecticut School of Medicine, Farmington, CT; 2Internal Medicine, Saint Francis Hospital and Medical Center, Hartford, CT. (Control ID #4273161) CASE: A 61-year-old man with type 2 diabetes and hyperlipidemia presented to the emergency department with a chief complaint of chest pain and was found to have elevated triglycerides (>4000 mg/dL) and cholesterol (>1000 mg/dL), as well as anion gap metabolic acidosis with blood glucose of 250 mg/dL and urine ketones. The workup for a cardiac cause of chest pain was negative. He denied abdominal pain and amylase and lipase were both within normal limits. He reported discontinuation of all prescribed medications, including insulin, two years prior. He recently started intermittent fasting for up to 72 hours at a time and a ketogenic diet. Treatment was initiated with insulin drip and fibrate, however his presenting transaminitis was initially a barrier to statin use. Despite aggressive therapy, lipid panel the following day showed minimal improvement. Plasmapheresis was initiated with good response, bringing triglyceride level <500 mg/dL and cholesterol level <300 mg/dL in a single session. IV insulin was continued until his anion gap closed, per DKA protocol, at which point he was transitioned to a fat-restricted diet with subcutaneous insulin. He was discharged on insulin, fibrate, and statin. IMPACT/DISCUSSION: This case illustrates the potential for severe metabolic consequences of intermittent fasting with uncertain contribution of a ketogenic diet, particularly in those predisposed to metabolic derangements such as insulin-dependent diabetics. Combined with nonadherence to prescribed medications, strict high-fat diets with fasting can precipitate life-threatening conditions like severe hypertriglyceridemia and DKA. Although plasmapheresis is rarely required in cases of severe hypertriglyceridemia, it is a fast and effective way to lower serum lipid levels in patients refractory to medical therapy and at risk for pancreatitis and other sequelae.

Severe hypertriglyceridemia is characterized by triglyceride levels >500 mg/dL and carries risk of acute pancreatitis and adverse cardiac events. Its association with diabetic ketoacidosis has been reported in diabetics but rarely in type 1 diabetes. The ketogenic diet and intermittent fasting are popular weight loss interventions that may pose risk to those with underlying metabolic disorders. Intermittent fasting in particular has been associated with DKA in type 1 diabetes. DIABETIC MYONECROSIS AS A CAUSE OF ACUTE, ATRAUMATIC THIGH PAIN Samantha Shapiro1,2; Linda Baier Manwell2; David A. Feldstein3. 1Internal Medicine, UW Health, Madison, WI; 2Department of Medicine, Division of General Internal Medicine, University of Wisconsin-Madison, Madison, WI; 3Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI. (Control ID #4270490) CASE: A 55 year old male with poorly-controlled Type 2 diabetes presented to the ED with one week of left thigh pain and new-onset swelling that began when his dog jumped on his lap. Exam was notable for localized swelling and exquisite tenderness of the left lateral thigh, with mild warmth, no fluctuance, and limited range of motion of the left hip and knee due to pain. Patient was hemodynamically stable and afebrile. Labs revealed A1c 12.9%, leukocytosis to 12.4, elevated CRP 7.99, and normal ESR. Left thigh ultrasound showed abnormal vastus lateralis muscle, consistent with significant muscular contusion/strain or myonecrosis/myositis. MRI showed loss of expected architecture striations over the left vastus lateralis with a paucity of internal flow. Imaging was reassuring against necrotizing fasciitis. Rheumatology and endocrinology were consulted, and the patient was ultimately diagnosed with diabetic myonecrosis. After starting analgesics, NSAIDs, and insulin, the patient experienced clinical improvement over several days. He was subsequently discharged to short-term rehab for physical therapy. IMPACT/DISCUSSION: Diabetic myonecrosis is a complication of poorly-controlled diabetes, with equal preponderance in both Type 1 and Type 2 diabetes. Its prevalence is not clear, as most information about this condition arises from case reports. Diabetic myonecrosis is more commonly seen in women (53.7–61.5%), with a mean age at presentation of 42.6 to 44.5 years and mean hemoglobin A1c of 9.34%. This condition can affect any muscle, but classically presents as acute unilateral thigh pain. While diabetic myonecrosis is rare, with diabetes rates on the rise, it is important to include this condition on the differential for patients with poorly controlled diabetes who present with atypical muscle pain (particularly unilateral thigh pain) and have imaging negative for necrotizing fasciitis. For these patients, it may be prudent to hold off on diagnostic biopsy, as this can significantly prolong recovery time. The recommended treatment for diabetic myonecrosis is glycemic control, aspirin/NSAIDs, analgesics, and close monitoring. Compared to rest alone, aspirin/NSAIDs decrease recovery from 8 to 5.5 weeks. Surgical intervention can increase recovery up to 13 weeks. Even with recommended treatment, there is a high rate of recurrence (34.9-47.8%) within 6 months. This case made me aware of diabetic myonecrosis as a possible diagnosis for unilateral thigh pain and taught me the importance of avoiding biopsy for classic presentations.

1) Diabetic myonecrosis is a potential sequela of poorly-controlled diabetes, and should be considered for presentations of acute muscular pain (particularly unilateral thigh pain) with otherwise negative workup 2) If diabetic myonecrosis is highly suspected, biopsy should be avoided due to prolonged recovery time 3) Management of diabetic myonecrosis focuses on glycemic control, pain control, and aspirin/NSAIDs DIAGNOSIS AND MANAGEMENT OF SERONEGATIVE MYASTHENIA GRAVIS Reem Matar1; Margherita Milone3; Natalie Griffin2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 3Neurology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271070) CASE: A 37-year-old previously healthy woman presented with a year-long history of a constellation of symptoms following a viral illness in 2022. Her symptoms included hoarseness, dysphagia, unintentional weight loss, and left upper quadrant pain radiating to her back. She noted fasciculations in the arm muscles and electric shock-like pain in fingers and toes. Her dysphagia was initially managed as esophageal candidiasis, but further workup -including five esophagogastroduodenoscopies (EGD)- revealed mild lymphocytosis but no definitive diagnosis was made. MRI of the brain and spine, and electromyography (EMG) study were normal at an outside institution. She presented for a second opinion and underwent further workup. Neurological examination detected mild weakness of the frontalis and neck flexors and mild dysphonia. Her acetylcholine receptor (AChR), muscle-specific kinase (MuSK), P/Q type calcium channel, and lipoprotein-related protein 4 (LRP4) antibodies were negative. Repetitive nerve stimulation of the spinal accessory and facial nerve was normal but single-fiber EMG (SF-EMG) of the orbicularis oculi demonstrated increased jitter and blocking suggestive of a neuromuscular transmission defect. Genetic testing for congenital myasthenic syndromes detected no pathogenic variants. Following treatment with pyridostigmine (Mestinon), the patient reported significant improvement of her symptoms. IMPACT/DISCUSSION: This case illustrates the diagnostic challenges and clinical impact of seronegative myasthenia gravis, often leading to a delay in diagnosis. Myasthenia gravis is characterized by fluctuating muscle weakness and fatigability, with most cases being positive for AChR or less frequently for MuSK or LRP4 antibodies. The use of specialized diagnostic tools, such as single-fiber EMG, was crucial in identifying neuromuscular transmission abnormalities. Additionally, genetic tests excluded a congenital myasthenic syndrome, which sometimes can manifest in adulthood. Symptomatic treatment with pyridostigmine resulted in improvement of the symptoms, which did not require immunotherapy. The improvement seen with pyridostigmine reinforces the importance of considering empirical treatment when clinical suspicion remains high, even in the absence of definitive antibody findings.

1. Seronegative myasthenia gravis should be considered in patients with unexplained muscle weakness, dysphagia, dysphonia, and other neuromuscular symptoms, even in the absence of positive antibodies. 2. Diagnostic tools like SF-EMG, although non-specific, in combination with the proper clinical symptoms and findings, can be critical for accurate diagnosis. Treatment with cholinesterase inhibitors like pyridostigmine can lead to significant symptom improvement. 3. Congenital myasthenic syndromes must be excluded in seronegative myasthenia as they can manifest in adulthood and may require different pharmacological therapy. DIAGNOSTIC AND THERAPEUTIC COMPLEXITY OF DIARRHEA DURING CANCER TREATMENT: A CASE OF IMMUNE CHECKPOINT INHIBITOR (ICI) COLITIS Kabir Grewal, Suman M. Atluri, Kamal Hirani. Margaret M. and Albert B. Alkek Department of Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4241134) CASE: A 78-year-old woman with HTN, HLD, and stage IV right lung adenocarcinoma on treatment with carboplatin, pemetrexed, and pembrolizumab for seven months presented with nausea and diarrhea. Patient endorsed a three-week history of diarrhea with nearly ten episodes a day, abdominal pain, nausea, vomiting, and lethargy. She denied hematochezia, melena, fever, known sick contacts, or prior similar episodes. The symptoms began shortly after a Caribbean cruise. Admission vitals were stable without fever. The CBC showed slight leukocytosis (11,500/mm3) and the BMP showed mild AKI. Liver and pancreatic enzymes and bilirubin were unremarkable. Inflammatory markers CRP (106 mg/dL) and ESR (46 mm/hr) were elevated. Blood and stool bacterial cultures were negative, as was C. diff toxin. Stool calprotectin was extremely elevated at above 3,000 mcg/g (cutoff is 50) and stool viral panel was positive for Norovirus. CT showed diffuse inflammation of the distal ileum and entire colon. Upper and lower endoscopy was performed and showed marked inflammation in the duodenum, ileum, cecum, ascending colon, and rectum. Biopsies showed villous blunting with focal lymphocytosis. These findings were consistent with an auto-immune mediated process, and with recent pembrolizumab use, likely from immune-checkpoint inhibition. The patient was started on steroids at 1 mg/kg/day, and due to a lack of improvement, Vedolizumab, a gut integrin inhibitor, was added. Over the next week the symptoms improved, and the patient was discharged on a steroid taper with scheduled clinic visits for further Vedolizumab infusions. IMPACT/DISCUSSION: Determining the cause of diarrhea in cancer patients undergoing therapy can be difficult. Traditional chemotherapy damages the growth of all rapidly dividing cells in the body, including the digestive tract, often leading to diarrhea. Chemo also suppresses marrow and immune cell proliferation, increasing susceptibility to infections such as GI pathogens. Immune-checkpoint inhibitors (ICI), like pembrolizumab, are now a mainstay of cancer therapy and function by enhancing T-cell mediated destruction of cancer cells. Unfortunately, this can also lead to hyperactive T-cells attacking our own organs, as in ICI colitis. It is theorized that this process can be triggered by infections, such as Norovirus, causing immune hyperactivity. ICI colitis typically presents as prolonged diarrhea and abdominal pain of variable severity. Inflammatory markers tend to be elevated, and endoscopy is the diagnostic gold standard. Findings include diffuse inflammation with leukocytic invasion of the intestines on biopsy. Treatment includes a high-dose steroid taper, with refractory cases requiring further immunosuppression through drugs such as Infliximab or Vedolizumab.

1. Diarrhea related to cancer treatment may be due to chemo-induced cellular destruction, infections, or ICI Colitis 2. ICI Colitis is diagnosed through biopsy and treated with steroids, and if refractory, further immunosuppression DIAGNOSTIC APPROACH AND MANAGEMENT FOR LATE-ONSET SERONEGATIVE INFLAMMATORY RHOMBENCEPHALITIS Tracy Swan1; Cihang Gu2; Daniel Boucek3; Leah Koenig4. 1Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Internal Medicine, UPMC, Pittsburgh, PA; 3Hospital Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA; 4General Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4270391) CASE: a 68-year-old male with history of remote right basal ganglia stroke, hypertension, and hyperlipidemia presented with 2 weeks of dysphagia, diplopia, and unsteadiness. Exam revealed bilateral cranial nerve VI palsy with left-beating nystagmus, hyperreflexia, wide-based gait, positive Babinski sign, and absent vibratory sensation in lower extremities. Labs showed mild hyponatremia (131 mmol/L) and normal ESR/CRP. Brain/spine MRI revealed lobulated enhancement in the medulla and C1-C2 spinal cord with edema extending to C5-C6 with differentials including glioma, lymphoma, and sarcoidosis. Lumbar puncture showed elevated protein (75.7mg/dl) and abnormal IgG index of 0.9. CT revealed borderline enlarged right hilar and mediastinal lymph nodes (~1cm) with small bilateral lung nodules (4-5mm). PET scan showed no significant FDG uptake. Broad infectious workup was negative, including negative blood and cerebrospinal fluid cultures, and Lyme serology. Autoimmune workup was negative for multiple sclerosis (MS), neuromyelitis optica, and IgG4. Empiric IV methylprednisolone (1g x 5 days) followed by oral prednisone led to symptom improvement, including normalization of reflexes (2+/4, no longer brisk), negative Babinski sign, and resolution of ataxic gait. There were no sites amenable to biopsy for confirmatory diagnosis, prompting empiric treatment. A repeat brain MRI after 12 days showed improvement in lesion size. The patient was discharged home on a prolonged steroid taper. IMPACT/DISCUSSION: Rhombencephalitis refers to nonspecific brainstem and cerebellar inflammation and can present with heterogenous neurological symptoms. Diagnostic criteria includes T2 hyperintensities in the brainstem on MRI. Previous literature reveals a wide variety of etiologies including autoimmune (MS, Behcet’s syndrome, lupus), infectious (listeria, EBV, tuberculosis), and paraneoplastic (anti-Yo, anti-Tr antibodies), however most cases are idiopathic. Treatment of inflammatory rhombencephalitis includes immunomodulators, such as corticosteroids. The optimal duration and choice of therapy are poorly understood, with some studies investigating multimodal combination of steroids with IVIG, rituximab, or tocilizumab (Lee et al., 2022).

Rhombencephalitis can manifest with myriad clinical presentations of brainstem and cerebellar features. Management of rhombencephalitis requires careful evaluation for autoimmune, infectious, neoplastic, and metabolic/toxic causes. In our patient, interval improvement after steroids points towards an inflammatory etiology, however follow-up across several years may be the most telling. Guidelines for treatment of seronegative rhombencephalitis are an area of current investigation. Rhombencephalitis can cause significant morbidity, thus prompt diagnosis and treatment are essential and clinicians should remain vigilant despite its nonspecific and perplexing constellation of symptoms. DIAGNOSTIC DILEMMA: ICTEROHEMORRHAGIC LEPTOSPIROSIS IN A PATIENT WITH ALCOHOL ABUSE Hillary Gan1; Mariam Noori2; Oladimeji Okubadejo1; Geevarghese John1; Timea Csak1. 1Internal Medicine, Northwell Health, New Hyde Park, NY; 2Pulmonary Critical Care Medicine, California Pacific Medical Center, San Francisco, CA. (Control ID #4270275) CASE: 61-year-old male with history of hypertension, hyperlipidemia, arthritis, and alcohol use disorder presented with three days bilateral hip and leg pain. He worked as a custodian and stated that symptoms began after handling trash. He reported generalized weakness and worsening of chronic back pain. Exam was notable for scleral icterus, jaundice, and tenderness of right upper quadrant and epigastric region. Labs revealed leukocytosis (12k), thrombocytopenia (44k), acute kidney injury with creatinine (SCr) 3.56 mg/dL from baseline of 0.76 mg/dL, INR 1.29, albumin 1.2 g/dl, and hyperbilirubinemia (direct and indirect, total bilirubin 5.7) with transaminase elevation (< 5x ULN). ALP normal. He was found to have mild rhabdomyolysis (CK1095 U/l). Bilirubin rapidly increased and he became oliguric. Total bilirubin peaked at 20.3 mg/dl and SCr peaked at 5.47 mg/dl. Abdominal imaging (ultrasound, MR/MRCP) showed hepatomegaly, hepatic steatosis, normal biliary tree and gallbladder. Hemolysis panel was negative and peripheral smear revealed no schistocytes. Workup for viral hepatitis, autoimmune serologies, and cultures negative; ferritin and ceruloplasmin normal. Leptospirosis serology was obtained and was positive. He was initiated on penicillin with significant clinical improvement. Renal function and platelet count normalized by day 6 on therapy, while bilirubin and liver enzymes normalized after 1 month. IMPACT/DISCUSSION: Leptospirosis, a zoonotic disease caused by spirochetes, is transmitted through contact with infected animal urine. Its presentation can range from a self-limiting febrile illness to the severe Weil's Disease characterized by jaundice and renal failure. Early antibiotic treatment has been associated with better prognosis. Penicillin has been the preferred drug, but ceftriaxone and cefotaxime are emerging alternatives. The pathogenic mechanism of hyperbilirubinemia in leptospirosis is not well understood; however, studies have shown hepatic infiltration with disruption of intercellular junctions leading to leakage of bile from bile canaliculi. The acute liver injury that occurs can mimic alcoholic hepatitis, posing a diagnostic challenge. If leptospirosis is suspected confirming the diagnosis via serology is paramount as prompt treatment can reduce mortality.

Leptospirosis is often overlooked in patients with a history of alcohol use disorder and undifferentiated jaundice due to potentially overlapping clinical features. In our patient, the degree of renal insufficiency was not fully explained by rhabdomyolysis or liver disease, and his liver function tests were not fully characteristic for alcoholic hepatitis. This case expands the differential of undifferentiated jaundice in a patient with alcohol abuse to include leptospirosis as a possible etiology, particularly with occupational exposure. DIAGNOSTIC EVALUATION AND MANAGEMENT OF PULMONARY HYPERTENSION WITH CONCOMITANT INCIDENTAL PARTIAL ANOMALOUS PULMONARY VENOUS RETURN Isaac K. Ng2; Zi Yi Christopher Thong1; Adrian Chin Leong Kee1; Kei Jun Poon2; Peter Daniel2; Gaurav Deep Singh2. 1Respiratory and Critical Care Medicine, National University Health System, Singapore, Singapore, Singapore; 2Internal Medicine, National University Health System, Singapore, Singapore, Singapore. (Control ID #4243874) CASE: 74-year-old Chinese male, a chronic smoker of 50 pack-years, with background of diabetes mellitus and hypertension, presented with breathlessness, dry cough, lower limb edema and drowsiness, and found to be in acute decompensated type 2 respiratory failure. Electrocardiogram showed sinus tachycardia and features of right heart strain, chest X-ray (CXR) demonstrated patchy airspace opacities in bilateral lung fields, and point-of-care-ultrasound (POCUS) revealed a hypokinetic and dilated right ventricle, with a D-shaped septum.As the patient was hemodynamically unstable and required non-invasive ventilation, he was admitted to the intensive care unit, and a left internal jugular central venous catheter (CVC) for inserted in view of potential need for inotropic support. A CXR to assess CVC placement showed a malpositioned catheter within a hitherto unidentified PAPVR. Further workup then revealed that the patient had undiagnosed pulmonary hypertension with right heart failure which was predominantly attributed to chronic obstructive pulmonary disease, with minor contribution from the PAPVR. He was treated with bronchodilator therapy, long-term oxygen therapy (LTOT), sildenafil and spironolactone. IMPACT/DISCUSSION: CVC malpositioning has a reported prevalence of 6.7%. PAPVR is a rare, congenital heart condition with 0.4-0.7% prevalence, characterised by aberrant drainage of one or more PVs into the right atrium (RA) or its venous tributaries. Till date, less than 20 cases of CVC cannulation of anomalous PVs have been described in literature, mostly involving left IJV CVC placement into left-sided PV that drains into left brachiocephalic vein. In patients with newly diagnosed PAH and concomitant PAPVR, management depends on identifying the primary drivers of PAH and assessing the PAPVR shunt significance. Typically, each PV contributes 20-25% of total PV drainage – consequently, an isolated PAPVR, in the absence of ASD or other left-to-right cardiac shunts, will almost invariably not cause cardiac decompensation or warrant surgical intervention. Definitive treatment of underlying aetiology includes calcium channel blockers (if positive pulmonary vasoreactivity) or pulmonary vasodilators (endothelin receptor antagonists, phosphodiesterase-5 inhibitors or prostacyclin analogues) for group 1 PAH, treatment of left heart/lung disease for group 2/3 PAH, and anticoagulation and surgical/procedural interventions (e.g. surgical pulmonary endarterectomy or interventional balloon pulmonary angioplasty) for group 4 PAH.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital condition that is typically asymptomatic, but occasionally identified incidentally on diagnostic imaging. In a patient with newly diagnosed pulmonary hypertension, the concomitant presence of incidental PAPVR makes its subsequent evaluation and management more complicated, requiring a systematic aetiological workup and assessment of degree of PAPVR shunt contribution to pulmonary hypertension. DIAGNOSTIC JOURNEY OF FOLLICULAR LYMPHOMA: FROM PERSISTENT PULMONARY FINDINGS TO REVEALING LYMPHADENOPATHY Jowan Al-Nusair1; Momin Noor1; Zakaria Alagha1; Fuad Zeid2. 1Internal Medicine, Marshall University Joan C Edwards School of Medicine, Huntington, WV; 2Pulmonology/Critical Care, Marshall University Joan C Edwards School of Medicine, Huntington, WV. (Control ID #4245986) CASE: A 71-year-old male was referred to pulmonology following abnormal findings on a chest X-ray during a preoperative dental evaluation. Imaging showed a persistent left lower lobe opacity (5 × 6.4 cm) and associated pleural effusion, unchanged over six months. The patient, a lifelong non-smoker with no significant occupational exposures, had a medical history of restrictive lung disease, coronary artery disease, atrial fibrillation, type 2 diabetes, chronic kidney disease, and hepatitis C. He reported chronic exertional dyspnea for two years but had denied cough, systemic symptoms, or significant weight loss. Serial imaging from 2021 to 2023 demonstrated progressive left pleural effusion, persistent lung consolidation, and mediastinal pleural thickening, initially attributed to chronic inflammatory changes. However, in early 2024, CT revealed enlarged mediastinal lymphadenopathy, increased pleural effusion, and progression of lung consolidation. The patient also reported a 20-pound weight loss. PET-CT confirmed hypermetabolic mediastinal and infraclavicular lymphadenopathy. Bronchoscopy with EBUS-guided transbronchial needle aspiration (TBNA) of subcarinal lymph nodes (station 7) revealed follicular lymphoma with a monotypic CD10+ B-cell population. IMPACT/DISCUSSION: Primary pulmonary lymphoma (PLL) is a rare neoplasm, accounting for less than 1% of non-Hodgkin lymphomas. It is defined as a clonal lymphoid proliferation confined to the lungs, with or without hilar lymph node involvement, and no extrapulmonary disease at diagnosis or within three months. For this patient, the evolution of symptoms and imaging findings, raised the suspicion of a neoplastic process. Chronic weight loss, a red flag symptom, further supported this concern. Bronchoscopy with EBUS-guided TBNA provided a definitive diagnosis of follicular lymphoma. The clinical presentation of PLL varies widely, and patients are mostly asymptomatic. For those symptomatic, nonspecific respiratory symptoms such as cough, dyspnea, and chest discomfort predominate. Imaging in PLL is often nonspecific and can mimic chronic inflammatory or infectious processes, as demonstrated in this case, where findings were initially attributed to chronic inflammation. Histologic confirmation through biopsy is also crucial for diagnosis. The identification of follicular lymphoma in this case is notable, as it is a relatively uncommon histologic subtype within the spectrum of PLL. Treatment strategies for PLL are tailored to disease extent and histology. Given the patient’s comorbidities, careful consideration of treatment tolerability and optimization of supportive care are essential components of the management plan.

1- It is important to maintain a broad differential diagnosis when evaluating persistent pulmonary abnormalities, particularly in patients with progressive imaging findings and systemic symptoms. 2- Early tissue diagnosis is essential for guiding appropriate management and improving outcomes in this rare disease. DIAGNOSTIC UNCERTAINTY AMID CATASTROPHE: WHEN TO TREAT PROBABLE CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME Emily S. Long, Mark D'Alesio. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4271079) CASE: A 40-year-old male with epilepsy and recent hospitalization for glomerulonephritis with probable lupus nephritis (biopsy pending) presented with acute dyspnea and encephalopathy and was found to have acute hypoxic respiratory failure requiring intubation, acute kidney injury on chronic kidney disease, anemia, and thrombocytopenia. Exam was notable for volume overload, livedo reticularis, and splinter hemorrhages. He was treated with broad spectrum antibiotics, maintained on a ventilator, and diuresed aggressively. Lab work-up was notable for positive lupus anticoagulant, anticardiolipin antibodies, and anti-ß2-glycoprotein antibodies on two occasions 6 weeks apart, positive ANA 1:320, elevated dsDNA, elevated CRP, and hypocomplementemia. Renal biopsy from prior admission was insufficient to assess for lupus nephritis but showed a membranoproliferative glomerulonephritis pattern. On hospital day 5, the patient developed acute right-sided paralysis and was found to have an ischemic left frontal lobe stroke. This new stroke, along with respiratory failure and acute kidney injury in the setting of positive antiphospholipid antibodies x2, raised concern for catastrophic antiphospholipid syndrome (CAPS). The patient met criteria for probable CAPS but not definite CAPS due to lack of biopsy confirming small vessel occlusion. He was too unstable for repeat biopsy, so we treated for CAPS with pulse dose steroids, anticoagulation, and plasma exchange (PLEX) therapy. The patient recovered and was discharged to inpatient rehab. IMPACT/DISCUSSION: To diagnose definite CAPS, one must meet all of the following criteria: Involvement of ≥ 3 organ systems, development of all symptoms within 1 week, small vessel occlusion confirmed with biopsy, and positive antiphospholipid antibodies. Probable CAPS is defined by meeting ¾ criteria. The most common reason for a presentation to not meet criteria for definite CAPS is lack of biopsy demonstrating small vessel occlusion, often due to clinical instability precluding biopsy. Physicians should not wait for antiphospholipid antibody or biopsy results to initiate treatment for CAPS due to the high morbidity and mortality (50%) of the disease. If CAPS is suspected and there is evidence of organ failure, combination treatment with anticoagulation, steroids, and PLEX or intravenous immunoglobulins should be initiated immediately.

- Patients with suspected CAPS may be too unstable for biopsy, which automatically excludes them from meeting definite CAPS criteria - The diagnostic criteria for CAPS were developed for research studies and not for clinical practice. If there is high clinical suspicion for CAPS, the benefits of treatment outweigh the risks, and treatment should be initiated immediately, even without antibody or biopsy results DIAGONSTIC UNCERTAINTY AND A CHALLENGING CASE OF CUTANEOUS LYMPHOMA WITH CENTRAL NERVOUS SYSTEM INVOLVEMENT Samuel C. Ficenec1; Grant J. Gonzalez2; Besim Ademi2. 1Department of General Internal Medicine, Tulane University School of Medicine, New Orleans, LA; 2Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4272278) CASE: The patient is a 64-year-old man with a past medical history of a cutaneous T-Cell Lymphoma (TCL), Permanent Atrial Fibrillation, Hypothyroidism, and a prior right-sided Bell’s Palsy which resolved spontaneously. The patient presented to the hospital with a complaint of facial weakness and balance difficulties. He noted that his symptoms began after starting chemotherapy 3 months ago. However, he noted these symptoms progressed, prompting his presentation to the hospital. At this time the patient’s vital signs were within normal limits, but physical exam found unilateral hearing loss, right sided facial droop, and decreased lower extremity strength. Given this history there was concern for an acute stroke, chemotherapy complications, Bell’s palsy reactivation, meningitis, or central nervous system (CNS) involvement of the underlying TCL. After admission to the hospital a CT angiogram, MRI brain, and a lumbar puncture including cerebrospinal fluid (CSF) flow cytometry, and lab panels for paraneoplastic, viral, syphilis, and cryptococcal syndromes were obtained. Besides an elevated opening pressure and increased CSF protein all of the initial diagnostic workup was negative and without significant findings. The patient was given treatment for aseptic meningitis, however his symptoms progressed. Reevaluation of the differential diagnosis led to interdisciplinary discussions between the internal medicine, radiology, oncology and neurology teams who with the additional clinical context provided by the internist diagnosed the patient with CNS involvement of his underlying T-Cell Lymphoma and began treatment with intrathecal chemotherapy. IMPACT/DISCUSSION: This case demonstrates the broad differential of facial weakness and highlights the rare complication of CNS involvement of a TCL. Cutaneous TCL is itself an uncommon entity with an incidence of 8.5 cases per one million individuals. CNS involvemen is a more uncommon complication with a prevalence of only 2-7% among all TCL. Risk factors for CNS involvement include: an advanced stage, bone marrow involvement, multiple extra-nodal sites, elevated LDH, or ALK-positivity all of which were absent in this patient. More importantly, this case demonstrates the importance and of maintaining a broad differential and the utility of the bedside evaluation in diagnosis. Literature reviews have found that a lack of definitive findings is common in these cases. As CSF cytology has a low sensitivity (2-3%) and imaging findings are often atypical and non-specific. Although these techniques are crucial, overreliance on these tests with limited clinical context may introduce new biases and complicate already challenging diagnostic dilemmas.

In conclusion, this case represents the diagnostic challenges associated with uncommon complications of uncommon diseases. When approaching these cases astute physicians would do well to maintain and reevaluate a broad differential diagnosis in the setting of limited clinical improvement. DIGGING DEEPER: A CASE OF RECURRENT PNEUMOMEDIASTINUM Anjana Murali2; Claire E. Fishman2; Robert Kotloff1. 1Pulmonology, Penn Medicine, Philadelphia, PA; 2Medicine, Penn Medicine, Philadelphia, PA. (Control ID #4272579) CASE: A 43-year-old woman with history of remote gastric sleeve and recent diagnosis of pneumomediastinum (PNM) one month prior presented with weakness and shortness of breath and was found to have evolving, uncomplicated PNM. The differential diagnosis for PNM, or excessive air between the heart and lungs, includes spontaneous PNM secondary to smoking/drug use, structural lung diseases like asthma or COPD, excessive vomiting or coughing causing tracheal or esophageal perforation, and blunt trauma. During the first hospitalization, life-threatening causes of PNM were ruled out with a barium esophagram that was negative for perforation and right and left heart catheterizations that showed normal pressures. The patient received guidance on rest at home to allow the PNM to self-resorb. Just one month later, she re-presented with the same symptoms. During this second hospitalization, the primary team discussed various etiologies of PNM, ultimately concluding that this presentation was due to alveolar rupture. However, the mechanism remained elusive. When the team observed the patient had severely restricted oral intake at meals, they questioned whether an underlying diagnosis of disordered eating was exacerbating the PNM presentation. Only after a female provider spent an hour at bedside creating allyship with the patient did the patient admit to body dysmorphia, restrictive eating, and excessive exercising habits. When pressed on purging, the patient repeatedly denied bulimia-type behaviors. However, she did admit to “a terrible gag reflex when cleaning her tongue.” Further motivational interviewing uncovered OCD-like behaviors. Ultimately, the team determined that disordered eating coupled with excessive gagging from tongue cleaning, resulted in alveolar rupture leading to PNM. This underlying diagnosis was not identified at the first hospitalization, leading to persistent behaviors and recurrent hospitalization. A multi-disciplinary team helped create a safe discharge plan with close outpatient follow-up to help address underlying issues. IMPACT/DISCUSSION: This case demonstrates the need for quality interviews and a deep curiosity for understanding the drivers of disease presentation. Although this patient did not have serious consequences of PNM, namely airway compromise or pneumopericardium, it begged the question of where a diagnostic failure occurred. Further investigation of the underlying cause was pivotal in providing a safe discharge and preventing further recurrence of PNM and hospitalization.

This case highlights the necessity of a comprehensive diagnostic evaluation in patients with PNM, a rare but possibly life-threatening diagnosis. Ultimately, a thorough and patient-centered approach led to the correct underlying diagnosis, emphasizing the critical role of patient allyship and multi-disciplinary teams to create holistic treatment plans in both the inpatient and outpatient settings. DISCORDANT DISEASE BEHAVIOR: PROGRESSIVE LEUKEMIA CUTIS IN STABLE SYSTEMIC CLL Kavya Sudireddy1; Aviv Liani5; Yana Salei2; Ryan Svoboda3; Sindha Thomas4; Shrinkhala Khanna2. 1Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; 2Hematology-Oncology, University of Massachusetts Chan Medical School, Worcester, MA; 3Dermatology, University of Massachusetts Chan Medical School, Worcester, MA; 4Pathology, University of Massachusetts Chan Medical School, Worcester, MA; 5University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4273006) CASE: An 88-year-old male with a medical history of asthma and eczema was referred to Oncologic care in October 2022 for evaluation of asymptomatic leukocytosis (12-15k/uL). Examination revealed palpable cervical and axillary lymphadenopathy, confirmed by PET scan. IR-guided right axillary lymph node biopsy confirmed IGHV-mutated Chronic lymphocytic leukemia (CLL), Rai-stage 1. Without B-symptoms, cytopenias, or a concerning physical exam beyond an eczematous rash, the patient was monitored clinically and did not need systemic treatment per the International Workshop on CLL guidelines. In May 2024, a diffuse erythematous papulonodular rash developed across the patient’s torso, back, and upper limbs, distinct from his prior rash. Biopsy of a right arm plaque-like nodule confirmed CLL involvement, treated with intralesional triamcinolone (ILK). By November 2024, despite ILK, the patient developed diffuse, rapidly enlarging nodular lesions. An abdominal skin lesion biopsy showed leukemia cutis (LC) with areas of increased prolymphocytes and wild-type P53 staining. He denied B symptoms, peripheral blood counts were stable, and PET scan showed stable lymphadenopathy without Richter’s transformation. Peripheral blood smear revealed 33% lymphocytes without increased prolymphocytes. He then started treatment with Zanubrutinib at a 50% dose reduction given the lower side effect profile and titration ability given rapid LC progression. IMPACT/DISCUSSION: LC, a cutaneous manifestation of CLL, involves skin infiltration of neoplastic leukocytes and occurs in 25-40% of patients.1,2 It presents as papulonodular lesions on the head, neck, trunk, or extremities and is a marker of CLL onset or progression.3 Treatments include active non-intervention, skin-directed therapy (intralesional steroids, local radiation), or systemic therapy. Systemic therapy is used when lesions progress rapidly despite local treatment. 4,5 While LC does not necessarily affect prognosis, a rapid increase in absolute lymphocyte count, lymphadenopathy, or Richter’s transformation is associated with worse outcomes.5, 6 Given our patient’s widespread progression of LC with prolymphocytes and the potential risk of systemic disease progression, systemic chemotherapy was initiated. We highlight a rare presentation of rapidly progressive LC in a patient with stable systemic disease.

Further research is necessary to improve early recognition of atypical presentations, better characterize disease behavior, and aid in developing targeted treatment strategies.A multidisciplinary approach, involving collaboration between primary care, dermatology, oncology, and pharmacy, is crucial for management. DISGUISED AS TTP: A FASCINATING PRESENTATION OF ATYPICAL HEMOLYTIC UREMIC SYNDROME Stanley E. Atencah1; Amanda Hathaway2,1; Chinenye Egwuonwu1; Abigail S. Mills-Annoh1. 1Internal Medicine, Piedmont Athens Regional Internal Medicine Residency Program, Athens, GA; 2Hematology/Oncology, University Cancer and Blood Center, Athens, GA. (Control ID #4246029) CASE: 51-year-old woman with multiple sclerosis presents to the hospital with increasing weakness, difficulty walking and confusion. Lab studies showed Hb 7.6 g/dL (11.4 prior 2 weeks), platelets 61,000 (133,000 two weeks prior), LDH 2220 and creatinine 1.34. CTA chest showed right middle and lower lobe pulmonary emboli and she was started on apixaban. Initial concern for MS flare so received IV methylprednisolone 1g daily. Repeat tests revealed Hb 7.1 g/dL, platelets 56,000, haptoglobin <8, high reticulocyte count and bilirubin 3.0. Peripheral smear uncovered scattered schistocytes and prominent nucleated RBCs. She was deemed to have TTP and ADAMTS13 was requested. She was commenced on plasma exchange. After 5 days of therapy, ADAMTS13 returned normal (68%). Patient was discharged on prednisone for non-immune hemolytic anemia but was readmitted after 2 weeks with altered mentation and lethargy. This time, blood glucose read 894 g/dL, had AKI (Cr 1.45) with continued anemia and thrombocytopenia. Prednisone was restarted with resolution of confusion. High suspicion for atypical HUS was raised and complement genetic testing was ordered. Planned for prednisone taper but continued to hemolyze so was commenced on ravulizumab-cwvz. She was seen in clinic with improvement in symptoms and lab findings IMPACT/DISCUSSION: Atypical hemolytic uremic syndrome (aHUS) is a form of TMA hypothesized to be complement mediated. TMAs cause injury and occlusion of microvessels resulting in tissue ischemia and organ damage and comprises of aHUS, TTP, C3 glomerulopathy, congenital B12 deficiency among others. Approximately 10% of all HUS cases may be aHUS. Atypical HUS primarily affects the kidneys but may affect other organs and usually presents with intravascular hemolytic anemia, thrombocytopenia and AKI. It remains a diagnosis of exclusion. Diagnosis can be challenging, which frequently delays treatment and contributes immensely to chronic long-term morbidity. Etiology of aHUS may be familial or sporadic. Atypical HUS can be classified as primary or secondary; where primary is associated with dysregulation and overactivity of the complement alternate pathway likely due to isolated mutations in complement and complement regulatory proteins in 60% of cases. Secondary aHUS are associated with malignancies, chemotherapy, infections, pregnancy and autoimmune disorders. There is no age or sex predilection and if left untreated, may lead to end stage renal disease. Management is with plasma exchange and therapy targeted against C5 complement with medications like Ravulizumab. Renal and liver transplants may be considered in advanced situations of ESRD

This case underscores the need for heightened awareness of aHUS among clinicians, as prompt diagnosis invariably leads to quicker treatment and may influence progression of disease and its associated complications. Accurate diagnosis and comprehensive management, including use of Ravulizumab is essential to improve patient outcomes and quality of life DISSEMINATED COCCIDIOIDOMYCOSIS IN AN 83-YEAR-OLD MAN POST COVID-19 PNEUMONIA Mihran Ogaryan. Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #4269055) CASE: An 83-year-old man with coronary artery disease (CAD) post-coronary artery bypass grafting (CABG), diabetes mellitus type 2 (A1c 6.5), hypertension, hyperlipidemia, peripheral vascular disease (PVD), and macular degeneration presented with fever and dyspnea following a recent COVID-19 infection treated with molnupiravir. He reported progressive weakness and high-grade fevers (102°F). Examination revealed leukocytosis (WBC 15,000/μL) and right lower lobe consolidation on chest X-ray. CT chest confirmed right middle lobe pneumonia with scattered micronodules and mediastinal lymphadenopathy. Empiric antibiotics were initiated, but his condition deteriorated, requiring intubation. Bronchoalveolar lavage (BAL) identified mold, and cytology revealed yeast and spherules consistent with Coccidioides. Initial serology for coccidioidomycosis was negative, but BAL culture confirmed the diagnosis. He was treated with micafungin and voriconazole, later escalated to liposomal amphotericin B due to clinical worsening. In the ICU, the patient developed acute hypoxic respiratory failure secondary to bacterial pneumonia and COVID-19. Despite high ventilator settings and permissive hypercapnia, oxygenation declined. Multiorgan failure ensued, including acute kidney injury, elevated liver enzymes, and metabolic acidosis. Hemodynamic instability required vasopressors (norepinephrine, vasopressin, phenylephrine) and SLED dialysis, which was poorly tolerated. Progressive lung consolidation led to a pulseless electrical activity (PEA) arrest, and despite aggressive resuscitation, the patient expired. IMPACT/DISCUSSION: This case highlights the diagnostic and therapeutic challenges of disseminated coccidioidomycosis in an immunocompetent host with significant comorbidities. His recent COVID-19 infection likely impaired immune function, compounding his vulnerability. Overlapping bacterial pneumonia symptoms delayed diagnosis, underscoring the need for early consideration of endemic fungal infections in refractory pneumonia, particularly in endemic regions. Bronchoalveolar lavage was essential for diagnosis when initial serologies were negative. The patient's rapid progression highlights the aggressive nature of disseminated disease and the critical importance of timely antifungal therapy. Advanced age, diabetes, and post-COVID immune dysregulation likely contributed to his poor outcome. This case adds to the limited literature on disseminated coccidioidomycosis in immunocompetent individuals, emphasizing its clinical complexity and the importance of maintaining suspicion in patients with risk factors and epidemiologic exposure.

Early consideration of endemic fungal infections is critical in refractory pneumonia, particularly in patients from endemic regions. Bronchoalveolar lavage is invaluable when initial serologies are inconclusive. Advanced age, diabetes, and COVID-19 may significantly increase susceptibility to disseminated fungal infections, requiring early, aggressive management. DISSEMINATED CRYPTOCOCCAL INFECTION IN A NON-HIV, NON-TRANSPLANT PATIENT PRESENTING AS RECURRENT URINARY TRACT INFECTIONS Rana H. Asif1; Supriya Mannepalli2. 1Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA; 2Infectious Diseases, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4272379) CASE: 62 year old male with history of liver cirrhosis, meth abuse, kidney stones s/p bilateral ureteral stent presented with right flank pain, dysuria, hematuria and subjective fevers associated with nausea and vomiting going on for a few weeks. He had multiple ED visits and admissions for similar concerns over the last few months and was treated with antibiotics several times. On exam he was toxic appearing and had generalized abdominal tenderness with guarding and right CVA tenderness. Labs showed urinalysis positive for moderate leukocytes, large blood, WBC 45. Imaging with CT stone protocol showed pyelitis with right renal stones, bibasilar opacities favoring pneumonia, fluid collection in the prostate representing prostate abscess, retroperitoneal lymphadenopathy, splenomegaly with fluid collections concerning for abscess, 2.5 cm right adrenal nodule, and prominent R renal pelvis with fatty stranding and cystitis. A few weeks prior during an ED visit patient was found to have a positive urine culture for yeast and later Cryptococcus neoformans. Labs this admission were positive for serum cryptococcal antigen and titer of 1:160. Treatment with Amphotericin B was initiated. Further testing was negative for CSF infection, TB and HIV. Additional imaging with MRI brain and abdominal US were also unremarkable. He was discharged on oral Fluconazole 400mg daily for 9 months. IMPACT/DISCUSSION: Cryptococcosis can affect multiple organs simultaneously in immunocompromised hosts including the prostate, but urinary irritation symptoms at disease onset are uncommon. However, in this case the patient was a resident of the chicken capital therefore epidemiologically increasing the risk of exposure to Cryptococcus. He had presented multiple times with symptoms consistent with UTI and prior imaging showed unresolved protstatic abscess despite multiple antibiotic courses. Most recently a urine culture grew yeast finalizing as cryptococcus which was at the time not considered of relevance. This resulted in disease progression and dissemination with multiple organ involvement including lungs, spleen, kidney and adrenal gland by the time it was diagnosed and appropriately treated. Physicians should increase awareness of fungal infection with prostate involvement in immunocompromised individuals specially in a high exposure setting, as early identification and accurate delineation of cryptococcal disease is essential to guide suitable treatment choice and duration.

Clinicians should be more cognizant of atypical presentations of cryptococcal disease, and have a high index of suspicion for disseminated disease with varied organ involvement. Prompt diagnosis and treatment are critical to minimizing complications and reducing mortality. Geographical context should also play a key role in diagnostic considerations. For instance, in the poultry capital of the U.S., a positive urine culture for Cryptococcus neoformans demands special attention due to the increased risk of exposure to this pathogen. DISSEMINATED HERPES TRACHEOBRONCHITIS IN A PATIENT WITH WEGENER'S GRANULOMATOSIS Zainab Khan1; Chris X. Yang1; Elijah Humphries2. 1Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 2Philadelphia College of Osteopathic Medicine - Georgia Campus, Suwanee, GA. (Control ID #4272482) CASE: A 61-year-old male with a past medical history significant for diabetes mellitus, COPD, hypothyroidism, and obesity presents to the hospital with complaints of generalized weakness and suspicious skin lesions for the past week. The patient denied any fevers, diarrhea, recent travel, injuries, or similar family history. On admission, vital signs were normal On physical exam, the patient was noted to have diffuse violaceous skin lesions with central necrosis. Laboratory results revealed a mild leukocytosis of 11 K/uL. Erythrcyte sedimentation rate was noted to be 53 mm and C-reactive protein was 9.70 mg/dL. Rheumatoid factor and anti-CCP antibodies were negative. However, the patient tested positive for c-ANCA with a 1:40 ANCA IFA titer. IgG antibodies against serine protease3 were elevated at 120 AU/mL. While IgG antibodies against myeloperoxidase were negative. The patient was started on high-dose methylprednisolone and rituximab for treatment of Wegener's granulomatosis However, 72 hours after immunosuppresive treatment was initiated, the patient reported significant shortness of breath and cough. Physical exam was also remarkable for multiple groups of vesciular lesions. A CT chest revealed multiple cavitary nodules present in the upper lobes. A bronchoscopy was performed, showing multiple tracheal mucosal lesions with ulceration. Bronchoalveolar lavage samples were positive for HSV-1, but negative for Aspergillus, Histoplasma, acid-fast bacteria, Legionella, and fungi. The patient was subsequently treated with intravenous acyclovir and recommended to continue treatment with valacyclovir in the outpatient setting. IMPACT/DISCUSSION: Herpes simplex virus (HSV) infection of the lung and lower respiratory tract has been thought to be a rare and fatal disease, usually in patients with immunosuppression, severe burns, or prolonged intubation. It has been well known that HSV can cause fatal respiratory infection in patients with burns, organ transplantation, malignancy, immunosuppressive therapy, prolonged intubation, and alcoholic liver disease. (1) Recently, several cases of localized infection in the respiratory tract of the patient with normal immune status have been reported, in some of them recovery occurred spontaneously but some immunocompromised patients adverse outcome have been reported as well. (2). Most of the respiratory infections were fatal in an immune-compromised host. (2). We present a rare case of disseminated herpes simplex tracheobronchitis as evidenced by mucocutaneous-involving skin, oral mucosa, tracheal lesions in the patient with profound immunosuppression from high-dose corticosteroids/Rituximab for granulomatosis with polyangiitis.

HSV-related tracheobronchitis or pneumonia is associated with increased mortality in critically ill patients. Induction treatment with rituximab-an anti-CD20 monoclonal antibody-may increase the risk of Herpes simplex virus infection in patients with antineutrophil-cytoplasmic-antibody-associated vasculitis(3). DISSEMINATED HERPES ZOSTER IN AN IMMUNOCOMPROMISED PATIENT Aaron M. Perry, Mariano Iberico, Molly E. McCoy. Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4272432) CASE: A 46-year-old man with a renal transplant due to end stage renal disease secondary to focal segmental glomerulosclerosis on immunosuppressives presented with 2 days of a painful, pruritic rash involving dermatomes on both sides of the body, including the left leg, back, chest, genitals, scalp, and face. The patient noted that the rash appeared as red clustered vesicles that would rupture with drainage of a thin, clear fluid. He had a temperature of 36.9 °C, HR 83, BP 148/88 and an otherwise unremarkable physical and neurocognitive assessment. Laboratory workup was notable for a normal complete blood count, creatinine of 1.17, and a tacrolimus level of 6.0. No imaging studies or microbial cultures were obtained. The patient noted a history of chicken pox but no prior immunization with the recombinant zoster vaccine. He was diagnosed with disseminated herpes zoster and started on IV acyclovir and multimodal pain control. The patient was continued on home doses of prednisone and tacrolimus, but mycophenolate was held. Following initial clinical improvement, the patient was transitioned to PO valacyclovir and discharged home. IMPACT/DISCUSSION: Herpes zoster, also known as shingles, is characterized by the eruption of a painful vesicular rash, typically effecting 1-2 contiguous dermatomes, from reactivation of the latent varicella-zoster virus within the sensory ganglia. Disseminated infection is defined by the involvement of >2 contiguous dermatomes, non-contiguous dermatomes, or dermatomes on both sides of the body and is most common in immunocompromised patients. Patients with disseminated disease should be treated with intravenous acyclovir that should be continued until initial clinical improvement is seen. Following improvement, the patient may be transitioned to oral valacyclovir or famciclovir to be continued until all lesions have crusted. The recombinant zoster vaccine (Shingrix) is recommended by the CDC in immunocompetent adults ≥50 years old and adults ≥18 years old who are immunodeficient or immunosuppressed for the prevention of herpes zoster. Regardless of shingles history, 2 doses of the vaccine should be given, typically given 2-6 months apart; however, the second dose may be given 1-2 months after the first in cases of immunodeficiency. In solid organ transplant patients, if vaccination was not administered prior to transplantation, patients may be safely vaccinated 6-12 following transplantation at a time of stable graft function and maintenance immunosuppression.

Disseminated herpes zoster involves >2 contiguous dermatomes, non-contiguous dermatomes, or dermatomes on both sides of the body. Immunocompromised hosts with herpes zoster are at greater risk for cutaneous dissemination and should be treated promptly with IV acyclovir. Shingrix is recommended in solid organ transplant recipients. DISSEMINATED PNEUMOCOCCAL BACTEREMIA COMPLICATED BY MITRAL VALVE PERFORATION AND DISCOVERY OF MULTIPLE MYELOMA Shijo Benjamin. Internal Medicine, St Luke's University Health Network, Bethlehem, PA. (Control ID #4271781) CASE: A 48-year-old male with no past medical history presented to the emergency department after he was found somnolent with increased fatigue. Patient was admitted to the ICU for septic shock and required intubation due to decompensating neurological status. Initial imaging demonstrated a hemorrhage in the left parietal lobe and pneumonia of the right lung while blood cultures grew Streptococcus pneumoniae. Further studies revealed diffuse vegetation on the mitral valve with severe regurgitation as well as possible vegetations of mobile pedunculated masses on the pulmonic and tricuspid valves. There were multiple acute infarcts in the bilateral frontal lobes and numerous small scattered patchy osseous lucent nodules in the sternum, cervical, and upper thoracic spine. After a negative workup up including HIV, hepatitis, and lymphoma/leukemia, an SPEP showed monoclonal peak in the gamma region. Patient was diagnosed with multiple myeloma with bone marrow biopsy confirmation. Patient continued with antibiotic treatment and required multiple blood transfusions as well as emergent mitral valve replacement surgery after the mitral regurgitation acutely worsened with perforation of the anterior leaflet base (Figure 1). Patient recovered to baseline mental status and was discharged with follow up for treatment of IgG kappa multiple myeloma. Revised multiple myeloma international staging was calculated using high risk translocation involving FGFR3/IGH, and prognosis was determined to be Stage II. IMPACT/DISCUSSION: Multiple myeloma is a neoplastic disease marked by the proliferation of plasma cells which results in a seven-fold increased risk for infection due to polyclonal hypogammaglobulinemia. While pneumonia and bacteremia are common infections that can occur in patients with multiple myeloma, infective endocarditis of a native valve is less prevalent. Further, triple valve endocarditis is an extremely rare finding and usually associated with intracardiac devices, congenital heart disease, and intravenous drug use. There are less than 20 reported cases of native triple valve infective endocarditis, and none are in relation to a malignancy. We present an extremely rare and interesting case that demonstrates the severe complications of multiple myeloma that can occur without proper diagnosis and treatment.

We present an unusual presentation of multiple myeloma that was first recognized after numerous complications including sepsis, triple valve endocarditis, pneumonia, and stroke. This case highlights the extreme immunologic effects, severe infections, and life-threatening complications that can be a consequence of not addressing the underlying disease. DISSEMINATED TOXOPLASMOSIS AS A RARE AND SUBTLE CAUSE OF HEMOPHAGOCYTIC LYMPHOHISTIOCTYOSIS: A CASE REPORT Colin Ly1; Ravi Patel1; Affan M. Ahmed2; Leslie Cler1. 1Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; 2Internal Medicine , Methodist Health System, Dallas, TX. (Control ID #4273324) CASE: We present a case of a 41-year-old male with persistent diarrhea and fever.The patient remained febrile throughout admission with no identifiable source of infection. Labs obtained revealed normal blood cultures, enteric pathogen panel, respiratory viral panel, C. difficile, CMV, EBV, histoplasma, blastomycosis, Fungitell, HIV, Cryptosporidium, stool ova and parasites, Giardia, HSV, and AFB. Rheumatologic workup was performed which revealed negative ANA, ANCA, double-stranded DNA, rheumatoid factor, and celiac panel. IL-2 was significantly elevated over 4000 and ESR greater than 130. CTA of the chest showed small pleural effusions, pleural thickening and two enlarged mediastinal lymph nodes. A CT abdomen and pelvis revealed enteritis. Indium-111-labeled white blood cell scan and an initial echocardiogram were performed although they were negative for any abnormalities. The individual was monitored in the intensive care unit and progressively decompensated. He developed encephalitis, heart failure and sustained multiple PEA arrests and eventually expired. An autopsy revealed disseminated Toxoplasma gondii infection and associated HLH. IMPACT/DISCUSSION: Hemophagocytic Lymphohistiocytosis (HLH) is a rare, severe immunologic condition that can lead to a life-threatening systemic inflammatory syndrome. The pathogenesis of HLH is multifactorial, often involving genetic predispositions, infections, or immune irregularities, which can dysregulate natural killer cells, cytotoxic lymphocytes, and macrophages, resulting in a cytokine storm. HLH can be challenging to diagnose and is more commonly associated with malignancy, infection, and autoimmune conditions, contributing to multiorgan failure if left untreated. While primarily diagnosed in pediatric populations, HLH may occur at any age, with individuals potentially experiencing a single episode or developing relapses over time. Clinically this patient met 6 of the 8 criteria needed for diagnosis of HLH which included fever, cytopenia, increased ferritin levels, hypertriglyceridemia, elevated soluble IL-2 and decreased natural killer cells. High-dose steroids and etoposide are treatment options that should be considered at the earliest clinical suspicion to reduce the risk of mortality associated with HLH. Prompt treatment with anti-toxoplasma therapy, such as pyrimethamine and sulfadiazine, would have been recommended to address the hidden and underlying toxoplasmosis.

Toxoplasmosis is a rare cause of HLH. Infectious causes account for 24% of HLH cases and 2% of all infectious causes are due to toxoplasmosis. While many individuals are infected with Toxoplasma without exhibiting symptoms, a high degree of clinical suspicion for HLH should be raised in cases of unexplained multiorgan failure, as it can lead to increased mortality. DISTILLING THE ORIGIN OF AN UNEXPECTED STROKE Kimberley Ho1; Mitchell Jenkins2. 1White River Health System Inc, Batesville, AR; 2University of Arkansas for Medical Sciences, Little Rock, AR. (Control ID #4272693) CASE: A 33-year-old female presented to an outside hospital after development of acute left-sided weakness, dysarthria, and diplopia, NIHSS 5. After cranial CT ruled out acute cranial hemorrhage, tenecteplase was administered; she was transferred to our center for post-thrombolytic management. Past medical history was negative for stroke, significant for former intravenous methamphetamine drug use 6 months prior to admission. For one month, she had experienced subjective fevers and occasional night sweats. She was afebrile on presentation with stable vital signs. Complete blood count, renal, and chemistry panels were within normal limits. Brain MRI with contrast revealed an acute infarct in the left hemipons. Venous Duplex of bilateral lower extremities were negative for thrombus. TEE was negative for shunt and valve vegetations. On the second day of admission, lumbar puncture was obtained with CSF analysis showing leukocytes of 57 (neutrophils 41%, lymphocytes 40%, protein 180, glucose 15). Infectious disease service was consulted with concerns about an infectious etiology. Serum cryptococcal antigen resulted in a titer of 1:2, prompting addition of CSF cryptococcal antigen, which returned positive with a titer of 1:20. Patient was initiated on liposomal amphotericin B and flucytosine for cryptococcal meningitis. Standard meningitis/encephalitis/autoimmune panel and Borrelia burgdorferi, Treponema pallidum, Ehrlichia chaffeensis, Rocky mountain spotted fever, West Nile virus, Acid-Fast Bacillus tests resulted negative. HIV 1/2 antibodies and HIV-1 P24 antigen screenings were negative; CD4 count was normal. Patient developed headaches, which was relieved with lumbar punctures; opening pressures of 24mmHg resolved to 15mmHg. CSF culture grew one colony of cryptococcal neoformans. At discharge, induction phase of amphotericin and flucytosine treatment for cryptococcal meningitis had been completed, with plan to transition to consolidation and maintenance phases with fluconazole as outpatient. IMPACT/DISCUSSION: This presentation of cryptococcal meningitis as a lacunar infarct in a young relatively healthy non-immunocompromised female without classic meningeal signs highlights the importance of evaluating for a root cause of stroke. Cryptococcal meningitis carries a high risk of stroke, particularly in the basal ganglia. The patient’s prior fever and night sweats appeared to have signaled a subacute infectious process, though the overall clinical picture was inconsistent with fungal meningitis. She lacked risk factors for stroke, including elderly age, inflammatory processes, and immunocompromise. It is thought that her IV drug use led to cryptococcus neoformans bacteremia manifesting as a pontine stroke with the infection mimicking septic emboli.

With her acute treatment inpatient, this case illustrates the importance of vigilance with this atypical presentation of cryptococcal meningitis and the involvement of specialty teams to deliver proper treatment and follow-up. DISULFIRAM INDUCED LIVER INJURY Britney He1; Aaron D. Smith1; Jess Dreicer2. 1School of Medicine, University of Virginia, Charlottesville, VA; 2Medicine, University of Virginia, Charlottesville, VA. (Control ID #4268581) CASE: A 72-year-old woman with a history of daily alcohol use over the past decade presented with two days of confusion. Four weeks earlier, she had started disulfiram therapy to support abstinence and had not consumed alcohol since. On presentation, her liver enzymes were elevated in a cholestatic pattern, accompanied by hyperbilirubinemia, consistent with hepatocellular injury or cholestasis. A comprehensive workup ruled out other common causes of liver injury, including autoimmune hepatitis, hepatitis B and C, and acetaminophen toxicity. Liver ultrasound showed no structural abnormalities, such as obstructing stones or bile duct dilation. Based on the exclusion of other etiologies and the temporal relationship to disulfiram initiation, a clinical diagnosis of disulfiram-induced acute hepatic injury was made. Disulfiram was discontinued immediately, and the patient was treated with N-acetylcysteine for hepatoprotection. Thiamine was administered due to concerns for Wernicke’s encephalopathy given her chronic alcohol use. During hospitalization, she exhibited signs of refeeding syndrome, requiring potassium and phosphorus supplementation. She transitioned to acamprosate for ongoing alcohol use disorder management upon discharge. At a one-month follow-up, her liver enzymes had normalized. IMPACT/DISCUSSION: This case highlights the importance of liver function monitoring during the early stages of disulfiram therapy, particularly within the first 12 weeks, as this period carries the highest risk for DILI. Most cases of disulfiram-induced liver injury occur during this timeframe, although hepatotoxicity can manifest later in treatment. While the incidence of this complication has declined due to reduced disulfiram use, hepatic failure can be life-threatening and potentially fatal if not promptly identified and managed. Patient education is crucial for early recognition of disulfiram-induced DILI. Patients should be informed about the risks and advised to report symptoms such as jaundice, nausea, vomiting, abdominal pain, or confusion, which should trigger immediate hepatic function testing. Proactive monitoring combined with patient education enhances the likelihood of timely intervention, reducing the risk of severe hepatic injury. This case underscores the need for informed consent, routine monitoring, and early recognition of complications associated with disulfiram therapy. Renewed attention to these practices can improve patient safety and inform future guidelines for managing alcohol use disorder with disulfiram.

Disulfiram-induced liver injury is a rare but serious complication, with the highest risk occurring within the first 12 weeks of therapy. Educating patients about the risks and symptoms of hepatotoxicity when starting disulfiram may ensure timely reporting and intervention for DILI. DON’T MEMORIZE LIVER INJURY PATTERNS A CASE OF ETHANOL-INDUCED CHOLESTASIS Aidan Flanagan1; Brenda Queen2. 1Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA; 2Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA. (Control ID #4269395) CASE: Alcoholic Hepatitis (AH) is an inflammatory hepatic condition commonly following acute-on-chronic alcohol consumption. It involves alcohol-induced hepatocellular (HC) injury via reactive oxygen species, gut barrier disruption, and bacterial translocation, triggering an inflammatory cascade with hepatocyte injury, apoptosis, and necrosis. Alcohol also impairs mitochondrial function and autophagy, amplifying inflammation and neutrophil hepatic infiltration. Patients typically present with rapid-onset jaundice, tender hepatomegaly, and signs of hepatic decompensation. Labs classically show HC injury with an AST/ALT ratio >1.5. Here, we discuss a patient with a cholestatic injury pattern in the setting of chronic alcohol use. A 33-year-old Caucasian woman with a history of gout, depression, anxiety, and alcohol use disorder presented after a week of heavy drinking with new jaundice, right upper quadrant pain, nausea, vomiting, and 22 lbs weight loss over a month. Admission labs showed Sodium 131, Potassium 2.8, Chloride 88, Bicarbonate 26, Anion Gap 17, AST 332, ALT 110, Alkaline Phosphatase 646, Total Bilirubin 10, Direct Bilirubin 8, Albumin 3.5, Lipase 49, WBC 12.2, MCV 100.3, PT 15, INR 1.2, PTT 29, and negative Hepatitis A, B, and C serologies except for Hepatitis B Surface Antibody. CT Abdomen/Pelvis showed hepatic steatosis with hepatomegaly. R-factor score was 1.23, Maddrey’s Score 23.8, and MELD-Na 22. No steroids were given. Initially, AH was suspected, but lab findings suggested cholestatic injury, prompting GI consultation. Workup included Alkaline Phosphatase isoenzymes (liver 46%, bone 43%, intestinal 11%), GGT 3510, and alpha-1 antitrypsin 215 (normal phenotype M1M2). Ceruloplasmin, AMA, ANA, ASMA, serum and urine drug screens, acetaminophen, salicylate levels, HIV, blood, and urine cultures were negative. Ferritin 667, transferrin 121, and iron 80 indicated anemia of chronic disease. PEth 1429 confirmed heavy alcohol use. MRCP revealed hepatomegaly, significant heterogeneous hepatic steatosis, borderline splenomegaly, and small ascites, suggestive of portal hypertension without biliary dilatation. Liver biopsy was deferred due to risks. The patient was diagnosed with AH, referred to Addiction Medicine, and started on Acamprosate to reduce alcohol cravings. IMPACT/DISCUSSION: This case deviates from the typical AST/ALT ratio >1.5 in AH, presenting with cholestatic labs. AH-induced cholestasis is driven by neutrophil-mediated cholangiocyte injury, microscopic cholangitis, and bilirubinostasis, thereby worsening jaundice. Highlighting the need for a broad differential in hepatobiliary injury and recognizing atypical AH presentations.

AH may present with hepatocellular or cholestatic liver enzyme derangements, requiring strong clinical suspicion to pursue further workup. Recognizing these mechanisms in atypical presentations is critical for tailoring diagnostic and therapeutic approaches, particularly when traditional AH patterns are absent. DON’T MISS DOXY: A CASE OF SEPSIS OF UNKNOWN ORIGIN IN A PATIENT WITH SOLID ORGAN TRANSPLANT Caroline Burley1; Paul O'Rourke2; Jane Abernethy2. 1Department of Medicine, Johns Hopkins Medicine, Baltimore, MD; 2Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4273111) CASE: A 70-year-old male patient with a history of end stage renal disease secondary to reflux nephropathy, living donor kidney transplant in 2022 (on Tacrolimus and Prednisone), cerebellar infarction (2021), hypertension, and Type II diabetes, presented to the hospital in late spring after 2 days of fever, body aches, and malaise. He reported months-long intermittent cough with occasional yellow sputum. He had nausea and one episode of emesis on the day of presentation. On exam, patient was febrile to 40C, tachycardic, tachypneic, with progressive hypotension. Rhonchi were heard in the left middle and lower lung lobes. Initial labs were unremarkable. CT imaging showed left lower lobe consolidation and mild perinephric stranding around the transplanted kidney. The next day he developed copious diarrhea and new 6-liter oxygen requirement. Labs showed 30% bands, down-trending platelets (132 to 55), and creatinine elevation to 2.4 (baseline 1.7). Sputum, urine, and blood cultures were unrevealing. He was treated for presumed urosepsis, aspiration pneumonia, and infectious diarrhea with cefepime, vancomycin, azithromycin, metronidazole, and posaconazole. He did not have clinical improvement and continued to have profuse diarrhea, fevers, hypotension, and kidney injury. Lab abnormalities evolved with worsening cytopenia, D-dimer, lactate dehydrogenase elevation, and normal fibrinogen, concerning for developing DIC. Infectious disease, nephrology, and hematology were consulted. Further interview revealed recent travel to Arkansas, frequent gardening, and mold and rat feces exposure in his shed. He recalled a tick exposure 2 weeks before presentation. Doxycycline was added for empiric tick-borne illness coverage, and Babesia, RMSF, Lyme, and ehrlichiosis testing was sent. Ehrlichia chaffeensis PCR was ultimately positive, and antimicrobial regimen was deescalated to doxycycline monotherapy, after which he demonstrated prompt clinical improvement. IMPACT/DISCUSSION: Diagnosis of human monocytic ehrlichiosis (HME) in solid-organ transplant patients is challenging, as it is not an opportunistic infection, and presents with non-specific symptoms of fever, myalgias, and headache. Delays in treating immunocompromised patients risks progression to septic shock, respiratory failure, meningoencephalitis, and coagulopathy with or without secondary HLH. National cases have risen significantly since 2000. In endemic areas, it is important to have clinical suspicion, probe for potential exposures, and in severe illness without obvious infectious agent, consider expanding empiric regimen to include doxycycline.

HME is endemic to the mid-Atlantic, southeastern, and south-central United States. The main vector is the lone star tick and the majority of cases occur in spring and summer. Typical symptoms are fever, headache, myalgias, malaise, and chills. Rash is uncommon in immunocompromised patients. Most common lab abnormalities in HME infection are leukopenia, thrombocytopenia, and transaminitis. DOUBLE HEMOLYTIC CRISIS WITH VASO-OCCLUSION AND AUTOIMMUNE PHENOMENA: AN INTERSECTION BETWEEN PLASMA AND RED CELL EXCHANGE Sandra Abadir, Birk Nelson, Jasprit Takher. Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #4232306) CASE: A 28-year-old man with SCD presented with back and knee pain, productive cough, and myalgias typical of previous sickle cell crises. He had a history of alloantibodies from prior transfusions and experienced an autoimmune hemolytic crisis at age 19, which resolved with corticosteroids. His hemoglobin had been stable above 12 g/dL on voxelotor for the year prior to admission. Vital signs were stable and physical examination was mostly unremarkable, except for bilateral knee tenderness. Laboratory findings revealed white blood cells at 14.4 x 10^9/L, hemoglobin at 9.1 g/dL, reticulocyte count at 17%, total bilirubin at 2.5 mg/dL, and lactate at 20.9 mg/dL. Chest X-ray was negative, but a CT scan raised concern for acute chest syndrome. After initial symptomatic improvement with blood transfusion, his hemoglobin dropped to 7.0 g/dL. A positive Coombs test indicated hemolysis, and the patient subsequently experienced neurological deterioration with respiratory distress and signs of bowel ischemia. Red blood cell exchange (RBCE) was planned, but cross-matched blood was found incompatible due to suspected new alloantibodies. This led to the diagnosis of a severe sickle cell crisis alongside autoimmune hemolytic anemia. He underwent plasma exchange (PLEX) for the hemolytic anemia, followed by RBC exchange before surgery. Unfortunately, he suffered cardiac arrest and expired. IMPACT/DISCUSSION: Sickle cell disease (SCD) is an autosomal recessive disorder marked by significant morbidity and mortality. A single base pair mutation in the hemoglobin β gene leads to the sickling of red blood cells (RBCs), resulting in vaso-occlusive crises. Autoimmune hemolytic anemia (AIHA) is a rare condition, affecting 1-3 individuals per 100,000 annually. It occurs when anti-RBC autoantibodies, often complement-mediated, cause hemolysis. We present a case of a patient who developed an autoimmune hemolytic crisis in the context of SCD. Management of sickle cell crises typically involves blood transfusions and RBCE, which improve tissue oxygenation and reduce vaso-occlusive events. While transfusions are beneficial for acute chest syndrome or stroke, RBC exchange reduces Hemoglobin S concentration and prevents hyperviscosity. Studies suggest recurrence of stroke is less likely with RBC exchange than with transfusion alone. AIHA management focuses on treating the underlying cause and supportive care, potentially including immunoglobulin therapy, splenectomy, rituximab, corticosteroids, and PLEX. Cold AIHA patients may require anticoagulation due to an elevated thrombotic risk.

This case illustrates the rare combination of AIHA and SCD, presenting significant therapeutic challenges. Given the limited guidance on managing concurrent hemolytic conditions, we implemented PLEX followed by RBC exchange. However, the efficacy of this approach remains uncertain, which highlights the need for further research to determine how to optimize therapy for patients with dual hemolytic anemias. DOUBLE TROUBLE: BILATERAL LUNG NODULES AS A MANIFESTATION OF GRANULOMATOSIS WITH POLYANGIITIS Anjali Alangaden1; Madison Martinez1; Kathryn Leyens2,1. 1Internal Medicine and Pediatrics, UPMC, Pittsburgh, PA; 2Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4272563) CASE: A 24-year-old woman with mild asthma presented with several weeks of fatigue and persistent nonproductive cough. Her symptoms progressed to daily subjective fevers, malaise, night sweats, and hemoptysis. She had also developed a tender, bruise-like rash on her bilateral lower extremities that was improving at time of admission. No lifetime tobacco use. She has traveled extensively and recently visited family in West Africa. On examination, she was febrile to 38.3°C with a normal respiratory rate and oxygen saturation of 97% on room air. She had an unremarkable cardiopulmonary exam. Skin exam revealed hyperpigmented, mildly-indurated lesions on the shins and feet. A CT angiogram of the chest showed multiple bilateral round pulmonary nodules with associated regions of necrosis and cavitation. Blood cell counts, renal and liver function tests, and urinalysis were largely normal. Further workup was notable for significantly elevated ESR 106, negative ANA, negative tuberculosis screening, and elevated anti-PR3 antibodies. Pathology from a punch biopsy of her rash helped confirm a diagnosis of granulomatosis with polyangiitis. She was initiated on steroids and rituximab with improvement in symptoms. IMPACT/DISCUSSION: The differential diagnosis for bilateral pulmonary nodules is extensive and includes infectious, malignant, autoimmune, and vascular etiologies. A thorough history that includes a chronology of symptom onset, family and travel history, and a careful review of carcinogen and infectious exposures can help narrow the differential and limit unnecessary testing. For this patient, the constellation of subacute constitutional symptoms, cough, hemoptysis, purpuric rash, and multiple lung nodules suggested a rheumatological etiology. Granulomatosis with polyangiitis (GPA) is a rare, multi-system necrotizing vasculitis that typically affects small- to medium-sized arteries. It frequently presents with nonspecific respiratory tract symptoms, including cough, dyspnea, hemoptysis, and sinusitis. Prompt diagnosis and treatment is critical to avoid life-threatening complications like alveolar hemorrhage and rapidly progressive glomerulonephritis. Initial evaluation when GPA is suspected includes ESR, ANCA antibodies, and urinalysis and creatinine to evaluate renal involvement. CT of the chest is a valuable tool in evaluating for thoracic manifestations of GPA with the most common finding being multiple pulmonary nodules. The nodules seen in GPA typically occur bilaterally, have no zonal predilection, and are frequently cavitary.

The differential for multiple bilateral pulmonary nodules includes malignant, infectious, autoimmune, and vascular etiologies, with the history and physical exam being crucial to guide a more focused work-up. Granulomatosis with polyangiitis frequently presents with respiratory tract involvement, including cough, hemoptysis, and dyspnea. Multiple cavitary nodules with bilateral distribution are a common finding of GPA. DOUBLE TROUBLE: DUAL ENDOCRINE EMERGENCIES IN A YOUNG FEMALE PATIENT Yoshua Mathai, Michael D. Martin, Keith Barron. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4273575) CASE: A 20-year-old female with only past medical history of depression not on medication, presented to the emergency department (ED) for seizure-like activity and altered mental status reported by her roommate. She was found to be profoundly hypoglycemic and hypothermic on arrival along with hypotension that was at first fluid responsive. She had a witnessed seizure in the ED shortly after arrival and was intubated for a few hours for airway protection. A few minutes after being called to admit the patient to ICU, the ED called again saying her blood pressure had significantly decreased and that intravenous (IV) norepinephrine was being initiated. Due to concern for adrenal crisis, we immediately initiated IV hydrocortisone. Cortisol and thyroid stimulating hormone (TSH) were checked, demonstrating undetectable cortisol and a very high TSH. IV levothyroxine was ordered for concern of concurrent myxedema coma, and endocrinology service was consulted. As for the cause of the concurrent adrenal crisis and myxedema coma, it was not entirely clear as toxicology screens were negative as was a thorough infectious workup including lumbar puncture. Patient ultimately was weaned off norepinephrine and discharged home on hydrocortisone, fludrocortisone, and levothyroxine. At discharge, she had the new diagnoses of adrenal insufficiency and primary hypothyroidism (confirmed by positive thyroid peroxidase antibodies). IMPACT/DISCUSSION: This case presents two endocrine emergencies, myxedema coma and adrenal crisis, in an atypical demographic. Interestingly, myxedema coma primarily occurs in elderly and very rarely in young adults like in this case. It also occurs typically in patients with known hypothyroidism for many years. The same can be said for adrenal crisis as most patients have an established diagnosis of adrenal insufficiency prior to crisis. In terms of a proposed diagnostic criteria from the American Association of Clinical Endocrinology, this patient scored well above 60 which is highly supportive of a myxedema coma diagnosis. It is still unclear as to what triggered this presentation, but a leading differential is psychological stressors/trauma which can lead to both adrenal crisis and myxedema coma. Of note, this patient was sexually assaulted by her biological father at age 15 and also presented 6 months prior to presentation for suicidal ideation. This case helps to illustrate the importance of recognizing the warning signs of adrenal crisis and myxedema coma, even in patients who do not carry adrenal or thyroid disorders as diagnoses.

This case emphasizes that even if it is unexpected, if the warning signs of certain diagnoses are present, they should still be on the differential work up should be initiated. In an atypical case like this, it is also important to obtain a good history as it may explain odd presentations such as this patients prior mental health issues and trauma which have shown to be associated with these endocrine emergencies. DOUBLE TROUBLE: UNMASKING ADENOVIRUS AND EBV IN AN ELDERLY PATIENT WITH PANCYTOPENIA AND TRANSAMINITIS tarannum Mohammadi1; Wali M. Kamran2; Stacey Smith1. 1internal medicine, Lehigh Valley Health Network, Allentown, PA; 2Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4272812) CASE: A 70-year-old man with hypothyroidism, dyslipidemia, renal calculus, and osteoarthritis presented with fever, fatigue, nausea, vomiting, diarrhea, and shortness of breath. He had a fever of 100.5°F, tachycardia, and lab findings including leukopenia and thrombocytopenia. Respiratory panels were negative, and pancytopenia with systemic inflammatory response syndrome (SIRS) was suspected. Despite vancomycin and cefepime treatment, his platelets dropped as low as 35,000 ***units. Hepatitis A, B, and C were ruled out, but stool testing revealed adenovirus. Supportive care improved his CBC and symptoms. Near discharge, EBV IgM tested positive, suggesting a multifactorial etiology involving adenovirus and EBV. IMPACT/DISCUSSION: EBV and CMV are well-known causes of acute hepatic toxicity, with EBV also linked to anemia and cases of aplastic anemia. Adenovirus, though typically causing mild respiratory infections in children, has been associated with severe complications in immunocompromised patients and rare cases of hepatitis in healthy adults. This patient’s condition likely stemmed from both EBV and adenovirus, as both can contribute to hepatic toxicity and anemia.

This case underscores the importance of considering viral infections in older patients presenting with pancytopenia and transaminitis, even without immunosuppression. The concurrent detection of EBV and adenovirus highlights the need for thorough diagnostic evaluation. Supportive care remains the cornerstone of treatment, and clinicians should maintain vigilance for atypical viral presentations to ensure timely management. Our medical education system heavily emphasizes Occam’s Razor, favoring the simplest explanation for clinical presentations. However, Hickam’s Dictum reminds us that patients can have multiple concurrent diseases. This case serves as a reminder to avoid prematurely concluding investigations and to consider multifactorial etiologies, ensuring comprehensive and accurate patient care. DOUBLE TROUBLE - ANATOMY AND GENETICS: MAY THURNER SYNDROME IN A PATIENT WITH FACTOR II MUTATION Shristi Nepal1; Ranjit Sapkota1; Navin Bhatt2; Nihal Khan1; Ricardo Conti1. 1Internal Medicine, AdventHealth Orlando, Orlando, FL; 2Department of Medicine, NYC Health + Hospitals/Elmhurst, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272360) CASE: A previously healthy 50-year-old female presented to the emergency department with an acute onset of swelling and redness in her left leg. Initial evaluations, including a complete blood count and comprehensive metabolic panel, were unremarkable. A CT angiogram of the abdomen and pelvis revealed deep venous thrombosis (DVT) in the left common femoral vein, left external iliac vein, left internal iliac vein, and left common iliac vein, associated with May-Thurner anatomy representing May-Thurner Syndrome (MTS). A CT angiogram of the chest showed no evidence of pulmonary embolism. The patient was started on an unfractionated heparin drip. Subsequently, she underwent a percutaneous thrombectomy with stent placement in the left leg, which resulted in significant symptomatic improvement. After stabilization, she was discharged on rivaroxaban and aspirin. An outpatient hypercoagulable workup revealed that she is heterozygous for the Factor II Gene 20210 A mutation. IMPACT/DISCUSSION: MTS, also known as ilio-caval compression syndrome, iliac vein compression syndrome, or Cockett syndrome, is a rare vascular condition in which the right common iliac artery compresses the left common iliac vein against the lower part of the spine. This condition progresses through three stages: Stage I involves asymptomatic left iliac vein compression, Stage II involves the formation of venous spurs, and Stage III involves DVT of the left lower extremity. While many patients with May-Thurner anatomy remain asymptomatic, some may present with chronic venous insufficiency or acute or recurrent proximal DVT.A common complication of symptomatic MTS is post-thrombotic syndrome, characterized by chronic pain, edema, and ulceration of the affected limb. Treatment for non-thrombotic MTS typically involves angioplasty and venous stenting. For patients with confirmed thrombus, anticoagulation is necessary. Those with thrombus of the iliofemoral vein secondary to MTS may require additional interventions such as thrombus removal or catheter-directed thrombolysis, along with iliac venous stenting to address external iliac vein compression. For patients who cannot undergo lytic therapy, open thrombectomy with angioplasty and stenting is performed. In our patient, a hypercoagulability workup revealed the presence of the prothrombin 20210A mutation, which independently increased the risk of venous thromboembolism. This patient had both genetic and anatomic factors contributing to thromboembolism, which resulted in the formation of a large clot burden.

MTS is a rare vascular condition that predisposes patients to hemodynamic complications due to its unique anatomical features. While the anatomy itself increases the risk of thrombus formation, it is crucial for physicians to consider other underlying hypercoagulable disorders that may coexist. Patients with such disorders are at an even higher risk for thrombotic events, potentially leading to more severe manifestations of MTS. DRESSED LIKE A TEN DIFFERENTIATING INPATIENT RASHES Casey Chmura, Brandon Dixon, Youssef Saklawi. Medicine, Emory University, Atlanta, GA. (Control ID #4273281) CASE: This is a case of a 63 year-old male with urothelial cancer complicated by left-sided hydronephrosis with left percutaneous nephrostomy tube, and urinary retention presenting to our hospital for acute blood loss anemia. On admission, the patient was febrile to 100.9F with stable blood pressure and tachycardia. He reported dysuria and hematuria. CT abdomen/pelvis was significant for a bladder mass. He initiated on treatment for urinary tract infection with intravenous ceftriaxone for five days (hospital day #1-5) and transitioned to oral ciprofloxacin for an additional two days (hospital days #6-7) when urine cultures returned with Klebsiella pneumoniae and Citrobacter koseri. On hospital day #9, he developed sepsis and was started on intravenous vancomycin and piperacillin-tazobactam. This regimen was maintained for five days (hospital days #9 – 13) and de-escalated to intravenous ceftriaxone on hospital day #14. On hospital day #16, he reported non-pruritic, non-painful blistering papules in the left antecubital region and neck. Over the following hours, the rash progressed into tense bullous lesions of the arms, neck, and back. No mucus membranes were affected. Vitals were unremarkable. All antibiotics were held. A skin biopsy was significant for subepidermal bulla with subjacent dermal mixed inflammatory infiltrate containing prominent neutrophils and scattered eosinophils. Direct immunofluorescence showed linear staining of the basement membrane with IgA; all other antibodies were non-reactive. The findings were consistent with linear IgA bullous dermatosis secondary to vancomycin, which was discontinued three days earlier. The patient was treated with topical steroid cream and there was improvement in the bullae within days. IMPACT/DISCUSSION: Antibiotics are commonly prescribed in both inpatient and outpatient settings, with dermatologic side effects ranging from Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and Drug Reaction with Eosinophilia and Systemic Symptoms, to less severe reactions such as fixed drug eruptions or morbilliform rashes. Drug-associated linear IgA bullous dermatosis (LABD) is a blistering rash that may be associated with diverse medications. It frequently presents 1-14 days after exposure to vancomycin and involves the trunk and extremities. Drug-induced LABD is less commonly associated with mucosal lesions than autoimmune LABD. Inpatient, exposure to many antibiotics and new medications may result in diagnostic uncertainty; however, the incidence of vancomycin-induced LABD is increasing. Most patients with drug-induced LABD do not have unstable vitals, whereas patients with other vancomycin-induced rashes may rapidly decompensate.

Linear IgA bullous dermatosis is a blistering skin rash that is often associated with vancomycin, most commonly 1-14 days after exposure to the medication. Linear IgA bullous dermatosis may be treated with topical steroids, colchicine, or dapsone. It typically resolves within 4-6 weeks of treatment. DROPPED GALLSTONES POST-LAPAROSCOPIC CHOLECYSTECTOMY MOHAMMAD AL-HADIDI1; Rami Dali2; Hamza Ali3; Arif Sarowar4; Bashir Hakim5. 1Medical School, Wayne State University School of Medicine, Detroit, MI; 2Medical School, Oakland University William Beaumont School of Medicine, Rochester, MI; 3Student, Wayne State University School of Medicine, Detroit, MI; 4Medicine, Wayne State University, Detroit, MI; 5Radiology, Trinity Health, Livonia, MI. (Control ID #4270957) CASE: A 55-year-old male initially presented to his PCP with epigastric and RUQ pain, nausea, and postprandial discomfort after fatty meals, leading to laparoscopic cholecystectomy in December 2021. In March 2022, he developed acute chest and RUQ pain. A contrast-enhanced CT revealed a right-sided pleural effusion with loculated fluid, an abnormal contour of the posterior hepatic lobe, and a nodular lesion suggestive of abscess or hemorrhage, likely a surgical complication. Video-assisted thoracoscopic surgery (VATS) with chest tube placement and debris removal resulted in temporary improvement. Eight months later, worsening abdominal symptoms prompted a CT revealing a pleural-based mass-like lesion in the right lung and tethering of adjacent liver tissue, raising concern for malignancy. Subsequent imaging, including contrast-enhanced CT and PET/CT, identified hypermetabolic pleural and perihepatic nodules. Biopsies showed fibrosis and inflammation, not malignancy. In July 2023, an MRI characterized ill-defined, mildly T2-hyperintense perihepatic lesions as inflammatory and fibrotic. The findings were attributed to chronically dropped gallstones, which caused persistent inflammation and metabolic uptake mimicking malignancy. Laparoscopy confirmed the diagnosis, with the removal of dropped gallstones and associated abscesses, resolving the patient’s symptoms. IMPACT/DISCUSSION: Dropped gallstones can complicate the clinical picture, leading to misdiagnoses such as primary or metastatic tumors and peritoneal loose bodies. While often asymptomatic, they may cause chronic inflammation and abscesses, complicating imaging interpretation. Their low-density, cholesterol-rich composition often limits CT detection unless calcified, which occurs in only 10–15% of cases. Symptoms may arise years post-cholecystectomy, emphasizing the importance of clinical history. In this case, the radiologist’s careful correlation of imaging with the patient’s history led to the definitive diagnosis of dropped gallstones.

Managing complications from dropped gallstones requires surgical removal to prevent recurrence. Unlike other abdominal abscesses treated with antibiotics or drainage, abscesses linked to dropped gallstones recur unless the stones are removed, as seen in this case where VATS provided only temporary relief. Radiology plays a vital role in detecting and managing these cases. The integration of CT, MRI, and PET imaging, combined with the radiologist’s expertise, facilitated accurate diagnosis and guided treatment. The key lesson from this case is the importance of correlating imaging findings with patient history and postoperative events. This approach led to the diagnosis and significantly improved the patient’s quality of life. Clinicians and radiologists must remain vigilant and integrate imaging with clinical evaluations to reduce misdiagnoses and improve outcomes. Comprehensive assessments and proactive management are essential in addressing the challenges of dropped gallstones. DYSPHAGIA FOLLOWING ACDF SURGERY: A CASE OF HARDWARE-INDUCED OBSTRUCTION WITH LARGE OSTEOPHYTES Sahalia Rashid, Patrick W. Kollman, Peter Morkos, Rachel Konchal, Tanushri Bhushan, Amir Iqbal. School of Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4273379) CASE: The patient is a 69 y/o male with a PMH significant for lumbar and cervical radiculopathy, cervical myelopathy, dysphagia, and OSA who presented to the emergency department (ED) for worsening dysphagia and odynophagia. The patient has experienced symptoms since undergoing C2-C3 ACDF 18 months prior to presentation. The onset of his symptoms coincided with his ACDF surgery; he had experienced progressively worsening trouble swallowing both solids and liquids, significant pain with swallowing, and associated weight loss. CT images showed that the ACDF hardware at C2-C3 was protruding into the posterior wall of the pharynx. Specifically, the C2-C3 fusion plates overlied large osteophytes and indented into the hypopharynx. He was evaluated by ENT, speech language pathology (SLP), and general surgery and subsequently transferred to a nearby hospital with neurosurgical services. The surgeon that originally performed his ACDF was available and took the patient to the OR for hardware removal. The surgery proceeded smoothly, with the surgeon noting a massive amount of osteophytes at the C2-C3 level that were impossible to remove without risking damage to the esophagus. Within five days post-operatively, the patient was tolerating oral intake of food and liquids and was discharged in improving condition with close follow-up with neurosurgery IMPACT/DISCUSSION: Dysphagia after cervical spine surgery, particularly after ACDF, is a relatively uncommon but significant complication. This case highlights the clinical impact of hardware protrusion into the posterior pharyngeal space, which can lead to mechanical obstruction and irritation, manifesting as dysphagia and odynophagia. While dysphagia post-ACDF has been reported in the literature, the association with hardware protrusion into the hypopharynx, particularly with associated osteophytes, is a rare occurrence. This case portrays the need to maintain a broad differential when evaluating dysphagia following ACDF surgery. While cases have been reported post operatively, the etiology and potential treatments are poorly understood. Typically, initial evaluation includes conservative measures, however, it is important to include repeat imaging for evaluation of abnormalities related to both the hardware and anatomy of the patient. This case reveals an extremely rare cause of dysphagia secondary to large osteophytes causing protrusion into the hypopharynx - with resolution only achieved with repeat surgical intervention.

1. Dysphagia after ACDF should raise concern for hardware complications, such as protrusion into the pharyngeal space, particularly in patients with worsening swallowing. CT imaging is essential for diagnosis. 2. Large osteophytes can complicate hardware removal, risking damage to surrounding structures. Preoperative planning is crucial to minimize surgical risks. 3. A multidisciplinary approach, including ENT, speech therapy, and neurosurgery, is key to managing complex post-ACDF dysphagia and optimizing outcomes. EARLY DETECTION AND MANAGEMENT OF DUODENAL ADENOCARCINOMA IN AN 81-YEAR-OLD FEMALE: A CASE REPORT Christopher Solowiej Singh, Dana Dhami, Aaron Sidhu. Internal Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4272328) CASE: An 81-year-old female with a history of type 2 diabetes, atrial fibrillation, and prior cancers (colon and breast) presented with fatigue, dyspnea, and microcytic anemia during a routine wellness visit. After an initial blood transfusion for hemoglobin of 7.1 g/dL, further evaluation showed persistent anemia (Hb 7.3 g/dL), prompting hospital admission. Esophagogastroduodenoscopy (EGD) revealed an ulcerated, infiltrative duodenal mass, confirmed by biopsy as moderately differentiated DA. The patient was discharged after stabilization, with follow-up planned in hematology-oncology. At follow-up in the hematology-oncology clinic, a PET-CT scan revealed duodenal thickening without distant metastases, though small stable lung and adrenal nodules were noted. Genetic testing was initiated due to her history of breast and colon cancer. No lymph node metastases were identified. During hospitalization, she was treated for a urinary tract infection and superficial venous thrombosis, both managed without complications. Given her comorbidities and the absence of metastatic disease, the care team prioritized close monitoring and conservative management over immediate aggressive intervention. IMPACT/DISCUSSION: Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy, accounting for less than 1% of all GI cancers. DA diagnosis is often delayed due to non-specific symptoms, and limited data exist to guide treatment. Imaging and endoscopic biopsies are crucial for early detection. Treatment typically involves surgical resection, though the role of adjuvant chemotherapy remains controversial. This case underscores the importance of vigilant anemia evaluation and the utility of genetic testing in guiding management.

This case illustrates the importance of timely evaluation of unexplained anemia in elderly patients and highlights the utility of PET-CT and genetic testing post-discharge in staging and management. Surgical resection remains the cornerstone for DA, though the role of adjuvant therapy is uncertain. Further research is needed to establish optimal treatment protocols and better define prognostic indicators for DA. EARLY PLASMAPHERESIS IN SEVERE HYPERTRIGLYCERIDEMIA-INDUCED PANCREATITIS Moyan Sun, Adeoluwa Adewuyi, Jana Byrd, Abijha Boban, Vikas Kilaru. Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4268478) CASE: A 27-year-old man with type 2 diabetes on metformin presented with 3 days of blurry vision progressing to unrelenting nausea and vomiting. He had no preceding respiratory infection, medication noncompliance, abdominal pain, or alcohol consumption. He was afebrile with pulse of 130 beats/min, BP of 158/96 mmHg, and RR of 27 breaths/min. Physical exam revealed dry mucous membranes and a benign abdomen. Labs revealed pH 7.3, CO2 < 10 mmol/L, glucose 645 mg/dL, sodium 107 mmol/L, and lipase 73 U/L. He was diagnosed with DKA and started on an insulin infusion, but attempts to check beta-hydroxybutyrate were unsuccessful due to elevated lipids. Thus, a lipid panel was obtained, and triglyceride was revealed to be 9,563 mg/dL. He then developed epigastric pain radiating to his back, and the consequent CT abdomen showed peripancreatic inflammatory changes with edema. He was diagnosed with acute pancreatitis due to severe hypertriglyceridemia and underwent plasmapheresis with improvement of triglyceride to 461 mg/dL the following day. His DKA and abdominal pain subsequently resolved, and medications were adjusted to subcutaneous insulin, fenofibrate, and high-dose metformin. At a 4-month follow-up phone visit, he had no recurrent pancreatitis and is working toward establishing care with endocrinology. IMPACT/DISCUSSION: Hypertriglyceridemia-induced pancreatitis (HTGP) is a common cause of pancreatitis, accounting for up to 35% of all cases. Severe cases of HTGP are associated with marked triglyceride elevation and concomitant comorbidities such as uncontrolled diabetes, excess alcohol use, or medication use. The concurrent presentation of diabetic ketoacidosis (DKA), hypertriglyceridemia, and acute pancreatitis is uncommon. However, existing literature indicates that the severity of hypertriglyceridemia may correlate with a poorer prognosis. Additionally, the evidence supporting the effectiveness of plasmapheresis remains limited. In a prospective study involving 60 patients with HTGP who underwent plasmapheresis, there was no statistically significant reduction in complications or mortality. It is worth noting that these outcomes may have been influenced by delays in initiating plasmapheresis. Although the evidence for plasmapheresis in severe HTGP is still inconclusive, our patient’s rapid clinical response underscores the potential value of early plasmapheresis.

This case emphasizes the need for further research to assess the efficacy of plasmapheresis for HTGP, particularly when administered early in the disease course in cases of severe hypertriglyceridemia. EASILY MISSED MEDICAL CONDITION IN PSYCHIATRIC PATIENTS: NEUROLEPTIC MALIGNANT SYNDROME Aakash Arbab1; Nimra Siddiqui1; Zahwa Farooqui1; Alia Choudhry1; anil kapoor2. 1Internal Medicine, Flushing Hospital Medical Center, Flushing, NY; 2Neurology, Flushing Hospital Medical Center, Flushing, NY. (Control ID #4271416) CASE: A 32-year-old male with bipolar disorder presented to the emergency department with altered mental status (AMS) after refusing his prescribed aripiprazole. The patient became extremely agitated during evaluation and had a low-grade fever. WBC count, electrolyte levels, creatine kinase levels, and liver function as well as CT head were normal. Lumber Puncture to rule out acute/chronic meningitis was normal. Patient received multiple doses of haloperidol for agitation but no aripiprazole. Two days after admission, tachycardia, hyperthermia, and muscular rigidity developed. Laboratory findings included elevated creatine kinase to 412 U/L (normal 55-177 U/L), WBC count and anion gap. LFTs and other electrolytes were normal. Repeat CT followed by MRI of the brain showed no abnormalities. The diagnosis of NMS was made based on International Expert Consensus diagnostic criteria. The patient’s score of 78, exceeded the score of 74 indicating NMS positivity. Treatment included passive cooling, IV fluid administration, and benzodiazepine therapy. Family declined treatment with bromocriptine and valproate due to concern about side effects. After stabilization, transfer to a psychiatric inpatient unit was recommended but refused. The patient was discharged with instructions for outpatient follow-up. IMPACT/DISCUSSION: NMS is a rare but life-threatening condition associated with the use of first- and second-generation antipsychotics. NMS presents with AMS, lead-pipe rigidity, hyperthermia, and autonomic instability. If left untreated, NMS can result in stupor, coma, or death. The syndrome is commonly diagnosed using three major criteria, including exposure to dopaminergic blockers, muscle rigidity and hyperthermia. Differentiating NMS from conditions with similar symptomology, like serotonin syndrome, malignant hyperthermia, meningitis, or encephalitis is crucial for early detection and proper treatment. Notably, NMS occurs following the use of antipsychotic medications, whereas these other conditions do not. Treatment involves discontinuing the offending agent, supportive measures (hydration, cooling), and pharmacologic therapies such as bromocriptine or dantrolene in severe cases. This case highlights the challenges in treatment when empirical treatments are declined, showcasing the need for facilitated communication with patients and caregivers.

Early recognition of this easily missed condition is necessary to improve patient outcomes. Caution should be used when prescribing antipsychotic medications to patients. Communication among providers and caregivers or patients is paramount to prevent delays in treatment. ECHOES OF AMYLOID: DISTINGUISHING CARDIAC AMYLOIDOSIS FROM PHENOTYPES OF HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY Siya Bhagat1; Nanditha Venkatesan2; Abdullah Zoheb Azhar3; Prem Soman3. 1Internal Medicine, UPMC, Pittsburgh, PA; 2Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 3Heart Vascular Institute, UPMC, Pittsburgh, PA. (Control ID #4272832) CASE: An 85-year-old male with a history of paroxysmal atrial fibrillation, non-obstructive coronary artery disease, and aortic aneurysm presented with worsening dyspnea and lower extremity swelling. A transthoracic echocardiogram (TTE) at that time showed left ventricular hypertrophy (LVH), bicuspid aortic valve, moderate aortic insufficiency, mitral valve prolapse, and moderate mitral regurgitation. He was medically managed but experienced continued progression of symptoms. He underwent a cardiac MRI which revealed LVH with a counterclockwise helical pattern, patchy late gadolinium enhancement in the basal anteroseptal, mid/basal inferolateral, and anterolateral walls, as well as flow acceleration of the left ventricular outflow tract (LVOT) without systolic anterior motion or leaflet elongation. Repeat TTE noted a resting outflow gradient of 94 mmHg, which increased to 116 mmHg with Valsalva. He was diagnosed with hypertrophic obstructive cardiomyopathy (HOCM) and was started on beta-blockers. Initially, he experienced some improvement in symptoms with resolution of the LVOT gradient on repeat TTE. However, increased doses of metoprolol were limited by fatigue. His symptoms continued to worsen over time with a sharp functional decline. Given his intolerance to up-titration of beta blockers and atypical findings on cardiac MRI, cardiac amyloidosis (CA) was considered as a differential diagnosis. A Tc-99m PYP scan demonstrated significant myocardial radiotracer uptake on SPECT imaging. Serum and urine studies were not suggestive of AL amyloidosis. Genetic testing was negative for ATTR gene mutations. An endomyocardial biopsy, which was Congo red positive, confirmed transthyretin (ATTR)-CA via liquid chromatography-tandem mass spectrometry. IMPACT/DISCUSSION: The phenotypic overlap between CA and HOCM can present diagnostic challenges. Once underdiagnosed, CA is now increasingly recognized as a common cause of heart failure with preserved ejection fraction in the elderly. This report details the case of an elderly patient initially diagnosed with HOCM based on typical findings of LVH and LVOT obstruction. However, after the patient showed insufficient symptomatic improvement despite beta-blocker therapy for HOCM, further investigation revealed CA. This case underscores the importance of considering CA as a key differential diagnosis in newly diagnosed HOCM among elderly patients.

1. CA should be a primary differential diagnosis in elderly patients newly diagnosed with HOCM due to overlapping clinical phenotypes. 2. Due to the degree of restrictive cardiomyopathy and the preload-dependent state of patients with CA, their cardiac output is rate-dependent, necessitating careful use of nodal-blocking agents. ECTHYMA GANGRENOSUM: A RARE CLINICAL INDICATOR OF PSEUDOMONAS BACTEREMIA Alba L. Caceres Munoz, Victor Adenuga, Carolina Nadin De La Porte, Albert Alexis A. Annan, Stephanie Paduano, Obulakshmipriya Subramanian. Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #4273195) CASE: A 66-year-old male with a history of stage IV chronic kidney disease (CKD), hypertension, and relapsed stage III kappa light chain multiple myeloma on second-line palliative treatment with Daratumumab, Dexamethasone, and Lenalidomide presented to the hospital with highly diffuse painful skin lesions, which began two weeks before presentation. On examination, the patient had several 2-4 cm tender, indurated nodules with surrounding erythema present in his lower extremities and back. Upon admission, he was found to be in septic shock and acute kidney injury (AKI), requiring ICU admission, vasopressors, and broad-spectrum antibiotics (Cefepime and Vancomycin). Laboratory workup revealed pancytopenia, elevated procalcitonin, and lactic acidosis. Blood cultures identified Pseudomonas Aeruginosa, which was sensitive to Cefepime in vitro. The presence of these skin lesions, in the setting of Pseudomonas bacteremia, confirmed the diagnosis of Ecthyma Gangrenosum, and Vancomycin was discontinued promptly. The patient showed an appropriate clinical response, and vasopressors were weaned off. Skin biopsy was deferred due to the gradual resolution of his skin lesions on antibiotics. IMPACT/DISCUSSION: Ecthyma gangrenosum (EG) is a rare but potentially deadly skin infection. The most common risk factors for EG are immunosuppression, hematologic malignancy, and treatment with immunosuppressive drugs. Pathogenesis of EG involves hematogenous seeding of the skin in the setting of bacteremia.[4] Nevertheless, the early stages of the skin lesions can mimic several dermatologic conditions that delay diagnosis - thus, clinicians should have a high level of suspicion in immunocompromised hosts. In the largest case series to date, Pseudomonas aeruginosa was identified as the culprit organism in 73% of cases of EG [3] and the most important prognostic factor of mortality in invasive forms is the presence of neutropenia at diagnosis.[2] Therefore, the presence of these skin lesions raises a high possibility of bacteremia with this organism, and appropriate antibiotic coverage in these patients is crucial.

Ecthyma gangrenosum, though rare, is a significant skin infection that can signal the presence of Pseudomonas bacteremia. Awareness of this condition should prompt appropriate and timely antibiotic treatment to prevent serious complications. EFFECTIVE TREATMENT OF CORONARY ARTERY ANEURYSMS: INSIGHTS AND STRATEGIES Sulochana Gnanasekaran. Internal Medicine, New York Medical College, Valhalla, NY. (Control ID #4272728) CASE: A 56-year-old male with a history of gastroesophageal disorder, managed with over-the-counter antacids, presented with persistent and severe heartburn of 4 hours' duration. He endorsed running every day and denied exertional chest pain or dyspnea. He denied smoking or alcohol use. On examination, the patient was hemodynamically stable. Electrocardiography showed sinus rhythm with left ventricular hypertrophy, while serial troponin levels rose from 1,748 to 17,000. Due to findings indicating NSTEMI, and persistent atypical chest pain despite receiving nitroglycerin, along with a loading dose of aspirin and clopidogrel, the patient was taken for coronary angiography. Coronary angiography revealed patent left main and LAD arteries, with ectasia in the proximal LAD. The LCA exhibited medium mid-section aneurysms, a slow-flow segment without stenoses exceeding 50%, and a small aneurysmal dilation in its distal segment, with no obstruction. The RCA was diffusely ectatic with no significant stenoses. These findings implicated coronary ectasia as the cause of NSTEMI. The patient was managed with apixaban, carvedilol, atorvastatin, and losartan. IMPACT/DISCUSSION: Most case reports focus on the surgical management of coronary ectasia, while our study explores the debated approach of medical management. Coronary artery aneurysm (CAA) incidence has increased from 5% to 8%. Atherosclerosis is the leading cause, with others including Kawasaki disease and connective tissue disorders. Pathophysiology is poorly understood but involves ulceration with positive remodeling and chronic nitric oxide overstimulation in those with genetic predisposition. Most coronary artery aneurysms are asymptomatic, often detected incidentally via angiography when patients come in for ACS or angina evaluation. Symptomatic patients, often presenting with exercise intolerance, typically have thrombosis, plaque, or significant enlargement of the aneurysm compressing adjacent structures. Management varies: surgical intervention and stent placement are reserved for high-risk cases like large aneurysms (>10 mm) with increased risk of rupture, plaque disease, or symptomatic patients (stable angina). For atherosclerosis-related aneurysms, medical management is debated due to limited guidelines. Anticoagulants (e.g., apixaban for multivessel disease) or dual antiplatelet therapy (for single-vessel disease) are used selectively. ACE inhibitors/ARBs may prevent further enlargement by reducing positive remodeling. Risk factor modification, including statin therapy for atherosclerosis, and serial monitoring with CT angiography is essential. Beta-blockers like carvedilol may have antihypertensive benefits, though they have no significant impact on the hemodynamics of the aneurysm. For the above-mentioned reasons, our patient received apixaban, losartan, atorvastatin, and carvedilol.

Treatment should be individualized, considering the risk factor, aneurysm size and location, vessel involvement, and symptoms. ELBOW DEEP IN INFECTION: A RARE CASE OF NOCARDIA SEPTIC ARTHRITIS Purva H. Rumde1; Samantha P. Beik2; Lauren G. Navitsky2. 1Medical School, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Division of General Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4273294) CASE: A 75-year-old woman with type 2 diabetes, COPD (50 pack-year smoking), liver cirrhosis (Child-Pugh B), and ESRD on hemodialysis presented with two weeks of progressive right elbow pain and weakness impacting daily activities. She denied subjective fevers and recent elbow trauma, but had a resolved lower extremity hardware infection (P. aeruginosa and C. albicans) five months prior. Outpatient elbow synovial cultures revealed Nocardia sensitive to most antibiotics except doxycycline, minocycline, and clarithromycin. Elbow CT at a community hospital showed no effusion or bony erosions, and all labs were at baseline. She received vancomycin and trimethoprim-sulfamethoxazole (TMP-SMX) for an E. coli-positive urine culture before transfer to our institution for persistent symptoms. Here, an elbow MRI showed cellulitis, joint effusion, and osteomyelitis, and brain MRI revealed multiple abscesses, indicating disseminated infection. Chest CT showed nonspecific ground-glass opacities unchanged from older scans. Her elbow was surgically debrided and she was discharged on a course of IV meropenem and oral TMP-SMX. Follow-up imaging showed resolving infection and her clinical symptoms significantly improved. IMPACT/DISCUSSION: Nocardia infections are increasingly common in functionally immunocompromised patients with chronic diseases such as diabetes (10.5%), CKD (15.8%), COPD (51.2%), and liver cirrhosis per recent studies. While traditionally associated with primary immunodeficiencies, transplantation, and HIV/AIDS, the rise of chronic diseases in the U.S. necessitates the inclusion of Nocardiosis in infectious differentials. Pulmonary Nocardiosis is most common, occurring in 81% of immunocompromised patients and in 67% of cases as the original infection site. Disseminated infections may also involve the CNS (e.g., brain abscesses in 8.4% of renal transplant cases) and skin (34.5% in chronic disease patients). Nocardia septic arthritis, however, is rare, with only 37 reported cases by 2022, all involving the knee and resolving with surgical debridement and prolonged antimicrobial therapy. Other joints (sternal, wrist, shoulder) have since been reported, often with concurrent CNS, cutaneous, or pulmonary infections. Our case of Nocardia elbow joint septic arthritis, without pulmonary or cutaneous involvement, is novel. The patient had asymptomatic brain abscesses, a severe manifestation, despite not being a transplant recipient. This underscores the importance of assessing Nocardia in septic joints and screening for systemic dissemination (via brain MRI and chest CT) in immunocompromised patients, even without pulmonary, cutaneous, or CNS symptoms.

Patients with chronic diseases (diabetes, COPD, CKD, and liver cirrhosis) are functionally immunocompromised and are at risk for Nocardia infections. Pulmonary and cutaneous Nocardiosis, both key infection sites, may not be present in severe disseminated infections. Nocardiosis of the elbow joint is possible in disseminated infections. ELEVATED PROCALCITONIN IN ADVANCED LUNG ADENOCARCINOMA: A DIAGNOSTIC CHALLENGE IN THE ABSENCE OF INFECTION Bolivia C. Fernandes1; Ajitha Virinchipuram Ganesan1; Warren Fernandes2; Mohana Priya Manoharan1; Vinod Nookala1. 1Internal Medicine, NYMC at St. Mary's General Hospital and Saint Clare's Health, Parsippany, NJ; 2Internal Medicine, Saint Vincent Hospital, Worcester, MA. (Control ID #4271067) CASE: A 68-year-old male with stage IV adenocarcinoma of the lung and extensive metastases to the liver, bone, adrenal glands, and mediastinum on chemotherapy presented to the emergency department after being found unresponsive. En route to the hospital, he experienced multiple seizures and required intubation for airway protection. On examination, he was tachycardic and hypertensive, with limited neurological assessment due to sedation. Laboratory work-up revealed leukocytosis (13.4), anemia (hemoglobin: 10.4), lactic acid (2.2), and markedly elevated procalcitonin (PCT) >25. Brain MRI revealed enhancing lesions in the right parietal-occipital and temporal-occipital lobes consistent with neoplastic vasogenic edema. The patient was treated with IV levetiracetam and dexamethasone. Given the elevated PCT and septic presentation, empiric antibiotics were initiated. However, an exhaustive infectious work-up, including pan cultures, was negative, and antibiotics were discontinued. Over the hospital course, the patient’s condition improved, and he was extubated. He was referred for palliative stereotactic brain radiation therapy for the extensive metastases. IMPACT/DISCUSSION: PCT is a well-recognized biomarker for bacterial infections and sepsis but can also be elevated in non-infectious conditions, including malignancy. In this case, a markedly elevated PCT in the absence of infection highlighted the challenges in distinguishing between infectious and non-infectious causes of elevated PCT. Mechanisms for PCT elevation in malignancy may include the inflammatory tumor microenvironment, cytokine release, direct tumor production, or systemic response to high tumor burden and therapeutic interventions. Literature reports have shown PCT elevation in neuroendocrine tumors such as small-cell lung cancer (SCLC) and large-cell neuroendocrine carcinoma. Although rare, elevated PCT levels are also seen in non-small-cell lung cancers (NSCLC), including adenocarcinoma. Elevated PCT levels have been associated with liver metastases in lung cancer patients, suggesting a link between metastatic disease and systemic PCT elevation, consistent with this patient’s extensive metastases. Emerging evidence suggests that PCT may have prognostic implications in malignancy. In SCLC, higher PCT levels correlate with worse survival outcomes. Although its prognostic value in NSCLC remains less defined, this case underscores the need for further investigation into the role of PCT in malignancy.

Although PCT is a valuable marker for bacterial infections, its elevation in non-infectious conditions such as malignancy necessitates cautious interpretation. This case highlights the importance of carefully evaluating elevated PCT levels in the context of malignancy, avoiding overtreatment with antibiotics, and optimizing patient management. EMPHYSEMATOUS HEPATITIS: A CRISIS OF GASES IN THE LIVER AND CHAOS IN THE BODY Amna Naveed Butt, Anum Mubasher, Karina Gomez, Diego A. La Torre, Dhruvangkumar Modi. GME- Internal Medicine Residency, Texas Health Resources, Arlington, TX. (Control ID #4257128) CASE: A 68-year-old man with hypertension,tobacco abuse,and type 2 diabetes presented to ER with altered mental status,worsening abdominal pain,nausea,and vomiting over several days.He had not seen a physician in years and had no home medicines.He was hypotensive(BP 83/64mmHg),tachycardic(HR 117bpm),and had generalized abdominal tenderness without guarding or rigidity.Labs showed leukocytosis(22,000/uL),elevated liver enzymes(ALP 476;AST 877,ALT 921,total Bilirubin 3),Lactic acidosis(9mmol/L),hyperglycemia(345 mg/dL),hyperkalemia(6.0mEq/L) and elevated creatinine(5.4 mg/dL).Abdominal USG and CT scan showed extensive gas within the right liver lobe, without bile duct dilation or bowel distention.Initial concerns included acute cholangitis, abscess, or bowel ischemia.Empiric antibiotics(piperacillin-tazobactam) were initiated;gastroenterology and surgery were consulted.Emergent diagnostic laparoscopy showed bilious ascites and right upper abdominal fibrinous tissue without bowel ischemia;cholecystostomy tube was placed for biliary drainage.Imaging results ruled out other etiologies and diagnosis of EH was established.Over next few hours,despite CT-guided liver catheter placement for hepatic gas removal,patient went into shock,was intubated,requiring vasopressor support and stress dose steroids.He also developed worsening coagulopathy,thrombocytopenia,hyperammonemia and anuria,requiring continuous renal replacement therapy.Blood and peritoneal fluid cultures grew Escherichia coli.He later developed heart failure with ejection fraction of 40 to 45% and atrial fibrillation with rapid ventricular response.Despite aggressive management,patient continued to deteriorate with guarded prognosis.He was eventually shifted to hospice and passed away. IMPACT/DISCUSSION: Emphysematous hepatitis (EH) is an extremely rare and life-threatening disorder characterized by the presence of gas within liver parenchyma,in the absence of a biliary or vascular origin.The first case was described in 2002; since then less than 20 cases have been reported.EH results from mixed acid fermentation from bacterial tissue necrosis and gas accumulation within liver parenchyma.Common microbes implicated include Enterococcus faecalis,Escherichia Coli,Klebsiella pneumonia,Enterobacter spp,Pseudomonas aeruginosa and Proteus spp.EH has nonspecific symptoms,often mimicking other abdominal emergencies like cholangitis or bowel ischemia.CT findings of gas in liver parenchyma are key for diagnosis.Despite aggressive treatment with broad-spectrum antibiotics, and biliary drainage,there is rapid progression to multi-organ failure and death.Literature review showed that up until 2023, only 4/18 cases have been successfully treated.

Our case highlights the challenges of diagnosing and managing EH. Even with early diagnosis and aggressive treatment,prognosis remains poor.Thus,there is need for ongoing research and multidisciplinary team collaboration to improve patient outcomes with rare and life-threatening conditions. ENCEPHALITIS AND ACUTE HEMOLYSIS AS A RESULT OF PARANEOPLASTIC SYNDROME FROM RENAL CELL CARCINOMA- A RARE PRESENTATION Masuma Islam1; Vadim Zarubin2. 1Internal medicine, UConn Health, Farmington, CT; 2St. Mary's Health, Waterbury, CT. (Control ID #4270381) CASE: A 76-year-old male with a history of chronic kidney disease (CKD) stage 4 and hypertension was admitted with altered mental status(AMS). Initial evaluations revealed acute kidney injury(AKI) on CKD with uremia and hypernatremia. Stroke, seizure, and central nervous system infections were ruled out. During the hospital course, the patient developed acute on chronic anemia and thrombocytopenia, with laboratory evidence of hemolysis. Suspecting Thrombotic thrombocytopenic purpura (TTP), Treatment with plasmapheresis was initiated, leading to an improvement in mental status, and steroids were started, ADAMS13 activity was normal, leading to the discontinuation of plasmapheresis. An incidental finding of a left renal mass larger than 10 cm, suspicious for malignancy, prompted oncology and urology teams to recommend elective nephrectomy once the patient was medically stable. A multidisciplinary discussion involving oncology, nephrology, and pulmonology recommended holding off on plasmapheresis and starting intravenous immunoglobulin (IVIG) for suspected immune encephalitis related to paraneoplastic syndrome. Oncology suggested switching to steroids for better penetration. Nephrectomy was performed to remove the primary tumor, followed by adjuvant chemotherapy. IMPACT/DISCUSSION: Paraneoplastic syndromes are rare but significant complications associated with malignancies, often preceding the diagnosis of underlying cancer, The case is unusual due to the concurrent presentation of encephalitis and acute hemolysis in the context of paraneoplastic syndrome secondary to RCC. Paraneoplastic encephalitis is typically immune-mediated with autoantibodies targeting neuronal antigens, In this patient, the encephalitis was likely driven by an autoimmune response triggered by the RCC. Acute hemolysis, on the other hand, could be attributed to paraneoplastic autoimmune hemolytic anemia (AIHA), where the immune system mistakenly attacks red blood cells. The dual presentations of encephalitis and hemolysis posed a diagnostic challenge. Early recognition and treatment of the underlying malignancy are crucial. In this case, immunotherapy with high-dose corticosteroids and intravenous immunoglobulins was initiated, leading to partial improvement in neurological and stabilization of hemoglobin levels.

This case highlights the complexity of diagnosing and managing paraneoplastic syndromes, particularly with the rare concurrent presentation of encephalitis and acute hemolysis associated with renal cell carcinoma( RCC). This case underscores the importance of considering paraneoplastic syndromes in patients with unexplained neurological and hematological abnormalities. Encephalitis and acute hemolysis as manifestations of the paraneoplastic syndrome from RCC are exceedingly rare but should prompt thorough evaluations for an underlying malignancy. Early diagnosis and management of primary cancer and appropriate immunotherapy are essential for improving patient outcomes. ENTEROPATHOGENIC E. COLI CAUSING NEUTROPENIC FEVER IN AML WITHOUT DIARRHEA Sonia Mehra2; Richard G. Vaca4; Shamit Patel3; Violetta Laskova1. 1Medicine, Columbia University, New York, NY; 2Internal Medicine, Mount Sinai Morningside Hospital, New York, NY; 3Medicine, Mount Sinai Health System, New York, NY; 4Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273511) CASE: A 54-year-old male with history of GERD presents to the ER with 2-3 week of intermittent postprandial emesis associated with fatigue, fever/chills, and 20-pound weight loss over the prior 2-3 months. He did not have diarrhea. Symptoms started 1 week after returning from vacation in Mexico 1 month prior. Patient had negative outpatient EGD/colonoscopy and completed H pylori treatment and started on H2 blocker for presumed GERD. Outpatient labs 7 weeks prior to presentation did show neutropenia with ANC 900 with mild anemia. In ER, patient was febrile at 102.9F, tachycardiac and tachypneic and physical exam was otherwise unremarkable. Labs showed severe neutropenia (WBC 1.1 with ANC 400) with mild thrombocytopenia and macrocytic anemia. He was admitted and started on broad spectrum antibiotics for neutropenic fever. Cultures remained negative but Gi PCR was positive for Enteropathogenic E. coli (EPEC). Patient clinically improved and was discharged on oral Levofloxacin. The following week he underwent an outpatient BM biopsy with hematology which showed a hypocellular marrow (80%) with 18% blasts & 54% promyelocytes with multilineage dysplasia. He was diagnosed with MDS/AML with a deletion on chromosome 17p and was promptly started on chemotherapy and referred for BM transplant. IMPACT/DISCUSSION: MDS is a group of clonal hematopoietic bone marrow disorders with an increased risk of transformation to AML. AML and MDS can have an indolent, waxing & waning course which often presents with symptoms related to anemia, neutropenia or thrombocytopenia. AML is slightly more common in males and the average patient presents around age 65. Our patient presented with neutropenic fever suspected due to EPEC sepsis without the typical symptoms of diarrhea. Neutropenic patients often have a muted inflammatory response and are at risk for invasive infection from colonizing bacteria with fever often being the prominent presenting symptom. Our patient was noted to have neutropenia with anemia several weeks prior to his presentation. Persistent or worsening pancytopenia, even with a normal peripheral smear, in an otherwise healthy patient over age 45 with indolent symptoms should flag a differential diagnosis of AML. These patients should be referred for a timely hematological workup especially if severely neutropenic as they are susceptible to further infections and AML progression.

A lesson learned from this case is that AML and MDS can have an indolent often asymptomatic course with only mild lab work abnormalities. The timely recognition of new or persistent pancytopenia as an initial harbinger for the disease in otherwise healthy middle-aged patients can lead to an earlier diagnosis. A prompt referral to a hematologist for a bone marrow biopsy can lead to earlier treatment, prevent disease progression and lead to better outcomes. EOSINOPHILIC MYOPERICARDITIS SECONDARY TO ANCA-NEGATIVE EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA) Sneha Bupathi. Internal Medicine, Mount Sinai West Medical Center, New York, NY. (Control ID #4273463) CASE: A 46-year-old woman with a history of ulcerative colitis and adult-onset asthma presented with chest pain and palpitations for a week. She was under evaluation for EGPA in the outpatient setting, with symptoms including asthma, vocal cord polyps, chronic urticaria, mononeuritis multiplex, and peripheral eosinophilia. Examination revealed no murmurs or edema, and labs showed elevated troponin (602 ng/L), white blood cell count (26 K/ul), absolute eosinophil count (14.5 K/uL), ESR (98 mm/hr), and CRP (35 mg/L). Further workup showed a 1:40 ANA, elevated IgE, and negative c/p-ANCA, anti-MPO/PR3 antibodies. TTE revealed new HFmrEF, mild pericardial effusion and CT with bilateral ground-glass opacities. LHC showed normal coronaries, and RV biopsy demonstrated eosinophilic myocarditis. She received methylprednisolone and cyclophosphamide, with subsequent normalization of labs and symptom resolution. She was discharged on a steroid taper and GDMT therapy with follow-up. IMPACT/DISCUSSION: Cardiac manifestations are not uncommon in EGPA, though myopericarditis is rare and life-threatening due to tamponade risk. EGPA-associated myopericarditis typically occurs in patients with asthma. Cardiac findings are more common in ANCA-negative EGPA, with cardiac involvement being a significant negative prognostic factor, contributing to 50% of disease-related deaths. Severe complications include heart failure, intracardiac thrombi, arrhythmias, and sudden death. Prompt diagnosis and treatment with corticosteroids, immunosuppressive agents, and targeted cardiac therapies are crucial. EGPA-related myopericarditis is challenging to diagnose due to nonspecific findings like elevated troponin or EKG changes. When cardiac symptoms predominate with minimal systemic symptoms, diagnosis can be delayed. Cardiac MRI is essential for diagnosing myopericarditis and should be considered, as it can improve outcomes through early identification. Early recognition and management of myopericarditis in EGPA is vital to prevent complications.

Myopericarditis is a rare but potentially life-threatening manifestation of EGPA that requires prompt recognition and management. Early diagnosis is essential in preventing progression of diagnosis. Cardiac MRI should be considered in the diagnostic workup for EGPA, especially in cases with myopericarditis, as it plays a crucial role in identifying and managing cardiac involvement and preventing further complications. EPSTEIN-BARR VIRUS-INDUCED PORTAL VEIN THROMBOSIS: A RARE CRITICAL ENTITY Ayushi Garg1; Tripti Nagar6; Pranav Chalasani2; Nour Aldaoud2; Vamsi Krishna Lavu5; Mohamed Mansour4; Anthony Calabrese3; Muhammad H. Siddiqui2. 1INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine Residency, Wayne State University School of Medicine, Detroit, MI; 3internal medicine, Wayne State University, Detroit, MI; 4Internal Medicine Residency Program, Wayne State University School of Medicine, Detroit, MI; 5Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 6Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4272414) CASE: A 34-year-old man with a history of supraventricular tachycardia, status-post ablation presented with right upper quadrant (RUQ) abdominal pain radiating to his back. Six days prior, he was diagnosed with Ebstein-Barr virus infectious mononucleosis (EBV-IM) after developing sudden onset of fever, chills, and extreme fatigue. Upon physical examination, he had significant RUQ tenderness without signs of ascites or organomegaly. Laboratory evaluation showed ALT at 216 U/L and AST at 43 U/L, but otherwise normal blood counts and metabolic panel. A CT scan of the abdomen revealed extensive portal vein thrombosis (PVT) with complete occlusion of the left portal vein, non-occlusive thrombi in the right and main portal veins, and associated splenomegaly. Given his ongoing EBV-IM infection, post-viral thrombosis was the most likely etiology of the PVT. Further testing ruled out more common thrombotic causes, including hepatitis, CA 19-9, antithrombin 3 deficiency, HIV, CMV, and rotavirus. The patient was started on an anticoagulation regimen and subsequently discharged in stable condition. IMPACT/DISCUSSION: While this case illustrates the rare occurrence of PVT in a young, healthy individual without traditional risk factors, such as malignancy or liver disease, post-viral thrombotic complications are increasingly recognized in younger patients. EBV-induced PVT is exceptionally rare and more commonly seen in immunocompromised hosts. This is thought to result from transient elevations in antiphospholipid antibodies and endothelial damage caused by EBV. Recognizing these symptoms early is crucial, as abdominal pain and fatigue can be nonspecific and easily overlooked, leading to delays in treatment. Prompt anticoagulation initiation is essential to prevent severe complications like intestinal ischemia or portal hypertension.

This case highlights the need for clinical vigilance in maintaining a high index of suspicion for PVT in patients presenting after recent viral illnesses, even in the absence of other risk factors. ERYTHRODERMIC PUSTULAR PSORIASIS TRIGGERED BY RED LIGHT/LASER THERAPY Ingrid Rocha1; Emily Falkowski1; Meghan Mansour2; Thomas Hagerman3; Jalal Maghfour4; Rachel Karmally3; Holly Kerr4. 1Wayne State University School of Medicine, Detroit, MI; 2Department of Dermatology, MetroHealth Medical Center, Cleveland, OH; 3Department of Internal Medicine, Henry Ford Health System, Detroit, MI; 4Department of Dermatology, Henry Ford Health System, Detroit, MI. (Control ID #4269423) CASE: We report a 47-year-old female with a 25-year history of psoriasis, previously stable without treatment for 13 years, presenting with a flare following a first-time session of red light/laser therapy (RLLT). Initial symptoms of joint pain and localized plaques became widespread following RLLT. The thick, scaly plaques, bright red patches, and pustules on her palms, fingers, and toes covered 90% body surface area. She also experienced generalized edema and pruritus. Aside from RLLT, she had no new exposures. Upon admission, the patient was febrile (102°F) and tachycardic (HR 115). Lab results showed leukocytosis (WBC 19,000/μL), lymphopenia, elevated CRP (40.1 mg/L), ESR (87 mm/hr). Blood cultures, urinalysis, infectious, and autoimmune workups were unremarkable. She was treated with infliximab 5 mg/kg, topical therapies, and celebrex for joint pain. Within two days the patient experienced significant improvement of erythema, pustules, and joint pain. IMPACT/DISCUSSION: Psoriasis is an immune mediated inflammatory skin condition with various presentations. Pustular psoriasis (PP) is characterized by sterile pustules on background erythema. Erythrodermic psoriasis (EP) is rare and life-threatening, presenting with systemic symptoms and an erythematous scaly rash on 75% of the body. Due to this patient’s symptoms she was determined to have a very rare presentation of EP with concomitant PP. First-line therapy of PP is potent topical steroids or, if severe, cyclosporine or infliximab. Treatments for EP are cyclosporine and infliximab in unstable patients or acitretin and methotrexate in stable patients. Unlike for PP, steroids are highly contraindicated for EP due to the potential for severe withdrawal rebound of symptoms. In this case infliximab was chosen over cyclosporine due to less immunosuppressive effects given the initial concern for infection. Although RLLT has shown as a promising treatment for plaque psoriasis, this case seemed to have triggered a cascade of worsening symptoms, indicating possible Koebner phenomenon. This phenomenon describes the appearance of new lesions on previously unaffected areas of the body following trauma or injury to that area. The patient had been experiencing bilateral hand edema and muscle aches prior to the full-body RLLT, suggesting a flare-up during the RLLT session, thus triggering koebnerization and explaining the full-body severity.

PP and EP are rare, severe variants and seldomly co-occur. This case illustrates a severe psoriasis flare likely triggered by RLLT, with significant systemic inflammatory symptoms that required prompt biologic intervention and a multidisciplinary approach. The patient's response to Infliximab highlights the importance of timely treatment in managing severe psoriasis with systemic involvement. Although RLLT has shown potential for treating psoriasis, clinicians must consider the risk of novel therapies triggering a worsening of symptoms and the potential for Koebner phenomenon. ESOPHAGEAL CARCINOMA CUNICULATUM, A RARE SQUAMOUS CELL CARCINOMA SUBVARIANT, MANAGED VIA EARLY ENDOSCOPIC SUBMUCOSAL DISSECTION AND NEOADJUVANT CHEMOTHERAPY Jalal Samhoun, Raphael Khella, Zachary Daily, ALLISON CHIN, Carolyn Garcia, David Forcione. Internal Medicine, Florida Atlantic University, Boca Raton, FL. (Control ID #4273106) CASE: A 70-year-old male with Crohn's disease & dysphagia presented to the hospital due to progressive dysphagia with solids for the past several months. He had presented to the hospital 1 month prior with complaints of dysphagia. At that time, esophogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) demonstrated a large fungating mass involving approximately 50% of the esophageal circumference at 32 cm near the gastroesophageal junction (GEJ). Endoscopic biopsies were nondiagnostic revealing atypical squamous proliferation without definitive evidence of malignancy. He was discharged in stable condition & underwent a positron emission tomography (PET) computed tomography (CT) scan which demonstrated markedly dominant fludeoxygluocse F18 (FDG) avidity in the distal esophagus. The patient was offered surgical management with esophagectomy however declined. EGD with EUS was repeated 6 weeks later & endoscopic submucosal dissection (ESD) was performed. Histopathologic analysis demonstrated esophageal carcinoma cuniculatum (ECC) with involvement of the boarder margins of the resected tissue. The patient was discharged from the hospital in stable condition & instructed to follow up with Medical Oncology for initiation of neoadjuvant chemotherapy consisting of fluorouracil, leucovorin, & oxaliplatin administered every 2 weeks for 3 cycles for a total 5 weeks. IMPACT/DISCUSSION: ECC is a rare esophageal squamous cell carcinoma (ESCC) subvariant that is challenging to diagnose due to its unique clinical & pathological features. Globally, ESCC accounts for about 90% of esophageal cancers. However, there are only 28 cases of ECC reported as of 2024. ECC typically affects males and presents with progressive dysphagia & weight loss. The pathogenesis of ECC remains poorly understood given the scarcity of recorded cases, however, risk factors likely include GERD, smoking, alcohol use, & achalasia. Early endoscopic evaluation with tissue sampling is crucial to establish the diagnosis, however, tissue pathology is often equivocal. Histologically, ECC differs from typical SCC by exhibiting well-differentiated features like hyperkeratosis & intraepithelial neutrophilic inflammation. Treatment mirrors that for SCC, prioritizing surgery with esophagectomy being the preferred method due to the tumor’s aggressive nature, although ESD may be considered in non-surgical candidates.

ECC is a rare, well-differentiated ESCC variant with unique clinical & pathological traits, often misdiagnosed due to its complex histological features. Unfortunately, misinterpretations that delay early treatment contribute to poor outcomes. Esophagectomy is preferred over endoscopic management since neoplastic deep tissue invasion often has occurred at the time of initial presentation. Collaborative efforts between General Surgery, Gastroenterology & Pathology are crucial for establishing the diagnosis early, preventing treatment delay and improving favorable outcomes. EUGLYCEMIC DIABETIC KETOACIDOSIS WITH SODIUM-GLUCOSE COTRANSPORTER 2 INHIBITORS AND GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST Isna Khaliq1; Roselyn Cristelle I. Mateo2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Hospital Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4273051) CASE: A 62-year-old man with Type II Diabetes Mellitus (DM) presented with vomiting for two days. Vitals indicated tachycardia. Laboratory tests showed: white blood cell count 12 K/uL, potassium 5.7 mmol/L, glucose 150 mg/dL, anion gap 26, and ketones 7.4 mmol/L. Venous blood gas had a pH of 7.2, serum bicarbonate of 13 mmol/L, and pCO2 of 32 mm Hg. The diagnosis of Euglycemic diabetic ketoacidosis (euDKA) was made once other causes of high anion gap metabolic acidosis were ruled out. He received fluids and was started on continuous insulin. It was found that the patient had been taking a weekly dose of 7.5 mg Tirzepatide, a glucagon-like peptide-1 (GLP-1) receptor agonist and glucose-dependent insulinotropic polypeptide (GIP) agonist, for 4 months and abruptly stopped for 6 weeks, only to resume it again two days prior to his hospital admission. He had also been taking Empagliflozin, a sodium-glucose cotransporter 2 inhibitor (SGLT2i), 25 mg daily. After the patient’s anion gap and ketone levels normalized, he was transitioned to subcutaneous insulin. Upon discharge, Empagliflozin was discontinued, Tirzepatide was reduced to 2.5 mg weekly, and long-acting insulin was started. Close outpatient follow-up was arranged. IMPACT/DISCUSSION: EuDKA is a rare but life-threatening condition and is characterized by severe metabolic acidosis, ketonemia, and blood sugar levels below 250 mg/dL. In Type I DM, DKA is driven by absolute insulin deficiency, leading to ketosis and hyperglycemia. In contrast, DKA with SGLT2i is driven by reduction in plasma glucose levels due to urinary glucose losses, which then leads to decreased insulin secretion and an increase in glucagon secretion, resulting in lipolysis and ketoacidosis. The most likely mechanism of ketoacidosis with the use of GLP-1 receptor agonists is starvation ketoacidosis, caused by the side effects of vomiting, nausea, diarrhea and poor caloric intake of these agents. Also, GLP-1 receptor agonists can suppress appetite, prolong gastric emptying and decrease calorie intake. Another possibility is the insulin resistance status that could indicate relative insulin deficiency in obese patients with DM. This patient experienced euDKA while using an SGLT2i. The episode was likely triggered by the sudden reintroduction of a dual GLP-1 receptor agonist and GIP agonist after a six-week break. This could have induced a starvation state, which combined with the effects of Empagliflozin, eventually led to ketoacidosis.

SGLT2i and GLP-1 receptor agonists are becoming popular given their powerful ability to improve chronic conditions such as diabetes, obesity, and heart failure. Thus, it is essential to educate patients about their side effects. In particular, patients should receive guidance on dose management, negative impact of using both medications, and signs of euDKA. This can not only help to prevent euDKA, but also ensure that if it develops, patients can recognize it and seek out interventions, which if done timely, will save lives. EVALUATING THE EFFECT OF CLOT BURDEN ON RIGHT VENTRICULAR FUNCTION AND CLINICAL OUTCOMES IN ACUTE PULMONARY EMBOLISM—A CASE SERIES Jairah Shaikh1; Osama Karajeh1; Hassan Tariq1; Ali Yusuf1; Samra Iqbal2; Onyinye S. Ugoala3; Tarek Naguib4; Bradley Trinidad5. 1Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 2Internal Medicine, Texas Tech University Health Sciences Center Amarillo, Amarillo, TX; 3Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; 4Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX; 5Vascular Surgery, Northwest Physicians Group, Amarillo, TX. (Control ID #4272661) CASE: Cases of acute pulmonary embolism (APE), including 3 males and 2 females, were followed. Four were high-risk on the simplified pulmonary embolism severity index (sPESI). A 48/M presented with shortness of breath (SOB), hypotension, and sudden-collapse. High-sensitivity troponin (HS-t) was not elevated, and no evidence of right ventricular (RV) dysfunction was found on echocardiography, thus classifying him as a high-risk, massive APE. CT-pulmonary angiography showed filling defects at the bilateral interlobar arteries with emboli involving all lobes with moderate clot burden, resulting in an estimated Qanadli score (QS) of 20. After resuscitation from cardiac arrest, he was treated with a half-dose tissue plasminogen activator and IV heparin infusion and had an uncomplicated hospital course. A 53/F presented with SOB and tachycardia without hypotension. HS-t was elevated, and the echocardiogram revealed a depressed RV function with a markedly elevated systolic pressure. QS was 15 with thrombi in the right main and lower lobe pulmonary arteries. She recovered following mechanical thrombectomy. A 62/M presented with transient SOB and mild chest tightness without hemodynamic instability. HS-t was not elevated, and no right heart strain was present. Filling defects were seen in all lung lobes as well as in the left main pulmonary artery. QS was 25, and catheter-directed thrombolysis (EKOS) was successful. An 86/M similarly had an uncomplicated presentation with a QS of 25 but was managed conservatively with oral anticoagulation due to the patient’s goal of care. Lastly, an 80/F without significant cardiac history presented with sudden cardiac arrest and hypotension, and a normal-range HS-t. Filling defects were seen in the right lower lobe affecting adjacent segments, yielding a QS of 8. Despite IV heparin infusion, she decompensated within 24 hours. IMPACT/DISCUSSION: APE is a serious complication of thrombotic occlusion in the cardiopulmonary circuit. The strain effect on the RV function of the heart has been measured and used to prognosticate clinical outcomes. The extent of clot burden, quantified through QS (>18), and RV dysfunction have been widely utilized as independent predictors of APE clinical outcomes. Both their sensitivity and specificity have been reported to be ~75%. In this series, clinical presentations, based on sPESI and RV dysfunction, ranged from low-risk APE to intermediate high-risk APE, which did not correlate with their respective clot burden. With therapeutic strategies, such as EKOS and mechanical thrombectomy, becoming the emerging standard of care for APE of higher risk, further studies may be warranted to investigate and potentially expand the role of these treatments, especially when predictors of clinical outcomes are uncertain.

Clot burden and RV dysfunction are often incongruous and unreliable predictors of patient outcomes, thus lending to the importance of overall clinical status in the guidance of management and prognostication. EVALUATION OF NEUROPSYCHIATRIC SYMPTOMS IN AN UNCOMPLICATED YOUNG ADULT PATIENT ON THE GENERAL MEDICAL WARD Ana M. Jimenez. Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4271157) CASE: A 25-year-old RN without past history presented to the ED for confusion 1 week following a wisdom tooth extraction. Patient received nitrous oxide, fentanyl, midazolam, and propofol. Patient developed forgetfulness, insomnia, fevers, night sweats, jerks, and mental fog. Though hypertensive and tachycardic, they were discharged. Upon re-presentation for religious preoccupation with similar vitals, patient was admitted to psychiatry for psychosis. After 9 days on olanzapine, patient was transferred to medicine for evaluation of encephalopathy. An extensive workup revealed only elevated B12. After 6 days, patient returned to baseline mentation and was discharged on olanzapine despite minimal improvement attributed to it. IMPACT/DISCUSSION: Delirium is a common, yet misunderstood and misdiagnosed, neurocognitive syndrome in acutely ill medical-surgical patients. Its heterogenous presentation affecting memory, attention, processing, visuo-spatial ability, orientation, and affective and psychotic symptoms correlated with severity, makes it challenging to differentiate from other psycho-mimetics. Delay in diagnosis is associated with adverse outcomes in morbidity and mortality, length of hospitalization, institutionalization, and functioning. This is exacerbated by diagnostic overshadowing, heuristics, and communication errors. This postoperative patient with exposure to medications known to precipitate delirium presented with altered mental status, a common chief complaint for medicine. Despite the temporality, prodrome, absence of psychiatric biopsychosocial factors, and abnormal physiologic parameters, the patient was inappropriately admitted to a service. In the ED, given limited time, resources, and lack of a standard medical work-up for psychiatric symptoms, the accuracy of mental health diagnoses given is variable. Although there was documentation of fluctuating alertness at different times of day, delirium was not made the active problem and precautions were not implemented to optimize recovery. Without any indication, the patient remained on standing olanzapine as recommended by the psychiatry-consultant liaison. This occured despite the absence of distressing psychosis and safety concerns with overt inattention. Antipsychotics are not without risk and are known to not reduce duration of delirium and may actually prolong it given its sedative properties. The more severe the delirium, the more likely patients may experience psychologic distress in recalling traumatic events such as physical restraints and emergency intramuscular injections, vivid hallucinations and/or delusions, all of which this patient experienced. Although the patient improved, the clinical implications of this missed delirium diagnosis are yet to be known.

Any acute change in mental status is encephalopathy until proven otherwise. Delirium is a diagnosis always indicative of underlying organic pathology. Presence of neuropsychiatric symptoms are not exclusive to psychiatric disorders. EVANS SYNDROME IN A 39-YEAR-OLD MALE INITIALLY PRESENTING WITH DIARRHEAL DISEASE Adrian Sarita, Bilash Poudel, Lee Shapley. Internal Medicine, Nuvance Health, Lagrangeville, NY. (Control ID #4270570) CASE: Case: 39-year-old male who initially presented with diarrheal disease with anasarca. He had an extensive infectious workup notable for a stool culture showing blastocytosis hominis. He completed a course of metronidazole. His hospital course was complicated by pancytopenia for which he ultimately underwent a bone marrow biopsy showing hypercellular marrow with granulocytic and megakaryocytic hyperplasia. Karyotyping was normal, FISH negative for MDS and molecular studies were negative for myeloid neoplasm. TTP was suspected and was transferred to our institution. On presentation he was hemodynamically stable, with good saturation on room air, Physical examination notable for bilateral lower extremity edema, with rest of exam unremarkable. Initial labs with LH 316 U/L, WBC 3.3 cells/microliter, Hgb 8.4 g/dL and platelets of 15x10(9)/L. He was started on high-dose steroids and underwent 3 sessions of plasma exchange. Workup was negative for G6PD, and ADAMTS13, at which time plasma exchange was stopped. He was found to have IgG and C3 positive warm autoantibodies. Additionally, he was found to have positive latent tuberculosis infection. IVIG was started and platelet levels improved to 39x10(9)/L. He was ultimately discharged on Prednisone. Rituximab was offered but the patient declined. Outpatient follow-up had Improvement of hemoglobin to 14 g/dL and platelet to 86x10(9)/L. IMPACT/DISCUSSION: Evans syndrome is a rare disorder and is often a diagnosis of exclusion. An extensive hematologic-oncologic workup is indicated, prior to diagnosing the syndrome. Commonly it presents as autoimmune hemolytic anemia and idiopathic thrombocytopenic purpura, and less frequently with autoimmune neutropenia. Evans syndrome can be primary or secondary due to diverse conditions including infection, systemic autoimmune diseases, primary immunodeficiencies, and lymphoproliferative syndromes, with most cases occurring in the pediatric age group. Adult cases are rare with an incidence rate is 1 to 9 cases per million. The mainstay in treatment is immunosuppressives, often starting with steroids with adjunct IVIG. Second-line treatment includes Rituximab, Mycophenolate Mofetil, Cyclosporine and Azathioprine. Splenectomy can be considered as well. This disease is characterized by frequent relapses despite treatment and is associated with significant morbidity and mortality from infection and bleeding. Prognosis is poor when compared to isolated AIHA or ITP.

Evans syndrome is a rare and likely underdiagnosed disease in the adult population. It carries significant morbidity and mortality. It is a diagnosis of exclusion and should be in the differential diagnosis, especially in atypical presenting cases. Prompt treatment should be initiated to prevent catastrophic infection or hemorrhage. Once in remission, vigilant outpatient monitoring should bedone due to its recurrent course. EXPANDING THE CLINICAL SPECTRUM OF ANTI-GAD65 ANTIBODY SYNDROME: A UNIQUE CASE OF CEREBELLAR ATAXIA, REFRACTORY EPILEPSY, AND CRANIAL NEUROPATHY Usman Bin Hameed, Mujtaba Moazzam, Ayesha Sharif, Dilip Khanal. Internal Medicine, Corewell Health, Royal Oak, MI. (Control ID #4272463) CASE: A 21-year-old male with a history of focal epilepsy, Bickerstaff brainstem encephalitis diagnosed two months prior and mesial temporal sclerosis with progressive weakness and dysphagia over the past week. He described intermittent diplopia, which improved with forward gaze. No family history of neuromuscular disorders. BP 105/55 mmHg, HR 50 bpm, RR 24 breaths/min, and O2 saturation 99% on room air, BMI at 15.4. Physical examination revealed left ptosis, mild left medial rectus palsy, cerebellar ataxia and proximal muscle weakness graded 2/5 in the upper extremities and 3/5 in the lower extremities, without sensory deficits. Patient had anti-GAD65 antibodies (serum titer: 464 nmol/L, CSF titer: 39.2 nmol/L). Brain MRI demonstrated mild asymmetric hippocampal atrophy and increased FLAIR signal consistent with mesial temporal sclerosis. Infectious and Paraneoplastic work-up was negative. Electromyography revealed a post-synaptic neuromuscular junction dysfunction. Patient was started on high-dose IV methylprednisolone and IVIG infusions, but the respiratory status worsened necessitating intubation. Given rapid worsening, he was transitioned to therapeutic plasma exchange, completing a total of seven sessions. This resulted in notable improvement in muscle strength, successful extubation and partial resolution of symptoms. Following plasmapheresis, the patient was initiated on rituximab. His dysphagia significantly improved, allowing him to pass a modified barium swallow (MBS) study, and he was transitioned to an oral diet with successful removal of the nasogastric tube. IMPACT/DISCUSSION: The presentation of drug-resistant temporal lobe epilepsy, cerebellar ataxia, cranial neuropathies, and proximal muscle weakness, along with elevated anti-GAD65 antibodies in serum and CSF, confirmed a diagnosis of anti-GAD65 antibody syndrome. MRI findings of mesial temporal sclerosis supported autoimmune epilepsy, and oculomotor nerve involvement indicated multifocal CNS autoimmune involvement. Management involved escalating immunotherapy. High-dose IV methylprednisolone yielded minimal improvement, likely due to a high antibody burden. IVIG modestly reduced seizure frequency, while persistent systemic symptoms necessitated plasmapheresis to remove circulating pathogenic antibodies, achieving significant neurological and respiratory improvements after seven sessions. Rituximab was initiated post-plasmapheresis to deplete B cells and prevent relapse, aligning with its established efficacy in refractory autoimmune neurological syndromes.

Anti-GAD65 antibody syndrome has a broad, evolving presentation, as seen in this case with refractory TLE, ataxia, and cranial neuropathies. Plasmapheresis provided the most significant improvement, while rituximab, initiated early, may ensure sustained control. EXTENSIVE ARTERIAL THROMBOSIS IN A PATIENT TAKING RAD-140 (TESTALONE) Theresa Paul, Krushi Shah, Keerthi Cedeno, Joseph Hong. Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4269934) CASE: A 48-year-old man with hypogonadism on Testosterone Replacement Therapy (TRT) presented with abdominal pain and vomiting for one day. In addition to his TRT, he was also taking unprescribed RAD-140 (Testalone), which he had obtained from the black market three weeks prior to use for bodybuilding. Computerized Tomography (CT) of the abdomen/pelvis revealed splenic and right renal infarct. CT Angiography (CTA) of the chest revealed distal descending aortic thrombus. He had no history of hereditary thrombophilia; hypercoagulable workup resulted negative. Transthoracic echocardiogram revealed a small patent foramen ovale (PFO) but no thrombus; duplex of lower extremities was negative for deep vein thrombosis. No attributable factors for thrombosis other than the use of RAD-140 were identified. Patient was then placed on full dose anticoagulation and was advised to stop RAD -140. Following PFO closure, repeat CTA chest/abdomen/pelvis showed resolution of the aortic thrombus, and no new infarcts were seen at 3 months. IMPACT/DISCUSSION: RAD-140, a Selective Androgen Receptive Modulator (SARM), interacts with the hypothalamic-pituitary-gonadal axis, disrupting its negative feedback loop, and leading to an increase in testosterone levels. It is popular as a performance-enhancing substance among athletes. To date, no previous cases of RAD-140-induced arterial thrombosis have been reported. The exact mechanism by which RAD-140 may induce arterial thrombosis is unknown; however, the elevation of testosterone levels is likely a key factor. The pathophysiology of thromboembolism is explained by Virchow's triad: hypercoagulability, stasis, and endothelial injury. Testosterone can create a procoagulant state shortly after administration. In particular, TRT has been shown to upregulate the thromboxane A2 (TXA2) receptors on platelets, which may contribute to arterial thrombosis formation. TXA2 is a vasoconstrictor and a platelet-aggregating agent, increasing the risk of thrombosis development. The combined effects of TRT and RAD-140 likely resulted in the clinical presentation of our patient. The procoagulant effects of testosterone are more pronounced at higher levels; unfortunately, the testosterone level was not measured in our patient, making it unclear if his levels were within physiological limits or elevated.

The combination of RAD-140 and testosterone therapy could create a "perfect storm" for arterial thrombosis, highlighting the importance of awareness, monitoring, and further research on the health effects of RAD-140 as it continues to circulate in the market unregulated. EXTRINSIC GASTRIC OUTLET OBSTRUCTION FROM METASTATIC LOBULAR BREAST CARCINOMA MIMICKING DIABETIC GASTROPARESIS: A DIAGNOSTIC CHALLENGE Deepti Mahajan1; Stephanie Sabido2; Diana Mora2; Jessica Sheng1. 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 #4273290) CASE: A 64-year-old female with a history of bilateral breast cancer (2009 right breast DCIS treated with lumpectomy, sentinel lymph node dissection, chemo/radiation; 2020 bilateral ductal carcinoma ER+/PR+/HER2- and lobular carcinoma treated with mastectomy) and type 2 diabetes (HbA1c 11%) recently started on Ozempic two weeks prior presented with three days of nausea, vomiting, epigastric pain, and weakness. Symptoms were initially attributed to diabetic gastroparesis. CT imaging revealed proximal small bowel obstruction at the third portion of the duodenum, managed with nasogastric decompression. Endoscopy confirmed an impassable duodenal stricture concerning for malignancy, but biopsies showed chronic duodenitis. Chest CT identified a left chest wall mass, biopsy demonstrated ER+/PR+/HER2- immunostaining consistent with her 2020 breast cancer. PET confirmed recurrent lobular carcinoma in the left chest wall, a retroperitoneal mass interfacing the duodenum, and osseous metastases. Persistent symptoms necessitated robotic palliative gastrojejunostomy, which alleviated symptoms. Patient was discharged with close oncologic follow-up for chemotherapeutic/ radiation therapy. IMPACT/DISCUSSION: This case highlights the diagnostic challenges of distinguishing medication-induced gastroparesis from mechanical obstruction in patients with diabetes and malignancy. GLP-1 receptor agonists, such as Ozempic, delay gastric emptying and mimic gastroparesis, delaying recognition of metastatic disease. Endoscopic findings of food residue and duodenal stricture identified mechanical obstruction, while PET/CT clarified the extent of metastases. Metastatic lobular carcinoma involving the duodenum is rare but documented. Case reports by Wang et al. (2018), Zhao et al. (2012), and Kim et al. (2015) describe similar presentations of lobular carcinoma misdiagnosed as benign obstruction. This case emphasizes the importance of a high index of suspicion for malignancy and multidisciplinary management, including palliative gastrojejunostomy, to improve patient outcomes.

Consider malignancy in patients with persistent gastrointestinal symptoms despite plausible alternative explanations like diabetes or medication effects. Endoscopy and advanced imaging are essential for diagnosing and evaluating mechanical obstruction. Palliative interventions like gastrojejunostomy improve quality of life for patients with advanced malignancy causing obstruction. FAHR SYNDROME - A CASE REPORT HIGHLIGHTING THE INTERSECTION OF PSEUDOHYPOPARATHYROIDISM AND NEUROLOGICAL MANIFESTATIONS Angelin Raju1; Nkoyo Effiom2; Carolina De La Porte1; Dipaben Patel1; Tania Multani3. 1GME, Texas Health Resources, Arlington, TX; 2Internal Medicine, Texas Health Resources, Arlington, TX; 3Texas Health Resources, Arlington, TX. (Control ID #4230454) CASE: A 67-year-old woman presented with fall due to unsteady gait. She had a history of Hereditary Albright syndrome, pseudohypoparathyroidism, spinal stenosis and cervical myelopathy. Her unsteady gait and bilateral jerky movements of upper and lower extremity, noted few weeks after recent cervical laminectomy. Initially diagnosed with early onset movement disorder and she was advised to follow up with neurology. However, her symptoms worsened, leading to two additional falls, last of which caused significant bruising and prompted ED visit. A CT head was unremarkable for intracranial hemorrhage but revealed extensive calcification in the cerebellum, cerebral subcortical white matter and basal ganglia. Physical exam was consistent with Hereditary Albright syndrome with short stature, short neck, round face, shortened digits. Neurological examination revealed dysdiadochokinesia, altered finger-nose test, and myoclonic jerks on extremities and shuffling gait without cognitive impairment or focal deficits. Laboratory tests showed hypocalcemia (serum calcium: 7 mg/dL), elevated PTH (261 pg/mL), and elevated phosphate (5.5 mg/dL), suggesting abnormal calcium-to-PTH ratio. MRI confirmed bilateral symmetrical calcifications of the basal ganglia. These findings suggested Fahr syndrome, particularly given her endocrinopathy. Treatment with intravenous calcium gluconate and increased calcium and vit d supplementation lead to significant improvement in her symptoms. It was found that the patient who had recently relocated, had not been receiving her prescribed calcium supplements, which likely exacerbated her condition. She was discharged with recommendations for continued calcium supplementation and follow-up with endocrinology and neurology. IMPACT/DISCUSSION: Fahr syndrome or Bilateral Striopallido Dentate Calcinosis, is an exceptionally rare disorder with a prevalence of less than 1 in 1,000,000. It is often linked to hypoparathyroidism but can also be associated with other conditions like neuroferritinopathy, certain infections including syphilis, toxoplasmasmosis, CMV. Clinical manifestations include neurological symptoms such as seizures, motor issues like uncontrolled movements, and neuropsychiatric symptoms such as early-onset dementia, psychosis. Management of Fahr syndrome focuses on symptom control including the treatment of underlying calcium metabolism disorders and the use of appropriate medications to address neurological symptoms.

This case illustrates the diagnostic and therapeutic complexities of Fahr syndrome. The patient’s significant improvement following calcium treatment highlights the importance of considering calcium metabolic disorders in its diagnosis. Accurate diagnosis requires comprehensive assessment, including neuroimaging to differentiate Fahr syndrome's specific calcifications from incidental findings. This case underscores the rarity of Fahr syndrome and the need for a multidisciplinary approach in its management. FATAL REFRACTORY INTESTINAL BLEEDING AND BOWEL ISCHEMIA IN AN ADULT WITH IGA VASCULITIS Priyanka Mitta1; Carlie Stein2; Daniel Cooper2; Madhuri Molleti1. 1School of Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; 2Medicine, UAB, BIrmingham, AL. (Control ID #4268845) CASE: We report the case of a 58-year-old male patient who developed Immunoglobulin A vasculitis during treatment of endophthalmitis. The patient initially presented to an outside hospital with weakness and diarrhea and was found to have MRSA bacteremia secondary to an infected tunneled hemodialysis catheter. Other infectious and diarrhea workups were negative. He subsequently developed bilateral vision loss after initiating bacteremia treatment and was transferred to our institution for management of endophthalmitis. Upon transfer, the patient was afebrile and hypertensive (175/101 mmHg) with a noncontributory physical exam. Initial labs showed normocytic anemia with leukocytosis. On day 13, the patient developed new palpable, non-blanching erythematous lesions on the sacrum, legs, and feet with biopsy findings consistent with IgA vasculitis. Subsequently, the patient developed coffee ground emesis and dark tarry stools. The patient’s recurrent gastrointestinal bleeding was refractory to corticosteroids, IVIG, rituximab, and embolization. Disease progression was complicated by the development of bowel ischemia requiring resection and subsequent death. IMPACT/DISCUSSION: Immunoglobulin A vasculitis (IgAV) is a small vessel systemic vasculitis. Gastrointestinal manifestations are more common in adults and can include nausea, vomiting, abdominal pain, diarrhea, and gastrointestinal bleeding. Severe, fatal, and recurrent cases of IgAV-related GI bleeding in adults are uncommonly seen with limited literature for management including the long-term outcomes of corticosteroids and immunosuppressive agents. Current literature suggests management of IgAV in adults with corticosteroid and immunosuppressive therapy based on disease severity. However, recurrent GI bleeding episodes in those with IgAV are rare in literature with limited management guidelines for refractory cases of GI involvement. In our case, management with such therapy was complicated by the need to taper steroid dosage due to altered mental status, recurrent GI bleeding, and concurrent management of end-stage renal disease and bacteremia. Management of IgAV with steroids and immunosuppressive agents requires careful monitoring of disease severity and patient symptoms.

This case illustrates the complexity of managing severe IgAV with refractory GI bleeding. While corticosteroids and immunosuppressive therapies are the cornerstone of management, careful monitoring, rapid intervention, and individualized treatment plans are critical. The limited literature on the long-term outcomes and management strategies for such severe and refractory cases of IgAV-related GI bleeding underscores the need for continued research and clinical experience in guiding treatment decisions. FEVERS, SYNCOPE, AND THE BRUGADA DILEMMA: NAVIGATING THE COMPLEXITIES OF ICD DECISION-MAKING IN AN ATYPICAL PRESENTATION Lorna Devkota1; Michael Hoffer-Hawlik2; Albert Jung3. 1Internal Medicine, NYU Langone Health, New York, NY; 2Internal Medicine, New York University, New York, NY; 3Cardiology, NYU Langone Health, New York, NY. (Control ID #4271970) CASE: Patient is a 20-year-old male with no prior medical history who presented with a fever to 103oF and an episode of syncope while walking upstairs. It is unclear if loss of consciousness occurred. No eye rolling, tongue biting, or incontinence was reported. EKG completed on admission was consistent with Brugada Type 1 pattern. The patient had no relevant family history nor medications. Cardiac examination was unremarkable. Structurally normal heart on echocardiogram and cardiac MRI. Patient underwent an electrophysiological study with procainamide challenge which was negative for Brugada Type 1 pattern but did demonstrate an atypical right bundle branch block. In conjunction with the family of the patient, the decision to place an ICD was made for primary prevention of sudden cardiac death (SCD). IMPACT/DISCUSSION: BrS is a rare genetic ion channel channelopathy that can result in syncope or SCD due to ventricular arrhythmias. BrS with Type 1 EKG account for the majority of cases and is characterized by coved ST-segment elevation ≥2 mm with a negative T-wave in the right precordial lead. Although BrS is diagnosed with a type 1 EKG pattern without an obvious trigger, there are currently limitations in the diagnostic approach for BrS if Type 1 pattern is fever, or pharmacologically, induced. For patients with intermediate risk, the decision to place an ICD for primary prevention is complex. This patient presented with syncope in the setting of a febrile illness and had an EKG consistent with Brugada Type 1 pattern. Though this patient did not demonstrate Type 1 pattern during procainamide challenge, there were dynamic EKG changes consistent with an atypical right bundle branch block supportive of a sodium channel issue. Further, retrospective studies have shown that younger patients are more susceptible to life-threatening arrhythmic events in the setting of fevers. Decision regarding placement of an ICD for primary prevention in BrS patients must factor the absolute risk of inappropriate shocks or other device complications compared to the risk of SCD. While the syncope this patient experienced could not be definitively attributed to an arrhythmic cause given lack of EKG monitoring at the time of the event, the combination of clinical and diagnostic findings ultimately prompted shared-decision making and ICD placement for primary prevention of SCD.

Clinicians should recognize that BrS can be triggered by fever or pharmacological agents. A fever-induced Type 1 pattern requires careful evaluation, especially in the absence of spontaneous Type 1 EKG or a positive provocation test, as seen in this case. ICD placement for primary prevention in young patients with fever-induced BrS is complex and involves risk stratification, including age-related factors (younger patients are more susceptible to arrhythmic events while febrile), potential complications of the device, and the balance between the risk of SCD versus inappropriate shocks. FILAMIN C: AN UNEXPECTED CULPRIT OF SYSTOLIC HEART FAILURE AND ARRHYTHMIAS James Pollock1; Hata Mujadzic2; Chandler Richardson1; Susan A. Feldman1; Logan Carlyle1. 1Internal Medicine, Prisma Health Midlands, Columbia, SC; 2Cardiology, Prisma Health Midlands, Columbia, SC. (Control ID #4272934) CASE: A 54-year-old male with past medical history significant for atrial flutter, heart failure with reduced ejection fraction, hypertension, obstructive sleep apnea, and insulin-independent type II diabetes mellitus presented to outpatient cardiology following discharge from a recent admission for new-onset acute heart failure likely secondary to atrial flutter with rapid ventricular response. During the hospitalization, he underwent successful transesophageal echocardiogram cardioversion followed by left heart catheterization which was negative for obstructive coronary artery disease. Estimated left ventricular ejection fraction (LVEF) at that time was 35-40%. He was discharged on hospital day 5 with appropriate medical therapy in stable condition. Despite compliance with guideline-directed medical therapy and regular follow up, however, his LVEF continued to decline. The most recent estimate prior to this appointment, and just weeks following discharge, was approximately 25-30%. The patient reported subjectively not feeling well, and he now required a cane with ambulation. He regularly attends cardiac rehabilitation twice weekly but still feels short of breath with minimal activity. Orders were placed for cardiac MRI which revealed normal left ventricular size and reduced LVEF at 28% with late gadolinium enhancement images significant for myocardial fibrosis involving the basal-to-mid septal and anterior segments. Patient provided DNA samples via buccal swab which were sent for genetic testing and revealed a heterozygous mutation at the FLNC gene locus (p.Val1732Leu). Considering his reduced LVEF and newly discovered genetic cardiomyopathy, the patient was counseled on the recommendation for ICD placement and advised to continue with guideline-directed medical therapy. Four months later, his LVEF had improved to 40-45%. IMPACT/DISCUSSION: Mutations at the FLNC locus result in changes to the filamin C protein, a component of the sacrolemma found in striated muscle. In this patient's case, the p.Val1732Leu mutation has been shown to result in a missense mutation that compromises overall muscle integrity. FLNC mutations are known to be associated with both dilated and hypertrophic cardiomyopathies, as well as other cardiac diseases. What truly distinguishes FLNC-associated cardiomyopathies, however, is the strong tendency of patients to develop ventricular arrhythmias, myocardial fibrosis, and an increased risk of sudden cardiac death. In fact, recent guidelines regarding FLNC cardiomyopathy suggest that the presence of an LVEF < 45% is an indication for ICD placement due to the proclivity for developing fatal arrhythmias. Despite being genetic in nature, FLNC cardiomyopathy typically presents in middle-aged adults.

This case highlights an uncommon genetic etiology for both dilated and hypertrophic cardiomyopathy that requires special attention and treatment to appropriately mitigate the risk for sudden cardiac death from potentially fatal ventricular arrhythmias. FLECAINIDE-INDUCED QRS WIDENING IN ATRIAL FIBRILLATION: A RARE BUT IMPORTANT COMPLICATION Bolivia C. Fernandes2; Warren Fernandes1; Sumukh Arun Kumar3; Sushmita Prabhu1; Rajaeaswaran Chinnamuthu1; Rhea Bohra1; Ajitha Virinchipuram Ganesan2; Kedar Mahagaokar1. 1Internal Medicine, Saint Vincent Hospital, Worcester, MA; 2Internal Medicine , NYMC GME at St Mary's General Hospital and St Clare's Health, Denville, NJ, US, Parsippany, NJ; 3Hematology and Medical Oncology, Bayhealth Medical Center, Dover, DE. (Control ID #4273157) CASE: An 86-year-old female with a history of atrial fibrillation and sick sinus syndrome post a dual chamber pacemaker (PPM) presented after a 1-minute episode of syncope. She was managed with flecainide and apixaban for atrial fibrillation. She was hemodynamically unstable with wide complex tachycardia (QRSd 400 msec), diagnosed as ventricular tachycardia, and successfully treated with cardioversion. PPM interrogation revealed no tachycardic events. Labs were notable only for elevated pro-BNP (10,839 pg/mL), with normal electrolytes. Differential diagnoses included ventricular tachycardia, bundle branch block, and electrolyte disturbances. Hyperkalemia was considered; however, multiple potassium levels were normal. Flecainide toxicity was then suspected, and flecainide levels were sent out for investigation. The flecainide was then held. After the discontinuation of flecainide and drug washout, the QRS normalized. Flecainide levels were eventually found to be significantly elevated (2.29; normal 0.2-1.0 mcg/mL). IMPACT/DISCUSSION: Flecainide, a Class IC antiarrhythmic, is effective in managing atrial fibrillation but carries a risk of toxicity, particularly in elderly patients with altered drug metabolism. Toxicity often manifests as arrhythmias, including ventricular tachycardia and marked QRS widening, as seen in this case. Our patient, an 86-year-old female with atrial fibrillation and a dual-chamber pacemaker, presented with hemodynamic instability due to ventricular tachycardia. The markedly prolonged QRS duration (400 ms) and lack of other significant abnormalities, such as electrolyte imbalances, prompted suspicion of flecainide toxicity, confirmed by elevated serum levels (2.29 mcg/mL; normal 0.2–1.0 mcg/mL). Flecainide toxicity is rare but critical to recognize due to its life-threatening potential. Risk factors include advanced age, renal impairment, or drug interactions affecting hepatic metabolism. In this patient, no renal dysfunction or overt drug interactions were identified, highlighting the importance of close monitoring even in the absence of obvious predisposing factors. The normalization of QRS duration following flecainide discontinuation further supported the diagnosis. This case emphasizes the importance of maintaining a high index of suspicion for flecainide toxicity in patients presenting with wide-complex tachycardia, particularly when other causes have been ruled out. It also underscores the need for judicious prescribing and regular therapeutic drug monitoring to prevent such events.

Flecainide toxicity should be considered in elderly patients presenting with wide-complex tachycardia, even when serum potassium and pacemaker interrogation are unremarkable. Early recognition and drug discontinuation are pivotal to reversing its potentially fatal arrhythmic effects. FLOW OBSTRUCTION: A CASE OF RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION CAUSED BY LEFT VENTRICULAR ANEURYSM POST INFERIOR WALL MYOCARDIAL INFARCTION Mohamed Bassiony, Ariela Baur, Avery Hum, Alena Gonzalez, Colin Carpenter, Samantha Lo, Pedro Rafael Vieira de Oliveira Salerno, Alexander Conant. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273091) CASE: Background: Right ventricular outflow tract obstruction (RVOTO) is a rare cause of acute hemodynamic instability, commonly associated with metastatic cancer or congenital heart defects. Here, we present a case of RVOTO resulting from a left ventricular aneurysm (LVA) following an inferior wall myocardial infarction. Case: A 58-year-old man presented with an inferior wall MI, and subsequent catheterization revealed a 99% occlusion in the proximal right coronary artery. Post-catheterization, the patient developed hypotension and was found to have a high-pitched systolic murmur. Echocardiogram showed normal left ventricular size, mildly decreased systolic function, and a large LVA compressing the right ventricular outflow tract. IMPACT/DISCUSSION: Discussion: Due to hemodynamic instability, the patient was managed with inotropic support and ECMO. He unfortunately succumbed to intracranial hemorrhage nine days later. The most common etiology of RVOTO is mechanical compression due to tumor metastasis, accounting for 42% of cases in the current literature. RVOTO has also been reported as a complication of cardiac surgery, congenital cardiac disease, and hypertrophic cardiomyopathy.

Conclusion: To our knowledge, this is the first reported case of RVOTO secondary to LVA. This case highlights the need for considering RVOTO as a potential diagnosis in patients with hypotension post-MI, especially those exhibiting new murmurs. It also emphasizes that further research is necessary to determine optimal management strategies for this unique cause of RVOTO. FLUOXETINE-INDUCED NAUSEA: A GUT REACTION TO ANTIDEPRESSANT THERAPY Isabel Lopera1; Brent J. Gawey1; Thomas Gossard1; Benjamin Quiram1; Adam P. Sawatsky2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2General Internal Medicine, Mayo Clinic, Rochester, MN. (Control ID #4271184) CASE: A 76-year-old woman was admitted for a right gluteal hematoma in the setting of a right paraspinal mass. Her medical history included stage 4 chronic kidney disease, previous donor kidney transplant on chronic immunosuppression, renal cell carcinoma, heart failure, hypoalbuminemia, and depression. She had a series of infections secondary to her immunocompromised status, including Nocardia abscesses, Pneumocystis pneumonia, C. difficile colitis, and Alternaria soft tissue infection. As a result, she started several antimicrobials, including trimethoprim/sulfamethoxazole, minocycline, fidaxomicin, vancomycin, and posaconazole. Throughout her hospitalization, she had dysphagia, xerostomia, and severe food aversion associated with nausea and vomiting. An esophagogastroduodenoscopy did not reveal any structural abnormalities. Esophagram showed evidence of possible esophageal retention but was inconclusive. Due to poor oral intake and malnutrition, she had a nasogastric tube placed for tube feeds; however, she developed a vigorous gag reflex and had it removed. Given significant polypharmacy, medication toxicity remained high on the differential for ongoing nausea. Her plasma fluoxetine level was 1414 ng/mL (therapeutic range 120-500 ng/mL). The patient had her fluoxetine held for one week and her symptoms gradually improved. Repeat plasma fluoxetine level down trended to 1181 ng/mL. A psychotropic pharmacogenomics gene panel revealed she was a poor metabolizer of the CYP2C9 and CYP3A45 enzymes, both involved in fluoxetine metabolism. The patient discontinued fluoxetine permanently at discharge. IMPACT/DISCUSSION: Gastrointestinal symptoms are commonly observed in fluoxetine toxicity and include anorexia, xerostomia, nausea, and diarrhea. Fluoxetine is primarily metabolized by CYP2D6 followed by CYP2C9, CYP2C19, and CYP3A enzymes. Fluoxetine and its active metabolite, norfluoxetine, are inhibitors of CYP2D6 leading to prolonged elimination of fluoxetine, further compounded by its long half-life. In this case, the patient was a poor metabolizer of secondary enzymes involved in fluoxetine metabolism, likely contributing to decreased clearance of the drug. Fluoxetine is also highly protein-bound, up to 94.5% of the drug is bound to serum proteins, primarily albumin. In the setting of hypoalbuminemia, one would have an increase in the free fraction of fluoxetine and norfluoxetine, which are pharmacologically active.

1) Given that SSRIs are widely prescribed, physicians should routinely ask patients about gastrointestinal intolerances. In cases of refractory nausea, vomiting, xerostomia, and anorexia, physicians should consider evaluating plasma fluoxetine levels if indicated. 2) Fluoxetine has auto-inhibitory effects on its metabolism, especially at high doses (40 mg daily). 3) Poor metabolizers of cytochrome P450 enzymes can acquire toxic levels that lead to severe refractory gastrointestinal symptoms. FOCAL SEIZURES AND LEPTOMENINGEAL ENHANCEMENT LEADING TO THE DIAGNOSIS OF METASTATIC COLONIC ADENOCARCINOMA Masuma Islam1; Abdul Mumin2; Vadim Zarubin3. 1Internal medicine, UConn Health, Farmington, CT; 2Bangladesh Institute of Research and Rehabilitation in Diabetes Endocrines and Metabolic Disorders, Dhaka, Dhaka District, Bangladesh; 3Hematology-Oncology, St Mary's Hospital, Waterbury, CT. (Control ID #4235173) CASE: 72-year-old male with a history of Type 2 Diabetes Mellitus,presented with new-onset focal seizures characterized by right upper extremity jerking, aphasia, and right-sided facial twitching. Neurological examination was notable for intact comprehension, fluent speech, normal motor strength, and symmetric reflexes. Initial imaging, including an MRI brain, revealed left frontal sulcal FLAIR hyperintensity and leptomeningeal enhancement. A lumbar puncture showed mildly elevated protein but was otherwise unremarkable. EEG was normal, and the patient was started on Keppra,which resolved seizures but caused mild cognitive side effects.Further investigations included pan-CT imaging, which identified a suspicious liver lesion. A PET/CT confirmed an isolated metastatic liver lesion, and subsequent colonoscopy and liver biopsy established the diagnosis of colonic adenocarcinoma with liver metastasis. Guardant testing revealed no actionable mutations. The patient is scheduled for robotic low anterior resection of the primary tumor and partial hepatectomy. Postoperative plans include systemic chemotherapy with FOLFOX and bevacizumab. IMPACT/DISCUSSION: Neoplastic meningitis is the term commonly used to describe the multifocal seeding of the leptomeninges by malignant cells. When these cells come from a solid tumor, lymphomatous or leukemic meningitis, or when involvement is connected to these underlying disorders, this condition is also known as leptomeningeal carcinomatosis or carcinomatous meningitis. Any cancer that infiltrates the leptomeninges is a dangerous consequence that has a significant morbidity and death rate.This rare complication can result from cancers such as lung, breast, melanoma, leukemia, or intestinal malignancies (4–14% of cases). Neoplastic cells infiltrate the subarachnoid space, causing neurologic damage through direct invasion of the brain, spinal cord, or cranial and spinal nerves. Diagnosis relies on detecting malignant cells in CSF, neuroaxis imaging findings, and clinical symptoms. While neuroimaging is commonly used, no gold-standard, non-invasive diagnostic method exists. Unlike localized brain metastases treated with local therapies, LMC requires systemic treatment. In this case, postoperative FOLFOX and bevacizumab are planned to address both primary and metastatic disease.

This case highlights the complexity of adenocarcinomas, which can include numerous organs and spread through leptomeninges. Each oncology case should be carefully assessed, taking into account the patient's treatment with both systemic and surgical therapies as well as the use of modern imaging and biopsy techniques to determine the full extent of the disease. To handle these kinds of problems, interdisciplinary collaboration is essential. FROM BACTEREMIA TO SUBDURAL EMPYEMA: A RARE CASE OF GROUP B STREPTOCOCCUS MENINGITIS WITH NEUROLOGICAL COMPLICATIONS Jo Onaka1; Takahiro Fukushima1; Akihito Yoshida1; Takaaki Kobayashi2; Kazuaki Aoki1. 1General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan; 2Internal Medicine, University of Kentucky, Lexington, KY. (Control ID #4268062) CASE: A 74-year-old man with type 2 diabetes mellitus (DM) presented to the outpatient clinic with progressive walking instability over five days. He reported headache and diarrhea three days prior, which had resolved a day before his visit. On presentation, his temperature was 39.0°C, but other vital signs were normal. Neurological examination revealed no nuchal rigidity or focal deficits, and his physical examination was otherwise unremarkable. Given suspected intracranial pathology such as cerebral infarction, a brain Magnetic Resonance Imaging (MRI) was performed but showed no abnormalities, and the patient was sent home. One day later, blood cultures grew Streptococcus agalactiae, and the patient was admitted. Empiric therapy with ampicillin-sulbactam was initiated and later narrowed to penicillin G. On Hospital Day 3, the patient experienced transient disturbance of consciousness and right upper limb paralysis. A repeat brain MRI suggested a subdural empyema. On Hospital Day 4, lumbar puncture and FilmArray testing confirmed S. agalactiae in cerebrospinal fluid samples. The same day, the patient experienced tonic-clonic seizures with conjugate gaze deviation. Abscess drainage surgery was performed on Hospital Day 5, resulting in marked clinical improvement and significant reduction in abscess size. The patient was discharged on an 8-week course of penicillin G. IMPACT/DISCUSSION: Streptococcus agalactiae, an encapsulated β-hemolytic Gram-positive coccus, is the most common cause of meningitis and sepsis in neonates but is an uncommon cause of bacterial meningitis in adults. In this case, it is unclear if GBS bacteremia led to meningitis or vice versa. However, the initial MRI was normal, suggesting that the subdural empyema developed as a complication of meningitis. Subdural empyema is rare, complicating approximately 3% of adult bacterial meningitis cases. Its nonspecific initial symptoms, such as fever, headache, and vomiting, pose diagnostic challenges. As the disease progresses, focal neurological deficits and seizures may develop. Mortality rates among patients with neurological deficits secondary to subdural empyema are as high as 50–55%. Early diagnosis and timely intervention, including surgical drainage, are crucial for improving outcomes.

This case emphasizes the importance of considering GBS meningitis in the differential diagnosis when patients with GBS bacteremia develop neurological symptoms. Clinicians should maintain a high index of suspicion for intracranial complications and consider repeating brain imaging, even if initial findings are normal, as meningitis can progress to subdural empyema. FROM CHRONIC WOUND TO CANCER: THE TRANSFORMATION INTO MALIGNANT SQUAMOUS CELL CARCINOMA Omair Syed, Sheel Dalal, Bassem Chaar, Allison Isabelli, Torrie Hook, Samee Farooqi, Michael Kim. Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4270089) CASE: A 42-year-old male with paraplegia following a gunshot wound, ileostomy, neurogenic bladder, urostomy, chronic hip wound complicated by multidrug resistant osteomyelitis, and a urethro-cutaneous fistula, presented with a right hip burning rash, fever and chills. Exam revealed right hip swelling, tenderness, and an erythematous draining rash. Labs most importantly revealed hypercalcemia (Ca 10.9 mg/dl) and hypoalbuminemia (2.2 g/dl). The chronic pelvic wound had been present for 2 years. Hypercalcemia workup revealed an elevated parathyroid hormone-related protein, suppressed parathyroid hormone, proteinuria, and no monoclonal paraproteinemia. CT scan revealed diffuse soft tissue effacement with heterogeneous areas of thickening and small foci of interspersed gas. Multiple biopsies revealed moderately differentiated invasive squamous cell carcinoma. A staged surgical resection with groin lymph node dissection failed to achieve negative margins. Pathology revealed an extensive infiltrative malignancy involving the deep dermis, subcutaneous tissues, bones, and lymph nodes with extranodal extension. Immunotherapy with Cemiplimab-rwlc was initiated. Unfortunately, before he could have a chance to respond, he developed small bowel obstruction, likely due to metastatic disease, and he transitioned to hospice care. IMPACT/DISCUSSION: Squamous cell carcinoma is the most reported cause of PTHrP-mediated hypercalcemia. The cutaneous variant (cSCC) is the second most common skin cancer. A risk factor for cSCC is chronic wounds, which rarely undergo malignant transformation. In this case, we highlight the importance of this risk and the need to consider this in the management of chronic ulcers, including timely biopsies, hypercalcemia evaluation, and a multidisciplinary approach.

Chronic wounds can undergo malignant transformation through sustained inflammation and abnormal healing. Identifying hypercalcemia and elevated PTHrP can provide clues to the possibility of malignant degeneration. Hypercalcemia mediated by PTHrP is often triggered by solid tumors like cutaneous squamous cell carcinoma. cSSC is a curable malignancy in its early stages, and metastasis tends to occur at a slow rate if the disease is neglected or unrecognized. The presence of PTHrP-mediated hypercalcemia, in presence of a chronic wound, should prompt the consideration of an evolving cSCC. Prompt recognition would allow for surgical resection of locally advanced disease, or rapid institution of immunotherapy that can have profound implications on disease control, quality of life impact and patient survival. Routine assessment with a chemistry profile, in patients with chronic wounds, can help identify early hypercalcemia, prompting evaluation, wound biopsy and identification of malignant wound degeneration, potentially leading to improved outcomes, quality of life and potentially survival. FROM HEADACHE TO HYDROCEPHALUS - A CASE OF TUBERCULOUS MENINGITIS Kevin C. Chang1,2; Analiese DiConti-Gibbs2,1. 1Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA; 2Medicine, Los Angeles General Medical Center, Los Angeles, CA. (Control ID #4269965) CASE: A 22-year-old transgender-male with 1 month history of headache and admission 2 weeks prior for presumed viral meningitis, presented with worsening mental status, vomiting, and seizure-like activity. On admission, he was febrile to 39.4C and tachycardia to 110. Exam noted nuchal rigidity, left CN VI palsy, tangential thought process and fluctuating orientation. Labs showed a WBC 16.6 with neutrophil predominance. CT chest, abdomen and pelvis were unremarkable. MRI brain demonstrated bilateral leptomeningeal enhancement with acute to subacute infarcts in the insula and left temporal lobe. LP showed opening pressure of 37cmH2O, 151 nucleated cells with 77% PMNs and 22% lymphocytes, glucose 25 mg/dL, and protein 102 mg/dL. CSF acid-fast bacilli (AFB) culture was sent. CSF adenosine deaminase was not elevated at 1.9mg/dL. Interferon-gamma release assay was indeterminate. Sputum MTB PCR and AFB culture were negative. CSF meningoencephalitis panel, fungal serologies, Karius testing, free living amoeba, and brucella serologies were all negative. HIV test was negative. Treatment was initiated with broad antifungal and anti-tuberculosis agents. Dexamethasone was started. Serial LPs demonstrated increasingly leukocyte predominant pleocytosis. On day 16, CSF AFB culture sent day 1 resulted with mycobacterium tuberculosis (TB) growth. Treatment was narrowed to TB therapy and he was discharged to acute rehab. IMPACT/DISCUSSION: We present a case of tuberculous meningitis (TBM) in an immunocompetent patient. TBM typically progresses through a subacute prodromal phase, an meningitic phase, and a paralytic phase over the course of weeks. This timeline is a major differentiating factor from other bacterial and viral meningitides. Key differentials of subacute meningitis include fungal and atypical bacterial organisms like brucella. CSF studies in TBM demonstrate lymphocytic pleocytosis, hypoglycorrhachia, and elevated protein levels, although early infection may be mixed or PMN predominant, as in this patient. Hydrocephalus, basilar meningeal enhancement and signs of infarct, especially in the basal ganglia, are classically seen on imaging. CSF AFB cultures return positive in only 30-60% of cases, often after weeks of incubation. Greater volume and repeated LPs have improved diagnostic yield. Empiric therapy with anti-tuberculosis medications should not be delayed, and CSF studies may remain diagnostic for up to 3 days after initiation of treatment. Dexamethasone as adjunctive therapy decreases mortality, but likely does not reduce severe neurological deficit.

- TB meningitis typically presents with a more subacute timeline than bacterial or viral meningitides and CSF cell count may be neutrophil predominant though is typically lymphocyte predominant - Early initiation of empiric treatment should not be delayed pending diagnostic clarity in cases where TB meningitis is suspected FROM INTOXICATION TO INFECTION: CRYPTOCOCCAL MENINGITIS MASQUERADING AS ACUTE OPIOID INTOXICATION Joseph T. Vaughan, Seema Tekwani, Daniel Barboto. Medicine, Emory University, Atlanta, GA. (Control ID #4269895) CASE: A 40-year-old male with no known medical history was brought to the emergency department after being found minimally responsive at a bus stop. Initial history was limited due to his mental status, and no family could be located. On arrival, he was hypotensive, bradycardic, hypothermic, and had respiratory depression with pinpoint pupils. Laboratory studies revealed lymphopenia (100 cells/μL) and a negative urine drug screen. A CT head scan showed no acute abnormalities. Given strong clinical suspicion for opioid intoxication, a naloxone drip was started, and the patient was admitted to the MICU for airway monitoring. While his vital signs and neurologic status improved slightly, his encephalopathy persisted on transfer to the general medicine floor. HIV testing returned positive, with a CD4 count of 21 cells/μL. Lumbar puncture revealed a cryptococcal antigen titer of 1:1280, confirming cryptococcal meningitis, and antifungal therapy was initiated. Brain MRI showed meningoencephalitis, hydrocephalus, and multiple infarcts. The patient was later transferred back to the MICU for aspiration and intubated for airway protection. His course was further complicated by pneumocystis jirovecii pneumonia, central diabetes insipidus, and multiple hospital-acquired infections. After undergoing tracheostomy and PEG tube placement, he was discharged to a long-term acute care facility. Despite extensive interventions, his neurologic status did not recover. IMPACT/DISCUSSION: Acute encephalopathy is a common condition encountered by the general internist, representing 4 to 10 percent of emergency department presentations, and has numerous potential causes. A broad differential is essential, especially when patients do not improve with initial therapy. Early CSF sampling should be considered when patients also have features concerning for infection, such as hypothermia and lymphopenia. In this case, investigation into the patient’s lymphopenia led to his diagnosis and markedly altered his clinical course. Lymphopenia is common in HIV-infected patients, particularly in advanced disease or those not on effective antiretroviral therapy. Cryptococcal meningitis is a frequent complication of uncontrolled HIV, with over 150,000 annual cases worldwide. Clinicians should have a low threshold for HIV testing in undifferentiated patients, especially in high-prevalence regions, as identifying this condition can significantly impact morbidity and mortality.

1. A broad differential diagnosis is critical for acute encephalopathy, especially with persistent symptoms that fail to respond to initial treatments. 2. Consider early CSF sampling in patients with lymphopenia and hypothermia. 3. HIV should be considered as a potential cause of lymphopenia. 4. In high-prevalence areas, HIV testing should be part of the evaluation of undifferentiated severe illness. FROM LUNG TO JOINTS: A RARE RESPIRATORY VIRAL TRIGGER FOR REACTIVE ARTHRITIS Luke S. Vest1; William Mannherz1,2; Sanjna L. Surya1; Vatsal Bhatt1. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Harvard Medical School, Boston, MA. (Control ID #4242165) CASE: A healthy 34-year-old female presented to the hospital with severe left lower extremity pain. Patient reported four days of progressively worsening left upper thigh and hip pain that caused her to become bedridden. She endorsed fevers, chills, and myalgias but denied vomiting, diarrhea, trauma, travel, sexual activity, or IV drug use. Vitals were stable except mild tachycardia. On exam, she had diffuse left thigh and hip tenderness without erythema or fluctuance. Labs showed elevated inflammatory markers and normal CK. A respiratory viral panel was positive for rhinovirus/enterovirus. Other infectious and autoimmune workup was negative including blood cultures, urine Chlamydia and Neisseria, Lyme, ANA, RF, anti-CCP, and HLA-B27. MRI of the left hip showed a small joint effusion. Arthrocentesis yielded cloudy, serous fluid containing 35,000 nucleated cells with 85% neutrophils, no birefringent crystals, and negative gram stain. Her pain was uncontrolled despite IV opioids. IV vancomycin was initiated but stopped after no improvement over 48 hours and negative aspiration cultures. In conjunction with rheumatology consultation, a clinical diagnosis of reactive arthritis due to respiratory viral illness was made. IV steroids were started. Patient’s symptoms and inflammatory markers rapidly improved and she was discharged home with a 30-day steroid taper. IMPACT/DISCUSSION: This case is unique because it highlights that reactive arthritis (ReA) is a clinical diagnosis and in rare cases is associated with respiratory viral illness. Our team relied on clinical information to make the diagnosis in a case where labs and imaging were non-diagnostic. ReA is commonly triggered by GI and urogenital bacterial infections. Viral respiratory causes are rare though SARS-CoV-2 has been implicated in several case reports. Rhinovirus and enterovirus have rarely been associated with ReA. One case report discussed ReA associated with rhinovirus infection, but there was simultaneous Chlamydia pneumoniae infection, a known trigger. Given that rhinovirus and enterovirus were the only identified pathogens, this may represent a rare case of ReA triggered by rhinovirus/enterovirus respiratory infection. Though HLA-B27 can be a marker suggestive of ReA, currently there are no established diagnostic criteria. Initial therapy with NSAIDs and glucocorticoids is indicated for symptomatic relief of ReA as highlighted in our case.

ReA should be considered in patients presenting with acute oligoarticular arthritis and recent GI, genitourinary, or respiratory infection. A multitude of organisms have been associated with this condition, and suspicion should remain even if common triggers are not identified. When septic and crystalline arthritides have been ruled out, anti-inflammatory and glucocorticoid medications should be considered to relieve symptoms. FROM MIGRATION TO MANIFESTATION: POTT’S DISEASE AFTER NEARLY FOUR DECADES Uchechukwu Alanza1; Muhammad Ahmed Khan1; Safia Mohamed1; Kathryn Jobbins2. 1Internal Medicine, Baystate Medical Center, Springfield, MA; 2Internal Medicine, University of Massachusetts Chan Medical School - Baystate Regional Campus, Springfield, MA. (Control ID #4271260) CASE: An 89 year old Portuguese immigrant with a history of nonischemic cardiomyopathy and smoldering multiple myeloma (SMM) presented to our hospital twice in a 7-week period with atraumatic lumbar back pain. Her first admission was prompted by findings of T12-L1 discitis and osteomyelitis with concerns for paraspinal and epidural abscesses on an outpatient magnetic resonance imaging (MRI) obtained by her primary care team. On admission, she was afebrile with an unremarkable physical exam though she had an elevated C-reactive protein of 11.0 mg/dL and erythrocyte sedimentation rate greater than 129 mm/hr, without leukocytosis. In consultation with infectious diseases and neurosurgery, she had a repeat lumbar MRI with similar findings and T12-L1 bony destruction. She underwent a computed tomography (CT) guided biopsy of her epidural abscess which yielded no organisms on culture. Thus, she was discharged on a 6-week course of antibiotics for vertebral osteomyelitis. However, she returned to the hospital 6 weeks later with worsening lumbar radiculopathy and inability to bear weight. Repeat MRI showed progression of her T12-L1 bony destruction, increase in abscess sizes, and mass effect on the subarachnoid space and conus medullaris. She then underwent T12-L1 laminotomy, facetectomy, discectomy and evacuation of phlegmon to relieve the mass effect. Her operative bone samples grew Mycobacterium Tuberculosis (MTB) prompting initiation of MTB induction treatment after ruling out a concomitant Human Immunodeficiency Virus infection. This led to improvement in her symptoms and inflammatory markers. Active pulmonary MTB was ruled out with absent respiratory symptoms and negative acid-fast bacilli smears. IMPACT/DISCUSSION: Pott's disease is a rare vertebral infection caused by MTB, accounting for only 1%–2% of all cases of MTB. Risk factors include immunosuppression, close contact with individuals with active MTB and immigration from MTB-endemic areas. Notably, SMM caused a degree of immunosuppression in our patient, increasing her risk of Pott’s disease. However, this coincidental occurrence is very rare in existing literature, adding to this case’s uniqueness. Additionally, our patient emigrated from Portugal 38 years ago and had no prior MTB exposures, eliminating those classic risk factors.

Overall, this case shows the importance of comprehensive history taking, including travel history when formulating a differential diagnosis. Given the rare occurrence of Pott’s disease, this case shows the importance of keeping a broad differential diagnosis even if lumbar back pain is a common presenting complaint in the geriatric population. FROM ORAL FLORA TO PULMONARY PATHOGEN: A RARE CASE OF SLACKIA EXIGUA EMPYEMA Jessica Santucci2; Nabeel Akhtar1. 1Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA; 2Penn State College of Medicine, Hershey, PA. (Control ID #4271748) CASE: A 28-year-old female with a history of viral-induced dilated cardiomyopathy and bipolar disorder initially presented in the outpatient setting with dyspnea and cough. She was afebrile and hemodynamically stable on room air with a leukocytosis (14.46 × 103/μL). Chest x-ray and CT showed a consolidation in the right lower lobe, thought to be community-acquired pneumonia. She was treated with azithromycin and amoxicillin-clavulanate acid, and when did not improve within a week, she was switched to moxifloxacin. Two weeks after initial presentation, she presented to the emergency department for worsening dyspnea. While afebrile and hemodynamically stable on room air, her leukocytosis worsened to 21 × 103/μL. Imaging did not show a pulmonary embolism but a worsening lung consolidation and loculated right pleural effusion. She was admitted to Internal Medicine. Infectious workup included negative respiratory virus panel and blood and sputum cultures. She was empirically treated with broad-spectrum antibiotics. She underwent a CT-guided chest tube placement and then given lytic therapy. Chest tube aspirate was positive for Slackia exigua. She was then switched to ampicillin-sulbactam. Her dyspnea later resolved, and she was discharged on amoxicillin-clavulanate acid. She is now awaiting follow-up with Pulmonology. IMPACT/DISCUSSION: Slackia exigua is an anaerobic, gram-positive rod bacterium in the Coriobacteriaceae family, typically found in normal human oral microbiota. coccobacillus bacteria native to human oral flora. Extra-oral infections caused by S. exigua are extremely uncommon, but there have been reports of bacteremia, abscesses, osteomyelitis, and meningitis. Only two case reports implicate this bacterium as the cause of empyema. Despite this relevance, S. exigua remains poorly understood. Detection of S. exigua is challenging due to its slow growth and its inability to be identified by conventional anaerobic culture methods. Diagnosis relies on gene sequencing or mass spectrometry. In this case, S. exigua was isolated from a chest tube aspirate culture, which was unexpected given the limited evidence of this bacteria infecting the lungs. S. exigua infections can be treated with antibiotics with gram-positive and anaerobic coverage such as amoxicillin-clavulanate acid, clindamycin, piperacillin-tazobactam, amoxicillin, and metronidazole.

S. exigua is an anaerobic, gram-positive rod bacteria native to the oral cavity; extra-oral infections are rare. S. exigua infections, oral or extra-oral, can be treated with antibiotics with gram-positive, anaerobic coverage. Organism identification is complicated by slow growth and complex bacterial culturing. Clinicians should be aware of this commensal organism, its clinical manifestations, and treatment options. The organism should be in the differential when considering treatment for complicated cases of pneumonia. FROM OTC TO ICU: PRES IN THE SETTING OF PHENYLEPHRINE USE Luke Ciminera, Tinsa Varughese, Courtney Hill, Biraj Shrestha, Courtney Bennett. Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4273375) CASE: A 34-year-old male with no recent medical follow-up presented with a one-week history of dyspnea and lower extremity edema. He reported routine use of over-the-counter medications containing phenylephrine for several weeks to relieve recent viral symptoms. On admission, severe hypertension 210/150 and elevated cardiac biomarkers were appreciated. Echocardiogram revealed a reduced left ventricular systolic function of approximately 30%. He was started on a nitroprusside drip, and was admitted to the cardiac intensive care unit for hypertensive emergency and new-onset heart failure. After developing intermittent visual disturbances and facial paresthesias, neurology was consulted. Magnetic resonance imaging revealed changes consistent with posterior reversible encephalopathy syndrome (PRES) and early papilledema, without evidence of acute infarct or hemorrhage. His antihypertensive regimen including hydralazine, isosorbide dinitrate, spironolactone, and beta-blockers was cross titrated to allow for discontinuation of nitroprusside, with blood pressure and renal function improving gradually. The patient was counseled to have follow-up imaging to confirm resolution of the PRES findings at 3 months and follow up ophthalmology evaluation was arranged. IMPACT/DISCUSSION: PRES is a neurologic condition that can present with a variety of symptoms such as visual disturbances, headaches, and seizures. It often occurs in context of acute uncontrolled hypertension. This case highlights the critical nature of hypertensive emergencies, with damage manifesting as new-onset heart failure and neurological changes. Failed cerebral autoregulation and resultant vasogenic edema triggered by abrupt surges in blood pressure were likely exacerbated by over-the-counter phenylephrine use. Management required careful use of intravenous antihypertensives, avoiding rapid pressure reductions to prevent ischemic complication. Ultimately, this case underscores the importance of early recognition, thoughtful hemodynamic management, and appropriate follow-up to ensure full recovery.

This case demonstrates that uncontrolled hypertension may remain asymptomatic until catastrophic presentations occur. Early recognition and aggressive management of hypertensive emergencies can reverse potentially life-threatening complications, including cardiac dysfunction and neurologic impairment. Application of evidence-based principles allowed selection of appropriate imaging and medication strategy to guide management. At the same time, a patient-centered framework maintained the individual’s involvement, acknowledged preferences and clarified the role of seemingly benign agents like phenylephrine. By integrating careful counseling on sustained blood pressure control, arranging timely evaluations, and encouraging active participation in follow-up, a pathway to restored stability beyond the patient's acute phase of care was achieved. FROM PAIN RELIEF TO PSYCHOSIS Krishna Kothamasu1; Eric Del Valle1; Amanda Sinderovsky1; Dhara D. Patel2; Jessica A. Schumann3; Olubunmi Olarewaju3. 1Internal Medicine, Jefferson Health - Northeast, Philadelphia, PA; 2Internal Medicine, Jefferson Torresdale Hospital, Philadelphia, PA; 3Hospital Medicine / Emergency Medicine, Jefferson Health - Northeast, Philadelphia, PA. (Control ID #4273242) CASE: This is a case of a 69 year old female with past medical history including chronic back pain, morbid obesity, atrial fibrillation (on rivaroxaban), hypothyroidism, and hypertension who was admitted for metabolic encephalopathy. She presented with three days of audiovisual hallucinations after she increased her home Baclofen from 10 milligrams (mg) three times daily (TID) to twenty mg TID for a few days prior to admission. She noted ambulatory dysfunction and weakness, leading her to abruptly stop the baclofen prior to onset of the audiovisual hallucinations. Endocrine, neurologic, and infectious workup revealed the following: normal levels of vitamin B12, thyroid stimulating hormone, folate, ammonia, along with two unremarkable head computed tomography (CT) scans. Ceftriaxone was initiated after initial urinalysis was concerning for a urinary tract infection (30 white blood cells, 2+ leukocyte esterase). Antibiotics were discontinued when the subsequent urine culture was negative. Psychiatry initiated risperidone for one day, but during a rapid response event for worsening hallucinations, all medications were held due to concern for polypharmacy. Baclofen was the only medication to be reintroduced at twenty mg TID, which resolved the hallucinations within two days. The patient was discharged on a baclofen taper without symptoms recurrence. IMPACT/DISCUSSION: Baclofen is one of the most commonly prescribed muscle relaxants in the United States, ranking as the 104th most prescribed medication in 2022. With fewer than 100 recorded cases, abrupt baclofen withdrawal associated-psychosis is a rare sequela. Chronic baclofen use downregulates GABAb pathways. It is theorized that with abrupt cessation, a surge of unregulated activation may lead to psychosis. Research shows that benzodiazepines offer a pharmacologic treatment due to their similar mechanism of action on the GABAa receptor pathway. While no standard of care exists, per our case and emerging research, a gradual taper may be more effective for baclofen withdrawal than initiating antipsychotics. Research to confirm the causal relationship between cessation and psychosis has yet to be determined, and this case underscores the importance of recognizing this phenomenon to better manage it inpatient.

- Occurrence of baclofen withdrawal psychosis is a rare but serious complication that may be underdiagnosed in the hospital setting - This case suggests that restarting baclofen with a gradual taper may be more effective than initiating antipsychotics. - With how commonly baclofen is used, further research is imperative to better understand the mechanism behind withdrawal psychosis and manage these symptoms. FROM RELAPSE TO REMISSION: A CASE OF NEUROMYELITIS OPTICA SPECTRUM DISORDER HIGHLIGHTING EMERGING THERAPIES talar acob, Tigran Kakhktsyan. Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ. (Control ID #4273244) CASE: A 46-year-old Hispanic woman with a history of left optic neuritis and blindness presented with sudden blurred vision in her right eye, headache, and dizziness. She reported a similar episode seven years ago causing complete left eye blindness. She denied extremity weakness, numbness, tingling, or urinary incontinence. A brain MRI was unremarkable, but face, neck, and orbit MRIs showed optic nerve sheath prominence, atrophy, and increased T2 signal in the left optic nerve. Labs revealed mildly elevated NMO IgG (3.2 u/mL) with normal serum AQP4. She received high-dose IV Solu-Medrol followed by a five-day course of plasmapheresis and steroids, leading to improved vision and discharge. Six days later, she returned with a persistent right supraorbital headache (7/10) and blurred vision but no other neurological symptoms. NSAIDs were prescribed, and neurology initiated Rituximab, which was discontinued after a severe allergic reaction. She transitioned to Inebilizumab-Cdon infusions every six months, resulting in significant symptom relief and sustained remission during follow-up. IMPACT/DISCUSSION: Neuromyelitis optica (NMO), also known as neuromyelitis optica spectrum disorder (NMOSD) or Devic disease, is a rare central nervous system disorder primarily targeting the optic nerve and spinal cord. Global prevalence rates have varied over the past two decades: 1/100,000 in Whites, 3.5/100,000 in East Asians, and up to 10/100,000 in Blacks . The typical age of onset peaks around 35–45 years but can affect children and the elderly. There are two established autoimmune types of NMO with unique autoantibodies: Aquaporin-4 (AQP4) antibodies: Found in about 75% of patients, these antibodies target aquaporin-4, a water channel on astrocytes. Myelin Oligodendrocyte Glycoprotein (MOG) antibodies: These antibodies damage MOG, a membrane protein on oligodendrocyte cell surfaces and the outer myelin sheath, making it a prime candidate for autoimmune demyelination. In over 90% of cases, NMO involves unpredictable attacks of optic neuritis, myelitis, or both.

Recognize Diverse Presentations: NMOSD can present with symptoms such as recurrent optic neuritis or myelitis, often with significant variability between patients. Timely recognition of these symptoms is crucial for early intervention. Importance of Tailored Treatment: The case illustrates the importance of individualized therapy, with the patient's transition from Rituximab to Inebilizumab-Cdon, which led to sustained remission. This highlights the need for flexibility and vigilance in managing treatment responses and adverse effects. Collaboration Across Specialties: Managing NMOSD requires coordination among internists, neurologists, and immunologists, emphasizing the need for a multidisciplinary approach to optimize patient outcomes. FROM RUPTURE TO RECOVERY: A PATIENT'S JOURNEY WITH RENAL PARENCHYMAL RUPTURE AND URINOMA Alina Sehar1; John Fanning2; Hinal Rathi3. 1Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL; 2Internal Medicine, The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL; 3Internal Medicine, University of Alabama Huntsville Regional Campus, Huntsville , AL. (Control ID #4236598) CASE: A 70-year-old male with a history of a right-sided ruptured renal cyst following nephrostomy and stent placement presented to the hospital with acute right-sided flank pain. He reported experiencing right flank tenderness for several weeks, which had recently worsened, and noted decreased urine output during the same period. A CT scan revealed a large free fluid collection around the right kidney, raising concerns for renal parenchymal rupture. The urology team was consulted, and the patient underwent cystoscopy, pyelogram, and right ureteral stent placement. A diagnosis of urinoma secondary to chronic ureteropelvic junction (UPJ) obstruction was confirmed. Management included the placement of a perinephric drainage tube and a Foley catheter. The patient underwent a repeat cystoscopy and right ureteral stent removal. A subsequent Lasix scan demonstrated abnormal renal function. Following a successful voiding trial, the Foley catheter was removed, and the patient achieved normal urine output without complications. He was discharged with the nephrostomy drain in place and instructed to follow up with urology as an outpatient. IMPACT/DISCUSSION: Ureteral injury is an uncommon occurrence, with an incidence of approximately 1%, and is typically associated with blunt or penetrating trauma. These injuries are classified by location: ureteropelvic junction (UPJ), abdominal ureter, and pelvic ureter. In this case, chronic UPJ obstruction led to renal parenchymal rupture, culminating in the formation of a urinoma. Diagnosing urinoma can be challenging due to its nonspecific clinical presentation. However, a high spot creatinine level in the drained fluid strongly supports the diagnosis. Timely diagnosis and intervention are crucial to prevent severe complications, including complete loss of renal function or mortality.

Urinoma is a rare retroperitoneal mass that forms as a result of encapsulated urine leakage due to ureteral injury. Such injuries can occur from trauma, urinary obstruction, or surgical procedures. Diagnostic approaches include high-dose excretion urography or a dedicated CT scan. Management typically involves drainage through catheter placement, empiric antibiotic therapy, nephrostomy tube insertion, and, in certain cases, surgical intervention. FROM SIPS TO SYMPTOMS: A CASE OF DIETHYLENE GLYCOL TOXICITY Sandra Abadir, Muhammad Durrani, Arian Gower. Internal Medicine, Los Robles Regional Medical Center, Thousand Oaks, CA. (Control ID #4248617) CASE: A 54-year-old mn with a history of alcohol use disorder was found unresponsive by his family. He was hemodynamically stable, and physical examination revealed dilated pupils and contracted arms. Laboratory findings were significant for a white blood cell count of 27.9 × 10^9/L, a creatinine level of 3.99 mg/dL, elevated liver enzymes, and anion gap 0f 26 with bicarbonate level of 4.9 mmol/L, concerning for metabolic acidosis with kidney injury. Urine toxicology was negative, and his osmolar gap was elevated, raising suspicion for toxic alcohol ingestion. The patient was intubated and admitted to the ICU. Nephrology started him on. Imaging studies revealed no significant findings, except for multifocal pneumonia, managed with antibiotics. Despite aggressive medical management, the patient’s condition worsened, and brain death was suspected after clinical deterioration and abnormal neurological findings, including absent reflexes and encephalopathy. Family history revealed a prior similar episode at age 17. A bottle of brake fluid was later found at home, raising suspicion of DEG ingestion. IMPACT/DISCUSSION: Diethylene glycol toxicity, though rare, should be suspected in patients with elevated osmolar and anion gaps. DEG is metabolized by alcohol dehydrogenase into its toxic metabolites, including 2-hydroxyethoxyacetic acid, which is further metabolized into DGA, causing renal tubule necrosis. The classic presentation progresses through three phases: gastrointestinal symptoms (Phase 1), acute kidney injury (Phase 2), and neurotoxicity (Phase 3). In this case, the patient exhibited symptoms consistent with Phase 3 upon presentation, which complicated the diagnosis and delayed identification of DEG poisoning. The osmolar gap, which measures the difference between the calculated and measured osmolality, is a key diagnostic clue. An elevated osmolar gap, along with an anion gap metabolic acidosis, suggests toxic alcohol poisoning, which should prompt further investigation for substances like ethylene glycol, methanol, or DEG. Early intervention with ethanol or fomepizole is essential, as these agents inhibit alcohol dehydrogenase, preventing the further conversion of DEG to toxic metabolites. However, in severe cases, especially in the later phases, hemodialysis is required to remove the accumulated toxic metabolites, including DGA. Unfortunately, the prognosis for DEG poisoning remains poor, with a high mortality rate, especially if kidney failure progresses or if neurotoxicity is severe.

This case underscores the importance of recognizing DEG toxicity in patients with elevated osmolar and anion gaps. Early diagnosis and treatment, including the administration of alcohol dehydrogenase inhibitors and hemodialysis, are crucial for improving survival and mitigating long-term damage. However, even with optimal care, the mortality rate for DEG poisoning remains high, highlighting the need for vigilance in identifying and managing these cases early to improve outcomes. FROM SYNCOPE TO DYSPHAGIA: A CHALLENGING CLINICAL PRESENTATION Sofia A. Soto Chavez, Sam Jalali, Hardik Thakkar, Neha Verma. Internal and Hospital Medicine, Moffitt Cancer Center, Tampa, FL. (Control ID #4273451) CASE: A 75-year-old male with metastatic melanoma, recently treated with ipilimumab/nivolumab presented to his local emergency room in the southern United States, two days following his second cycle of immunotherapy with complaints of severe fatigue, generalized weakness, and two episodes of syncope. There, telemetry was concerning for sick sinus syndrome, and an EKG showed ST changes. His troponin level was over 4,000 ng/mL, which prompted emergency coronary catheterization and pacemaker placement. The catheterization revealed no coronary obstruction, and transthoracic echocardiogram (TTE) showed a preserved ejection fraction (60-65%) and no wall abnormalities. Despite this, the patient's condition worsened, with new-onset dyspnea and dysphagia. He presented for a third immunotherapy cycle but was emergently transferred to another hospital for evaluation of suspected ICI myocarditis, treated with colchicine and moderate-dose steroids. TTE showed new heart failure with moderately reduced ejection fraction (40-45%). An esophagram indicated aspiration, and dysphagia was attributed to neck involvement from the patient's cancer. He was transferred to a cancer center for further management. Upon arrival, he was noted to have ptosis, 4/5 strength with neck extension, weakness in the upper extremities, and shallow breathing with hypoxia, requiring 2L NC. His wife reported he had been experiencing head lag, ptosis, and blurry vision for the past two weeks. Given these symptoms and his significantly elevated CK, there was high concern for Triple “M” Overlap Syndrome (TMOS). High-dose IV steroids were continued and IVIG was initiated. The patient’s condition continued to deteriorate, and he elected to go home on hospice, where he unfortunately passed away the next day. IMPACT/DISCUSSION: Myocarditis is a common and fatal cardiotoxicity from immune checkpoint inhibitor (ICI) therapy. Symptoms like elevated troponins and new arrhythmias are common indicators of myocarditis. It can co-occur with ICI- associated myasthenia gravis and myositis presenting as TMOS. Myasthenia gravis in this setting often requires ventilatory support more frequently than typical MG. Myositis, which often presents with muscle weakness and an elevated CK alone carries a high mortality rate of 21%. TMOS carries a mortality rate of approximately 40%. High dose IV glucocorticoids and IVIG are vital to improving patient outcomes and reducing mortality. Risk factors include older age and combination ICI therapy. This case contributes to the current literature on TMOS by highlighting the challenges in early diagnosis of this rare condition.

This case highlights the importance of prompt recognition and treatment of immune-related adverse events (iRAEs), particularly TMOS, in cancer patients treated with ICIs. Early consultation with medical oncology, cardio-oncology, and neuro-oncology are essential to improving outcomes. FROM THE HEART TO THE BONE: A CASE OF ACTINOMYCES ODONTOLYTICUS STERNAL OSTEOMYELITIS MASQUERADING AS POST-CABG WOUND INFECTION. Alina Sehar1; John Fanning2; Farrah Ibrahim2; Hassoun Ali3. 1Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL; 2Internal Medicine, The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL; 3Alabama Infectious Disease Centre, Huntsville, AL. (Control ID #4236505) CASE: A 71-year-old female with a history of diabetes mellitus, coronary artery disease, hypertension underwent urgent CABG in April for triple-vessel disease. Her initial postoperative recovery was uneventful. However, two weeks after discharge, she developed lower sternal erythema and started on emperic antibiotics. Despite treatment, patient experienced serous drainage and persistent erythema, necessitating placement of wound VAC in addition to antibiotics. Due to persistent purulent discharge and formation of blister and tunneling at incision site, she underwent additional hardware removal and debridement. Sternal wound cultures revealed A. odontolyticus, and she was started on piperacillin-tazobactam (Zosyn) and instructed to follow up with infectious disease specialists. At follow-up visits, she showed satisfactory progress with no further complications. IMPACT/DISCUSSION: A. odontolyticus, first isolated in 1958 from individuals with dental and periodontal diseases, associated with infections ranging from cervicofacial and thoracic to abdominal, central nervous system involvement. While it has been implicated in cutaneous infections, peritonitis, and brain abscesses, thoracic infections, including sternal osteomyelitis, remain rare. Bacterium’s propensity to invade surrounding tissues can result in fistula formation and the production of characteristic sulfur granules in purulent drainage. This case highlights an unusual instance of A. odontolyticus causing sternal osteomyelitis following CABG—a presentation not widely reported in the literature. Diagnosing A. odontolyticus infections requires a combination of imaging studies, intraoperative evaluation, and microbial culture analysis. Treatment typically involves surgical debridement followed by prolonged antibiotic therapy. The recommended regimen includes 4–6 weeks of intravenous penicillin, often followed by 6–12 months of oral antibiotics to ensure eradication.

This case underscores the importance of considering A. odontolyticus in the differential diagnosis of sternal infections, especially when initial management fails to resolve symptoms. Prompt recognition and appropriate treatment are critical to preventing complications such as mediastinitis and ensuring a favorable outcome. FROM UTI TO CVA: ACQUIRED THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP) PRESENTING AS ACUTE STROKE (CVA) Melissa Gunchenko1; Ramkumar Narendran1; Yolla Haibe2; Jessica Igiede3. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Hematology/Oncology, Rush University Medical Center, Chicago, IL; 3Rush University Medical Center, Chicago, IL. (Control ID #4272887) CASE: A 33 year old obese female presented with aphasia and right hand numbness starting after Augmentin initiation for E. coli UTI. On arrival, vital signs were normal. Physical exam revealed decreased sensation to pinprick on the right hand. Laboratory studies showed WBC 11.3 K/uL, hemoglobin (hgb) 7.8 g/dL, platelets (plt) 40 K/uL, total bilirubin (TB) 3.7 mg/dL, haptoglobin <8 mg/dL, direct antiglobulin test (DAT) negative, reticulocyte count (RC) 375 x 103/mL, peripheral smear without schistocytes or red blood cell defect, and creatinine 1.11 mg/dL. Neuroimaging revealed no acute infarct. She was diagnosed with hemolytic anemia (HA) and discharged with prednisone taper. The next day, she returned with generalized weakness. Laboratory studies showed WBC 26.5 K/uL, hgb 5.5 g/dL, plt 24 K/uL, TB 5.7 mg/dL, direct bilirubin 0.4 mg/dL, haptoglobin <8 mg/dL, RC 459 x 103/mL, fibrinogen 234 mg/dL, creatinine 1.49 mg/dL, and ADAMTS13 activity <5%. She received methylprednisolone and daily plasmapheresis (PLEX). On day 3, she developed altered mental status; neuroimaging showed multifocal bilateral acute infarcts, likely embolic. Thrombolytic therapy was contraindicated due to severe thrombocytopenia. As thrombocytopenia was refractory to 4 sessions of PLEX, rituximab was given, and she was transferred for escalation of care. On arrival, methylprednisolone and PLEX were continued with normalization of platelet count by day 6. She was discharged with aspirin and prednisone taper, eventually receiving rituximab as an outpatient. She is following with hematology and showing gradual improvement. IMPACT/DISCUSSION: TTP, caused by severe ADAMTS13 deficiency, is characterized by microthrombi formation causing thrombocytopenia, HA, and multi-organ failure. Acquired TTP, the most common form, can be triggered by infection and medications, as in this patient. Diagnosis can be challenging as the classic pentad is uncommon; gastrointestinal, neurologic, and constitutional symptoms are the most common presentations. TTP can be distinguished from HA by the presence of severe thrombocytopenia. Because the mortality rate of untreated TTP is >90%, it is essential to consider TTP in patients with HA and thrombocytopenia. The most critical component of treatment is early initiation of PLEX, performed daily until platelet count normalizes. Rituximab may be considered for refractory TTP; however, treatment response may take several weeks. Standard stroke protocols should be followed in patients with a concurrent ischemic event.

TTP is characterized by HA, thrombocytopenia, and multi-organ failure; it is distinguished from HA by the presence of severe thrombocytopenia. Early initiation of PLEX and high-dose steroids can drastically reduce mortality. Patients with a concurrent ischemic event should be managed according to standard stroke protocols. FROZEN IN TIME THE CATATONIC CONUNDRUM Michelle Kraslow1; Amber Casado2. 1Internal Medicine, Wellstar MCG Health, Augusta, GA; 2College of Allied Health Sciences, Physician Assistant Program, Wellstar MCG Health, Augusta, GA. (Control ID #4270593) CASE: 86 year old black male with seizures, atrial fibrillation, vascular dementia with prior stroke, type 2 diabetes, and failure to thrive now with percutaneous endoscopic gastrostomy tube presented as a code stroke. The patient reportedly became aphasic and then obtunded within 48 hours of admission. Family confirmed that he normally is conversant and oriented, just dependent for daily activities. On admission, face appeared symmetrical, but he was cachectic, nonverbal, intermittently opened eyes, and withdrew arms to pain. All vital signs and labs were within normal range. CT head and MRI brain ruled out acute stroke. He was presumed to be postictal, thus loaded with Keppra, but mental status remained unchanged. EEG was without seizures and lumbar puncture was normal. On re-evaluation, the hospitalist noticed the patient’s waxy flexibility, prompting a benzodiazepine challenge with IV midazolam. The patient could immediately answer basic questions, including his name. Psychiatry was consulted and repeated the challenge with oral lorazepam given a Bush Francis Catatonia Rating Scale score of 14. In 1 hour, the patient was opening his eyes to verbal stimuli and shaking hands. This dose was continued 3 times daily, but within a few days the patient reverted to somnolence and upper extremity rigidity. He underwent 5 sessions of electroconvulsive therapy while lorazepam was tapered. By discharge, the patient verbalized and followed simple commands. IMPACT/DISCUSSION: Catatonia, a complex neuropsychiatric disorder, significantly impacts patient outcomes due to delayed recognition and treatment. With presentations varying from mutism and immobility to agitation, diagnosis is elusive. Diagnostic challenges are further complicated by overlapping symptoms with neuroleptic malignant syndrome, serotonin syndrome, status epilepticus, and delirium. Also, medical causes like encephalitis, seizures, toxins, and metabolic conditions are more common etiologies, though previously it was thought that underlying psychiatric disorders were often responsible. Not surprisingly, robust and costly workups are often employed, as in this case, and underdiagnosis leads to severe complications such as venous thromboembolism, stasis ulcers, rhabdomyolysis, and malnutrition.1 This highlights the need for awareness of catatonia among all healthcare professionals.

1. Smith AC, Holmes EG. Catatonia: A narrative review for hospitalists. American Journal of Medicine Open. 2023;10:100059-100059. doi:https://doi.org/10.1016/j.ajmo.2023.100059

Catatonia should be included in the differential for patients with acute encephalopathy. Providers should assess for medical, not only psychiatric, causes. Early recognition is key to decreasing the burden of this condition on patients and healthcare systems. GASTROINTESTINAL BLEEDING SECONDARY TO MULTIFOCAL COLONIC TELANGIECTASIAS IN A PATIENT WITH SCLERODERMA Mohammed Abourahma1; Dinkar Ahuja1; Joyce Loh2; Agnes Libot3. 1Internal Medicine, Loyola University Medical Center, Chicago, IL; 2Department of Gastroenterology and Nutrition, Loyola University Medical Center, Chicago, IL; 3Associate Professor, Department Of Medicine, Loyola University Medical Center, Chicago, IL. (Control ID #4235516) CASE: A 70-year-old woman presented with orthopnea and hematochezia. Twenty years prior to presentation, she was diagnosed with systemic scleroderma as well as Sjögren's syndrome. Ultimately, she developed pulmonary hypertension with right ventricular failure. Physical examination revealed joint stiffness, digital ulcers, masked facies, thick, waxy skin as well as sclerodactyly, rendering her unable to make a fist. There were many telangiectasias appreciated on her skin. Cardiopulmonary examination revealed a parasternal heave with clear but diminished breath sounds at the lower lobes. Hemoglobin was 7.5 g/dL from a baseline of 12 g/dL with iron deficiency anemia on iron studies. She was positive for anti-centromere antibodies and negative for RNA polymerase III antibodies. CRP was 13.6, and an ESR was 116. Cardiac imaging had no mention of aortic stenosis with severe tricuspid regurgitation. Prior EGDs and colonoscopies had no vascular malformations. Repeat EGD on presentation showed candidal esophagitis, mildly erythematous mucosa in the antrum, and fundic gland polyps. A colonoscopy revealed numerous small and large angiodysplastic lesions throughout the entire colon with diverticulosis. She was treated with numerous hemoclips and Argon Plasma Coagulation and succesfully did not have recurrence of her bleeding in the following 48 hours. IMPACT/DISCUSSION: With the widespread nature of these malformations, we wanted to emphasize the importance of comprehensive endoscopic evaluation in these patients with evidence of gastrointestinal bleeding. Individuals with scleroderma are at an increased risk of both upper and lower gastrointestinal bleeding. While it is well established that these malformations can occur dermatologically, they are rarely described in the literature as being found in the colon.

Overall, this case highlights the rare presentation of multifocal colonic telangiectasias in a patient with scleroderma. Given the extensive nature of these lesions, this case aims to highlight the essence of thorough endoscopic evaluation in patients with hematochezia and scleroderma. While prior studies have illustrated the correlation between gastrointestinal bleeding and scleroderma, there has been no specific link between multifocal colonic telangiectasias as the cause of the bleeding. This case report contributes by explaining the probable etiology of this increased risk by describing the unusual presentation of mucocutaneous angiodysplasia. With the abundance of these lesions, rebleeding is likely to pose a challenge when managing these cases. Further research should be concentrated on strategies for reducing the long-term risk of recurrent bleeding and should emphasize the need for endoscopic evaluation when symptoms present. GASTROINTESTINAL COMPLICATIONS OF OZEMPIC- A CASE REPORT OF GASTROPARESIS IN A TYPE 2 DIABETES PATIENT Drushik Gangasani1; Kusum Joshi1; Mayura R. Kesara2. 1Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4272571) CASE: A 35-year-old female with Type 2 diabetes, hypertension, dyslipidemia, and a mood disorder presented to the emergency department with a three-day history of worsening nausea, vomiting, and abdominal cramping. These symptoms began after starting Ozempic 10 days prior for blood sugar control. Although non-compliant with previous medications, she was adherent to Ozempic. On presentation, she was febrile (101.3°F), tachycardic (HR 106 bpm), and dehydrated with dry mucous membranes. Physical exam revealed epigastric tenderness but no signs of peritoneal irritation or organomegaly. Laboratory findings showed hyperglycemia (290 mg/dL), an elevated anion gap (17), and low bicarbonate (18 mEq/L), indicating starvation ketosis. Hemoglobin A1c was 12.4%, confirming poor long-term glucose control. Urinalysis showed glucosuria and ketonuria, and a peripheral blood smear revealed increased parasitemia. The patient was diagnosed with starvation ketosis and started on insulin therapy. She also reported a history of polydipsia, nocturia, and intermittent nausea before starting Ozempic. Considering the temporal relationship between Ozempic initiation and gastrointestinal symptoms, along with laboratory and clinical findings, a diagnosis of gastroparesis likely induced by Ozempic was made. The patient’s symptoms improved after discontinuing Ozempic, with glucose levels and anion gap trending down. She was discharged on the sixth hospital day with supportive care and insulin therapy IMPACT/DISCUSSION: Gastroparesis, characterized by delayed gastric emptying without mechanical obstruction, is often linked to poorly controlled diabetes. GLP-1 receptor agonists like Ozempic (semaglutide) delay gastric emptying to control postprandial blood sugar, but can worsen gastroparesis in susceptible individuals. In this patient, symptoms of nausea and vomiting coincided with Ozempic initiation, suggesting medication-induced gastroparesis. Diagnosis was clinical, with improvement after discontinuing Ozempic. Although gastric emptying studies are the gold standard, clinical signs often guide management, as in this case, where the patient responded to supportive care and insulin therapy

This case highlights the potential for Semaglutide to induce or worsen gastroparesis, particularly in individuals with poorly controlled Type 2 diabetes. The gastrointestinal side effects associated with semaglutide, such as delayed gastric emptying and nausea, should be considered when evaluating diabetic patients who develop symptoms of gastroparesis following the initiation of this medication. Clinicians should be aware of this potential complication and consider discontinuation of Ozempic or dose adjustments if gastroparesis is suspected. Further research is needed to better understand the full extent of GLP-1 receptor agonists in modulating gastric motility and to explore strategies for managing this side effect in patients with diabetes. GEMELLA SPECIES BACTEREMIA ASSOCIATED WITH SPINAL DISCITIS WITHOUT APPARENT PREDISPOSITION Amin Ashraf2; Abeer Asif1; Isaac A. Pearce1,2. 1Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH; 2Wright State University Boonshoft School of Medicine, Dayton, OH. (Control ID #4272112) CASE: A 74-year-old female with past medical history of osteoporosis, osteoarthritis, and degenerative disc disease (DDD) presented to the ED with low-back pain and altered mental status. CT completed two days prior for her DDD showed no significant change in her known chronic spinal degeneration and no sign of fracture. She had no focal neurologic or red flag symptoms, and her exam was unremarkable, but ultimately required admission for intractable back pain. On day two of admission, the patient became hypotensive necessitating initiation of vasopressors and broad-spectrum antibiotics. An MRI of the lumbar spine was performed and demonstrated known DDD and a fluid collection within the L5 to S1 disc with marrow edema signaling involving the inferior endplate concerning for discitis and/or osteomyelitis. At this point, the blood cultures obtained on admission were reported as growing Gram-positive cocci which further resulted as pan-sensitive Gemella species. TTE was obtained but had poor visualization of the left ventricle and valve anatomy, requiring TEE which demonstrated tricuspid valve thickening but no definite vegetation. Repeat cultures showed no growth at five days, and the patient was discharged on six weeks of IV vancomycin. IMPACT/DISCUSSION: Gemella species is a catalase-negative, Gram-positive coccus, that is part of the normal flora of the oral cavity and upper GI tract. While an uncommon pathogen, it can cause infections such as endocarditis, meningitis, and septic arthritis in patients who have predisposing risk factors including immunodeficiency, IV drug use, underlying heart disease, or recent GI or dental procedures. A review of the available literature reveals few reported cases of Gemella-species spondylodiscitis, and the majority of cases involved a recent dental procedure or periodontitis. This case is unique in that the patient had no risk factors, predisposing infections, or recent procedures. Given its atypical nature as an infective agent, a better understanding of the predisposing factors to Gemella infections will aid in assessment and management of patients without otherwise clear clinical signs.

Gemella species can be a rare cause of spondylodiscitis and can occur in patients without a history of periodontitis or recent dental procedure. Thorough investigation into the source of Gemella bacteremia should be guided by patient risk factors; an absence of risk factors will necessitate broad work-up. GESTATIONAL TROPHOBLASTIC NEOPLASIA, MISSED TO BE FOUND WITH METASTASIS Mai Hamaad1; Mohamed Sleem2; Ali Yusuf1; Doan Ngoc Chau Nguyen5; Fatema Mahjabeen6; Aisha Tahbib1; Mahmoud Elmahi3; James ". Walker4. 1Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; 2Internal Medicine, Texas Tech University Health Science Center/Amarillo, Amarillo, TX; 3Internal medicine, TTUHSC amarillo, Amarillo, TX; 4Internal Medicine, Texas Tech, Amarillo, TX; 5Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX; 6Internal medicine , Texas tech university health sciences center amarillo, Amarillo, TX. (Control ID #4271456) CASE: A 34-year-old woman with a history of recurrent miscarriages presented with continuous vaginal bleeding two days post-D&C, alongside acute left-sided facial droop and left upper limb weakness. She denied lower limb weakness. Eight weeks earlier, she had a positive pregnancy test but had not seen an OB/GYN. Two weeks prior, she experienced heavy vaginal bleeding with blood clots and uncertain passage of products of conception. Her beta-hCG level was markedly elevated at 157,541 mIU/mL. CT Brain: Acute right frontal lobe hematoma (28x27x28 mm) with surrounding edema but no midline shift. CT Chest/Abdomen/Pelvis: Bilateral solid pulmonary nodules and masses consistent with metastatic disease, with subtle peritumoral hemorrhage. A heterogeneous uterine fundal mass (4.0x3.3x4.5 cm) suggested a primary malignancy. In the following days, the patient developed dizziness, unsteadiness, and epistaxis. Repeat brain imaging showed progression of the hemorrhagic mass, necessitating ICU transfer. Neurosurgery and oncology were consulted. Pathology of her recent Uterine Curettage: Choriocarcinoma with fragments suspicious for PSTT. Frontal Lobe Biopsy: Atypical trophoblastic proliferation, morphologically consistent with metastatic GTN. Seven months earlier, the patient was treated with methotrexate for a missed abortion. However, fluctuating beta-hCG levels persisted. Laparoscopy, chromotubation, and curettage revealed no evidence of ectopic pregnancy, but pathology showed dyssynchronous endometrium with no definitive trophoblastic elements. The patient was lost to follow-up, and a partial molar pregnancy was suspected. IMPACT/DISCUSSION: Gestational trophoblastic neoplasia (GTN) is a rare group of malignant neoplasms arising from trophoblastic tissue, which can follow any pregnancy event, including molar pregnancies, spontaneous abortions, or term deliveries. Histological types include invasive mole, choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT). GTN commonly presents with elevated beta-hCG levels, abnormal bleeding, and, in advanced stages, distant metastases. GTN arises in approximately 50% of molar pregnancies and 25% each of spontaneous abortions and term pregnancies. Metastatic choriocarcinoma is the most aggressive form, often presenting with pulmonary or neurological symptoms. Persistently elevated or rising beta-hCG levels in reproductive-age females should prompt evaluation for GTN, while excluding other causes like normal pregnancy, ectopic pregnancy, pituitary hCG, or phantom hCG.

Early recognition and timely intervention are critical in managing GTN. Persistently elevated beta-hCG levels warrant further investigation to prevent disease progression. This case emphasizes the importance of high clinical suspicion, regular follow-up, and collaborative management to improve patient outcomes. GLIOBLASTOMA PRESENTING AS NON-SPECIFIC INFLAMMATORY CHANGES ON MRI Michael Eason1; Nathan Clement2; Karl Soderlund3; Michael Burns1. 1Internal Medicine, Naval Medical Center Portsmouth, Portsmouth, VA; 2Brooke Army Medical Center, Fort Sam Houston, TX; 3Radiology, Naval Medical Center Portsmouth, Portsmouth, VA. (Control ID #4231120) CASE: Glioblastoma Multiforme (GBM) is the most common primary malignant brain tumor with a rate of incidence of 3 to 4 per 100,000 in the U.S. The classic MRI finding is a mass lesion with contrast enhancement, central necrosis, and surrounding edema. Though this is widely taught, up to 4% may show non-enhancement initially, mimicking conditions such as infectious and autoimmune encephalitides, cerebritis, and post-ictal edema. We examine the case of a 47-year-old male with a history of migraines who presented with headache, nausea, vomiting, and transient loss of consciousness. Initial MRI showed right temporal gyral expansion, edema, and mass effect with increased perfusion signal, but no enhancement, hemorrhage, or reduced diffusion. A differential diagnosis of encephalitis (viral or autoimmune), cerebritis, post-ictal edema, and infiltrative neoplasm was proposed and a short interval follow-up MRI and CSF analysis was recommended. A lumbar puncture (LP) and tests for infectious and autoimmune etiologies were conducted as well as imaging for other primary neoplasms. Testing returned negative. Symptoms resolved and he was discharged with follow-up for serial MRI brain scans. Subsequent MRIs at 8- and 40-days showed stable, non-specific T2 signal changes in the vicinity of the right temporal lobe. Repeat LPs were non-diagnostic and the patient remained stable with no recurrence of symptoms. Given persistent imaging findings, he was referred for biopsy, which was positive for IDH wild-type GBM. IMPACT/DISCUSSION: This case underscores the importance of a broad differential when imaging is non-specific as well as the need for serial imaging in patients with unresolved neurologic symptoms. Unexplained seizures, confusion, headache, focal neurologic deficits, and central vertigo that remain unexplained after extensive workup should raise suspicion for neoplasm even in the absence of definitive radiologic evidence. These features become even more important since risk-factors for GBM remain ill-defined beyond genetic syndromes and exposure to ionizing radiation. Though case-control studies have reported mixed results, there exists a possible connection between traumatic brain injury and GBM due to inflammatory changes in the brain parenchyma. This in addition to the clinical features above helps raise suspicion in certain populations who present with unexplained neurologic findings. Diagnosing GBM from initial to final scan can take 4.5 months, by which time classic imaging signs usually appear. Those findings never manifested in this case. In one review of 102 GBM patients, non-specific abnormalities were seen on MRI in seven patients, all of whom presented with seizures. Another eight showed negative findings on initial neuroimaging.

This highlights the need for suspicion of glioblastoma in patients with unclear cerebral lesions and the importance of biopsy after ruling out other etiologies. Early diagnosis can lead to better outcomes associated with earlier treatment. GLP-1 INDUCED SUPERIOR MESENTERIC ARTERY SYNDROME: AN INTERESTING COMPLICATION IN THE AGE OF GLP-1 AND SGLT-2 MEDICATIONS Omar Zuhdi, Vasu Malhotra, Michael Sabina, Camila Villacreses, Paola Campillo, Adeeb Mustafa. Internal Medicine , Lakeland Regional Health Medical Center, Tampa, FL. (Control ID #4269868) CASE: The patient is a 77-year-old female with a past medical history of type 2 diabetes, who initially presented due to abdominal pain, nausea, and vomiting. The patient reported significant weight loss over the last few months and stated that she had started taking dulaglutide for her diabetes. A CT of the abdomen was ordered and showed significant distention of the stomach and proximal portion of the duodenum. Narrowing of the mid to distal duodenum was noted as it passed between the aorta and superior mesenteric artery with decreased aortomesenteric angle. Superior mesenteric angle was noted to be approximately 13%, compared to a normal superior mesenteric artery angle several months prior. Upper gastrointestinal series showed abdominal distention with enlargement of the duodenal bulb and delayed passage of contrast from the duodenal bulb into the remaining portions of the duodenum. A nasogastric tube was placed and the patient was started on erythromycin to aid in gastric emptying with improvement in the patient’s symptoms. IMPACT/DISCUSSION: Superior mesenteric artery syndrome (SMA syndrome) is associated with compression of the third portion of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. SMA syndrome is often related to loss of the mesenteric fat pad and patients usually present with symptoms consistent with proximal small bowel obstruction. While weight loss is a common cause of SMA syndrome, other causes include anatomic abnormalities, cancer, AIDS, and malabsorption syndromes. SMA syndrome can be treated conservatively with nasogastric tube decompression and electrolyte replacement. If conservative management is not effective, surgical intervention may be required. With the increased popularity of GLP-1 and SGLT-2 medications, an increased incidence of SMA syndrome following initiation of these medications may become more prevalent. Monitoring patients on GLP-1 and SGLT-2 medications is recommended to prevent proximal small bowel obstructions and prevent complications including electrolyte abnormalities, gastric perforation, and gastric pneumatosis. Increased awareness of SMA syndrome as a potential complication of GLP-1 and SGLT-2 medications is essential, especially as prescription of these medications becomes more widely prevalent.

Rapid weight loss associated with GLP-1 and SGLT-2 medications may result in complications including superior mesenteric artery syndrome. GLP-1 and SGLT-2 induced SMA syndrome is a rare phenomenon which may become more prevalent as more patients are prescribed these medications. Many patients are unaware of this complication prior to initiating these medications. Increased monitoring for SMA syndrome can prevent a delay in diagnosis among these patients. GQ1B GANGLIOSIDE AUTOANTIBODY NEGATIVE MILLER FISHER SYNDROME FOLLOWING ADMINISTRATION OF COMBINED TETANUS, DIPHTHERIA AND PERTUSSIS (TDAP) VACCINE Maimona Chaudhary1; Riddhi Upadhyay2. 1Wright Center for Graduate Medical Education, Scranton, PA; 2Geisinger Community Medical Center, Scranton, PA. (Control ID #4266377) CASE: The patient is a 60-year-old male with a past medical history of hypertension, coronary artery disease, history of Lyme disease and Bell’s palsy who presented to the hospital for bilateral upper and lower extremity (LE) weakness and pain. He stated that his symptoms started about a week ago with right bicep pain and weakness leading to bilateral shoulder pain and eventually bilateral LE pain causing falls. The patient denied recent infections. He reported receiving the Tdap vaccine for a neck wound two weeks before his symptoms began. Vital signs were unremarkable. Physical examination was remarkable for 4/5 and 3/5 muscle strength in bilateral upper extremities (BUE) and bilateral hips respectively, decreased biceps, brachioradialis and triceps reflexes, absent patellar and Achilles tendon reflexes, decreased/absent sensation in BUE and ophthalmoplegia. Magnetic resonance imaging (MRI) of the brain and lumbar spine showed no acute abnormalities. Electromyography findings were consistent with asymmetric, sensorimotor, predominantly demyelinating polyneuropathy with evidence of axonal loss. GQ1b ganglioside autoantibody (GQ1bGA) was negative. While admitted, the patient developed respiratory distress requiring BiPAP. He was treated with intravenous immunoglobulin (IVIG) for 5 days for Miller Fisher syndrome (MFS), which improved his symptoms and was discharged to a rehabilitation center. IMPACT/DISCUSSION: MFS is a rare variant of Guillian Barre Syndrome with a worldwide incidence of 1-2 per million people. It has a male predominance and is commonly seen in early middle age. It is caused by molecular mimicry, leading to an inflammatory response against myelin-producing Schwann cells. Axonal degeneration can occur as a secondary response. The main autoantibody is directed against ganglioside GQ1b. It typically presents with the clinical triad of ophthalmoplegia, ataxia and areflexia, also seen in our case. Other associated symptoms can be ptosis, facial nerve palsy, para/hypoesthesia and respiratory muscle weakness. Although infections cause most cases, other causes can include certain drugs, autoimmune diseases, surgery and vaccines. While there are multiple reported cases of post-influenza vaccine MFS, only a couple cases of Tdap-induced MFS were found. Diagnosis is clinical and can be supported by cerebrospinal fluid albuminocytologic dissociation, the presence of GQ1bGA (seen in 85-90% of cases), MRI spine showing thickening and enhancement of the intrathecal spinal nerve roots and cauda equina, and electrodiagnostic studies showing reduced or absent sensory responses without slowing of conduction velocities, as highlighted here. Treatment is supportive along with IVIG or plasmapheresis, both are known to be equally effective. The prognosis is good with the patients recovering in 8-12 weeks. Relapse occurs in <3% of patients.

MFS is a rare complication of Tdap vaccine. Early recognition and treatment is associated with complete recovery. GRANULOMATOSIS WITH POLYANGIITIS: A DIAGNOSTIC AND THERAPEUTIC CONUNDRUM Aparna Venkatesan1; William Denton4; Misa Ito2; Hirotaka Kato3. 1Internal Medicine, University of Kentucky, Lexington, KY; 2MedPeds, University of Kentucky, Lexington, KY; 3Internal Medicine, University of Kentucky College of Medicine, Lexington, KY; 4College of Medicine, University of Kentucky, Lexington, KY. (Control ID #4272545) CASE: A 56-year-old man with a history of hepatitis B on entecavir, prior hepatitis C, injection drug use, and mitral valve replacement for endocarditis was admitted for a 2-week history of tongue mass/ulceration, progressive dyspnea, polyarthralgia, and palpable purpura. Physical exam showed SpO2 of 80% on RA, tongue ulceration, nasal mucosal hyperemia, and palpable purpura. Initial workup revealed WBC 12 x 10^3/L, CRP 122 mg/dL, and negative blood and fungal cultures. CT showed diffuse pulmonary edema. Echocardiogram showed severe prosthetic mitral valve stenosis without vegetation. Autoimmune workup notable for ANA 1:160, cANCA (1:1280) and positive PR3-ANCA, raising concern for granulomatosis with polyangiitis (GPA) versus IgA vasculitis. Skin punch biopsy was inconclusive. His hypoxia improved with diuresis, he was discharged on day 11 but readmitted a week later for worsening polyarthralgia, new tongue ulcers, necrotic purpura, and recurrent hypoxia. Chest x-ray showed diffuse interstitial opacities, concerning alveolar hemorrhage with hemoptysis. Repeat skin biopsy showed leukocytoclastic vasculitis. He was started on pulse steroids on day 3, followed by weekly steroid taper and rituximab infusion. His hospital course was complicated by Mobitz type I heart block, otherwise had symptomatic improvement and discharged on prednisone 80 mg and pneumocystis prophylaxis. At follow up, Avacopan 30 mg twice daily was added to aid steroid taper and avoid volume overload. IMPACT/DISCUSSION: GPA is a rare small vessel vasculitis, typically affecting respiratory tract, skin, and kidneys. C- and PR3-ANCA are diagnostic hallmarks. Ruling out mimickers like immune-complex or embolic phenomena due to severe prosthetic mitral valve disease and infection are crucial. When small vessel vasculitis is strongly suspected, the 2022 ACR/EAAR classification criteria help differentiate GPA from microscopic polyangiitis and eosinophilic GPA. A score of 5 or above has a high sensitivity (92.5%) and specificity (93.8%) to accurately classify GPA (our patient scored 8 at the minimum). The 2021 ACR guideline recommends reduced dose steroids, in addition to rituximab, for active severe GPA cases. However, we must recognize the conditions to trigger high-dose or pulse steroid treatment, including alveolar hemorrhage and glomerulonephritis. C5a receptor inhibitor, Avacopan, may substitute steroids if patients cannot tolerate steroids. Conduction abnormalities can rarely occur with GPA, but outcomes are not different irrespective of cardiac involvement.

With recent advances in GPA diagnosis and management, general internists play a key role in ruling out vasculitis mimickers and recognizing the indications for higher dose steroids. GRANULOMATOSIS WITH POLYANGIITIS MISTAKEN FOR RECURRENT PNEUMONIA: A CASE REPORT Kathleen Mattingly1; Jonathan Grube1; Daniela E. Velez1; Chandra Bhanu Mandapati1; Chandan Mitra2. 1HCA Healthcare Inc, Ocala, FL; 2UCF College of Medicine, Ocala, FL. (Control ID #4272994) CASE: A 54 year old male presented to the emergency department complaining of generalized fatigue and hemoptysis. The patient was diagnosed with pneumonia about 6 months ago for which he had completed multiple courses of antibiotic treatment without resolution of symptoms. The patient also reports that he was being treated outpatient for recurrent rhinitis. Labs revealed WBC 24.7, BUN 27, and creatinine 3.0. The chest x-ray was unremarkable. Urinalysis revealed urine protein >300, large urine blood, >50 RBC, 11-25 WBC, moderate bacteria, and 1-2 granular casts. IV fluids and antibioitcs were started. A renal ultrasound revealed bilateral minimally enlarged kidneys without hydronephrosis or stones. The patient’s kidney function continued to worsen with Cr 6.1 and signs of volume overload. Hemodialysis was initiated. A renal biopsy was performed and revealed negative paraffin immunofluorescence indicating pauci-immune glomerulonephritis. Serology revealed positive c-ANCA, negative p-ANCA, normal complement 3 and 4, and negative ANA. The patient was started on pulse methylprednisolone followed by oral prednisone. Plasma exchange therapy (PLEX) and then rituximab induction therapy was inititated. The patient’s clinical status significantly improved with creatinine down trending to 4.4. IMPACT/DISCUSSION: GPA is a necrotizing vasculitis that involves inflammation of the vascular wall as well as peri- and extravascular granulomatosis. GPA has an estimated prevalence of 3 per 100,000 individuals, with a higher incidence observed in people of Eastern European descent. The disease typically involves the upper and lower respiratory tracts and kidneys. Histophathologically, layers of ischemic necrosis are seen in small vessels such as aterioles, capillaries, and venules along with the formation of sterile abscesses and granulomas. Chronic sinusitis or rhinitis are often the first indications of the disease. Pulmonary involvement often presents as patchy infiltrates on radiographic imaging and clinically with persistent cough. Kidney biopsy findings often include necrotizing and crescentic glomerulonephritis. If left untreated, GPA has an estimated mortality of about 70%. Current treatment for GPA centers on corticosteroids and immunosuppressive therapies. Remission occurs in about 80% of cases and relapse occurs in about 50%. Despite the high rate of relapse, the 10-year survival rate is about 75%.

Early diagnosis and treatment are essential to prevent irreversible organ damage. Currently, diagnosis relies on clinical evaluation, laboratory findings, and radiographic imaging. Treatment with corticosteroids and immunosuppressive agents, such as rituximab or cyclophosphamide, has significantly enhanced survival rates, but long-term follow-up is crucial for detecting relapses and managing complications associated with treatment. GUILLAIN-BARRé SYNDROME AS AN ADVERSE EFFECT OF KEYTRUDA IN THE TREATMENT OF METASTATIC MELANOMA Yarden O. Goldman Gollan, Arie Szeinfeld, Gordon White, Michelle Lopez Baez. Internal Medicine, HCA JFK Hospital - University of Miami Consortium, Atlantis, FL. (Control ID #4273468) CASE: An 80-year-old female with a history of melanoma in situ and newly diagnosed stage 3 metastatic melanoma of the left upper arm presented with generalized weakness and confusion. Her medical background includes hypertension, hypothyroidism, and mild chronic obstructive pulmonary disease. She was initiated on adjuvant Keytruda (pembrolizumab) on August 14, 2023, with a planned course of one year. The patient tolerated the first four doses well; however, after the fifth dose on November 13, 2023, she developed progressive weakness and cognitive dysfunction. In December 2023, she was admitted to HCA JFK Hospital with confusion and worsening weakness. MRI of the brain and C/T/L spine revealed no metastatic disease. Lumbar puncture analysis showed cerebrospinal fluid (CSF) with albuminocytological dissociation, consistent with Guillain-Barré syndrome (GBS). Neurology initiated intravenous immunoglobulin (IVIG) therapy over five days (December 12-16, 2023). Post-treatment, the patient showed partial improvement and was discharged with plans for monthly IVIG. She returned on January 8, 2024, with altered mental status and profound weakness, necessitating ICU admission for acute hypoxic respiratory failure and intubation on January 16, 2024. Repeat treatment with plasmapheresis (PLEX) and high-dose corticosteroids was initiated. During her ICU course, she received five cycles of PLEX and transitioned from Solu-Medrol to oral prednisone with a slow taper. Her condition fluctuated with challenges such as anemia, significant nosebleeding (Hgb drop to 5.7), and lower extremity deep venous thrombosis. By early February 2024, she completed additional IVIG doses and improved enough for planned transfer to a rehabilitation center. IMPACT/DISCUSSION: This case highlights a significant immune-related adverse event associated with pembrolizumab in metastatic melanoma treatment. Immune checkpoint inhibitors like Keytruda have transformed the prognosis for advanced melanoma but carry risks of immune-mediated complications. Guillain-Barré syndrome, an autoimmune polyneuropathy, is a rare but severe side effect, characterized by rapid-onset muscle weakness and respiratory compromise. The correlation between pembrolizumab administration and GBS underscores the need for vigilance in monitoring neurologic symptoms during immune therapy. Early identification and management with IVIG and PLEX are crucial for mitigating morbidity. This case emphasizes the potential for GBS to recur or require prolonged treatment despite initial therapy. Continued interdisciplinary care, including neurology, hematology/oncology, and critical care, was essential in this patient’s management.

- Immune checkpoint inhibitors can lead to severe neurologic complications like Guillain-Barré syndrome. - Prompt recognition and treatment with IVIG, corticosteroids, or plasmapheresis are critical for patient outcomes. - Multidisciplinary management and extended monitoring may be necessary due to the risk of recurrence. GUT DYSBIOSIS-AN INTERESTING CASE OF AN ELEVATED BUN LEVEL Rachel L. Fine1; Jhonn Bernate2; Adnaan Sheikh3; Amanda McGeorge1; Ann Finke4; Sumaita Alam5; Sidney Greene6; Juan Carlos Aycinena1. 1Internal Medicine, University of Kentucky, Lexington, KY; 2Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY; 3Nephrology/Critical Care, University of Kentucky College of Medicine, Lexington, KY; 4internal medicine- nephrology, University of Kentucky, Lexington, KY; 5Nephrology/Critical Care, Midwestern State University, Wichita Falls, TX; 6nephrology, University of Kentucky, Lexington, KY. (Control ID #4271599) CASE: A 64 y.o. male was admitted with a newly diagnosed plasma cell leukemia as well as a non-oliguric acute kidney injury felt to be secondary to either a prerenal etiology from poor oral intake or an intrinsic cause from light chain nephropathy. Initial BUN and sCr levels on admission were 39 mg/dL and 3.99 mg/dL respectively. After administering IV fluids, the patient’s renal parameters 18 days later were BUN 163 mg/dL and sCr 3.11 mg/dL. System review was significant for constipation supported by CT imaging revealing a large colonic stool burden. The differential diagnosis for an isolated elevation in BUN is broad and includes medications, increased catabolic states, dehydration, urinary tract obstruction, steroid use, GI bleeding, high protein diet, heart failure, and gut dysbiosis. A stepwise approach was taken to delineate the cause in order to guide patient management. Volume depletion, urinary tract obstruction, medications, heart failure, and GI bleeding were ruled out. There was also no evidence of an increased catabolic state. Gut dysbiosis was felt to be the likely etiology given the patient’s noted constipation and the downtrending of his BUN level following the resumption of normal bowel activity. IMPACT/DISCUSSION: The isolated rise in the BUN level of this patient was suggestive of a non-renal etiology. Gut dysbiosis, a diagnosis of exclusion, is an imbalance of the normal microbial flora and metabolic byproducts found in the patient’s GI tract. The three mechanisms contributing to this process are a loss of beneficial bacteria, an overgrowth of pathogenic bacteria, and the loss of bacterial diversity seen in the normal or healthy state. The presentation of gut dysbiosis is nonspecific and includes abdominal pain and/or distension, malaise, diarrhea, or constipation. Additionally, constipation may serve as a causative factor in this process. The delay in colonic transit allows for an increased concentration of metabolites from an imbalanced GI bacterial flora. These bacterial byproducts can disrupt the GI mucosal barrier, be absorbed systemically, trigger inflammation, and act directly as renal and other organ toxins. As our understanding of the gut microbiome evolves, so too will an integrated approach to the diagnosis and treatment of gut-specific metabolic disorders. Further research is warranted to explore the mechanisms underlying these relationships and to evaluate the potential benefits of microbiome-targeted therapies to maintain metabolic and organ health.

● An isolated elevation in BUN level necessitates a broad evaluation to exclude the most common etiologies (dehydration, urinary tract obstruction, medications, increased catabolism, heart failure, dietary changes, and gastrointestinal bleeding) with gut dysbiosis serving as a diagnosis of exclusion. ● Early diagnosis of gut dysbiosis is important as this process can lead to metabolic and systemic disorders which suggests a potential benefit to future microbiome-targeted therapies. HEAVY METAL CONTAMINATION IN SUPPLEMENTS: AN ATYPICAL CAUSE OF ACUTE PANCREATITIS Ginu Kurian2; Yazmin Rustomji1; Merin Mathew1. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Internal Medicine, Virginia Commonwealth University, Richmond, VA. (Control ID #4272938) CASE: A 24-year-old transgender female presented with one week of nausea, vomiting, and abdominal pain. Physical examination demonstrated epigastric tenderness radiating to her back. Laboratory results showed a lipase of 66, and hemoglobin of 16. CTAP revealed pancreatic fat stranding, raising suspicion for acute pancreatitis. The etiology of her pancreatitis was investigated after initial empiric management with IV morphine and fluids. Triglyceride levels were normal, and a RUQ ultrasound showed no gallstones. The patient denied alcohol use and recent sick contacts. She reported discontinuing estrogen replacement therapy three months prior. Upon further questioning, she disclosed the daily use of several supplements, including "shilajit," which she purchased online. Analysis of the supplement showed that it contained heavy metals, including lead and mercury. This finding was discussed with the patient, and she was advised to discontinue use of the supplement. Her symptoms improved, and she was subsequently discharged. IMPACT/DISCUSSION: This case highlights the often overlooked role of dietary supplements in causing acute pancreatitis, particularly when abdominal symptoms are unexplained. “Shilajit”, a natural supplement marketed for its antioxidant properties, has been linked to adverse effects due to contamination with heavy metals like lead and mercury, which can be toxic to multiple organ systems, including the pancreas. Therefore, it is important to perform a thorough social history and medication reconciliation for every patient encounter. While common causes such as gallstones, alcohol use, and hypertriglyceridemia were excluded, the identification of supplement use was essential in this case. The growing prevalence of unregulated supplements, with their potential for contamination, poses significant risks to patient safety. A comprehensive review of both prescribed medications and over-the-counter supplements should be routine. In this patient, identifying the contaminated supplement was critical to prevent recurrent symptoms in the future.

Although acute pancreatitis is most often associated with gallstones, alcohol, and elevated triglycerides, this case illustrates the need for clinicians to consider supplement-induced pancreatitis in their differential diagnosis. Physicians should always include both prescription and over-the-counter supplements in medication reconciliation to identify potential pathologic etiologies. It is critical to be aware of the risks of contamination in unregulated supplements, which can lead to serious adverse effects such as heavy metal poisoning. HEMORRHAGIC SHOCK FROM ACQUIRED HEMOPHILIA SECONDARY TO PENICILLIN EXPOSURE: A CASE REPORT Brianna Graham1; Shivani Kumar1; Maha Inam1; Sanjana Kalvehalli Kashinath2; Aamir Ajmeri3; Ashwin Karanam3. 1Internal Medicine, Temple University Hospital, Philadelphia, PA; 2Hematology, Temple University, Philadelphia, PA; 3Pulmonary, Critical Care, Temple University, Philadelphia, PA. (Control ID #4272696) CASE: A 75-year-old female with a medical history of hypertension, hyperlipidemia, diabetes, COPD, and schizophrenia presented with severe tongue and neck swelling concerning for Ludwig's angina. To secure her airway, the patient underwent nasal intubation, during which she sustained a nasal laceration and severe nasopharyngeal bleeding. This resulted in hemorrhagic shock, necessitating ICU admission and transfusion of 4 units of packed red blood cells. She was transferred to a tertiary center for advanced evaluation and management. Labs revealed persistently elevated PTT levels (80-90 sec). A PTT mixing study demonstrated partial correction with immediate mix (50 sec) but prolonged levels after incubation (66 sec at 1 hour and 78 sec at 2 hours), consistent with a clotting factor inhibitor. Clotting factor assays confirmed a factor VIII level of 5%, normal von Willebrand factor levels and activity, slightly low factor XI and XII levels, and a normal factor IX and thrombin time. The patient was managed with a two-pronged approach: stabilization of hemostasis and reduction of the inhibitor burden. Recombinant factor VII was administered to achieve hemostasis, and before any procedures. However, due to inadequate hemostatic control, emicizumab was added. Immunosuppression to eliminate the inhibitor included high-dose steroids (initially for Ludwig's angina, followed by an extended taper) and four weekly doses of rituximab. This combination therapy led to excellent hemostatic control. Since emicizumab interferes with APTT assay, a chromogenic factor VIII assay was sent that is still low at 8% but the inhibitor titer has improved from 27 to 15. A thorough review of the patient’s history was conducted and it was noted patient has received penicillin recently for recurrent dental infection. It is thought the acquired hemophilia was likely triggered by the recent penicillin exposure. Penicillin was listed as an allergy and patient advised to avoid the class in the future. IMPACT/DISCUSSION: Acquired hemophilia A is associated with underlying conditions 30-50% of the time including malignancy, rheumatologic conditions, infections and drugs. This case highlights the diagnostic and therapeutic challenges in managing acquired hemophilia A, particularly in the setting of a potential drug-induced etiology. Early recognition, a strategic two-fold management approach, and careful review of potential triggers are critical for successful outcomes in these complex cases.

1. Recognizing Acquired Hemophilia - Persistent elevated PTT levels with a mixing study showing partial correction should prompt consideration of acquired hemophilia A, a rare but potentially life-threatening condition, often triggered by medications like penicillin. 2. Managing Hemorrhagic Shock in Acquired Hemophilia - Hemostasis in patients with acquired hemophilia requires a two-pronged approach: bypassing agents like recombinant factor VII and immunosuppressive therapies to address the underlying inhibitor. HEMOSUCCUS PANCRE… WHAT? Claire Arnold. Internal Medicine, Mayo Clinic Department of Internal Medicine, Rochester, MN. (Control ID #4271689) CASE: A 38-year-old male with a history of chronic pancreatitis and known pancreatic pseudocyst presented to the emergency department (ED) with several months of recurrent melena. Despite extensive testing—including a CT angiography (CTA), Meckel’s scan, MRI enterography, RBC nuclear scan, esophagoastroduodenoscopy (EGD), push enteroscopy, double balloon endoscopy, capsule endoscopy and colonoscopy—the source of his gastrointenstinal (GI) bleed remained undetermined. On exam, he was slightly tachycardic but otherwise hemodynamically stable. His hemoglobin was noted to be 7.4 and ferritin was 24. A CTA in the ED did not reveal evidence of acute GI hemorrhage but revealed his known pancreatic pseudocyst. He was started on IV proton pump inhibitor BID and was admitted with a plan for EGD in the morning. Overnight, his condition worsened, requiring 1 unit of packed red blood cells. Interventional radiology (IR) was consulted and his images were re-reviewed demonstrating a small pseudoaneurysm arising from the gastroduodenal artery. He underwent urgent IR coil embolization due to concern for hemosuccus pancreaticus. He was transferred to the medical ICU following the procedure for closer monitoring and he didn't have any further melena and/or drop in his hemoglobin. He was discharged home in stable condition a few days later. IMPACT/DISCUSSION: Hemosuccus pancreaticus is a rare but serious cause of upper GI bleeding, resulting from hemorrhage into the pancreatic duct. Pancreatic pseudocysts, a common complication of pancreatitis, can erode into adjacent blood vessels, leading to the formation of a pseudoaneurysm. The splenic artery is the vessel most commonly affected, and this condition can lead to severe, potentially life-threatening hemorrhage. Mesenteric arteriography with coil embolization is the preferred method for managing acute bleeding. For cases of persistent or severe hemorrhage, surgical intervention, such as pancreaticoduodenectomy and vessel ligation, is necessary.

The differential diagnosis for upper GI bleeding is extensive, with the most common causes being gastric or duodenal ulcers, erosive gastritis or duodenitis, and erosive esophagitis. Although rare, hemosuccus pancreaticus should be considered as a potential etiology, particularly in patients with a history of chronic pancreatitis, pancreatic pseudocysts, or pancreatic tumors. HEPATIC DIFFUSE LARGE B-CELL LYMPHOMA WITH SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS Andrea Y. Sun1; Yu-Han Chen2; Cho-Hao Lee3. 1College of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; 2Internal Medicine, Englewood Health, Englewood, NJ; 3Hematology/Oncology, National Defense Medical Center, Taipei City, Taipei City, Taiwan. (Control ID #4270035) CASE: A 69-year-old male presented with fever and dark urine for five days. Physical examination revealed tenderness of the right upper abdomen, yellow skin and eyes, and fever of 39°C. Initial laboratory findings exhibited abnormal values: WBC 5350/μL, hemoglobin 11.1 g/dL, PLT 96,000/mm3, AST 85 U/L, ALT 113 U/L, albumin 2.3 g/dL, triglycerides 801 mg/dL, total bilirubin 23.3 mg/dL, and direct bilirubin 16.2 mg/dL. Prothrombin time and ammonia were normal. With the impression of biliary tract infection, empiric broad spectrum antibiotics were administered. However, progressive pancytopenia soon developed, with WBC 1780/μL, Hb 7.6 g/dL, PLT 86,000/mm3, and an elevated ferritin level of 9634 ng/mL. Drug screen and viral pathogens such as cytomegalovirus, dengue, Epstein-Barr, herpes simplex 1 and 2, hepatitis A, B, and C were negative. Tests for malaria, leptospirosis, scrub typhus, and autoimmune diseases were also negative. Abdominal CT revealed hepatosplenomegaly. Magnetic resonance cholangiopancreatography (MRCP) did not show biliary tract dilation but revealed enlarged lymph nodes in the hepatoduodenal ligament space on diffusion-weighted imaging, with the largest one measuring about 3 x 1.8 cm. Bone marrow biopsy demonstrated hemophagocytosis without hematological malignancy. Liver biopsy revealed significant infiltration by large abnormal lymphocytes and staining of the tumor cells was positive for CD79a and Bcl-2, but negative for CD3. Moreover, the clinical presentation met six out of the eight criteria for HLH, including fever, splenomegaly, pancytopenia, hyperferritinemia, hyperlipidemia, and hemophagocytosis in the bone marrow. The final diagnosis was primary hepatic diffuse large B-cell lymphoma with secondary HLH. The patient responded well to six cycles of rituximab containing chemotherapy. IMPACT/DISCUSSION: Hepatic lymphoma is commonly secondary to the extranodal spread of advanced lymphoid malignancies. Primary hepatic lymphoma is extremely rare, accounting for only 0.016% of non-Hodgkin lymphomas. HLH, as the initial presentation, can be easily misdiagnosed as sepsis or acute liver failure. A life-threatening disorder characterized by excessive inflammation, HLH is uncommon in adults and is associated with viral infections, autoimmune disorders, and malignancies, particularly lymphoma. The prognosis is poor due to rapid progression and multi-organ dysfunction. Therefore, timely investigations to determine the underlying causes through tissue biopsies and imaging are crucial for improving patient survival.

When encountering patients with unexplained jaundice, hepatitis, and progressive cytopenia, it is essential to consider HLH as part of the differential diagnosis. If laboratory tests or imaging studies have excluded infection and do not reveal the underlying cause HLH, a liver biopsy may be necessary to diagnose infiltrative liver diseases such as lymphoma. Early treatment targeting the underlying disease provides patients with improved survival. HEYDE SYNDROME: DIAGNOSING THE OVELOOKED LINK BETWEEN HEART AND GUT Kayla Hernandez1; Omar Zuhdi1; Paola Campillo1; Michael Sabina1; Avinash Khanna2. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2Cardiology, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4271634) CASE: This report will discuss an 87-year-old male who presented for chest pain in the setting of acute anemia who underwent a work up with cardiology and gastroenterology ultimately revealing a case of Heyde Syndrome (HS). He has history of atrial fibrillation, hypertension and hyperlipidemia. Workup revealed a hemoglobin of 4.6 and review of records showed he had a recent hemoglobin of 12.8. The cardiology and gastroenterology teams were consulted. Given the history of atrial fibrillation in the setting of his current chest pain, an ECHO was ordered revealing moderate to severe aortic stenosis (AS). An Esophagogastroduodenoscopy was performed showing evidence of gastritis, but no clear cause for acute anemia. A colonoscopy showed multiple vascular abnormalities in the large bowel consistent with angiodysplasias. The patient was stabilized and referred to a cardiovascular surgeon for transcatheter aortic valve replacement (TAVR). IMPACT/DISCUSSION: Heyde Syndome presents with AS and gastrointestinal (GI) bleeding. It is believed that the collection of symptoms seen is due to increased shear forces across the aortic valve and the resultant cleavage of von Willebrand Factor (VWF) multimers. As the VWF multimers cross over the stenotic aortic valve, the von Willebrand polymer is converted into an elongated, asymmetric protein that exposes the A2 domain. ADAMTS13, a metalloproteinase, binds to the newly exposed domain and the high-molecular-weight multimers are reduced in size and become less hemostatically competent. It is believed that there is a pathological cause for the development of angiodysplasia seen with von Willebrand Factor deficiency (VWD). There is evidence of an intrinsic vascular anomaly that is seen in patients with VWD, where there is increased capillary dilation, tortuosity and blood extravasation observed. Therefore, one could deduce that VWF plays an essential role in maintaining vascular integrity. First line therapy for HS is a TAVR and is associated with less risks than the alternative surgical aortic valve replacement. Workup and management of GI bleeding in HS is the same as any other etiology of GI bleeding and initial evaluation should be aimed at ruling out the presence of acute, life-threatening bleeding. In HS, most sources of GI bleeding from angiodysplasias occur in the small bowel and upper/lower endoscopies may not locate a source of bleeding. As such, further investigation with push enteroscopy or video capsule endoscopy may be required to identify the source.

Heyde Syndrome is characterized by aortic stenosis, GI bleeding and acquired von Willebrand Syndrome. It is a multisystem diease that occurs across the cardiovascular, GI and hematological systems. HS is most commonly seen in patients greater than 65 years of age. Due the regularity at which GI bleeding and AS is identified in this population, it is likely that Heyde Syndrome is underdiagnosed and underreported. HICKAM'S DICTUM OR OCCAM'S RAZOR? LEPROSY A FORGOTTEN DISEASE Nkoyo Effiom, Angelin Raju, Jonathan Pham, Dipaben Patel, Obulakshmipriya Subramanian. GME, Texas Health Resources, Arlington, TX. (Control ID #4272238) CASE: A 35-year-old Micronesian man presented to the emergency department (ED) several times from 2017 to 2021 for painless, erythematous, papular skin lesions on face and extremities. He was managed with oral antibiotics and steroids but had frequent reoccurence of lesions. His last visit to Micronesia was in 2014. Due to family history of leprosy, a skin biospy was done which was positive for lepromatous leprosy. He was treated with rifampicin and dapsone for 1 year, he completed therapy in September 2022. He developed erythema nodosum leprosum (ENL) immediately after completing therapy and was placed on thalidomide. In March 2023, he had fever and reocurrence of painful skin lesions after missing 2 weeks’ dose of thalidomide. Symptoms improved on IV steroid and thalidomide and he was discharged on an 8-days prednisone taper. Skin lesions and fever reoccured immediately after completing steroids. He was readmitted, a repeat skin biopsy was positive for lepromatous (multibacillary) leprosy. The patient returned to Micronesia for treatment at the Hansen Clinic with rifampicin and dapsone for 1 year, he completed therapy in June 2024. He presented to the ED 4 months later with painful lesions on both hands and feet. IV steroids were started and thalidomide resumed for presumed ENL. Repeat skin biospy showed recurrent/persistent lepromatous leprosy. He was placed on a multidrug therapy with rifampicin, dapsone and clofazamine to be completed after two years of therapy. IMPACT/DISCUSSION: Leprosy is an ancient disease that was dreaded for its incurable and disfiguring nature. Today, it is known that leprosy is curable and is not spread by casual contact, however, some of the stigma lingers on. After the introduction of the mutidrug therapy (MDT) in the 1960s, the incidence of leprosy decreased significantly. The World Health Organization reports about 200 000 new cases annually in more than 120 countries. Leprosy is an infection of the skin and peripheral nerves caused by the Mycobacterium leprae complex. The WHO recommends MDT with rifampicin, dapsone and clofazimine with a duration of 6 months for paucibacillary type and 12 months for multibacillary type. In patients with high initial bacillary index, prolonged therapy for 24 months is associated with higher infection clearance rates. Erythema nodosum leprosum (ENL) is a type 2 immunologic reaction to leprosy which can present similarly and confound the diagnosis of recurrent or persistent leprosy in incompletely treated patients as in this case. A skin biopsy of an ENL lesion shows neutrophilic infiltrates which is uncommon in leprosy skin lesions and can aid in differentiating between both conditions.

Leprosy remains a global health concern. With increasing international travel and migration, it is important to recognize the common features of leprosy and maintain some suspicion for this disease in at risk populations. Early diagnosis and treatment will interrupt transmission and minimize the risk of permanent disability. HIDDEN DANGER: EXPLORING THE ENIGMA OF UNFORESEEN ASPIRIN TOXICITY Abdul Arham1; Musfira khalid2; faheem javad3; Abira Khalid2; Abdul Waheed4; brendan korb1; Hamza Khalid5; Muhammad Ahmed Khan6. 1Internal Medicine, Baystate Health, Springfield, MA; 2Fatima Jinnah Medical University, Lahore, Punjab, Pakistan; 3Al Nafees Medical College and Hospital, Islamabad, Islamabad Capital Territory, Pakistan; 4Post Graduate Medical Institute Ameer-ud-Din Medical College, Lahore, Punjab, Pakistan; 5Internal Medicine, Shifa College of Medicine, Islamabad, Islamabad Capital Territory, Pakistan; 6Internal Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4270168) CASE: A 50-year-old male with no past medical history, presented to the emergency department with 2 days of acute onset progressive shortness of breath, dyspnea on exertion, tinnitus, and occipital headache. His review of systems was otherwise negative. He carried no diagnosis of any cardiopulmonary diseases. Aside from some sinus tachycardia, his vitals were stable and within normal limits. His examination was only notable for hyperpnea. CT head and chest imaging was unremarkable. Patient’s labs were normal aside from a primary respiratory alkalosis and a primary anion gap metabolic acidosis. Further inquiry revealed chronic self-administration of over-the-counter aspirin for chronic right shoulder pain, with ingestion of up to 10 g daily over a period of 3 to 4 days. Patient’s serum aspirin level was 80.9mg/dl (normal 10-30mg/dL) which confirmed the diagnosis of severe aspirin toxicity. IMPACT/DISCUSSION: Management: Managment Involved urine and blood alkalization through sodium bicarbonate infusion, coupled with urgent dialysis. With treatment, his serum aspirin levels normalized with corresponding resolution of symptoms. Patient was discharged the following day.

Due to its spectrum of application and easy access, aspirin remains one of the most commonly used medications in the US. According to a 2005 survey, 22.7% of adults aged 45-64 were taking aspirin without any cardiovascular indication [2]. Diagnosing acute and chronic toxicityis often delayed leading to higher morbidity and mortality. Atypical presentations mimicking other diseases such as diabetic ketoacidosis,delirium,CVA, and ACS make chronic aspirin toxicity a diagnostic challenge [3].In 2004, there were over 20,000 reported cases of salicylate poisoning, a figure that surged to 30,000 in 2011 [1]. Our case highlights the importance of including aspirin toxicity in the differential in patients presenting with symptoms of shortness of breath and exertional dyspnea.

The accessibility of aspirin as an over-the-counter medication renders it highly prone to misuse. Given the similarity of presentation with other, more common, cardiopulmonary ailments, aspirin toxicity is often missed, leading to delay in proper treatment. Aspirin toxicity should remain on the differential for any patient presenting with dyspnea and prompt further investigation and appropriate screening. HIDDEN IN PLAIN PAIN: DIAGNOSING ISCHEMIC ENTERITIS THROUGH SURGICAL INTERVENTION Aya Obata1; Takaaki Kobayashi2; Rui Ouchi1; Akihito Yoshida3. 1General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan; 2Department of Internal Medicine, University of Kentucky, Lexington, KY; 3General Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan. (Control ID #4267810) CASE: An 89-year-old woman with a history of myocardial infarction, type 2 diabetes mellitus, and dyslipidemia presented with progressively worsening postprandial abdominal pain over three months. She had been hospitalized twice at another facility, where her symptoms temporarily improved with conservative treatment but recurred upon resuming oral intake, leading to a third admission. Given her significant atherosclerotic risk factors, intestinal ischemia was suspected. Contrast-enhanced computed tomography (CT) revealed edema around a segment of the ileum and mild proximal bowel dilation. However, an angiogram did not identify stenosis or thrombosis in the corresponding blood vessels. On hospital day 28, laparoscopic partial small bowel resection was performed. A 4 cm segment of the ileum with circumferential stenosis and proximal dilation was identified and resected. Histopathological examination revealed circumferential ulceration and transmural fibrosis, consistent with chronic intestinal ischemia. The patient resumed oral intake on postoperative day 2 without recurrence of abdominal pain. IMPACT/DISCUSSION: Ischemic enteritis is a rare condition caused by impaired arterial inflow to the small intestine without major arterial occlusion. Its rarity is attributed to the rich arterial supply and collateral circulation of the small intestine. The absence of standardized diagnostic criteria makes ischemic enteritis challenging to diagnose. This condition predominantly affects individuals over 60 years old with atherosclerotic risk factors, such as hypertension, diabetes mellitus, ischemic heart disease, or cerebrovascular disease. Symptoms typically include abdominal pain, nausea, and vomiting; melena or hematochezia is uncommon. Ischemic enteritis can be classified into transient and stenotic forms, with the latter often presenting as intermittent obstruction due to progressive narrowing. CT findings, such as afferent stenosis with proximal bowel dilation, are suggestive but not specific. The ileum is the most frequently affected site. Double-balloon enteroscopy offers direct visualization and biopsy capability but is technically demanding and invasive. Surgical resection remains the definitive diagnostic and therapeutic approach, especially for stenotic lesions.

In patients with recurrent postprandial abdominal pain and significant atherosclerotic risk factors, ischemic enteritis should be considered despite its rarity. This case highlights the importance of surgical intervention, which can provide both symptom relief and a definitive diagnosis when noninvasive methods are inconclusive. HIDDEN IN PLAIN SIGHT: A STORY OF AN UNDIAGNOSED SYSTEMIC LUPUS ERYTHEMATOSUS WITH A RARE CLINICAL PRESENTATION Ayotunde I. Buremoh1; Yuqing Wang1; Brianna Smith2; Mylene Vista1; Saira Akhtar1. 1Internal medicine, Montefiore Wakefield Campus, New York, NY; 2internal medicine, Montefiore Medical Center, New York, NY. (Control ID #4272407) CASE: A 32-year-old woman presented with progressively worsening abdominal distention for weeks associated with abdominal pain, postprandial nausea and emesis. The physical exam was notable for generalized tenderness and fluid wave. Lab work revealed proteinuria, acute kidney injury, normocytic anemia and leukocytosis. She had undergone a diagnostic paracentesis at an outside hospital that had shown serum-ascites albumin gradient of 0.6 indicating lack of portal hypertension. There was no evidence suggesting the common causes of low SAAG ascites including peritoneal malignancies, mycobacterium tuberculosis, and nephrotic syndrome. Upon further investigation, she reported chronic pain in bilateral wrists and knees with morning stiffness and occasional swelling. She also endorsed hair loss, dry mouth, dry eyes and Raynaud's phenomenon. A rheumatological disorder was suspected; Antinuclear antibody, double-stranded deoxyribonucleic acid anti-ribonucleoprotein, anti-Ro, and anti-La antibodies were all markedly positive. Rheumatology was consulted for systemic lupus erythematosus (SLE) and the ascites was thought to be from lupus serositis. Intravenous methylprednisolone 48mg daily was commenced resulting in significant improvement in her ascites. Patient was discharged on methylprednisolone 32mg daily and hydroxychloroquine 200mg daily to follow up with rheumatology as an outpatient. IMPACT/DISCUSSION: SLE is an autoimmune disease characterized by a widespread loss of self-tolerance and consequent multiorgan inflammation caused by genetic factors, endocrine, environmental, triggers and aberrant innate immune responses. This case exemplifies the diagnostic challenge posed to clinicians when patients present with atypical symptoms resulting in delayed diagnosis and care. Typical symptoms include fatigue, fever, malar rash and arthralgias. In our case, the presenting symptom was ascites caused by lupus serositis, which is a diagnosis of exclusion. Ascites occurs in only 10% of patients with lupus and can be secondary to peritoneal serositis, protein-losing enteropathy, nephrotic syndrome, or constrictive pericarditis. Lupus serositis commonly affects the pleural, pericardium and rarely the peritoneum. Lupus serositis is a type III hypersensitivity reaction where immune complexes deposit on serosal surfaces, triggering complement activation. Neutrophils and other immune cells are recruited, enhancing inflammation, tissue injury and fluid accumulation in serous cavities. Peritoneal inflammation leads to abdominal pain and ascites, as in our patient.

Atypical presentations in SLE constitute a diagnostic dilemma for physicians due to the wide range of clinical manifestations of the disease, however, a detailed history and a high index of suspicion can help with appropriate diagnosis. Even though ascites is not included in the official classification criteria of SLE, it should be considered for patients with an unclear etiology of ascites in addition to the classic lupus symptoms. HIDDEN IN PLAIN SIGHT: MRSA BRAIN ABSCESS PRESENTING AS BRAIN METASTASIS Jun Ki Jeon, Aparna A. Rathnam, Harleen Sindhu, Thanushiree Sivalingam, Mya Hnin Lwin. Medicine, NYC Health + Hospitals / Elmhurst, Icahn School of Medicine at Mount Sinai, Elmhurst, NY. (Control ID #4271678) CASE: A 60-year-old undomiciled man with a history of schizophrenia and IV drug use presented after a witnessed seizure. Despite initial stabilization with benzodiazepines, he experienced another seizure and was treated with levetiracetam. During examination, he was in a postictal state but was stable and afebrile. Laboratory results showed a white cell count of 16.7 × 10^3/μL, pH 7.23, and lactate 3.4 mmol/L. A brain CT revealed a right parietal mass with vasogenic edema, for which dexamethasone and antiepileptics were started. CT imaging of the chest, abdomen, and pelvis revealed multiple pulmonary nodules and heterogeneous bone lesions, raising suspicion for metastatic disease. Blood cultures grew MRSA, prompting treatment with Vancomycin. During hospitalization, he developed agitation and left arm twitching, so valproic acid was added to the regimen. Ceftaroline was also added for persistent bacteremia. Brain MRI identified a 4 cm cystic right parietal mass, suspicious for either metastasis or abscess. The patient underwent a craniotomy, during which profuse pus was drained, with cultures confirming MRSA. Vancomycin and ceftaroline were continued until blood cultures cleared, followed by a six-week course of daptomycin. Follow-up MRI demonstrated abscess size reduction. The patient was discharged to a rehabilitation facility with outpatient neurosurgery follow-up. IMPACT/DISCUSSION: A brain abscess is a collection of purulent material within the brain parenchyma. The classic presentation is a triad of fever, headache, and focal neurological deficits. However, the full triad is only seen in 20% of patients. Brain metastases and abscesses share overlapping symptoms and are difficult to differentiate on CT. MRI is required for a preliminary diagnosis. Aspiration of a brain abscess will provide a confirmatory diagnosis. Our patient presented with new onset seizures which are seen in 25-35% of brain abscess patients, and CT findings suggested metastasis. Due to his agitation, there was a delay in obtaining the MRI required for diagnosis. Delays in diagnosis can lead to complications such as persistent seizures, neurological deficits, and mortality. Effective source control is crucial for the clearance of bacteremia and the resolution of the infection. MRSA is an uncommon etiology of intracranial abscesses. In a meta-analysis of brain abscesses, only 2.7% were caused by MRSA. Intracranial infections caused by MRSA are a therapeutic challenge due to the poor penetration of IV antibiotics across the blood-brain barrier. The management of MRSA-induced brain abscesses requires a multidisciplinary approach involving long-term IV antibiotics and surgical intervention.

This case illustrates the complexity of diagnosing and managing a brain abscess. The overlapping clinical and radiological features with other intracranial pathologies can delay diagnosis and treatment. Early recognition, advanced imaging, and tailored treatment with a multidisciplinary approach are crucial. HIDING IN PLAIN SIGHT: LEPTOMENINGEAL DISSEMINATION IN PRIMARY CENTRAL NERVOUS SYSTEM MELANOMA Margaret S. Bove1; Ly Michele1; Michael Simonson2. 1Internal Medicine - Pediatrics, UPMC, Pittsburgh, PA; 2Department of Medicine, UPMC Presbyterian-Shadyside, Pittsburgh, PA. (Control ID #4273504) CASE: A 57-year-old female with primary CNS metastatic melanoma maintained on nivolumab, prior tumor resection resulting in central adrenal insufficiency, hydrocephalus requiring ventriculoperitoneal (VP) shunt, and dysphagia requiring feeding tube dependence presented with subacute somnolence and concerns about feeding tube function. Recently, the patient had been diagnosed with immune-checkpoint-inhibitor (ICI) encephalitis, requiring cessation of Nivolumab. On exam, the patient had normal vital signs. She was orientated to person only. Pupils were appropriately sized but minimally reactive. There was impaired downward gaze bilaterally. Due to feeding tube dysfunction, all medications were transitioned to parenteral form with exception of bromocriptine for neurostimulation as no intravenous form was available. Throughout her hospitalization, the patient had progressive drowsiness and inability to follow commands with no other new neurological deficits. CT Head was negative for acute infarction or hemorrhage. Her VP shunt was determined to be functioning properly. Ultimately, a brain MRI showed new nodular areas of enhancement within the foramen of Luschka and lateral ventricles, concerning for metastatic leptomeningeal disease (LMD). A multidisciplinary team including neuro-oncology, neurosurgery, palliative care, and internal medicine discussed the case and potential treatments. Given identification of LMD despite treatment, a family meeting was held to consider hospice. IMPACT/DISCUSSION: Changes in mental status present a unique challenge for diagnosis and management, particularly in patients with primary CNS malignancies. This is due to the overlapping and often vague clinical presentations of many diagnoses. In patients receiving ICI therapy, many immune-mediated effects must be considered. ICI encephalitis is a rare, but increasingly recognized complication of immunotherapy - however, there is a paucity of research on diagnosis and treatment. The presentation of LMD is also highly nonspecific, making early detection a challenge. In this patient, many conditions were possible: toxic/metabolic encephalopathy due to missed nutrition or neurostimulant medications, VP shunt malfunction, infection, progressive ICI encephalitis, or tumor recurrence and metastasis. A multidisciplinary team helped interpret the MRI findings in the context of the patient’s disease and consider whether certain treatment plans would align with her values. Practicing collaborative medicine allowed the patient and her family to understand the available options and make decisions that aligned with their goals.

Primary CNS malignancies, by nature, pose a risk for leptomeningeal dissemination. Metastatic disease should always be considered in subacute worsening of mental status, as this can significantly influence discussions regarding prognostication and goals of care. HIDING IN PLAIN SIGHT: WHEN CANCER ISN’T CANCER Andrew T. Ng2; Tyler Steve2; Prarthna V. Bhardwaj1. 1Hematology and Oncology, Baystate Health, Springfield, MA; 2Internal Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4230778) CASE: A 22-year-old male presented to the hospital for worsening back pain, bilateral lower limb weakness, and incontinence. He had also experienced back pain and night sweats for the past year. MRI and CT imaging showed pathological T8 fracture and T8 spinal soft tissue mass extending into the paraspinal region and diffuse lymphadenopathy suggesting a malignant process. Right axillary lymph node biopsy was consistent with Hodgkin Lymphoma (HL). Given the extensiveness of the lesions, he was diagnosed with stage IV HL. He was not a candidate for decompressive spinal surgery due to the multiple levels of pathologic fractures and was treated with bracing and dexamethasone. He started lymphoma-directed therapy with brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine (AAVD) inpatient and was discharged. Two months later, after two cycles of AAVD, a repeat MRI showed the resolution of the T8 spinal mass. However, PET-CT revealed persistent disease with hypermetabolic activity at T8, various lymph nodes, and the liver. He was switched to monotherapy with nivolumab due to concern for refractory HL. A month after his second cycle of nivolumab, he presented to the hospital with dyspnea and worsening back pain. On MRI, at T8 there was a collection suspicious for an abscess. Fine-needle aspiration cytology of the abscess revealed acid-fast bacilli. Imaging also revealed new pulmonary lesions and increasing liver lesions. A Biopsy of the liver lesion showed granulomatous inflammation without Hodgkin cells. 16S RNA testing was indeterminate for nontuberculous Mycobacterium. Samples taken from bronchoscopy grew mycobacterium avium (MA). Additionally, 3 different core biopsies were taken of an anterior mediastinal mass that also appeared on imaging, but no lymphoid tissue or cells suggestive of HL were found. Instead, it showed many acid-fast bacilli. His MA infection was treated with ethambutol, rifabutin, and clarithromycin. A month later, the patient was hospitalized again due to Moraxella bacteremia but repeat imaging showed improvement in his paraspinal fluid collection as well as a decrease in anterior mediastinal mass, and lymphadenopathy. All further lymphoma-directed therapy was discontinued due to competing medical issues. IMPACT/DISCUSSION: Disseminated MA and HL can have similar symptoms and even imaging findings. The disease and treatment of HL increase the risk of disseminated MA infection. Thus, when findings of HL persist despite appropriate therapy, repeat biopsy should be considered to ensure the patient is still suffering from the disease and is on appropriate treatment. It is possible that the patient had early-stage-HL with disseminated MA at the time of diagnosis rather than extensive-stage lymphoma.

Disseminated MA and HL can have similar symptoms and imaging findings Signs of persistent HL despite appropriate therapy should prompt a repeat biopsy to confirm the diagnosis HIGH-GRADE OLIGODENDROGLIOMA IN PREGNANCY: PRESENTATION AND MANAGEMENT Olivia Steczko1; Janani Arunachalam2; Brian Byrne3. 1PCIM, University of Connecticut School of Medicine, Farmington, CT; 2Internal medicine, UConn Health, Farmington, CT; 3Hematology & Oncology, Hartford HealthCare Cancer Institute, New Britain, CT. (Control ID #4245130) CASE: A 41-year-old G4P1021 with history of bariatric surgery, tobacco use and iron deficiency had been in her usual health until she developed lightheadedness at 23w5d. A coworker witnessed her have a tonic seizure and called EMS. During transfer she experienced another seizure which responded to midazolam and magnesium. Both episodes involved incontinence, tongue-biting and postictal state. History was negative for prior seizures, preeclampsia or clotting disorder. In the ED, vital signs were unremarkable. She returned to baseline mentation within an hour. Physical examination was unremarkable. Studies revealed WBC 8.8, H/H 11.9/35.3, PLT 228, Na 135, K 3.6, Mg 2.0, CO2 18, BUN/Cr 7/0.4, lipase 174, LA 5.7, toxicology with benzodiazepines and cannabinoids, UA without infectious process. After evaluation by neurology and obstetrics she underwent MRI of the brain which revealed a 7.5mm T2-hyperintense nonenhancing left frontal white matter lesion with calcification and edema. Findings raised concern for primary malignancy and she was started on levetiracetam. She was evaluated by neurosurgery and deferred biopsy to 28 weeks. A month later she underwent left frontal craniotomy resection. Postoperatively she developed recurrent focal-to-bilateral tonic-clonic seizures requiring antiepileptic escalation with lacosamide and dexamethasone. Postoperative head CT revealed new multifocal parenchymal hemorrhage and subdural blood adjacent to the surgical bed. Hospital course was further complicated by cerebral salt wasting treated with hypertonic saline, salt tablets and fludrocortisone, and tachyarrhythmia secondary to PICC placement. She underwent serial head CT monitoring with improvement and C-section at 32 weeks. Pathology confirmed grade 3 oligodendroglioma. Treatment options included watchful waiting, radiation therapy (RT) and adjuvant chemotherapy with procarbazine-lomustine-vincristine (PCV) or temozolomide (TMZ), or IDH-inhibitor (IDHi). Ultimately IDHi therapy with ivosidenib was pursued on a compassionate care basis. IMPACT/DISCUSSION: Oligodendrogliomas account for 5% of primary CNS tumors. Presenting symptoms may be nonspecific but seizures are common. Diagnosis is confirmed by IDH mutation and 1p19q deletion. Grading relies on histopathologic features with subdivision into WHO grade 2 (low) or 3 (high). Differentiation between grades can present a challenge and distinction may be small. Resection is not curative and treatment typically involves prompt RT and PCV or TMZ. Recent trials have shown improved progression-free survival and time to next intervention (PFS-TNNI) in lower-grade tumors treated with vorasidenib. Vorasidenib was unavailable at presentation but ivosidenib is approved for other malignancies.

In this patient, IDHi therapy was favored due to her young age as IDHi may delay RT-chemotherapy. Studies suggest improvement in PFS-TTNI. Vorasidenib received FDA approval in August 2024; followup is ongoing. HINTS AT A CEREBELLAR STROKE IN A YOUNG ADULT: DIAGNOSTIC AND CLINICAL IMPLICATIONS Madison Martinez1; Anjali Alangaden1; Jussie Correia Lima3; Margaret Shang2. 1Internal Medicine and Pediatrics, UPMC, Pittsburgh, PA; 2General Internal Medicine, UPMC, Pittsburgh, PA; 3Neurology, UPMC, Pittsburgh, PA. (Control ID #4271626) CASE: A 29-year-old woman with type 2 diabetes and iron deficiency anemia was admitted for acute onset, severe vertigo, nausea, and vomiting refractory to antiemetics. She had mild improvement with a right-sided Epley maneuver and was diagnosed with benign paroxysmal positional vertigo. At vestibular therapy follow-up, she was diagnosed with acute vestibular neuritis and prescribed a prednisone taper. A week later, she presented to the hospital with five days of abnormal taste and right-sided tongue and pharyngeal numbness. Her review of systems was otherwise negative. Vitals were normal except for mild hypertension (146/86). She was alert and oriented. Her cranial nerves were grossly intact except for nystagmus on right gaze and torsional nystagmus on upward gaze. Strength and sensation were normal in the upper and lower extremities bilaterally. Her gait was appropriate without ataxia. BMP and CBC were normal except for a WBC of 15.3 x 10E9/L with 94% neutrophils. Non-contrast CT head and CT angiography were unremarkable. A subsequent brain MRI recommended by neurology showed a small acute infarct of the right middle cerebellar peduncle. The remainder of her stroke workup was normal, including echocardiography and preliminary hypercoagulable labs. She was discharged with a 30-day event monitor, aspirin, and statin. IMPACT/DISCUSSION: Acute vestibular syndrome (AVS) has a broad differential that poses a diagnostic challenge to clinicians. While peripheral etiologies are more common, central etiologies still comprise about 20% of AVS cases and are often overlooked, leading to higher rates of morbidity and mortality. However, history alone cannot distinguish between peripheral and central causes. For example, vestibular neuritis and cerebellar stroke can present similarly with constant vertigo, nausea and vomiting, and difficulty walking. The HINTS+ exam (Head Impulse, Nystagmus, Test of Skew, Hearing Test) indicates central causes of vertigo if any are present: normal head impulse test, bidirectional nystagmus, vertical skew deviation, and/or new hearing loss. HINTS+ can indicate a central cause of vertigo with high sensitivity and specificity, outperforming MRI in the first 24-48 hours. However, the value of HINTS+ can be undermined by improper technique, underscoring the importance of training generalists to perform and interpret the exam accurately.

This case highlights the diagnostic complexities of AVS and emphasizes the importance of recognizing atypical presentations of ischemic stroke. HINTS+ is a valuable clinical tool for distinguishing between peripheral and central etiologies of vertigo. Early and accurate identification of central causes, such as cerebellar stroke, is critical to initiating appropriate management and improving outcomes. HISTOPLASMOSIS IN HIDING: FEVER OF UNKNOWN ORIGIN IN AN IMMUNOCOMPROMISED INDIVIDUAL Rachel Moffett1; Michael Leonard2; Elaine G. Patel1; Lauren M. Harmon1. 1Internal Medicine, Atrium Health, Charlotte, NC; 2Infectious Diseaes, Atrium Health, Charlotte, NC. (Control ID #4272132) CASE: A 30-year-old male from El Salvador presented to a hospital in North Carolina with intermittent fevers and left arm weakness. He was diagnosed with human immunodeficiency virus (HIV) with a viral load of 1,140,000 copies/mL and a CD4 count of 11, meeting criteria for acquired immunodeficiency syndrome (AIDS). Brain magnetic resonance imaging (MRI) subsequently revealed multiple rim-enhancing lesions in the right temporal and parietal lobes, and he was found to have a positive Toxoplasma antibody in his serum. He was treated empirically for central nervous system (CNS) toxoplasmosis, initially with sulfadiazine-pyrimethamine and later transitioned to sulfamethoxazole-trimethoprim. He experienced gradual improvement of his left arm weakness and had radiographic evidence of improvement seven days later on MRI. Curiously, the patient continued to have intermittent high-grade fevers to 39.5 degrees Celsius with progressive pancytopenia. He underwent a bone marrow biopsy which demonstrated organisms consistent with Histoplasmosis. He was treated with amphotericin, had resolution of his febrile episodes, and had rapid improvement in his pancytopenia. IMPACT/DISCUSSION: Histoplasmosis is a fungal infection which classically leads to subacute pneumonia and can be asymptomatic or present with constitutional symptoms of fever, cough, and myalgias. Rarely, in immunocompromised individuals, Histoplasmosis can result in a disseminated infection causing hepatosplenomegaly, pancytopenia, and mucocutaneous lesions. The patient discussed in this case is from El Salvador, which was a pertinent aspect of his social history. South America is one of the regions where Histoplasma capsulatum is increasing in prevalence. As global climates change and intercontinental commerce increases, endemic mycoses may become more prevalent in areas where they were previously considered sparce. Also, this patient was found to have profound immunosuppression in the setting of his untreated HIV infection. Although he was diagnosed with CNS toxoplasmosis, he failed to fully improve with the standard treatment. Given his profound susceptibility to opportunistic pathogens, it was important to maintain a high degree of suspicion for simultaneous infections and reassess systematically as additional clinical clues arose. Additionally, his case demonstrates how a bone marrow biopsy can be a valuable diagnostic tool, particularly when evaluating fever of unkonwn origin in an immunocompromised individual.

Although this patient had improvement in neurologic symptoms after being treated for CNS toxoplasmosis, his recurrent fevers indicated that another process was ongoing. Further workup with a bone marrow biopsy provided a definitive diagnosis of disseminated Histoplasmosis, and he had rapid clinical improvement following initiation of comprehensive treatment. HISTORY IS KEY: THE OVERLOOKED ROLE OF HEPATITIS C IN CIRRHOSIS DECOMPENSATION Suyog K. Buttar1; Maria F. Sanes Guevara2; Valerie Gobao2. 1Medicine and Pediatrics, University of Pittsburgh, Pittsburgh, PA; 2Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4272511) CASE: A 55-year-old woman with morbid obesity status post gastric bypass, metabolic-associated liver disease cirrhosis, severe malnutrition, polysubstance use (remote alcohol use now in remission, active fentanyl insufflation, tobacco and alprazolam use) presented after several falls with newly decompensated cirrhosis with large-volume ascites. Focused exam showed several liters of ascitites fluid in the abdomen, moderate altered mental status and no asterixes. Workup for decompensation was negative for infection (including spontaneous bacterial peritonitis), gastrointestinal bleeding (GIB), portal vein thrombosis, or hepatocellular carcinoma. She denied recent alcohol consumption, NSAIDs, or other hepatotoxic substance use and endorsed chronic constipation. She also denied any intravenous drug (IVD) use but reported concerns about needlestick injuries while cleaning up her son’s needles, as he was actively using IVDs. Viral serologies revealed anti-hepatitis C virus (HCV) antibodies (62.20 COI) and HCV RNA at 325,904 IU/mL. Her previous hepatitis serologies obtained 5 years earlier were all negative. IMPACT/DISCUSSION: This case highlights a common cause of hospital admission and the importance of careful history taking in evaluating cirrhosis decompensation. While common etiologies of decompensation such as infection, GIB, increased alcohol intake, or a drug-induced injury are rarely missed, new chronic viral infection can be overlooked. Oftentimes, in clinical practice, bloodborne infection screening in patients with cirrhosis is performed once and may not repeated. HCV contributes to systemic inflammation and liver fibrosis. This can worsen existing complications, such as ascites, hepatic encephalopathy, and variceal bleeding.

For all etiologies of decompensated cirrhosis, early identification and management is crucial to prevent further complications and optimize patient outcomes. This case illustrates the importance of revisiting viral hepatitis testing, particularly in patients with risk factors—such as needlestick injuries—who may develop new infections over time. HLH SECONDARY TO OSTEOMYELITIS IN THE SETTING OF NECROTIZING VASCULITIS Catherine Colonna1; Pamela Pride2. 1Internal Medicine, Medical University of South Carolina, Charleston, SC; 2Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4272218) CASE: This was a 61 year-old female with systemic necrotizing vasculitis of unclear etiology, PAD s/p LLE revascularization, and HTN who initially presented for gangrene and osteomyelitis of the left foot. She subsequently underwent BKA and received a 14-day course of vancomycin and zosyn. However, her stay was further complicated by lymphadenopathy, acute hypoxic respiratory failure with recurrent pleural effusions, GOO, and AKI requiring hemodialysis, all of which did not have a clear explanation. The patient had a complex history with initial onset of symptoms 2-year prior after a COVID-19 infection. While she initially presented with this gangrene and osteomyelitis, her further hospital complications raised suspicion for other undifferentiated auto-inflammatory disease, including hemophagocytic lymphohistiocytosis (HLH). One of the work-ups included a wedge liver biopsy to investigate lymphadenopathy seen on PET. Pathology revealed diffuse histiocytosis with admixed lymphocytes suggestive of granulomatous inflammation with abnormal B cells. Of note, she also received thoracentesis for recurrent pleural effusions which were mildy exudative with diffuse hemophagocytosis noted as well. After her BKA, her ferritin was elevated to over 10,000 (13,375) ng/mL, triggering suspicion for HLH. Supportive criteria include elevated ferritin, CRP, and ESR. She also had low fibrinogen (228mg/dL) and normocytic anemia. IL-2 receptor was notably elevated to 2700pg/ml. In addition, serum and liver pathology were positive for EBV, a known viral trigger for HLH. The multifactorial nature of her vasculitis, osteomyelitis, significantly elevated ferritin with high CRP and ESR, as well as ongoing anemia and elevated soluble IL-2, raised clinical suspicion for HLH as explanation for her clinical sequelae in her hospital course. Having already been on steroids for her vasculitis, she was started on Anakinra with improvement. Subsequent PET scan showed decreasing liver lesions and lymphadenopathy without any new superficial lymph nodes. Inflammatory markers ferritin, ESR, and CRP all decreased but remained elevated. IMPACT/DISCUSSION: The diagnosis of HLH is complex and can be due to multiple triggers. HLH is often associated with infections, malignancy, and rheumatologic disorders in adults. The diagnostic criteria of HLH include meeting 5 of the following: fever above 38.5 C, splenomegaly, cytopenia, hypofibrinogenemia, hemophagocytosis in spleen, liver, lymph nodes or other tissues, low natural killer cell activity, serum ferritin above 500ug/L, and soluble IL-2 receptor (CD25) greater than 2400 U/mL.

For the internist, clinical suspicion for HLH should specifically be raised when ferritin is elevated above 10,000, as there are few other causes which will raise it this high, including malignancy and hepatitis. Elevated ferritin above 10,000 is both sensitive and specific to the diagnosis of HLH. HOSPITALIZED AFTER LOSING ADAM’S AID Deborah Cabral Fleischman B C Cunha1; Karla De Jesus Nunez1; Kristin A. Swedish2. 1Medicine, Montefiore Wakefield Campus, New York, NY; 2Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4273263) CASE: A 46-year-old woman with history of pelvic inflammatory disease (PID), presented with severe lower abdominal pain for two days after unprotected intercourse. Initial workup was remarkable for leukocytosis, and a pelvic ultrasound revealed a tubo-ovarian abscess. She was treated with metronidazole and doxycycline and discharged home. She returned five days later with worsening abdominal pain, vomiting, and weakness. Subsequent complementary studies revealed persistent leukocytosis, a significant drop in hemoglobin, severe thrombocytopenia, acute kidney injury (AKI), and indirect hyperbilirubinemia raising concern for hemolytic anemia, which was confirmed. Thrombocytopenic thrombotic purpura (TTP) versus drug-induced thrombotic microangiopathy (DITMA) was suspected. Although DITMA is not typically caused by metronidazole, her antibiotic regimen was changed. Her thrombocytopenia was refractory to transfusions necessitating plasmapheresis (PLEX) and intravenous steroids. ADAMTS13 inhibitor testing was positive with its activity severely suppressed. Drug-dependent antibody test for metronidazole was negative, proving that our patient had an acquired TTP triggered by the tubo-ovarian abscess rather than DITMA. IMPACT/DISCUSSION: Immune-mediated TTP, due to autoantibodies against ADAMST13, is most commonly triggered by pregnancy and infection, though cancer, HIV, and autoimmune disease can also be triggers. There is very limited data about pelvic infections triggering TTP; with few cases described in the literature. This case highlights the importance of maintaining an ongoing differential diagnosis. Microangiopathic hemolytic anemia (MAHA) is a broad term used to describe red blood cell fragmentation observed in three conditions: (TTP), (DITMA), and (DIC). It is crucial to distinguish between TTP and DITMA, as DITMA can often be cured by simply removing the causative medication. The primary difference between these conditions lies in their underlying triggers which are going to guide the therapeutic approach. Our case also highlights the importance of approaching patients comprehensively and recognizing the value of timely diagnosis in life-threatening conditions such as TTP.

This case illustrates a rare, potentially lethal complication highlighting the importance of recognizing unusual etiologies for TTP. It also demonstrates the value of a thorough patient history and validating patient concerns. Understanding how microangiopathies can involve multiple organ systems emphasizes the utility of identifying the etiology of the condition and the importance of an interdisciplinary approach to improve patient outcomes. HOW ENCEPHALOPATHY UNCOVERED A HIDDEN PRIMARY HYPERPARATHYROIDISM Tinsa Varughese1; Tyler Wark2; Wali Kamran3; Caroline Quindlen4; William Ghaul2; Brian Costello2. 1Internal Medicine, Lehigh Valley Health Network, Allentown, PA; 2Internal Medicine, Lehigh Valley Hospital - Cedar Crest, Allentown, PA; 3Internal medicine, Lehigh Valley Health Network, Allentown, PA; 4Drexel University College of Medicine, Philadelphia, PA. (Control ID #4270604) CASE: The patient is a 75-year-old male who presents with generalized weakness, malaise, confusion, and recurrent falls. He had been complaining of generalized weakness before the fall and had multiple falls recently. On admission, labs were notable for albumin of 4.0 and calcium 10.5. During his hospitalization, he exhibited waxing and waning mentation that was initially attributed to hepatic encephalopathy after a diagnosis of cirrhosis was made during the admission with ammonia level of 69. Lactulose and rifaximin were initiated, however, minimal improvement in mentation was noted. Notably, our patient’s serum calcium continued to trend upward to a peak of 14.0 two weeks into his hospitalization. Workup included a PTH which was found to be 52. With further testing, a diagnosis of PHPT was made. The patient was treated with pamidronate and calcitonin with an improvement of calcium levels as well as patient’s mentation. Due to the patient’s comorbidities, he is a poor surgical candidate and was otherwise not interested in surgical intervention. IMPACT/DISCUSSION: It is often taught that primary hyperparathyroidism presents as the mnemonic “stones, thrones, bones, groans, and psychiatric overtones” and refers to the overproduction of parathyroid hormone by the parathyroid gland. This leads to elevation of serum calcium which presents as nephrolithiasis, constipation, osteoporosis, and/or CNS effects—notably, a small number of patients with PHPT present with these classically taught symptoms. Nonspecific features often reign supreme as a preeminent feature upon diagnosis or show these signs in the background of their presenting illness (lethargy, fatigue, depression, memory loss, psychosis, delirium). Primary hyperparathyroidism is diagnosed with elevated serum calcium concentration with PTH minimally elevated or within normal range. Surgical intervention for patients with asymptomatic primary hyperparathyroidism is indicated if serum calcium is greater than 1 mg/dl above the upper limit of normal, osteoporosis is determined with DXA scan, history or evidence of kidney dysfunction with eGFR 250 mg/day in women and >300 mg/day in men), or nephrolithiasis, or age less than 50 years old. Our patient did not meet this criteria with his primary complaint being altered mentation. Neuropsychiatric symptoms such as memory impairment, gait difficulty, and fatigue present in up to 23% of patients with primary hyperparathyroidism. However, these symptoms are not specific indications for surgical intervention per international guidelines as there is limited data.

This case highlights how primary hyperparathyroidism does not always present with classic symptoms and should be considered in the differential in a patient presenting with altered mental status. It also underscores the criteria for surgical intervention and medical management for patients who do not meet it. HUMAN BITE-ASSOCIATED NECROTIZING FASCIITIS OF UPPER EXTREMITY DUE TO STREPTOCOCCUS PYOGENES: REPORT OF RARE CASE AND REVIEW OF THE LITERATURE Nirmala Ghimirey1; Joseph P. Myers2. 1Internal Medicine, Summa Health System, Akron, OH; 2Medicine, Summa Health System, Akron, OH. (Control ID #4269928) CASE: A 56-year-old male with past medical history of alcohol abuse and hypertension presented to ED with left-hand wound from a defensive bite to the web space between 1st and 2nd digits by his girlfriend in an altercation 4 days previously. Patient reported fever, chills, pain, and swelling of the hand with appearance of blisters at the bite site on day before admission. Vitals signs: BP = 81/60 mmHg, Temp 98.2 F, RR 20, HR 130. The left hand was edematous with some bullae and with purulent drainage. Laboratory data showed leukocytosis (18.1K), lactic acidosis (4.7), bandemia (47), and elevated C-reactive protein (700). In the setting of septic shock, the patient was resuscitated with fluids, cultured, and started on piperacillin/tazobactam, vancomycin, and clindamycin followed by ICU admission. Orthopedic surgery was consulted for emergent incision and drainage for presumed necrotizing fasciitis. Streptococcus pyogenes was isolated from 2 blood cultures and multiple superficial and deep wound specimens. Despite antibiotic therapy and multiple aggressive surgical debridement procedures, the infection progressed eventually requiring trans-humeral amputation. Antibiotics were changed to IV ceftriaxone which was continued for total of 17 days via PICC line and outpatient parenteral antimicrobial therapy. IMPACT/DISCUSSION: Necrotizing fasciitis (NF) is a rapidly progressing and potentially life-threatening condition that affects skin, fascia, and subcutaneous tissue. NF is further divided into two categories: type 1 is due to a polymicrobial variant such as Gram-positive, Gram-negative and anaerobic bacteria; type 2 is usually caused by Streptococcus pyogenes. NF most frequently affects the lower extremities but 6-27% of cases involve the upper extremities. NF may be the result of trauma, injury or cutaneous compromise. NF from human bite wounds is rare. Both aerobic and anaerobic microorganisms may be responsible, including Streptococcus spp., Staphylococcus aureus, Peptostreptococcus spp., Haemophilus influenzae, and Eikenella corrodens. The rate of infection after human bite is 10-30% with human bite-related NF usually caused by oral Streptococcus spp with mortality around 13 to 18%. NF infection requires immediate surgical and medical management. Recommended antibiotic treatment includes penicillin and clindamycin. Despite rapid and continued surgical intervention and appropriate antimicrobial therapy, our patient required right arm amputation.S. pyogenes is a rare cause of human bite infection. A PubMed® search for “Group A streptococcal infection AND human bite” resulted in 8 reported cases, 2 fatal.

Human bite wound infections are notoriously severe but usually caused by Eikenella corrodens and other mouth microflora. S. pyogenes NF is immediately life-threatening but most commonly occurs on the lower extremities. We report the 9th known case of S. pyogenes NF of the upper extremity in a patient who survived only with amputation of his dominant upper extremity. HYDRALAZINE-INDUCED LUPUS PRESENTING AS PLEURISY AND PLEURAL EFFUSION Maryam Yousefi, Muhammet Sait Saglam, Krunal Patel, Ayfer Ekiz. Garnet Health, Middletown, NY. (Control ID #4231356) CASE: An 84-year-old male with a history of coronary artery disease, hypertension, chronic kidney disease stage 4, and benign prostatic hyperplasia presented with chest pain and shortness of breath. His symptoms had worsened over the past few days, and a recent nuclear stress test showed mild to moderate ischemia, though left heart catheterization was deferred due to renal insufficiency. Examination revealed decreased breath sounds on the right side, and imaging showed bilateral pleural effusion, prominent on the right, with basilar consolidation. Lab results indicated elevated troponin, proBNP, and BUN/creatinine, suggesting both cardiac and renal involvement. Given the patient’s recent hydralazine use, a workup for autoimmune causes of the pleural effusions was initiated. Thoracentesis revealed exudative pleural fluid with positive ANA, anti-histone, and anti-chromatin antibodies, confirming hydralazine-induced lupus (HILS). Cytology and cultures were negative for infection or malignancy. After hydralazine was discontinued, the patient's symptoms improved, and a diagnosis of HILS was confirmed. The patient was advised to avoid hydralazine and follow up with rheumatology and pulmonology. IMPACT/DISCUSSION: Drug-induced lupus (DIL), first described 60 years ago, is commonly caused by hypertension medications, particularly hydralazine. The occurrence of DIL is dose-dependent, with higher doses like our patient’s (increased from 25 to 100 mg BID) carrying a greater risk. Risk factors include doses ≥200 mg daily, prolonged therapy, female gender, and a family history of autoimmune diseases. Symptoms often include musculoskeletal complaints such as arthralgia, fever, fatigue, and rash, but can rarely present with pleural effusion, pulmonary edema, or pericardial effusion. Diagnosis is confirmed by clinical findings and positive anti-histone antibodies. Increased hydralazine use following the A-HeFT trial has raised awareness of this risk. Early recognition and discontinuation of hydralazine could have prevented the pleural effusion in our case. Upon diagnosis, hydralazine should be discontinued and replaced with an alternative antihypertensive, with corticosteroids or immunosuppressive therapy considered if symptoms persist.

It is crucial to consider drug-induced lupus (DIL) when a patient on hydralazine presents with lupus-like symptoms. Clinical suspicion should be heightened in patients with pleural effusion and a history of hydralazine use. The most important step is to discontinue the offending medication and closely monitor for improvement in symptoms. HYPERCALCEMIA AND WHAT'S BREWING FROM WITHIN: A CASE OF SEVERE HYPERCALCEMIA IN A LIVER TRANSPLANT PATIENT WITH A NEWLY DIAGNOSED POST-TRANSPLANT LYMPHOPROLIFERATIVE DISEASE Carlo Gabriel C. Casipit1; Bruce Adrian Casipit2. 1Internal Medicine, Jefferson Einstein Philadelphia Hospital, Philadelphia, PA; 2Loma Linda University, Loma Linda, CA. (Control ID #4270484) CASE: A 69-year-old male with Type 2 Diabetes Mellitus, Hepatitis C Cirrhosis complicated with Hepatocellular Carcinoma status post Liver Transplant in 2007, presents with generalized weakness and fatigue for 1 week. He has no sick contacts or medications besides Metformin and Tacrolimus. He denied any fever, dyspnea, jaundice, chest pain, abdominal pain, diarrhea, hematochezia, rash, or joint pain. Vital signs and physical examination were unremarkable. Laboratory tests showed Creatinine 2.6 (ref 0.5-1.5) , Calcium 15.5 (ref 8-10), Phosphate 5 (ref 2.5-4.5), PTH 11 (ref 15-65), 25 hydroxy Vitamin D 33 (ref 20-40), 1, 25 Hydroxy Vitamin D 111 (ref 18-72), EBV negative. Endocrinology was consulted and the patient was started on fluids, calcitonin, and Denosumab with minimal calcium response. CT Abdomen showed normal liver but had extensive mesenteric lymphadenopathy with the largest confluent lymph node mass measuring 11.4 x6.8 cm. Intraabdominal lymph node biopsy revealed monomorphic post-transplant lymphoproliferative disorder. Oncology was consulted and the patient was started on steroids and chemotherapy. However, his hospital course was complicated by sepsis which warranted a pause in his chemotherapy, leading to rebound hypercalcemia with concomitant volume overload and uremia, necessitating hemodialysis. Unfortunately, few days after, the patient succumbed to his illness. IMPACT/DISCUSSION: Post-transplant lymphoproliferative disorder is a rare complication of solid and hematopoietic organ transplant, occurring in only <1% of the transplant population, and is due to chronic immunosuppression and decreased T cell surveillance. Most cases are associated with EBV infection. However, 50% of PTLD cases are EBV-negative, which was found to carry a worse prognosis by previous studies. Our patient presented with profound hypercalcemia, and the disproportionate elevation of 1,25-dihydroxyvitamin D compared to 25-hydroxyvitamin D means an excess 1α-hydroxylase activity, enhancing calcium and phosphate absorption. This pathway is responsible for <1% of malignancy-associated hypercalcemia, which most commonly occurs in non-Hodgkin lymphoma cases. Previous studies also supported that the presence of hypercalcemia in patients with malignancy signifies a poor prognosis, and 50% of these patients reportedly die within 30 days.

Post-transplant lymphoproliferative disease is a rare yet life-threatening complication of transplantation. It can present in various ways and rarely prominently presents as hypercalcemia due to increased 1α-hydroxylase activity. Treatment of malignancy-associated hypercalcemia is centered on safely lowering calcium levels while addressing the underlying malignancy. Therefore, all physicians should be well-equipped with the knowledge to consider unusual causes of hypercalcemia in the right clinical setting and be able to provide continuous patient education, early referral, and prompt treatment. HYPERCALCEMIA LEADING TO A DIAGNOSIS OF CANCER OF UNKNOWN PRIMARY Robyn Kuchler1; Mohamad Alabdaljabar3; Maleka Khambaty2. 1Mayo Clinic Alix School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, MN; 2Hospital Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 3Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271505) CASE: A 52-year-old male presented to the ED with 6 months of progressive weakness, poor appetite, and a 50 lb weight loss. He used chewing tobacco for 20 years and has 1-3 alcoholic drinks per day. Recent colonoscopy was reassuring. He was vitally stable in the ED, and laboratory workup was significant for a calcium of 12.1 mg/dL, PTH < 6 pg/mL, total vitamin D of 55 ng/mL, PTHrP of 2 pmol/L, and was otherwise unremarkable. CT chest/abdomen/pelvis imaging showed several hepatic, peritoneal, and bone lesions, and diffuse lymphadenopathy without a primary mass/source identified. The patient was admitted for further workup and underwent a liver biopsy. Biopsy results were suggestive of adenocarcinoma. His CEA and CA 19-9 were elevated at 14.9 ng/mL and 431 U/mL respectively with normal AFP and PSA. He was diagnosed with a cancer of unknown primary (CUP) and was discharged from the hospital with close outpatient follow up with oncology for further management. IMPACT/DISCUSSION: In a patient presenting with new hypercalcemia, malignancy should always be included on the differential as malignancy is the number one cause of hypercalcemia in hospitalized patients. The most common cause of hypercalcemia in malignancy is humoral hypercalcemia of malignancy due to release of PTHrP. Humoral hypercalcemia of malignancy is commonly seen with solid tumors and some lymphomas. Bony metastases are common causes of hypercalcemia in patients with multiple myeloma and some solid organ tumors. Lastly, Hodgkin, and some non-Hodgkin, lymphomas cause hypercalcemia because of increased 1,25-dihydroxyvitamin D production. In CUP, including our patient, hypercalcemia can happen due to cancer related characteristics (PTHrP secretion or vitamin D production) or bone metastasis. CUP is associated with a poor prognosis. Typically, these cancers are rapidly growing, are more resistant to or incompatible with curable treatment options, and it is more difficult for clinicians caring for these patients to determine the most effective treatment regimens. Several factors influence survival in CUP. CUP incidence has decreased over the years with advancement in the available diagnostic modalities. Adenocarcinoma histology, elevated CA 19-9 and CEA levels, increased LDH, CK20 positivity, metastasis not confined to lymph nodes, and bone metastasis are all factors related to shorter survival. Of these, the patient in this case has adenocarcinoma, elevated CA19-9 and CEA markers, and bone metastases. Patients with extranodal adenocarcinoma have worse overall survival as compared to those without extranodal metastasis (median survival 3 vs 9 months).

There are several mechanisms in which malignancy can cause hypercalcemia, including release of parathyroid hormone-related peptide (PTHrP), bony metastases with osteoclast activating factors, and production of 1,25-dihydroxyvitamin D. CUP is a rare entity (3-5% of all cancer diagnoses) that carries a poor prognosis. HYPERTRIGLYCERIDEMIA-INDUCED FACTITIOUS HYPOBICARBONATEMIA Aleksander D. Bermudez Perez, Sruthi Selvakumar. Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #4273314) CASE: We present a case of a 52 year old male with history of hypertension, hyperlipidemia, hypertrophic cardiomyopathy, and alcohol use disorder, who presented due to weakness, dizziness, and a recent fall. Initial workup for stroke was negative. On presentation, laboratory findings revealed a bicarbonate level of 9 mEq/L and an anion gap of 21. Despite these laboratory findings, the patient exhibited no clinical signs of metabolic acidosis. Interestingly, an iSTAT CHEM8+ test showed normal bicarbonate levels without an anion gap. A venous blood gas showed a pH of 7.49 and pCO2 of 38, and an arterial blood gas showed similar results with a pH of 7.46 and pCO2 of 40. A lipid panel showed an elevated triglyceride level of 962 mg/dL. He was started on a clear liquid diet as well as fenofibrate. Repeat triglyceride levels showed reduction to 324 mg/dL. Subsequent comprehensive metabolic panels had normal bicarbonate levels between 23-25 mEq/L and normal anion gaps. IMPACT/DISCUSSION: This case illustrates a rare, but important, consideration when evaluating low serum bicarbonate levels and elevated anion gap without clinical manifestations of true metabolic acidosis. The pH and PCO2 values observed on the arterial and venous blood gas analyses suggested that there was no true underlying acidosis, and further investigation revealed the hyperlipidemic effect on the chemical assay. Although the mechanism is not fully understood, it is hypothesized that the light-scattering effect of hyperlipidemia interferes with the comprehensive metabolic panel assay used, which results in factitious low bicarbonate levels, thus leading to an elevated anion gap1. This is potentially the reason why, in our case, we observed abnormally low bicarbonate levels compared to the iSTAT CHEM 8+ results. The resolution of his pesudohypocarbonatemia following treatment of hypertriglyceridemia with a fenofibrate further emphasizes the importance of the above-stated findings.

1 Rifkin, Stephen I., and Beth Shaub. “Factitious hypobicarbonatemia associated with profound hyperlipidemia.” Renal Failure, vol. 36, no. 7, 21 May 2014, pp. 1155–1157, https://doi.org/10.3109/0886022x.2014.917945.

Severe hypertriglyceridemia can cause laboratory abnormalities due to the interference of lipids with biochemical assays, potentially leading to misinterpretation of laboratory results. Providers should consider lipid panel assays in the presence of abnormally low bicarbonate levels and a high anion gap, especially in the setting of normal blood gas findings and lack of clinical symptoms. Early recognition and treatment of high triglyceride levels can normalize these values and improve patient outcomes without the use of unnecessary treatments such as bicarbonate replacement therapy. HYPONATREMIA MEETS ITS MATCH: A CASE OF OXCARBAZEPINE OVERDOSE, SEIZURES, AND THE SODIUM DILEMMA Walaa Hasan, Cristofer Francisco Santamaria Garcia, Inamul Khan. internal medicine, Trinitas Regional Medical Center, Elizabeth, NJ. (Control ID #4243473) CASE: Hyponatremia, a common but underreported side effect of oxcarbazepine, occurs in 29.9% of patients, with severe cases in 2.5–3%. Patients with seizure disorders are more prone to seizures from electrolyte imbalances, highlighting the need for careful management. Oxcarbazepine-induced hyponatremia, often due to SIADH, involves low serum osmolality and inappropriate urine concentration. A 59-year-old woman with a history of epilepsy managed on Keppra and recently initiated on oxcarbazepine presented to the ED with symptoms of a seizure aura, fatigue, and unwellness. She had recently increased her oxcarbazepine dose to 1200 mg due to a self-perceived loss of medication efficacy after experiencing diarrhea. On presentation, her serum sodium was critically low at 119 mEq/L, serum osmolality was 273 mOsm/kg, urine osmolality was 165 mOsm/kg, and urine sodium was 30 mEq/L. These findings strongly supported the diagnosis of SIADH as the underlying mechanism of her hyponatremia. She experienced a tonic-clonic seizure in the ED, prompting the administration of Ativan and hypertonic saline infusion. Poison control was contacted for consultation, and activated charcoal was administered as a precautionary measure. Neurology evaluation confirmed oxcarbazepine-induced hyponatremia, likely potentiated by long-term Keppra use, and recommended discontinuation of both medications. The patient was admitted to the hospital for close monitoring and sodium correction, with significant improvement seen after hypertonic saline therapy (serum sodium increased to 129 mEq/L). Oxcarbazepine and Keppra were permanently discontinued, and Vimpat was initiated after stabilization. The case highlights the rapid, dose-dependent nature of oxcarbazepine-induced hyponatremia and the complexities introduced by patient self-management behaviors. IMPACT/DISCUSSION: Oxcarbazepine, a carbamazepine derivative, has fewer adverse effects overall but significantly predisposes patients to hyponatremia, primarily through SIADH, causing water retention, low serum osmolality, and concentrated urine. Hyponatremia usually develops within three months and worsens with higher doses. While Keppra rarely causes hyponatremia, it may potentiate it with oxcarbazepine. Diarrhea, dose escalation, and seizure disorder further complicated this case, highlighting the need for patient education on medication adjustments.

This case highlights the need to recognize oxcarbazepine-induced hyponatremia as a cause of breakthrough seizures, especially in patients on polytherapy. Clinicians should suspect hyponatremia in patients with fatigue, GI symptoms, or seizure recurrence and emphasize patient education on safe dosing and early medical consultation. Personalized antiepileptic strategies are crucial for those prone to electrolyte imbalances. HYPONATREMIA SECONDARY TO HORSETAIL TEA TOXICITY Neil M. Zalavadia1; Omar Yaghi2; Bennett Levy3; Adrienne Poon4. 1Internal Medicine, George Washington School of Medicine and Health Sciences, Washington, DC; 2Graduate Medical Education: Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 3George Washington School of Medicine and Health Sciences, Washington, DC; 4Internal Medicine, The George Washington University Hospital, Washington, DC. (Control ID #4250383) CASE: A man in his 50s with a past medical history of hypertension, diabetes, and chronic kidney disease presented to the Emergency Department with abdominal bloating and nausea. The patient reported consuming 2 cups of horsetail tea as a home remedy for hypertension and CKD. He stated that he was otherwise monitoring and limiting free water intake to less than 1L. On physical examination, his blood pressure was 165/97 mmHg, he was euvolemic with a distended, nontender abdomen. Initial laboratory studies included sodium (Na) level of 102 mEq/L was revealed. Other relevant findings included potassium (K) blood level of 4.0 mEq/L, random blood glucose level of 70 mg/dL, HCO3 was 22 mEq/L, Albumin was 3.4 g/dL, Creatinine was 6.1 mg/dL, and Blood Urea Nitrogen (BUN) was 84 mg/dL. Serum osmolarity was 243 mOsm/kg and urine studies were obtained. Urine Na – 21 mmol/L, urine urea – 253 mg/dL, urine osmolarity – 201 mOsm/kg. Following the lab findings and pertinent history, the patient was admitted, and a preliminary diagnosis of severe, asymptomatic, hypotonic, euvolemic hyponatremia secondary to horsetail tea toxicity was made. The patient was treated with diuresis, salt tabs and fluid restriction. Fluid restriction and diuresis with bumetanide was continued outpatient. IMPACT/DISCUSSION: The use of herbal remedies has been steadily growing in the western hemisphere, creating an industry that generates billions annually.(8,9,10) Thus, it is important to ask patients about any supplements they might be taking, as they can cause various side effects and drug-drug interactions. Equisetum, commonly known as horsetail, is a medicinal plant traditionally used as a diuretic, anti-inflammatory, and remineralization agent.(11-14) Its safety remains unapproved by health authorities globally, including the FDA, which lists it as an herb with undefined safety.(4-7,15,16) The diuretic effects of horsetail are attributed to its mineral, flavonoid, and phenolic compound content.(17) A randomized, double-blind, placebo-controlled trial found 900 mg/d of horsetail showed significant diuretic effects comparable to hydrochlorothiazide, with no notable kidney or electrolyte abnormalities.(15) However, unrestricted consumption, particularly as a tea has been linked to hyponatremia, often concomitant to syndrome of inappropriate anti-diuretic syndrome (SIADH). (6,7,16) Thus, it is important to keep a broad differential diagnosis when investigating hyponatremia as it could be secondary to heart, kidney or liver failure, SIADH, drug-induced, or multifactorial.

Although several benefits are seen with the use of horsetail tea, it is recognized that the level of evidence required for its continuous use is lacking. We hope that in future better studies can investigate the safety and efficacy of this potentially beneficial remedy. IMMUNE CHAOS: HLH IN HIV Diana M. Marmolejo, Jazmin Mexia Cabrales, Youssef Samaha, Franklin Liu. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273520) CASE: A 45-year-old man with a history of AIDS (CD4 count: 183, Viral load: 107) on antiretroviral therapy (ART), and treated gastrointestinal tract tuberculosis, presented with fever for 3 days, dry cough, and a mild headache. He also reported painful bilateral inguinal lymphadenopathy for 1 month. On exam, he was afebrile, but his BP was 85/42 with a heart rate of 131. He had bibasilar inspiratory crackles and bilateral tender inguinal lymphadenopathy (LAD). Initial labs were notable for hemoglobin of 10.6 g/dL (12.0-16.0 g/dL) and platelets of 72.000 10^3/mcL (150-450 10^3/mcL). CT of the abdomen and pelvis revealed LAD at the portal vein, small bowel mesentery, retroperitoneum, bilateral iliac chains, and the inguinal region, as well as hepatosplenomegaly. CT chest showed a spiculated soft tissue density in the right upper lobe, and mediastinal and axillary LAD. The patient received IV fluids and vasopressors, as well as vancomycin, cefepime, and atovaquone. He continued to have fevers and hypotension, and antibiotic coverage was broadened to meropenem and vancomycin. Extensive infectious workup was negative. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy. The biopsy revealed acute-on-chronic inflammation and no granulomas. BAL culture, AFB and Pneumocystis smear were negative. Ferritin level was 20,000 ng/mL (30-400 ng/mL). HLH work-up showed elevated sIL2 (CD25) receptor levels, as well as hypertriglyceridemia, and increased D-dimer. A bone marrow biopsy showed hemophagocytic cells, suspicious for hemophagocytic lymphohistiocytosis, and hyperplastic bone marrow with hyperplasia of erythroid and megakaryocytic cells, with no definitive evidence of myeloid neoplasm. The diagnosis of HLH was made, so the patient was started on steroids and etoposide and rapidly improved. IMPACT/DISCUSSION: HLH is a potentially fatal condition characterized by persistent immune system activation in response to viral infections, immune disorders, or malignancy, which can lead to severe multi-organ dysfunction. Diagnosis is based on the presence of at least 5 of 8 criteria. These include the most common clinical features, fever and splenomegaly (up to 80% of cases), and 6 laboratory findings. Most of the criteria (fever, splenomegaly, bi-cytopenias, hypertriglyceridemia, and hyperferritinemia) can be present in patients with advanced HIV with or without opportunistic infections and with or without ART. Thus, it is important to keep HLH on the differential diagnosis in HIV-positive patients with these findings.

HLH syndrome is an uncommon but life-threatening condition. Diagnosing HLH in patients with HIV is challenging and requires a high index of suspicion. IMMUNE CHECKPOINT INHIBITOR PNEUMONITIS FOR THE INTERNIST Jeffrey Wang. Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4270149) CASE: A 74-year-old male former smoker with lung cancer and COPD presented to the hospital with subacute dyspnea. 5 months ago, he was diagnosed with localized left lower lung adenocarcinoma. He received 3 cycles of neoadjuvant nivolumab, carboplatin, and paclitaxel followed by left lower lobectomy one month ago. At home, he had progressively worsening dyspnea with exertion over the last week, to the point where he could barely get out of bed. He did not have fevers, change in his chronic cough or sputum production, wheezing, chest pain, orthopnea, or leg edema. On exam, he was afebrile, hemodynamically stable, and hypoxic to 85% on 4 liters of oxygen, which was titrated up to 12L high flow nasal canula. He spoke in short sentences. On auscultation, there were bilateral crackles in the mid lung fields and decreased breath sounds at the left base. Labs revealed white blood cell count 17,000 (88% neutrophils) and C reactive protein 20 (normal <1 mg/dL). Respiratory viral panel was negative. Arterial blood gas showed mild respiratory alkalosis with a PaO2 74 on 60% FiO2. CT PE protocol was negative for pulmonary embolism but showed extensive ground glass opacities in both lungs. The patient was started on broad IV antibiotics and given IV diuretics. Despite this, his oxygen requirements and work of breathing worsened over the next 48 hours, requiring ICU admission. Given his exposure to immune checkpoint inhibitor therapy and presumed severe pneumonia, the patient was started on IV methylprednisolone 1mg/kg per day. Sputum and blood cultures from admission were negative, and antibiotics were discontinued after completing a 5-day course. He continued to require high flow oxygen for 7 more days, then was weaned to 4L. He was discharged to complete a 6-week taper of oral steroids for immune checkpoint inhibitor pneumonitis. IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICI) are increasingly used to treat solid cancers. Internists should recognize that these therapies predispose to immune toxicities that can affect any organ system. In a series of 915 patients treated with ICI therapy, the incidence of pneumonitis was 5%, of which 28% were severe (requiring hospitalization), with a 36% mortality rate. Median time from first ICI dose to pneumonitis diagnosis was 2.8 months but can happen at any point in time after receiving the medication. NCCN guidelines recommend patients who require oxygen to be treated with 1mg/kg/day IV methylprednisolone followed by oral prednisone taper. Internists should have a low threshold to start empiric steroids in patients with respiratory failure from severe pneumonia or pneumonitis. CAPECOD showed mortality benefit for hydrocortisone in severe CAP, whereas another trial in patients with CRP >15mg/dL showed that IV methylprednisolone decreased treatment failure (but not mortality).

Internists should recognize immune effects of ICI therapy In cancer patients with respiratory failure, steroids treat pneumonitis and pneumonia IMMUNE CHECKPOINT INHIBITORS CAUSING RENAL TUBULAR ACIDOSIS Fathima Alam1; Roshmita Bardhan2. 1Internal Medicine, Bon Secours Mercy Health, Cincinnati, OH; 2Internal Medicine, Mercy Health, Cincinnati, OH. (Control ID #4273354) CASE: A 75-year-old female with a medical history of metastatic renal cell carcinoma status post nephrectomy, treated with nivolumab and cabozantinib chemotherapy, presented to the hospital with lethargy. The patient had an incidental finding of a right renal mass on CT imaging in 2016. Subsequently, she underwent total right nephrectomy due to concern for renal cell carcinoma. Lost to follow-up, she established care with a primary care provider years later. During a visit for lower quadrant abdominal pain, a large abdominal mass was noted on physical examination, prompting a CT scan that revealed retroperitoneal and pelvic tumor implants, along with multiple basilar pulmonary metastases. A CT-guided liver biopsy confirmed metastatic carcinoma consistent with renal cell carcinoma, stage IV, for which palliative therapy with nivolumab and cabozantinib was initiated 11 months prior to hospitalization. Upon arrival at the ED, laboratory findings included Na 134, K 3.0, Cl 103, bicarbonate 18, BUN 30, and creatinine 1.3. Further investigation revealed urine chloride 41, urine creatinine 99.6, microalbumin/creatinine ratio 111, urine osmolality 580, urine potassium 62.0, urine sodium 71, and urine nitrogen 807. Despite potassium replacement therapy, the patient experienced refractory hypokalemia. Nephrology consultation led to initiation of low-dose Aldactone with oral and IV potassium supplementation. Prednisone 30 mg daily with a two-week taper was also started. The findings of hypokalemia, normal anion gap, positive urine anion gap, and high urine pH are most consistent with renal tubular acidosis type I in the context of immune checkpoint inhibitor therapy. IMPACT/DISCUSSION: Kidney-related injuries associated with immune checkpoint therapy are extremely rare. When present, acute tubulointerstitial nephritis is the most common pathology reported. However, in this case, distal renal tubular acidosis occurred in the context of immune checkpoint inhibitor therapy. It is crucial to consider renal tubular acidosis in patients receiving these chemotherapy agents to avoid overlooking appropriate evaluation and treatment. Increasing numbers of cases highlight the occurrence of distal RTA with these agents, though the exact mechanism remains unclear.

This case underscores the emerging complexity of renal complications associated with immune checkpoint inhibitors, exemplified by the development of renal tubular acidosis type I in a patient with metastatic renal cell carcinoma. While immune-related adverse events predominantly involve acute tubulointerstitial nephritis, our findings highlight a less recognized manifestation—distal renal tubular acidosis—potentially induced by these therapies. Clinicians should maintain a high index of suspicion for renal tubular acidosis in patients undergoing immune checkpoint inhibitor treatment, particularly when encountering refractory electrolyte disturbances. IMMUNOFLUORESCENT FAKE OUT: WHEN COXSACKIEVIRUS PUTS ON A LIGHT SHOW Kathryn R. Sharma1; Elbert B. Chun2. 1Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2Hospital Medicine, Emory University Hospital, Atlanta, GA. (Control ID #4273398) CASE: Ms. K is a 46-year-old woman who presented with two days of recurrent pleuritic chest pain and shortness of breath. She previously presented twice within one month to an outside hospital for a similar complaint and was found to have a pericardial effusion requiring a pericardial window and pleural effusions requiring a thoracentesis. During the pericardial window, fibrinous material on the epicardium consistent with pericarditis was observed. Pleural fluid studies revealed an antinuclear antibody (ANA) 1:1280 with a nuclear speckled pattern and the patient was presumed to have a new diagnosis of systemic lupus erythematous (SLE). The patient had a remote history of ovarian hyperstimulation syndrome and recent history of an acute upper respiratory illness prior to her first hospitalization. The patient also complained of persistent abdominal pain and distension; a computed tomography (CT) scan of the abdomen and pelvis which revealed an ovarian cyst, which was confirmed via transvaginal ultrasound. Laboratory evaluation revealed serum ANA 1:320, normal complements and dsDNA. Additional labs, including hepatitis and viral panels, were drawn. Her symptoms began to improve with non-steroidal anti-inflammatory medication. After discharge, laboratory evaluation revealed high titers for both coxsackie B3 (>1:640) and B5 (1:160) viruses and it is presumed that pericarditis and serositis were triggered by a self-limited viral infection. IMPACT/DISCUSSION: The ACR criteria for classification of SLE requires an ANA titer of ≥1:80. Criteria from 7 clinical and 3 immunologic domains are weighted and added together to give a total score. A patient must have at least one clinical criterion and a total score of greater than or equal to ten to classify SLE. While the serum ANA was 1:320 and there were clinical findings of pericarditis, the total score was 6, which did not meet the ACR criteria for SLE. The ANA is an important tool for detection of rheumatic diseases, including SLE. However, physicians should recognize that an ANA may also be positive due to non- rheumatic causes: up to 90% of positive ANAs are non-rheumatic. The list of non-rheumatic causes includes other autoimmune diseases (such as disease of the thyroid and liver), malignancy and, in our case, infections. Infections known to cause a positive ANA include Epstein-Barr virus, HIV, hepatitis B and C, and parvovirus B19. One mechanism for which viruses can induce production of autoantibodies is by causing cell lysis in which cytoplasmic autoantigens are released and then presented to T and B cells by macrophages.

This case reminds us that while it is enticing to consider SLE when an ANA is positive, there are many other etiologies which contribute to inflammation and the presence of antinuclear antibodies. A thorough history will help to broaden our differential to consider other causes of the patient’s presentation, including more common causes such as a viral infection, which could alter the treatment plan markedly. INCIDENTAL BONE LESION IN A CASE OF SUSPECTED EOSINOPHILIC FASCIITIS: A DIAGNOSTIC CHALLENGE Ginu Kurian, Ayush Kaushish, Pete Meliagros. Internal Medicine, Virginia Commonwealth University Department of Internal Medicine, Richmond, VA. (Control ID #4272396) CASE: A 45-year-old man with alcohol use disorder presented with 10 weeks of progressive swelling in the left lower extremity following a mechanical fall. He denied fever, trauma, or systemic symptoms. He had no significant family history or medication use. On examination, the left lower extremity exhibited woody induration from the knee to the ankle, with mild erythema and warmth. He had reduced active and passive range of motion due to swelling and mild discomfort. No other systemic findings were noted. Lab studies revealed elevated alkaline phosphatase (143), CRP (4.6), ESR (89), and decreased transferrin saturation (12%). MRI showed a predominantly T1 hypointense lesion with hyperintense foci and diffuse T2 STIR hyperintensity in the proximal left femur. Mild edema was noted in the posterior lateral muscles of the left thigh and soft tissue edema in the lower extremity. While eosinophilic fasciitis was suspected, imaging raised concerns for malignancy, osteomyelitis, or localized scleroderma. A skin biopsy to confirm the inflammatory process was deferred in favor of further investigation of the femoral lesion, and no steroids were administered. Although the initial workup focused on the left lower extremity swelling, the incidental bone lesion shifted the focus of the workup to include primary bone malignancy, metastatic disease, and localized scleroderma. A subsequent bone biopsy showed bone marrow fibrosis without evidence of a hematolymphoid neoplasm. Follow-up with dermatology is pending for an outpatient biopsy of the soft tissue in the lower extremity. IMPACT/DISCUSSION: This case highlights the diagnostic challenges of eosinophilic fasciitis, particularly when incidental findings, such as a bone lesion, redirect the clinical focus to alternative diagnoses. The discovery shifted the evaluation and treatment from a presumed inflammatory condition to concerns about malignancy or osteomyelitis, emphasizing the importance of maintaining a broad differential. The decision to withhold steroids until malignancy or infection was excluded underscores the need for caution when considering immunosuppressive therapy without definitive evidence. Key insights from this case include the critical role of imaging and pathology in guiding diagnostic decisions, the importance of delaying empiric therapy when differential diagnoses remain unexcluded, and the utility of biopsy in differentiating reactive from malignant processes. This case reinforces the value of thorough evaluations when initial impressions are challenged by new findings, ensuring patient safety and avoiding premature treatment. It highlights the diagnostic uncertainty posed by incidental findings and the need for a methodical, evidence-based approach to care.

Incidental imaging findings can significantly alter clinical priorities, necessitating a broad and methodical diagnostic approach. Caution is critical when initiating immunosuppressive therapy without excluding key alternative diagnoses. INFECTIOUS DISEASE CONSULT- MYSTERY DIAGNOSIS Rida Farook1; Nicholas Yared2. 1Medical School, Wayne State University School of Medicine, Detroit, MI; 2Henry Ford Health System, Detroit, MI. (Control ID #4271628) CASE: A 57 year old male with alcoholic cirrhosis and psoriasis presented with 3 weeks of erythematous, tender, purple plaques on bilateral upper and lower extremities. He was intubated and sedated due to respiratory distress. The patient's wife shared that the patient had experienced a 14-pound weight loss and had a nonproductive cough over the past 3 months. She said he had no recent sick contacts, fevers or chills, but did endorse travel to the Upper Peninsula of Michigan a few weeks prior to symptoms. On presentation, the patient was afebrile, tachycardic, normotensive, and intubated on mechanical ventilation with an FiO2 of 100% and PEEP of 18. Physical exam revealed coarse breath sounds in bilateral lower lung fields and purple crusted plaques on bilateral upper and lower extremities with no drainage, warmth, or edema. Due to the patient's medical history, recent travel, and current symptoms, our differential included fungal pneumonia, tuberculosis, invasive aspergillosis, histoplasmosis, blastomycosis, vasculitis, and noninfectious lung disease. Labs showed leukocytosis (11.4 x 109 cells/L) but were negative for urinalysis, blood and respiratory cultures, immunoglobulins, C3, C4, ANA, ANCA, anti-GBM, hepatitis screening, HIV, RPR, Cryptococcal antigen, and Fungitell test. Chest x-ray showed diffuse parenchymal airspace abnormalities and CT chest revealed ground-glass heterogeneity throughout the lungs. A high suspicion for disseminated blastomycosis was maintained due to the patient's immunocompromised state, geographic exposure, pulmonary findings, and characteristic skin lesions. Infectious Disease was consulted and IV amphotericin B was started. Unfortunately, the patient coded and died 2 days after starting treatment. Urine antigen and skin biopsy later confirmed Blastomyces dermatitidis. IMPACT/DISCUSSION: Our case highlights the importance of a detailed social history, specifically regarding microbial exposure from travel. This case reinforces the significance of considering disseminated fungal infection in immunocompromised patients. Finally, it depicts the limitation of relying on Fungitell, which has low sensitivity for the yeast form of Blastomyces, particularly in ICU patients. Fungitell's sensitivity can range from 27% to 100% depending on the assay used, positive cutoff criteria, and patient population. When blastomycosis is suspected, alternative diagnostics including urine antigen testing, skin biopsy histopathology, and/or KOH stain and fungal culture from respiratory samples should be considered.

This case underlines the importance of obtaining a comprehensive social history, maintaining suspicion for disseminated fungal infection in immunocompromised patients with respiratory illness, and studying the sensitivity of diagnostic tests. INFECTIVE ENDOCARDITIS COMPLICATED BY MEDIASTINAL ABSCESS Zahra Ukani1; Ashley Wong2; Aditya Maddali1; Danielle V. Lefebvre3. 1Internal Medicine, The George Washington University Hospital, Washington, DC; 2Internal Medicine, The George Washington University Department of Medicine, Washington, DC; 3Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4273419) CASE: A 33-year-old woman with a medical history of substance use disorder and chronic hepatitis C presented with malaise, hematemesis, and shortness of breath found to have severe sepsis. Chest x-ray revealed opacification of the left hemithorax with leftward shift. A chest CT revealed a large pericardial effusion, small bilateral pleural effusions, and bilateral consolidations. A transthoracic echocardiogram (TTE) showed a severe pericardial effusion with a large 0.6 cm x 1.6 cm mobile mass vegetation on the tricuspid valve. She was started on broad spectrum antibiotics and admitted to medicine for management of infective endocarditis with septic emboli to the lungs. Blood cultures were positive for methicillin sensitive staph aureus. Pericardiocentesis was performed with negative fluid cultures. Antibiotics were subsequently narrowed to Cefazolin IV. Cardiothoracic surgery (CTS) was engaged to evaluate the patient's candidacy for surgery. With antibiotic therapy, repeat blood cultures were negative. She underwent thrombectomy of the tricuspid valve vegetation with plans to complete a six week course of IV antibiotics outpatient. She returned two weeks later with worsening respiratory symptoms, admitting to missing antibiotic doses, and found to have an 8 mm mycotic aneurysm at the subsegmental right lower lobe pulmonary artery and persistent septic emboli. She was restarted on broad spectrum antibiotics, but unfortunately, left against medical advice. A week later, she re-presented with worsening shortness of breath, fever, and cough. CT revealed multiloculated cavitary lesions and a new mediastinal pleural abscess (6.2 x 3.9 by 8.7 cm). Blood cultures remained negative. CTS was re-engaged, without indication for surgical intervention or sampling. She completed a week and a half of IV Linezolid and Cefepime with improvement in the abscess on imaging (3.5 x 4.5 x 3.9 cm) and discharged with plans to complete three additional weeks of oral antibiotics. On discharge, she was referred to a local methadone clinic and an addiction specialist. IMPACT/DISCUSSION: We present a case of uncommon complications of infective endocarditis associated with high morbidity and mortality, including mycotic aneurysm and mediastinal pleural abscess. These complications specifically with our patient were possibly due to lapses in treatment in the setting of nonadherence to antibiotics and leaving against medical advice. Recognizing patient’s barriers to completing medical care including active opioid withdrawal may influence the success of standardized treatment. We hope this case highlights the importance of organizing treatment plans with these considerations in mind.

Mediastinal abscess is a rare and life threatening complication of infective endocarditis. INFLAMED INSIDE AND OUT: THE CUTANEOUS MANIFESTATIONS OF CROHN'S DISEASE Amol N. Baryah1; Asuwin Anandaram1; Wali M. Kamran2; Rachel Patel2; Tinsa Varughese2; Alaynna Kears1. 1Internal medicine, Lehigh Valley Health Network, Allentown, PA; 2Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4272275) CASE: A 36-year-old male with a history of Crohn's disease presented with a sore throat, decreased appetite, and lip lesions. CT imaging showed asymmetric thickening of the left aryepiglottic fold. ENT suspected Candida infection and initiated fluconazole. However, genital lesions raised concern for Behçet’s disease. Although CRP was elevated at 191 mg/L, a thorough infectious workup, including tests for HIV, hepatitis, syphilis, gonorrhea, and herpes, was negative. Infectious disease recommended discontinuing all antimicrobials and referred the patient to rheumatology. Negative pathergy and HLA-B51 tests ruled out Behçet’s disease. Dermatology biopsied the genital lesions, identifying an inflammatory rather than infectious cause. Gastroenterology was consulted and restarted infliximab therapy (first initiated in 2010). His hospital course was complicated by a small bowel obstruction. MRE revealed terminal ileitis with a stricture and proximal ileal loop involvement, suggesting residual inflammation. GI started prednisone 40 mg with a taper. Two weeks later, the patient tolerated a regular diet, passed flatus, and showed significant improvement in skin lesions. IMPACT/DISCUSSION: Extraintestinal manifestations (EIM) of Crohn's disease are commonly seen in about 25-40% of cases, which can involve the musculoskeletal system, eyes, lungs and the skin. They can present prior to any of the gastrointestinal manifestations and are, at times, not responsive to treatments curated for inflammatory bowel disease. Here, we highlighted a rare case of cutaneous manifestations of Crohn's disease presenting as oral and genital ulcers. This case underscores the challenge of distinguishing cutaneous manifestations of Crohn's disease compared to those from infectious etiologies. EIM of Crohn's disease occur in 25–40% of patients, and developing one EIM increases the risk of subsequent EIMs. This significantly influences decisions about continuing treatments for Crohn’s disease during hospitalization. Early involvement of gastroenterology and rheumatology is crucial for better outcomes, along with regular follow-ups, including timely colonoscopies. Monitoring initial biologic antibodies in the outpatient setting is vital, as elevated levels may indicate treatment failure and contribute to Crohn's flares or EIMs. Switching to other biologics should be considered in these cases.

Understanding the complexity of managing extraintestinal manifestations of Crohn's disease Early multidisciplinary involvement for accurate diagnosis and effective management Regular follow-ups with timely adjustments to biologic therapies which can optimize outcomes and prevent treatment failures Individualized care and proactive management in patients with Crohn's disease and EIMs INFLAMMATION, OR SOMETHING MORE? A CASE OF SEVERE LEUKOCYTOSIS IN A PATIENT WITH ALCOHOLIC HEPATITIS Paola Zinser Peniche, Megan E. Cavrak, Tanya Nikiforova. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4272748) CASE: A 28-year-old man with a history of alcohol use disorder, hypertension, and major depressive disorder presented to the ED with worsening leukocytosis. He was recently hospitalized for severe alcoholic hepatitis complicated by multifocal pneumonia and pulmonary embolism. At that time, his WBC of 30-40K cells/uL was attributed to inflammation from alcoholic hepatitis and infection. One week after discharge, he presented with a WBC of 52.9K (ANC 47,600), which peaked at 56.8K. The patient reported fatigue and night sweats for the past month, but no fevers. Exam revealed normal vital signs, scleral icterus, jaundice, and peripheral edema, but no signs of infection. Direct bilirubin was 13.2 mg/dL. A CT chest/abdomen/pelvis revealed hepatomegaly, splenic infarcts but no lymphadenopathy. As alcoholic hepatitis does not typically present with leukocytosis over 50,000, hematology was consulted to assist with work up for malignancy. Peripheral smear showed increased bands without blasts, flow cytometry was unremarkable, and FISH for BCR-ABL was negative. Peripheral blood myeloid NGS panel was normal. Over the following weeks, bilirubinemia and leukocytosis both slowly improved. He was discharged with a presumed diagnosis of a leukemoid reaction secondary to alcoholic hepatitis. IMPACT/DISCUSSION: Severe leukocytosis is commonly defined as a WBC over 40,000 cells/uL, and may result from a hematologic malignancy or a leukemoid reaction (LR). A thorough history, physical exam, and targeted tests are essential for evaluation. In cases of neutrophilic leukocytosis, the differential for malignancy primarily includes chronic myelogenous leukemia (CML) and chronic neutrophilic leukemia (CNL). Diagnostic workup should include a white blood cell differential, peripheral smear, and a combination of bone marrow studies, cytogenetic testing, and immunophenotyping. Clonality studies can help distinguish CNL from LR. LR is a diagnosis of exclusion, defined as a transient WBC elevation >50,000 cells/μL with neutrophil predominance. Major causes of LR include severe infections (e.g., tuberculosis, C. difficile, pertussis, larva migrans), intoxications/medications, and nonhematologic malignancies. Leukemoid reactions improve with resolution of the underlying cause, such as infection or inflammation. Patients with severe leukocytosis should be monitored for leukostasis, which can cause headaches, visual disturbances, or neurological symptoms and can be life-threatening.

In patients with severe leukocytosis, leukemoid reactions should be differentiated from hematologic malignancies. Alcoholic hepatitis is not a common cause of leukemoid reactions, however, this case documents this association and highlights the importance of a comprehensive evaluation to ensure accurate diagnosis. INFLAMMATORY SACROILIITIS AS AN IMMUNE-RELATED ADVERSE EVENT TO NIVOLUMAB IN A PATIENT WITH HLA-B27 POSITIVITY Hakeem Asad1; Selene Rubino2; Omar Asad4; Aarif Motorwala3; Can Sungur2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Rheumatology, Mayo Clinic Minnesota, Rochester, MN; 3AdventHealth Orlando, Orlando, FL; 4Internal Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4241494) CASE: A 32-year-old male with a history of reactive arthritis (HLA-B27 positive) and stage IV Hodgkin’s lymphoma presented with debilitating right sacroiliac (SI) pain two months after initiating nivolumab in combination with AVD chemotherapy. He was unable to take NSAIDs due to interaction with Eliquis for acute DVT. His pain did not improve with low-dose prednisone. On admission, he was afebrile with a normal heart rate and WBC count. ESR was 73 mm/hour and CRP was 121 mg/L. Imaging revealed sacroiliac periarticular bone marrow edema, synovitis, and capsulitis. A CT-guided SI joint fine needle aspiration was performed. With no growth of organisms after 48 hours, a glucocorticoid SI injection was administered. Two hours later, pathology reported concern for osteomyelitis, however pathology, rheumatology, and infectious disease teams determined that the same features could be found in inflammatory arthritis. The patient’s negative blood/synovial cultures and Karius testing further reduced suspicion for a true infection. He was discharged on a prednisone taper with close follow-up. Unfortunately, the patient could not taper below 20 mg prednisone daily without recurrence of joint pain. Nivolumab was discontinued and etanercept was initiated, resulting in partial improvement. Repeat MRI findings showed improved inflammation in the right SI joint but revealed new, asymptomatic involvement of the left SI joint. Given the suboptimal response and persistent steroid dependence, etanercept was replaced with tofacitinib for escalation of therapy. IMPACT/DISCUSSION: This case highlights inflammatory sacroiliitis as an irAE associated with ICIs. With the growing use of ICIs in oncology, clinicians must remain vigilant for irAEs, particularly in patients with risk factors such as HLA-B27 positivity or history of reactive arthritis. Managing ICI-related sacroiliitis is challenging, as treatments like TNF-α and JAK inhibitors increase immunosuppression in cancer patients. Bass et al. (ARD 2023) demonstrated that TNF/IL-6 inhibitors achieve faster arthritis control but are associated with shorter time to cancer progression compared to methotrexate, underscoring the need to balance immune suppression with oncologic outcomes. Future research should explore whether routine screening for HLA-B27 or a history of reactive arthritis should be implemented, whether PD-1 inhibitors pose higher risks than CTLA-4 inhibitors, and what immunosuppressive regimens can best preserve functional status without compromising cancer therapy.

- ICIs, such as nivolumab, can induce severe immune-related sacroiliitis, especially in HLA-B27 positive patients or those with a history of reactive arthritis. - Screening strategies for high-risk patients remain undefined, requiring clinicians to balance the risk of irAEs with the benefits of cancer therapy. - Management of ICI sacroiliitis often requires TNF-α or JAK inhibitors, which carry significant risks of immunosuppression in cancer patients. INTENSE REACTION TO A COMMON MEDICATION: A CASE OF CEFEPIME INDUCED TOXIC EPIDERMAL NECROLYSIS Matthew McAuliffe1; Humberto Urrutia1; Grace Shin1; Avery Roland1; Anna Cichon3; Julia Fischer1; Antony Awad2; Thomas Higgins2. 1Internal Medicine, Baystate Medical Center, Springfield, MA; 2Critical Care, Baystate Medical Center, Springfield, MA; 3University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4269323) CASE: A 55-year-old Caucasian female with a past medical history of hypertension, end-stage-renal-disease on dialysis, breast cancer status post lumpectomy, and anxiety was admitted for concern for infection of a recently placed AV fistula graft. She was originally treated with Vancomycin. Cefepime was added for pseudomonal coverage. Shortly after receiving Cefepime, she experienced urticaria and shortness of breath. She was treated with steroids and epinephrine for possible anaphylactic reaction to Cefepime. She had recieved one dose of this antibiotic during a previous hospitalization with smiliar, yet not as bothersome side effects. Cefepime was promptly discontinued. Symptoms improved slightly after treatment. Within 24 hours of Cefepime dosing, the patient developed a bullous rash on her right proximal arm. The rash also spread to the lower extremities, abdomen and back. There was extensive mucosal involvement, primarily on the tongue as well as bilateral eyelids. The diffuse spread of macular and bullous lesions and mucosal involvement occupied approximately 70% of body surface area. The patient remained hemodynamically stable. Blood, urine, and respiratory bacterial and fungal cultures were negative. The patient was evaluated for transfer to a burn center for treatment of TEN. IMPACT/DISCUSSION: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of life-threatening adverse reactions characterized by epidermal detachment due to keratinocyte death. SJS is characterized by less than 10% of body surface area. TEN is characterized by more than 30% body surface area involvement. Common triggers of SJS/TEN include sulfonamide antibiotics, anticonvulsants, allopurinol, and NSAIDs, however rarely cephalosporins. The underlying mechanism of epidermal damage is a drug-induced immunologic reaction mediated by CD8+ cytotoxic lymphocytes and natural killer (NK) cells. Cytotoxic proteins, particularly granulysin are key mediators of keratinocyte apoptosis. In the acute phase of TEN, impairment of T-regulatory cells contributes to the extent of epidermal detachment. The management of TEN includes wound and ocular care in a burn unit. The role of systemic glucocorticoids is limited to the early stages of the disease. IVIG, plasmapheresis, and cyclosporine have been used in the acute treatment, however efficacy is inconsistent. Studies have shown that Infliximab and Etanercept, a monoclonal antibody and soluble fusion protein for TNF-a, respectively, could improve mortality in TEN.

Cefepime is a rarely documented cause of TEN. Early recognition and cessation of the causative agent are imperative in treatment of TEN. INTERSTITIAL LUNG DISEASE (ILD): SARCOIDOSIS WITH POSITIVE AUTOANTIBODIES OR AN ATYPICAL PRESENTATION OF RHEUMATOID ARTHRITIS (RA)? Abdelrahman Gadallah, Binita Ghosh, Samrat Jayanth. Internal Medicine, SSM Health St Mary's Hospital St Louis, St. Louis, MO. (Control ID #4273110) CASE: A 63-year-old African American non-smoker male with history of hyperlipidemia, and hypertension came to the hospital with worsening shortness of breath, and productive cough for a month, and was found to be hypoxic. He had a significant history of occupational dust exposure. His family history is significant for hypertension, pancreatic cancer, and heart disease. His labs showed mild metabolic alkalosis, mildly elevated BNP, leukocytosis, and AKI. CT chest showed bilateral ground glass opacities with increased interstitial infiltrates, mild subpleural bullae consistent with interstitial pulmonary fibrosis in usual interstitial pneumonia (UIP) pattern, hilar and mediastinal lymphadenopathy. Infectious work-up was negative. During hospitalization, an extensive work-up was performed to identify the cause of pulmonary fibrosis. He was found to be positive for rheumatoid factor (43), and high positive Anti-CCP (>250) raising suspicion for rheumatoid arthritis- associated ILD. Also, the Anti PL- 12 antibody was positive which is associated with anti-synthetase syndrome. However, he did not have any clinically evident arthritis, dermatomyositis, or polymyositis. He was tested negative for C-ANCA, p-ANCA, and myositis panel with normal C3 and C4. He was discharged on home oxygen, mycophenolate, and prednisone taper. He followed up with pulmonology and rheumatology. On outpatient follow-up, he had undergone pulmonary function test showing a restrictive pattern of pulmonary disease with decreased diffusion capacity. Bronchoscopy with mediastinal lymph nodes biopsy was done showing non-caseating granulomas which favored the diagnosis of pulmonary sarcoidosis. IMPACT/DISCUSSION: ILD by itself could be the first presentation of an underlying autoimmune disease like RA or anti-synthetase syndrome preceding joint involvement by several months. However, having elevated autoantibodies itself cannot diagnose the condition without clinical and pathological correlation. Nevertheless, monitoring the disease progression and treatment response is crucial to reconsider the underlying etiology in case of treatment failure, especially if new symptoms appear like arthritis, dermatomyositis, or myositis.

Our case is unique due to its presentation as ILD with positive autoimmune antibodies. It highlights the importance of maintaining a broad clinical differential for ILD and performing a targeted, timely workup to identify and address the underlying cause as well as continued follow up for disease progression. INTRACTABLE DIARRHEA AND ABDOMINAL PAIN IN A RENAL TRANSPLANT PATIENT – A CASE REPORT Valerie Stark1; Alex Fukunaga3; Amanda Pareira3; Ashley Wong2; zarah haleem4; Sami Droubi4. 1Internal Medicine, The George Washington University, Washington, DC; 2Internal Medicine, The George Washington University Department of Medicine, Washington, DC; 3The George Washington University Department of Medicine, Washington, DC; 4Nephrology, The George Washington University Department of Medicine, Washington, DC. (Control ID #4248080) CASE: A 41-year-old Ethiopian male with ESRD, received a kidney transplant at age 14 and another at age 38 maintained on prednisone, tacrolimus, and mycophenolate (MMF). After biopsy revealed interstitial fibrosis and tubular atrophy (IFTA); tacrolimus was switched to sirolimus. He was admitted one month later for diarrhea and abdominal pain due to high sirolimus levels, improved with dose adjustment, but returned with intractable abdominal pain, blood-tinged diarrhea, and 25-pound weight loss two weeks later. CT scan revealed pancolitis, and both MMF and sirolimus were held. Colonoscopy noted multiple cratered ulcers with edema, erythema, and friable mucosa throughout from colon to anus. Biopsy revealed patchy crypt atrophy and ulceration suggestive of MMF-induced colitis. Symptoms resolved after discontinuing MMF and sirolimus. He was transitioned to dual therapy with decreased tacrolimus dose given IFTA, azathioprine, and low-dose prednisone. IMPACT/DISCUSSION: MMF is widely used in transplant patients to prevent organ rejection but has been associated with gastrointestinal side effects, including rare cases of colitis.1 MMF inhibits inosine monophosphate dehydrogenase, impairing lymphocyte proliferation, affecting rapidly dividing intestinal epithelial cells, and leading to mucosal damage and inflammation.2,3 While about 40% of kidney transplant patients on MMF experience self-resolving diarrhea after starting the medication, MMF-induced colitis is a rare diagnosis of exclusion, requiring stool studies, imaging, endoscopic evaluation with biopsy and symptom improvement with medication discontinuation.4,5 Clinicians should suspect MMF-induced colitis in patients with gastrointestinal symptoms, particularly after initiating or increasing MMF dosage. Differential diagnoses include infectious colitis, inflammatory bowel disease, and ischemic colitis.6 Given the patient's travel history, broad opportunistic infectious work up including gastrointestinal tuberculosis, Cytomegalovirus, and Epstein-Barr virus was obtained. Histological findings of immunosuppressant-induced colitis include crypt apoptosis or architectural distortion7 but cannot differentiate between colitis caused by MMF versus sirolimus. In this case, both MMF and sirolimus were discontinued and switched back to tacrolimus, despite IFTA, when the patient developed colitis. This highlights the delicate balance of limited immunosuppressive options to maintain graft function while minimizing side effects.

- MMF-induced colitis should be suspected in patients with gastrointestinal symptoms, particularly after initiating or increasing MMF dosage, and should prompt endoscopic evaluation with pathologic confirmation. - Managing colitis in transplant patients requires careful consideration of alternative immunosuppressive regimens. This case emphasizes the complexity of transplant management, underscoring the importance of personalized treatment and ongoing research to expand therapeutic options. INTRAVASCULAR LARGE B CELL LYMPHOMA (IVLBCL) PRESENTING WITH CAUDA EQUINA SYNDROME: A DIFFICULT AND FORGOTTEN DIAGNOSIS Jessica Kline, Anastacia Bankey, Kunal Patel. Internal Medicine, Emory University, Atlanta, GA. (Control ID #4234765) CASE: A 59-year-old man with past medical history of possible myelofibrosis presented with 2 weeks of fevers, perianal paresthesia, and bilateral lower extremity weakness. Spinal MRI showed enhancement of the cauda equina nerve roots; physical exam was consistent with cauda equina syndrome. Over 1 month, the patient had extensive work-up for etiology, including specialty consults. Vitals were notable for a max temperature of 100.9, and he had elevated lactate dehydrogenase (LDH), elevated interleukin-2 (IL2), and thrombocytopenia. Paraneoplastic syndrome remained high on the differential; an exophytic renal mass was noted on imaging, and biopsy revealed benign renal parenchyma. PET-CT whole body findings were nonspecific, without another high-risk biopsy target. Bone marrow biopsy, peripheral blood, and CSF flow cytometry found no abnormal hematolymphoid populations. Elevated serum and CSF ACE suggested neurosarcoidosis though there was no evidence of granulomatous disease. The patient was discharged to subacute rehab on high-dose steroids and methotrexate for presumed neurosarcoidosis, with transient improvement in symptoms. He presented 1 week later with hypoxemia. We reengaged consultations and Dermatology due to nonspecific red, dome-shaped papules on the abdomen. They performed random skin biopsies to evaluate for intravascular large B cell lymphoma (IVLBCL); tissue exam was consistent with this diagnosis. While the patient was intended to start treatment the next day, his condition deteriorated and he was transferred to the ICU, where he passed away 2 days later. IMPACT/DISCUSSION: IVLBCL is a subtype of lymphoma that presents without usual findings of lymphadenopathy, regions of PET uptake, or flow cytometry with abnormal hematolymphoid cell populations. IVLBCL has been described as a “chameleon” for its ability to masquerade as other syndromes, delaying diagnosis. Our patient’s presentation—most notable for cauda-equina syndrome thought to be secondary to neurosarcoidosis due to elevated serum and CSF ACE levels despite no granulomatous disease noted on pathology—demonstrates this, particularly in the context of an otherwise negative, thorough workup including imaging, serology, renal mass and bone marrow biopsy, and CSF sampling.

This case of IVLBCL demonstrates the possibility of elevated serum and CSF ACE levels due to the disease process and supports clinical use of random skin biopsy with criteria proposed by Matsue et al (2011). INVASIVE HEMOPHILUS INFLUENZAE CAUSING SEPTIC ARTHRITIS IN A YOUNG FEMALE: A CASE REPORT Kendymill Taveras, Adam Treitman. Internal Medicine , Advocate Christ Medical Center, Orland Park, IL. (Control ID #4272393) CASE: A 26-year-old female with a medical history of hypertension presented with six days of left-sided lower back pain. The pain had begun abruptly and progressively worsened, significantly limiting her mobility. She initially sought care at an outside hospital, where she was discharged with a presumptive diagnosis of a "disk issue." Over the following days, the pain intensified and was associated with fevers, chills, and decreased oral intake. The patient also reported right ankle pain and swelling, which she attributed to prior ankle surgery. On arrival at the emergency department, the patient was febrile and tachycardic. MRI of the pelvis revealed findings consistent with septic arthritis of the sacroiliac joint and an intramuscular abscess within the iliacus muscle measured up to 4.4 cm. Blood cultures grew nontypeable H. influenzae. The patient was started on IV Ceftriaxone and underwent abscess drainage. She was discharged with a pigtail catheter and a PICC line to complete four weeks of antibiotics. IMPACT/DISCUSSION: Hemophilus influenzae is an anaerobic, gram-negative coccobacillus that colonizes the upper respiratory tract. There are nontypeable strains of H. influenzae that can cause invasive diseases such as meningitis, bacteremia, septic arthritis, endocarditis, and osteomyelitis. Invasive H. influenzae infections commonly arise from local spread within the nasopharynx, as seen in sinusitis, otitis media, conjunctivitis, and pneumonia. These infections primarily affect the very young, the elderly, and immunocompromised individuals. Despite the availability of a vaccine that protects against H. influenzae serotype b, there is no current vaccine for nontypeable strains [1]. Between 2009 and 2015, the highest incidence of nontypeable H. influenzae infections was observed in patients under one year of age and over 65 years old [2]. This case is notable because the patient does not fit the typical age distribution for invasive H. influenzae. Despite being a healthy 26-year-old with no significant immunodeficiencies, malignancy, HIV, or structural lung disease, she developed septic arthritis. The exact source of this infection remains unknown. She reported no preceding symptoms of respiratory infection and her immunization records confirmed she had received the full series of H. influenzae type b vaccines during infancy. It is hypothesized that she may have carried a nontypeable strain in her nasopharynx [3] or may have colonized it in the genital tract [4]. Lastly, perhabs this could have been a skin and soft tissue infection of the right ankle that lead to bacteremia [5]. This case underscores the need for further investigation into the pathogenic mechanisms of nontypeable H. influenzae, particularly in healthy individuals outside the typical age distribution.

In conculusion, invasive H. influenzae infection has been categorized in the immunocompromised and patients of bimodal age distribution but not occasionaly in a healthy 26 year-old-patient. IS 10 DAYS ENOUGH? A CASE OF STREPTOCOCCUS ANGINOSUS LUNG MASS Sathish Krishnan, Faizan Shaikh. Pulmonary and Critical Care, Community Health Network Inc, Indianapolis, IN. (Control ID #4271670) CASE: A 60-year-old female presented to the Emergency Department (ED) with a 7-day history of progressively worsening dyspnea and cough. She reported chest congestion but denied sputum production, fever, or night sweats. The patient had a significant smoking history of 45 pack-years and a past medical history of COPD (Chronic Obstructive Pulmonary Disease) and breast cancer. A chest X-ray revealed a right hilar mass, prompting a follow-up CT scan, which showed a 5 cm × 4.5 cm mass in the right hilum and an 8 mm × 7 mm nodule in the right upper lobe (RUL). Given her smoking history and COPD, the presentation was highly suspicious for malignancy. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies of the right hilar mass. Pathology showed acute inflammation, and the BAL cultures were unremarkable. However, cultures from the transbronchial biopsy grew Streptococcus anginosus. She was started on ceftriaxone during hospitalization and was discharged with cephalexin to complete a total 10-day antibiotic course. Six weeks later, she returned to the ED with a 10-day history of worsening cough and dyspnea, this time associated with the production of thick yellow sputum. A repeat CT chest scan showed resolution of the right hilar mass but significant progression of the RUL nodule, which had enlarged to a 5.5 cm × 6.5 cm mass with surrounding infiltrates. A second bronchoscopy was performed, and BAL cultures grew Streptococcus anginosus. The patient was discharged on a 4-week course of amoxicillin-clavulanic acid. A follow-up CT chest scan, obtained 4 weeks later, demonstrated significant improvement of the RUL mass and resolution of the right hilar mass. IMPACT/DISCUSSION: The Streptococcus anginosus group consists of three species: S. anginosus, S. intermedius, and S. constellatus. It belongs to the viridans streptococci subgroup and is associated with a broad range of infections, including those of the skin/soft tissue, oropharynx, abdomen, brain, and respiratory tract. In the respiratory system, infections commonly manifest as aspiration pneumonia, lung abscess, and empyema. However, Streptococcus anginosus infections presenting as a lung mass are rare and can be misdiagnosed as lung cancer or metastasis, particularly in patients with malignancy risk factors or a history of cancer. The optimal duration of antibiotic therapy for these cases remains uncertain. Standard community-acquired pneumonia treatment, typically 5–7 days of antibiotics, may be insufficient for Streptococcus anginosus infections presenting as a lung mass. Due to the unclear treatment duration and the potential for the infection to mimic lung cancer, short-term follow-up imaging is crucial.

This case emphasizes the need to consider Streptococcus anginosus infection in the differential diagnosis of a lung mass. It highlights the importance of prolonged antibiotic therapy and short-term follow-up imaging to ensure continued improvement. ISCHEMIC OR IRRITABLE? A CASE OF IBS WITH A MISLEADING PRESENTATION Tyler Steve1; Andrew Ng1; Yesenia Greeff2. 1Internal Medicine, Baystate Medical Center, Springfield, MA; 2Gastroenterology, Baystate Medical Center, Springfield, MA. (Control ID #4270378) CASE: 28-year-old male with no significant medical history presented to outside hospital with epigastric pain, nausea, vomiting and diarrhea, denying hematochezia or hemoptysis. His pain worsened after eating and improved with defecation. He reported abdominal pain since childhood had a similar incident of severe pain 6 months prior to presentation with biopsy proven ischemic colitis of the sigmoid. On presentation patient was stable, no lab abnormalities and EKG revealed atrial fibrillation with rapid ventricular response. He underwent CT scan of the abdomen and pelvis which showed mild diffuse colitis with pneumatosis intestinalis of the cecum and no evidence of bowel perforation. A CT angiogram ruled out mesenteric ischemia. He was started on heparin over concern for thromboembolic event and transferred to our hospital with symptom improvement. Surgery recommended no intervention due to improved symptoms on the Heparin drip. Gastroenterology (GI) evaluated the patient and felt symptoms aligned with ischemic colitis and recommended NPO and advancing diet as tolerated. An echocardiogram showed no abnormalities. Over several days he continued to fail advancement of diet with recurring abdominal pain, nausea, and diarrhea but no hematochezia. He underwent significant gastroenterology testing including stool PCR, tissue transglutaminase IgG, fecal calprotectin; and hypercoagulable workup including anti-beta 2gp1, anticardiolipin antibodies and JAK2 mutations which were all negative. A repeat CTA showed questionable nonocclusive thrombus in the superior mesenteric vein versus admixture. Hematology did not feel his symptoms were due to the questionable nonocclusive thrombus due to the findings not being seen on the initial CTA and no resolution of symptoms with anticoagulation. He continued with several days of abdominal pain and underwent flexible sigmoidoscopy with biopsies showing normal colonic mucosa. He remained in normal sinus rhythm the entire hospitalization. GI diagnosed the patient with IBS having met Rome IV criteria and he was discharged with instructions to continue a low FODMAP diet, and apixaban for 3 months. IMPACT/DISCUSSION: IBS is diagnosed based on Rome IV criteria which requires recurrent abdominal pain at least once a week in the last 3 months associated with two or more of the following: related to defecation, associated with change in frequency of stool, or associated with a change in form of stool. Symptom onset should be 6 months prior to diagnosis1. IBS itself carries an increased risk for ischemic colitis. In one study patients with IBS have a RR 3.17 times higher for ischemic colitis2. When concern exists for ischemic colitis a biopsy is important to rule it.

IBS and ischemic colitis have many overlapping clinical symptoms. IBS is diagnosed clinically using Rome IV criteria. If there is concern for ischemic colitis a biopsy is important to rule it out. IS IT INFECTION, MALIGNANCY, AUTOIMMUNITY, OR ALL THE ABOVE? Tennyson Jellins1; Bryan Richie2; Henry R. Kramer1. 1Medicine, University of Colorado System, Denver, CO; 2Texas Christian University, Fort Worth, TX. (Control ID #4271712) CASE: A 76-year-old male with rheumatoid arthritis presented with 4 months of fevers, weight loss, night sweats, myalgias, and bone pain following a COVID-19 infection. He was rhinovirus positive and met 5/9 criteria for hemophagocytic lymphohistiocytosis (HLH): pancytopenia, transaminasemia, hyperferritinemia, elevated sIL-2R, and splenomegaly. CT demonstrated mediastinal, hilar, and abdominal adenopathy. A bone marrow biopsy and flow cytometry were negative for hematologic malignancy but demonstrated increased marrow histiocytes and multiple possible foci of hemophagocytic activity. Upon transfer to a higher level of care, he was started on dexamethasone and hematology and rheumatology were consulted. His EBV titer was positive, and a neck ultrasound (US) demonstrated enlarged cervical lymph nodes. Diagnostic considerations included macrophage activating syndrome (MAS) related to RA, or HLH related to Rhinovirus or EBV. Symptoms improved on dexamethasone, and he was discharged on a prednisone taper with close follow up, including a repeat neck US. Sixteen days later, he presented with systemic inflammatory response thought to be worsening HLH in the setting of steroid taper. An excisional biopsy of a cervical lymph node was consistent with classic Hodgkin lymphoma, EBV-associated, and demonstrated significant hemophagocytosis. PET/CT revealed FDG-avid lymph nodes, spleen, and liver. The patient was referred for treatment with nivolumab-AVD (doxorubicin, vinblastine, and dacarbazine), and the ultimate diagnosis was thought to be malignancy-associated HLH. IMPACT/DISCUSSION: HLH is the result of excessive immune activation spurred by an event that disrupts homeostasis. The disorder can be familial or sporadic and presents in single or relapsing episodes. It is most prevalent in infants up to 18 months and considered rare in adults. Risk factors for HLH include malignancies, infections, autoimmunity, genetics, or drugs. Macrophage activation syndrome (MAS) is a diagnostic mimic defined as HLH in the setting of a rheumatologic disorder. MAS can develop at any time and can be associated with a concurrent infection. The diagnosis of HLH is challenging, as there can be multiple triggers with complex relationships. Relevant to this case, EBV can independently trigger HLH, but it can also cause lymphoproliferative disorders which lead to malignancy-associated HLH. There have been reported cases of HLH secondary to COVID-19 infections, and MAS is a consideration in RA, representing a small subset of patients that develop HLH.

HLH is a rare condition caused by unchecked immune dysregulation which largely affects young infants. When suspected in an adult, timely diagnosis is imperative for halting immune imbalance and recognizing life-threatening triggers of the condition. In an adult with multiple risk factors, including rheumatologic disease, EBV, COVID-19, and rhinovirus, it is important to maintain a high degree of suspicion for underlying malignancy, especially Hodgkin’s Lymphoma. IS IT REALLY MYASTHENIA GRAVIS? PUSHING BACK AGAINST DIAGNOSTIC MOMENTUM: A CASE REPORT OF ADALIMUMAB-INDUCED IMMUNE-MEDIATED NECROTIZING MYOPATHY Rachel D. Cutting1; Setse A. Bush2,1; Sam Woodworth1,2; Brian J. Keroack1. 1Medicine, Maine Medical Center, Portland, ME; 2Medicine, Tufts University School of Medicine, Boston, MA. (Control ID #4270768) CASE: A 62-year-old male with a history of cirrhosis, autoimmune hepatitis, and psoriatic arthritis on adalimumab presented to the ED with falls. He was afebrile and hemodynamically stable with a normal O2 saturation on room air. His exam was notable for global muscle weakness and fatigable diplopia. Neurology evaluated the patient and recommended treatment with prednisone/pyridostigmine given concern for myasthenia gravis (MG). On hospital day 1, the internal medicine service noted that admission labs included 1) a urinalysis positive for blood but no RBCs and 2) an AST-predominant transaminitis. Myopathy was added to the differential diagnosis. A creatine kinase subsequently returned elevated (6973 U/L, peaking ~17000 U/L). The patient's respiratory status worsened despite initiation of BiPAP and ongoing treatment for MG. Rheumatology was consulted given the diagnostic uncertainty. A muscle biopsy and myositis-specific antibodies were obtained. The possibility of a medication-induced inflammatory myopathy was considered (statin vs. adalimumab). The anti-acetylcholine receptor antibody ultimately returned negative, arguing against a diagnosis of MG. A negative anti-HMG-CoA reductase antibody ruled out a statin-induced myopathy. A myomarker panel returned weakly positive for Mi-2 (unlikely clinically relevant given the lack of anything else suggesting dermatomyositis). Muscle biopsy pathology was consistent with an immune-mediated necrotizing myopathy (muscle fiber necrosis, minimal inflammation). A diagnosis of adalimumab-induced immune-mediated myopathy was thought to be most likely and the medication was discontinued. The patient remained hospitalized while receiving a methylprednisolone taper. His weakness improved and he was eventually discharged to a rehab facility. IMPACT/DISCUSSION: It is important to slow down and reexamine data that does not fit into the picture of a leading diagnosis. Even a seemingly small clue from a urinalysis (i.e., positive blood and no RBCs) became the first push against diagnostic momentum towards MG in this case. It helped providers reframe the case and ultimately arrive at the correct diagnosis of immune-mediated necrotizing myopathy (IMNM). IMNM is a rare inflammatory myopathy. A small body of literature supports the development of new autoimmune diseases (including one other report of IMNM) in some patients treated with TNF-α blockers. Although the precise mechanism behind these illnesses is unknown, it is thought that once there is a blockade of TNF-α, the immune system shifts to over-synthesis of IFN-α, which can result in paradoxical autoimmunity. In most cases of TNF-α-induced autoimmunity, removing the offending agent and administering glucocorticoids results in rapid clinical improvement.

This report urges providers to push back against diagnostic momentum when there are laboratory values arguing against a leading diagnosis. It also highlights the need for a recognition of IMNM, particularly the possibility of drug-induced variants. ISOLATED FACIAL NERVE PALSY: A RARE NEUROLOGICAL MANIFESTATION OF SEVERE HYPOTHYROIDISM SOPHIA A. VOZZA1; Zoya Khan2; Niraj Pathak3; Analise McGreal2. 1GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 3Nova Southeastern University, Fort Lauderdale, FL. (Control ID #4271545) CASE: A 59-year-old female with a history of hyperlipidemia and hypothyroidism presented to the emergency department with a right-sided facial droop. Physical examination revealed a right-sided facial droop, inability to close the right eye, and impaired eyebrow raise. Signs of myxedema coma were not present. Initial non-contrast CT of the head showed no evidence of hemorrhage, and subsequent MRI of the brain was negative for acute ischemia. Laboratory evaluation demonstrated severe hypothyroidism, with a TSH of 270 μIU/mL, undetectable free T4 (<0.10 ng/dL), and low T3 (0.39 ng/dL). The patient received three days of IV levothyroxine prior to the resumption of oral levothyroxine with mild improvement in symptoms, particularly ability to close the right eye. The presentation suggests cranial nerve VII palsy (Bell’s palsy) likely related to severe hypothyroidism due to nonadherence to thyroid hormone replacement therapy. IMPACT/DISCUSSION: Hypothyroidism is known to be associated with neurologic manifestations, though typical symptoms include lethargy, mood changes, or nerve entrapment. Most cases of Bell’s palsy are idiopathic, with a smaller portion viral or autoimmune in etiology. This case describes an instance where cranial nerve VII palsy was the presenting complaint in a patient with severe hypothyroidism. This highlights a rare association between two common concerns and demonstrates the need for clinicians to remain vigilant to the possibility of hypothyroidism underlying cranial nerve palsies.

Severe hypothyroidism, resulting from two to three months of medication nonadherence, was identified as the primary etiology of this patient’s facial nerve palsy. The patient quickly experienced mild improvement with resumption of thyroid replacement therapy. In future practice, the addition of thyroid function testing to the evaluation of cranial nerve VII palsy may be warranted in certain cases. Identification of hypothyroidism may provide an opportunity for efficient symptom relief for some patients. ISOLATED NEUTROPENIA INDICATIVE OF APL: A CASE FOR THE SCREENING CBC Brianna Mussman1; Jessica Mirakov Cohen2. 1Internal Medicine, Jackson Memorial Hospital, Miami, FL; 2Internal Medicine, VA Miami Healthcare System, Miami, FL. (Control ID #4272850) CASE: A 69 year old woman with hypertension, hyperlipidemia, obesity, major depression, osteoarthritis, and fibromyalgia was sent to the ED by her primary care doctor for abnormal labs. The patient was in her usual state of health and saw her outpatient rheumatologist to work up positive cANCA; labs showed a low WBC count. She denied having any symptoms: no fever, chills, worsened fatigue, easy bleeding, rashes, infections. She denied taking new medications, only her aripiprazole, aspirin, escitalopram, lisinopril, magnesium oxide, semaglutide, sennosides, simvastatin, and as-needed celecoxib, topical lidocaine and diclofenac. Vital signs were within normal limits. Physical exam was unremarkable; she was well-appearing, no ecchymosis on skin, no focal neurologic deficits, and had mild thoracic paraspinal muscle tenderness. Labs were remarkable for WBC 1.6 with ANC 0.4, hemoglobin 11.7, platelets 201. Of note, labs 5 months prior to presentation had WBC 6.1 with ANC 4.0; one month prior to presentation labs showed WBC 4.1 with ANC 1.5. CMP was within normal limits, respiratory viral panel and UA negative. Peripheral blood smear had atypical lymphocytes, no blasts. Chest X-ray found no osseous or airspace abnormalities. Abdominal ultrasound found normal spleen size and fatty liver. Hematology was consulted, and with a new presentation of severe neutropenia and atypical lymphocytes on peripheral blood, there was concern for a malignant etiology. As she was stable with no evident infection, she was discharged to complete a bone marrow biopsy outpatient. Within a week she was urgently called with the results: acute promyelocytic leukemia (APL). Marrow cytogenetics were positive for PML:RARA fusion, with 40% blasts and visible Auer rods, hypercellular infiltrated marrow with 30% immature mononuclear cells and 26% blasts. Notably, peripheral blood cytometry was negative for the PML:RARA fusion, indicating that this leukemia was found extremely early in its course. She re-presented to start ATRA and arsenic treatments inpatient, and she continues cycles of treatment. IMPACT/DISCUSSION: Asymptomatic neutropenia is common and often benign. However, suspicion must remain high for malignant etiology. This case demonstrates that screening CBCs may lead to early diagnosis of leukemia prior to blast crisis. APL requires urgent chemotherapy and often initially presents with bleeding, pancytopenia, B symptoms, and neurologic deficits. Few case reports describe patients in whom APL is found incidentally, and none are published where neutropenia was the sole presenting sign. This case demonstrates peripheral blood smears and cytometry may have false negatives prior to blast crisis which can impact how quickly patients receive life-saving care.

-In early leukemia, peripheral blood smear and flow cytometry may be falsely negative if no blasts are captured in the sample -Keep high suspicion for malignant etiology of new severe neutropenia, with urgent specialist consultation and bone marrow biopsy IT'S SPORE THAN PNEUMNIA- A FATAL CASE OF DISSEMINATED ASPERGILLOSIS Danica Smith. DGIM- Section of Hospital Medicine, UPMC, Pittsburgh, PA. (Control ID #4272890) CASE: A 65 year old woman with recent diagnosis of severe ulcerative colitis refractory to medical treatment (corticosteroids one month prior and infliximab three weeks respectively) presented as a transfer from an outside hospital for total abdominal colectomy. Her post-operative course was complicated by poor nutrition, decreased participation in activities, tachycardia and acute hypoxic respiratory failure for which medicine was consulted. She started broad spectrum antibiotics for hospital acquired pneumonia. Physical exam demonstrated sinus tachycardia, anasarca, scattered rales, disorientation to place, and tangential thoughts. Imaging included CT chest with numerous bilateral pulmonary nodules, few cavitary lung lesions, and bilateral pleural effusions. Her encephalopathy persisted prompting CT head then subsequently MRI brain with rim-enhancing structure in frontal lobe and multiple septic emboli. Laboratory work demonstrated elevated b-d-glucan levels without evidence of bacteremia. Infectious disease was involed in her care and she was continued on antibiotics. Despite this, her mental and respiratory status deteriorated prompting intubation, bronchoscopy, and initiation of anti-fungal therapy. Post-mortem fungal and bronchoalveolar lavage cultures grew Aspergillus fumigatus. IMPACT/DISCUSSION: Invasive aspergillosis typically presents as a pulmonary process in patients that are immunocompromised and portends a high morbidity and mortality. Poor prognosis is seen in disseminated aspergillosis, particularly with central nervous system involvement as seen in our patient. Corticosteroids and immunomodulators such as anti-TNF agents are cornerstones of treatment for inflammatory bowel disease (IBD) and lead to immunosuppression. Infliximab carries a black box warning for opportunistic infections (OI), which can occur within several days of initiation of therapy. The incidence of OIs is low in IBD; at times leading to less consideration for these diseases. Risk factors for invasive fungal infections not only include use of corticosteroids and anti-tumor necrosis alpha therapy, but additionally those that have underlying malnutrition, advanced age, and underlying chronic diseases. Our patient, while she had only been on steroids and immunomodulator therapy for less than a month, suffered from additional malnutrition and advanced age which may have put her at an increased risk for developing an invasive fungal infection.

While invasive fungal infections are rare, specifically invasive aspergillosis, if not considered or identified quickly, they can lead to a high risk of mortality. It is important to have a high index of suspicion for invasive fungal infections for patients with IBD on steroids and anti-TNF agents with new onset fever and pulmonary infections. IVC LEIOMYOSARCOMA MIMICKING THROMBOTIC LESION: A DIAGNOSTIC CHALLENGE Resham Mirza1; Kofi B. Opoku1; Isamilka Sanchez1; Sebastian Casillas-Berumen1; Bhavana Rebba2; Craig Snyder2. 1Internal medicine, Hackensack Meridian Raritan Bay Medical Center, Perth Amboy, NJ; 2Hackensack Meridian JFK University Medical Center, Edison, NJ. (Control ID #4269407) CASE: A 74-year-old woman with diabetes, hyperlipidemia, hypertension, coronary artery disease, and chronic pedal edema presented after three syncopal episodes following metolazone initiation. Episodes were preceded by lightheadedness without chest pain, palpitations, or seizures. Exam showed bilateral pedal edema with stable hemodynamics. Labs indicated acute kidney injury and elevated ProBNP, and EKG showed multifocal PVCs. Echocardiography identified a right atrial thrombus and IVC dilation, suspicious for thrombus which was confirmed by TEE. Anticoagulation was started, and she was discharged on Xarelto despite upper GI bleeding due to thromboembolic risk. One month later, she was readmitted with anemia from GI bleeding and worsening lower extremity swelling. Imaging showed a large IVC clot, leading to surgical thrombectomy. Intraoperative findings revealed a solid IVC mass resistant to suctioning, with initial biopsy consistent with findings of a thrombus. A follow up procedure for possible caval mass removal and biopsy confirmed high-grade leiomyosarcoma at the atriocaval junction, partially occluding the IVC. Due to the tumor's size, location, and extent, resection was unfavorable, and she received targeted radiation followed by chemotherapy with dacarbazine and doxorubicin. IMPACT/DISCUSSION: Leiomyosarcoma of the IVC is a rare, aggressive malignancy originating from smooth muscle cells, accounting for 1–2% of soft tissue sarcomas and predominantly affects females aged 40–60. Nonspecific symptoms and thrombus-like imaging appearance often delay diagnosis. Diagnostic imaging, including Doppler ultrasound, CT, and MRI, should be complemented by cavography or echocardiography. Although no standard protocol exists, comprehensive CT scans incorporating pre-contrast, arterial, venous, and delayed phases can be done. These techniques enhance diagnostic accuracy and reduces treatment delays. When imaging is inconclusive, biopsy confirms malignancy. Surgical resection with or without vascular reconstruction is the preferred treatment, but it may not always be feasible, necessitating adjuvant radiation and chemotherapy. This case underscores the importance of considering rare malignancies in patients with persistent thrombi unresponsive to anticoagulation. Early diagnosis and intervention are vital for improved outcomes.

Leiomyosarcoma of the IVC is a rare but serious malignancy that poses significant diagnostic and therapeutic challenges due to its proximity to vital structures, mimicry of common conditions, and risk of complications. Another important takeaway is that persistent or atypical thrombi should prompt evaluation for malignancy or non-thrombotic causes. KEEP AWAY STRAYS: A DOCUMENTED CASE OF MURINE TYPHUS Colin Ly1; Ravi Patel1; Affan M. Ahmed2; Leslie Cler1. 1Internal Medicine, Methodist Dallas Medical Center, Dallas, TX; 2Internal Medicine , Methodist Health System, Dallas, TX. (Control ID #4273550) CASE: A 53 year old male presented with a ten day history of progressively worsening fever with a generalized, diffuse headache. His fever developed on day 3 of feeling ill. The fevers were subjectively worse from the evening into the night and he would wake up to drenched bed sheets. He was evaluated at an urgent care and prescribed a seven day course of amoxicillin without improvement in symptoms. Labs obtained on admission revealed normal WBC, procalcitonin, lactic acid, and blood cultures. Abnormal labs included hyponatremia and liver enzymes elevation with AST greater than 5 times the upper limit and ALT 9 times the upper limit. CT three phase chest with abdomen revealed 2 pulmonary nodules in the upper lung measuring up to 13mm, a liver lesion suspected to be a hemangioma and splenomegaly. Further investigations revealed a history notable for the adoption of stray kittens in the month of August. Broad workup was obtained to investigate the source of infection which revealed normal results for Brucella, West nile, Bartonella, Toxoplasma, Histoplasma, EBV, and CMV. A conclusion was made when rickettsia typhi antibodies for IgG (1:1024) and IgM (1:512) resulted. Interestingly the patient had a positive Monospot and QuantiFERON. The individual was started on doxycycline for 7 days total with clinical improvement, resolution of fever and headache and improvement in liver enzymes. IMPACT/DISCUSSION: Murine Typhus is an uncommon zoonotic disease caused by Rickettsia typhi. This condition has been distributed worldwide, but most cases in the United states are reported in Texas, California, and Hawaii. Cats and mice often serve as hosts for transmission through fleas. Infection occurs following inoculation with flea feces from bites. Individuals affected by this condition may experience mild general symptoms that include persistent fever, headache, rash, and gastrointestinal symptoms. The nonspecific symptoms and abnormal liver function tests, can make it difficult to distinguish from other viral illnesses like SARS-CoV-2, Zika, and dengue. Rarely, typhus can manifest as life threatening disease such as shock, myocarditis, or splenomegaly with reported cases of splenic rupture.

Zoonotic diseases have been known to contribute to the emergence of infectious diseases, with rickettsia previously implicated in 54.3% of such outbreaks. However, given the serious morbidity associated with murine typhus, clinicians should maintain a high index of suspicion and rule out these other potential causes. Overall, this case underscores the importance of maintaining vigilance for rare zoonotic diseases like murine typhus, especially in the context of a broad differential diagnosis. KEEPING UP WITH THE JONESES Adrian Lazarevic-Fogelquist. Department of Medicine, University of Washington, Seattle, WA. (Control ID #4251013) CASE: A 38-year-old man presented to an emergency department with two weeks of daily fevers, pleuritic chest pain, odynophagia, fatigue, and migratory myalgias and arthralgias. He returned home from traveling to various music festivals throughout the US shortly before developing symptoms. He did not present with cough, GI symptoms, rash, or neurologic symptoms. His exam was notable for tachycardia, with otherwise normal vitals, oropharyngeal erythema, cervical lymphadenopathy, and edema of his right ankle with mildly limited range of motion. Labs demonstrated leukocytosis, anemia, markedly elevated ESR/CRP, and mildly elevated troponin and BNP. Initial workup for infection included negative respiratory viral panel, HIV, EBV, rapid strep, and serial blood cultures. CT scans of chest, abdomen, and pelvis showed prominent tonsils and mild cervical lymphadenopathy. A broad infectious and rheumatologic workup demonstrated no evidence of sexually transmitted infections, nor viral, fungal, or zoonotic bacterial infections. While hospitalized he developed an evanescent truncal rash and tender lower extremity subcutaneous nodules. Echocardiography demonstrated no evidence of ischemic, valvular, or pericardial pathology. Eventually his pharyngeal group A strep (GAS) culture returned positive, despite initially negative rapid testing. His anti-streptolysin O titer was also markedly elevated, consistent recent GAS pharyngitis. He was ultimately diagnosed with acute rheumatic fever, treated with penicillin, and discharged home to follow up in Infectious Disease and Cardiology clinic. IMPACT/DISCUSSION: Our case demonstrates an uncommon etiology of systemic illness for adults in high-income settings. We and our consultant colleagues initially struggled to find a unifying diagnosis for his constellation of symptoms, and it was only after the positive strep culture that the patient remembered that his other symptoms were preceded by a particularly painful sore throat. The diagnosis was ultimately made on the basis of the Jones criteria (revised 2015) and microbiologic evidence of preceding GAS infection. A review of the literature reveals that the incidence of acute rheumatic fever markedly declined in high-income countries throughout the 20th century. The global burden of disease now disproportionately affects patients in middle- and low-income countries, and indigenous and economically disadvantaged populations in high-income countries.

Given the high potential morbidity of acute rheumatic fever, clinicians need to maintain a high index of suspicion for the diagnosis for patients presenting with the appropriate constellation of symptoms. ARF is a clinical diagnosis made by either two major, or one major and two minor Jones criteria. The criteria are major: carditis, arthritis, chorea, erythema marginatum, and nodules; and minor: arthralgia, fever, elevated inflammatory markers, and PR prolongation. KEEP MOVING TO FIND A DIAGNOSIS IN A PATIENT WHO IS NOT MOVING: CATATONIA AS A PRESENTATION OF CERVICAL NEUROENDOCRINE CARCINOMA Divya Y. Popat, Joslyn Fisher, Meghana Nadella, Suchi Agrawal. Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4273406) CASE: A 34 year-old woman with no significant past medical or psychiatric history presented to the ED with concern for catatonia. Two months prior, the patient developed sudden onset of bizarre behavior, aggression, and psychosis leading to a one-month admission at an outside psychiatric hospital. Despite treatment with dual antipsychotics and mood stabilizers, she did not improve clinically and was admitted for evaluation of psychosis with catatonic features. Her husband provided history, reporting no history of head trauma, alcohol or drug use, or family history of autoimmune/neurologic/malignant conditions. On exam, patient was alert but disoriented, exhibiting echolalia, paranoia, psychomotor slowing, and reduced oral intake. She had minimal improvement with escalating doses of lorazepam to treat suspected catatonia. Labs, CT head, and CSF studies were unremarkable. Infectious work up was negative. MRI Brain demonstrated nonspecific findings of encephalitis, prompting initiation of IV methylprednisolone followed by IVIG and rituximab for suspected autoimmune encephalitis, with no clinical response. Given her age with new onset psychosis and treatment-refractory symptomatology, further imaging was ordered to investigate for potential paraneoplastic etiology. CT chest/abdomen/pelvis revealed pelvic lymphadenopathy, and MRI pelvis identified an exophytic cervical mass. Cervical biopsy confirmed stage IIIC2 cervical neuroendocrine tumor. CSF studies returned positive for NMDA receptor antibodies. Patient was initiated on chemotherapy and discharged for outpatient management. Two months after discharge, psychiatry noted normal neuropsychiatric function. IMPACT/DISCUSSION: Psychiatric conditions with features of psychosis are most commonly diagnosed in adolescence through early adulthood. Our patient’s acute onset of psychotic symptoms in her mid-thirties— refractory to antipsychotics and mood stabilizers—constitute alarm features that prompted further evaluation for an underlying medical cause. N-methyl-D-aspartate receptor (NMDAr) encephalitis is an autoimmune disorder that presents with a broad spectrum of neuropsychiatric symptoms, including psychosis, seizures, and catatonia. Approximately 38% of NMDAr encephalitis cases are paraneoplastic, most often associated with ovarian teratomas. This case highlights an atypical presentation of paraneoplastic NMDAr encephalitis secondary to cervical neuroendocrine carcinoma. While cervical cancer is relatively common in reproductive-age females, its association with paraneoplastic autoimmune encephalitis is rare. Steroids and IVIG may temporize symptoms, but ultimate treatment is addressing the underlying cancer.

New onset psychosis or catatonia in mid-adulthood is a clinical red flag that warrants exploring a broad differential, including infectious, autoimmune, primary neurodegenerative, and paraneoplastic etiologies. Early identification and treatment can reduce morbidity associated with a missed or delayed neoplastic diagnosis. KNOWLEDGE NEEDED TO TREAT: RITUXIMAB VERSUS VANCOMYCIN Basil McIntosh1; Nancy E. Wareing2; Dan Hunt3; Justin Cheeley4. 1School of Medicine, Emory University, Atlanta, GA; 2Internal Medicine Residency Program, Emory University, Atlanta, GA; 3Division of Hospital Medicine, Emory University, Atlanta, GA; 4Department of Dermatology, Emory University, Atlanta, GA. (Control ID #4270077) CASE: A 63-year-old male was transferred to our hospital with malaise, sinus congestion, epistaxis, oral ulcerations, hemoptysis, palpable purpura, and diffuse joint pain. Symptoms began shortly after taking azithromycin for an upper respiratory illness (URI). Diagnostic punch biopsy revealed perivascular IgM, IgG, IgA, and C3. Notable labs included a 1:640 speckled ANA titer, ANCA IFA titer > 1:1280, and elevated serine protease 3 and CRP. High dose steroids were initiated for presumed vasculitis. Chest CT revealed early cavitations, which led to bronchoscopy for biopsy, bronchoalveolar lavage (BAL), and sputum culture. Pneumonia pathogen panel and respiratory culture of BAL specimen detected MRSA. The patient received a seven-day course of vancomycin, and TTE and TEE, neither of which showed any vegetations, were performed. By hospital day seven, the creatinine rose from 1.34 to 1.56. Urinalysis showed muddy brown casts and microscopic hematuria. Renal biopsy showed ~10% crescentic glomeruli with necrosis, thought to be consistent with granulomatosis with polyangiitis (GPA). As the creatinine continued to rise, the patient started treatment with rituximab. Nephrology also recommended the addition of cyclophosphamide. However, the patient did not tolerate this therapy well, so it was discontinued after one dose. After rituximab and cyclophosphamide therapies, the creatinine rose from 5.58 to 7.15 over three days, which led to the decision to begin hemodialysis. IMPACT/DISCUSSION: Hospitalists not infrequently care for patients with vasculitis, which requires complex therapeutic decisions involving multiple consultants. GPA is the inflammation of blood vessels in the lungs, kidneys, nose, sinuses, and ears, which can lead to sinusitis, epistaxis, palpable purpura, fever of unknown origin, night sweats, fatigue, and malaise. Our patient experienced many of these symptoms. In addition to clinical correlation, the diagnosis was supported objectively by the elevated c-ANCA titer, immunologic perivascular infiltrates on punch biopsy, oropharyngeal ulcerations on visual inspection, and pulmonary nodules seen on CT. The detection of S. aureus on bronchoscopy delayed adding rituximab to corticosteroids despite worsening renal function. However, after careful consultation with infectious diseases, nephrology, dermatology, and pulmonology, the initial treatment of MRSA was considered the patient’s safest option. After a 38-day admission, our patient was discharged with a plan to continue hemodialysis three times per week and follow up nephrology, rheumatology, and primary care to ensure adequate delivery of outpatient care.

This case highlights the challenge of deciding whether a possible infection should delay aggressive immunosuppression for a patient with rapidly advancing vasculitis. Additionally, it shows how multidisciplinary collaboration drives patient care. LAMOTRIGINE TOXICITY - THE UNEXPECTED CULPRIT Aya Hasan1; Tania Multani1; Sonakshi Mirchandani1; Kishan P. Talagadadeevi2. 1Internal Medicine, Texas Health Resources, Arlington, TX; 2internal medicine, Texas Health Resources, Arlington, TX. (Control ID #4244609) CASE: A 58-year-old male with bipolar disorder, ADHD, hypertension, history of alcohol abuse (8 months sober), and BPH presented to the ER with complaint of nausea, vomiting, blurred vision, dizziness, and ataxia onset morning of admission, along with elevated blood pressure of 200’s systolic at home. Patients home medications included lamotrigine 400mg daily, metoprolol 50mg daily, Ritalin 20mg daily. He endorsed a change in his medications from Adderall to Ritalin one month prior. On initial examination, the patient had dysarthria, prominent dysmetria, along with monocular diplopia and positive Romberg test. A stroke work up was initiated in the emergency department. CT Head without contrast was negative for any acute abnormalities, along with MRI Brain without contrast and CTA Head/Neck angiogram. All of the patients' electrolytes and blood counts were unremarkable, UDS and ethanol negative. Given the history of alcohol abuse, the patient was started on high dose thiamine. Vitamin B1, B12, and folate levels were ordered, all of which were found to be in normal ranges. After negative workup for stroke and persistence of symptoms, a lamotrigine level was ordered, along with, per recommendation from the neurology team, MRI brain/spine (with contrast) and a lumbar puncture. Imaging and fluid studies from the LP were unremarkable. The lamotrigine level was found to be in the toxic range at 23.3 ug/ml (> 20 ug/ml is toxic). The psychiatry team was consulted, lamotrigine was discontinued, and the patient was subsequently started on quetiapine. Within two days of discontinuation, the patient's neurological symptoms dramatically improved, with nearly complete resolution of dysarthria, dysmetria, and a negative Romberg test prior to discharge. Given the patients' symptoms on admission, he was discharged to an acute rehab facility. The Naranjo adverse drug reaction (ADR) probability scale was calculated to be 9, suggesting patient's symptoms were a definite ADR from Lamotrigine. IMPACT/DISCUSSION: This case highlights the importance of thorough medication review and literature search of possible side effects. Several studies have highlighted that elimination kinetics of lamotrigine may be non-linear in some individuals. If toxicity was not considered, this patient may have continued his lamotrigine with no resolution of his symptoms. Furthermore, several cases studies have reported patients being misdiagnosed with posterior circulation stroke or TIA. This highlights the importance of considering a rapid lamotrigine level on similarly presenting patients, which may alleviate an extensive and costly work up.

Lamotrigine is a well known medication used in bipolar and seizure disorders. It is usually carefully titrated to maintain therapeutic levels, but when toxic levels are reached, ataxia, vertigo, diplopia along with other symptoms may ensue. It is important, especially in cases like this, to thoroughly review medication side effects, and order drug levels if suspecting toxicity. LAST CALL: A FATAL CASE OF ACUTE LIVER FAILURE IN THE SETTING OF CHRONIC ALCOHOLIC HEPATITIS Matthew S. Carnevali1; Rachel Patel1; Lawrence Stawkowski1; Daniel A. Fernandez Felix2; Andres Zirlinger2. 1Internal Medicine, Lehigh Valley Health Network, Allentown, PA; 2Pulmonary and Critical Care, Lehigh Valley Health Network, Allentown, PA. (Control ID #4271744) CASE: A 35-year-old female with history of alcohol abuse presented for abdominal bloating. The patient endorsed two alcoholic drinks per day for the last several months, along with abdominal pain, swelling, and dyspnea. Physical exam showed a markedly distended abdomen without evidence of encephalopathy. Initial laboratories included AST 219 U/L, ALT 37 U/L, ALP 132 U/L, total bilirubin of 4.0 mg/dL, and lactate of 5.4 mmol/L. Imaging showed massive hepatomegaly, hepatic steatosis, and anasarca. Her MELD-Na score was 25. She was diagnosed with acute-on-chronic decompensated cirrhosis and portal hypertension in the setting of chronic alcohol abuse and admitted to the ICU. Work-up for contributing causes of liver failure was unrevealing. The patient was started on oral prednisone for her elevated Maddrey’s Discriminant Function score. She later developed undifferentiated shock, acute kidney injury and respiratory failure requiring intubation. She was treated with vasopressors, renal replacement therapy, and antibiotics due to suspected sepsis. However, she continued to worsen and eventually was transitioned to comfort measures and passed away. The patient’s cause of death was identified as acute liver failure and shock secondary to suspected enterocolitis in setting of chronic alcoholic hepatitis. IMPACT/DISCUSSION: Rates of alcohol use and associated ALF have been increasing in US young adults over the last two decades. Recent studies have shown a spike in incidence, prevalence, and mortality of alcoholic cirrhosis specifically in patients under 40 years old. Rising numbers of young adults are being evaluated for liver transplants. This leads us to suspect that there are unrecognized factors contributing to patient mortality. Our patient presented with only abdominal pain and dyspnea associated with abdominal distention. She rapidly progressed to multi-organ failure and death in less than one week. This shows the extremely precarious nature of ALF in younger patient populations with minimal comorbidities and moderate alcohol use. The combination of inherent vasodilatory shock as a direct consequence of ALF, along with sepsis due to subsequent infection, can lead to overwhelming vascular compromise for which even young patients cannot compensate. This case exemplifies the increasing rates of alcohol-associated liver disease and acute liver failure in young-adult patients.

Develop pro-active methods for addressing alcohol use in young adult patients Do not assume that younger patients have favorable chances of recovery Recognize that patients with ALF are at high risk for sepsis and subsequent fatal complications LATE AGE DIAGNOSIS OF HEREDITARY HEMOCHROMATOSIS: A CASE REPORT HIGHLIGHTING THE GAP IN GUIDELINES FOR DIAGNOSIS AND TREATMENT OF INDIVIDUALS WITH P.H63D MUTATION Elise Moix1; Alexandra C. Gillotte1; Nikaash Pasnoori2; Theresa Asuquo1. 1Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 2University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4273388) CASE: We present the case of a male who didn’t develop clinical manifestations of hereditary hemochromatosis (HH) until age 89, and question whether that could be related to his lifelong blood donation history. This patient presented with 2 months of painless jaundice and the following labs: total bilirubin 26.4, alkaline phosphatase 1139, AST 288, and ALT 187. Imaging showed a biliary stricture, initially suspected to be the cause of his hyperbilirubinemia. Hyperbilirubinemia failed to improve with stenting so further imaging was obtained, demonstrating hepatosplenic iron overload. Additional history revealed the patient donated blood every 6 weeks for 75 years, only stopping 3 years prior to presentation. Subsequently, iron chelators were started, reducing his total bilirubin by half. On hospital day 17, testing revealed a H63D homozygous mutation and elevated IgG-4 to 488 mg/dL (reference range 2-96 mg/dL), concerning for HH and IgG-4 disease, respectively. Prednisone was added in conjunction with iron chelation, and the patient had clinical improvement allowing for a safe discharge. IMPACT/DISCUSSION: HH is an autosomal recessive iron metabolism disorder that typically presents between ages of 40-60 with laboratory & clinical findings suggestive of iron overload. Genetic testing for HH is crucial for diagnosis and treatment. Multiple mutations are associated with HH, but their ability to precipitate iron overload varies. The C282Y variant significantly increases the likelihood of developing iron overload, while the more prevalent H63D mutation only results in clinical manifestations in 3-6% of individuals. Our case highlights a need for additional research into why only some individuals with the H63D mutation present with phenotypic hemochromatosis. Currently, researchers postulate that an additional insult may trigger iron overload. In our case, it’s suspected this insult was the combination of IgG4 disease and cessation of blood donation. This case highlights the gap in H63D research, particularly the role of screening for HH-associated mutations and the need for updated guidelines on managing iron overload. It is important to inquire about blood donor status in patients with HH on their differential, given this patient’s late presentation may be due in part to his frequent blood donations. This case underscores the importance of investigating the trigger for late-onset HH. Failure to do so could have delayed the diagnosis of IgG4-related disease for this patient, increasing his morbidity and mortality.

- A detailed history is essential for diagnosing late-onset hemochromatosis (HH). - Research on H63D and other HH mutations is still evolving and requires further study. - Identifying and addressing triggers of new-onset HH can reduce morbidity and mortality. LATE-ONSET PROPAFENONE-INDUCED HEPATOTOXICITY IN AN ELDERLY PATIENT: A CLINICAL VIGNETTE Adeoluwa Adewuyi, Gurleen Kaur. Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4232342) CASE: An 84-year-old female with persistent atrial fibrillation presented with painless jaundice, weakness, and fatigue 7 weeks after initiating propafenone (300 mg daily). Medical history included hypertension and osteoarthritis. Other medications were metoprolol and apixaban. Physical examination revealed jaundice, icteric sclerae, and mild hepatomegaly. Laboratory tests showed elevated liver enzymes: ALT 121 U/L, AST 72 U/L, ALP 1037 U/L, total bilirubin 4.3 mg/dL, and GGT 425 U/L. Extensive workup excluded other etiologies. Liver biopsy revealed mild hemosiderosis and steatosis. Propafenone was discontinued, and supportive care initiated. Liver function gradually improved, with near-normalization of enzymes at 4-week follow-up. IMPACT/DISCUSSION: This case highlights atypical features of propafenone-induced hepatotoxicity: extended latency period (7 weeks vs. typical 2-6 weeks), advanced patient age, gradual symptom onset, and predominantly cholestatic pattern. These findings expand our understanding of drug-induced liver injury in elderly patients, suggesting that the risk may extend beyond the commonly accepted monitoring period. The case raises questions about age-related factors influencing drug metabolism and susceptibility to hepatotoxicity, including reduced hepatic blood flow and decreased drug-metabolizing enzyme activity. The predominantly cholestatic pattern observed differs from the mixed hepatocellular-cholestatic pattern more commonly reported, suggesting possible age-related changes in hepatobiliary function. This report emphasizes the need for extended hepatotoxicity monitoring in elderly patients receiving propafenone and contributes to the limited literature on propafenone-induced liver injury in this population.

Propafenone-induced hepatotoxicity can occur beyond the typical 2-6 week window, especially in elderly patients, necessitating extended monitoring. Age-related factors may influence the risk and presentation of propafenone-induced liver injury, warranting high clinical suspicion even with atypical presentations or extended latency periods. A predominantly cholestatic pattern of liver injury may occur with propafenone in elderly patients, differing from the mixed pattern more commonly reported. LATE PERICARDIAL TAMPONADE ONE MONTH AFTER SAVR Amina Kureshi1; Pang Lam2. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4271701) CASE: This 71-year-old male with history of COPD (not on home oxygen), hypertension, hyperlipidemia, coronary artery disease status post percutaneous coronary intervention, gastritis, hypothyroidism, chronic kidney disease, history of severe aortic stenosis for which the patient was initially evaluated for transcatheter aortic valve repair and was noted to have heavy burden of calcium in the left ventricular outflow tract leading to a routine SAVR. Preoperative labs revealed normal coagulation profile and hemoglobin. Intraoperatively the patient did require blood products. Post operative course was complicated by atrial fibrillation and rapid ventricular response on POD 2. He was started on intravenous amiodarone and converted to normal sinus rhythm. Echocardiogram on POD 3 revealed normal functioning valves. Patient was noted to have difficulty ambulating stairs due to shortness of breath with adequate oxygen saturation on room air and was discharged to subacute rehabilitation on POD 9. On POD 17 the patient presented to the emergency room with symptomatic anemia and hemoglobin of 6.6, lower extremity edema, and atrial fibrillation. He was transfused, started on supplemental oxygen via nasal cannula, admitted to surgical stepdown unit and treated with amiodarone, metoprolol, apixaban, and was continued intravenous furosemide per pulmonary consult recommendations. Dopplers were negative for lower extremity thrombus. CT angiogram of the chest (POD 21) revealed new widening of pericardial sac to 2 cm. The patient was weaned off oxygen and pending placement for discharge. However, on POD 25 rapid response was called for respiratory failure. Critical care was consulted and the patient was intubated, started on vasopressors and admitted to the intensive care. Echocardiogram revealed tamponade; emergent pericardial window was performed and the patient was weaned off all vasopressor agents. POD 26 the patient was extubated and transitioned to bilevel positive airway pressure. IMPACT/DISCUSSION: Late pericardial tamponade (LPT) is a known complication of surgical aortic valve repair (SAVR) with occurance of 4% in patients with a median delay of 11 days post-operatively. Independent risk factors for LPT are single valve surgery and high preoperative hemoglobin level. Older age correlates with lower risk of LPT. Despite not having significant risk factors for LTP, this patient developed LPT on postoperative day 25 on a second inpatient admission which makes this case unique. Prophylactic posterior pericardial window (PPPW) has been shown to decrease in occurrence of late tamponade in heart valve surgery patients and does have a role in preventing LPT but is not routinely used. PPPW should be used more routinely and can prevent readmission to inpatient and critical care units.

Physicians should have a low threshold to repeat echocardiogram in patients with recent SAVR, even one month postoperatively, as timely diagnosis can decrease mortality and prevent intensive care admission. LEAD POISONING MIMICKING MYELODYSPLASTIC SYNDROME Joyce Chen1; Jordan Selep1; Austin M. Cohen1; Cyrus Adams-Mardi1; Chandana Reddy2; Samah Nassereddine2. 1Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Hematology/Oncology, George Washington University Medical Faculty Associates, Washington, DC. (Control ID #4273196) CASE: A 60-year-old female with history of breast cancer in remission, diabetes, and coronary artery disease presented to hematology clinic for evaluation of new onset anemia with a hemoglobin of 7.6g/dL. Symptoms included fatigue, shortness of breath, constipation, brain fog, insomnia, and a 20 lb weight loss over six months attributed to poor appetite. She denied bleeding or bruising. Labs showed no evidence of nutritional deficiency or acute hemolysis but were notable for elevated ferritin. Flow cytometry did not show evidence of leukemia or lymphoma. Given the unexplained anemia and significant weight loss, bone marrow biopsy (BMB) was completed to rule out bone marrow processes such as lymphoproliferative disorders or ineffective erythropoiesis. Bone marrow biopsy showed mildly hypercellular marrow with trilineage hematopoiesis and mild erythropoiesis with 15-20% ringed sideroblasts (RS) suggestive of ring sideroblast myelodysplastic syndrome (MDS-RS). FISH and next-generation sequencing were negative for MDS and hematologic malignancies. The patient was diagnosed with lead toxicity after labs showed a lead level of 115 ug/dL. The Department of Health was notified, and the patient was advised to abstain from using excessive amounts of spices after they were found to contain higher lead content than recommended. Her anemia and symptoms resolved with lead chelation therapy. Repeat BMB was completed with no evidence of ringed sideroblasts previously seen. IMPACT/DISCUSSION: The finding of ring sideroblasts on bone marrow biopsy opens the door to a wide range of differentials including copper deficiency, zinc or lead overload, toxic ingestion, or MDS. Given lead's effect on multiple organ systems, poisoning with this metal can present with a broad range of symptoms such as high blood pressure, renal failure, cognitive decline, constipation, or confusion. After chelation therapy, the patient’s repeat bone marrow biopsy did not show dysplasia or ringed sideroblasts as previously seen; therefore, lead toxicity was determined to be the most likely source of her original abnormal bone marrow biopsy. Given that MDS presents with signs of ineffective erythropoiesis and RS similar to lead poisoning, it is important for clinicians to not anchor on a diagnosis in the absence of broad workup and molecular testing to avoid misdiagnosing or mistreating the underlying cause. MDS diagnosis should not be made lightly, molecular testing as well as testing for secondary etiologies of RS should be done prior to establishing a diagnosis of MDS.

Lead poisoning can present nonspecifically, and it is important to keep it on the differential when considering etiology of ineffective erythropoiesis It is important to consider all secondary causes of ineffective erythropoiesis, and perform a complete molecular and genetic analysis before making a final diagnosis. LEGIONNAIRES' DISEASE: MORE THAN JUST PNEUMONIA Sundus Nasim, Timothy Hall, Kiran Chamarti, Shabraiz Rasul. Internal Medicine, Stony Brook Southampton Hospital, Southampton, NY. (Control ID #4250781) CASE: We present two cases of Legionnaires' disease complicated by deep venous thrombosis. A 54-year-old male with hypertension presented with fever and diarrhea. He was hypoxic, tachycardic, and tachypneic. Chest radiograph showed pneumonia, and lab results indicated hyponatremia. Given his occupation as a commercial fisherman, blood cultures and a Legionella urine antigen test were ordered. Two days later, he developed an occlusive left peroneal vein thrombus. The Legionella test was positive, and he was treated with Levofloxacin for Legionnaires' disease and Enoxaparin for deep venous thrombosis (DVT), later transitioning to Apixaban upon discharge. A 55-year-old female with a history of depression, hyperlipidemia, and hidradenitis suppurativa presented with dyspnea and myalgias. She was hypoxic and required intubation. Broad-spectrum antibiotics, sedation, and fluids were initiated. Chest radiograph showed bilateral pneumonia. An ultrasound revealed bilateral DVTs, treated with Enoxaparin. The patient was also diagnosed with Legionella and treated with Levofloxacin. She developed complications, including fungemia, acalculous cholecystitis, and seizures, and remains in the intensive care unit. IMPACT/DISCUSSION: Legionnaires' disease was first identified in 1976 after an outbreak at an American Legion convention. It spreads via inhalation of aerosolized water containing the bacteria, but no direct exposures were identified in our patients. One patient was a fisherman, while the other’s occupation is unknown. While Legionella has rarely been reported in freshwater, saltwater, and drinking water, it is unclear whether these environments contributed to our patients' illnesses. Immunosuppression may predispose patients to this infection, but it was not the case in our patients. One case shows hirsutism as an early sign before Legionnaires' onset, while our patient had a history of hirsutism. Whether the two conditions are related remains unclear. Both patients presented with fever, cough, chills, and diarrhea, which are common symptoms. Diagnosis was made using urine antigen tests, radiographic evidence of pneumonia, and clinical suspicion. Lab findings included hyponatremia, as seen in our cases. The recommended treatment is Levofloxacin or Azithromycin, with fluoroquinolones as alternatives. Legionnaires' disease has been linked to complications such as cerebellar involvement, transient parkinsonism, myocarditis, and rhabdomyolysis. A rare complication is DVT, which may lead to pulmonary embolism (PE). Two case reports describe Legionnaires' complicated by DVT, possibly due to bacterial toxins activating the coagulation cascade or elevated inflammatory markers. We present two cases of Legionnaires' disease complicated by extensive DVTs without other hypercoagulable risk factors.

The authors highlight the importance of timely diagnosis, treatment, and prompt recognition of complications in Legionnaires' disease to improve patient outcomes. LEPTOSPIROSIS IN A PATIENT EXPERIENCING HOMELESSNESS IN SAN FRANCISCO: A CASE REPORT Katya Lavine1; Cynthia Chalk2; Helen Jackson2; Leonid Yankulin2; Jonathan Volk2. 1Internal Medicine, UCLA Health, Los Angeles, CA; 2Kaiser Permanente San Francisco Medical Center, San Francisco, CA. (Control ID #4267799) CASE: A 68-year-old woman with an unknown medical history presented to the emergency department after a bystander noticed her looking unwell in a park. Her vital signs were normal. She endorsed moderate, bilateral leg pain. Exam was notable for scleral icterus. While alert and oriented, she was unable to provide additional history. Notable laboratory results included thrombocytopenia (platelets 20 K/uL), anemia (hemoglobin 10.6 g/dL), hypokalemia (K 2.5 mEq/L), abnormal renal function (creatinine 1.5 mg/dL), and abnormal liver function tests (total bilirubin 2.1mg/dL, ALT 56 U/L, AST 86 U/L). On hospital day two, piperacillin/tazobactam was started after blood cultures grew gram-positive rods, which was later determined to be a contaminant. Urinalysis was consistent with a urinary tract infection, and cultures grew Klebsiella pneumoniae. Due to her constellation of laboratory findings, bilateral leg pain, and homelessness, urine and serum Leptospirosis polymerase chain reaction (PCR) assays were ordered. Piperacillin/tazobactam was continued for her drug resistant Klebsiella and empiric treatment of possible leptospirosis. She remained clinically stable and completed a seven day course of piperacillin/tazobactam. Her urine leptospirosis PCR resulted positive near the end of this antibiotic course. Two weeks later, her platelets, liver tests, and creatinine had all improved. IMPACT/DISCUSSION: Leptospirosis is a zoonotic bacterial infection caused by Leptospira, a mobile, aerobic spirochete. Infections occur after exposure to water or soil contaminated by animal urine. There are 100-200 cases reported annually in the United States, with more than half in Hawaii. The last case of leptospirosis reported to the San Francisco Department of Public Health was in 2020 in a patient experiencing homelessness, although this patient had also traveled outside of the city. Other locations in the United States, including both in Florida and New York City have identified homelessness as a risk for infection, with dogs and rodents the likely bacterial reservoirs [1,2]. The patient’s non-oliguric renal failure, hypokalemia, and jaundice are consistent with Weil’s disease, a serious complication of leptospirosis. Other notable clinical and laboratory findings that are consistent with leptospirosis include lower extremity muscle tenderness, fever, thrombocytopenia, proteinuria, microscopic hematuria, muddy brown and WBC casts in the urine, elevations in ALT/AST, and hyperbilirubinemia. Notably, about half of patients with leptospirosis have conjunctival suffusion, which our patient did not have.

While leptospirosis is rare in most of the United States outside Hawaii, our patient’s homelessness increased her risk for exposure to infected animals and their urine. Leptospirosis should be considered in all patients from temperate and tropical areas of the world with the characteristic constellation of clinical findings and laboratory results, particularly in individuals experiencing homelessness. LIFTING THE VEIL ON BRONCHOALVEOLAR CARCINOMA: A CASE OF LOCALLY METASTATIC LEPIDIC ADENOCARCINOMA Omair A. Syed. Internal Medicine, Alameda Health System, Oakland, CA. (Control ID #4271140) CASE: A healthy 59-year-old immunocompetent female presented to the emergency department with progressive dyspnea, hypoxia, hemoptysis, and weight loss. She was hospitalized several months ago with similar symptoms, for which she received antibiotic treatment for community-acquired pneumonia. Computed tomography (CT) at that time showed left predominant multilobar consolidation with air bronchograms, bilateral ground-glass opacities (GGOs), and areas of nodularity deemed infectious in etiology. Symptoms subsided shortly after discharge, however they soon recurred with the addition of weight loss and worsening dyspnea. Follow-up CT after 3 months demonstrated significant expansion of GGOs. Initially, a top differential, diffuse alveolar hemorrhage was deemed unlikely given the chronicity and lack of an identifiable etiology. Infectious etiologies seemed unlikely given no constitutional signs or symptoms, acid-fast bacilli smears and cultures were negative, and bacterial and fungal cultures only grew normal flora. Vasculitis was considered given the anti-nuclear antibody (ANA) titer 1:40, but anti-neutrophil cytoplasmic antibodies and other markers were negative. Bronchoscopy yielded turbid/milky appearing fluid, concerning for pulmonary alveolar proteinosis, lipoid pneumonia, or malignancy. A subsequent biopsy confirmed the diagnosis of lung adenocarcinoma. The patient was treated for acute hypoxic respiratory failure and started on chemotherapy while admitted. IMPACT/DISCUSSION: This case highlights the importance of recognizing rare phenotypes of lung adenocarcinoma. Lung cancers are commonly seen as spiculated nodules or discrete masses; this can contribute to availability heuristic and anchoring bias. In recent years, there has been a paradigm shift in adenocarcinoma classification and understanding. Previously seen as distinct entities, BAC and invasive lung adenocarcinoma are now hypothesized to be representative of a spectrum from premalignant to invasive lung cancer. In 2017, the 8th edition of TNM (tumor, lymph nodes, metastasis) staging recognized new subclassifications and renaming of BAC based on histopathology. This change aimed to help guide management and further risk stratification. Recognizing the signs and symptoms of BAC early allows for adequate management, however, this may be a challenge due to BAC’s indolent course. This again contributes to its deceptive nature and can lead to misdiagnosis and delayed intervention.

This case report seeks to provide an example of a rare subtype of a common cancer. It is important to remember that radiographic findings may represent a multitude of etiologies and diagnostic workup should be tailored to the evolving clinical presentation. LMWH-INDUCED SKIN NECROSIS: A RARE BUT POTENTIALLY SERIOUS SIDE EFFECT Zachary Provenzano. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4272423) CASE: This patient is a 58-year-old male with a history of chronic pancreatitis who was admitted for sepsis, abdominal pain, and acute metabolic encephalopathy. On day one of admission, this patient was started on Enoxaparin 40mg injections daily as part of the typical venous-thromboembolism prophylaxis protocol for hospitalized patients. By day five of admission, he developed painful, bilateral purpuric skin lesions at injection sites on both his left and right lower quadrants. LMWH injections were promptly stopped, and these lesions slowly improved over the course of his two-week hospitalization. Platelet factor 4 antibody was ordered and was positive, but he did not develop thrombocytopenia, as can rarely be seen in cases of LMWH skin necrosis. Hematology recommended utilizing an oral anticoagulant for VTE prophylaxis, but ultimately he was not transitioned to another form of pharmacologic prophylaxis as there was significant concern for gastrointestinal hemorrhage during his hospitalization. Given his positive PF-4 antibody, he should avoid heparin products in the future. IMPACT/DISCUSSION: Skin necrosis is a very rare side effect of LMWH injections. A PubMed search resulted in less than forty cases of this reaction with LMWH, although similar reactions with unfractionated heparin have been much more commonly observed. LMWH-induced skin necrosis usually begins at injection sites within 6-12 days after administration, although it can begin sooner, especially in patients that have been previously exposed to heparin. Thankfully, most reported cases resolved with cessation of LMWH, although one particularly severe case necessitated surgical intervention and reconstruction after a single dose of dalteparin. With the current predominance of enoxaparin use for VTE prophylaxis for inpatients, clinicians should be aware of this potentially serious complication. If skin necrosis is suspected, LMWH should be stopped. Serotonin release assay or PF-4 antibody assay should be performed even without thrombocytopenia or significant suspicion for HIT, as thrombocytopenia is relatively uncommon in LMWH skin necrosis. Wound care should be promptly consulted for management of lesions, and surgical consultation can be considered for extensive necrosis that may require debridement or reconstruction. In the acute setting, patients should be monitored for HIT with frequent platelet count monitoring, and if necessary, alternative methods of anticoagulation should be explored. Patients who require continued therapeutic or prophylactic anticoagulation can be transitioned to a direct thrombin inhibitor or an oral anticoagulant.

- LMWH can cause significant local or systemic skin reactions, typically presenting as painful lesions at injection sites. - Early recognition and cessation of LMWH generally prevents poor outcomes. - Patients with known LMWH skin necrosis should be monitored for signs of HIT, and if clinically indicated, patients should be transitioned to non-heparin anticoagulation. LOSARTAN-INDUCED REFRACTORY ACQUIRED THROMBOTIC THROMBOCYTOPENIC PURPURA TREATED WITH CAPLACIZUMAB Joey Bettencourt1; George Warda2; Sanika Joshi3; Shrilkumar P. Bhatt4. 1Internal Medicine, Abrazo Health Care, Phoenix, AZ; 2internal medicien, Abrazo Health Care, Phoenix, AZ; 3Internal Medicine, Midwestern University, Glendale, AZ; 4Hospital Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4272622) CASE: This case discusses a 43-year-old nurse (G2P2) with a history of preeclampsia who presented with altered mental status, slurred speech, blurry vision, and facial droop that progressed over the course of 2.5 weeks that was subsequently diagnosed as Acquired Thrombotic Thrombocytopenic Purpura (aTTP) in the setting of recent Losartan administration. The patient began Losartan 50 mg after routine labs showed normal platelets (353) and hemoglobin (14.5). After one week, she developed blurred vision, fogginess, and ecchymoses. Upon increasing Losartan to 75 mg in week two, symptoms worsened, prompting discontinuation of the drug. Days later, confusion and facial droop led to her hospitalization. Upon admission, confusion and facial droop resolved, but additional findings included jaundice, petechiae and extreme fatigue. Labs were remarkable for hemoglobin 5.4, platelets 10, elevated D-dimer (4.72), elevated LDH (1134), and undetectable haptoglobin. A PLASMIC score of 7 prompted emergent plasma exchange and high-dose corticosteroids. ADAMTS13 activity <2% confirmed TTP, and Losartan was discontinued. Treatment included initiating Rituxan (day 7) and Caplacizumab (day 12) after minimal platelet improvement. By day 15, platelets rose to 59, and she was discharged on day 19 with platelets at 207 and ADAMTS13 at 26.7%, continuing Caplacizumab outpatient. IMPACT/DISCUSSION: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening microangiopathic hemolytic anemia characterized by thrombocytopenia, hemolytic anemia, renal, neurologic and systemic dysfunction. It results from congenital or acquired deficiencies of ADAMTS13, a von Willebrand factor-cleaving protease, leading to microthrombi formation and end-organ damage. This case represents the first documented instance of Losartan-induced TTP, with only one previous report linking Losartan to thrombocytopenia. TTP requires urgent diagnosis and treatment within 6 hours of presentation, distinguished from drug-mediated thrombotic angiopathy by ADAMTS13 activity (10% in drug-mediated thrombotic angiopathy). Standard treatment includes plasma exchange and corticosteroids, while caplacizumab can be used for refractory cases to inhibit von Willebrand factor-mediated platelet aggregation. The link between symptom onset and increased Losartan dosage underscores the importance of recognizing drug-mediated TTP to guide management and avoid unnecessary interventions. Using the DI-TTP criteria, this case qualifies as a “Possible” case of drug-induced TTP (DI-TTP) by meeting criteria 1 and 2. While it does not meet criterion 3, this is consistent with other reported cases, many of which are categorized as “Possible.” Clinicians must maintain high suspicion due to the rarity of such cases and limited available data.

Early use of the PLASMIC score and rapid initiation of plasma exchange with corticosteroids can be lifesaving. Suspect DI-TTP in patients with thrombocytopenia and anemia after recent medication changes. LOW-DOSE METHOTREXATE-INDUCED TOXICITY WITH GLOBAL SKIN MANIFESTATIONS AND LIFE-THREATENING MYELOSUPPRESSION Prajwal Gowda, Kohei Suzuki, Reshma Narain, Reeni Abraham. Internal Medicine, The University of Texas Southwestern Medical Center Medical School, Dallas, TX. (Control ID #4270775) CASE: The patient is a 62-year-old female with a past medical history significant for sarcoidosis, rheumatoid arthritis (RA), and CKD stage 4 who presented to the emergency department with seven days of bleeding lip sores and painful abdominal ulcerative lesions of the skin. She also presented with epistaxis. Of note, the patient was prescribed methotrexate (MTX) 7.5 mg PO weekly at an outside hospital less than two months prior to this encounter to initiate the management of RA. Her initial vitals were notable for a temperature up to 101.2 F. Her exam was notable for marked skin lesions within her oral cavity, petechiae and clean-based ulcers on her chest, and clean-based vulvar ulcers with erythema. Her labs were notable for WBC: 0.43, ANC: 10, Hgb: 9.4, and Platelets: 4. Her creatinine increased from 4.2 to 6.8 over the previous four days. CCP titers measured on admission were negative. MTX level was 0.05. The patient was placed on broad spectrum antimicrobials due to neutropenic fever. Hematology and dermatology were consulted for further investigations of pancytopenia and skin ulcerations. Skin biopsy showed interface dermatitis with epidermal dysmaturation, which indicated the diagnosis of MTX toxicity. Her course improved after discontinuation of MTX and treatment with leucovorin and filgrastim. The rheumatology consult team also determined she did not have findings suggestive of RA and thus MTX treatment was never clinically indicated. IMPACT/DISCUSSION: This patient’s case of MTX toxicity is significant from several perspectives. The patient displayed a plethora of possible studied symptoms of MTX toxicity including mucositis, dermatitis, myelosuppression with febrile neutropenia; however, it is one of the rare cases that was diagnosed based on skin manifestations with a pathological evaluation leading to the diagnosis. There are multiple recorded cases of MTX toxicity in patients with renal impairment; however, these patients were typically taking MTX for greater than one year. This case was especially concerning given she was started on MTX as an outpatient for a diagnosis of RA even with a negative CCP titers and minimal diagnostic evidence on exam. Therefore, this case highlights the importance of concluding diagnostic workups to ensure that a medication with such a high toxicity profile is indicated in the first place. Furthermore, this case was notable in that low measured MTX levels and duration of medication (two months) did not correspond to the high severity of toxicity. In terms of management, the patient's symptoms improved after eliminating the use of MTX and using leucovorin, which is the most studied and utilized therapy for MTX toxicity.

Serum MTX level did not correspond to the severity symptoms in low-dose MTX toxicity. It is important to complete the diagnostic workup of inflammatory arthropathies before prescribing MTX, especially in those with pre-existing renal impairment. LUPUS LYMPHADENITIS: A CAUSE OF REFRACTORY FEVER IN A 24-YEAR-OLD FEMALE WITH SYSTEMIC LUPUS ERYTHEMATOSUS Lillian Hallmark1; Benjamin Bryant2; Fernando Sigala2. 1Medical College, Rush University Rush Medical College, Chicago, IL; 2Hospital Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4244426) CASE: A 24-year-old female with a recent diagnosis of systemic lupus erythematosus (SLE), pulmonary hypertension, and iron deficiency anemia presented to the emergency department with 2 days of worsening maculopapular rash on her face and extremities, as well as two episodes of nonbloody diarrhea. She reported that these symptoms were similar to her most recent lupus flare 2 weeks prior. She also endorsed mild cramping abdominal pain, fatigue, rhinorrhea, and chills. On arrival to the emergency department, she was tachycardic to 164 beats per minute (bpm) and febrile to 103.1 degrees Fahrenheit (F). Physical exam was notable for a diffuse rash with non-painful, non-blanching erythematous macules and patches on her right face and bilateral upper and lower extremities. Electrocardiogram revealed sinus tachycardia. Labs were notable for elevated inflammatory markers, although lupus markers (C3, C4, anti-dsDNA) were decreased from prior admission. A computed tomography angiogram (CTA) of the chest showed no pulmonary embolism but revealed enlarged bilateral axillary and subpectoral lymph nodes with interval decrease since prior admission. She was started on empiric IV antibiotics and given IV fluids with minimal improvement in tachycardia. Rheumatology was consulted who suggested her fever and tachycardia were most likely related to an infection rather than a lupus flare based on her downtrending lupus labs. Dermatology diagnosed her rash as interstitial granulomatous dermatitis. A thorough infectious workup revealed C. diff positive stool and and HSV1 positive upper lip lesion treated with PO Vancomycin and PO Valacyclovir respectively. Despite broad spectrum antibiotics and treatment for identified infections, she remained cyclically febrile. Hematology was consulted for the lymphadenopathy identified on imaging and a new leukopenia on day 6 of admission. A CT of the neck showed multiple left supraclavicular lymph nodes bilaterally. The patient underwent a core needle biopsy of the left axillary lymph node with interventional radiology which revealed lupus lymphadenitis and no lymphoma. The patient’s prednisone was increased from 40 mg to 60 mg daily and her fever resolved three days later. IMPACT/DISCUSSION: Our patient presented with fever, diffuse rash, diarrhea, and lymphadenopathy and was found to have C. diff, HSV1, and lupus lymphadenitis. Lupus lymphadenitis is a rare cause of prolonged fever in patients with lupus and presents similarly to Kikuchi Fujimoto disease, which is a benign self-limited necrotizing histiocytic lymphadenitis. While Kikuchi Fujimoto disease is treated with supportive care, lupus lymphadenitis requires high dose steroids for treatment (0.5 mg/kg/day).

An excisional or core lymph node biopsy is indicated to establish the diagnosis of lupus lymphadenitis after a thorough infectious workup. It is important to determine the clinical significance of lymphadenopathy in SLE patients through a thorough clinical, laboratory, and pathological evaluation. LUPUS MYOPERICARDITIS IN A POSTPARTUM FEMALE Ali Bhutto. internal medicine, Baystate Medical Center, Springfield, MA. (Control ID #4267690) CASE: A 30-year-old female, G4P2, 8 weeks postpartum, with a history of hypertension, anxiety, depression, HSV-1, and a family history of sudden cardiac death, presented to the ED with worsening shortness of breath, headache, and stabbing chest pain for two weeks. The pain worsened when lying down or taking a deep breath and improved when leaning forward. She was breastfeeding and reported joint stiffness and pain, relieved by massage and heating pads. Labs showed elevated white blood cells, microcytic anemia, thrombocytosis, elevated D-dimer, proteinuria, and elevated protein-to-creatinine ratio. Immunology workup revealed positive ANA, anti-DNA, SM, and RNP antibodies. Chest X-ray indicated bilateral lower lobe pneumonia with pleural effusion. The echocardiogram showed reduced ejection fraction and mild diastolic dysfunction. Cardiac MRI revealed non-ischemic cardiomyopathy. She was treated with colchicine, and aspirin for acute pericarditis and started on Solu-Medrol and hydroxychloroquine for lupus myocarditis. Renal biopsy confirmed focal lupus nephritis (Class III) with thrombotic microangiopathy. She was started on CellCept after counseling regarding renal biopsy results and disease activity. IMPACT/DISCUSSION: Cardiac manifestations of SLE are multifaceted and can involve any part of the heart, including the valves, myocardium, pericardium, coronary arteries, or conduction system. Myocarditis is a rare presentation. Diagnosis is typically made through clinical evaluation and imaging studies. While myocardial biopsy can be used, it is less sensitive and difficult to interpret due to the focal nature of the disease. Our patient met the criteria for this diagnosis based on the SLICC guidelines. She presented with serositis (pericarditis and effusion), positive ANA and ds-DNA antibody titers, and involvement of multiple interphalangeal joints. Primary lupus myocarditis is uncommon, with few reports of heart failure or acute myocarditis as the initial manifestation of SLE. Borenstein et al. identified only 5 cases of myocarditis in 140 patients with SLE. Treatment with high doses of steroids has been shown to improve left ventricular function and acute pericarditis, while DMARDs remain the mainstay of treatment for disease remission.

Our case was peculiar due to multiple confounding factors that may have delayed diagnosis and management, including being 6 weeks postpartum and having a family history of sudden cardiac death. High clinical suspicion and a multidisciplinary approach were essential for timely diagnosis and treatment. The most challenging aspect of treatment in our patient's case was her decision to continue breastfeeding. Since DMARDs can pass into breast milk, the patient was primarily treated with high doses of steroids and hydroxychloroquine. After further discussions regarding the disease prognosis, she was started on mycophenolate mofetil. We continued to monitor her case, and she showed improvement in cardiac function with ongoing treatment. LYMPHADENOPATHY IN 20-YEAR-OLD FEMALE Molly Fitzpatrick1; Rita Poon1; Matt Coster2. 1Internal Medicine, MedStar Georgetown University Hospital, Washington, DC; 2Hospital Medicine, Georgetown University, Washington, DC. (Control ID #4273453) CASE: A 20-year-old female with no significant past medical history presents with a 5-week history of intermittent fever, loss of appetite, and tender cervical lymphadenopathy. She is otherwise a healthy college student with family history of lupus in her aunt. She denied any recent travel, sick contacts, or history of immunosuppression. Prior to this visit, she had tested negative for COVID, flu, RSV, and mononucleosis. She is up to date on her vaccinations. She has had prior EBV infection. On presentation, she was afebrile with normal CBC, BMP, and vitals. On exam, she appeared well, but had firm, well circumscribed, tender left cervical lymph nodes, most noticeably posterior auricular. CT neck showed diffuse left cervical lymphadenopathy with central necrosis. Patient was seen by hematology/ oncology and ENT for concern for lymphoma. Excisional biopsy showed lymph node with a histiocytic infiltrate, necrosis, no granulomas, consistent with Kikuchi-Fujimoto Disease (KFD). IMPACT/DISCUSSION: KFD, or histiocytic necrotizing lymphadenitis, is a rare, benign, self-limiting condition. Between its discovery in 1972 and 2014, only 22 cases had been documented in the United States. Symptoms include cervical lymphadenopathy and intermittent fever that can be accompanied by rash, splenomegaly, and weight loss. It occurs in younger adults and children, with a slightly higher predominance in women. The etiology is largely idiopathic but may be associated with SLE and infectious triggers, such as EBV, HHV 6, and HIV. KFD is often initially misdiagnosed as lymphoma, SLE, or lymphadenitis. Diagnosis of KFD relies on histologic analysis. It is characterized by focal necrosis with lymphocytes and CD8+ histocytes with a noticeable lack of neutrophils or granulomas. While lymphoma tends to have more CD4+ predominance, Kikuchi is CD8+ predominant. To distinguish from infectious lymphadenitis, KFD has a distinct lack of neutrophils or granulomatous tissue. KFD can look very similar to SLE lymphadenitis. Findings such as plasma cells, hematoxylin bodies, or neutrophilic infiltrate can point to SLE, though often clinical features must be considered as well. Excisional biopsy is the most reliable way to diagnose KFD. While fine needle aspiration is a less invasive method for diagnosis of other conditions on the differential, it may lead to a misdiagnosis that results in unnecessary treatment and psychological distress for young patients.

This case of a 20-year-old presenting with lymphadenopathy and intermittent fever demonstrates the characteristics of KFD, as well as the benefit of swift excisional biopsy in accurately diagnosing the patient. M. PNEUMONIAE-INDUCED RIME: A CASE REPORT Sasha Ghofrani1,2; Sierra Barber3,2; George Angelakakis3,2; Matthew S. Carnevali4; Clark Veet2. 1-, Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 2Lehigh Valley Health Network, Allentown, PA; 3University of Southern Florida Health Informatics Institute, Tampa, FL; 4Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4272462) CASE: A 38-year-old male with no relevant history presented for odynophagia. The patient endorsed flu-like symptoms for the previous few days, including rhinorrhea, watery eyes, and cough. On day 4 of illness, he developed intense throat pain, difficulty swallowing, and desquamation of the mucosa of his lower lip, mouth, and pharynx. He further endorsed new onset of 2-3 painful scrotal ulcers. These progressed to numerous genital lesions within 24 hours. At the time of admission, he was in acute distress due to pain but afebrile. Exam demonstrated mucosal sloughing of the soft and hard palates, lips, and throat; diffuse tonsillar exudates, and multiple scrotal skin lesions. At this time, working diagnosis included Steven-Johnson Syndrome (SJS). Chest imaging demonstrated bilateral pulmonary infiltrates. Laryngoscopy with ENT showed diffuse ulcerations of the epiglottis and hypopharyngeal surface. Infectious workup was positive for M. pneumoniae, leading to a diagnosis of reactive infectious mucocutaneous eruption (RIME) and M. pneumoniae-induced rash and mucositis (MIRM). The patient was treated with prednisone 50 mg twice daily for five days, followed by 50 mg once daily for five days. His genital lesions were treated with topical mupirocin. Pain management included “magic mouthwash,” acetaminophen, viscous lidocaine, oxycodone, morphine, and phenol throat spray. With treatment, the patient showed steady improvement with increasing tolerance of solid food. Repeat laryngoscopy on day 13 of admission showed marked resolution of laryngeal ulceration. The patient was discharged on day 14 of hospitalization with follow-up for ENT. IMPACT/DISCUSSION: RIME/MIRM can present similarly to SJS, and a clinician may have difficulty differentiating them by exam alone. Both can present with desquamating oropharyngeal ulcers and genital lesions. In this case, MIRM was supported by its lack of extensive external skin involvement compared to SJS. The presence of pulmonary infiltrates on imaging provided further evidence of an infection-associated disease as the underlying cause. This case demonstrated the importance of using multiple diagnostic tools such as blood work and imaging alongside detailed history and physical exam to rule out SJS and correctly identify the diagnosis. While the role of systemic steroids in the treating of MIRM is debated, this case demonstrated their efficacy in controlling inflammation and promoting recovery.

Respiratory prodrome and minimal to no external skin involvement are important features in the identification RIME/MIRM and its differentiation from SJS. Multiple diagnostic modalities can be used to identify infection-associated mucosal and skin conditions from alternative causes like medication-induced dermatopathy. MACULOPAPULAR RASH AND ASCENDING POLYNEUROPATHY IN A PATIENT WITH ACUTE MYELOID LEUKEMIA Stephanie Barna1; Ariel Majjhoo2. 1Wayne State University School of Medicine, Detroit, MI; 2Detroit Medical Center, Detroit, MI. (Control ID #4273434) CASE: A 51-year-old man with recently diagnosed acute myeloid leukemia (AML) presented to the ED for a one-month history of progressive neuropathy and weakness in a glove and stocking distribution along with five-day history of maculopapular rash. The patient’s neuropathy, described as numbness and tingling, began gradually the week following his first round of chemotherapy consisting of five days of cytarabine and two doses of gemtuzumab ozogamicin, after which a bone marrow biopsy was done showing complete disease remission. Symptoms progressed to include sensory loss to the shoulders and distal thighs bilaterally. Complete motor function was lost only in the left foot, however patellar and ankle reflexes were absent bilaterally. Additionally, the patient displayed a mildly pruritic non-painful maculopapular rash which began in the flexural surfaces of the legs, eventually spreading to the trunk. CT head and MRI of the brain, stem and cervical spine showed benign findings. Electromyography and nerve conduction studies showed demyelinating polyradiculoneuropathy suggestive of Guillain-Barre syndrome, which was further supported by albuminocytologic dissociation noted in CSF. Further immunophenotypic analysis of CSF showed 53% abnormal monocytes, suggestive of AML with CNS involvement. The patient’s rash was evaluated by punch biopsy with pathology suggestive of leukemia cutis. The patient initially underwent six sessions of plasmapheresis and started gilteritinib, after which azacitidine, venetoclax, and intrathecal methotrexate were added. CSF was clear of atypical cells 12 days after initiation of therapy regimen. At time of discharge, 25 days after admission, cutaneous lesions were completely resolved and neurological symptoms had improved moderately with lingering weakness of the lower extremities, especially on the left side, necessitating the use of a walker for ambulation. IMPACT/DISCUSSION: This case illustrates an unique presentation of ascending polyneuropathy in a medically complex patient which led to the discovery of reoccurrence of AML with CNS and cutaneous involvement in a patient that had been deemed to be in remission via bone marrow biopsy approximately two weeks prior. Questions remain about whether neurological symptoms were due to leptomeningeal disease or sensory dominant Guillain-Barre syndrome secondary to paraneoplastic syndrome, as treatment for both was started concurrently resulting in improvement of symptoms. Regardless, recognition of this presentation is critical in providing appropriate therapy promptly in effort to mitigate long-term harm.

AML uncommonly displays CNS and cutaneous manifestations, especially without disseminated disease. Awareness of this presentation provides internists with the insight to initiate the appropriate and timely evaluation and treatment needed to reduce morbidity and mortality in patients. MAGNESIUM MATTERS: A CASE OF HYPOMAGNESEMIA INDUCED CEREBELLAR SYNDROME Shoshana Terebelo, Aized Imtiaz. Northwell Health, New Hyde Park, NY. (Control ID #4218554) CASE: A 59-year-old male presented to the emergency room with confusion, dysarthria, weakness, and diarrhea for 6 days. He reported taking colchicine for a gout exacerbation a week prior. Past medical history was significant for gout, non-Hodgkin's lymphoma (in remission), and partial small bowel resection. Vital signs were within normal limits. Physical exam revealed dysarthria, bidirectional nystagmus, ataxia and dysmetria. Laboratory studies revealed the following electrolyte levels: potassium 2.0 mmol/L, calcium 5.7 mg/dL and magnesium <0.3 mg/dL. CT scans of the brain, abdomen and pelvis were unremarkable, so were cerebrospinal fluid results. MRI brain demonstrated cerebellar hyperintensity. A diagnosis of Hypomagnesemia Induced Cerebellar Syndrome was made. He was initially treated with intravenous magnesium supplementation. Due to ongoing diarrhea and slow improvement in serum magnesium levels, peripheral parenteral nutrition (PPN) was initiated which resulted in much more rapid improvement. Calcium was also replaced intravenously. His gait, weakness and dysarthria improved as his electrolyte levels normalized. Subsequently he was discharged from the hospital. We called the patient three weeks later and he confirmed continued improvement in his symptoms with ongoing oral magnesium supplementation. IMPACT/DISCUSSION: Hypomagnesemia induced cerebellar syndrome is a rare condition which should be on the differential diagnosis for any patient with cerebellar symptoms and hypomagnesemia. Due to the low prevalence of this condition, it is very easy to misdiagnose it for a stroke or for Wernicke’s encephalopathy. The differentiating test is brain MRI; in Wernicke’s Encephalopathy we are more likely to find hyperintensity in the mamillary bodies or temporal lobes instead of in the cerebellum. On literature review, we identified 24 cases; ours is the 25th. We found that up to 50% of patients also presented with hypocalcemia and/or hypokalemia. These patients showed symptomatic improvement after magnesium replacement, but 50% showed significant sequelae, and 46% relapsed. The use of PPN was a creative way of managing our patient and has not been reported before. We recommend further investigation into its clinical utility in such cases. Also, in hindsight, we should have initially admitted the patient to the ICU given the risk of arrhythmias.

Hypomagnesemia Induced Cerebellar Syndrome is a rare manifestation of critically low serum magnesium levels and can easily be misdiagnosed Individuals with this condition are at high risk of ventricular arrhythmias, seizures, and other complications of severe electrolyte derangements and should initially be admitted to the intensive care unit MANAGEMENT OF CIPROFLOXACIN-INDUCED IMMUNE THROMBOCYTOPENIA Maximilian Choo. Internal Medicine, East Alabama Medical Center, Opelika, AL. (Control ID #4272485) CASE: A 78-year old male with a past medical history of COPD arrived to the hospital with bleeding in his mouth that had started two days prior to admission. Patient had reported taking ciprofloxacin from his primary care physician for a urinary tract infection in those two days. Patient’s initial platelet count was 11,000/mcL and had a normal metabolic panel. Patient was admitted for thrombocytopenia. Initial physical exam showed stable vital signs, no signs of confusion, and multiple oral hematomas without acute bleeding. 1 Day after admission, his platelet count declined to 7,000/mcL with normal coagulation studies. Peripheral smear found no fragmented red blood cells and enlarged platelets. Patient was monitored for spontaneous bleeding. In the afternoon, medicine team was notified by nursing that the patient’s blood pressure dropped to 70/40 and altered mentation. Patient was sent to the ICU where he was started on IV norepinephrine and BiPAP. A full body CT scan was done and revealed no bleeding. Patient’s mentation and blood pressure improved. Hematology was consulted and confirmed ITP. Patient given IV dexamethasone 40 mg. Patient’s platelet count did not improve with 4 days of steroids. IVIG was given instead and platelets improved to 158,000/mcl in 6 days. Patient’s ITP was suspected to be associated with ciprofloxacin given use prior to admission, recovery after cessation, and alternative causes were excluded. IMPACT/DISCUSSION: ITP can be a difficult condition to assess since it is a diagnosis of exclusion. Careful history should be taken to find any inciting factor since secondary ITP can be caused by medications especially antibiotics. Fluoroquinolones are a family of antibiotics used for broad-spectrum coverage of bacterial infections. Known side effects include tendinopathy, neuropathy, cardiac conduction abnormalities and rarely, ITP. Normal treatment protocol for ITP begins with removing the inciting factor and platelet transfusion as needed but can escalate with IV steroids or IVIG with a platelet count less than 10,000/mcl. In our case, with a lack of response to steroids, a dose of IVIG was given and the ITP improved. Research in the management of ITP showed IV steroids and IVIG to be equally effective with IVIG working more rapidly than steroids1. Consensus between the two treatments is that either can be used and when one treatment fails the other can be used2. This case helps to reinforce that perspective.

Clinicians should take a thorough history when assessing a patient with severe thrombocytopenia to find any inciting factors especially medications. Assessment of ITP should involve hematology and a peripheral smear. Frequent clinical re-assessments are indicated in patients with severe thrombocytopenia to monitor adverse events such as spontaneous bleeding. Lastly, the management of ITP should begin with either IV steroids or IVIG depending on treatment response and should be adjusted in the setting of treatment failure. MANAGEMENT OF HEPARIN-INDUCED THROMBOCYTOPENIA IN A CARDIOGENIC SHOCK PATIENT REQUIRING LVAD INSERTION Charbel Matar2; Austin M. Cohen1. 1Internal Medicine, The George Washington University, Washington, DC; 2Hematology/Oncology, The George Washington University, Washington, DC. (Control ID #4273327) CASE: 66-year-old female with a past medical history of non-ischemic cardiomyopathy, heart failure with reduced ejection fraction, and atrial fibrillation on apixaban who was admitted to the cardiac intensive care unit for cardiogenic shock requiring an Impella device and eventual left ventricular assist device (LVAD) placement. During her admission, she developed a down-trending platelet count after the initiation of a heparin drip raising suspicion for heparin-induced thrombocytopenia (HIT), which was confirmed by a positive serotonin release assay and thus complicating the planned LVAD implantation procedure given the standard utilization of intraoperative heparin. In this case, we demonstrate an approach to perioperative management of HIT. This approach utilized preoperative transition to Bivalirudin, a direct thrombin inhibitor, which was used to stabilize platelet counts, and preoperative plasma exchange (PLEX) to reduce HIT antibodies. This combination successfully optimized the patient for re-exposure to intraoperative heparin during the LVAD surgery. IMPACT/DISCUSSION: This case highlights the complex challenges of managing patients with cardiogenic shock requiring procedures and HIT simultaneously. While heparin is a standard and effective agent for preventing thrombosis during cardiovascular procedures, there is a notable lack of literature and guidelines for patients who need cardiovascular procedures and have HIT. Consequently, there is no established protocol for patients like the one in this case, who required an LVAD procedure but faced significant thrombosis risk due to HIT. Despite the added complexity of HIT, this approach allowed the patient to successfully undergo LVAD implantation with the administration of intraoperative heparin.

This case employs an approach that shows that preoperative Bivalirudin and PLEX can be effective in managing HIT, prior to intraoperative heparin exposure, which remains the standard anticoagulant for high-risk cardiovascular surgeries. While there is some evidence that both PLEX and Bivalirudin have demonstrated efficacy in managing HIT in the context of cardiovascular procedures, there remains a significant lack of data, guidelines, and expert input for patients who need cardiovascular procedures and have HIT. MANAGEMENT OF NEW ONSET ATRIAL FIBRILLATION IN A PATIENT WITH PAROXYSMAL NOCTURNAL HEMOGLOBINURIA AND TETRALOGY OF FALLOT Brooke Escoe, Jacob Keesee, Reggie Skains, Javier Escobar, Mohamed Faris. Internal Medicine, Grand Strand Regional Medical Center, Myrtle Beach, SC. (Control ID #4273300) CASE: Here we present the case of a 54-year old female admitted with new onset atrial fibrillation (Afib) complicated by multiple chronic risk factors. On admission she was noted to have a positive COVID test one day prior to admission and given nirmatrelvir/ritonavir. Past medical history was notable for paroxysmal nocturnal hemoglobinuria (PNH) and Tetralogy of Fallot (TOF) with status post surgical repair. The patient’s home medications were lorazepam, aspirin, and ravulizumab q56 days. Physical examination on presentation was notable for jaundice and scleral icterus. Initial labs were notable for hemoglobin of 8.5 gm/dl, white blood cell count 2.4 k/mm3, total bilirubin 6.2mg/dL, and LDH 373 Units/L. The patient was treated for Afib with amiodarone, digoxin, and metoprolol. She was evaluated by cardiology and underwent transesophageal echocardiogram that revealed no evidence of clots and underwent successful cardioversion to normal sinus rhythm. The patient’s CHA2DS2-VASc Score was 1 (female gender), however given her increased risk of thromboembolism due to PNH, the decision was made to start the patient on apixaban therapy for stroke prevention with close hemoglobin monitoring. The patient was discharged home with instructions for close follow up with hematology and cardiology. IMPACT/DISCUSSION: Atrial fibrillation is a relatively common complication of TOF often resulting from atrial scarring post surgical repair. This is the first case report we are aware of that describes new onset atrial fibrillation in a patient with both PNH and TOF. Additionally, this patient had COVID 19 infection which may have precipitated her atrial fibrillation. While PNH has no known association with atrial fibrillation it does complicate management because the associated hemolysis increases risk of thrombosis as well as bleeding. This unique case highlights the lack of data available for anticoagulation in patients with PNH and atrial fibrillation. While C5 inhibitors (eculizumab, ravulizumab) have reduced rates of thrombotic events in patients with PNH, management of anticoagulation in Afib presents unique challenges as data remains lacking. This unique case highlights the difficulties of risk stratifications for anticoagulation of Afib and the need for additional assessment tools to assess risks and benefits in complicated patients such as the one presented here.

1. A thorough review of risks and benefits should be reviewed and discussed with patients with PNH and atrial fibrillation prior to initiation of anticoagulation therapy 2. More data is needed to develop recommendations/guidelines for anticoagulation in patients with PNH and atrial fibrillation MANAGEMENT OF OPIOID WITHDRAWAL IN A PATIENT WITH PROLONGED QTC AND TORSADES DE POINTES (TDP) Daniela Suarez-Rebling, Stephanie Conner. Department of Medicine, Columbia University, New York, NY. (Control ID #4269360) CASE: 49yo M with polysubstance use disorder (fentanyl, cocaine, cannabinoids) on methadone 280mg daily, HCV, HFrEF (EF 30-35%), bipolar disorder, depression, and housing insecurity was brought in by EMS after being found down in a park with a syringe. He was given Narcan and placed on non-rebreather for hypoxia. He was bradycardic and hypotensive. The patient reported his last dose of methadone on the day of presentation and used cocaine and fentanyl earlier in the day. In the ED, his vitals showed HR 53 bpm, BP 115/91, respiring normally on room air. He was unresponsive. Labs revealed potassium 5.5mmol/l, peak troponin 93ng/l and lactate 2.4mmol/l. ECG showed sinus bradycardia and prolonged QTc. His urine drug screen was positive for benzodiazepines, cannabinoids, cocaine, fentanyl, methadone, opiates, and PCP. Naloxone was administered and he was admitted to the acute care unit. On admission, he was alert but bradycardic with reported chest pain. Repeat ECG notable for TWI in anterolateral leads. COWS Score of 2. Shortly after arrival, a rapid response was activated for unresponsiveness. He had pinpoint pupils and bradypnea that responded to Narcan. He admitted to surreptitious opioid ingestion and was transferred to a stepdown unit (SDU) for a Narcan drip. In the SDU, his ECG showed progressive TWI I, II, V2-6, and QTc 642ms. Telemetry showed bradycardia and sinus pauses of 2-3s. TTE revealed LVEF 25-30%, global hypokinesis and new regional variations. Catheterization was deferred due to suspicion of type 2 (demand) ischemia. COWS monitoring was initiated and tylenol, gabapentin, dicyclomine, and klonopin were used to manage withdrawal. However, he progressed to severe withdrawal with diaphoresis, anxiety, nausea, and abdominal pain. ECGs notable for considerable ectopy and 2-4s of polymorphic VT/TdP. He was dosed IV magnesium, and magnesium and lidocaine drips were started. He denied cardiac symptoms throughout his course but experienced severe withdrawal. To avoid QT-prolonging medications, symptoms were managed with gabapentin, clonazepam, Tylenol, and hydromorphone with positive results. Trimethobenzamide, dicyclomine, and lorazepam were used for nausea. Poison control recommended buprenorphine micro-induction initiation with slow up-titration given methadone in his system. His QTc normalized, and he was discharged on buprenorphine three times daily, valproic acid for mood symptoms, and other supportive treatments with close QTc monitoring. IMPACT/DISCUSSION: This case highlights the challenges of managing withdrawal with QTc prolongation and TdP. Care requires ECG monitoring, avoiding QT-prolonging drugs, and specialized input for safe treatment.

1. Methadone prolongs QTc and routine ECGs are essential. 2. Managing opioid withdrawal in patients with prolonged QTc requires alternative medications. 3. High-risk patients should be closely monitored due to TdP's potential lethality. MANAGEMENT OF RECURRENT MALARIA COMPLICATED BY HEMOLYTIC ANEMIA Alexander Papadogiannis1; Samuel McFarlane2; Aashish Didwania2. 1Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4272519) CASE: A 30-year-old woman presented to our institution’s ED with a chief concern of headache, emesis, and fevers lasting several days. History was significant for a recent admission four weeks ago, where she had been treated for a malaria infection with IV artesunate and PO Artemether/Lumefantrine. In the ED, the patient had a Tmax of 100.3 and was tachycardic to the 110s. Initial labs were significant for a Hgb of 7.8 (baseline after discharge: 9.2), haptoglobin 500, consistent with a hemolytic anemia. A Malaria PCR was positive for P. falciparum, and a subsequent smear showed parasitemia of .01%. ID was consulted and recommended reinitiation of IV Artesunate. A direct antiglobulin test (DAT), was also collected to rule out autoimmune hemolytic anemia (AIHA), which was positive. Hematology was consulted regarding the positive DAT and concluded that the anemia was most likely secondary to the Artesunate the patient had received during her previous admission. A discussion was held with ID regarding the management of relapsed malaria with concurrent AIHA and a decision was made to transition the patient to Atovaquone-Proguanil, for which she completed a 5-day course. The patient was discharged with close follow-up. One month after discharge, the patient received outpatient labs, which were significant for the improvement of her anemia (Hgb: 11.5), and the resolution of her hemolysis labs (LDH/Haptoglobin). Her malaria PCR and smear were also negative at the time. IMPACT/DISCUSSION: An acute malaria infection can present with ambiguous symptoms including fever, malaise, and headaches. P. falciparum is the parasite associated with severe malaria. The initial management of severe malaria is IV Artesunate. An uncommon side effect of Artesunate is AIHA. However, this side effect is usually observed around 14 days after treatment but may occur at any time, and monitoring with weekly hemolysis labs is recommended for up to four weeks after therapy. Management of AIHA secondary to IV Artesunate includes transfusions for HgB <7 and consideration of IVIG and corticosteroids. Our case is unique because our patient presented with both AIHA and a relapsed malaria infection. There are no guidelines on this scenario and a decision about what treatment to use should be made in conjunction with ID specialists. In our case, a decision was made to trial our patient on a non-artemisinin agent, atovaquone-proguanil

● Autoimmune hemolytic anemia secondary to Artesunate is an uncommon complication but should be monitored, for four weeks after treatment. ● Management of concurrent autoimmune hemolytic anemia with an active malaria infection requires a two-pronged approach including a transfusion goal of Hgb>7, consideration of IVIG and corticosteroids, and discussions about an alternative anti-malarial therapy with the ID team. MANAGING AUTOIMMUNE PANCREATITIS WITH SPLENIC VEIN THROMBOSIS: A CASE REPORT ON TREATMENT DECISIONS AND OUTCOMES Tesnim Hamdan1; Iryna Witt1; Yukiko Brewer1; Nameer Ascandar1; Ali Basaran2; Stephen Ofori1; Soordal Prakash1. 1Internal medicine, HCA Healthcare Inc, Nashville, TN; 2Bahcesehir Universitesi, Istanbul, İstanbul, Turkey. (Control ID #4219025) CASE: A 56-year-old Caucasian woman with a medical history of recurrent pancreatitis, hypertension, hyperlipidemia, and thyroid cancer (post-thyroidectomy) presented with a month-long history of worsening left upper quadrant pain. Upon hospital admission, she was afebrile and hemodynamically stable. Lab tests revealed elevated lipase (1081 U/L), AST (31 U/L), ALT (14 U/L), alkaline phosphatase (97 U/L), normocytic anemia (hemoglobin 9.4 g/dL), and a triglyceride level of 147 mg/dL. A CT scan revealed a focal fluid collection in the pancreatic body and a small air bubble suggesting an intrapancreatic hematoma. Acute pancreatitis of the pancreatic head with splenic vein and portal vein occlusion was also noted. Absence of the gallbladder was consistent with her prior cholecystectomy. The patient was started on intravenous fluids and a heparin drip due to concerns about vascular involvement. An endoscopic ultrasound was performed, revealing acute inflammation without malignancy. Elevated IgG4 levels (147 mg/dL) raised suspicion of autoimmune pancreatitis. Hematology/oncology specialists were consulted to manage anticoagulation due to concerns about hemorrhagic pancreatitis. To mitigate the risk of further thrombosis and potential ischemia in the portal system, low-dose Eliquis (2.5 mg twice daily) was initiated alongside corticosteroids (prednisone 40 mg daily). This treatment aimed to balance the thrombotic and bleeding risks associated with her condition. The patient experienced significant clinical improvement, with reduced pain and better quality of life. IMPACT/DISCUSSION: Splenic vein thrombosis secondary to pancreatitis (PISVT) is an acquired complication of pancreatitis, historically linked to neoplasms. However, recent evidence points to pancreatitis itself as the primary cause of PISVT. The inflammation, enzyme release, and necrosis around the pancreas contribute to vessel wall damage, blood flow stasis, and thrombosis formation. The pathogenesis of vascular involvement in AIP remains unclear, with no strong evidence supporting the role of a hypercoagulable state in these patients. In the literature, studies, such as one by Ishikawa et al., suggest that vascular complications in autoimmune pancreatitis may improve with steroid therapy alone, without the need for anticoagulation. However, given the uncertainty, the use of low-dose anticoagulation in this patient alongside corticosteroids resulted in clinical improvement and highlights the need for further research into the management of autoimmune pancreatitis with vascular involvement.

This case underscores the complexity of treating autoimmune pancreatitis with splenic vein thrombosis and the ongoing debate about anticoagulation management. A balanced approach with both steroids and anticoagulation led to a favorable outcome for this patient, but further studies are needed to guide treatment strategies in such cases. MANAGING PHEOCHROMOCYTOMA IN A PATIENT WITH HEART FAILURE: A DELICATE FLUID BALANCE Anna B. Lichtiger2; Mohammed Bashier1; Hamza Sadhra2; Josette M. Kamel2; Mohammad Aziz3; Benjamin T. Galen2. 1Albert Einstein College of Medicine, Bronx, NY; 2Internal Medicine, Montefiore Medical Center, Bronx, NY; 3Division of Endocrinology & Diabetes, Montefiore Medical Center, New York, NY. (Control ID #4270041) CASE: A 48-year-old man with no significant medical history presented to the emergency department with six days of shortness of breath. Three years earlier, he was incidentally found to have a 4.5 cm heterogeneous right adrenal mass on a contrast-enhanced CT scan, with pre-contrast Hounsfield units of 44 and markedly elevated plasma metanephrines, suggestive of the diagnosis of a pheochromocytoma. He was lost to follow up in the intervening time. On presentation, he was tachycardic with evidence of pulmonary edema. Echocardiogram revealed systolic heart failure with an ejection fraction of 25%, suspected to be due to his pheochromocytoma. He was started on phenoxybenzamine for alpha blockade and diuresed until he was euvolemic. Maintenance fluids were initiated given the priority for volume expansion prior to adrenalectomy. However, he had recurrent pulmonary edema and respiratory failure. He was transferred to the cardiac care unit with plans for right heart catheterization to optimize his tenuous volume status. He thereafter developed massive strokes from a new left ventricular thrombus, which was a sequela of his cardiomyopathy, leading to further clinical deterioration and ultimately his death. IMPACT/DISCUSSION: Surgical resection is the definitive treatment for a pheochromocytoma. Therefore, preoperative management of this rare tumor is an important skill set for general internists. Preoperative management focuses on alpha- then beta-adrenergic receptor blockade to prevent hypertensive crises during anesthesia induction and during catecholamine surges from tumor manipulation. Intravascular volume expansion with intravenous fluids and a high sodium diet helps prevent vasodilatory shock after tumor resection. Heart failure develops in 8-11% of patients with pheochromocytoma due to the excessive catecholamine secretion which can lead to tachycardia-induced and Takotsubo cardiomyopathies. Although preoperative optimization for pheochromocytoma resection in patients with heart failure is critical, clear guidelines are lacking. In patients with acute decompensated heart failure, volume expansion and sodium repletion can exacerbate hemodynamic decompensation, which makes careful monitoring essential. Case studies have demonstrated the utility of mechanical circulatory support, inotropic support, and invasive hemodynamic monitoring with right heart catheterization as methods for stabilizing patients’ hemodynamic status and facilitating the appropriate preoperative management.

Pheochromocytoma can cause tachycardia-induced and Takotsubo cardiomyopathies. In patients with pheochromocytoma and decompensated heart failure, the intravascular volume expansion that accompanies alpha and beta adrenergic blockade can precipitate hemodynamic decompensation. Therefore, advanced hemodynamic monitoring and support, such as right heart catheterization, should be considered for precise volume optimization. Despite best efforts, delayed presentation or treatment can lead to poor outcomes. MARKED INTRA- AND EXTRAHEPATIC DUCT DILATION IN AN 85-YEAR-OLD MALE: A CHALLENGING DIAGNOSIS OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS Sruthi Selvakumar1; Aleksander D. Bermudez Perez2. 1Internal Medicine, University of South Florida, Tampa, FL; 2Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #4273083) CASE: We present a case of an 85-year-old male with hypertension, hyperlipidemia, and a 30-pack-year smoking history who presented with a 1-day history of nausea, right upper quadrant abdominal pain, subjective fevers, and nonbloody, nonbilious emesis. He also had decreased appetite, unexplained 5-pound weight loss, and steatorrhea over the last two weeks. He was afebrile, normotensive, and tachycardic up to 120s. Laboratory findings on admission included elevated white blood cell count (13,210/mm3), alanine transferase (ALT, 155 U/L), aspartate transferase (AST, 146 U/L), alkaline phosphatase (ALP 570 U/L), total bilirubin (1.9 mg/dL) with predominantly direct bilirubin, amylase (284 U/L), and lipase (396 U/L). Additional labs showed CA 19-9 of 75.49 U/mL and procalcitonin of 25.94 ng/mL. Of note, the patient had rising liver function tests for the last 3 months leading up to his presentation. A magnetic resonance cholangiopancreatography two weeks prior had demonstrated marked intrahepatic and extrahepatic biliary dilation, dilated common bile duct up to 1.5 centimeters, and main pancreatic duct dilation up to 1 centimeter. On admission, abdominal computed tomography reaffirmed the marked biliary and pancreatic ductal dilation. Endoscopic ultrasound showed dilation of both ducts with the pancreatic duct dilated to 1 centimeter around the pancreatic head and evidence of main pancreatic duct intraductal papillary mucinous neoplasm (IPMN). No pancreatic mass was identified. The patient’s symptoms and laboratory findings resolved during the hospitalization, and he was discharged with outpatient general surgery follow-up. IMPACT/DISCUSSION: This case demonstrates an alternative diagnosis in a patient who was presumed to have a pancreatic malignancy. IPMNs can be asymptomatic but in some cases may present with non-specific gastrointestinal symptoms, obstructive jaundice, pancreatitis, or exocrine pancreatic insufficiency. While a dilated common bile duct may not be common for main pancreatic duct IPMN, it has been previously observed, likely due to the sluggish pancreatic flow. IPMNs may involve either the main duct or a branch, but main pancreatic duct IPMNs have a higher rate of developing malignancy and have a risk of concurrent occult malignancy at the time of diagnosis. In the presence of symptoms attributable to the IPMN, surgical resection is recommended provided that the patient is a good surgical candidate. In this case, consideration of risks versus benefits in an elderly patient with multiple comorbidities is necessary. If asymptomatic, management is typically determined by duct size and suspicion for malignancy.

Main duct IPMN is a possible cause of acutely elevated liver function tests and gastrointestinal symptoms. Double duct sign, which is simultaneous dilation of the common bile duct and pancreatic duct, is often concerning for pancreatic malignancy, but other etiologies should be explored. MASKING MYASTHENIA: LATE DIAGNOSIS OF MYASTHENIA GRAVIS IN THE SETTING OF RHEUMATOID ARTHRITIS Sumaiyah Fatima1; Mubashira Sarnaik1; Virginia Bustamante2; Cesar A. Sanchez Padron3. 1Internal medicine, Marshfield Clinic Health System, Marshfield, WI; 2Med Peds, Marshfield Clinic Health System, Marshfield, WI; 3neurology, Marshfield Clinic Health System, Marshfield, WI. (Control ID #4247362) CASE: A 66 year old male with a history seronegative rheumatoid arthritis on intermittent prednisone therapy, recent diagnosis of Hodgkin's lymphoma, diabetes mellitus type 2, hypertension, CAD and OSA presented to the ED with concerns of dysarthria and dysphagia for 4 days. Patient had intermittently been on prednisone in the past due to his seronegative RA but had been off prednisone for greater than 2 weeks in preparation for his biopsy for generalized lymphadenopathy which revealed Hodgkin's lymphoma. Workup in the ED showed mild leukocytosis, elevated blood glucose levels, total protein and alkaline phosphatase. CT, MRI brain and cervical spine with contrast ruled out CVA or any structural abnormalities. Over the following days, patient's dysphagia worsened with increased oral secretions and difficulty swallowing. NG feeding tube was inserted. ENT, neurology, speech therapy services were involved. Flexible nasopharyngolaryngoscopy was done which showed normal true vocal cord mobility. Given his progressive muscle weakness noted by NIF and VC decline and decrease in diaphragmatic excursion, the patient was transferred to ICU and intubated for impending respiratory failure. CSF analysis was unremarkable. He was started on IV methyl prednisone, pyridostigmine, and IVIG empirically for a working diagnosis of Myasthenia gravis vs Lambert-Eaton syndrome. Thereafter, his NIF improved significantly and got extubated 5 days later. His ACh receptor antibody returned positive, thus confirming diagnosis of myasthenia gravis. IMPACT/DISCUSSION: Unusual presentations of myasthenia gravis like dysarthria or dysphagia can lead to consideration of various neurological disorders like stroke, Parkinson's disease, multiple sclerosis, myasthenia gravis, amyotrophic lateral sclerosis (ALS), pseudobulbar palsy, muscular dystrophy, paraneoplastic syndrome, as well as esophageal disorders in the differential diagnosis and cause delay in diagnosis and treatment of myasthenia gravis. The unique aspect about this case is the initial unusual presentation of myasthenia gravis with dysphagia and dysarthria superimposed on a parallel new diagnosis of Hodgkin's lymphoma. The history of usage of steroids also could have contributed to the suppression of symptoms and led to delay in diagnosis.

Our case demonstrates the need for consideration of myasthenia gravis in the differential diagnosis of isolated dysarthria, dysphagia or respiratory muscle weakness as these can be unusual presentations of the disease and lack of prompt diagnosis can lead to delay in treatment and serious complications like respiratory failure. Also to be wary of the fact that prior history of treatment with steroids can mask the symptoms and lead to delayed diagnosis. MEDICALLY RARE MEETS COMPLEX CARE - A CASE OF KIKUCHI-FUJIMOTO DISEASE FLARE Matthew Steinberg, Malika Elhage Hassan, Jake MacDonald, Sydney Taylor, Bonnie L. Cruser. Medicine, Emory University, Atlanta, GA. (Control ID #4270483) CASE: A 21-year-old female with a past medical history significant for hypoxic ischemic encephalopathy and G-tube dependence presented with a three-week history of progressive left cervical and axillary lymphadenopathy and intermittent fevers. Bloodwork also revealed leukopenia. She presented with similar symptoms at age 12 and was diagnosed with Kikuchi-Fujimoto disease (KFD) via lymph node biopsy, and at that time her symptoms self-resolved. Her current presentation raised concern for a KFD flare, although recurrence rate of KFD is only 3-4% (Perry and Choi, 2018. Kikuchi-Fujimoto Disease: A review). Differential diagnosis included infectious lymphadenitis, systemic lupus erythematosus (SLE), and lymphoma. After ruling out these alternative causes, she was treated with a tapering course of prednisone leading to symptom improvement. IMPACT/DISCUSSION: KFD, or histiocytic necrotizing lymphadenitis, is a rare, benign inflammatory disorder of unclear etiology affecting mostly young women. KFD’s pathophysiology remains unclear, although viruses and autoimmune mechanisms have been proposed. It often presents with painful cervical lymphadenopathy, low-grade fever, and systemic symptoms such as fatigue and night sweats. Hematologic abnormalities, such as leukopenia, may also occur. Diagnosis requires lymph node biopsy, which reveals characteristic findings of patchy necrosis with karyorrhectic debris, abundant histiocytes, and the absence of granulocytes or plasma cells. The differential diagnosis of cervical lymphadenopathy with systemic symptoms in this patient included KFD flare, infection, lymphoma, and systemic autoimmune diseases such as SLE. Microbiologic, serologic, and imaging studies excluded these other etiologies, and her history of biopsy-confirmed KFD supported a flare. Diagnosis was delayed by social determinants, including limited access to physicians familiar with KFD and the patient’s inability to communicate verbally at baseline. An initial ENT evaluation, likely not clinically necessary, prolonged hospital stay and underscores the need for greater provider awareness of this rare condition, especially important in this patient who had difficulty advocating for herself. Treatment of KFD is generally supportive, as the disease is self-limiting in most cases. However, corticosteroids are indicated in patients with severe or refractory symptoms, such as significant lymphadenopathy or prolonged fever.

This case highlights the diagnostic and therapeutic dilemmas posed by KFD flares in medically complex patients. Recurrence of symptoms after years of quiescence required a thorough workup to exclude infectious mimics, and social determinants of health further complicated care. Lymph node biopsy remains the gold standard for diagnosis, and corticosteroids can effectively treat symptomatic flares. It is important to maintain a high index of suspicion for KFD flares with presentations of unilateral lymphadenopathy and fever, particularly if there is a prior history of KFD. MENINGITIS/PARAMENINGITIS ASSOCIATED WITH GROUP A STREPTOCOCCUS BACTEREMIA: A SINGLE INSTITUTION CASE SERIES. Alison Hager1; Alvarho Guzman1; Anh Nguyen4; Tanner Korponay3; Abigail Belasen2. 1Medical College, Albany Medical College, Albany, NY; 2Internal Medicine, Albany Medical College, Albany, NY; 3PM&R, Albany Medical Center, Albany, NY; 4Internal Medicine & Pediatrics, Albany Medical Center, Albany, NY. (Control ID #4266889) CASE: A 56-year-old woman with diabetes and recent diagnosis of HSV otitis presented with sepsis, worsening encephalopathy, and ear pain. The patient was started on empiric antibiotics after obtaining blood cultures. A lumbar puncture showed marked pleocytosis but grew no organisms. Blood cultures showed Group A Streptococcus. Her course was complicated by septic shock requiring ICU stay. Head imaging showed mastoiditis. She was treated with a two-week course of ceftriaxone, left myringotomy tube, and ofloxacin otic drops. Symptoms, including cognition, improved. The patient returned to the hospital nine days later with back pain. MRI showed L5-S1 discitis/osteomyelitis. Blood cultures and bone biopsy showed no growth of organisms. Infectious Diseases recommended a 6-week course of daptomycin to cover for both GAS and possible nosocomial organisms that may have seeded her spine from the PICC line she had placed. A 64-year-old man with history of cirrhosis presented with encephalopathy, headache, right-sided weakness and tonic-clonic seizure days after a fall resulting in head strike and hand laceration. Upon arrival, he was found to be unresponsive with significant skin lesions with black eschar. A CT head showed mild prominence of the CSF along the cerebral convexities attributed to parenchymal volume loss or chronic subdural collections. Seizures continued. He was intubated and transferred to ICU for further care. He was placed on empiric meningoencephalitis coverage with acyclovir, ceftriaxone, and vancomycin. Lumbar puncture revealed opening pressure of 36-mmH2O with frank pus. MRI brain showed subdural empyema, ventriculitis, and cerebritis. CSF cultures showed GPCs in pairs-and-chains. Blood cultures grew GAS. He underwent surgical washout and subdural drain placement. He was treated with 3 weeks of ceftriaxone with gradual improvement in cognition. IMPACT/DISCUSSION: Here we report two adult cases of meningitis/parameningitis caused by GAS bacteremia. Streptococcus pneumoniae is the most common organism associated with meningitis, with an incidence of 5.16-6.11 cases per 100,000. Comparatively, the incidence of GAS meningitis is only 0.7 per 100,000. There are several case series of GAS meningitis in the pediatric population, but reports of adult GAS meningitis are much rarer. A recent study done in Denmark showed a 21-fold increase in GAS meningitis, which corroborates our case series. Risk factors for more severe infection in this series include diabetes, cirrhosis, and disruption of the skin-barrier.

Although the incidence of meninigeal/paramenigeal infections due to GAS continues to be low, it is important to recognize GAS as a causative organism given its severe morbidity and mortality. MERKEL CELL CARCINOMA PRESENTING AS UNILATERAL LEG SWELLING Lauren A. Sachs1; Jennifer Schmidt2. 1Internal Medicine Residency, Washington University in St Louis School of Medicine, St Louis, MO; 2Internal Medicine, Washington University in St Louis School of Medicine, St Louis, MO. (Control ID #4239501) CASE: A 77 yo woman with history of RA, CVA, HTN, remote colon cancer s/p resection presented for months of unilateral right lower extremity edema. She denied leg pain but endorsed diffuse warmth to the leg. She initially attributed the symptoms to an RA flare, but had not improved with meloxicam. On further discussion, she also noted a “mole” to her right buttock, increasing in size over the last two years. Denied weight loss, night sweats, dyspnea, chest pain, nausea, vomiting, fevers, or chills. Medications included methotrexate, folic acid, tofacitinib, hydroxychloroquine, valsartan, carvedilol, and aspirin. Family history included son with esophageal cancer. Denied alcohol, tobacco, or illicit drug use. She was afebrile with normal vital signs. Extremity exam revealed 2+ pitting edema in her right lower extremity, foot to hip, with mild erythema and warmth. A 6x4cm red/brown nodule with irregular borders was noted on her on right gluteus. CBC, CMP, lactate, and CEA were all normal/negative. Lower extremity dopplers were negative for DVT. CT scan showed a 6 cm enhancing lesion with neovascularity, and concommitant right inguinal, right iliac, and retroperitoneal adenopathy causing mass effect on the right external iliac vein. Biopsy of the lesion and a right inguinal lymph node were both consistent with Merkel cell carcinoma (MCC). Her unilateral swelling was attributed to decreased venous return due to iliac vein compression. She was treated with pembrolizumab followed by carboplatin/etopside, but continued to have progression on this regimen, as well as a subsequent regimen of ipilimumab/nivolumab. She passed away on hospice 7 months after her initial diagnosis. IMPACT/DISCUSSION: MCC is a rare but highly aggressive skin cancer, with about 7 cases per 1,000,000 people. It is more often seen in immunocompromised patients and those with other malignancies. Two prior case reports detail similar cases of women developing MCC while on tofacitinib, with one similarly developing the lesion on a non-sun exposed region, uncommon for MCC. Large database analyses have also demonstrated an association between JAK inhibitors and these rare cancers. MCC is often initially thought to be a benign lesion, and given its aggressive growth rate only 65% of cases are diagnosed prior to lymph node involvement or metastasis. Five year survival rate in the setting of distant metastasis is about 24%. Unilateral lower extremity edema is often due to DVT, venous insufficiency, cellulitis, or an MSK etiology. A more rare cause is May-Thurner syndrome. However, a mass in the pelvic region could also cause unilateral edema by compressing venous or lymphatic vessels. These include benign masses, such as uterine fibroids, but this could also be the first indicator of an occult pelvic malignancy.

While typically due to a more benign etiology, unilateral lower extremity edema can be the first manifestation of a pelvic malignancy MCC is a rare, often initially misdiagnosed, but highly aggressive skin cancer MILIARY TUBERCULOSIS AS AN ATYPICAL PRESENTATION OF UNDIAGNOSED HIV Alexandra Gaudet2,1; Ashley Yoo2; Sarah Conway3. 1Internal Medicine, The George Washington University Hospital, Washington, DC; 2Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 3Hospital Medicine, The George Washington University, Washington, DC. (Control ID #4270675) CASE: A 59-year-old female with a history of hypertension presented with generalized weakness. She endorsed a 30-pound weight loss, drenching night sweats, and recurrent low-grade fevers over several weeks. She immigrated from Zimbabwe 16 years ago, with her last travel three years prior. She denied sexual activity since immigration, HIV testing, and substance use. She denied known exposure to mycobacterium tuberculosis (MTB) and reported negative MTB testing three years ago. At that time, she had an inconclusive interferon-gamma release assay and subsequent lymph node biopsy for localized lymphadenopathy (LAD), which was negative for Acid-Fast Bacilli (AFB). She was afebrile and tachycardic on presentation. Physical examination revealed oropharyngeal thrush, diffuse LAD, non-focal weakness, and normal lung auscultation. Laboratory tests were notable for leukocytosis (13,800 cells/uL), anemia, and mild transaminitis. A CT scan showed innumerable centrilobular nodular opacities throughout the lungs and extensive bulky LAD throughout the chest, abdomen, and pelvis, suspicious for malignancy. HIV ELISA was positive, confirmed by PCR with a viral load of 87,600 copies/mL and an absolute CD4 count of 4 cells/uL (3%). Sputum samples revealed numerous AFB and MTB on PCR. She was diagnosed with advanced HIV infection and miliary MTB and treated with rifampin, isoniazid, pyrazinamide, and ethambutol. Antiretroviral therapy was delayed by one week to reduce the risk of immune reconstitution inflammatory syndrome. She was discharged after clinical improvement and safe response to MTB and antiretroviral therapies. IMPACT/DISCUSSION: While HIV often presents with nonspecific symptoms, about one-third of patients are co-infected with MTB. Immunosuppression increases the risk of progression to miliary disease. This case illustrates the diagnostic challenges of miliary MTB, particularly without classic pulmonary symptoms, with up to 10% misdiagnosed due to atypical radiographic patterns and nonspecific symptoms. Such presentations may reflect rapid progression from recent primary infection, as 8-10% of immunocompromised individuals progress to active MTB within months. Alternatively, HIV and MTB may have gone undiagnosed due to false-negative testing, as AFB and PCR have reduced sensitivity in miliary disease.

This case underscores the importance of early diagnosis and repeat screening for HIV and MTB, especially in those with epidemiologic risk factors. The rising MTB incidence highlights the need for heightened clinical suspicion and improved provider education about evolving presentations in non-endemic areas. Clinicians must remain vigilant for atypical MTB presentations despite negative tests. Early HIV diagnosis and proactive testing in high-risk patients with nonspecific symptoms are vital to improving outcomes and preventing the spread of HIV and MTB. MISINTERPRETED SYMPTOMS: A CASE OF DERMATOMYOSITIS INITIALLY DIAGNOSED AS SKIN INFECTION Fathima Alam. Internal Medicine, Bon Secours Mercy Health, Cincinnati, OH. (Control ID #4273431) CASE: A 70-year-old male with a past medical history of severe chronic obstructive pulmonary disease (COPD) status post-Zephyr procedure presented to his primary care physician with erythema on his back, neck, chest, and face. These skin lesions were accompanied by pruritus. His primary care physician diagnosed him with a Staphylococcus aureus skin infection and treated him with doxycycline and mupirocin ointment, with no significant improvement after the treatment course. His symptoms progressed to include pain and weakness in his shoulders and thighs. Due to worsening symptoms, he visited the hospital and was admitted for further evaluation. Initial workup revealed elevated CK (4000), elevated CRP (81), elevated liver function tests, thrombocytosis, and elevated aldolase. However, his ANA, anti-Jo, anti-SCL70, and anti-RNP antibodies were negative. A chest X-ray showed multiple round masses in the left upper lung, up to 6 cm. The patient underwent an IR biopsy, which revealed non-small cell carcinoma, likely reflecting primary lung carcinoma. CT of the abdomen showed multiple renal masses, suggestive of primary renal cell carcinoma. An MRI revealed nonspecific myositis involving the supraspinatus, infraspinatus, short head of the biceps brachii, deltoid, and trapezius muscles. A muscle biopsy of the deltoid showed end-stage severe myofiber atrophy, consistent with chronic denervation atrophy. The patient was started on prednisone 30 mg daily. According to the rheumatologist, the most likely diagnosis is paraneoplastic dermatomyositis, and treatment of the patient's cancers will be required to resolve his symptoms. Unfortunately, the patient experienced acute respiratory failure, was emergently intubated, but the family requested a transition to comfort care, and he was compassionately extubated. IMPACT/DISCUSSION: Dermatomyositis is rare disease, it is a form of idiopathic inflammatory myopathy that involves skeletal muscle and skin, and its classic presentation includes symmetric proximal muscle weakness, along with signs such as the V-sign, shawl sign, Gottron's papules, or a heliotrope rash. Dermatomyositis can mimic many different skin conditions, but it is important to recognize the classic findings and consider it in your differential diagnosis.

Dermatomyositis is an idiopathic inflammatory myopathy characterized by progressive muscle weakness and distinct skin manifestations. Diagnosis is typically based on the presence of muscle weakness, characteristic skin rashes, elevated serum muscle enzymes, muscle biopsy findings, and abnormal electromyogram results. Although the incidence of DM is rare, it is notably associated with various malignancies, with lung cancer being the most common. This case report discusses a patient with classical DM and lung cancer. Emphasizing the importance of early detection, precise diagnosis, and timely intervention can significantly improve patient survival outcomes. MORE THAN A QUICK ADJUSTMENT: A CASE OF GIANT CELL TUMOR REVEALED BY PATHOLOGIC FRACTURE AFTER CHIROPRACTIC MANIPULATION Karla Chamorro Garcia1; Jacob Riegler1,2. 1Internal Medicine, Cambridge Health Alliance, Cambridge, MA; 2Accounting and Management, Harvard Business School, Boston, MA. (Control ID #4273008) CASE: A 24-year-old man from Honduras with no medical history presented to the emergency department (ED) after acute onset pain in the right hip following chiropractic manipulation. During his visit to the chiropractor, he noted a loud “crack,” after which he was unable to ambulate or weight bear on the right side. He was seeking care at a chiropractor following a fall seven months prior to presentation with persistent hip pain. Notably, the patient stated that he was going to the chiropractor for “rubbing” of the right limb, a cultural practice that involves deep lymphatic massage meant to treat unclear pains or unresolving illness. In the ED, the initial exam revealed pain on passive range of motion in the right hip with mild right hip bruising. CT scan of the right hip showed a large lytic lesion with cystic appearance in the right femoral neck and intertrochanteric region with nondisplaced comminuted fractures of the femoral neck and greater trochanter. Initial differential was most concerning for unicameral vs aneurysmal bone cyst. Given that these cystic lesions can hide malignancy, our medical team recommended MRI of the right hip and biopsy during the planned open reduction and internal fixation (ORIF) by orthopedics. MRI revealed large complex enhancing lesions with fluid levels in the femoral shaft, which was concerning for giant cell tumor, aneurysmal bone cyst, or osteosarcoma. Biopsy revealed a diagnosis of giant cell tumor. The patient is now back at functional baseline following ORIF and there are ongoing discussions regarding further treatment. IMPACT/DISCUSSION: Giant cell tumors are benign bone tumors that are accountable for 20% of benign primary skeletal tumors with a peak onset between ages 20-50. The most common locations for these are the distal femur, tibia, and radius. This case represents a rare location for a giant cell tumor that had atypical features on imaging. It is important for general internists to consider that a cystic appearance, particularly unicameral vs aneurysmal bone cysts, on imaging may hide benign or malignant bone lesions and this warrants biopsy regardless of the location of the lesion. Another important factor in this case was the cultural belief that motivated the patient to seek chiropractic manipulation, which unfortunately led to an exceedingly rare complication of hip adjustment with a pathological hip fracture. Cultural awareness and discussion regarding concomitant traditional medical treatment were essential to providing culturally competent care for this patient.

A cystic appearing bone lesion may hide underlying malignant or benign lesions and if surgery is planned biopsy should always be performed Hip fracture is an exceedingly rare complication of chiropractic manipulation, and this should raise concern for pathologic or osteoporotic fracture Culturally competent care is crucial in guiding patients through challenging diagnoses with complications that arose through non-traditional medical care MORE THAN MEETS THE EYE: A CASE OF BURKITT’S LYMPHOMA IN AN IMMUNOCOMPETENT ADULT Alex P. Danielson, David Raslau. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4272756) CASE: A 75-year-old male with a history of former tobacco use presented to the emergency department with worsening double vision, headache, and generalized weakness. Two weeks prior, he had been hospitalized for similar symptoms and diagnosed with bilateral cavernous sinus thrombosis. Despite being started on apixaban, his symptoms had continued to progress. He reported one episode of dark, tarry stool a week earlier. On presentation, he was afebrile and hemodynamically stable. Neurological examination revealed right eye ptosis, as well as right cranial nerve III and VI palsies. An ulcerated mass was noted on the inside of his mouth along the left lower gumline. Abdominal and cardiopulmonary examinations were normal. Laboratory results showed a hemoglobin of 8.7 g/dL, decreased from 13.5 g/dL one week prior. A computed tomography (CT) head venogram redemonstrated findings of cavernous sinus thrombosis and a mass-like soft tissue thickening around the left mandibular body with associated osseous erosive changes. To investigate the acute anemia, an esophagogastroduodenoscopy (EGD) was performed, revealing several oozing ulcers that were biopsied. A mandibular biopsy was also conducted to evaluate the ulcerated mass. Despite continued anticoagulation, the patient developed new cranial nerve impairments and left eye ptosis, prompting a magnetic resonance (MR) brain venogram. This showed enlargement of the soft tissue masses in the cavernous sinus, concerning for progressive neoplasm rather than thrombus. Anticoagulation was subsequently discontinued, and pathology from both the stomach ulcer and mandibular mass biopsies confirmed Epstein-Barr virus (EBV)-positive Burkitt’s lymphoma (BL). A skull to thigh positron emission tomography (PET) CT scan showed extensive bony and extramedullary involvement. The patient underwent three cycles of chemotherapy inpatient. He was discharged to complete three additional cycles, with subsequent remission. At a six-month follow-up, the patient reported feeling well, and surveillance imaging showed no evidence of recurrent lymphoma. IMPACT/DISCUSSION: BL is an aggressive B cell non-Hodgkin lymphoma that usually presents in children, as either the sporadic or endemic subtype, or is associated with immunodeficiency. It is rarely observed in immunocompetent adults over 65. The patient's presentation was atypical, as he initially presented with cranial nerve palsies resulting from central nervous system (CNS) tumor burden. Jaw or facial bone involvement and gastrointestinal bleeding are additional clinical findings of BL, which helped prompt this patient’s diagnosis. BL is rapidly progressive, however cure rates are high for patients who are treated with timely chemotherapy.

Here we present a rare case of BL seen in an immunocompetent adult. Metastatic lymphoma should be considered in the differential diagnosis of patients with cranial nerve palsies and constitutional symptoms, particularly if symptoms progress. MORE THAN MEETS THE EYE: UNDERDIAGNOSED CAUSE OF VISION CHANGE Paola Campillo1; Zein Barakat2; Omar Zuhdi3; Chidozie Igbonagwam4; Anas Bizanti5. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2Internal medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 3Internal Medicine , Lakeland Regional Health Medical Center, Tampa, FL; 4GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 5IM, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4272667) CASE: A 58-year-old male with no significant past medical history presented with progressive, painless central vision loss in the left eye, which later involved the right eye. Initial symptoms included blurred central vision and "ink blot" shadows. Social history revealed a recent unprotected sexual encounter, but the patient denied any prior genital ulcers, rash, or systemic symptoms. Physical examination noted an afferent pupillary defect, bilateral optic nerve margin blurring, and Argyll Robertson pupils. MRI of the orbits demonstrated optic neuritis, and cerebrospinal fluid analysis showed lymphocytic pleocytosis and elevated protein, initially leading to a diagnosis of autoimmune optic neuritis. Steroid therapy resulted in transient improvement, but subsequent fundoscopic evaluation revealed bilateral chorioretinitis with hypopigmented placoid lesions. Serologic testing confirmed syphilis. The patient received 14 days of intravenous benzyl penicillin, which led to mild visual improvement; however, the patient was lost to follow-up, leaving long-term outcomes unclear. IMPACT/DISCUSSION: This case highlights the diagnostic complexity of ocular syphilis, particularly when traditional systemic manifestations and risk factors are absent. Ocular syphilis mimics autoimmune and other infectious processes, which can delay appropriate management. Unlike the typical demographic (men who have sex with men or patients with HIV co-infection), this patient represented an atypical presentation, emphasizing the need for clinicians to maintain a broad differential diagnosis for unexplained vision changes. This case underscores the importance of thorough sexual histories and early serologic testing for syphilis. It also contributes to the literature by showcasing a case of bilateral optic neuritis and chorioretinitis as the sole manifestations of late-stage syphilis.

Ocular syphilis should remain a consideration in any patient presenting with unexplained visual symptoms, even in the absence of traditional risk factors. Early serologic testing and timely initiation of penicillin therapy are critical to improving outcomes and preserving vision. MOSQUITO’S BITE – FROM THE WEST NILE TO LOUISIANA Besim Ademi, Luke Taggart. Internal Medicine, Tulane University School of Medicine, New Orleans, LA. (Control ID #4215904) CASE: A 72-year-old man presented to the emergency room with reported headache, chills, subjective fever and joint pains. On his initial workup, his laboratory work, vitals and physical exam were reassuring and the patient was discharged. A week later, the patient re-presented with persistent symptoms and new onset confusion described as short-term memory loss and brief disassociation episodes. Repeat evaluation demonstrated an elevated white count of 18.0 K/uL, fever of 102.1°F as well as disorientation on physical exam. Comprehensive workup, including HIV, TSH, RPR, blood culture and urine culture were all unrevealing. MRI of the brain did not demonstrate any abnormalities. The patient was placed on empiric bacterial meningitis coverage with vancomycin, ampicillin and ceftriaxone. He also received dexamethasone. Subsequent lumbar puncture was notable for elevated protein of 90.0 mg/dL, glucose of 49.0 mg/dL and 83% lymphocytes. Other cerebrospinal fluid (CSF) studies, including meningitis panel, VDRL, HSV, cryptococcus, gram stain and culture were negative. On the next day, the patient had significant clinical improvement. With more detailed history, the patient relayed that he had spent considerable time outside by his pool and was bitten by multiple mosquitoes prior to onset of symptoms. Even more, the patient was able to relay that he noticed one mosquito that was abnormally large. A West Nile IgG and IgM were added to the CSF studies, which both later became positive. However, given the initial CSF findings and clinical history, a viral borne meningitis was strongly suspected. Antibiotics were discontinued and the patient was discharged in a stable condition with supportive management. IMPACT/DISCUSSION: Appropriate diagnosis and antimicrobial coverage remains paramount in mitigating mortality and improved patient outcomes in meningioencephalitis. West Nile Virus (WNV) is often overlooked as a possible cause of meningoencephalitis and poses a significant diagnostic challenge. With only 65 reported cases of WNV in Louisiana, it can often be overlooked as a cause of altered mental status and meningoencephalitis. In this case, elevated protein in the CSF and lymphocyte predominance pointed towards a viral etiology. In WNV, IgM antibodies will become positive 3-8 days following onset of illness and can persist for months. IgG antibodies can likewise persist for long periods of time. Classically, the presence of IgM indicates an acute infection while IgG notes a response or prior infection.

In the summer months of the year, especially in the Gulf Coast states, WNV should be considered as part of the underlying differential for altered mental status and meningoencephalitis. Specific clinical questions, such as time spent outside or exposure to mosquitoes, should also be asked to these patients. Though the treatment is supportive, eliciting a diagnosis or suspicion of WNV can shorten hospital stays and significantly help dictate safe antimicrobial decisions and tapering. MULTIBACILLARY LEPROMATOUS LEPROSY WITH ERYTHEMA NODOSUM LEPROSUM: A CASE OF CYCLIC FEVERS, RASH, AND ARTHRALGIAS David G. West1; Morgan Baudoin2; Taylor Bundy3. 1School of Medicine, Spencer Fox Eccles School of Medicine at the University of Utah, Millcreek, UT; 2Internal Medicine, University of Utah Health, Salt Lake City, UT; 3Internal Medicine, Intermountain Healthcare, Salt Lake City, UT. (Control ID #4272542) CASE: Introduction: This case describes a 23-year-old male from Venezuela presenting with recurrent fevers, rash, and arthralgias, ultimately diagnosed with lepromatous Hansen's disease. It highlights the challenges of diagnosing rare infectious diseases in patients with extensive exposure history. Presentation: A 23-year-old male was admitted for cyclic rash and fevers. Symptoms began three years prior, with fatigue, intermittent fevers, and a macular rash originating on the upper and lower extremities. Additional symptoms included 8 kg weight loss, night sweats, arthralgias, orchitis, and lymphadenopathy. In Venezuela, he was diagnosed with brucellosis and leptospirosis after cardiac arrest and treated with penicillin, rifampin, and doxycycline, with initial symptom resolution. A year later, symptoms recurred and were managed with ivermectin. After immigrating to the U.S., episodic recurrences of rash, fevers, and arthralgias prompted multiple emergency and outpatient evaluations. Exposure history included agricultural work with cattle, cats, and dogs; contact with animal placenta; unpasteurized dairy and raw seafood consumption; travel through jungles and rivers in multiple Central American countries; and mosquito bites. Physical exam revealed painful violaceous skin nodules on thighs, hypoesthetic scaly plaques on shins, and diffuse painful lymphadenopathy. Workup: Imaging revealed splenomegaly and calcified granulomas. Lymph node biopsy was unremarkable. Extensive rheumatologic and ID workup was negative. Skin biopsy of nodular lesions showed spongiotic dermatitis and neutrophilic panniculitis with granulomatous inflammation. Positive FITE staining for mycobacterium leprae confirmed the diagnosis of lepromatous Hansen's disease. The patient later disclosed that his father had been treated for leprosy, corroborating the diagnosis. Management: The patient was started on rifampin, dapsone, and clarithromycin, with plans to add clofazimine pending availability. ID specialists collaborated with the National Hansen's Disease Program and county health department for treatment and contact tracing. Corticosteroids were given for erythema nodosum leprosum, and ophthalmology and EMG follow-ups were arranged for monitoring complications. He was educated on the 12-month treatment plan and reassured of non-contagious status 72 hours after therapy initiation. IMPACT/DISCUSSION: This case highlights the diagnostic challenges of Hansen's disease in non-endemic regions. Lepromatous leprosy often presents insidiously with nonspecific systemic symptoms, requiring high clinical suspicion and thorough tissue evaluation. The case emphasizes the importance of maintaining a broad differential and understanding exposure history in evaluating febrile illnesses.

This presentation of nonspecific symptoms underscores the complexity of diagnosing rare tropical diseases in a globalized world. Thorough workup, multidisciplinary management, and public health collaboration were critical in optimizing care. MULTIFOCAL INFECTIOUS EMBOLI WITHOUT IDENTIFIED SOURCE PRESENTING AS ACUTE PYELONEPHRITIS Ahmed Siddiqui, Austin M. Cohen, Michael Holman, Gina Jabbour. Internal Medicine, The George Washington University, Washington, DC. (Control ID #4272925) CASE: 59 year-old man with a history of hypertension, ankle surgery with hardware in place, presents to the hospital after several days of bilateral flank pain associated with nausea, vomiting, increased urinary frequency, and fevers. He denies chest pain, dyspnea, hematuria, dysuria, diarrhea, constipation. Temperature 102.3 F, blood pressure 156/94 mmHg, heart rate 90 bpm. He appears in moderate distress, tachycardic with mild tachypnea, soft/nontender abdomen, and right CVA tenderness present. Patient denies smoking, alcohol, drugs. Family history noncontributory. White blood cell count is 11.85, and other routine laboratory test results are normal. Urinalysis was normal. Computed Tomography (CT) of the abdomen reveals hypoattenuation of the right kidney lower pole with surrounding perinephric fat stranding suggestive of pyelonephritis, and associated filling defects within the right renal vein concerning for nonocclusive renal vein thrombosis. Patient was admitted for sepsis and started on ceftriaxone for pyelonephritis and heparin for renal vein thrombosis. Blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA), prompting initiation of vancomycin. Heparin was discontinued due to new concern for septic emboli with subsequent radiographic evidence showing septic emboli to the lungs. Following 48 hours of vancomycin, repeat cultures were negative and patient clinically improved. Transesophageal echocardiogram (TEE) showed no evidence of structural heart disease or vegetations. The patient was treated with IV vancomycin for six weeks, with no new infectious concerns at follow-up visits. IMPACT/DISCUSSION: The high specificity of CT imaging in pyelonephritis and the patient’s triad of flank pain, fever, and nausea, led to an initial focus of treating pyelonephritis, although a sterile urinalysis made the diagnosis less plausible. With renal vein thrombosis on initial imaging and positive blood cultures, the filling defect on CT was deemed consistent with a septic embolus, and further CT imaging of the chest revealed septic emboli in the lung. This prompted further workup, with a primary concern for infective endocarditis (IE). TEE in our patient’s case did not reveal endocarditis, however, clinically this was the diagnosis that would best explain his presentation. The patient met modified Duke’s criteria for possible but not definite endocarditis. The ICE-PCS study found that in a cohort of patients diagnosed with IE, 13% did not have radiographic evidence of endocarditis. Studies suggest that the AHA guideline for repeat TEE in suspected IE can impact management, although in this case, no repeat TEE was performed.

- Septic emboli can lead to infection and/or inflammation characteristic of pyelonephritis - Question diagnosis of pyelonephritis in the setting of sterile UA - TEE is not always definitive in identifying radiographic evidence of endocarditis MULTIORGAN FAILURE FOLLOWING COVID-19 IN A PATIENT WITH POTOCKI-LUPSKI SYNDROME: RAISING NEW CONCERNS ABOUT IMMUNE SYSTEM PREDISPOSITIONS. Karam Zakharia1; Radia Ksayer1; Maissaa Janbain2. 1Internal medicine, Tulane University, New Orleans, LA; 2Hematology/Oncology, Tulane University, New Orleans, LA. (Control ID #4270966) CASE: Potocki-Lupski Syndrome (PTLS) is a rare genetic disorder caused by duplication of chromosome 17p11.2. It is associated with developmental delays, delayed gross motor milestones, and occasional congenital cardiovascular abnormalities, such as atrial septal defects (ASD) and ventricular septal defects (VSD). However, little is known about the systemic impact of infections like COVID-19 in PTLS patients, particularly on patients without congenital cardiovascular anomalies. A 24-year-old male with PTLS, diagnosed at age 18, had a transthoracic echocardiogram (TTE) at the time of diagnosis showing normal cardiac structure and function. He had no history of cardiovascular disease or thrombotic events. In 2024, he tested positive for COVID-19 after last being vaccinated in 2021. Two days later, he presented with worsening dyspnea and fatigue and was admitted to the hospital. On arrival, laboratory findings demonstrated multiorgan failure consistent with shock: lactic acid 20 mmol/L, creatinine 2.45 mg/dL, AST 2009 U/L, ALT 1274 U/L, total bilirubin 4.3 mg/dL, and INR 6.1. Coagulation studies revealed disseminated intravascular coagulation (DIC), with low fibrinogen levels (60 mg/dL). Cardiac markers were elevated, with troponin at 300 ng/L and BNP at 2361 pg/mL. Inflammatory markers included CRP at 7.1 mg/dL. Electrocardiogram showed sinus rhythm with prolonged QTc (547 ms), and repeat TTE revealed severe left ventricular dilation, reduced ejection fraction (15-20%), and a large mural thrombus in the left ventricle. Systemic inflammation, hypercoagulability, and acute cardiac dysfunction suggested a cytokine-mediated inflammatory response triggered by COVID-19. Despite aggressive management, the patient’s condition deteriorated rapidly. Given severe shock and multiorgan failure, advanced interventions were not considered. Care was transitioned to comfort measures after discussions with the family. IMPACT/DISCUSSION: COVID-19 causes cardiovascular complications, including myocarditis, thromboembolism, and cardiomyopathy. This patient with PTLS, despite no congenital cardiac abnormalities, developed left ventricular dilation, acute heart failure, and a mural thrombus. Coagulopathy and organ dysfunction highlighted systemic inflammation’s role in multiorgan failure progression. While PTLS is linked to congenital cardiovascular anomalies, this case suggests PTLS patients, even without defects, may have heightened vulnerability to severe infections. PTLS has not been tied to immune dysfunction, but this case raises concerns warranting further study.

This case highlights the severe impact of COVID-19 on PTLS patients enen those without congenital structural cardiac abnormalities. COVID-19-induced cardiomyopathy, likely cytokine-mediated, led to multiorgan failure and thrombus formation. These findings stress the importance of cardiac monitoring, early intervention, and vaccination to prevent severe outcomes. MULTI-ORGAN THROMBOEMBOLIC EVENTS ORIGINATING FROM A RARE PULMONARY VEIN THROMBUS Yanis Belkadi1; Wali Kamran2; Bharani Pusukur1; Satinder P. Singh1; Apurva V. Vyas3. 1Internal Medicine, Lehigh Valley Health Network, Allentown, PA; 2Internal medicine, Lehigh Valley Health Network, Allentown, PA; 3Cardiology, Lehigh Valley Health Network, Allentown, PA. (Control ID #4272117) CASE: A 52-year-old male with metastatic lung cancer on immunotherapy presented with left-sided chest pain, shortness of breath, and epigastric discomfort. His history included recent osteomyelitis and subarachnoid hemorrhage from suspected septic emboli. Labs showed elevated troponin (0.90 ng/mL), leukocytosis, anemia, thrombocytosis, and a normal d-dimer (1.09 μg/mL). Imaging revealed hemoperitoneum and splenic rupture near an enlarged lesion, requiring splenic artery embolization. Neurological symptoms progressed, with imaging showing a right occipital hemorrhage and subdural hematoma. TEE identified a 3.7 cm mobile thrombus in the right upper pulmonary vein extending into the left atrium, with no valvular vegetations or positive cultures. Retrospective review of prior CT imaging from 2 months prior also demonstrated the presence of possible small size thrombus. He later developed gastric perforation. Due to contraindications for anticoagulation and high surgical risk, he was transitioned to hospice care. IMPACT/DISCUSSION: Pulmonary vein thrombosis (PVT) is a rare condition often associated with malignancy, thoracic surgery, or pulmonary vein ablation. Risk factors include hypercoagulability, infection, and immune modulation, as seen in this patient with metastatic cancer, pembrolizumab use, and ongoing infection. In our case, PVT served as the likely source of recurrent systemic emboli, leading to splenic rupture, subarachnoid, and intraparenchymal brain hemorrhages. Ongoing infection also predisposed the patient to develop septic emboli, with high hemorrhagic risk. Management of PVT typically involves anticoagulation or thrombectomy, both of which were contraindicated in our patient given his co-morbidities. This case underscores the systemic impact of untreated PVT and highlights the interplay of cancer, infection, and thrombosis in driving severe complications. Early detection, high index of suspicion in cases of unexplained embolic phenomenon, a multidisciplinary approach, and compassionate care for the patient and their families are vital in managing such complex cases.

This case illustrates severe systemic consequences of PVT in advanced malignancy and emphasizes the importance of multimodality imaging in diagnostic evaluations. It also highlights the challenges in balancing treatment risks and the importance of patient-centered decision-making in terminal cases. MUST BE SOMETHING IN THE WATER: DECODING A MYSTERY OF MULTIORGAN INVOLVEMENT Eduarda Macera1; Priyank Jain2; Linda Shipton3; Steven Patalano1. 1internal medicine, Cambridge Health Alliance, Cambridge, MA; 2Medicine, Cambridge Health Alliance, Cambridge, MA; 3Infectious Diseases, Cambridge Health Alliance, Lincoln, MA. (Control ID #4271682) CASE: A 26-year-old previously healthy female presented with three days of fever, nausea, vomiting and headache. She had recently hiked in New Hampshire but no international travel. She denied sick contacts.On presentation, she was afebrile, tachycardic and normotensive. She was ill appearing and pale, with mild right upper quadrant tenderness. Her labs revealed anemia, leukocytosis, thrombocytopenia, elevated creatinine, hypokalemia and mildly elevated direct and total bilirubin Differential diagnoses included biliary tract infection, urinary tract infection, and meningitis. She was given empiric broad spectrum antibiotics and was hospitalized for further evaluation. Disseminated intravascular coagulation secondary to sepsis, thrombotic thrombocytopenic purpura, and tick-borne diseases were also considered due to thrombocytopenia. A right upper quadrant ultrasound ruled out biliary obstruction. Blood smear showed no schistocyte, decreasing suspicion for TTP. The DIC panel was negative. The headache improved soon after IV hydration which decreased suspicion for meningitis so LP was not done. UA showed moderate blood, trace ketones and protein but no signs of infection. Elevated Cr and hypokalemia were initially attributed to vomiting but the values were disproportionate to her fluid losses which raised our suspicion for leptospirosis. The infectious disease team recommended continuing ceftriaxone while awaiting results of further testing. The patient improved quickly with treatment, her fever, nausea and abdominal pain resolved, and all her lab abnormalities were also improving. On day 4, she was discharged with Augmentin to complete a 7 days course. On her follow-up in the ID clinic , all her labs had normalized, the blood culture was negative, serology for Lyme, anaplasmosis, borreliosis, CMV, EBV and HIV were negative. Leptospirosis IgM was found to be positive. We could not add on Leptospira IgG at our hospital. Despite the lack of confirmatory test, the absence of another plausible diagnosis, and presence of consistent clinical course strongly suggests acute leptospirosis as the diagnosis in our patient. IMPACT/DISCUSSION: Leptospirosis is traditionally associated with tropical and subtropical regions. It is often spread through exposure to urine of infected animals either from direct contact or from contact with contaminated soil or water. Leptospira inhibits the Na+K ATPase enzyme which is why hypokalemia can be an important clue to diagnosis. Leptospirosis is primarily diagnosed through serology, with IgM indicating recent infection However, IgG is required for definitive diagnosis.

Leptospirosis, though more common in tropical regions, can occur in non-endemic areas like Massachusetts. 100-150 cases are reported annually in the US with Puerto Rico and Hawaii reporting the majority of cases MYASTHENIC CRISIS ( MC ) INDUCED BY METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ( MRSA ) INFECTION Yadana Oo. Internal Medicine, Baptist Health Floyd, New Albany, IN. (Control ID #4273204) CASE: A 74-year-old caucasian male with a recent diagnosis of myasthenia gravis ( MG ) presented to the hospital with fatigue, dyspnoea, and weakness in all four extremities for 1 day. The patient received the intravenous immunoglobulin (IVIg) infusion as an outpatient for underlying MG. In the ED, the patient had acute respiratory failure and was started on the BIPAP. Given the recent diagnosis of MG, MC was significantly concerned. The patient was transferred to the ICU level of care. The neurologist and nephrologist were consulted. During the hospital stay, the patient received five sessions of plasmapheresis. Blood cultures were positive for MRSA, and the port for IVIg infusion was suspected as the source of infection. Echocardiogram was negative for endocarditis. The patient was started on IV Vancomycin, and the port was removed. The patient clinically improved and was discharged with IV Vancomycin for 4 weeks. He was instructed to follow up with his primary neurologist. IMPACT/DISCUSSION: MG is an antibody-mediated autoimmune neurological disease characterized by autoantibodies against the acetylcholine receptors (AChRs). MC is a life-threatening condition of MG. The primary clinical manifestation is respiratory failure that requires the use of invasive or non-invasive ventilation. This is due to the respiratory muscle weakness. Multiple factors, including infections like MRSA and surgery, can precipitate MC. MRSA is a leading cause of both community- and hospital-acquired infections. As the MC is lethal, it is crucial for clinicians to diagnose the MC and start prompt management to reduce mortality. The immediate treatment is to protect the airway and identify the triggers. Plasmapheresis is the treatment of choice for MC compared to IVIg infusion.

Diagnosing of MC and prompt treatment are crucial to prevent adverse events. Lastly, a multidisciplinary approach is essential for comprehensive patient care. MYCOPLASMA PNEUMONIAE – INDUCED ANGIOEDEMA AND RASH WITHOUT MUCOSITIS Karla Geisse, Charles Lamberton, Jasanjeet Jawanda. Southwest Internal Medicine Residency, Indiana University School of Medicine, Indianapolis, IN. (Control ID #4243482) CASE: A 37-year-old-female with no significant past medical history presented in December with four days of fever, headache, neck pain, facial swelling, rash and nonproductive cough. The rash was red/purple, targetoid, maculopapular, non-blanchable and distributed over bilateral upper extremities, upper chest and back. The patient’s two children had fever and nonproductive cough in the weeks prior. On admission, the patient was febrile to 100.6 °F and tachycardic. White blood cell count (WBC) was 10,900 without eosinophilia and platelet count 250,000. Erythrocyte sedimentation rate was 45 mm/hr and C-reactive protein was 11.5 mg/dL. Respiratory viral panel was negative. Chest x-ray revealed no abnormalities. A lumbar puncture (LP) was performed, and she was started on vancomycin and ceftriaxone. LP showed normal glucose, WBC and protein. Blood cultures had no growth. On hospital day two, the patient developed left periorbital and upper lip swelling in addition to her previous lower facial swelling. Computed tomography (CT) maxillofacial showed subcutaneous inflammation of the lower face and chin with mildly prominent cervical lymph nodes. CT chest showed left lung base tree-in-bud opacities. Respiratory culture showed normal flora, rapid streptococcal throat polymerase chain rection (PCR) was negative, and legionella urinary antigen was negative. There was suspicion for Mycoplasma pneumoniae (MP) infection, and MP throat PCR was obtained. The patient was started on doxycycline and her fever, rash, and facial swelling resolved. After discharge, the Mycoplasma pneumoniae (MP) throat PCR resulted positive. IMPACT/DISCUSSION: MP is a common cause of community acquired pneumonia, accounting for 10% of cases. The CDC has noted an increase in MP infections in 2024, with higher rates in children. This case highlights extrapulmonary manifestations of MP infection including rash and the lesser-known manifestation of angioedema. The literature suggests MP infection may be a trigger for developing angioedema and has been reported in two previous cases. Immune complex formation by cold agglutinins acting as an anaphylatoxin has been proposed as a mechanism for MP-induced angioedema. Approximately 25% of MP infections have an extrapulmonary component. Mycoplasma-induced rash and mucositis (MIRM) is an example, where mucositis occurs with/without vesiculobullous/atypical targetoid lesions. MRIM differs in course and mortality compared to conditions such as erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis, which were included in differentials when caring for this patient. Rashes may be associated with respiratory tract infections and should be differentiated from hypersensitivity reactions.

Extrapulmonary manifestations of disease should be considered as presenting symptoms for an MP infection. Angioedema, while rare, has been associated with MP infections, resolving completely in our patient following treatment with doxycycline. MYSTERY RASH: A CASE OF BULLOUS ERUPTIONS IN AN IMMUNOSUPPRESSED WOMAN Vianey Perez Maldonado, Antoinette Alugbue, Farah Shaheen. Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #4271043) CASE: A 31-year-old woman with a history of SLE complicated by Class V lupus nephritis, pericarditis, Libman-Sacks endocarditis with mitral valve repair, presented to the ED with painful intact expanding bullae of her right dorsal foot, left fourth finger, and right middle back. The etiology was thought to be due to a skin and soft tissue infection, so she was started on ceftriaxone. However, she did not improve. Her physical exam was notable for a large denuded bulla on the right dorsal foot with surrounding erythema, crusted and healing small denuded bulla on the left fourth finger, and a similar bulla on the right posterior flank. ESR/CRP were within normal limits. CT of the lower extremity was notable for “subcutaneous edema and stranding...superficial cutaneous fluid collection at the dorsal aspect of the forefoot, likely a blister.” Her other labs were within normal limits, except for an elevated creatinine. Dermatology was consulted, and given the bullae being large, sparse, and on the acral surfaces on a background of violaceous erythema, the most likely diagnosis was a bullous fixed drug eruption from pantoprazole. The differential diagnosis included drug-induced bullous pemphigoid and cutaneous lupus. However, those would consist of widespread lesions rather than limited eruptions. A punch biopsy showed spongiotic and interface dermatitis, compatible with a fixed drug eruption. The likely culprit was pantoprazole, which was used for gastric ulcer prophylaxis given long-term steroid use. Her other medications were also considered, including Bumex. However, per dermatology, we would expect extensive eruptions with Bumex. Ultimately, Pantoprazole was discontinued and she was started on clobetasol cream which improved the bullae. IMPACT/DISCUSSION: As drug availability increases and prescription practices change over time, it is important to recognize potential adverse drug reactions, including fixed drug eruptions (FDEs). Certain populations such as the elderly and immunocompromised are at increased risk of developing a drug eruption. As this case highlights, drug eruptions can be easy to miss as they can mimic other dermatological diseases. Generally, the most common culprits for FDEs are NSAIDs and anti-microbials. In medically complex patients, particularly the immunocompromised, multiple medications in their regimen can be likely causes. In this case, pantoprazole, bumetanide, amlodipine, atovaquone, and chlorthalidone were all high-risk medications on this patient’s medication list that could have caused an FDE. In this patient, her intense high-dose immunosuppressive medications for SLE likely caused an atypical presentation of FDE.

Lupus is the great imitator. Fixed drug eruptions can also grossly and histopathologically appear similar to other skin diseases. Recognizing the “clues” that point towards an FDE being the likely culprit is important. Certain patients, particularly immunosuppressed individuals, are at higher risk for FDEs. MYXEDEMA COMA PRESENTING AS NEW-ONSET SEIZURES Kimberley Ho, Esther Kabaswaga, Karla Cano, Janani Baskaran. White River Health System Inc, Batesville, AR. (Control ID #4272886) CASE: A 68-year-old man presented to the hospital due to altered mental status and seizure-like activity. His past medical history was significant for hypothyroidism due to a thyroidectomy performed for thyroid cancer treatment, atrial fibrillation, and Parkinson’s disease with dementia. He was hypotensive to 52/30 mmHg with a heart rate of 46 bpm and temperature of 92.2°F. Physical exam was remarkable for a disoriented patient with cool skin, but without generalized edema. Initial tests revealed cystitis, hyponatremia, and lactic acidosis. After a subsequent grand mal seizure in the hospital, he was taken to the ICU and started on vasopressors for sepsis. A head CT scan was normal and ECG showed sinus bradycardia. This combination of bradycardia, shock, seizure, hypothermia, and hyponatremia raised suspicion for myxedema coma. TSH was 134 and free T4 was 0.19. A score of 80 on the diagnostic scale for myxedema coma confirmed the diagnosis. Antibiotics, intravenous levothyroxine, and hydrocortisone were started. Neurology was consulted. An EEG showed signs of a focal seizure. Hypothermia resolved by day 2, bradycardia improved, and he was weaned from vasopressors by day 4. After adrenal insufficiency was ruled out, steroids were discontinued. T4 levels normalized by week 2 with IV levothyroxine being transitioned to a stable oral dose. He was discharged with new antiepileptic medication and optimized hypothyroidism medication to a long-term care facility. IMPACT/DISCUSSION: Myxedema coma is a medical emergency with a high mortality rate. It can be particularly challenging to manage when there are confounding factors. It has an annual incidence of 2.6 cases per million in the United States. Although uncommon, it carries a high mortality rate ranging from 30% to 50%. Myxedema is a complication of severe hypothyroidism leading to decreased mental status, hypothermia, and slowing of organ processes. It is commonly precipitated by a systemic illness. Our patient developed myxedema due to his noncompliance with medications due to dementia with insufficient social support, exacerbated by his cystitis, and resulted in development of seizures. The diagnosis was confounded by the patient’s underlying dementia, which could have been used to explain the patient’s general obtundation and his abnormal movements at home merely a sign of his Parkinson’s. Due to his known hypothyroidism, suspicion remained high for myxedema with seizures as a complication. Levothyroxine is the drug of choice since it has a slow onset and fewer side effects than T3, which is more potent but can increase tissue oxygen consumption and strain the cardiovascular system, thus risky for elderly patients. TSH level is reflective of the thyroid status over 6 weeks, thus response to therapy is determined by T4 levels and clinical status.

This case underscores the importance of quickly identifying and treating myxedema coma in patients, especially in those with confounding diagnoses, to improve outcomes. NATIVE VALVE AORTIC ENDOCARDITIS CAUSED BY GUT BACTERIA TRANSLOCATION FROM GASTROENTERITIS Allison Molstad, Elizabeth Willis, Alicia Latta. Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH. (Control ID #4272410) CASE: Patient is a 64 year old female with no pertinent past medical history presented with acute onset shortness of breath after a flight home from Florida. She also reported weakness, nausea, vomiting, rigors, and night sweats for 2-3 weeks, but denied chest pain, fevers. She mentioned a week of nonbloody diarrhea during her trip that had since resolved. CTA in the ER showed acute pulmonary embolism without evidence of right heart strain. TTE was obtained during work up for her PE and showed a mobile density on the right coronary cusp concerning for vegetation. TEE confirmed a mobile density on the right coronary cusp of the aortic valve, consistent with an aortic valve vegetation greater than 10mm in size. Infectious disease was consulted and started IV vancomycin for empiric coverage. Patient’s blood cultures resulted positive for Streptococcus oralis/mitis, and the patient was subsequently diagnosed with infective endocarditis based on 2023 Duke-ISCVID Criteria. Due to the size of the vegetation and the moderate degree of aortic insufficiency, cardiology recommended transfer for cardiothoracic surgery evaluation, and underwent early aortic valve replacement. IMPACT/DISCUSSION: Native valve infective endocarditis (IE) refers to infection resulting from seeding of bacteria onto the valves of the heart, usually in patients with one or more risk factors such as intravenous drug use, poor dentition or recent dental surgery, prior structural or valvular heart disease, or indwelling cardiac devices. This patient’s presentation of acute pulmonary embolism with subsequent unexpected finding of aortic valve vegetation was an atypical initial presentation, although the patient’s secondary symptoms of night sweats and chills are consistent with the diagnosis. Patient did not have any of the previously mentioned risk factors for IE prior to presentation. The cause of the infective endocarditis in this patient is unclear. Based on the patient's history of a week of nonbloody, profuse diarrhea prior to any other symptom onset, it is likely that a GI source with bacterial translocation from the gut during an acute bout of gastroenteritis was the source of the bacteremia that led to the vegetation. Although viridans group strep is a common cause of IE, it is uncommon for it to be caused by gut bacteria translocation from gastroenteritis. Viridans group strep are generally from the oral cavity, less commonly a lower GI source. This patient had no recent dental procedures nor did she have any dental issues to suggest an oral route of infection.

This case highlights the rare occurrence of native valve infective endocarditis due to gastrointestinal bacterial translocation in the absence of typical IE risk factors. This patient's atypical presentation emphasizes the importance of a broad differential and the need to consider a broader list of sources when considering the etiology of IE. NAVIGATING HYPONATREMIA: A CASE OF EXTREME PRIMARY POLYDIPSIA WITH NEUROLOGICAL SYMPTOMS Mahmoud Abdelwahab1; Lucinda Dass2; Aya Yaseen1; Atefeh ghorbanzadeh1; Bushra Saleem1; Hafsah Ijaz1; Rolando L. Cruz Ferrer1. 1Internal Medicine, Capital Health Regional Medical Center, Trenton, NJ; 2Internal Medicine, Jersey City Medical Center, Jersey City, NJ. (Control ID #4273386) CASE: A 36-year-old male with depression, anxiety, and schizoaffective disorder presented from a correctional facility with altered mentation. Initially unconscious and repeating speech, he was alert and oriented on arrival. His baseline sodium levels were normal months prior, and no outpatient medications were documented. Initial labs showed severe hyponatremia (serum sodium 100 mmol/L), elevated creatine kinase (41,655 U/L), low urine sodium (9 mmol/L), low urine osmolality (124 mOsm/kg), and serum osmolality (248 mOsm/kg). Thyroid and adrenal function tests were unremarkable. He received a 150 mL bolus of hypertonic saline in the ED and was admitted to the ICU with nephrology consulted. The patient exhibited polyuria (500–800 mL/hour) and, upon regaining mentation, reported drinking over 6 liters of water daily with frequent urination. Based on clinical and lab findings, primary polydipsia was diagnosed. Management was complicated by concurrent rhabdomyolysis, necessitating IV fluids. Sodium rose to 110 mmol/L within 6 hours, exceeding correction goals, prompting administration of dextrose 5% water infusion (100 mL/hour) and desmopressin (4 mcg). Sodium reached 128 mmol/L within 19 hours, requiring further desmopressin. Sodium levels stabilized and the patient was discharged on day 8 with a sodium level of 133 mmol/L IMPACT/DISCUSSION: This case highlights the complexity of diagnosing and managing hyponatremia, especially with neurological symptoms. Diagnostic evaluation includes assessing serum and urine osmolality, and urine electrolytes Primary polydipsia, though rare, must be considered when excessive water intake overwhelms renal excretion, leading to hyponatremia. The patient’s condition required controlled sodium correction to prevent osmotic demyelination syndrome (ODS), a life-threatening complication of rapid correction. Proactive use of desmopressin and dextrose 5% water infusion helped mitigate overcorrection risks and stabilize sodium levels. In cases of reversible hyponatremia, desmopressin with hypertonic saline allows predictable sodium correction, especially in the presence of polyuria. This strategy mimics an iatrogenic syndrome of inappropriate antidiuretic hormone for safer management. Close monitoring of serum sodium and urine output is critical to avoid complications. Point-of-care ultrasound can assist in volume assessment when clinical findings are unclear. This case emphasizes the importance of individualized strategies for treating acute-on-chronic hyponatremia. Patient education on fluid intake is crucial to prevent recurrence in psychiatric populations prone to primary polydipsia.

Severe acute-on-chronic hyponatremia from primary polydipsia presents unique challenges. A systematic approach involving history-taking, examination, and laboratory studies is vital for diagnosis. Controlled sodium correction with desmopressin minimized complications, highlighting the value of individualized management to optimize outcomes and prevent recurrence. NAVIGATING LAMBL’S EXCRESCENCE - A COMPELLING CASE CHRONICLE Bolivia C. Fernandes3; Warren Fernandes1; Vishwas H. Ravishankar1; Sumukh Arun Kumar2; Rajaeaswaran Chinnamuthu1; Rhea Bohra1; Ajitha Virinchipuram Ganesan3; Kedar Mahagaokar1. 1Internal Medicine, Saint Vincent Hospital, Worcester, MA; 2Hematology and Medical Oncology, Bayhealth Medical Center, Dover, DE; 3Internal Medicine , NYMC GME At St.Mary's General and St Clare's Health, Denville, NJ. (Control ID #4273253) CASE: A 72-year-old woman presented with an unsteady gait for 2 days. A physical exam showed left facial droop and subtle left arm weakness. Brain MRI revealed acute punctate infarctions in the pons, bilateral internal capsule, and left cerebellar hemisphere, consistent with an embolic shower. Transthoracic echo (TTE) showed a large mobile echo density on the mitral valve and a smaller aortic valve mass. Differentials included infective endocarditis, thrombus, papillary fibroelastoma, atrial myxoma, and Nonbacterial thrombotic endocarditis(NBTE). The patient underwent surgery, revealing a healed IE mass on the mitral valve and filamentous mass consistent with Lambl’s excrescence (LE) on the aortic valve. The masses were excised, and a St. Jude bioprosthesis was implanted. She recovered well from surgery and was discharged on Coumadin. IMPACT/DISCUSSION: This case highlights the diagnostic complexity of cardiac masses presenting with embolic phenomena. Our patient presented with acute embolic strokes and was found to have mobile cardiac masses on echocardiography. Differential diagnoses included infective endocarditis (IE), thrombus, papillary fibroelastoma, atrial myxoma, and nonbacterial thrombotic endocarditis (NBTE). Surgical pathology revealed a healed IE mass on the mitral valve and a filamentous lesion on the aortic valve identified as Lambl’s excrescence (LE), an uncommon finding. LEs are thin, filamentous structures, often incidental findings, associated with age-related degenerative changes on valve surfaces. Though generally benign, LEs can rarely embolize, mimicking other pathological entities like IE. The clinical presentation of LE-related embolism is often nonspecific. A stroke can occur due to small emboli breaking off from the excrescences, as seen in our patient. TTE is the first diagnostic step, followed by transesophageal echo if suspicion persists. Treatment involves surgery or anticoagulation based on symptoms and mobility. Our case also highlights the importance of considering healed endocarditis in patients with prior embolic events and structural valve abnormalities, even when clinical signs of infection are absent. The patient's outcome underscores the value of a multidisciplinary approach, combining imaging, early surgical intervention, and pathological examination to guide diagnosis and management.

This case demonstrates the importance of a comprehensive diagnostic approach to cardiac masses presenting with embolic phenomena. It emphasizes the importance of considering uncommon entities like Lambl’s excrescence in the differential diagnosis of embolic phenomena, especially when other more common causes, such as IE or thrombi, are ruled out. Early recognition, appropriate imaging, and timely surgical intervention are crucial for optimal outcomes, emphasizing the value of a multidisciplinary team in guiding diagnosis and management. NAVIGATING RARE COMPLICATIONS - CHEMO PORT ASSOCIATED HEMOPHILUS INFLUENZAE TYPE B INFECTION IN A CANCER SURVIVOR Drushik Gangasani1; Mayura R. Kesara2,1. 1Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4272439) CASE: Patient is a 53-year-old male with history of stage II squamous cell carcinoma of the right tonsil, post-chemoradiation therapy, presented with purulent discharge from the chest wall port catheter. On arrival, the patient was febrile (102°F), hypotensive (BP 91/58 mmHg), and tachycardic (100 bpm), with adequate oxygen saturation on room air. Laboratory findings revealed leukocytosis (12.8 x 10^9/L), acute kidney injury (creatinine 3.14 mg/dL), and hypokalemia (2.8 mmol/L). Patient had erythema and purulent discharge around the port site on examination. Patient had a recent history of respiratory symptoms, suggesting a possible respiratory source of the infection. He was admitted with sepsis secondary to catheter-related infection and was initially treated with broad-spectrum antibiotics, including Zosyn and vancomycin, along with intravenous fluids for AKI management. Blood cultures later grew Haemophilus influenzae, prompting a de-escalation of antibiotics to ceftriaxone. Once stabilized, the patient was transitioned to oral amoxicillin to complete a 14-day course of antibiotics IMPACT/DISCUSSION: This case highlights a rare chemoport-associated Haemophilus influenzae type B (Hib) infection in an immunocompromised cancer patient. Chemoports, essential for treatment, increase infection risk due to their invasive nature. The patient presented with sepsis symptoms, including fever, hypotension, leukocytosis, and port site erythema. Early blood cultures identified Hib, enabling a switch from broad-spectrum antibiotics to targeted therapy, leading to recovery. Key points include recognizing atypical pathogens like Hib, timely intervention with tailored antibiotics, and preventive measures such as regular port monitoring and aseptic handling. This rare case expands the understanding of chemoport infections and emphasizes the value of early diagnosis and treatment

Although rare, chemoport-associated Hib infections are a significant clinical concern in immunocompromised patients. This case underscores the importance of maintaining a high index of suspicion for atypical pathogens, ensuring timely intervention to prevent severe outcomes. Regular monitoring of central lines and early blood culture testing in febrile patients are crucial for early detection and effective management of these infections. Understanding the unique challenges posed by these infections can help clinicians improve outcomes and reduce the risk of complications in vulnerable patient populations NAVIGATING RECURRENT PNEUMOTHORAX IN TSC-LAM: A CASE FOR VATS AND PLEURODESIS IN A FREQUENT FLYER Vikas Kilaru1; Palwasha Khan1; Abijha Boban1; Darrin Lowe1; Hely Patel2; Quresh Savliwala3; Moyan Sun4; Shahzaib Khan1. 1Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 2Emory University, Atlanta, GA; 3School of Medicine, Touro University, New York, NY; 4Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4267594) CASE: 38-year-old female with PMH of Tuberous Sclerosis (TSC) associated with lymphoangioleimyomatosis (LAM), stage 3 CKD s/p left nephrectomy, and history of left pneumothorax (PTX) presented for shortness of breath and right sided chest pain after a coughing spell at home. She was recently discharged for right sided PTX one week prior, which was treated with chest tube. On examination, she was tachycardic and tachypneic, in acute respiratory distress, with decreased right sided breath sounds. Creatinine was elevated at 2.0 mg/dL, and WBC was 11.1 K/uL. Chest X-ray showed increasing right sided PTX with evidence of tension. Chest tube was emergently placed with gradual resolution of PTX. Cardiothoracic surgery was consulted, who originally planned to manage conservatively. The patient, who worked in corporate sales, flew every two weeks for meetings. Due to this risk factor, along with chronic coughing spells, video-assisted thoracoscopic surgery (VATS) was recommended. VATS along with right middle lobe wedge resection and mechanical pleurodesis was successfully performed. Pulmonology was consulted and recommended establishing with a LAM specialist as well as mTOR therapy 2-3 weeks after her procedure. IMPACT/DISCUSSION: LAM is a progressive cystic lung disease predominantly affecting women of childbearing age, associated with TSC in one-third of cases. PTX occurs due to proliferation of smooth muscle-like LAM cells and cystic remodeling of lung parenchyma, predisposing the lung to rupture under stress. Recurrent PTX is a hallmark complication of LAM, occurring in up to 70% of patients, but can be reduced to ~30% with pleurodesis. While initial PTXs are often managed conservatively, intervention such as pleurodesis or pleurectomy are indicated in recurrent cases. VATS with pleurodesis has demonstrated efficacy in reducing recurrence and is preferred due to its minimally invasive nature and shorter recovery time compared to open thoracotomy. In this case, the decision for VATS and pleurodesis was influenced by the patient’s occupational need for frequent air travel, which increases the risk of PTX due to barometric pressure changes during flights. Mechanical pleurodesis promotes pleural adhesion, obliterating the pleural space and preventing lung collapse. Follow-up is needed to monitor disease progression, as LAM can lead to chronic respiratory insufficiency.

This case highlights the importance of individualized management strategies in patients with LAM and recurrent pneumothorax. VATS with pleurodesis is an effective intervention to reduce recurrence risk, particularly in individuals whose lifestyle or occupational requirements increase susceptibility to pneumothorax complications. Early recognition and proactive management of LAM-associated complications are crucial for improving quality of life and preventing morbidity. Further research is warranted to explore the role of pharmacologic interventions alongside surgical management in this patient population. NAVIGATING THE CHALLENGES: MANAGEMENT OF LIFE-THREATENING PURE RED CELL APLASTIC ANEMIA WITHOUT TRANSFUSION Ellen Choi, Yu-Han Chen, Todd Lavine, Vivienne Qie, Tanganyika Barnes. Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #4267290) CASE: A 64-year-old Jehovah’s Witness woman with stage IV thymoma was referred to the emergency department by her oncologist after routine laboratory tests revealed a hemoglobin (Hgb) level of 3.9 g/dL, with no source of active bleeding identified. She had completed chemotherapy, including cisplatin, doxorubicin, and cyclophosphamide, two months prior to presentation. Despite her critical lab results, the patient denied experiencing symptoms such as shortness of breath, fatigue, palpitations, or weakness. Upon arrival, she was tachycardic with a pulse of 122 bpm. Initial labs showed Hgb at 4.1 g/dL, MCV 95.0 fL, reticulocyte count 0.2%, and WBC 20 k/μL. Her hemoglobin later dropped to 2.1 g/dL during hospitalization. A bone marrow biopsy confirmed PRCA, showing decreased erythroid precursors on CD71 immunostaining, with fluorescence in situ hybridization and next-generation sequencing ruling out myelodysplastic syndrome. The patient declined transfusion due to her religious beliefs, prompting a bloodless management strategy, including the administration of epoetin alfa, ferric gluconate, folic acid, vitamin B12, 100% oxygen therapy, and propranolol while workup continued. The Palliative Care team was consulted to discuss goals of care in the setting of critically low Hgb levels. While the prognosis was guarded, immunosuppressive therapy with prednisone and cyclosporine was initiated on day 5 and day 13, respectively. Her hemoglobin levels rose from 2.1 g/dL to 2.4 g/dL, with a concurrent increase in reticulocyte counts from 0.2% to 7.9%. After 16 days of cyclosporine and 25 days of prednisone treatment, her hemoglobin reached 5.9 g/dL at discharge and continued to improve, eventually stabilizing at 13.0 g/dL. IMPACT/DISCUSSION: This report describes the successful management of life-threatening PRCA without the use of transfusion. In this case, supportive bloodless measures were pivotal in stabilizing the patient until the underlying cause of anemia was identified and immunosuppressive therapy took effect. While there have been other cases of successfully managing PRCA without transfusion, none have reported hemoglobin levels as low as 2.1 g/dL, as seen in our patient. Additionally, proactive goals of care discussions were essential in ensuring treatment that the treatment plan aligned with the patient’s values and preferences, especially in cases where standard interventions, such as transfusions, were declined.

Managing life-threatening anemia is particularly challenging when blood transfusion is not an option. Early identification of the underlying cause of anemia is crucial to prevent severe complications, such as multi-organ failure and death. Despite the challenges, respecting the patient’s wishes remains paramount in guiding treatment decisions. NAVIGATING THE CLINICAL CROSSROADS: ANTICOAGULATION IN PORTAL VEIN TUMOR THROMBUS WITH INTRACARDIAC EXTENSION Samyuktha Manikandan2; Jill Allenbaugh1. 1GIM, Lewis Katz School of Medicine at Temple University, Philadelphia, PA; 2Medicine, Temple University Health System Inc, Philadelphia, PA. (Control ID #4235616) CASE: A 69-year-old male with a history of multiple chronic conditions including CAD s/p CABG, HFrEF (EF of 10-15%), HTN, microcytic anemia, and alcohol use disorder presented to the hospital with several weeks of vague abdominal pain. Alpha-fetoprotein (AFP) was elevated at 3312.6 ng/mL and a CT of the abdomen and pelvis revealed a likely primary malignancy in the right hepatic lobe, with associated tumor thrombus in the right portal vein, inferior vena cava (IVC), and right atrium, as well as malignant ascites. Anticoagulation was initiated with heparin and transitioned to therapeutic Lovenox. A transthoracic echocardiogram showed mildly reduced right ventricular function, right atrial dilation, and septal bowing into the right atrium with redemonstration mass in the right atrium and IVC. A CT of the chest did not reveal any filling defects in the pulmonary vasculature. After thorough review of imaging and an in-depth discussion with hematology and hepatology, it was determined that the thrombus exhibited minimal characteristics of a superimposed bland thrombus over the tumor thrombus.After discussion with hematology and hepatology, As a result, the anticoagulation regimen was adjusted from therapeutic to deep vein thrombosis (DVT) dosing. IMPACT/DISCUSSION: This case highlights the complexity of anticoagulation decision-making in patients with tumor thrombosis, particularly in the context of malignancy-associated thrombi. Imaging and elevated tumor markers suggested a malignancy-related thrombus, but the patient's tenuous clinical status rendered biopsy impractical. Managing such cases requires a delicate balance between the increased thromboembolic risk associated with malignancy and the heightened bleeding risk from liver dysfunction and abnormal coagulation markers. Anticoagulation for tumor thrombi is further complicated by limited efficacy, as these clots often incorporate tumor tissue, making them less responsive to conventional therapies. In this case, the thrombus's intracardiac extension and the elevated pulmonary embolism risk prompted consideration of therapeutic anticoagulation. However, due to significant bleeding concerns, a prophylactic dosing strategy was chosen. This decision underscores the importance of individualized risk assessment, carefully weighing the prevention of venous thromboembolism (VTE) against the bleeding risk especially in the steting of the absence of standardized guidelines for managing malignant portal vein thrombosis (PVT).

This case emphasizes the need for further research and guideline development to address such scenarios. It also highlights the value of close interdisciplinary collaboration, ensuring that management decisions are guided by collective expertise and tailored to the patient's unique clinical situation. NAVIGATING THE RISKS OF MODERN DIABETES THERAPY: OZEMPIC-INDUCED KETOACIDOSIS Mitchell Boshkos, Suman M. Atluri, Kamal Hirani. Margaret M. and Albert B. Alkek Department of Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4268719) CASE: A 70-year-old man with a history of uncontrolled type 2 diabetes mellitus (T2DM) (HbA1c 9.2% in November 2024), hypertension, and paroxysmal atrial fibrillation on Xarelto presented with subacute nausea and vomiting. He was diagnosed with mild diabetic ketoacidosis (DKA), likely triggered by the recent initiation of Ozempic (semaglutide). The patient was briefly treated with an insulin drip before transitioning to his home regimen of subcutaneous glargine insulin 50 units twice daily the same evening. He tolerated a regular diet and was discharged the next day in stable condition. At discharge, the patient was advised to avoid GLP-1 agonists in the future due to the risk of recurrence. IMPACT/DISCUSSION: GLP-1 receptor agonists have become increasingly popular in diabetes management due to their ability to lower blood sugar and reduce cardiovascular risk. While these medications are generally considered safe, they have been linked to rare cases of DKA. A review of FDA adverse event reports identified over 1,300 cases of DKA associated with GLP-1 agonists over a 15 year period, with semaglutide accounting for some of the highest rates among this drug class. Recent research is shedding light on how reduced insulin, suppressed glucagon, and metabolic stress combine to create atypical presentations of DKA, adding a new layer of complexity to its recognition and management. By reducing glucagon levels, GLP-1 agonists decrease hepatic glucose production, a benefit under normal conditions but potentially harmful when paired with reduced caloric intake or dehydration. Their appetite-suppressing effects, along with common side effects like nausea and vomiting, can lead to a calorie deficit, promoting ketogenesis. Compounding this, reduced insulin levels drive lipolysis and increase free fatty acids available for ketone production. This combination of factors often results in an atypical presentation of DKA, sometimes with mild or even normal blood sugar levels, making diagnosis challenging. Clinicians should remain vigilant, particularly for patients presenting with symptoms like nausea, vomiting, and metabolic acidosis. Early diagnosis hinges on detecting an anion gap and elevated ketone levels in the blood or urine. Treatment involves stopping the GLP-1 agonist, starting insulin therapy, and addressing dehydration with fluids. This case underscores the importance of closely monitoring patients, especially those with risk factors like poorly controlled diabetes or other conditions that increase metabolic stress, when initiating GLP-1 therapy. Educating patients about the warning signs of DKA is critical to ensuring timely intervention.

1. GLP-1 agonists, while effective for glycemic control, can precipitate rare cases of DKA, necessitating cautious use. 2. Management of GLP-1 agonist-induced DKA involves stopping the offending agent and providing prompt insulin therapy and supportive care. NEGATIVE PRESSURE PULMONARY EDEMA AFTER REDUCTION MAMMOPLASTY Xiaoni Zhao1; Mesrop Aleksanyan2; Nabil Mesiha3. 1Transitional Year Residency, Capital Health Medical Center - Hopewell, Pennington, NJ; 2Internal Medicine, Capital Health, Trenton, NJ; 3Pulmonary/Critical Care, Capital Health, Trenton, NJ. (Control ID #4246158) CASE: A 23-year-old female with a history of childhood asthma and obesity underwent elective bilateral breast reduction and axillary liposuction under general anesthesia. The procedure was uncomplicated with minimal blood loss and administration of 800mL Lactated Ringers. In the immediate postoperative period, she developed acute hypoxic respiratory failure with oxygen saturation of 70% and tachycardia required FiO2 of 100% via Non-Rebreather mask. CTA chest revealed diffuse patchy irregular consolidations throughout both lungs with peripheral sparing and no evidence of pulmonary embolism or pleural effusion. Labs were significant for leukocytosis (WBC 12.14 x10^3/mcL) without bandemia, elevated lactic acid (2.9 mmol/L), and arterial blood gas with moderate hypoxia and compensated respiratory alkalosis. Empiric antibiotics for aspiration pneumonia were started pending sepsis workup. NPPE was suspected given her clinical scenario and radiological findings. Patient was upgraded to intensive care unit. She was placed on CPAP, incentive spirometry, and received 20 mg IV diuretics with significant improvement in oxygenation. Transthoracic echo revealed no abnormalities. Infectious workup was negative and antibiotics were discontinued. On postoperative day 3, hypoxia resolved and pulmonary infiltrates on chest x-ray decreased. Patient was discharged home without supplemental oxygen to follow up with her surgical team. IMPACT/DISCUSSION: This case highlights the importance of recognizing NPPE as a potential postoperative complication. Pathophysiology involves forcible inhalation against a closed glottis causing negative pressure in the chest cavity and in the tissue spaces around blood vessels, which in turn causes interstitial and alveolar edema. The rapid onset of symptoms post-surgery, combined with radiological findings of diffuse bilateral infiltrates with peripheral sparing, is characteristic of NPPE. In this case, surgical binders following breast surgery likely exacerbated symptoms by restricting chest wall movement. Obesity predisposes patients to upper airway obstruction and may have also contributed to the development of NPPE. The case demonstrates the typically self-limiting nature of NPPE when properly managed. Treatment is mainly supportive care, including supplemental oxygen, CPAP, and careful fluid management. NPPE typically resolves within 12-48 hours with treatment. This case serves as a reminder that in young, healthy post-operative patients, early consideration of NPPE can avoid unnecessary treatments and allow for targeted therapeutic interventions.

NPPE is a rare complication with anesthesia and a potential cause of acute postoperative respiratory distress. NPPE typically resolves rapidly with oxygen, CPAP, and fluid management. NEUROSARCOIDOSIS - A DIAGNOSTIC DILEMMA Uma S. Jacobs, Balakumar Pandian. The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4269794) CASE: A 61-year-old man presented to an outpatient neurology clinic in January 2024 with 1 year of fatigue and 6 months of progressive cognitive deficits, gait instability and vertigo. He also complained of weight loss, low libido and chronic dry cough. Laboratory findings, including serum angiotensin-converting enzyme (ACE) level, were within normal limits. Physical exam was notable for dysarthria and a broad-based gait. His brain MRI demonstrated parenchymal, dural, and leptomeningeal enhancement. Brain biopsy showed granulomatous inflammation of the dura and leptomeninges with negative acid-fast bacilli (AFB) stain. Lumbar puncture showed pleocytosis with lymphocytic predominance, elevated protein, low glucose and elevated cerebrospinal fluid angiotensin-converting enzyme (CSF ACE). A CT chest scan showed ground glass opacities and nodules. Bronchoscopy with biopsy demonstrated no fungal elements and no granulomas. Preliminary tests for fungal organisms came back negative except for a positive Aspergillus antibody. Due to the risks of immunosuppression and of not treating disseminated aspergillosis, he was started on voriconazole in March 2024. On outpatient follow-up, his cognition and gait were stable but not improving. Pending fungal tests and Karius testing all came back negative. Voriconazole was then discontinued since he had no significant clinical response. Neurosarcoidosis was the most consistent diagnosis given the final negative fungal tests, brain biopsy results, and elevated CSF ACE. He was subsequently started on prednisone and methotrexate in May 2024. A follow up MRI in June 2024 demonstrated improved parenchymal, dural and leptomeningeal enhancement. On follow-up in October 2024, the patient reported significantly improved cognition, memory, and gait. IMPACT/DISCUSSION: This case exemplified how neurosarcoidosis can be difficult to diagnose due to the variety of conditions that can mimic the disease and the lack of reliable tests available for diagnosis. The criteria for diagnosing sarcoidosis include the presence of non-caseating granulomas on tissue biopsy, a consistent clinical presentation, and the exclusion of other granulomatous disorders. Our patient was initially diagnosed with disseminated aspergillosis and treated with voriconazole. However, when the remaining tests made it clear that fungal infection was unlikely, neurosarcoidosis became our top diagnosis because of the consistent clinical presentation, biopsy findings, and elevated CSF ACE. All diagnostic criteria for sarcoidosis were met and the patient was started on immunosuppression, with improvement in his symptoms.

Neurosarcoidosis, especially in patients without clear-cut pulmonary involvement, can be difficult to diagnose because it is a diagnosis of exclusion with many similarly presenting conditions that must be carefully ruled out. NEUROTOXIC SEQUELAE OF A BROWN RECLUSE SPIDER BITE: A RARE CASE OF TRANSVERSE MYELITIS Hope R. Fardanesh2; Sanika Joshi1; Laura Gray3; Robyn Chase3. 1Internal Medicine, Midwestern University, Glendale, AZ; 2Osteopathic Medicine, Midwestern University, Glendale, AZ; 3Veterans Affair Medical Center, Prescott, AZ. (Control ID #4271635) CASE: In September 2024, a 74-year-old male presented to a Southwest VA Emergency Department (ED) with dizziness, near syncope, malaise, and significant difficulty ambulating despite consistent physical therapy. His symptoms traced back to an acute onset of leg weakness two years earlier, which had required hospitalization. Detailed history-taking and evaluation revealed the cause: a brown recluse spider bite sustained during a hiking trip. The bite, located on his spine, was believed to have allowed venom to enter the cerebrospinal fluid (CSF), resulting in neurological deterioration. The initial bite occurred in April 2022, prompting an initial ED visit with symptoms of malaise, weakness, fever, chills, and neck stiffness. Physical examination revealed bilateral lower leg weakness, diminished reflexes, and a wide-based antalgic gait. Vital signs included 101.2°F, HR 94, BP 159/78, RR 16, and SpO2 95% on room air. Labs showed WBC 13.4, CRP 3.20, and lactic acid 3.7. Thoracic and lumbar MRIs were unremarkable. A lumbar puncture ruled out infectious meningitis but revealed albuminocytologic dissociation. Despite treatment with intravenous fluids, steroids, and antibiotics, his neurological deficits persisted. Electromyography (EMG) was normal, and tests for Lyme disease, syphilis, and vasculitis were negative. Since the bite, the patient has experienced persistent neurological symptoms, including gait instability, malaise, and recurrent ED visits for worsening ataxia and dizziness. His condition has not improved, resulting in progressive deconditioning and walker dependence — all attributed to the long-term effects of the brown recluse spider bite on his spine. IMPACT/DISCUSSION: Brown recluse spider bites rarely result in severe neurological complications. In this case, venom likely infiltrated the CSF, initiating an inflammatory response. CSF analysis revealed yellow discoloration and elevated protein levels, indicating neuroinflammation. Although Guillain-Barré Syndrome (GBS) was initially considered, normal EMG findings and the chronic progression of symptoms supported a diagnosis of idiopathic transverse myelitis. Despite aggressive treatment, the patient’s neurological deficits persisted, emphasizing the challenges of managing venom-induced neuropathology. This case adds to the literature by highlighting an uncommon presentation of brown recluse envenomation with severe neurological involvement. While prior studies focus on local necrosis or systemic loxoscelism, this case expands the clinical spectrum of brown recluse envenomation, highlighting its neurotoxic potential and encouraging research into diagnostics and treatments for these rare complications.

Identifying brown recluse bites as a cause of neuroinflammation emphasizes the importance of detailed history-taking in atypical neurological cases. Persistent neurological deficits despite treatment emphasize the need for multidisciplinary care and further research into targeted therapies for venom-related conditions. NON-OPERATIVE MANAGEMENT OF ACUTE COLONIC ISCHEMIA AND GI BLEEDING AFTER ST ELEVATION MYOCARDIAL INFARCTION. Dinkar Ahuja1; Mohammed Abourahma1; Ayokunle T. Abegunde2. 1Internal Medicine, Loyola University Medical Center, Chicago, IL; 2Gastroenterology, Loyola University Medical Center, Chicago, IL. (Control ID #4273370) CASE: A 61-year-old patient with no known past medical history presented following an out-of-hospital cardiac arrest. He was found to have a ST Elevation Myocardial Infarction(STEMI) and received percutaneous coronary intervention complicated by cardiogenic shock. CT abdomen and pelvis showed ascending colon wall thickening with significant dilation and pneumatosis. The patient simultaneously developed hematochezia and nausea with episodes of vomiting, but persistently denied abdominal pain. At that time laboratory evaluation was significant for lactate 1.3, white blood cell count 27,000, c-reactive protein 105.4, erythrocyte sedimentation rate 16, procalcitonin 0.88 and hemoglobin 7.2. A colonoscopy was performed revealing a large necrotic circumferential ulcer in the ascending colon with stricturing preventing passage of the adult colonoscope (Figure 1). Biopsies obtained confirmed the ulcer to be of ischemic origin. The patient remained hemodynamically stable and was managed conservatively with proton pump inhibitor, naso-gastric tube, and slow dietary advancement. He did not require further intervention, hematochezia resolved, and his diet was advanced. The patient made a full recovery. At his 4-week post-hospital outpatient visit he was tolerating a regular diet without difficulty. He is scheduled to undergo a repeat colonoscopy after he can safely stop dual antiplatelet therapy. IMPACT/DISCUSSION: Colon ischemia is the most common cause of gastrointestinal ischemia and includes a wide range of clinical presentations and outcomes. Findings associated with worse outcomes in colon ischemia include isolated ascending colon ischemia, longer duration of fasting and hospital stay in patients with ulceration, and severe characteristics with the presence of peritonitis or pneumatosis seen on imaging. We present a case of post-cardiac arrest colonic ischemia presenting with high risk features including pneumatosis, ulcer formation and isolated ascending colon pathology managed successfully with endoscopic monitoring. These features are strongly correlated with the need for surgery and increased mortality. However, the patient remained hemodynamically stable without signs of peritonitis.

Shared decision making resulted in successful conservative management with self-resolution of this patient's symptoms. This case highlights the heterogeneity that exists in colon ischemia and emphasizes the importance of supplementing diagnostic results with clinical decision making. Despite several high risk features, the laboratory evaluation and clinical symptoms allowed for a non-operative path to be pursued. NOT ALL WATER IS HEALING: AN UNCOMMON PRESENTATION OF GIARDIA Aidan Flanagan1; Brenda Queen2. 1Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA; 2Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA. (Control ID #4269054) CASE: Giardia is a parasitic infection that is transmitted via fecal-oral routes and ingestion of cysts. While typically presenting with lower gastrointestinal (GI) symptoms like acute watery diarrhea, bloating, and abdominal cramps: chronic infections can mimic other common GI issues leading to delay in diagnosis and malnutrition. We present a case of an Ethiopian man with hyperemesis, chronic epigastric discomfort, and a prolonged diagnostic journey, ultimately identified as giardiasis and successfully treated. A 54-year-old Tigrinya speaking, Ethiopian male with a past medical history of GERD and asthma presented in August 2024 with chronic, progressive nausea, epigastric and left upper quadrant pain, eructation, hyperemesis, polydipsia, and hematemesis on day of admission. Prior evaluation of his symptoms was significant for unremarkable EGD and colonoscopy (2020), elevated gastrin levels (2/8/24, 932 and 7/11/24, 321), chronic polycythemia, and thrombocytopenia, raising concerns for gastrinoma or hematologic pathology. Frequent ED visits, with recent CT abdomen pelvis concerning for enteritis. A February 2024 GI evaluation suspected that epigastric pain may be secondary to Small Intestine Bacterial Overgrowth or Irritable Bowel Syndrome. Previous treatment with combined proton pump inhibitor, H2 Blocker, and a 14-day Trimethoprim-Sulfamethoxazole course provided only transient relief. On admission, labs significant for Hg 19.3, HCT 55.4, WBC 16.2, ANC 14, eosinophilia 0.5, and platelets 154, ESR 3, and normal CMP. CT Abdomen and Pelvis imaging demonstrated proctocolitis and gastroenteritis. CT Neck and Chest were unremarkable. Infectious workup: respiratory pathogen panel, blood parasite panel, and H. Pylori test were negative; fecal leukocyte was positive, and GI pathogen panel was positive for Giardia lamblia. The patient began metronidazole 500mg BID for 7-days. We later learned that the patient regularly traveled to Ethiopia to visit Holy Water sites, where he consumed and bathed in the water, likely self-inoculating and exacerbating his chronic abdominal pain. IMPACT/DISCUSSION: This case illustrates giardiasis in a patient with upper GI symptoms and absence of typical diarrhea and bloating, emphasizing the need to consider giardia in such cases and gather a thorough infectious history, including cultural practices. At follow-up visit 3 days post-discharge, the patient reported dyspepsia relief following metronidazole. S. Futagami 2015, demonstrated an association between Giardia and post-infectious functional dyspepsia and irritable bowel syndrome, further emphasizing the importance of thorough evaluation and recognizing giardia can present with upper GI symptoms.

This case underscores the importance of considering giardiasis in patients with chronic upper GI symptoms, even without classic lower GI symptoms. It highlights the need for a thorough infectious disease history, including cultural practices, to guide accurate diagnosis and treatment. NOT JUST A HOLIDAY BURN: PNEUMONIA FROM DERMACOCCUS NISHINOMIYAENSIS FOLLOWING WOOD PELLET EXPOSURE Jennifer Trube, Chidozie Igbonagwam, Zachary Breslow, Michael Sabina, Yartin Kheti. GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4271941) CASE: A 29-year-old male with no significant past medical history presented to the emergency department with one week of progressively worsening shortness of breath and left-sided pleuritic chest pain. Computed tomography angiography (CTA) of the chest revealed localized airspace disease along the left heart margin and lingula, leading to an initial diagnosis of community-acquired pneumonia. He was discharged on doxycycline. The patient returned the following day with worsening symptoms, now with pleural effusion and increased airspace opacities at the left lung base. He was admitted to the hospital for treatment. After two days of IV antibiotics with Rocephin and Azithromycin patient reported increased dyspnea and discomfort. Repeat imaging two days later demonstrated a large loculated left pleural effusion and left lower lobe consolidation. Thoracentesis yielded 700 mL of turbid fluid with characteristics consistent with a complicated parapneumonic effusion and empyema. A chest tube was placed, and intrapleural tPA/dornase therapy was initiated. Cultures from the pleural fluid identified Dermacoccus nishinomiyaensis. Patient was switched to Vancomycin and Unasyn for antibiotic therapy. On further investigation, the patient reported recent exposure to wood pellets while smoking a turkey for Thanksgiving, suggesting this as the probable source of infection. The patient showed clinical improvement with chest tube drainage, intrapleural therapy, and targeted antibiotic treatment. IMPACT/DISCUSSION: Dermacoccus nishinomiyaensis is a gram-positive, non-spore-forming bacterium that rarely causes infection in human infections, with only a few cases reported in the literature. Infections caused by this organism are typically associated with catheter-related infections or urinary tract infections. To date, only one case of community-acquired pneumonia has been described in the literature. We present a unique case of complicated parapneumonic effusion and empyema caused by D. nishinomiyaensis, potentially linked to the use of wood pellets in food preparation. This bacterium is part of the normal human skin microbiome and has been isolated from wood pellet stove ash, suggesting this as an environmental source for our patient. While D. nishinomiyaensis is not commonly pathogenic, this case highlights the potential for atypical pathogens to cause pleuropulmonary infections, particularly in the context of unique environmental exposures such as wood pellet grilling. Early recognition, prompt drainage, and appropriate antibiotic therapy are essential in managing complicated parapneumonic effusions and empyema caused by such unusual organisms.

This case underscores the importance of detailed exposure histories in evaluating respiratory infections and adds to the growing recognition of Dermacoccus nishinomiyaensis as a potential opportunistic pathogen. Awareness of such atypical organisms is vital for timely diagnosis and management. NOT SO FAST: CONFRONTING DIAGNOSTIC MOMENTUM IN NON-CIRRHOTIC PORTAL HYPERTENSION Sarah McLaughlin1; Bethlehem Gebre2; Mohamad-Ali Tfaily2; Michael A. Gallagher2. 1Medicine, Emory University, Atlanta, GA; 2Internal Medicine, Emory University, Atlanta, GA. (Control ID #4267892) CASE: A 42-year-old woman presented with several weeks of abdominal swelling. She described abdominal fullness but no pain, nausea, vomiting, diarrhea, fever, chills, or confusion. She did not smoke or drink alcohol. She had a previous diagnosis of cirrhosis with recurrent ascites requiring near-weekly paracenteses despite treatment with furosemide, spironolactone, nadolol, prednisone, and azathioprine. On admission, vitals were unremarkable. Her abdomen was distended with positive shifting dullness and fluid wave. She had vitiligo on dorsal hands and nasolabial folds, but no palmar erythema or spider angiomata. Serum evaluation showed sodium of 129 mEq/L, glucose of 635 mg/dL, and albumin of 3.2 g/dL. AST was 27 U/L, ALT was 75 U/L, and alkaline phosphatase was 128 U/L. HbA1c was 10.3, increased from 5.0 5 months prior. Paracentesis drained 7.7 L of fluid with albumin of 1.2 g/dL, yielding a serum-albumin-ascites gradient of 2. Infectious workup proved negative. Anti-smooth muscle antibody titer was 1:20. A previous workup included a liver biopsy 5 months prior, after initiation of prednisone for possible autoimmune hepatitis (AIH). The biopsy showed distorted lobular architecture, sinusoidal dilatation, with portal phlebosclerosis suggestive of obliterative portal venopathy (OPV). Gastroenterology recommended continuing prednisone and azathioprine despite biopsy results due to high clinical suspicion of AIH. Treatment involved optimization of diuretics, and she was discharged with a new insulin requirement. One month later, she presented with myalgias consistent with steroid-induced myopathy. A prednisone taper was initiated, and ursodiol and azathioprine were discontinued. She continues to require insulin for steroid-induced diabetes, and paracenteses for relief from recurrent ascites. IMPACT/DISCUSSION: Patients with OPV are frequently misdiagnosed with cirrhosis, leading to unnecessary and potentially harmful treatments, as in this case. Despite clinical suspicion for AIH, biopsy results were consistent with OPV. Yet, the patient was treated with an extended course of steroids, leading to diabetes mellitus and myopathy. Failure to reconsider the initial diagnosis despite conflicting evidence led to inappropriate management and serious adverse outcomes. OPV is an often-overlooked cause of non-cirrhotic portal hypertension involving obstruction of portal blood flow due to inflammation, infection, or hypercoagulability. OPV causes pre-sinusoidal fibrosis, in contrast to sinusoidal fibrosis in cirrhosis. OPV typically presents with portal hypertension but preserved liver function. Histopathology showing evidence of phlebosclerosis, or luminal narrowing in the portal veins, in the absence of cirrhotic diagnostic findings may point to OPV.

This case demonstrates a need for improved awareness of OBV and other non-cirrhotic causes of portal hypertension, attention to cognitive biases in medical decision-making, and appreciation of the consequences of medication mismanagement. NOT SO GOOD SYNDROME Russell E. King2; Youssef Saklawi3,1; Adrian Umpierrez3,1. 1Medicine, Emory University, Atlanta, GA; 2J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA; 3Medicine, Grady Memorial Hospital, Atlanta, GA. (Control ID #4271178) CASE: A 63-year-old man with a past medical history of alcohol use disorder, recent thymoma status-post resection, congestive heart failure, and recurrent organizing pneumonias presented with progressive shortness of breath and increased cough over 5 days. In the emergency room, he was noted to be afebrile, tachycardic, and tachypneic. Chest imaging revealed consolidations concerning for multifocal pneumonia. Given the patient’s severe respiratory distress, he was admitted to the ICU and started on empiric antibiotics. Given the patient's known history of recurrent organizing pneumonia, we pursued additional workup. Due to his history of thymoma resection, we investigated a diagnosis of Good Syndrome (GS), as hypogammaglobulinemia is frequently associated with a history of thymoma. His serum immunoglobulin levels were all below normal limits, IgG: 173 (Normal 700-1300); IgM <20 (40-230); IgA: 11 (70-400); IgE <2 (0-100). The patient started immunoglobulin replacement therapy. His symptoms improved and he was discharged in stable condition to follow up with immunology for ongoing treatment. IMPACT/DISCUSSION: Cases of recurrent infections despite adequate therapy should be evaluated. Reviewing past medical problems, surgeries, injuries, and medications is the first step. An evaluation for secondary immunodeficiency should also be a part of the workup. In adults, most immunodeficiencies are from secondary causes such as HIV, diabetes mellitus, malignancy, or immunosuppressive agents. In the case of recurrent pneumonia, anatomic variations and immunodeficiency should be considered. However, there are primary immunodeficiencies that arise in adulthood. Good Syndrome is an adult-onset immunodeficiency characterized by thymoma, low or absent B cells, and hypogammaglobulinemia. Sinopulmonary infections are the most common site of recurrent infections.

Recurrent infections (>4 events in 1 year) should trigger additional workup. Initial evaluation should include the more common secondary causes of immunosuppresion. However, It is important to consider additional history as a basis for targeted workup. In patients with a history of thymoma or mediastinal mass and recurrent infections, consider Good Syndrome, which requires IVIG therapy as treatment. OCCULT ATRIAL FIBRILLATION AS A CULPRIT FOR RECURRENT STROKES—A CASE REPORT Jairah Shaikh1; Tanzina Afroze1; Mohammed Abdelsalam2; Aisha Tahbib1; Hassan Tariq1; Fatema Mahjabeen3; Aram Aslanian4; Tarek Naguib5; Ismaile Abdalla6,1. 1Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, 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 Sciences Center at Amarillo, Amarillo, TX; 5Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX; 6Cardiology, US Department of Veterans Affairs, Amarillo, TX. (Control ID #4271778) CASE: In atrial fibrillation (AF), whether paroxysmal, persistent, permanent, etc., the underlying pathophysiology of stagnant blood in the atria leads to a cardioembolic phenomenon that results in ischemic cerebrovascular accidents (CVAs). However, in cases of transient occult AF, the timing and condition under which thrombi form may conceivably be insufficient to result in significant thromboembolic sequelae. We report such a rare case, wherein this insidious rhythm may have resulted in recurrent cryptogenic CVAs. A 79-year-old male complained of lower extremity weakness over the course of 3 weeks. He has a history of 4 ischemic CVAs, coronary artery disease s/p 2 stents, hypertension, DM type 2, and a family history of arrhythmias and recurrent CVAs. Physical exam showed new ataxia and poor motor coordination of lower extremities with preserved sensation and strength. MRI revealed a subacute infarction of the right internal capsule and lateral thalamus. MRA of head and neck and transthoracic echocardiography were unrevealing for a thromboembolic source. On the third hospital day, telemetry detected a transient conversion of his baseline rhythm to AF, associated with erratic swings of HR 55 -110 bpm. Following a negative nuclear stress test and spontaneous conversion back to sinus rhythm (SR), he was started on apixaban and sotalol in attempt to maintain SR. However, AF recurred and became more sustained the following days. Sotalol was discontinued, and he was discharged with plans to readmit after 4 weeks of metoprolol and apixaban to attempt rhythm control with flecainide and possible electrical cardioversion. IMPACT/DISCUSSION: Detection of an occult AF in cryptogenic CVA has been reported to be 3% and 16% for 24-hour and 30-day continuous cardiac monitoring (CM), respectively. Moreover, the detection of AF in patients with cryptogenic CVA is 6.4 times greater in a 6-month period of monitoring using an insertable CM compared to placebo. The biologic gradient, in terms of the incidence of CVA associated with ephemeral forms of AF, is not well-established, as most literature is based on sustained forms of AF. In this patient’s case, previous CM was unable to detect occult AF, thus lending to the importance of prolonged monitoring. Upon detection of occult AF, a spontaneous reversion to a normal sustained rhythm cannot be assumed. Therefore, appropriate anticoagulation for at least 4 weeks along with rate control is necessary prior to chemical and electrical cardioversion with to reduce the risk of cardioembolic events.

Occult AF may be an underrepresented rhythm leading to CVAs. In high-risk patients, particularly those with recurrent CVAs or those with family history of cardiac arrhythmias and CVAs, long-term cardiac monitoring may be warranted for early detection and treatment of occult AF. OPENING THE VAULT: UNCOVERING A RARE SOURCE OF SEPSIS Caitlin Sarubbi, Jessica Cristallo. Medicine, Montefiore Medical Center, New York, NY. (Control ID #4270881) CASE: A 73-year-old female, bedbound, nursing home resident with a medical history of ESRD on dialysis, diabetes and hypertension, presented complaining of body aches, malaise, chills and cough. She was afebrile with normal range vitals. CBC showed a WBC of 21.8 with neutrophil predominance. CXR without focal pulmonary findings and urinalysis was negative for infection. Blood cultures showed no growth. Upon admission, the patient was noted to have rising leukocytosis with intermittent fevers and hypotension despite empiric antibiotics (vancomycin and aztreonam) and developed confusion and lethargy. Her HD catheter was removed, but cultures again returned negative. The patient underwent a CT A/P showing a hyperdense pelvic collection with punctate focus of gas and layering debris. Antibiotics were changed to ceftriaxone, metronidazole and doxycycline to treat presumed pelvic infection. The patient had an MRI pelvis which showed progressive hydrometra with persistent small foci of gas most consistent with pyometra. She underwent suction D&C during which frank stool was found in the vaginal vault and 300 cc of pus was evacuated from the uterus. Following the procedure, the patient had rapid clinical improvement. IMPACT/DISCUSSION: Sepsis is a common hospital admission diagnosis. Elderly, nursing home residents are more susceptible to developing sepsis than their younger, independent counterparts. Although respiratory and urinary tract infections are the most common etiologies, the underlying cause of sepsis can be more difficult to diagnose in the elderly due to atypical presentations. In our case, the patient’s rapid clinical decline and non-focal symptoms required the team to use various modalities to look beyond the common etiologies of sepsis. Ultimately, the team uncovered pyometra as her source of infection. Pyometra is a rare infection characterized by pus in the uterus. Patients may present with malodorous vaginal discharge, pelvic pain and bleeding, but many cases present without localized symptoms. Pyometra is slightly more common in postmenopausal women due to cervical os stenosis. Underlying pelvic malignancy or history of radiation are the most common risk factors. In our patient, ascending bacterial spread from fecal matter found in the vagina led to the development of pyometra. Her full dependency on others for activities of daily living made her more vulnerable to developing this rare infection. Definitive management of pyometra requires D&C as the infection is otherwise self-contained in the uterus (acting as an abscess) and impenetrable by antibiotics alone. In our case, despite the risk of D&C, source control was imperative to her survival and resulted in resolution of her infection.

Sepsis is a common cause of hospitalization for nursing home patients, however pyometra is an uncommon etiology. This case highlights the importance of uncovering and treating the source of sepsis for patients’ clinical recovery. ORBITAL CELLULITIS: DISTAL SOURCE OF INFECTION IN IMMUNOSUPPRESSED PATIENTS Eric Hu1; Hannah Hoang2; Brynn Zerbe1; Sarah Al-Obaydi2,3. 1College of Medicine - Student, Penn State College of Medicine, Hershey, PA; 2Penn State Health Milton S Hershey Medical Center, Hershey, PA; 3BayCare Health System, Clearwater, FL. (Control ID #4272559) CASE: A 67-year-old with a history of myelodysplastic syndrome on decitabine, oropharyngeal squamous cell carcinoma complicated by esophageal stricture, and radiation necrosis presented for right eye swelling and vision loss. Two weeks prior to the presentation, he was admitted for pseudomonas pneumonia and later discharged with a 14-day course of Cefepime. Several days before the most recent admission, he was admitted for right eye orbital cellulitis and was then transferred to this institution for evaluation of right orbital cellulitis. During the current admission, the patient was found to have right-sided endophthalmitis with secondary retinal detachment, optic neuritis, and orbital cellulitis for which he was started on IV ceftazidime and intravitreal vancomycin and ceftazidime. The patient later expressed chronic right wrist pain, which was evaluated via ultrasound-guided aspiration and X-ray that revealed right wrist osteomyelitis which was suspected to be the hematological source for the orbital cellulitis. Given vision loss and worsened general health, the patient elected hospice and died 2.5 weeks after admission. IMPACT/DISCUSSION: Orbital cellulitis is most associated with pediatric populations. The causative organisms are typically polymicrobial, with Staph. Aureus, Streptococci, and Pseudomonas aeruginosa as three common organisms. Orbital cellulitis can stem from tooth, middle ear, or facial infections. Trauma, ophthalmic surgery, or immunodeficiency may also play a role. This case highlights an unusual source of infection in the wrist that caused hematological spread in the setting of immunodeficiency from myelodysplastic syndrome. In these instances where there is an immunodeficiency, sources of orbital cellulitis may stem from any active infection site. This emphasizes the importance of culturing abnormal sites for high-risk/immunocompromised patients. Patients with orbital cellulitis who present with erythema, joint pain, or other signs of infection at distal sites may benefit from site cultures to further guide antimicrobial therapy. Additionally, this case also emphasizes the importance of symptom timeline in evaluating the source of infection. The patient’s episode of pneumonia and sepsis 2 weeks before presentation were likely due to the wrist infection, thus evaluation of the wrist may be more appropriate when trying to identify the source of this patient’s orbital cellulitis.

In summary, in the case of an immunocompromised patient with orbital cellulitis, it may be important to consider atypical sites of hematological spread and to take an accurate history of the onset of symptoms. OROFACIAL SPASMS FOLLOWING HYPOGLOSSAL NERVE STIMULATOR IMPLANTATION: A RARE COMPLICATION OF INSPIRE THERAPY Sahalia Rashid, Patrick W. Kollman, Mazhar Shapoo, Peter Morkos, Tanushri Bhushan, Pierre Tannous. School of Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4273365) CASE: A 41-year-old male with severe obstructive sleep apnea (OSA) and ADHD presented to the ED with a two-week history of orofacial spasms, five months after hypoglossal nerve stimulator implantation (Inspire surgery). The surgery, performed after a home sleep apnea test confirmed severe OSA and drug-induced sleep endoscopy showed 100% collapse at the velopharynx, base of tongue, and epiglottis, was uncomplicated, and the device was activated two months later. Three months post-activation, the patient reported new tongue and lower lip spasms, tongue numbness/tingling, slurred speech, and occasional difficulty swallowing with a choking sensation. He noted that at rest, his tongue contracted to his hard palate instead of the mouth floor, and during eating or speaking, it contracted superiorly and posteriorly. Symptom onset followed prolonged screaming at a concert, a minor fall, and a recent switch from Ritalin to Adderall. On admission, a lateral neck X-ray confirmed proper device placement, and ENT denied airway collapse. Examination showed intermittent dorsal tongue spasms in a curling motion without other abnormalities. ENT and sleep medicine planned outpatient follow-up and MRI. Two months later, the patient continued using the device with mild residual symptoms, including a stutter, tongue resting superiorly instead of inferiorly, and a persistent "buzzing" sensation. IMPACT/DISCUSSION: This case illustrates a rare complication of Inspire device implantation for obstructive sleep apnea (OSA)—orofacial spasms and altered tongue function. While generally safe, the device can cause side effects like dysphagia and muscle spasms due to hypoglossal nerve overstimulation. The patient's symptoms, including tongue spasms and swallowing difficulties, likely resulted from a combination of device effects, medication changes (Ritalin to Adderall), and vocal strain. Key points include monitoring for neurological side effects post-implantation, with attention to hypoglossal nerve dysregulation when symptoms like dysphagia or spasms arise. Multidisciplinary teams including sleep medicine, ENT, and neurology are critical in evaluating cases where device function or external factors contribute to symptoms. Imaging, including lateral X-rays, can confirm device position, with further imaging required for nerve irritation or device malfunction. This case underscores the importance of recognizing and managing delayed complications of the Inspire device, particularly when influenced by additional factors.

1. Recognize potential complications: Be alert for neurological side effects such as spasms and dysphagia in patients with Inspire devices, particularly in the early postoperative period. 2. Collaborate with specialists: Multidisciplinary consultations can help diagnose and manage complex symptoms, ensuring comprehensive care. 3. Consider patient factors: History and activities, like vocal strain or medication changes, should be considered when evaluating symptoms post-Inspire implantation. OSSEOUS INVOLVEMENT OF HAIRY CELL LEUKEMIA IN A MIDDLE-AGED MAN Dustin Wessells1; David T. Zhang2,1. 1Cardiology, Stony Brook Medicine, Stony Brook, NY; 2Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4272411) CASE: The patient is a man in his 60s with hairy cell leukemia s/p adjuvant cladribine and vemurafenib with no evidence of disease (NED), and metastatic sigmoid adenocarcinoma to liver s/p robotic partial colectomy and anastomosis with partial hepatectomy and s/p adjuvant folic acid/fluorouracil/oxaliplatin (FOLFOX) with NED who presented with subacute upper back pain. On presentation, his vital signs were within normal limits. On further interview, his back pain was midline in the upper thoracic region, gradual in onset, progressively worsening over the last month, and exacerbated by prolonged sitting/lying supine but improved with ambulation. He denied any fevers/chills, focal weakness, gait instability, or urinary/bowel incontinence. Normal neuro exam. MRI of the total spine demonstrated osseous thoracic (T1/T2) lesions with circumferential epidural extension, abutting and possibly mildly compressing the cord with suspicion for metastatic neoplasm. Positron emission tomography/computed tomography (PET/CT) on hospital day (HD) 3 demonstrated no fluorodeoxyglucose (FDG) avidity other than T1/T2. His initial set of blood cultures were drawn on HD2 which were notably positive for methicillin-resistant Staphylococcus epidermidis (MRSE). Cultures from his mediport were initially negative on HD2 but later positve. Follow-up peripheral blood cultures were negative from HD5 onward. Interventional neuroradiology performed a biopsy of the T1/T2 lesions on HD7. T1/T2 spinal biopsy demonstrated HCL. He was subsequently re-admitted one month after initial discharge for new severe pathologic T1-T2 compression deformity and extended spectrum beta-lactamase (ESBL) Escherichia coli bacteremia with osteodiscitis. The patient was again re-admittedin 1 month for altered mental status and was found to have Staph epidermidis osteomyelitis and spinal cord compression. The hospitalization was further complicated by respiratory failure, worsening altered mental status, as well as Clostridioides difficile infection. The patient ultimately was palliative and passed away. IMPACT/DISCUSSION: HCL is an uncommon cancer with skeletal involvement estimated at 3% of those cases with the majority being femoral head and neck. Rarely, it has been shown to invade the vertebral columns, and, in those cases, tended to have osteonecrosis and osteosclerosis. This was not an osteosclerotic lesion, unlike the majority of HCL cases. There was no other FDG uptake besides the T1/T2 lesions and other cases demonstrated signs of active HCL such as bone marrow FDG avidity. Given the radiographic data, history of adenocarcinoma, and bacteremia, the diagnoses of osteomyelitis with epidural abscess/extension or adenocarcinoma were on the differential.

Remember to rule out medical emergencies such a cord compression when patients present with back pain Consider the patient’s medical history when forming a differential diagnosis as less likely diagnosis in average patient could be more probable OSTEITIS FIBROSA CYSTICA: A CLINICAL AND PATHOLOGICAL OVERVIEW Apar Karki. Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY. (Control ID #4271889) CASE: 55 yr old female with a medical history significant for Chronic Kidney Disease stage 3 and past bone biopsy in Ecuador for a suspicious lesion (non-diagnostic), was admitted to a hospital in New York for evaluation of chest pain. She was found to be anemic (Hb11.1, Hct 32.4), hypercalcemic (Ca: 12.7) and with a creatinine of 1.8. Hematology workup revealed increased free kappa and lambda light chains (fK 71.3, fL 33.4 with fK:fL 33.4), as well as an elevated kappa/lambda ratio (put ratio here), though no monoclonal spike was identified. A computed tomography of abdomen/pelvis showed large lytic lesions in the iliac bones associated with cortical erosion. A repeat CT-guided biopsy of a lytic lesion was performed, which revealed normal erythrocytes, occasional lymphocytes, macrophages, and osteoblasts. No malignant cells were identified. Repeat bone marrow biopsy was considered given highly suspicious findings on radiology. Given hypercalcemia, the patient was seen by endocrinology. She was found to have inappropriately elevated intact parathyroid hormone (iPTH) normal phosphorus and 25-hydroxyvitamin D levels. Treatment with cinacalcet was initiated, resulting in a reduction of calcium levels. The patient was planned for left parathyroidectomy and thyroid lobectomy. Histopathologic examination of the resected tissues revealed an atypical parathyroid tumor, as well as a diagnosis of papillary thyroid carcinoma, classic subtype, associated with Hashimoto’s thyroiditis. These new findings prompted reevaluation of the radiologic findings of lytic lesions on her initial CT. The radiologic lesions were deemed highly consistent with brown tumors, a manifestation of osteitis fibrosa cystica. Following parathyroidectomy her hypercalcemia resolved (Ca: 8.7) and improvement were seen in her anemia and CKD. IMPACT/DISCUSSION: Osteitis fibrosa cystica (OFC), or brown tumors, are cystic bone lesions that occur as a result of chronic hyperparathyroidism. These lesions are typically seen in the advanced stages of hyperparathyroidism and have become less common due to early detection and treatment. Radiologically, they present as lytic bone lesions or multi-lobular cystic changes, often indistinguishable from other bone tumors, including bone metastases, multiple myeloma, giant cell tumors, and bone cysts. Diagnosis of brown tumors requires a combination of radiological findings, pathological analysis, and biochemical markers, including elevated PTH, calcium, and decreased phosphate levels, in the context of longstanding hyperparathyroidism

OFC is a rare but significant complication of hyperparathyroidism. Radiologic and biochemical findings, in combination with histopathologic confirmation, are essential for diagnosis. Early treatment, particularly parathyroidectomy, can lead to resolution of hypercalcemia and improvement in skeletal lesions. OFC should be considered in the differential diagnosis of lytic bone lesions, especially in the presence of elevated PTH and calcium levels. OVERCOMING RESISTANT HYPERTENSION: A MULTIDISCIPLINARY APPROACH IN A HIGH-RISK PATIENT WITH COMPLEX COMORBIDITIES Sameer Lohana1; Mohammad Hazique1; FNU Kalpana2. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4273258) CASE: A 63-year-old African American female with a history of hypertension (HTN), type 2 diabetes mellitus (T2DM), and metabolic syndrome (MS) presented to the emergency room following an unwitnessed fall and loss of consciousness (LOC). Despite being on a multi-drug antihypertensive regimen, her BP peaked at 203/145 mmHg, indicative of refractory hypertension (RH). Evaluation excluded secondary causes of hypertension, with comprehensive imaging and laboratory findings unremarkable. During a 15-day hospitalization, her antihypertensive therapy was progressively intensified. Initial home medications included Metoprolol Succinate, Nifedipine, Olmesartan, Pantoprazole, Rosuvastatin, and Terazosin. Hospital management began with increased doses of Hydralazine and the addition of medications such as Carvedilol, Nicardipine drip, Clonidine patch, Spironolactone, and Minoxidil. Despite challenges, her BP stabilized, and she was discharged with a tailored regimen comprising Losartan, Nifedipine, Clonidine, Chlorthalidone, Minoxidil, Spironolactone, and Terazosin. IMPACT/DISCUSSION: This case highlights the complexities of managing resistant hypertension (RH), particularly in high-risk populations like African Americans, who experience a higher prevalence of RH and its complications. Achieving optimal BP control required a structured, individualized, and patient-centered approach targeting multiple physiological pathways. Escalating antihypertensive regimens, including agents acting on the renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system, and hormonal pathways, effectively addressed the multifactorial nature of RH. These agents synergistically mitigated fluid retention, reduced arterial stiffness, and countered hormonal imbalances, though achieving control remained challenging. Beyond pharmacological interventions, shared decision-making was critical to ensure active patient participation. Addressing social determinants of health, such as medication affordability, dietary habits, and healthcare access, was essential for adherence and improved outcomes. For refractory cases, advanced interventions like renal denervation and newer antihypertensive agents offer promising solutions, particularly for high-risk populations.

Resistant hypertension is a challenging condition that requires a multidisciplinary, patient-centered approach for effective management. This case underscores the importance of combining tailored pharmacological strategies, shared decision-making, and emerging therapies to achieve optimal BP control in high-risk populations. Future research should focus on the long-term effectiveness of novel interventions, such as renal denervation, and their potential to reduce the burden of RH. PACEMAKER-INDUCED SUPERIOR VENA CAVA SYNDROME: A CASE OF SEVERE STENOSIS WITH THROMBUS FORMATION Dhairya Salvi1; Ayushi Garg2; Ripanjit Singh4; Vamsi Krishna Lavu1; Parshva Salvi1; Nishit Choksi3. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI; 3Cardiology, Ascension Providence Rochester Hospital, Rochester, MI; 4internal medicine, Wayne State University, Detroit, MI. (Control ID #4272297) CASE: A 71-year-old female with medical history significant for Atrial fibrillation on apixaban, supraventricular tachycardia (SVT), sick sinus syndrome status post permanent pacemaker (PPM) placement six years ago, coronary artery disease, diastolic heart failure and hypothyroidism presented with acute onset of shortness of breath, facial, neck and upper extremity swelling and insidiously developing dysphagia. She denied any exposure to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or known allergens. Vital signs showed a blood pressure of 93/46mm Hg, a normal heart rate and stable oxygen requirements. Initial chest x-ray was unremarkable, but a CT scan of the chest and neck soft tissue with contrast revealed small pleural effusions, ascites, and diffuse edema and third-spacing of soft tissues. Physical examination and imaging raised suspicion for superior vena cava (SVC) syndrome. Thereafter, a CT venogram revealed significant stenosis of the SVC near the site where the pacemaker wires entered the heart. Patient was immediately switched from apixaban to heparin drip. A conventional venography was performed to further assess the SVC stenosis, which confirmed severe stenosis with thrombus at the pacemaker entry site. Due to an enlarged thrombus at the site of stenosis, immediate angioplasty was not performed. The patient was switched from apixaban to rivaroxaban and discharged home with a scheduled CT venogram in six weeks to evaluate for thrombus resolution or organization, and to consider potential angioplasty and stenting. IMPACT/DISCUSSION: SVC syndrome consists of a constellation of symptoms that arise due to obstruction of blood flow through the SVC and is mostly due to external obstruction from mediastinal malignancies or less commonly can be from intrinsic stenosis or thrombosis from an intravascular device. Here, the patient developed shortness of breath, and facial, neck, and arm swelling without any obvious trigger. There was a high suspicion of angioedema especially with no tumor or stenosis identified on CT chest with iv contrast. However, further investigation in the form of a CT venogram which allows additional time to preferentially enhance the venous system, helped delineate the cause and hence is a better test than the former. A conventional venogram further confirmed that SVC stenosis was secondary to a thrombus formed due to a pacemaker wire in situ which served as a nidus for clot formation. Despite being on a full therapeutic dose of Apixaban, he developed a clot, which also suggests Apixaban failure.

It is important to keep a high degree of suspicion for SVC syndrome, especially of a thrombotic etiology, despite being on anticoagulation especially when there is an underlying nidus of clot formation. P-ANCA VASCULITIS WITH ANGIOEDEMA: A MULTISYSTEM CHALLENGE MASHA KRASNOFF, Owen House, Christopher Dietrich. Medicine, Rocky Vista University College of Osteopathic Medicine, Parker, CO. (Control ID #4251137) CASE: A 67-year-old male with a history of CKD stage III, HFpEF, and hypertension presented with acute angioedema and respiratory distress 24 hours after an elective VATS pleural biopsy for a lung nodule. Epinephrine, corticosteroids, and antihistamines as well as intubation were administered based on presumed anaphylaxis (Muraro et al., 2021). Limited improvement was shown, and the absence of an identifiable allergen or drug-related trigger prompted further evaluation. The patient’s testing results indicated a creatinine level of 2.7 mg/dL - elevated from a baseline of 1.6 mg/dL, microscopic hematuria, subnephrotic proteinuria, and P-ANCA positivity but without pulmonary hemorrhage, infectious, or hereditary causes of angioedema. A renal biopsy indicated pauci-immune glomerulonephritis and definitively confirmed P-ANCA-associated vasculitis, free of significant chronic renal damage. High-dose intravenous methylprednisolone was administered with a prednisone taper per PEXIVAS trial protocol (Fussner et al., 2024). As there was no pulmonary involvement or severe renal implication, rituximab treatment was postponed for initiation in an outpatient setting. The patient’s hypertension regimen was modified due to persistent bradycardia and resistant hypertension. Recent medication exposure to losartan and oxycodone was considered and ruled out as contributing factors given discontinuation prior to the patient’s symptom onset. At discharge, the patient’s angioedema and renal function resolved and stabilized. Multidisciplinary collaboration between nephrology, cardiology, and critical care was imperative to address the interaction of systemic inflammation, renal impairment, and cardiovascular instability. The patient was discharged with outpatient plans of rituximab initiation with close monitoring of disease resolution. IMPACT/DISCUSSION: This case underlines the importance of maintaining a broad differential diagnosis when clinical findings are atypical of classical presentations. Angioedema as an atypical presentation indicated an underlying systemic response that could have been otherwise overlooked. We were able to observe the therapeutic impact of early immunosuppressive therapy to stabilize disease activity, multidisciplinary collaboration in managing complex autoimmune conditions, and broad diagnostic differential for correct treatment as well as preventing progression to severe or life-threatening disease.

This report demonstrates the utility of comprehensive diagnostic strategies and collaborative multidisciplinary management in complex clinical cases. Angioedema, though rare in vasculitis, served as the first indication of systemic autoimmune disease. The diagnostic role of renal biopsy was central to confirming the underlying vasculitis and excluding other causes. Early recognition and prompt treatment stabilized the patient and prevented further progression, reinforcing the importance of broad diagnostic considerations in rare presentations of systemic diseases. PARAGONIMIASIS: A MIMICKER OF TUBERCULOSIS Zi Yi Christopher Thong1; Wilson G. Goh2; Norris Chun Ang Ling3. 1Respiratory and Critical Care Medicine, National University Health System, Singapore, Singapore, Singapore; 2Infectious Diseases, National University Health System, Singapore, Singapore, Singapore; 3Respiratory Medicine, Ng Teng Fong General Hospital, Singapore, Singapore. (Control ID #4246526) CASE: A 26 year old Indian lady presented to the emergency department with headache for 1 week duration with 2 months of unintentional weight loss of about 4kg with loss of appetite. A computed tomography (CT) of the brain showed focal oedema in the cortical and subcortical region of the right frontal periopencular region with swelling in the adjacent cortical sulci. CT thorax abdomen and pelvis revealed a 2x1.8cm nodular lesion with central low attenuation in the lateral basal segment of the right lower lobe. Lumbar puncture showed mild leucocytosis and lymphocytic cells. Her blood tests revealed eosinophilia and raised IgG4. She declined a bronchoscopy and bronchoalveolar lavage (BAL) initially but subsequently developed acute intraparenchymal haemorrhage. A BAL was subsequently performed and ova-cyst-parasite examination from the BAL was positive for paragonimus westermanii. She was started on praziquantel with clinical improvement and discharged. IMPACT/DISCUSSION: Paragonimiasis is endemic in many parts of Asia, Africa and South America. According to the World Health Organizing in 2015, about 1 million people are infected every year. In recent years, it is becoming a problem of public health in India. Humans can acquire the infection by ingestion of uncooked or undercooked crustaceans containing metacercariae which is the larval stage of the parasite. Patients generally present with atypical clinical features which may lead to delayed or missed diagnosis. Their symptoms may also mimic tuberculosis, which may be a red herring. There have been 28 previously reported misdiagnosed paragonimiasis from 2010-2020 and this highlights the diagnostic dilemma clinicians have when they encounter presentations of paragonimiasis. The primary site of infection is in the lungs but extra-pulmonary infections are not infrequent. Symptoms including cough, chest pain, dyspnea, which may follow tuberculosis or lung malignancy. The three key features of paragonimiasis is hypereosinophillia, positive diet history of crustaceans consumption and living conditions. Paragonimiasis also manifest in the lungs in 76-90% of cases. The definitive diagnosis is visualization of the characteristic golden brown, ellipsoidal or oval operculated paragonimus ova in body fluids or faeces by microscopy. The treatment of choice is praziquantel for both pulmonary and extra pulmonary paragonimiasis.

Paragonimiasis can mimic many conditions including but not limited to tuberculosis and malignancy and can be a diagnostic dilemma in clinical practice. It is important to have a high index of suspicion for paragonimiasis infection if a patient presents from endemic countries with the key manifestations of: hypereosinophillia, positive diet history of crustaceans consumption and living conditions, as early treatment can lead to improved outcomes in these patients. PARASITES AMONGST US: A CASE OF BABESIOSIS WITH HIGH GRADE PARASITEMIA AND LYME COINFECTION Julia Ossi, Gabriela M. Diaz, Grace Promer, Tamia Ross, Huey Huynh, Justin Liu, Noble Maleque. Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4240850) CASE: 82 year-old female with prior history of hypertension visiting from rural Wisconsin who presented to a Georgia hospital emergency room with cough, exertional dyspnea, fever, and fatigue. Temperature 40 degrees Celsius with other vital signs normal. Lung exam with expiratory crackles bilateral lung fields. Cardiac and skin exam were normal. Hematology labs with white blood cells 4900/mcL, Hemoglobin 6.3 g/dL, and platelet count of 40000/mcL. Chemistries showed AST 146 units/L, ALT 97units/L, LDH 780 units/L, and creatinine 1.2 g/dL, Chest Xray showed a right middle lobe opacity. She was started on empiric antibiotics for community acquired pneumonia. Due to pancytopenia, peripheral smear was performed and revealed presence of schistocytes and parasites. PCR testing confirmed Babesia microti and she was diagnosed with severe babesiosis with an initial parasitemia of 19% with positive IgM Lyme antibodies suggesting Lyme co-infection. She was subsequently treated with azithromycin, atovaquone, and doxycycline with marked clinical improvement. Despite her high grade parasitemia, evidence of severe hemolytic anemia, and acute renal failure, she improved with antibiotics and supportive blood transfusions without the need for adjunctive red cell exchange. IMPACT/DISCUSSION: Data from the CDC show that a total of 1,834 cases of babesiosis were reported in 2020 in the US, and zero cases were diagnosed in the state of Georgia. Treatment options for babesiosis depend on the clinical status of the patient. In patients with high-grade parasitemia (>10%) or one or more of the following: severe hemolytic anemia and/or severe pulmonary, renal, or hepatic compromise, IDSA guidelines provide a weak recommendation for consideration of exchange transfusion. While exchange transfusion is known to decrease parasitemia, there are significant adverse effects to consider including transfusion reactions, worsening of thrombocytopenia, and complications associated with venous access devices. Given these adverse effects, after infectious disease and hematology consultations, the decision was made to proceed with supportive therapy. It is likely that the patient had been co-infected with babesia and Lyme for several months, given her high-grade parasitemia, however, despite her older age and severe infection, she was discharged after five days of supportive therapy alone. Her parasitemia responded well to treatment and was almost undetectable after one week.

This report illustrates a case of babesia in a nonendemic region and addresses the lack of necessity of adjunctive red cell exchange in severe babesiosis. Given that it is already a weak recommendation, these findings provide further evidence that red cell exchange is not a necessary treatment for babesiosis, even when there is a co-infection with another illness among older adults. PAST SHADOWS, PRESENT PERILS: AN IMPORTANT PIECE OF THE PUZZLE RETAINED IN THE HISTORY Maria F. Sanes Guevara1; Nanditha Venkatesan1; Andrew J. Klein2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4271664) CASE: 44-year-old man with a history of childhood rhabdomyosarcoma and polysubstance use disorder presented with fever, chills, odynophagia, and right arm swelling. He stated that his port catheter (placed more than 30 years ago for chemotherapy) became infected and was partially removed a few months ago while he was incarcerated. He was tachycardic (136 bpm), hypotensive (84/63 mmHg) and hypoxic (88% on room air), with leukocytosis (29,500 cells/μL), elevated procalcitonin (60.55 mg/L), and lactate (6 mmol/L). Physical examination revealed bilateral rhonchi, diffuse neck and arm swelling, and a purulent left chest wound exposing the cut end of a catheter. Imaging revealed retained left subclavian port, bilateral internal jugular vein (IJV), subclavian vein, and superior vena cava thromboses, mediastinitis, along with pneumonia with cavitary lesions, empyema, severe odontogenic disease, and embolic infarcts in the kidneys, concerning for Lemierre syndrome. He was quickly intubated and started on vasopressors and broad-spectrum antibiotics for septic shock, including vancomycin. He received prompt surgical intervention for source control including right thoracotomy, left thoracoscopy with empyema evacuation, and debridement of chest wall abscesses. The left subclavian port was extracted. Blood cultures revealed MRSA bacteremia. Transesophageal echocardiogram showed a right atrial vegetation from the SVC. The course was further complicated by septic emboli to the brain, endophthalmitis, and soft tissue abscesses. IMPACT/DISCUSSION: This case underscores an atypical cause of Lemierre syndrome, where septic IJV thrombophlebitis, bacteremia, and embolic complications originated from a retained subclavian port, resulting in MRSA bacteremia and extensive thrombophlebitis. While Lemierre syndrome is often caused by Fusobacterium necrophorum from oropharyngeal infections, this case emphasizes the importance of considering other potential sources in patients with complex medical histories, such as retained catheters. It also highlights the necessity of including MRSA coverage in empiric treatment based on patient’s risk factors, alongside beta-lactamase-resistant antibiotics.

● Lemierre syndrome typically involves septic thrombophlebitis of the IJV and metastatic complications, often due to anaerobic bacteria from oropharyngeal or odontogenic infections. However, unusual sources, like retained catheters, must be considered. ● It is crucial to stress the importance of history for incarcerated patients as they may have incomplete medical records, increasing the risk of missed diagnoses and complicating treatment decisions. PATENT FORAMEN OVALE - THE LINK IN A CASE OF MIXED ARTERIAL AND VENOUS THROMBOSIS Kevin Soon Hwee Teo1; Jie Min Ong2; May Zin Myint1; Vijay Kumar Sharma1. 1Neurology, National University Hospital, Singapore, Singapore, Singapore; 2National University of Singapore Yong Loo Lin School of Medicine, Singapore, Singapore. (Control ID #4234622) CASE: A middle-aged female with no significant past medical history presented to the Emergency Department with acute-onset left-sided weakness, drowsiness and dyspnoea. Her GCS was E1V1M5 and she had a dense left hemiparesis with right gaze deviation (NIHSS 31). Her blood pressure was 125/88 mmHg, pulse 116 beats per minute, and oxygen saturations were 76% on room air. Chest radiograph showed no abnormalities. An electrocardiogram showed sinus tachycardia and bedside ultrasound showed a dilated right ventricle. N-terminal pro-brain natriuretic peptide and cardiac high-sensitive troponins were elevated at 278 pg/mL and 79.7 ng/ml respectively. CT Angiography identified an acute occlusion of the right middle cerebral artery M1 segment and right anterior cerebral artery. Filling defects in the bilateral pulmonary arteries were also detected on the caudal cuts of the CT and the presence of pulmonary embolism and right heart strain was confirmed on a subsequent CT pulmonary angiogram. Further history revealed no recent long-haul flights or periods of immobility. The patient had no history of recurrent miscarriages, joint pains, photosensitive rash or paroxysmal red discolouration of urine. A urine pregnancy test returned negative and there was no oral contraceptive use. Ultrasound of the lower limb veins did not identify any deep venous thrombosis. The patient’s low-Density lipoprotein was 2.6 mmol/L and her glycated haemoglobin was 5.2%. Her homocysteine levels were normal and antiphospholipid antibodies were negative. Computed tomography of the abdomen and pelvis (CTAP) showed no malignancy. A bedside transcranial doppler bubble study with agitated saline identified a Spencer Grade 5 right-to-left shunt, confirmed to be a large patent foramen ovale (PFO) on transesophageal echocardiography. The patient received intravenous thrombolysis and endovascular thrombectomy followed by inpatient rehabilitaion. She subsequently underwent a successful endovascular PFO closure 4 months after her acute stroke. IMPACT/DISCUSSION: The differential diagnoses for mixed arterial and venous thrombosis include hyperhomocysteinemia, antiphospholipid syndrome, malignancy, inherited thrombophilias and shunts. PFO is a common congenital cardiac anatomical variant and may be responsible for paradoxical emboli when right atrial pressure exceeds left atrial pressure, either through Valsalva or triggered by a pulmonary embolism as in this case. Patients selected for PFO closure should be aged 60 or younger, with embolic stroke topography, no other evident source of stroke, no concurrent indication for anticoagulation, and a possible, probable, or definitive likelihood that the stroke was causally related to the PFO according to the PASCAL system.

Intracardiac shunts should be considered as an etiology for patients presenting with acute ischemic stroke and venous thrombosis. PELVIC INFLAMMATORY DISEASE AS AN UNCOMMON CAUSE OF SMALL BOWEL OBSTRUCTION Alex Vargas Romero, Theresa Paul. Internal Medicine, Montefiore Wakefield Campus, New York, NY. (Control ID #4271623) CASE: A 21-year-old woman without significant surgical or gynecologic history presented with severe abdominal pain and vomiting for 2 days. Physical exam revealed tachycardia; abdominal exam revealed diffuse tenderness to palpation, more severe at lower abdomen, but no signs of peritonitis. Blood workup was remarkable for an elevated white blood cell count (13.2 k/uL) and C-reactive protein >32 mg/dL. Computed tomography (CT) scan of the abdomen and pelvis revealed small bowel obstruction (SBO) and thick-walled enhancing structures within the pelvis, which was attributed to abnormal loops of bowel vs dilated inflamed fallopian tubes. Pelvic magnetic resonance imaging revealed dilated and thickened bilateral fallopian tubes with multiple collections in bilateral adnexa and right ovary, compatible with tubo-ovarian abscesses (TOA) due to pelvic inflammatory disease (PID). The patient was treated conservatively with nil by mouth (NPO), intravenous (IV) fluids, nasogastric tube (NGT) decompression and antibiotic therapy to treat PID, with notable improvement in abdominal pain. She was discharged with outpatient Gynecology follow-up. IMPACT/DISCUSSION: PID is an infection of the upper female genital tract that can lead to severe complications, including chronic pelvic pain, infertility, and ectopic pregnancy. These potential consequences highlight the importance of early diagnosis and treatment. PID is typically diagnosed based on its characteristic clinical presentation; however, this case required a different approach due to the patient’s atypical clinical picture. The patient presented with abdominal pain, and imaging revealed SBO. While postoperative adhesions are the most common cause of SBO, this patient lacked a significant surgical history, prompting consideration of other etiologies. As SBO can be caused by various inflammatory processes; when imaging revealed TOA, our differential diagnosis was expanded to include PID. This case emphasizes an important clinical point: PID can involve the bowel, manifesting as SBO, though this association is not widely recognized. The link between PID and SBO has been documented in a few case reports, with most cases managed surgically. In this case, as there were no signs of peritonitis or bowel ischemia, it was decided to opt for a non-surgical management, which has been shown to have a success rate of 70-90%. This approach typically involves NPO, IV fluids, NGT decompression, and close clinical follow-up, and in our case, resulted in a positive clinical outcome.

This case highlights the importance of considering PID as a cause of SBO in young women with no significant surgical history or chronic inflammatory diseases. A non-surgical approach for SBO in the setting of PID could result in a good outcome in appropriately selected patients. PEMBROLIZUMAB-INDUCED ESOPHAGITIS: RECOGNIZING A RARE IMMUNE-RELATED ADVERSE EVENT Royce Lee2; Howard L. Li2; Anna K. Shah1. 1Department of Medicine, Johns Hopkins University, Baltimore, MD; 2School of Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4272340) CASE: An 80-year-old woman with a history of metastatic lung adenocarcinoma previously treated with chemotherapy/radiation and most recently on pembrolizumab, presented to the ED with a third episode of low-grade fevers, chills, dysphagia, and a sore throat. Four months prior to this presentation, pembrolizumab was discontinued because the patient had a hospitalization for urosepsis requiring IV antibiotics. Here, she was noted to have oral candidiasis and was treated with oral fluconazole. After discharge, her symptoms continued. She also experienced a 20-pound weight loss and generalized weakness requiring her to ambulate with a cane. She was treated with three separate courses of fluconazole without effect prompting presentation to the hospital. She was afebrile and hemodynamically stable, without signs of oral thrush. A comprehensive infectious workup, including throat cultures and respiratory viral panels, was negative. Endoscopy revealed esophageal candidiasis with small white plaques. She continued a 21-day course of fluconazole and omeprazole. But given symptoms refractory to multiple courses of fluconazole, there was a concern for an alternative etiology. Histopathology from endoscopic biopsies highlighted lymphocytic esophagitis with necrotic keratinocytes but negative fungal and viral testing. This raised suspicion of immune-mediated esophagitis, potentially related to pembrolizumab, an ICI. She was managed conservatively with proton pump inhibitors (PPIs) and repeat endoscopy in 12 weeks. IMPACT/DISCUSSION: While ICIs have been revolutionary in oncology, we must monitor for immune related adverse events (irAE), even after discontinuation. This case highlights the potential for pembrolizumab to induce esophagitis. Although ICIs are well-documented to cause colitis and gastroenteritis, reports on esophagitis remain limited and further studies need to be conducted. Esophagitis can occur at any point in the course of ICIs. Endoscopic gross appearance is variable, including ulcers, erythema, and even unremarkable appearances. Histopathology often reveals lymphocytic infiltration and apoptosis, which are distinct from infectious causes. Given our patient’s clinical course and histopathology, her esophagitis likely stemmed from ICI therapy. Treatment includes discontinuing the ICI, supportive care with PPIs, and systemic steroids for severe cases. TNF-alpha inhibitors may be reserved for refractory cases. Once the ICI has been discontinued, a repeat endoscopic evaluation is recommended to look for resolution of histopathologic signs.

- Monitor for immune related adverse events in patients receiving immune checkpoint inhibitor (ICI) therapy including esophagitis - A thorough evaluation of dysphagia in patients treated with ICIs includes endoscopy with repeat endoscopy after treatment looking for histopathologic resolution PENETRATING AORTIC ULCER LEADING TO ACUTE AORTIC SYNDROME Bolivia C. Fernandes1; Warren Fernandes2; Prachi Balani2; Rajaeaswaran Chinnamuthu2; Rhea Bohra2; Kedar Mahagaokar2. 1Internal Medicine, NYMC at St. Mary's General Hospital and Saint Clare's Health, Parsippany, NJ; 2Internal Medicine, Saint Vincent Hospital, Worcester, MA. (Control ID #4273557) CASE: A 78-year-old female presented with right scapular pain and a chronic Penetrating Aortic Ulcer (PAU) with a history of recurrent pericardial effusion. The physical exam was unremarkable. Pertinent labs included positive troponin of 0.066 and elevated pro-BNP of 44,314 pg/mL. EKG showed T wave inversions. Due to concerns about NSTEMI, the patient underwent coronary angiography, which showed subacute aortic root dissection extending to the right innominate artery. A CT angiogram showed dissection of the aortic root. Given the history of subacute to chronic PAU on the distal aortic arch, in retrospect, it could be that these ulcers penetrated and caused the dissection and may have potentially caused her pericardial effusion. She underwent emergent type A dissection repair. Postoperatively, she developed bowel perforation, leading to comfort measures only, following which the patient passed away. IMPACT/DISCUSSION: Acute aortic syndrome includes life-threatening conditions such as aortic dissection, intramural hematoma, and penetrating aortic ulcer (PAU). PAUs are rare but serious conditions characterized by erosion of the aortic intima into the media, most commonly affecting the descending thoracic aorta. In this case, a chronic PAU in the distal aortic arch may have been the inciting factor for the patient’s subacute aortic root dissection and recurrent pericardial effusion. The patient’s presentation with right scapular pain and elevated biomarkers, including troponin and pro-BNP, raised initial concerns for acute coronary syndrome. However, further evaluation revealed aortic root dissection extending to the right innominate artery, highlighting the overlap of clinical features between aortic pathology and cardiac ischemia. This diagnostic overlap underscores the importance of maintaining a high index of suspicion for aortic pathology in patients with atypical symptoms and cardiovascular risk factors. CT angiography confirmed the dissection, correlating with the history of PAU. Chronic PAUs can lead to adventitial weakening, increasing the risk of rupture, dissection, or effusion, as seen in this patient. The recurrent pericardial effusions may have been secondary to intermittent or contained ruptures from the dissection process, a phenomenon often associated with high morbidity. Surgical repair remains the mainstay of treatment for acute type A aortic dissections. While the patient underwent emergent repair, her postoperative course was complicated by bowel perforation, a rare complication of systemic hypoperfusion or reperfusion injury. This unfortunate outcome highlights the complexity of managing acute aortic syndromes, particularly in elderly patients with significant comorbidities.

This case emphasizes the need for early recognition, timely intervention in aortic syndromes, and a multidisciplinary approach to managing complications. It also illustrates the importance of closely monitoring patients with chronic PAUs for progression to more severe aortic pathology. PENICILLIN FAILURE WITH NEUROSYPHILIS Thea Danielle C. Amadasun1; Maria Jesusa Gracia De Guzman2. 1Medicine, Cebu Institute of Medicine, Cebu City, Cebu, Philippines; 2Emory University Hospital Midtown, Atlanta, GA. (Control ID #4239451) CASE: A 72-year-old HIV-negative male with a past medical history of neurosyphilis who received two complete 2-week regimens of IV Penicillin G and one IM Penicillin, was admitted due to a recurrence of blurry vision and gait instability. The patient’s symptoms started with dizziness noted since last year, which then progressed to gait instability associated with increasing falls, headache, floaters, and blurry vision. Initial work-up was remarkable for a serum RPR that was reactive (1:256). Neurosyphilis was established after CSF analysis demonstrated positive FTA-ABS, reactive VDRL 1:8, glucose 39, protein 103, and WBC 8. He was diagnosed with ocular syphilis as evidenced by vitritis and chorioretinitis. He was treated with IV Penicillin G for 2 weeks. All his symptoms improved after initiation of therapy, however, his symptoms recurred 48 hours after completion of treatment. He was readmitted a month later due to the persistence of symptoms and was treated to another round of IV Penicillin G. Despite improvement in serum RPR titers to > 1:156, he had a similar recurrence of symptoms 2 days after completion of treatment. He was readmitted for a third time. On examination, he had decreased sensation to the right lower extremity below the knee, a wide-based gait, a positive Romberg test, and decreased visual acuity bilaterally. He could not walk in a straight line and had difficulty turning. Extensive workup was done to rule out other diagnoses. Follow-up CSF analysis showed an improvement in CSF pleocytosis, protein and VDRL 1:4 levels. Serum RPR improved to 1:128. Patient was given his third course of IV Penicillin G for another 2 weeks. There was an improvement in the patient's clinical symptoms during follow-up. IMPACT/DISCUSSION: Syphilis is an infection caused by Treponema pallidum. The spirochete invades the central nervous system (CNS) and can present at any phase of the disease as neurosyphilis. Penicillin G is the standard treatment for all stages of syphilis. Penicillin resistance has not been well studied but there are reports of varied single-nucleotide polymorphisms (SNPs) of T. pallidum. There is no gold standard for determining a cure because direct in-vitro culture of T. pallidum from patient samples remains unsuccessful. Treatment response is the only measure of effectiveness which is a decrease of more than fourfold in titers. Patients can be considered as ‘cured’ after a negative non-specific antibody titer. About 10-20% of patients with early syphilis have treatment failure; there is not enough data on treatment failure with late syphilis or neurosyphilis.

In a patient who presents with a high suspicion of neurosyphilis relapse, close follow-up and careful re-evaluation of the diagnosis and consideration for re-treatment is imperative. PERCUTANEOUS REVASCULARIZATION OF PROXIMAL LIMA-LAD GRAFT STENOSIS 14 YEARS STATUS-POST CABG Ramkumar Narendran2; Nicholas C. Kosinski1; Christopher Heinrich2,3; Fareed Moses Collado2,3. 1Internal Medicine, Rush University Rush Medical College, Chicago, IL; 2Internal Medicine, Rush University Medical Center, Chicago, IL; 3Cardiovascular Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4267210) CASE: This case presents a 67-year-old woman with a history of multivessel coronary artery disease (mvCAD), heart failure with reduced ejection fraction (HFrEF) secondary to ischemic cardiomyopathy, peripheral artery disease (PAD), and hyperlipidemia. Her surgical history includes a quadruple coronary artery bypass grafting (CABG) 14 years prior, with grafting of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). She presented to a community hospital with a one-month history of worsening dyspnea on exertion and orthopnea. Her blood pressure was 152/95, BNP was elevated (3161 pg/mL), and troponin was 92 ng/L. Chest X-ray showed cardiomegaly, pulmonary edema, and pulmonary vascular congestion, while echocardiogram revealed an ejection fraction of <20%. Coronary angiography demonstrated chronic total occlusion (CTO) of the right coronary artery (RCA) and high-grade stenosis at the takeoff of the LIMA to LAD. The cardiology team attributed her heart failure exacerbation to graft stenosis and recommended stenting but transferred her to a tertiary center for further evaluation due to her reduced ejection fraction and potential need for mechanical circulatory support. At the tertiary center, percutaneous coronary intervention (PCI) was performed on the 70% lesion at the LIMA-LAD junction, with deployment of a Synergy XD 3.0x12mm drug-eluting stent. Post-procedure angiography showed TIMI III flow and no restenosis. She was initiated on dual antiplatelet therapy and her guideline-directed medical therapy (GDMT) was optimized, and she was discharged with follow-up care arranged with a heart failure specialist. IMPACT/DISCUSSION: Due to their high patency rates, the incidence of ostial stenosis of a LIMA graft is rare. Furthermore, the biological properties of the LIMA graft make it uniquely suitable to serve as a durable bypass around diseased coronary arteries. It is known to be self-reparative, but this can also lead to complications such as vasospasms and dissections. Evidence suggests that patency of these grafts remains as high as 95% 15 years after undergoing CABG. Most reports of LIMA graft failure document cases of distal LIMA or anastomotic site stenosis, rather than in the proximal or ostial segments of the LIMA graft. Thus, the present case highlights a unique complication of the otherwise reliable LIMA-LAD graft of which clinicians should consider in the appropriate clinical context. Furthermore, the present case contributes to a growing body of evidence supporting the implementation of percutaneous interventions as alternatives to redo CABG procedures in certain patients with LIMA graft lesions.

This case highlights the rare occurrence of symptomatic LIMA graft ostial stenosis more than a decade after CABG. PCI with stenting proved to be a safe and effective alternative to redo CABG. It expands knowledge of LIMA graft complications and emphasizes the growing role of percutaneous interventions in managing late post-surgical issues. PERICARDIAL EFFUSION AND RECURRENT TAMPONADE FOLLOWING COVID-19: A POST-VIRAL INFLAMMATORY COMPLICATION Ayushi Garg1; Pranav Chalasani2; Nour Aldaoud3; Vamsi Krishna Lavu2; mekdes asfaw4; Mohamed Mansour5; Dhairya Salvi2; Zaid Kasmikha6. 1INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 3Internal Medicine Residency, Wayne State University School of Medicine, Detroit, MI; 4Internal medicine, Wayne State University, Detroit, MI; 5Internal Medicine Residency Program, Wayne State University School of Medicine, Detroit, MI; 6Cardiology, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4273094) CASE: A 52-year-old female with a history of asthma, type 2 diabetes, and long-standing rheumatoid arthritis managed with long-term steroids presented with worsening pleuritic chest pain and shortness of breath. She was recently hospitalized and treated for COVID-19 infection and had minimal pericardial effusion(PEff) without tamponade features. She was readmitted a week later with similar complaints and an echocardiogram (echo) revealed a large circumferential PEff, and an emergent pericardiocentesis was performed removing approximately 400 mL of fluid. Additional workups, including bacterial, viral, and autoimmune serology, were all unremarkable. Pericardial fluid cytology revealed reactive mesothelial cells and neutrophilic inflammation. Serial echo revealed the resolution of PEff, and the patient was discharged on ibuprofen, colchicine, and corticosteroids. During this admission, an electrocardiogram revealed electrical alternans and a repeat echo revealed a new moderate PEff without tamponade physiology. Subsequently, a pericardial window and biopsy were performed, revealing acute and chronic fibrinous inflammation with fibrosis, consistent with a post-viral inflammatory process. Further workup on the biopsy tissue to rule out autoimmune and other infectious causes was unremarkable. Post-operatively, she was treated with ibuprofen and colchicine for extended management. IMPACT/DISCUSSION: This case illustrates the complex presentations of PEff following a COVID-19 infection, particularly when other potential causes have been ruled out. Pericardial effusion (PEff) has been documented in approximately 27% of patients with severe COVID-19, associated with a 60% higher overall mortality, and was found in 22% of COVID-19 patients more than two weeks after their initial positive COVID-19 test in a prospective study. As the size of the PEff increases, its chronicity also worsens, necessitating close monitoring due to the risk of tamponade. Studies have revealed a sharp rise in mortality due to PEff with the COVID-19 pandemic, reflecting the burden of post-COVID-19 complications such as pericarditis. The recurrence of symptoms and the need for emergent pericardiocentesis highlight how COVID-19 can trigger pericarditis independently, even in the absence of other known risk factors. The presence of PEff in COVID-19 patients indicates poor prognosis, with higher rates of Intensive Care Unit (ICU) admissions and mortality, underscoring the importance of vigilant follow-up and management.

This case highlights the critical need for recognizing PEff following COVID-19. It is crucial to monitor these patients closely and provide prompt management, including medications and interventions like pericardiocentesis, to reduce the risk of recurrence, ICU admissions, and mortality. PERIPHERAL FACIAL NERVE PALSY WITH CSF VZV POSITIVITY: A DIAGNOSTIC AND MANAGEMENT CONUNDRUM Isaac K. Ng1; Kevin Teo2; Wilson G. Goh3; Kay Ng2. 1Medicine, National University Hospital, Singapore, Singapore, Singapore; 2Neurology, National University Hospital, Singapore, Singapore, Singapore; 3Infectious Disease, National University Hospital, Singapore, Singapore, Singapore. (Control ID #4244236) CASE: A 73-year-old Chinese female presented with left-sided facial weakness and pain of 1-day duration, associated with hyperacusis, retro-auricular pain on the affected side, and change in lacrimation/taste. However, she also had mild dysphagia, dysarthria, and a three-week preceding history of left-sided headache. On examination, she had severe left-sided, peripheral facial nerve palsy, with sensory loss over the left trigeminal nerve territory. There were no vesicular rashes in the auditory canal, and formal audiometry revealed mild bilateral symmetrical sensorineural hearing loss. Given the atypical symptom prodrome, with concerns of concomitant trigeminal nerve involvement, and subjective dysphagia/dysarthria, neuroimaging and lumbar puncture were performed. Magnetic resonance imaging of the brain/internal acoustic meatus was unremarkable for cavernous sinus/cerebellopontine angle lesions or leptomeningeal enhancement. Facial nerve conduction study performed was consistent with left peripheral facial neuropathy, but blink reflex testing did not show trigeminal nerve involvement. On cerebrospinal fluid (CSF) analyses, white cell counts and glucose/protein levels were normal, but varicella-zoster virus (VZV) DNA was detected. Given the absence of clinical/radiological/CSF features suggestive of meningoencephalitis, the patient was treated as for peripheral facial nerve palsy secondary to VZV reactivation, with 7 days of prednisolone and 10 days of antiviral therapy, with good clinical recovery at 1-month follow-up. IMPACT/DISCUSSION: There are a few learning points from this unique case vignette: Firstly, it is important to recognise that Bell's palsy is a diagnosis of exclusion, therefore presence of atypical features such as bilateral or recurrent facial nerve palsies, gradual symptom onset or atypical prodrome, polycranial neuropathies, focal neurological deficits or systemic manifestations such as autoimmune or constitutional symptoms would trigger a low threshold for further neurological workup. From this case which turned out to be Bell's palsy, there were rare studies that showed that her headache and subjective facial numbness were possible prodromal symptoms. Secondly, there are a few diagnostic possibilities for cases of peripheral facial nerve palsies with isolation of VZV DNA in the CSF based on literature review. As such, we developed an evidence-guided diagnostic algorithm to approach such cases through systematically ruling out false positive molecular findings (through understanding of diagnostic specificities of viral panels and individual VZV DNA PCR), meningoencephalitis (through clinical/radiological/cerebrospinal fluid analyses), and Ramsay-Hunt syndrome, before attributing it to a diagnosis of Bell's palsy secondary to VZV reactivation.

For Bell's palsy with microbiological findings suggestive of VZV reactivation, treatment should involve steroids (ideally within 72h of symptom onset) as well as antiviral therapy (e.g. acyclovir). PERNICIOUS DECEPTION: UNCOVERING SEVERE VITAMIN B12 DEFICIENCY IN THE FACE OF NORMAL RESULTS Oikigbeme Oikeh1; Harleen Sidhu2; Jazmin Mexia Cabrales2; Hannah Hugo3. 1Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; 2Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; 3NYC Health and Hospitals Elmhurst, Elmhurst, NY. (Control ID #4273473) CASE: A 50-year-old man with chronic alcohol use presented with three months of malaise, lower extremity edema, and 20-pound weight loss. Physical exam revealed jaundice, macroglossia, 2/6 apical systolic murmur, bilateral crackles, abdominal distension, and bilateral lower extremity pitting edema. Initial labs were notable for pancytopenia with a hemoglobin of 2.3 g/dL, MCV 160 fL, WBC 4500/mcL, and platelets 16,000/mcL. Chest x-ray showed cardiomegaly, bilateral pleural effusions, and ascites. Further work up was consistent with intravascular hemolysis: LDH 860 U/L (140-280 U/L), total bilirubin 4.4 mg/dL (0.1- 1.2 mg/dL), direct bilirubin 2.6 mg/dL (0-0.3 mg/dL) and haptoglobin <20 mg/dL (30-200 mg/dL). Coombs testing was negative. A peripheral blood smear showed macrocytes and giant platelets. Vitamin B12 level was 243 pg/mL (211-946 pg/mL). Methylmalonic acid (MMA) levels, anti-intrinsic factor (IF), and parietal cell antibodies were sent. The patient was transfused packed RBCs and was empirically started on folate, thiamine, and intramuscular cobalamin. The patient did not have any overt bleeding throughout his hospital course. He was discharged with outpatient follow-up and parenteral cyanocobalamin. After discharge, MMA levels resulted and were markedly elevated to 263,482 nmol/L (0-378 nmol/L). Anti-IF and parietal cell antibodies were positive, confirming autoimmune gastritis. The patient continued to receive parenteral cyanocobalamin with improvement in his anemia (hemoglobin: 14.9 g/dL) and is currently awaiting outpatient endoscopic evaluation. IMPACT/DISCUSSION: Cobalamin deficiency is known to cause megaloblastic anemia and non-immune hemolytic anemia, possibly linked to increased homocysteine levels. Homocysteine has pro-oxidative qualities and has been found in vitro to provoke hemolysis through lipid peroxidation of cell membranes. Approximately 30-50% of patients with PA may present with falsely normal to high serum B12 levels. In patients with PA, anti-IF antibodies interact with assay reagents, leading to falsely elevated results. Patients with other manifestations of B12 deficiency should undergo further testing to determine MMA levels, and if elevated, should be tested for anti-IF and anti-parietal cell antibodies. Since failure to treat B12 deficiency can have severe consequences, patients with severe deficiency or neurological symptoms should receive treatment with intramuscular cobalamin while awaiting confirmatory testing.

As was the case with our patient, clinicians should remember that normal serum B12 levels do not exclude B12 deficiency. In patients with a history of malabsorption, alcohol use, and metformin use, as well as in Hispanic men (who have a high incidence of PA), clinicians should have a low threshold to test for B12 deficiency to avoid delays in diagnosis and treatment. PERSISTENT FUNCTIONAL NEUROLOGICAL DISORDER FOLLOWING GENERAL ANESTHESIA: A CASE REPORT Teresita Mendez2; Austen L. Hentschel1; michelle braha1; Guillermo Izquierdo-Pretel1,3. 1College of Medicine, Florida International University, Miami, FL; 2College of Medicine, Florida International University, Miami, FL; 3Jackson Memorial Hospital, Miami, FL. (Control ID #4272389) CASE: A 40-year-old female presented for scheduled IVC filter removal. Her medical history included Guillain-Barré Syndrome, IgA deficiency requiring monthly intravenous immunoglobulin infusions, systemic lupus erythematosus, and pulmonary embolism. Her surgical history included uncomplicated IVC filter placement. Social history included a retired paramedic, married with three children. Medications included IVIG, apixaban, and hydroxychloroquine. Preoperatively, she was alert, oriented, with 5/5 upper extremity and 4/5 lower extremity strength. Her baseline functional status was ambulation with a walker. The patient underwent a 3-hour procedure with general anesthesia and paralytics. She remained hemodynamically stable, and paralytics were reversed with sugammadex. She was extubated with normal respiratory function but exhibited diffuse muscle weakness, lethargy, flaccid extremities, and loss of sensation below C5/C6. Reflexes and cranial nerves were intact. Neurology was consulted. CT of the head and neck ruled out hemorrhage and large vessel occlusion. Laboratory studies were unremarkable. MRI revealed no evidence of stroke, cord compression, or other abnormalities. No organic etiology was identified. Despite supportive care, the patient’s neurological exam showed persistent flaccid paralysis and sensory loss below C5/C6. Following a second dose of sugammadex, partial recovery of motor and sensory function in the C6 distribution of the right hand was observed. However, urinary and fecal retention and autonomic dysfunction persisted. EEG and EMG were normal, further supporting a non-organic etiology. Psychiatry and rheumatology were also consulted, and autoimmune causes were ruled out. Therefore, Functional Neurological Disorder (FND) was suspected. The patient experienced gradual improvement in upper extremity function, with continued flaccid paralysis of the lower extremities. After 15 days, she was discharged to inpatient rehabilitation. Over the next week, she regained function to T12, but lower extremity paralysis and urinary retention persisted. IMPACT/DISCUSSION: While FND following general anesthesia has been reported, most cases resolve within 24 hours. This case highlights a rare instance of persistent quadriplegia with sensory loss lasting several days. The extended hospital stay and need for intensive rehabilitation highlights the significant impact FND can have on a patient’s functional recovery.

FND should be considered in patients with unexplained neurological deficits postoperatively after ruling out organic causes. This case emphasizes the importance of interdisciplinary care to optimize outcomes. PERSISTENT HYPOXIA AND CHOCOLATE-BROWN BLOOD: A RARE CASE OF PHENAZOPYRIDINE-INDUCED METHEMOGLOBINEMIA William Muniz2; Fahiye Ali2; Noel Maldonado2; Linda Youn2; Xiaolong Liu1. 1Internal Medicine , St. Bernard's Medical Center, Jonesboro , AR; 2Internal Medicine Residency Program, Saint Bernards Healthcare, Jonesboro, AR. (Control ID #4269922) CASE: A 41-year-old female with a history of gastroparesis, hypothyroidism, interstitial cystitis, and autoimmune hemolytic anemia presented with lower back pain, left lower quadrant pain, vomiting, dizziness, urinary frequency, urinary retention, dysuria and shortness of breath. On arrival, O2 saturations were 79–85% on a Ventimask, with chocolate-brown blood noted on phlebotomy. Initial labs revealed Hgb 9.0, Hct 28.8, platelets 623K, K 3.4, T. bili 2.4, and ABG showing 7.44/34/150/23. CT abdomen/pelvis and CTA chest were negative for acute findings, including PE. Despite supplemental oxygen, the patient’s hypoxia persisted, with repeat ABG showing Hgb O2 sat 72.9%, carboxyhemoglobin 4.8%, and methemoglobin 19.7%. She disclosed recent phenazopyridine use. A diagnosis of phenazopyridine-induced methemoglobinemia was made. Treatment with IV methylene blue and high-flow nasal cannula was initiated. The patient showed progressive improvement in oxygenation, transitioned to a regular nasal cannula by day 3, and was discharged in stable condition IMPACT/DISCUSSION: This case highlights the importance of recognizing rare complications of common medications like phenazopyridine. Persistent hypoxia that does not improve with supplemental oxygen can be hard to diagnose, but clues like chocolate-brown blood should raise suspicion for methemoglobinemia. Standard oxygen saturation readings can be misleading, so co-oximetry is critical to confirm the diagnosis. A careful review of medication history is key, including over-the-counter drugs like phenazopyridine, which are often overlooked but can cause serious complications. Once methemoglobinemia is identified, methylene blue is the first-line treatment and usually works quickly. In patients with G6PD deficiency, where methylene blue is contraindicated, alternatives like high-dose vitamin C should be considered. Risk factors such as anemia, kidney dysfunction, and repeated drug use increase the chance of phenazopyridine toxicity. This case shows the importance of keeping methemoglobinemia in the differential when hypoxia persists, especially when classic findings like chocolate-brown blood are present. It also highlights the need to review medications, including those patients carefully may think are harmless. Early diagnosis with co-oximetry and timely treatment with methylene blue can lead to rapid improvement and avoid delays in care.

● Hypoxia unresponsive to oxygen therapy with chocolate-brown blood should prompt suspicion for methemoglobinemia. ● Review medication history carefully, including over-the-counter drugs like phenazopyridine, as they may cause significant complications. ● Prompt treatment with methylene blue is essential, with vitamin C as an alternative in cases where methylene blue is contraindicated. PERSISTENT ST ELEVATIONS WITHOUT OBSTRUCTIVE CORONARY ARTERY DISEASE: A DIAGNOSTIC CHALLENGE PAULOMI GOHEL1; Krishna Tummalapalli2; Robin Girdhar2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2Cardiology, UPMC Shadyside, Pittsburgh, PA. (Control ID #4271679) CASE: A 60-year-old male with pancreatic cancer on chemotherapy, hypertension, and type 2 diabetes presented with diabetic ketoacidosis, intermittent chest pain, and ST-segment elevations in anterior and inferior leads. High-sensitivity troponin peaked to 45,000. A left heart catheterization revealed no obstructive coronary artery disease (CAD) but identified a small bridge over the LAD artery. Urgent transthoracic echocardiogram (TTE) demonstrated new anterior wall motion abnormalities with a reduced LVEF of 40%, and there was no evidence of a pericardial process. The patient was started on a nitroglycerin drip and nebivolol, but hypotension necessitated a switch to a transdermal nitroglycerin patch and metoprolol on day 2. Sharp chest pain and ST elevations in the anterior leads persisted for 3 days, but inferior lead elevations resolved on day 1. By day 4, anterior ST elevations began to resolve, but a repeat TTE revealed persistent wall motion abnormalities and systolic dysfunction that were not consistent with takotsubo cardiomyopathy. By day 6, the patient’s chest pain resolved, hemodynamics stabilized, and ST-segment elevations resolved. He was discharged on GDMT. IMPACT/DISCUSSION: This case presents a diagnostic challenge that does not clearly fit any known pathophysiology. Takotsubo cardiomyopathy was initially considered; however, it typically presents with transient apical, basal, or mid-ventricular ballooning and mild troponin elevation. In this case, persistent anterior wall abnormalities, troponin levels peaking in the 99th percentile, and QT prolongation resolving before ST-segment changes made takotsubo unlikely. Vasospastic angina was also a concern, as it can present with ST elevations and troponin elevation, but the persistence of chest pain and ST elevations following nitroglycerine argues against it. Additionally, the LAD bridge was considered, but such cases typically present with focal ST elevations in LAD distribution and are provoked by systolic stress. The diffuse anterior and inferior lead changes, along with intermittent chest pain unrelated to exertion, made this explanation less likely. While microvascular dysfunction remains possible, it is a diagnosis of exclusion. Tests within the cath lab, such as coronary flow reserve and index of microvascular resistance could have assessed microvascular perfusion. Provocative spasm testing using intracoronary acetylcholine may help confirm vasospastic angina.

In conclusion, this case highlights the challenges of diagnosing persistent ST-segment elevations and elevated troponin levels without obstructive CAD. Although takotsubo, vasospasm, and microvascular dysfunction were all considered, none fully explained the clinical presentation. Use of modalities such as PET and cardiac MR were deferred but have potential in diagnosing these complex cases. The role of LHC diagnostics, may also be of value in differentiating these entities. This case underscores the need for more comprehensive diagnostic criteria. PIECING THE PUZZLE: THE VITAL ROLE OF HISTORY TAKING IN DETECTING KRATOM-LINKED LIVER INJURY Sanjna L. Surya1; Luke S. Vest2; Vatsal Bhatt3. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Medicine, Brigham and Women's Hospital, Boston, MA; 3Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4242866) CASE: A 41-year-old female with chronic back pain presented with two weeks of progressive jaundice, clay-colored stools, and dark urine. She recently traveled to New Orleans and had two days of heavy alcohol consumption followed by nausea, vomiting, and diarrhea that resolved one week prior to presentation. Her baseline alcohol use was two beers a day three times a week. Physical exam showed jaundice and scleral icterus with no abdominal tenderness. Labs showed AST 458 U/L, ALT 606 U/L, ALP 182 U/L, TBili 9.5 mg/dL, DBili 6.8 mg/dL, and INR 1.4. RUQ US showed hepatic steatosis. A broad work-up was negative including acetaminophen level, hepatitis A, B, C, CMV, Epstein-Barr, antinuclear, anti-mitochondrial, and anti-smooth muscle antibodies, serum copper, ceruloplasmin, and alpha-1-antitrypsin levels. Given the negative work-up, our team reconducted a thorough history and discovered the patient had been taking an herbal supplement containing 3 g of kratom per serving three times a week for several years for back pain. In conjunction with the gastroenterology team’s assessment, her acute liver injury (ALI) was attributed to kratom use which she was advised to permanently discontinue. Her LFTs spontaneously improved during admission and later at outpatient follow up. IMPACT/DISCUSSION: Two unique elements about our case are: 1) meticulous history-taking to reach an unusual diagnosis and 2) the rare association of kratom use and acute liver injury (ALI). Without anchoring to the original history our team went back to the bedside to take a thorough history and broaden our differential, ultimately reaching the correct diagnosis. Drug-induced liver injury (DILI) is the most common cause of ALI in the US. Herb-induced liver injury (HILI) is an increasingly common subset of DILI due to the high frequency of herbal supplement use most of which are not regulated by the FDA. Kratom is an analgesic with opiate-like properties that is a rare but recognized cause of ALI and primarily affects young patients who may use it to self-medicate for chronic pain. In multiple case reports, patients presented with jaundice, dark urine, and a mixed or cholestatic liver injury pattern. Almost all cases self-resolve with discontinuation of kratom.2,5 Most kratom users do not experience ALI, but concomitant heavy alcohol use or binge-drinking may be a risk factor.

HILI is an increasingly common cause of ALI due to the ubiquitous use of unregulated herbal supplements such as kratom. Patients may not always disclose their use particularly if they have stigmatized comorbidities such as chronic pain. Therefore, healthcare providers should take a thorough history of supplement use with an open-ended and nonjudgmental approach and incorporate caution around the use of unregulated supplements into routine counseling for patients. PILATES GONE WRONG AN UNUSUAL CASE OF PELVIC PAIN Samantha Parks, Jamel Brown. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4216154) CASE: A 45-year-old female with a past medical history of hysterectomy presented with two-weeks of intense pelvic pain after she felt a “pop” during Pilates class. She also experienced progressive abdominal distension and decreased urine output. Labs were significant for sodium 132, potassium 5.3, phosphorus 5, creatinine 4.6, BUN 34. Urinalysis was negative for hematuria or infection. Small volume ascites was noted on point of care ultrasound. She underwent diagnostic paracentesis with ascitic fluid studies as follows: glucose 115, protein < .8, WBC 39, RBC 28, ANC 39, Cr 13.8, SAAG 2.9, and ascites:serum Cr ratio of 3.2. An abdominal ultrasound with doppler demonstrated no evidence of portal hypertension. A CT-retrograde cystogram was then performed, demonstrating contrast extravasation into the peritoneum consistent with bladder perforation. Urology was consulted and recommended placement of urinary catheter for bladder decompression with anticipated duration of 2-3 weeks. Creatinine improved to 0.9 immediately after catheter placement. She was discharged on prophylactic ciprofloxacin with close urology follow-up. Repeat cystoscopy three weeks post-discharge revealed resolution of the perforation. IMPACT/DISCUSSION: Spontaneous bladder perforation is relatively rare with an estimated incidence of 1 in 50,000 which makes it a diagnostic challenge. The vast majority of patients will have gross hematuria, however, in rare instances it may be absent. Other symptoms include pelvic and/or abdominal pain and difficulty voiding. A CT-retrograde cystogram is the gold standard for diagnosing bladder perforation. In a patient with ascites, a paracentesis may also be of utility. Urinary ascites is defined as an ascites:serum Cr ratio of >1. It is important to highlight that in these patients, the SAAG will be >1.1 and is often misdiagnosed as portal hypertension which can delay daignosis. Additionally, urinary ascites will be absorbed by the peritoneal cavity, manifesting as elevated BUN and creatinine, electrolyte derangements, and decreased urine output. Therefore, it is an uncommon mimic of renal failure but unique in that it will not respond to hemodialysis. According to the American Urological Association (AUA) guidelines, treatment depends on the location of perforation. Intraperitoneal rupture is generally repaired surgically while extraperitoneal rupture may be treated with catheter drainage.

Given that the mortality rate for spontaneous bladder perforation is as high as 25% when associated with a delay in diagnosis, it is important that we consider this on our differential in patients presenting with acute abdominal pain, especially as it can mimic other more commonly seen disease processes. We highlight a case that outlines the workup and management of spontaneous bladder perforation presenting with urinary ascites. PITUITARY APOPLEXY PRESENTING AS FEVER AND ENCEPHALOPATHY Emma Hunt, Vaishali Kumaraguru, Lauren Voskoboynik, Muhammad A. Zia, Abigail Belasen. Albany Medical Center, Albany, NY. (Control ID #4270464) CASE: A 65-year-old man with history of heart failure and atrial fibrillation presented with 3 months of fatigue, weight loss, subjective fevers, hematochezia, and several days of dyspnea and chest pain. On admission, he was oriented. Labs were unremarkable; TSH was 1.4. CT angiography showed possible subsegmental PE (limited by motion artifact). Anticoagulation was started. Given concern for malignancy, GI was consulted for endoscopic evaluation. Prior to the procedure, the patient developed transient, acute disorientation for which CT head showed incidental 1.7-cm pituitary mass with hypodense center. A non-urgent MRI brain was ordered but completed several days later. EGD/colonoscopy, rescheduled to hospital day 6, were normal. On hospital day 8, he developed sustained high grade fevers (Tmax 103.3) and waxing/waning encephalopathy. There was no leukocytosis. Blood cultures, chest x-ray, and urine culture were unrevealing. Empiric ceftriaxone and linezolid were started. High grade fevers persisted. A repeat CT angiography chest did not reveal PE. CTAP was normal. He then developed acute disorientation and blurred vision. Empiric meningoencephalitis (ceftriaxone, vancomycin, ampicillin, acyclovir) coverage was started. MRI brain was expedited and showed heterogeneously enhancing complex pituitary mass with mass effect on the optic chiasm/hypothalamic region and hemorrhage within the occipital horns of the lateral ventricles. Pituitary apoplexy was suspected; LP was deferred. Labs showed TSH 0.6, free T4 0.26, PRL 3.6, FSH 1.3, LH 0.5, testosterone 26. Urgent stress dose steroids were initiated (prior to baseline cortisol testing), followed by thyroid replacement therapy. Neurosurgery/ENT performed urgent endoscopic endonasal transsphenoidal resection of the pituitary tumor. He was found to have a pituitary adenoma with large areas of internal hemorrhage/clots consistent with apoplexy. Following resection, empiric antibiotics were discontinued. Fevers resolved and mental status improved. IMPACT/DISCUSSION: Patients with pituitary apoplexy have varying initial presentations. Typically, patients report acute onset headache, nausea/emesis, and visual changes. Encephalopathy can occur. Fever has been described, likely from the presence of blood and necrotic tissue into the subarachnoid space, but it is uncommon and other causes of fever should be sought. In this case, workup of fever including infection, venous thromboembolism, and overt malignancy was negative. The patient’s fevers resolved following pituitary resection, suggesting pituitary apoplexy as causal.

Patients with pituitary apoplexy can present with fever and encephalopathy, mimicking other conditions such as meningoencephalitis. This can lead to a delay in the diagnosis and management of this life-threatening condition. PLAYING WITH WATER AND SALT: A RARE CASE OF A TRIPHASIC ANTIDIURETIC HORMONE RESPONSE FOLLOWING TRANSSPHENOIDAL HYPOPHYSECTOMY Carlo Gabriel C. Casipit1; Bruce Adrian Casipit2. 1Internal Medicine, Jefferson Einstein Philadelphia Hospital, Philadelphia, PA; 2Loma Linda University, Loma Linda, CA. (Control ID #4241486) CASE: A 53-year-old male with Hypertension came to the hospital for a 3 month history of intermittent headaches and blurring of vision. He denied any fever, vomiting, hot or cold intolerance, presyncope, decreased libido, or changes in facial features. Vital signs were normal. The physical examination revealed euvolemia and a normal neurologic exam. Diagnostic tests showed Na 136(ref 135-145), K 3.6(ref 3-5), Creatinine 0.6(ref 0.5-1.5), and glucose 110(ref 70-140). Brain MRI showed a 2cm pituitary mass. Prolactin 15 (ref <20), IGF-1 20(ref 9-26), TSH 0.8 (ref 0.5-5), LH 2 (ref 1.8-8), and cortisol 18 (ref 5-25). He underwent transsphenoidal hypophysectomy and was started on Levothyroxine and Hydrocortisone.On day 2 postoperatively, he developed polyuria of approximately 3L in 24 hours with urine specific gravity of 1.002 (ref 1.005-1.030), urine osmolality 157(ref 500-850), plasma osmolality 307(ref 275-295), and serum Na 151 which is consistent with Diabetes Insipidus (DI), he was started on desmopressin which resulted in improvement of urine output.On day 6, he developed hyponatremia Na 131 with urine specific gravity of 1.041, urine osmolality of 870, plasma osmolality of 270, and urine output of <1L in 24 hours, which was consistent with SIADH for which fluid restriction was recommended, gradually improving his serum Na and urine output.However, on day 11, he reported recurrence of polyuria of about 3L in 24 hours. He was again treated supportively with fluids and desmopressin which gradually improved his symptoms. He was then discharged with close follow up with Endocrinology. IMPACT/DISCUSSION: Surgical manipulation of the pituitary gland can alter the metabolism and secretion of ADH. Postoperative DI is the most common complication after pituitary surgery. It is due to the insufficient secretion of ADH from the damaged hypothalamic-pituitary axis, resulting in polyuria and hypernatremia. Postoperative SIADH can occur due to the degeneration of axons along the hypothamic-hypophyseal tract causing release of stored ADH resulting in a low volume, concentrated urine with hyponatremia. However, approximately only 2% of patients will experience a Triphasic response characterized by an initial polyuric phase compatible with DI from impaired ADH release, followed by an antidiuretic phase due to ADH release from the damaged hypophyseal tract, and culminating with a polyuric phase from depletion of remaining ADH stores.The entire process can last for several weeks and treatment involves close monitoring of serum sodium, urine volume, and fluid balance, with desmopressin during DI phase and fluid restriction in the SIADH phase.

Disorders of sodium and water balance are common after pituitary surgery and can be overwhelming even for experienced physicians. Therefore, all physicians should understand the neurohormonal physiologic pathways to properly educate patients, know what to look and monitor for, pursue an early multidisciplinary approach, and provide prompt treatment. PLEURAL EFFUSION AS AN INITIAL PRESENTATION OF SYSTEMIC LUPUS ERYTHEMATOSUS Razan Aburumman, Tala Al Saleh, Sarine Tahmazian, Daniel Moore. internal medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4271065) CASE: Systemic lupus erythematosus (SLE) is an autoimmune disease that adversely affects multiple organs. Pleural effusion is a common feature of SLE; however, as an initial presentation in SLE, is rare. Here, we present a case of SLE that presented for the first time with shortness of breath and fever and was found to have pleural effusion on imaging. IMPACT/DISCUSSION: A 48-year-old female with a history of hypertension presented with low-grade fevers, fatigue, shortness of breath, and abdominal pain for three weeks. Workup was significant for elevated erythrocyte sedimentation rate at 73 mm/Hr, and a CT chest abdomen pelvis showed a trace left pleural effusion or mild pleural thickening, and spleen enlargement at 18 cm. She was discharged and referred to hematology/oncology, who suspected a rheumatologic cause and recommended a positron emission tomography scan. Worsening symptoms brought her back to the ED one week after discharge. She was found to have a small right pleural effusion and moderate right basilar consolidation. She was started on Ampicillin / Sulbactam and Doxycycline for suspected pneumonia and sent to our hospital. At our hospital, the patient arrived tachycardic at 112 beats per minute and tachypneic at 28 respirations per minute. Her stay was complicated by a fever, and low oxygen saturation at 83% when walking, prompting further imaging that showed worsening pleural effusion (Figure 1) and was negative for a pulmonary embolism. Thoracentesis was done, and fluid analysis revealed an exudative pattern. The fluid cytology was negative for malignant cells. She started reporting bilateral calf tightness during her stay, and imaging revealed right occluding acute deep vein thrombosis of the proximal to mid-calf gastrocnemius vein and left occluding acute deep vein thrombosis of one of the paired peroneal veins. The patient was started on Heparin which was later switched to Apixaban. Rheumatology was consulted, and they suspected SLE as the cause of her symptoms. They recommended further workup, which was remarkable for low C3 and C4 at 67 and 9 mg/ dl respectively. She was also found to have positive anti-double-stranded DNA antibodies with a titer > 1:320, and chart review showed a previous positive ANA with a titer of 1:640 from 6 months ago. She met the criteria for SLE and was discharged stable on a Prednisone taper, with a follow-up with rheumatology.

Pleural effusions occur in up to 60% of SLE patients, making them the most common pulmonary manifestation, though they are rarely the initial presentation. These effusions can be primary (due to lupus pleuritis) or secondary to conditions like infection, heart failure, or renal failure. They are usually bilateral and small-to-moderate in size. Pleural fluid analysis is essential for diagnosis, often showing an exudative pattern with neutrophils predominating. Management depends on symptom severity, with small effusions typically resolving on their own. PLUMBING THE DEPTHS OF LEGIONNAIRES DISEASE - A SEVERE CASE OF PNEUMONIA AND SEPSIS Arshiya Shabnam, Archana Ramalingam, Namratha V. Cherukuru, Vinod Nookala. Internal Medicine, New York Medical College, Valhalla, NY. (Control ID #4273470) CASE: A 62-year-old man with a history of coronary artery disease (CAD), status post-PCI to the LAD in 2019, and arthritis on prednisone, was brought to the ED for altered mental status suspected to be related to a DUI. He had nausea, vomiting, and diarrhea for three days. On arrival, he was tachycardic, hypotensive, and febrile with a diagnosis of metabolic encephalopathy secondary to sepsis, right lower lobe pneumonia, and hyponatremia. Lab results showed leukocytosis, lactic acidosis, hyponatremia, elevated troponin, and positive benzodiazepines on urine drug screen. Chest X-ray revealed right lower lobe pneumonia, and EKG showed atrial flutter. He denied chest pain but had shortness of breath attributed to pneumonia. ABG analysis showed metabolic acidosis, and lab values indicated thrombocytopenia, elevated neutrophils, and mild liver function test elevations. CT head was unremarkable. Blood, urine, and sputum cultures were negative, but Legionella urine antigen was positive. He was admitted with suspected acute infectious metabolic encephalopathy, acute hypoxic respiratory failure, and atrial fibrillation with rapid ventricular response likely secondary to pneumonia. He was started on empiric antibiotics (vancomycin, Zosyn), anticoagulation (Lovenox), and supportive fluids. After testing positive for Legionella, antibiotics were adjusted to Levaquin. Echocardiogram showed severe dilated cardiomyopathy with an EF of 20-25% and left ventricular thrombus. The patient was intubated for respiratory failure and shifted to the ICU. His condition improved with treatment, including tube feeds, and he was extubated. He was eventually discharged to rehab with a plan for follow-up with multiple specialists, including cardiology and infectious disease. He was started on mirtazapine for addiction and discharged on carvedilol, Eliquis, losartan, gabapentin, and mirtazapine, with ongoing prednisone and rosuvastatin. The State health department was notified of Legionnaires' disease. IMPACT/DISCUSSION: Legionnaire’s disease, caused by Legionella pneumophila, spreads through airborne mist and has an incubation period of 2-10 days. Symptoms include fever, chills, cough, myalgia, GI issues, and neurological symptoms like confusion. Diagnosis is confirmed with a urine antigen test, while sputum or blood cultures may take longer. Treatment typically involves quinolones or macrolides, with recent studies questioning the combined use of both. New tetracycline omadacycline shows promise for patients with liver or kidney impairment.

Legionnaire's disease has variable prognosis, with mortality rates of 5-15%. Timely, multidisciplinary care, including EMS, ER, specialists, and therapy teams, was key to this patient's recovery and stability. POINT-OF-CARE ULTRASOUND AND SERIAL SONOGRAPHIC EXAMS AS PART OF THE WORK-UP FOR UP-TRENDING BILIRUBIN IN A PATIENT WITH DECOMPENSATED CIRRHOSIS Rebecca Fine1; Timothy J. Libecap1; Shelby Montgomery1; Hirotaka Kato2. 1University of Kentucky College of Medicine, Lexington, KY; 2Internal Medicine, University of Kentucky College of Medicine, Lexington, KY. (Control ID #4266921) CASE: A 48-year-old man with a history of alcohol-associated cirrhosis, recent banding for variceal hemorrhage, and hepatitis C presented to an outside hospital with worsening abdominal pain and distension. He was transferred to our hospital since his MELD score worsened from 25 to 32 in 24 hours. On admission, his vitals were stable, and his physical exam was notable for severe jaundice, abdominal distension, and abdominal tenderness. His MELD-Na score was 32 including bilirubin of 22.8 mg/dL and creatinine of 1.56 mg/dL. CT and ultrasound showed a distended gallbladder with layering sludge without biliary dilation. He was evaluated by Hepatology and started on prednisolone 40 mg daily after confirming negative ascitic fluid culture on hospital day 3. His bilirubin continued to increase, rising from 26.3 to 30.1 mg/dL by hospital day 6. N-acetyl cysteine infusion was added. Repeat infectious workup showed new bilateral airspace disease, and a point-of-care ultrasound showed a nearly 8 cm distended gallbladder filled with sludge, borderline wall thickness, and a small amount of pericholecystic fluid. His prophylactic ciprofloxacin was switched to intravenous vancomycin and cefepime to cover hospital acquired pneumonia and acalculous cholecystitis. He soon experienced hematemesis and required serial EGDs for bleeding control in the ICU, and transitioned to comfort care on hospital day 14. IMPACT/DISCUSSION: Acute acalculous cholecystitis (AAC) is a rare but potentially fatal condition that can occur during critical illness. Pre-existing hyperbilirubinemia and ascites in patients with end-stage liver disease makes AAC a diagnostic and therapeutic challenge. Hepatobiliary scintigraphy lacks specificity (38%). CT is comparable to ultrasound, but the use of serial studies with parenteral contrast proves problematic in the acutely ill. In one study, ultrasound had a sensitivity of 92% and a specificity of 96% for AAC diagnosis using the following criteria: pericholecystic fluid or wall edema in the absence of ascites as major criteria, and sludge, distension > 8 cm in longitudinal dimension, or distension > 5 cm in transverse dimension as minor criteria. Since the patient met criteria but was not a surgical candidate, his antibiotic coverage was broadened to cover both pneumonia and cholecystitis and reduce risk of further complications.

AAC may be underdiagnosed in patients with end-stage liver disease as these patients have pre-existing hyperbilirubinemia, and prolonged cholestasis can silently progress to cholecystitis. Given the accessibility, repeatability, and minimally invasive nature of ultrasounds, serial ultrasounds should be part of the patient work-up when bilirubin continues to rise in acutely ill patients with decompensated cirrhosis and right upper quadrant pain. POLYMORPHOUS LIGHT ERUPTION FROM HYDROCHLOROTHIAZIDE Cynthia Zheng1; Alex Friefeld1; Karl Herman2. 1Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI; 2Internal Medicine, Brown University, Providence, RI. (Control ID #4223992) CASE: A 37-year-old female with a history of cirrhosis due to hepatitis C (post-treatment) and hypertension managed with hydrochlorothiazide (HCTZ) presented with a progressive rash. Two weeks prior, she experienced sunburn on her forearms before traveling to Florida. Despite sun avoidance, she noted worsening pustular, pruritic, and burning rashes on her forearms and knees upon returning. Over several days, the rash spread to her trunk, face, palms, and soles, prompting multiple urgent care visits. Treatments with emollients, antihistamines, and steroids were ineffective. On admission, she denied systemic symptoms such as fever, sick contacts, or recent tick or animal exposure, aside from house cats. She was initially started on IV acyclovir and Infectious Disease was consulted due to concern for disseminated zoster, but infectious serology and wound cultures were negative, allowing for discontinuation of antivirals. Dermatology consultation and skin biopsy revealed marked papillary edema, perivascular lymphohistiocytic infiltrate, and interstitial eosinophils. Based on these findings, a diagnosis of polymorphous light eruption (PMLE) triggered by HCTZ and sunburn with an associated id reaction was made. The patient received IV methylprednisolone, resulting in rapid improvement. HCTZ was discontinued, and she was discharged on an oral prednisone taper with dermatology follow-up. At her two-month follow-up, her rash had improved, and she continued using topical steroids as needed. IMPACT/DISCUSSION: HCTZ is the most commonly reported thiazide associated with drug-induced photosensitivity. While such reactions are typically self-limiting and confined to sun-exposed areas, severe cases can manifest as widespread PMLE, which may further trigger an immunologic id reaction requiring systemic steroids. PMLE is a recurrent condition, more common in women and northern latitudes, and can persist for years. Biopsy is often necessary to exclude other conditions, making early dermatology involvement essential. Furthermore, thiazides have been linked to an increased risk of non-melanoma skin cancers, underscoring the need to consider a patient’s UV exposure when prescribing these medications.

Drug-induced photosensitivity should be considered in patients presenting with diffuse rashes in sun-exposed areas, particularly those taking HCTZ. While most HCTZ-induced phototoxicity cases are self-limiting, severe manifestations like diffuse PMLE may require systemic steroids and close follow-up. Awareness of photosensitizing medication risks and early dermatology referral are critical for timely diagnosis and management. PORTAL VEIN THROMBOSIS AS EXTRAINTESTINAL COMPLICATIONS OF CROHN'S DISEASE: A RARE CASE REPORT Sushil Rayamajhi1,2; Gary Batra1,2; Mohammad Rizwan Alam1,2; Nischal Shrestha3; Sandhya Dhakal1,2. 1University of Central Florida, Orlando, FL; 2HCA Florida West Hospital, Pensacola, FL; 3Dhaulagiri Hospital, Baglung, Mid-Western Development Region, Nepal. (Control ID #4272194) CASE: A 42-year-old female with a history of Crohn’s disease presented to the hospital with severe abdominal pain and diarrhea lasting for 2 days. She was currently on Azathioprine, Mesalamine, and Prednisolone for her condition. The patient denied the use of oral contraceptives, recent prolonged immobilization, fever, weight loss, or excessive sweating. She was a non-smoker, did not consume alcohol, and had no history of substance abuse. Imaging with computed tomography (CT) of the abdomen and pelvis with intravenous contrast revealed extensive portal vein thrombosis (PVT), including near-occlusive thrombus involvement of the superior mesenteric vein, the main portal vein, and its branches extending into both the right and left portal veins. Following this diagnosis, an intravenous heparin infusion was initiated for anticoagulation therapy. Once the patient stabilized, she was discharged on the direct oral anticoagulant (DOAC) Apixaban, with a planned six-month treatment course. At the six-month follow-up, repeat imaging showed significant resolution of the thrombus, and the patient remained asymptomatic with normal laboratory parameters. IMPACT/DISCUSSION: Portal vein thrombosis (PVT) is a rare complication of Crohn’s disease, often occurring due to the hypercoagulable state induced by chronic inflammation. Patients with Crohn’s disease are at an increased risk for venous thromboembolism (VTE) due to the upregulation of inflammatory and coagulation pathways. The clinical presentation of PVT can be nonspecific, often being diagnosed incidentally during imaging for other symptoms, as in this case. CT imaging is crucial for diagnosing PVT, allowing for detailed visualization of thrombus extent. Anticoagulation therapy, typically with low molecular weight heparin followed by direct oral anticoagulants (DOACs), is the mainstay of treatment. This patient was successfully managed with Apixaban, with follow-up imaging showing significant resolution of the thrombus.

PVT symptoms are similar to the symptoms of an inflammatory bowel disease flare. Early recognition of PVT in Crohn’s disease is vital, as prompt anticoagulation can prevent complications like bowel infarction. This case emphasizes the importance of considering PVT in Crohn’s disease patients with abdominal symptoms, even when the presentation is nonspecific. PORTAL VEIN THROMBOSIS FORMATION IN A YOUNG FEMALE WITH ULCERATIVE COLITIS IN THE SETTING OF ACUTE EPSTEIN-BARR VIRUS INFECTION Erin Hollis, Deepa Chellappa. Internal Medicine, Lankenau Medical Center, Wynnewood, PA. (Control ID #4272438) CASE: A 24-year-old female with a history of well-controlled ulcerative colitis on mesalamine presented to her primary care physician due to one week of daily fevers despite standing anti-pyretics. Associated symptoms included mild congestion and lower abdominal pain. Labs revealed elevated aminotransferases (AST 604, ALT 549) as well as elevated direct bilirubin and alkaline phosphatase. Heterophile antibody was found to be positive and Epstein-Barr Virus (EBV) PCR ultimately returned elevated. The patient was referred to the emergency room for further workup. Right upper quadrant ultrasound was unremarkable. A magnetic resonance cholangiopancreatography (MRCP) was performed which revealed splenomegaly, questionable left renal infarct, and a portal vein thrombosis (PVT) in the right portal vein, and therapeutic anticoagulation was initiated. The patient was evaluated by gastroenterology and hematology. The workup to rule out a primarily hematologic cause of her PVT, including testing for an inherited or acquired thrombophilia was negative. Throughout her hospital course, the patient’s liver enzymes steadily downtrended. TTE ruled out cardiac thrombus. The patient was discharged on oral anticoagulation with eventual normalization of her hepatic function. Repeat magnetic resonance imaging two months later showed resolution of the PVT. IMPACT/DISCUSSION: PVT typically occurs in patients with cirrhosis and/or thrombotic disorders, including acquired and inherited thrombophilia, autoimmune disease, and malignancy. Patients may present with fever, abdominal pain, elevated levels of acute phase reactants, and transiently elevated liver enzymes. PVT has been described in case reports in association with viral illnesses, including hepatitis, coronavirus and cytomegalovirus, but rarely has been associated with EBV. Cases of EBV associated with PVT are infrequent amongst available literature and overall appear to occur in cases where the patient has another predisposing factor for thrombus formation, such as in our patient. This patient’s case highlights the importance of recognizing EBV as a cause of persistent fevers and elevated transaminases, as well as the association of EBV with PVT, especially in patients with underlying systemic risk factors for thrombosis.

-PVT as an extraintestinal manifestation in patients with IBD who present with fever and abdominal pain should be considered, even in the absence of inherited or acquired thrombophilia. -Though PVT related to EBV is less common, clinicians should be aware that EBV may cause a hypercoagulable state that promotes clot formation. POSACONAZOLE INDUCED PSEUDO-HYPERALDOSTERONISM IN A PATIENT RECEIVING STEROIDS Allyson Freedy1; Sarah Young2. 1Internal Medicine, University of Colorado System, Aurora, CO; 2Nephrology, University of Colorado System, Aurora, CO. (Control ID #4273066) CASE: Patient is a 70-year-old female with past medical history of interstitial lung disease status post right lung transplant, who was recently started on posaconazole for pulmonary aspergillosis. At a clinic visit two weeks after starting posaconazole, the patient was found to have lower extremity edema refractory to oral diuretics, metabolic alkalosis (HCO3 38) and hypokalemia (K 2.6). At this visit, her posaconazole and diuretics were discontinued and she was started on isavuconazonium and potassium supplementation. Following this visit, the patient was empirically treated for transplant rejection with three doses of intravenous methylprednisolone. One week later, the patient presented to the emergency department with fatigue and poor appetite. On admission, she was hypertensive (blood pressure 185/84). Initial labs showed metabolic alkalosis (HCO3 41) and hypokalemia (K 2.7). She received one dose of furosemide in the emergency department due to concern for volume overload. Repeat labs 24 hours after admission showed stable metabolic alkalosis (HCO3 42) and hypokalemia (potassium 3.4) despite potassium supplementation. Urine chloride was obtained, 24 hours after receiving diuretics, and was elevated at 63. Serum aldosterone was undetectable and renin activity was low normal at 0.4. Concern was raised for pseudo-hyperaldosteronism. A posaconazole level was 0.8 and 11-deoxycortisol was normal at 11.40. She was started on spironolactone for presumed pseudo-hyperaldosteronism, and her metabolic alkalosis and hypokalemia resolved. She was discharged home with close nephrology follow up. Labs at follow up clinic visit showed resolution of her metabolic alkalosis and hypokalemia (HCO3 30 and K 3.8). IMPACT/DISCUSSION: Pseudo-hyperaldosteronism is a known side effect of the azole anti-fungal agents, posaconazole and itraconazole. Our patient demonstrates many features of this condition: hypertension, hypokalemia and metabolic alkalosis with undetectable aldosterone after recent posaconazole use. Surprisingly, our patient had a normal 11-deoxycortisol level. Elevated levels of this steroid precursor are often used to diagnose pseudo-hyperaldosteronism. However, in our patient, 11-deoxycortisol level are not diagnostic because her endogenous steroid biosynthesis is suppressed by her ongoing oral prednisone use. Additionally, our patient’s pseudo-hyperaldosteronism was exacerbated by receiving high dose methylprednisolone, likely due to posaconazole’s inhibition of 11β-HSD2, an enzyme responsible for the conversion of methylprednisolone to an inactive metabolite. This case demonstrates a classic presentation of posaconazole induced pseudo-hyperaldosteronism and illustrates the nuances that steroid use provides in the presentation and diagnosis.

Pseudo-hyperaldosteronism can be differentiated from contraction alkalosis via high urine chloride and low aldosterone levels. Pseudo-hyperaldosteronism can be exacerbated by high dose steroids. POSTPARTUM ADULT-ONSET STILL’S DISEASE TRIGGERED BY PRIOR VIRAL INFECTIONS: DIAGNOSIS AND MANAGEMENT Doan Ngoc Chau Nguyen1; Imtiaz A. Khan1; Asim Ali1; Viet Nghi Tran2; Abhijit Gutal1. 1Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX; 2Dept. of Internal Medicine, Resilience Healthcare - Weiss Memorial Hospital LLC, Chicago, IL. (Control ID #4272575) CASE: A 28-year-old postpartum female, two months after a cesarean section, presented with persistent fever (100.2–103.1°F), sore throat, and polyarthralgia. Two weeks earlier, she experienced a transient, non-pruritic rash on her legs spreading caudally, resolving during afebrile periods. She denied tick bites or respiratory/urinary symptoms. Labs showed mild leukocytosis (8.7 K/μL), elevated CRP (88 mg/L), ESR (25 mm/hr), ferritin (2000 ng/mL), and mildly raised transaminases. Procalcitonin and lactate were slightly elevated with hypoalbuminemia 2.2 g/dL. Urinalysis showed no infection markers. Imaging revealed mild splenomegaly and nonspecific lymphadenopathy. Microbiological and serologic testing, including blood cultures, HIV, hepatitis panel, Monospot, HSV PCR, and autoimmune panels (ANA, RF, C3/C4, ANCA), were negative. Viral serologies showed IgG positivity and IgM negativity for CMV, EBV, and Parvovirus B19, indicating past infection. Examination revealed palpable cervical lymphadenopathy. Based on fever, arthritis, pharyngitis, rash, splenomegaly, elevated ferritin, and exclusion of autoimmune and infectious causes, Adult-onset Still's disease (AOSD) was diagnosed. Prednisone 40 mg daily was started, tapered over two months, with marked clinical improvement. IMPACT/DISCUSSION: AOSD is a rare autoinflammatory disorder characterized by spiking fever, arthritis, transient salmon-colored rash, and elevated ferritin levels. It primarily affects young adults. Pathogenesis involves dysregulated innate immunity via Pattern Recognition Receptors like NLRP3, which detect Pathogen- and Damage-Associated Molecular Patterns. These activate macrophages and neutrophils, triggering inflammasomes and the caspase pathway, leading to excess IL-1β and IL-18 production. The resulting cascade of proinflammatory cytokines, including IL-6 and TNF-α, drives systemic AOSD manifestations. Infectious triggers, particularly viral antecedents, may initiate or exacerbate AOSD by sensitizing the immune system to dysregulation. Postpartum immune shifts can predispose patients to flares, though pregnancy itself does not worsen pre-existing AOSD. AOSD is a diagnosis of exclusion guided by Yamaguchi’s and Fautrel’s criteria. Low glycosylated ferritin (GF) strongly correlates with inflammation and aids diagnosis, though cytokines like IL-1, IL-6, and IL-18 are not routinely measured. Treatment focuses on inflammation, symptom control, and complications like Macrophage Activation Syndrome (MAS) and chronic arthritis, with ferritin and GF monitoring aiding MAS risk assessment.

This case highlights the importance of considering AOSD in complex inflammatory presentations, particularly postpartum or with prior viral exposures. Prompt recognition and therapy are essential to prevent serious complications, including MAS and chronic joint damage. Further research is needed to elucidate triggers and the role of viral antigens in AOSD, guiding targeted therapeutic approaches. POSTPARTUM PITUITARY PROBLEMS: A CASE OF SHEEHAN'S SYNDROME UNVEILED Lauren Battle1; Joseph H. Stephens2. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4270841) CASE: A previously healthy 40-year-old female farmer from rural Uganda presented to a district hospital with one year of weakness and fatigue. A year ago, she gave birth to twins at home, followed by profuse vaginal bleeding. The following weeks, she began to feel cold, weak, and anorexic. She did not produce milk and never resumed menstruation. Both twins died at 1 month. Exam revealed significant orthostasis, flat affect, and intact visual fields. Labs showed Na 132 mEq/L, Hgb 10.7 g/dL, T4 2.9 mcg/dL (4.5-11.7), TSH 3.2 mIU/L (0.4-4.5), AM cortisol <0.5 mcg/dL, HIV and TB GeneXpert negative. Other hormone testing was unavailable and imaging prohibitively expensive. Given evidence of hypoadrenalism, hypogonadism, and secondary hypothyroidism in the setting of a post-partum hemorrhage, a diagnosis of Sheehan’s Syndrome was made. She was treated with prednisone, levothyroxine, and OCPs. After prednisone was started inpatient, her orthostatic hypotension resolved and she reported improved energy and appetite. After one clinic visit she never returned to care. IMPACT/DISCUSSION: Diagnosing AI and differentiating primary from secondary AI in low resource settings requires attention to the clinical context and presence or absence of electrolyte abnormalities, hyperpigmentation, and orthostasis. In primary AI, aldosterone deficiency leads to hyperkalemia, hyponatremia, and hypotension, and increased pituitary POMC production causes hyperpigmentation. Electrolyte disturbances are less common in secondary AI, however; hyponatremia, likely from ADH upregulation, can be seen. Hypotension can also be present in up to 1/3 of secondary AI cases. Postpartum hemorrhage is a major risk for pituitary infarct, or Sheehan’s Syndrome, an underappreciated cause of AI. Here, the secondary hypothyroidism and agalactorrhea suggest a pituitary origin of AI, with the hemorrhage indicating Sheehan’s as the etiology. Underpinning this case are issues with access to healthcare in rural Africa. This patient lived a 3-hour journey from the hospital and delayed seeking care for a year. In rural Uganda, 30% of women deliver at home where bleeding complications are common, and 64% report problems accessing health care. Hormone testing is largely unaffordable. Treatment, such as levothyroxine, on the WHO list of essential medicines, is typically unavailable at district hospitals. Even when these barriers are overcome, time and cost of travel lead to poor retention in care. Sheehan’s Syndrome is also important to consider in countries with high immigration rates, such as the US, as it may not present clinically until years after delivery.

Evidence of hypogonadism and secondary hypothyroidism may distinguish secondary from primary AI in low resource settings. While Sheehan’s syndrome is relatively uncommon in the US, it should be recognized as a cause of AI in rural Africa and those caring for immigrants from that region. PRIMARY ANGIITIS OF THE CENTRAL NERVOUS SYSTEM (PACNS): A CHALLENGING AND RARE DIAGNOSIS Rasika Patil1; Luke Hong2; Afrin Naz1. 1Internal Medicine, University of South Florida, Tampa, FL; 2Neurology, University of South Florida Morsani College of Medicine, Tampa, FL. (Control ID #4250120) CASE: The patient is a 59-year-old male with a history of stroke, hypertension, hyperlipidemia, tobacco use, and aortic aneurysm who presented with right-sided facial weakness, aphasia, and right upper extremity weakness. Computed tomography of the head (CTH) showed acute strokes in the right centrum semiovale, right frontal lobe, and left pons. CT angiography (CTA) showed high grade right middle cerebral artery stenosis for which non-emergent catheter cerebral angiogram was recommended. Transesophageal echocardiography was without vegetation or thrombus but did show a patent foramen ovale. The patient was discharged with dual antiplatelet therapy and a cardiac monitor. Three months later, he returned with malaise and slowed speech. Repeat CTA showed multiple stenotic lesions in a “string of beads” pattern concerning for vasculitis. Antinuclear antibody testing (1:80) was positive with other autoimmune workup negative. The patient started on intravenous solumedrol but continued to display fluctuating cognition and significant anterograde amnesia. He also demonstrated mild dysarthria and right facial droop and hemianopia. A repeat CTH showed a new hypodensity in the left posterior cerebral artery (PCA) territory. Lumbar puncture showed elevated protein with otherwise noncontributory findings. Digital subtraction angiography showed similar findings along with abnormal vessel wall enhancement indicative of PACNS. Biopsy was deferred due to likely low yield in setting of recent steroid use. The patient remained on prednisone for four weeks prior to taper and received cyclophosphamide induction with plans for monthly infusions. Unfortunately, the patient presented again with similar stroke symptoms later that month. Imaging showed a large acute infarct in the left occipital and mesial temporal lobe, likely representing completed infarction of the area surrounding prior strokes. CTA showed complete occlusion of the proximal left PCA. Ultimately, he was not a candidate for thrombolysis or endovascular intervention and was transferred to an inpatient rehabilitation facility. IMPACT/DISCUSSION: PACNS is a rare diagnosis of small and medium vessel vasculitis most commonly manifesting with nonspecific symptoms including headache, focal neurologic deficits, and fluctuating mentation. It has demonstrated high relapse and mortality rates with one meta-analysis identifying 2 large cohort studies with relapse rates of 30% and 34% and mortality rates of 23% and 8%. As no randomized trials exist on PACNS, its management with steroids and cyclophosphamide is informed by a small handful of retrospective and observational studies.

This case depicts the importance of maintaining a high index of suspicion when evaluating patients with recurrent strokes of unknown etiology. This patient presented to several hospitals with repeated focal neurologic deficits before PACNS was suspected, delaying treatment and significantly impacting functionality. PRIMARY CUTANEOUS SERRATIA MARCESCENS INFECTION IN AN IMMUNOCOMPETENT 76-YEAR-OLD FEMALE. Andrew Maza, Maheswara Koppula. Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #4273201) CASE: A 76-year-old female with a past medical history of transient ischemic attack and bipolar disorder presented with three days of weakness, confusion, and multiple falls at home. The patient did not lose consciousness or hit her head but had skin tears on her bilateral flanks. Admission labs were significant for lactic acid 2.6, creatinine 3.5, BUN 80, alkaline phosphatase 138, serum Na 122, and hemoglobin 10.7. Both wound and blood cultures drawn on admission later revealed growth of Serratia marcescens. In septic shock on initial presentation, the patient was also hypoxic and hypotensive. Despite normal white blood cell counts and creatinine kinase on admission, both increased to peaks of 21,100 U/L and 16,990 U/L, respectively. Whole-body anasarca with pitting edema of the bilateral abdominal walls and ischemic eschar of her wounds was observed on physical exam. An MRI of the abdomen with and without contrast did not suggest a definite fluid collection or the presence of necrotizing fasciitis. Bedside debridement of the wounds was performed, and superficial and deep wound cultures from the surgery were later positive for Serratia marcescens. Blood and wound cultures indicated sensitivity to meropenem, on which the patient completed a two-week course of 500 mg daily. Her hospitalization was complicated by septic shock, pneumonia with mixed flora on sputum cultures, acute hypoxic respiratory failure, renal failure with acute tubular necrosis, atrial fibrillation with rapid ventricular response, weakness secondary to spinal stenosis, and Serratia marcescens UTI. Therefore, she was also treated with vancomycin, micafungin, linezolid, and ceftriaxone. Repeat cultures were negative. Vital signs and lab values returned to baseline. The patient was discharged to an acute rehabilitation facility. IMPACT/DISCUSSION: Serratia marcescens is a well-known cause of nosocomial and opportunistic infections. It colonizes and may cause infections in the respiratory, genitourinary, and gastrointestinal tracts. Arthritis, septicemia, and endocarditis have also been well-documented. However, ocular, skin, or soft-tissue primary infections are rare, and affected patients are typically immunocompromised. A very limited number of cases of immunocompetent patients without an underlying medical condition have been reported. When present, primary cutaneous Serratia marcescens infection may take a life-threatening course.

While rare, primary cutaneous infection due to Serratia marcescens leads to a high risk for abscesses or necrotic ulcers, septic shock, and mortality. A small number of other cases have helped further illustrate this point. This case exemplifies that immunocompetent patients without chronic conditions may also be susceptible to skin or soft tissue Serratia marcescens infection, especially in the presence of repeated trauma and non-healing wounds. Wound debridement and appropriate antibiotic therapy as determined by susceptibility studies remain effective treatment. PRIMARY RENAL LYMPHOMA (PRL) IN A PATIENT WITH HISTORY OF LIVER TRANSPLANT PRESENTING AS HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) Melissa Gunchenko1; Ramkumar Narendran1; Yolla Haibe2; Seo-Hyun Kim2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Hematology, Rush University, Chicago, IL. (Control ID #4273308) CASE: A 64-year-old female with a history of autoimmune hepatitis status post orthotopic liver transplant (OLT) on immunosuppression presented with fever and generalized weakness. On arrival, she was febrile (100.5°F) but hemodynamically stable. Initial laboratory tests showed white blood cell (WBC) 9.79 K/uL, hemoglobin (hgb) 6.5 g/dL, platelets (plt) 92 K/uL, ferritin 5,524 ng/mL, creatinine 1.72 mg/dL, ALT 17 U/L, AST 41 U/L, Epstein Barr virus (EBV) DNA 2,076 copies/mL. Computed tomography (CT) of the chest, abdomen, and pelvis demonstrated no evidence of splenomegaly, lymphadenopathy, or renal mass. Worsening renal and hepatic function in the setting of up-trending ferritin levels raised concern for HLH. Additional laboratory analyses showed triglycerides 199 mg/dL, fibrinogen 562 mg/dL, normal NK cell activity, and sCD25 17,966 U/mL. Bone marrow biopsy revealed monomorphic post-transplant lymphoproliferative disorder (PTLD) with Diffuse Large B-Cell Lymphoma (DLBCL) involvement. Renal biopsy showed diffuse DLBCL involvement. Dexamethasone per HLH-2004 protocol was started, followed by modified R-CHOP; gradual improvement in her renal and hepatic function was observed on this regimen. IMPACT/DISCUSSION: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory syndrome characterized by multi-organ failure. Diagnosis requires meeting five of eight criteria: fever, splenomegaly, cytopenias, hypertriglyceridemia and/or hypofibrinogenemia, hemophagocytosis, low or absent natural killer (NK) cell activity, ferritin >500 ng/mL, and soluble CD25 (sCD25) >2400 U/m. HLH can be primary (e.g., familial HLH) or secondary, such as malignancy-associated HLH (MA-HLH), with DLBCL being the most common malignancy in Western countries associated with MA-HLH. A rare subtype of DLBCL, primary renal lymphoma (PRL), can also trigger HLH, complicating its diagnosis and management. Treatment of MA-HLH often involves a combination of therapies targeting both HLH and the underlying malignancy. This patient fulfilled five of eight HLH criteria. Because ferritin and sCD25 are often independently elevated in malignancy, optimal specificity for HLH has been demonstrated at sCD25 >10,056 ng/mL and ferritin >5,748 ng/mL. In this patient with chronic immunosuppression, the unchecked proliferation of EBV-infected B cells likely resulted in the development of PTLD, specifically PRL, which subsequently triggered HLH. An unusual feature of this case is the subtype of PTLD, namely PRL, particularly in a patient without prior kidney transplant. PRL typically presents as a renal mass, often discovered on abdominal imaging. This patient had no evidence of a renal mass on imaging, underscoring the importance of biopsy in diagnosing PRL.

Physicians should consider HLH in patients with unexplained organ failure. In cases of worsening renal function without radiographic findings, biopsy is crucial, and a multidisciplinary approach is vital for optimal outcomes. PROTEIN-LOSING ENTEROPATHY FROM CHRONIC PAINLESS GASTRIC ISCHEMIA IN A WOMAN WITH ANXIETY: WHEN UNCERTAINTY AND COGNITIVE ERROR COLLIDE Mary S. McGrath, Jess Dreicer. Internal Medicine, University of Virginia, Charlottesville, VA. (Control ID #4272421) CASE: A 69-year-old woman presented to an academic medical center’s emergency department with diarrhea. History included chronic diarrhea, anxiety, hyperlipidemia, and 40-pack-year smoking history. Patient reported one week of watery diarrhea with 10 daily stools and five pounds of weight loss. She denied fever, hematochezia, and recent travel. She reported a similar episode two years prior which was documented as “lisinopril side effect.” She had a normal colonoscopy in between her prior and current presentation. Her vital signs were significant for BMI 18.5 kg/m2. Physical exam revealed an anxious woman with benign abdomen. Results included leukocytosis which normalized with hydration, elevated inflammatory markers, and negative bacterial and parasitic testing. Cross-sectional abdominal imaging with arterial contrast revealed normal stomach, colitis, and “[chronic] occlusion of the celiac trunk, superior mesenteric artery (SMA) and inferior mesenteric arteries with … extensive collateralization … favoring a chronic process … No evidence of acute ischemic injury or thrombus.” In conjunction with vascular medicine, the diagnosis was deemed likely multifactorial from severe anxiety and food allergy/intolerance. Given her painless abdomen, diarrhea predominance, and extensive collateralization, vessel occlusions were thought non-contributory. Shortly before planned discharge, the patient reported a sense of impending doom; “something’s wrong with me,” she asserted. In response, esophagogastroduodenoscopy (EGD) was performed and revealed ischemic gastropathy (“severely pale” mucosa and ulcers). Patient promptly underwent SMA revascularization with rapid symptomatic improvement. Months later, she continues to feel well. IMPACT/DISCUSSION: This patient’s syndrome was ultimately due to ischemic gastropathy causing achlorhydria and malabsorption. Ischemic gastropathy is a rare entity in itself, and reports without characteristic symptoms nor imaging findings are virtually absent in the literature. While atypicality alone is associated with diagnostic error, presence in a female only adds risk of biases and misdiagnosis. Our misattribution of the patient’s symptoms to her underlying anxiety, known as diagnostic overshadowing, is particularly striking and resulted in treatment delay. There is a long history of provider dismissal of females’ symptoms, and our patient’s self-advocacy was pivotal in our re-evaluation. When approaching any patient with diagnostic uncertainty, clinicians must aim for earlier recognition of qualities (e.g., female sex, atypicality, mood disorders) known to leave patients vulnerable to implicit biases and cognitive errors.

- Chronic diarrhea with progression warrants consideration of subacute ischemic gastropathy despite nonclassical symptoms, and workup may include direct visualization with endoscopy - Females with concomitant psychiatric diagnoses are prone to providers’ cognitive errors including diagnostic overshadowing and premature closure PSYCHOSIS IN SUBACUTE MANIA: NEUROPSYCHIATRIC SEVERE HYPOTHYROIDISM WITHOUT MYXEDEMA COMA Elizabeth D. Auckley, Lisa Wehr Maves. Internal Medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4269847) CASE: A 40-year-old woman with history of gastric bypass, hypothyroidism secondary to Hashimoto's thyroiditis s/p thyroidectomy 2 years prior, presented to the hospital by police for psychosis. Psychiatric history includes 2 prior hospitalizations for psychotic and manic symptoms – the first 3 months after thyroidectomy and the second 4 months prior to presentation. TSH was elevated at both of these admissions. She had no psychiatric history before these hospitalizations. Family reported noticing changes in what she talked about with them 1-2 months ago. At presentation, medications included levothyroxine 200 mcg daily, lurasidone 40 mg daily, vortioxetine 10 mg daily, eszopiclone 2 mg nightly, clonazepam 0.5 mg daily as needed. Workup notable for a TSH of 227, free T4 of 0.18, and hemoglobin of 10.5. Other labs were unremarkable, including glucose level of 108 and urine drug screen positive for only benzodiazepines. Her vitals were normal. On admission, her home levothyroxine, lurasidone, and clonazepam were restarted. Zolpidem was substituted for eszopiclone per formulary. Vortioxetine was held due to manic symptoms. On hospital days 1 and 2 she remained hyperverbal and tangential with religious perseverations and the belief that she was Jesus. On hospital day 3 she exhibited some unusual speech patterns but no longer had religious perseverations, grandiose beliefs, or hallucinations. She has resolution of all psychiatric symptoms and discharged home on hospital day 4. IMPACT/DISCUSSION: Severe hypothyroidism is most commonly associated with presentation of myxedema coma with hypothermia, hyponatremia, hypercarbia, and hypoxemia requiring intensive care settings for emergent treatment. Typically psychiatric manifestation of hypothyroidism is depression with psychomotor slowing. One case report describes a man with late presentation of mania with prolonged manic episodes later found to have hypothyroidism with resolution of mania upon initiation of thyroid hormone replacement. A second case report describes acute mania with psychosis as presenting symptoms of severe hypothyroidism in a young woman with no prior psychiatric history. The case presented here offers course of a medically stable patient with repeated instances of subacute mania due to severe hypothyroidism with rapid resolution following thyroid hormone replacement therapy in a patient with prior psychiatric history. This offers increasing evidence that severe hypothyroidism may present with psychosis without myxedema.

All patients presenting with psychosis should be evaluated for hypothyroidism. Further, patients with initial diagnosis of hypothyroidism with history of psychiatric illness may warrant closer monitoring of medication compliance and psychiatric disease burden. PULMONIC VALVE INFECTIVE ENDOCARDITIS Meghan Stevenson. Internal Medicine Residency Program, St. Bernards Medical Center, Jonesboro, AR. (Control ID #4270983) CASE: A 40-year-old Caucasian male with a history of IV drug use (IVDU) and end stage renal disease on hemodialysis presented with generalized body aches, nausea and vomiting. Vitals revealed a temperature of 100.5°F and a heart rate of 130 beats per minute. Physical exam showed bilateral lower extremity pitting edema, a murmur, and diminished lung sounds in the bilateral bases. A chest x-ray was consistent with mild pulmonary edema. A set of two blood cultures grew Methicillin-Susceptible Staphylococcus aureus (MSSA). An additional blood culture from the tunneled central venous catheter which was placed for hemodialysis also grew MSSA. Transesophageal echocardiogram visualized a small mobile echodensity on the ventricular aspect of the pulmonic valve, consistent with a vegetation. Valvular function was preserved with no significant pulmonic regurgitation noted. The patient underwent six weeks of antibiotic therapy for treatment of IE of the pulmonic valve. IMPACT/DISCUSSION: In IVDU populations, valve injury is thought to occur secondary to direct endothelial damage caused by injected substances. Recurrent IVDU may then cause additional subclinical damage, which over time transforms into frank injury. Contaminated needles or substances introduce pathogens into the bloodstream, and the combination of valve damage and inoculation primes the valves for the development of an infective thrombus. For patients with intravascular devices, the valve damage is generally pre-existing and infection is typically introduced during device implantation. Although right sided IE is unusual, prognosis is more favorable than left-sided IE. This is due to several factors including younger patient age, decreased risk of embolization, and less drug-resistant infections.

Although prognosis is more promising in right sided IE it is important to maintain a high degree of suspicion in at-risk populations. Early detection and timely treatment are vital to improve outcomes. It is essential to not only treat the underlying pathology but also the social factors that contribute to the patient’s high risk status. This comprehensive approach requires a multidisciplinary team to optimize patient care. PUNT IT TO THE NEXT GUY: AN UNUSUAL CASE OF SHINGLES Aidan Flanagan1; Brenda Queen2. 1Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA; 2Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA. (Control ID #4268901) CASE: The Varicella-Zoster Virus, responsible for Herpes Zoster (HZ), is a global phenomenon. Known by many names—Shingles in English, Hezam Innar in Arabic (Belt of Fire), Helvetesild in Norwegian (Hell’s Fire)—HZ presents as a painful, vesicular rash, typically limited to a unilateral dermatome in immunocompetent individuals. The risk of HZ increases with age, especially in individuals over 50, women more often than men, and most commonly affects the thoracic region. The rash is often accompanied by burning neuralgic pain (herpetic neuralgia), which can precede the rash and persist for months after resolution. Scratching the rash may lead to secondary infection. This case describes an elderly woman initially presenting with cellulitis and ultimately diagnosed with HZ. A 71-year-old Caucasian female with a history of HFpEF, AFib, CKD3, gout, hypothyroidism, prediabetes, and left open trimallolar ankle fracture with Lisfranc injury (s/p ORIF and fusion, 8/31/2022), complicated by MRSA infection and osteomyelitis, was admitted on 7/29/2024 for presumed left lower extremity cellulitis. She received IV Cefazolin with some improvement and was discharged on PO cefdinir, but unfortunately returned with worsening erythema and a new petechial rash on the dorsal left foot. On presentation, she reported severe pain to palpation of the rash and was unable to ambulate. Labs on 8/7/2024 included WBC 8.5, ANC 4.9, hemoglobin 12.5, hematocrit 40.1, platelets 275, CRP 1.6, ESR 32, and CMP normal except glucose 188, BUN 33, creatinine 1.50, EGFR 37, and alkaline phosphatase 127. Varicella zoster IgG and HSV-1 were positive; HSV-2 negative. Wound cultures revealed mixed skin flora without staph or beta-hemolytic strep. XR of the left foot showed mild soft tissue swelling with no acute findings. Dermatology consultation led to a diagnosis of HZ, and the patient was treated with Acyclovir 1g BID for 10 days, resulting in marked improvement of the rash and pain. IMPACT/DISCUSSION: HZ typically affects the thoracic, trigeminal, cervical, lumbar, and sacral regions, but rarely involves extremities in immunocompetent individuals. This case highlights the importance of considering HZ in atypical anatomical regions, as such presentations can mimic cellulitis and lead to unnecessary antibiotics. Further, upon reviewing the patient's vaccination history, the patient had received Zostavax on 8/13/2013. Zostavax, a live-attenuated vaccine, has approximately 51% effectiveness against HZ, which declines to 32% after eight years. In contrast, the recombinant zoster vaccine (Shingrix) demonstrates 90% effectiveness with minimal decline over four years. This patient may have benefited from RZV, potentially preventing this episode of HZ.

This case highlights the need to consider HZ in atypical regions, even in immunocompetent individuals. Early recognition enables timely antiviral treatment and reduces complications, while vaccination plays a vital role in preventing HZ and easing its burden on older adults. PYOGENIC LIVER ABSCESS: A CASE OF ATYPICAL PRESENTATION AND DIAGNOSTIC CHALLENGES Parshva Salvi1; Akram Taha2. 1Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Corewell Health Beaumont Hospital Dearborn, Dearborn, MI. (Control ID #4270756) CASE: A 55-year-old female with a history of kidney transplant and diabetes presented with two days of nausea, loose stools, and periumbilical pain following a restaurant meal. She denied fever, chills, vomiting, melena, or lethargy. Initial labs revealed AST 257 U/L, ALT 725 U/L, total bilirubin 3.3 mg/dL, ALP 187 U/L, and WBC 12,000/μL. A viral hepatitis panel was negative, and a right upper quadrant ultrasound showed a normal liver, no biliary dilation, and no evidence of cholecystitis. Over the next three days, the patient reported worsening nausea with retching and right upper quadrant abdominal pain. She also started having fevers, chills, and night sweats, along with signs of jaundice. Labs showed rising WBC (22,300/μL), ALP (249 U/L), AST (376 U/L), stable total bilirubin (3.1 mg/dL), lactic acid of 2.6 mmol/L, and procalcitonin of 43 ng/ml, along with blood cultures growing E. coli. Anti-smooth muscle Ab was weakly positive with normal ANA. Given her continuously elevated LFTs and WBCs with fever, jaundice, and RUQ pain, MRCP was done to investigate for biliary pathology despite having a normal initial RUQ ultrasound. MRCP revealed an irregular 5.5 cm mass in the hepatic dome with possible air foci, consistent with an abscess or necrotic tumor which was further confirmed on the CT scan to be an abscess. No biliary dilatation was seen. Percutaneous drainage of the liver abscess yielded a brown purulent fluid growing E. coli. Antibiotics were tailored to culture results. The patient showed gradual clinical and laboratory improvement with repeat imaging 5 weeks later confirmed a reduction in abscess size from 5.5 cm to 2.5 cm. She remained asymptomatic at subsequent follow-ups, with normalization of LFTs and inflammatory markers. The patient’s drain was removed with plans for continued follow-up to ensure full resolution. IMPACT/DISCUSSION: In this case, her initial symptoms following a restaurant meal mimicked gastroenteritis and early LFT elevation was thought to be due to a combination of chronic fatty liver disease and immunosuppressive medications. Persistent symptoms and worsening labs with signs of cholangitis and sepsis ultimately prompted further evaluation. This illustrates the importance of recognizing atypical presentations of liver abscesses, particularly in immunosuppressed patients. The diagnostic challenge was compounded by a normal RUQ ultrasound, which underscores the need for higher sensitivity imaging such as CT scan, when clinical suspicion remains high despite negative initial studies.

This case highlights the challenges in diagnosing liver abscesses and the necessity for general internists to maintain a high index of suspicion for atypical presentations, and to use a comprehensive diagnostic approach in complex cases, particularly involving immunocompromised patients. RAPIDLY PROGRESSING METASTATIC PRIMARY LUNG ADENOCARCINOMA MISTAKEN AS NECROTIZING PNEUMONIA Rana H. Asif1; Mehak Zainab2; Phillip Gross1; Supriya Mannepalli3. 1Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA; 2Philadelphia College of Osteopathic Medicine, Philadelphia, GA; 3Infectious Diseases, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4271037) CASE: A 72-year-old male with a history of Stage IIb adenocarcinoma of the lung s/p resection, COPD, peripheral artery disease, chronic back pain, tobacco use, presented to the emergency department with visual hallucinations, confusion, and combativeness. The patient had been admitted twice within the past month. His initial admission was prompted by hypoxia, a productive cough, and shortness of breath. Two weeks later, he was readmitted with similar symptoms. CT chest imaging revealed cavitation with central necrosis in the right upper lobe and reimaging demonstrated progression of radiology imaging findings now involving the majority of the right middle and lower lobes, along with persistent necrotizing changes in the right upper lobe. Diagnostic BAL without biopsy was performed due to rapidly evolving CT changes and low suspicion for malignancy by pulmonology. He was extensively treated with broad spectrum antibiotics for necrotizing pneumonia both inpatient and outpatient during this time. During current admission, imaging revealed new infiltrates. MRI of the thoracic spine to evaluate worsening back pain showed a focal abnormality at T3. Subsequently, CT-guided biopsy of the T3 vertebral body identified metastatic poorly differentiated adenocarcinoma, consistent with a lung primary. IMPACT/DISCUSSION: Necrotizing pneumonia is a serious lung infection that can mimic acute lung malignancies. In patients with an underlying malignancy, differentiating between infectious processes and cancer related lung involvement can be especially challenging, as both conditions can cause extensive lung damage. Overlapping features such as respiratory distress, radiographic infiltrates, cavitary lesions, and systemic inflammatory responses can confound decision-making and obscure the true diagnosis. In this case, physician anchoring to the evolving CT findings consistent with pneumonia delayed further diagnostic interventions, despite the patient’s significant risk factors for lung cancer. This led to prolonged antibiotic therapy, diagnostic delays, and clinical deterioration. The case underscores the diagnostic complexity clinicians face when malignancies present with features indistinguishable from severe infections. This report highlights the importance of maintaining a high index of suspicion in high-risk patients. Early imaging, tissue biopsy, and a thorough diagnostic workup are essential for timely and accurate diagnosis, especially when clinical presentations are ambiguous.

Ultimately, this case emphasizes the critical need for a multidisciplinary approach in managing patients with complex pulmonary presentations. It serves as a reminder that clinicians must remain vigilant and avoid cognitive biases, particularly anchoring, when evaluating acutely evolving radiographic findings. Timely tissue diagnosis and comprehensive workup are pivotal in distinguishing between severe infection and cancer progression, facilitating appropriate treatment and improving clinical outcomes. RAPIDLY PROGRESSIVE ENCEPHALOPATHY AND DELUSIONAL PARASITOSIS: AN UNEXPECTED CASE OF CREUTZFELDT–JAKOB DISEASE AND ITS DIAGNOSTIC CHALLENGES Tony Huynh. Internal Medicine Residency, Washington State University, Pullman, WA. (Control ID #4273084) CASE: The patient was a 65-year-old male with past medical history of cannabis use, tobacco use, and COPD who presented to the emergency room for new onset encephalopathy and delusional parasitosis. He was brought in by two sisters who noticed progression of symptoms over 3 weeks. Prior to this event, the patient was oriented, of sound judgment, and without acute health complaints. In the emergency room, he displayed ataxia and was unable to demonstrate coherency and sound judgement. He was subsequently placed on an involuntary hold and admitted to receive evaluation and treatment. The differential for his symptoms ranged from vascular, infectious, metabolic, toxic, and structural etiologies. The initial workup in the emergency room did not reveal severe metabolic derangements. However, eventual MRI conducted to evaluate for stroke instead showed symmetrical restricted diffusion signals at the bilateral cerebral hemispheres. This increased concern for potential Creutzfeldt Jakobs Disease (CJD). He would receive a lumbar puncture with associated CSF studies, an encephalopathy-autoimmune paraneoplastic panel, and an EEG to further strengthen this diagnosis. The patient would transition to comfort care during his hospitalization and passed thereafter. His family requested autopsy for confirmation of the diagnosis which is currently ongoing. IMPACT/DISCUSSION: This case highlights important learning points for clinicians to factor in upon evaluating patients with the common yet unspecified chief complaint of encephalopathy. Physicians must approach this problem with a broad and comprehensive differential. They should use a thorough workup and involve pertinent specialists early in the case. The patient's primary team was able to expeditiously narrow his likely diagnosis to Creutzfeldt–Jakob Disease. The early consultation to the neurology team permitted a guided approach to his diagnostic evaluation. Additionally this patient presents an opportuntiy for physicians to learn about Creutzfeldt–Jakob Disease. This prion disease is rare, rapidly progressive, and invariably fatal. Clinically, symptoms often include ataxia, speech issues, and behavioral changes. Unfortunately for clinicians and patients, the symptoms are not unique to CJD. While the disease can only be definitively diagnosed with autopsy and neuropathology, the CDC has proposed diagnostic criteria. Physicians should familiarize themselves with these guidelines for appropriate workup for potential prion disease.

Physicians must keep a wide differential when working up encephalopathy despite its high prevalency. A comprehensive evaluation and conscientious avoidance of premature closure are essential. Creutzfeldt-Jakob Disease is a rare and fatal neurodegenerative disease. While confirmation necessitates neuropathology and autopsy, clinicians should incorporate CDC diagnostic criteria with supportive labs and imaging to workup patients. RAPIDLY PROGRESSIVE LOCKED-IN SYNDROME SECONDARY TO ATYPICAL HERPES SIMPLEX VIRUS-1 RHOMBENCEPHALITIS IN AN IMMUNOCOMPROMISED INDIVIDUAL Jeffrey Xia. Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4216995) CASE: A 61-year-old man with chronic lymphocytic leukemia (CLL) in remission on acalabrutinib presented to the hospital with four days of fatigue, confusion, and ataxia. Vital signs were normal. Physical exam was positive for dysmetria on finger-to-nose testing and ataxic gait but was otherwise normal. Initial labs were unremarkable aside from A1c 9.7%. MRI brain demonstrated diffuse multifocal enhancement and diffusion restriction of the pons. Cerebrospinal fluid (CSF) studies showed 113 nucleated cells (96% lymphocytes) and negative bacterial and fungal stains. He was initially managed for encephalitis with vancomycin, cefepime, ampicillin, and acyclovir. On hospital day (HD) 2, CSF was positive for acyclovir-sensitive HSV-1, and the patient felt increasingly fatigued. On HD3, he developed profound encephalopathy, dysarthria, and diplopia. Repeat MRI brain showed new enhancement and restricted diffusion in bilateral hippocampi, cerebral peduncles, and cerebellar loculus. On HD7, his weakness advanced to 2/5 motor strength in all extremities. He suffered a large aspiration event and was intubated and mechanically ventilated. He received IVIG for secondary hypogammaglobulinemia. By HD19, he regained full consciousness off sedation. Repeat exam demonstrated complete flaccid paralysis from the head down, retained cognitive ability, and communication by vertical eye movements only. He was diagnosed with locked-in syndrome secondary to HSV-1 rhombencephalitis. He was treated for multiple hospital acquired infections before discharged to nursing facility two months later, with no neurological improvement. IMPACT/DISCUSSION: This is the first documented case of locked-in syndrome secondary to irreversible damage of the pons from atypical HSV-1 rhombencephalitis with survival. HSV-1 encephalitis (HSE) usually presents with encephalopathy, fever, bulbar dysfunction, and seizures. Immunocompromised individuals with HSE are at higher risk of atypical presentation, mortality, and HSV-1 acyclovir resistance. Neurological damage is likely due to direct viral lysis of neurons and collateral damage from active immune response. Brainstem involvement, such as in this patient, is highly unusual as HSE typically involves the temporal lobes. His immunocompromising factors (CLL, acalabrutinib, history of alemtuzumab, secondary hypogammaglobulinemia, uncontrolled diabetes) likely contributed to atypical brainstem presentation leading to devastating locked-in complication. When suspecting encephalitis, lumbar puncture should be completed for CSF analysis which PCR positivity of HSV DNA confirms the diagnosis of HSE. Despite treatment with acyclovir, HSE has high mortality and high morbidity in survivors.

Rhombencephalitis represents a rare but highly morbid complication of HSV-1 encephalitis. This case underscores the need for heightened awareness of encephalitis in immunocompromised patients presenting with encephalopathy and the importance of early diagnostic testing and empiric treatment. RAPID-ONSET AND PERSISTENT ANTHRACYCLINE-INDUCED CARDIOMYOPATHY IN A YOUNG FEMALE WITH AML: A RARE CASE OF SEVERE HFREF WITHIN WEEKS OF CHEMOTHERAPY Usman Bin Hameed, Mujtaba Moazzam, Tanya Amal, Ramona Berghea. Internal Medicine, Corewell Health, Royal Oak, MI. (Control ID #4273310) CASE: A 39-year-old female with AML (KMT2A-rearranged) underwent 7+3 induction (cytarabine, daunorubicin) in October 2023, achieving remission while receiving a total of 270 mg/m2 of daunorubicin. Baseline cardiac evaluation showed LVEF 50%. Six weeks later, she developed dyspnea, orthopnea, and LE edema, with tachycardia and BNP 1226. Imaging revealed cardiomegaly, small pleural effusions, and LVEF 30% with global hypokinesis. Coronary angiography ruled out obstructive CAD. Due to her declining cardiac function, further chemotherapy was withheld after induction. Despite GDMT (spironolactone, low-dose beta-blockers) and IV diuresis, her LVEF further declined to <20% by January 2024. Cardiac MRI in March confirmed severe LV dysfunction without delayed gadolinium enhancement, ruling out ischemic, infiltrative, or inflammatory causes. Her course was complicated by GDMT intolerance due to hypotension, necessitating frequent hospitalizations for IV diuresis, milrinone, and ICU care. Pulmonary HTN and atrial arrhythmias required amiodarone. The inability to tolerate further chemotherapy exacerbated her oncologic prognosis. In her final hospitalization, she presented with worsening dyspnea, abdominal pain, and hypotension. Repeat RHC confirmed cardiogenic shock with low CO and end-organ hypoperfusion. Despite aggressive inotropic support and diuresis, she experienced fatal cardiac arrest due to refractory cardiogenic and septic shock. IMPACT/DISCUSSION: Anthracycline-induced cardiomyopathy incidence ranges from 400–450 mg/m2. Our patient received 270 mg/m2, below the high-risk threshold, yet developed severe cardiomyopathy, making her case unusual. Typically, LVEF reduction from anthracyclines manifests within the first year of treatment. Recovery after stopping therapy varies, with 62% regaining function over a mean of 14 months, though irreversible damage occurs in some cases. This patient’s rapid LVEF decline within weeks and sustained dysfunction despite GDMT suggest underlying predisposition or additional contributors such as genetic susceptibility, pre-existing subclinical cardiac conditions, or an exaggerated inflammatory response. Emerging data implicate AML itself in exacerbating cardiac dysfunction. Interactions between AML cells and cardiomyocytes disrupt cardiac energy metabolism, and tumor cell-derived IL-1α has been identified as a key factor amplifying daunorubicin-induced cardiotoxicity. This dual impact of AML and its treatment likely contributed to this patient’s rapid and refractory cardiomyopathy.

This case underscores the rapid progression of anthracycline-induced cardiomyopathy in AML patients, even at moderate doses, and highlights the need for early cardiac monitoring, risk stratification, and research into personalized interventions for this high-risk population. RARE, BUT REAL: CRYPTOCOCCAL MENINGITIS IN AN IMMUNE COMPETENT HOST Suyog K. Buttar, Maria F. Sanes Guevara, Valerie Gobao. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4272315) CASE: A 50-year-old man with a subarachnoid hemorrhage and communicating hydrocephalus after a remote motor vehicle accident presented with chronic gait instability, memory loss, headaches and nausea. Lumbar puncture at a local facility revealed: normal opening pressure, 65 white blood cells (97% lymphocytes), 1 red blood cell, protein 394, glucose 33, and negative bacterial culture. Serum Cryptococcus antigen (CrAg) was positive 1:5. After a dose of liposomal amphotericin and transfer, repeat testing showed similar cerebrospinal fluid (CSF) abnormalities and CSF CrAg of 1:128 (latex agglutination) and 1:20 (lateral flow assay), while serum CrAg was <1:5. MRI revealed leptomeningeal enhancement and ventriculomegaly. Extensive workup for immunodeficiencies and infectious etiologies was negative. Induction amphotericin B and oral flucytosine were started, but he developed an acute kidney injury (AKI) and nausea. Therapy was switched to oral fluconazole and flucytosine for one week but stopped due to ongoing nausea, AKI, and elevated transaminases attributed to flucytosine. He transitioned to high-dose fluconazole and then to a reduced dose for maintenance and consolidation. CSF fungal cultures obtained on day 1 and 3 were negative. Repeat lumbar puncture was deferred due to negative fungal culture on initial testing. IMPACT/DISCUSSION: Cryptococcal meningitis is a sub-acute infection that presents with headaches, fever, nausea, and vision changes typically in immunocompromised hosts (HIV, transplant recipients, liver disease, malignancy, or those on immunosuppressants). Although rare, it can affect immunocompetent hosts. The course can be indolent with periods of headaches, memory loss, and personality changes. Among immunocompetent patients, risk factors include alcohol or drug use, autoimmune disease, and some rare immunodeficiencies. Diagnosis can be challenging, as fewer organisms are present in the CSF and CSF antigen is more often positive than serum antigen. We hypothesize that our patient’s CSF fungal culture was negative due to his immunocompetence and exposure to antifungals. Induction therapy is amphotericin and flucytosine; however, in patients without HIV or transplant history, induction therapy with fluconazole and flucytosine has been proven to be equally effective and with fewer side effects. High-dose fluconazole alone can be used for induction for patients who can’t tolerate flucytosine.

Cryptococcal meningitis in immunocompetent hosts can have an indolent presentation with chronic headaches and other non-specific neurologic deficits. Induction treatment with fluconazole and flucytosine for immunocompetent patients is effective and better tolerated. RARE AORTIC INVOLVEMENT IN GRANULOMATOSIS WITH POLYANGIITIS (GPA) Ahmed Ibrahim1; Heba Aziza1; Fawad Ahmed2. 1Internal Medicine, AdventHealth Orlando, Orlando, FL; 2Nephrology Associates of Central Florida, Orlando, FL. (Control ID #4269090) CASE: A 20-year-old woman with a known history of Granulomatosis with Polyangiitis (GPA) involving the lungs presented to the emergency department with complaints of back pain. The patient had previously been treated with Rituximab and steroids, achieving remission. On physical examination, no significant findings were noted. Laboratory results upon admission revealed an elevated C-reactive protein (CRP) level of 68 mg/L, markedly elevated c-ANCA titer of 1:320 and positive Serum Protease 3 Antibody 701 AU/mL. Imaging studies, including a CT abdomen and CT angiography, revealed thickening of the juxta-renal and infrarenal aorta likely due to intramural hematoma with narrowing of the infra-renal aortic lumen to 8 mm. Patient was then started on Rituximab and steroids with gradual improvement of her symptoms. During her hospitalization, MRI lumbar and thoracic spine was done for her back pain showing signs of Infrarenal aortitis and tiny annular fissure at L5-S1 with no spinal stenosis or disc herniation. Vascular surgery service was consulted for fear of vascular complications and recommended medical treatment. IMPACT/DISCUSSION: Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease characterized by granulomatous inflammation of the respiratory tract and small to medium vessel vasculitis which often involves the kidneys. Large-vessel involvement is extremely rare. We reported a case of a 20-year-old who presented with aortic involvement in the background of GPA. According to one study, which identified large-vessel involvement in 24 cases of GPA, the most commonly affected vessel was the abdominal aorta, followed by the thoracic aorta, subclavian artery, and internal carotid artery. Aortic involvement in GPA can be challenging to diagnose because it is atypical and its symptoms may overlap with more common cardiovascular conditions, such as aortic aneurysms. Because of its rarity is often not initially considered in the differential diagnosis of patients with aortic disease. In this case, imaging played a critical role in the identification of aortic involvement, emphasizing the importance of advanced imaging modalities in the surveillance of patients with GPA, particularly when they develop new symptoms.

- Granulomatosis with Polyangiitis (GPA), though primarily affecting small to medium vessels, can involve large vessels such as the abdominal aorta, as seen in this rare case. - Imaging studies were essential in diagnosing infrarenal aortic involvement, emphasizing their importance in evaluating atypical presentations in GPA. - Prompt treatment with Rituximab and steroids led to symptom improvement, emphasizing the need for early intervention and multidisciplinary management in such complex cases. RARE BUT FATAL SIDE EFFECT OF NOVEL CANCER THERAPIES: IMMUNE CHECKPOINT INHIBITOR-RELATED MYOCARDITIS Changwoong Cho1; Arshdeep Dhaliwal2; Sara Diaz Saravia3; Tamara Goldberg4. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 3Department of Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; 4Internal Medicine, Mount Sinai St. Lukes West, New York, NY. (Control ID #4273307) CASE: A 72-year-old female patient with metastatic invasive ductal breast carcinoma s/p bilateral mastectomy, chemo and radiation (RT to C3-L5) recently started on adjuvant therapy (Pembrolizumab/Taxol) two weeks prior, presented to ED with 3 days of shortness of breath, cough, fever and lethargy. She was hypoxic to 80% on room air, tachycardic, and was noted to be confused and drooling. Initial CT chest showed multifocal pneumonia and left diaphragm elevation. She was eventually intubated due to acute hypoxic respiratory failure and started on pressor support with broad spectrum antibiotics. Her course was further complicated by elevated Troponin I to 6628 with accompanying CKMB of 168, ESR of 72 and CRP of 114.1 and EKG showed sinus tachycardia with anterior and inferior Q waves. She was then transferred to CCU due to concern for possible ACS vs type II MI vs myocarditis. Given the elevated biomarkers, signs of myocardial injury and severe LV dysfunction demonstrated on TTE, right/left heart catheterization was performed without endomyocardial biopsy (family declined), which showed absence of significant coronary atherosclerosis. Cardiac MRI was unable to be performed given her orthopnea, and the decision was made to initiate empiric treatment for suspected myocarditis with IV pulse steroid. Subsequently, biomarkers downtrended and she was transitioned to PO steroid taper. She was extubated after 24 hours of admission to the CCU and was discharged with BIPAP. IMPACT/DISCUSSION: Immune checkpoint inhibitors (ICIs) are novel cancer therapies which are monoclonal antibodies that target the host immune negative regulation receptors such as CTLA-4, PD-1 and PD-L1. Important side effects of ICIs are Immune-related adverse effects (IRAEs). Among IRAEs, ICI-related myocarditis is rare, and case reports suggest high mortality. The presentation of this rare clinical syndrome can manifest from asymptomatic elevations in cardiac biomarkers to severe decompensation with end-organ damage. Due to its rarely reported incidence, it is essential to consider the combination of predisposing medical history, clinical features and lab findings to prevent diagnostic delays and initiate treatment. In this case, our patient had a recent exposure to ICI with no prior cardiac history, elevated biomarkers, EKG findings. A comprehensive diagnostic approach is vital including endomyocardial biopsy and cardiac MRI, however if unable to be performed, empiric treatment with immunosuppression should be promptly initiated with monitoring of troponin and other biomarkers.

In summary, ICI-related myocarditis is a complex disease, and rare disease that is similar in presentation to other acute cardiac syndromes with a high mortality rate. Therefore, it is imperative for clinicians to have a high suspicion for this ICI-related myocarditis to ensure prompt treatment. RARE BUT RISKY: LESSONS FROM AEROCOCCUS URINAE INFECTIVE ENDOCARTIDI WITH LARGE VEGETATIONS AND EMBOLIC COMPLICATIONS Carolina Nadin De La Porte1; Albert Alexis A. Annan2; Aya Hasan2; Gerald Nelson1; Alba L. Caceres Munoz1. 1Internal medicine GME, Texas Health Resources, Arlington, TX; 2Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #4271657) CASE: A 68-year-old male with a history of diabetes mellitus, hypertension, and left nephrectomy presented with dyspnea malaise and chills. Was found septic, with leukocytosis, hypoxia, and acute kidney injury. Blood cultures grew Aerococcus urinae and TTE revealed a 2 × 3 cm mitral valve vegetation without regurgitation. Subsequent blood cultures were negative Cardiology and cardiothoracic surgeon recommended conservative management. Vegetation size reduced on follow-up TTE, supported the decision to forgo surgical intervention The patient was treated with piperacillin-tazobactam for two weeks, de-escalated to ampicillin and gentamicin, and discharged on IV ampicillin for six weeks with plans of outpatient surveillance TTE One week later, he returned with acute right hemiparesis and ischemic symptoms in the right upper extremity. Imaging confirmed an occipital stroke with additional infarcts and axillary artery thrombus. TEE revealed severe mitral regurgitation, flail posterior leaflet, and a large multilobular vegetation. He underwent mitral valve replacement with a bioprosthetic valve after intraoperative findings of vegetations on both mitral leaflets and the subvalvular apparatus. Postoperatively, he was discharged to a rehabilitation facility with a six-week course of ceftriaxone 2 gr daily IMPACT/DISCUSSION: Aerococcus urinae infective endocarditis (AUE) predominantly affects elderly males with urinary tract abnormalities. Despite fewer than 50 reported cases, its true prevalence is likely underestimated due to misidentification as streptococci or staphylococci caused by its alpha-hemolytic morphology, catalase negativity and clustered growth. Advanced diagnostic tools like 16S rRNA sequencing and MALDI-TOF mass spectrometry have improved identification accuracy Clinical features of AUE resemble those of other bacterial endocarditis.TTE often has limited sensitivity, making TEE the preferred diagnostic test. AUE is associated with large vegetations (0.7–1.8 cm) and high embolization rate (40–55%) which contributes to its severe clinical course. In vitro, AU is susceptible to beta-lactams, with penicillin and aminoglycosides demonstrating synergistic activity. For penicillin-allergic patients, vancomycin combined with gentamicin is an alternative. Treatment typically lasts 4–6 weeks, similar to other cases of endocarditis. Surgical intervention is indicated for severe mitral regurgitation, vegetations ≥10 mm, embolic events, or failure of medical therapy. Mitral valve repair, when feasible, is preferred due to lower mortality and better outcomes.

AUE is an emerging condition with significant risks of large vegetations and embolization. This case highlights the need for timely surgery when indicated and adherence to diagnostic protocols, including TEE and advanced microbiological techniques to prevent complications. Further research is essential to better understand AUIE, refine management strategies, and improve outcomes for affected patients. RARE CARDIAC COMPLICATIONS IN ANKYLOSING SPONDYLITIS: SECOND-DEGREE AND INTERMITTENT COMPLETE HEART BLOCK DURING A DISEASE FLARE Ali Yusuf1; Jairah Shaikh2; Sayma Yaqub5; Aram Aslanian3; Mohamed Sleem4; Mai Hamaad6; Fatema Mahjabeen7; James ". Walker8. 1internal medicine, Texas Tech university health science center Amarillo, Amarillo, TX; 2Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 3Internal Medicine, Texas Tech University Health Sciences Center at Amarillo, Amarillo, TX; 4Internal Medicine, Texas Tech University Health Science Center/Amarillo, Amarillo, TX; 5Internal Medicine , Texas Tech University Health Science Center Amarillo, Amarilo, TX; 6Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; 7Internal medicine , Texas tech university health sciences center amarillo, Amarillo, TX; 8Internal Medicine, Texas Tech, Amarillo, TX. (Control ID #4273574) CASE: Ankylosing Spondylitis (AS) is a chronic, progressive inflammatory disorder primarily affecting the axial skeleton, particularly the sacroiliac joints and spine. Cardiovascular involvement, including conduction abnormalities, occurs in 5%–33% of cases. While rare, complete heart block is a potentially fatal complication of AS. This report presents a patient with AS complicated by second-degree and intermittent complete heart block. Case: A 69-year-old male with a long-standing history of AS, managed with sulfasalazine, presented with worsening symptoms of immobility, including the inability to transition from his electric wheelchair to his bed for one week. On examination, persistent bradycardia with heart rates dropping into the 30s was noted. Initial EKGs demonstrated first-degree and second-degree type I heart block, with blood pressure at 138/60 mmHg. Despite initiating isoproterenol, the patient remained in second-degree type I heart block with heart rates in the 40s. Overnight telemetry revealed intermittent episodes of complete (third-degree) heart block during sleep. Further investigations revealed no electrolyte abnormalities. An ischemic workup, including a recent cardiac stress test, was negative. Echocardiography showed normal cardiac function with no evidence of valvular abnormalities, aortic regurgitation, or degenerative changes in the basal septum. Due to the recurring conduction abnormalities, a permanent pacemaker was placed, resulting in clinical stabilization. IMPACT/DISCUSSION: Conduction abnormalities in AS, although relatively uncommon, are important to recognize due to their potential severity. These abnormalities are thought to result from chronic inflammation and fibrosis affecting the cardiac conduction system, particularly the atrioventricular node. While first-degree heart block is more frequently encountered in AS, progression to second-degree and complete heart block is rare and often indicates severe disease involvement. This case highlights the necessity of vigilance in patients with AS presenting with bradycardia or conduction abnormalities, especially during disease flares. The absence of structural heart abnormalities or ischemic changes, as seen in this patient, suggests a primary conduction system involvement rather than secondary causes.

Conduction abnormalities in AS, although relatively uncommon, are important to recognize due to their potential severity. These abnormalities are thought to result from chronic inflammation and fibrosis affecting the cardiac conduction system, particularly the atrioventricular node. While first-degree heart block is more frequently encountered in AS, progression to second-degree and complete heart block is rare and often indicates severe disease involvement. RARE CASE OF CMV-INDUCED ATYPICAL MYOCARDITIS, LIVER INJURY, AND PULMONARY NODULES Abdullah Allaoa1; Allison Poles1; Christopher Bruti2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Departments of Internal Medicine and Pediatrics, Rush University Medical Center, Chicago, IL. (Control ID #4273228) CASE: An 18-year-old college student with no significant medical history presented with four days of left-sided pleuritic chest pain, palpitations, and exertional shortness of breath, improving with leaning forward. She reported a recent flu-like illness. Examination revealed tachycardia (130 bpm), mild jaundice, and scleral icterus, but no pericardial friction rub or hepatosplenomegaly. Diagnostic studies showed a normal chest X-ray, small left pulmonary nodules on CT, sinus tachycardia on EKG, and elevated cardiac troponins (69.6 ng/L). Liver enzymes (AST 79, ALT 81) and bilirubin (5.3 mg/dL) were elevated, suggesting hepatic involvement. CMV IgM and IgG were positive, and EBV IgG indicated past infection. Urinalysis showed dark urine with elevated urobilinogen and bilirubin. Initially suspected of pericarditis, she was treated with ibuprofen and colchicine, but tachycardia persisted. Transthoracic echocardiogram showed reduced left ventricular function (EF 40%), and cardiac MRI confirmed mild hypokinesis, but no myocardial edema or pericardial enhancement. Given these findings, myocarditis was suspected. She was started on metoprolol XL for tachycardia and reduced ejection fraction. Her condition improved with supportive care, and colchicine was discontinued. A follow-up echocardiogram two weeks later showed normalization of left ventricular function (EF 60-65%). She was discharged after five days, stable on metoprolol XL with no symptoms at a two-month follow-up. IMPACT/DISCUSSION: This atypical case of CMV-induced myocarditis in an 18-year-old woman presents with pleuritic chest pain, tachycardia, elevated cardiac enzymes, and mild hepatic involvement. Her recovery with supportive care and β-blockers suggests that CMV myocarditis in immunocompetent patients can often be managed conservatively without antiviral therapy. While CMV myocarditis is common in immunocompromised individuals, severe cases in the immunocompetent are rare. Most patients remain asymptomatic or experience mild symptoms, though some may develop complications like pneumonitis or encephalitis. This case suggests that antiviral treatment may not be necessary for mild CMV myocarditis in immunocompetent patients. This report also highlights the role of β-blockers in managing acute myocarditis, while antivirals remain essential for severe CMV complications in immunocompromised patients, such as those requiring liver transplant. In conclusion, CMV should be considered in immunocompetent patients with myocarditis following a viral illness, with supportive care and β-blockers as the primary treatment for mild cases. Further research is needed to clarify the role of antivirals in this population.

Consider CMV in atypical myocarditis: In immunocompetent patients with recent viral illness, transaminitis, and cardiopulmonary symptoms, CMV should be considered. Variable CMV presentation: While typically mild in immunocompetent individuals, CMV can cause severe manifestations requiring tailored management. RARE GASTRIC GLOMUS TUMOR IN THE GASTRIC BODY WITH SYSTEMIC METASTASIS Vigneshwar Kaveripaukkam Ramasamy1; Rees Ridout5; Cynthia Schwartz1; Vania Zayat3,2; Shoba Kankipati4. 1Internal Medicine Residency Program Greater Orlando Osceola, University of Central Florida, Orlando, FL; 2Section of Pathology, Orlando VA Healthcare System, Orlando, FL; 3University of Central Florida, Orlando, FL; 4Section of Hematology and Oncology, Orlando VA Healthcare System, Orlando, FL; 5College of Medicine, University of Central Florida, Orlando, FL. (Control ID #4271151) CASE: A 52-year-old man with a history of hypertension presented with an acute exacerbation of intermittent epigastric pain of 6 months duration that was accompanied by early satiety and constipation. CT Imaging revealed a low attenuation mass of dimensions 15 x 10 x 15 cm in the right hepatic lobe of the liver. Esophagogastroduodenoscopy (EGD) demonstrated a large submucosal polyp with inflamed mucosa infiltrating the wall of the stomach body. Biopsy showed malignant epithelioid neoplasm composed of solid sheets of cells with round-to-ovoid nuclei exhibiting nuclear hyperchromasia, nuclear enlargement, and scattered mitotic figures. The patient’s liver and stomach biopsies were morphologically similar with immunohistochemistry positive for Smooth Muscle Actin (SMA) and Smooth Muscle Myosin-Heavy Chain (SMM-HC). Next generation sequencing (NGS) was positive for MIR143-NOTCH2 fusion in the liver biopsy samples, confirming the diagnosis of malignant gastric glomus tumor. The patient was treated with 8 cycles of Docetaxel/Gemcitabine every 21 days with partial resolution, however, patient did not tolerate the adverse effects. In view of the unique distribution, rarity of the tumor, and quality of life for the patient, it was decided to administer a trial of Pazopanib and Trabectedin. IMPACT/DISCUSSION: Our patient had a unique presentation with respect to the site of glomus tumor location. Gastric glomus tumors, if present, usually localize to the gastric antrum as opposed to the gastric body. While rare, this case highlights the importance of using next generation sequencing for tumor confirmation and the challenges accompanied by management of a novel case not amendable by surgical resection. Literature review lacked specific chemotherapy of choice for this presentation, thereby requiring a trial-and-error approach and shared decision making between adverse side effects of chemotherapy and patient’s quality of life.

Glomus tumors are rare benign neoplasms involving the glomus body, an arteriovenous structure involved with thermoregulation. Common sites involved are subungual region and subcutaneous tissue, however, it can rarely present in the gastric antrum. Our patient had a primary glomus tumor of the gastric body, with hepatic and pulmonary metastasis. RARE INSTANCE AND PATHOPHYSIOLOGICAL INSIGHTS OF THROMBOTIC THROMBOCYTOPENIC PURPURA FOLLOWING PACEMAKER IMPLANTATION Christopher Solowiej Singh, Dana Dhami, Heather Murray, Anna Schwab. Internal Medicine, Abrazo Health Care, Phoenix, AZ. (Control ID #4272345) CASE: This is the case of a 71-year-old female with past medical history of atrial fibrillation status post ablation 2 months ago currently on apixaban, hypothyroidism, remote history of breast cancer treated with radiation therapy and mastectomy, thyroid cancer status post thyroidectomy, and non-hodgkin's lymphoma (marginal zone lymphoma) treated with bendamustine and rituximab chemotherapy in 2019 followed by rituximab maintenance through 2021. She presented with a 4-day history of progressively worsening weakness and altered mental status. Eight days prior to admission, the patient had a pacemaker placed which she tolerated well initially. She denied any associated facial droop, weakness, or difficulty walking. She also endorsed a 4 day history of diarrhea with red tinged bowel movements. She denied any associated abdominal pain, frank blood or melena. Stroke work up was initiated and a CT head was negative for acute findings. Lab work revealed a hemoglobin of 11.4, platelet count of 16,000, GFR of 48, and bilirubin of 4.4. Coagulation studies and fibrinogen studies were within normal limits. LDH was noted to be elevated to 1019 and haptoglobin was low. ADAMTS 13 was ordered and the patient was started on high dose steroids with solumedrol 1g daily as well as plasma exchange with FFP transfusion due to concerns of thrombotic thrombocytopenic purpura (TTP). After initiation of treatment, the patient had an uptrend in her platelets along with resolution of neurologic symptoms. Follow-up on lab work showed ADAMTS to < 2.0 confirming the diagnosis of TTP. IMPACT/DISCUSSION: Thrombotic thrombocytopenic purpura (TTP) following pacemaker implantation is a rare but potentially life-threatening complication. The pathophysiology of TTP involves the formation of microthrombi in small blood vessels, leading to thrombocytopenia, hemolytic anemia, and organ damage. This condition is typically associated with a severe deficiency in ADAMTS13, a protease responsible for cleaving large von Willebrand factor (vWF) multimers. During pacemaker implantation, endothelial injury and increased shear stress can promote the release and accumulation of these large vWF multimers, which, in the presence of an ADAMTS13 deficiency, leads to widespread microthrombosis. Other potential causes of TTP include autoimmune disorders, such as systemic lupus erythematosus, infections, certain medications (e.g., quinine, ticlopidine, clopidogrel), malignancies, and pregnancy. In these cases, the underlying pathophysiological mechanisms often involve the production of autoantibodies against ADAMTS13, leading to its functional deficiency and subsequent microthrombi formation.

The incidence of TTP after pacemaker implantation is extremely low, with few cases reported in the literature. This rarity underscores the importance of recognizing this potential complication, as timely diagnosis and treatment with plasma exchange can be lifesaving. RARE MANDIBULAR METASTASIS IN HEPATOCELLULAR CARCINOMA Mason Eghbali1; Mrudula Bandaru1; Shazia Samanani1; Joyce Chen2. 1Internal Medicine, The George Washington University Hospital, Washington, DC; 2Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4273411) CASE: A 65-year-old woman with hepatocellular carcinoma (HCC), Hepatitis C, alcohol-related cirrhosis, hypertension, type 2 diabetes, seizure disorder, and bipolar disorder presented with altered mental status. She was diagnosed with diabetic ketoacidosis (DKA) with blood glucose >800 mg/dL, an anion gap of 27, and VBG showing pH 6.975 and bicarbonate 5 mmol/L. After initiating the hospital’s DKA protocol, her chemistries and mentation quickly returned to baseline. Five days later, she developed an acute right-sided preauricular soft tissue mass with pain and subjective trismus. She reported it appeared overnight and persisted. Physical exam revealed a 2cm firm mass anterior and inferior to the TMJ, fixed to underlying bone. ENT was consulted and reviewed the admission CT head, which showed no mass but noted a lytic abnormality in the cortical bone of the mandibular condylar process, corresponding to the exam findings. This raised concern for a sub-periosteal fluid collection or bony metastasis. CT maxillofacial with contrast revealed a 2.3 x 2.2 cm heterogeneously enhancing mass at the right mandibular neck with bony destruction and soft tissue involvement, concerning for malignancy. The patient underwent a right partial parotidectomy with mandibular biopsy, confirming metastatic poorly differentiated HCC. She later received five palliative radiation sessions before choosing hospice care. IMPACT/DISCUSSION: HCC is the fifth most common cancer worldwide and the second leading cause of cancer-related mortality, with a 5-year survival rate of 18%. Common extrahepatic metastatic sites include the lung, lymph nodes, bone, and adrenal glands. Parotid gland metastasis is rare, with only nine cases reported. The vascularized mandibular angle and body facilitate metastatic cell deposition. Metastatic tumors in the oral cavity may mimic odontogenic tumors (if present as a swelling) or oral squamous cell carcinoma (if present with surface ulceration). Our patient presented with a 2 cm acute onset preauricular mass along the posterior ascending ramus. Such findings are nonspecific, leading to a broad differential. Radiographic findings are similarly nonspecific, these lesions may appear radiolucent or radiopaque; although malignancies typically show destructive radiolucent areas with ill-defined borders, as in this case. The nonspecific clinical and radiographic features of HCC orofacial metastasis make diagnosis challenging and sometimes delayed. Awareness of potential facial metastasis in HCC and maintaining high clinical suspicion are crucial for timely workup and treatment.

Although rare, metastasis to the parotid gland or mandibular region is possible in HCC and may mimic benign or odontogenic conditions. Given its nonspecific clinical findings, a thorough history, clinical correlation, and biopsy are necessary for accurate diagnosis. Recognizing this potential can expedite diagnosis and management in similar patients, potentially leading to improved survival and quality of life. RARE PERITONEAL INVOLVEMENT IN ADULT T-CELL LEUKEMIA/LYMPHOMA (ATLL): UNCOVERING LYMPHOMATOSIS AS A MIMIC OF PERITONEAL CARCINOMATOSIS Nithya Krishnamurthy1; Bruce Petersen2; Christian M. Farag1; Anthony Hafez3; Raksha Kulkarni3; Busra Cangut3; Roshan Asrani4. 1Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Pathology, Molecular and Cell Based Medicine, Mount Sinai Health System, New York, NY; 3Radiology, Mount Sinai Health System, New York, NY; 4Hematology and Medical Oncology, Mount Sinai Health System, New York, NY. (Control ID #4272064) CASE: A 60-year-old Caribbean male with no known medical history presented with three weeks of abdominal pain and new-onset scrotal edema. Abdominal computed tomography (CT) scan revealed peritoneal carcinomatosis with omental nodularity and ascites. Initial paracentesis at an outside hospital revealed an exudate (4% neutrophils, lactate dehydrogenase 1,372 IU/L), but no cytology was performed. He returned with worsening symptoms, and positron emission tomography (PET)-CT showed nodules with elevated fludeoxyglucose (18F-FDG) uptake throughout the mesentery, peritoneum, and bilateral lower lung pleura. Repeat paracentesis with cytology showed atypical cells with phenotype compatible with T-lineage lymphoma. Ultrasound-guided biopsy of an omental implant for confirmation revealed large atypical lymphoid cells that were CD3+, CD2+, CD4+, CD8-, CD5-, CD7-, Ki67 90%, indicating aggressive T-cell lymphoma. Peripheral blood RT-PCR was positive for HTLV-1, and the patient was diagnosed with Stage IV ATLL. The hospital course was complicated by spontaneous tumor lysis syndrome, recurrent malignant small bowel obstruction, and MSSA bacteremia. During port placement for dose-adjusted EPOCH, the patient suffered from aspiration pneumonitis, acute respiratory failure, and cardiac arrest with anoxic brain injury, and he passed away 32 days after admission. IMPACT/DISCUSSION: Peritoneal lymphomatosis is a rare complication of lymphomas that can appear similar to peritoneal carcinomatosis on imaging. It is most commonly associated with high-grade B cell lymphomas, rather than T cell lymphomas such as ATLL, a rare cancer with approximately 1,000 cases reported annually worldwide. A 14-year review of ATLL patients showed diverse clinical manifestations but no peritoneal involvement. The potential for peritoneal involvement in ATLL underscores the importance of PET-CT, over CT alone, for staging, due to its greater sensitivity for detection of lymphoma at extranodal sites. Diagnosis of peritoneal lymphomatosis ultimately relies on biopsy. This case emphasizes the importance of considering endemic contexts and pursuing a targeted workup. We highlight the importance of utilizing PET-CT and expeditious biopsy in the evaluation of peritoneal malignancies for timely diagnosis.

Consider Rare Diagnoses: For peritoneal involvement, especially in patients from endemic regions, consider ATLL to avoid misdiagnosis as peritoneal carcinomatosis. Consider imaging modalities and early biopsy when evaluating peritoneal malignancies: PET-CT offers higher sensitivity and specificity than CT and aids in targeting biopsy sites, while early biopsy can expedite diagnosis and treatment. Endemic and Multisystem Context: Evaluate the patient’s endemic background and multisystem manifestations to ensure accurate and timely diagnosis of ATLL. RASH DECISIONS : UNPACKING THE COMPLEXITIES OF REACTIVE INFECTIOUS MUCOCUTANEOUS ERUPTION Mridula Sree Naagendran1; Jason Carrese2. 1Internal Medicine, UConn Health, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT. (Control ID #4229302) CASE: 19 year old female healthy college student residing with parents presented with blistering and sloughing of the oral mucosa. Prior to admission, went to urgent care due to shortness of breath,fever of 103 F and was diagnosed with bronchitis.COVID and flu were negative. Started on prednisone,azithromycin and albuterol.Prior to initiating azithromycin,began noticing intraoral lesions, primarily over gingiva and buccal mucosa, and had been placing bacitracin and petroleum jelly.She denies use of any triple antibiotic lotion or other creams or lotions.Symptoms worsened necessitating emergency visit.Denied vision symptoms,vaginal and nasal involvement ,sexual contact including non penetrating/oral acts, HSV infection,personal or family history of autoimmune disease/genetic conditions,animal exposures/travel.Physical exam notable for febrile,tachycardic,normotensive patient with patent airway,extensive erosions involving the lips,superior and inferior gingivae,buccal mucosa,tongue,and hard plate.Chest Xray showed no acute cardiopulmonary process.EBV,mycoplasma,parvovirus,VZV, HSV,ANA,ENA,C3,C4,dsDNA,MPO/PR3,ANCA,Coxsackie and HLA-B51were negative.Dermatology was consulted and patient symptomatically improved with steroid taper. IMPACT/DISCUSSION: Reactive infectious mucocutaneous eruption( RIME ) is an uncommon dermatological disorder characterized by abrupt onset of mucosal and cutaneous lesions. RIME presents a challenge to clinicians as well as intriguing new insights on the intricate immunological responses of the body. RIME’s pathophysiology is hypothesized to involve aberrant immune response to infectious antigens, leading to cross reactive attack on mucocutaneous tissues.Clinically, it is important to differentiate RIME from related disorders including erythema multiforme and Stevens Johnson SYndrome (SJS) because of differences in their etiology and management. The main focus of management is supportive care. The role of antibiotics remains controversial.The effectiveness of corticosteroids and other immunomodulatory treatments has been inconsistent, therefore further study is required to provide standardized therapy regimes.

RIME, though rare, serves as a compelling example of the complex interplay between infectious agents and immune modulation in dermatological manifestations. Recognizing its distinct clinical features not only aids in early diagnosis and optimized management but also highlights the need for heightened awareness in differential diagnoses.This case underscores the value of integrating multidisciplinary insights ,advancing our understanding of immune-mediated skin responses, and potentially opening pathways for targeted therapeutic interventions.Our findings stress the importance of a vigilant approach to atypical cutaneous reactions , which may redefine standards in managing infection - induced mucocutaneous disorders. RASH OF RARITY: AN UNEXPECTED INPATIENT PRESENTATION OF CALCIPHYLAXIS Sarah A. Tupchong, Jessica Cristallo. Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4272641) CASE: A 50-year-old female with a history of CKD5, cervical cancer, and severe PAD presented to the ED with 1 day of altered mental status and hypoxia. She was found to be in septic shock with renal failure. She underwent emergent hemodialysis (HD) and was admitted to the ICU. Imaging was consistent with pneumonia, with cultures positive for Klebsiella. She improved rapidly with antibiotics. On hospital day 3, she was transferred to the general medicine floor. Two days later, she reported severe bilateral thigh pain. Exam showed new symmetric retiform purpuric plaques/angulated purpura & patches. Dermatology & Vascular surgery were consulted. CT angiogram showed no occlusion. The rash progressed to include her bilateral breasts and right forearm. Biopsy confirmed calciphylaxis. The patient's hospital course was further complicated by severe pain & difficulty tolerating HD. She was ultimately discharged to inpatient hospice. IMPACT/DISCUSSION: This is a case of calciphylaxis and its unexpected presentation mid-hospital course. The differential diagnosis included calciphylaxis, primary occlusive vasculopathy, acquired coagulopathy, and septic vasculopathy. Calciphylaxis was high on differential given the fatty area distribution and severe pain. Biopsy, tested with Von Kossa stain, showed classic findings of calcium in small blood vessels in the subcutis & connective tissue in the deep dermis. Early recognition of the rash's appearance, characteristic distribution, and biopsy allowed for timely diagnosis. Calciphylaxis is a rare, highly fatal condition usually seen in patients with ESRD. Our patient had CKD 5 with acute worsening of her renal disease in the setting of sepsis requiring HD. The rash is characterized by cutaneous arterial calcification causing tissue ischemia, resulting in painful non-healing wounds. It usually affects areas with increased adipose tissue such as the thighs, buttocks, and abdomen, as in our patient, whose rash began in the thighs and spread to her breasts. Mortality usually results from ulcerated lesions leading to infection and sepsis; 1-year mortality rates are between 45-80%, with a mean survival time of 9.5 months. Our patient died < 2 months after diagnosis; her cause of death was related to her discontinuation of HD. Many treatments, from sodium-thiosulfate infusions to parathyroidectomies, have been trialed without success. Early recognition allows patients to prioritize advanced care planning & for the clinical team to help ensure adequate pain control, which can be exceptionally difficult. Our patient required a hydromorphone PCA with both intermittent & continuous dosing, which was continued upon transfer to inpatient hospice.

Calciphylaxis should be considered in patients with CKD who have a rapidly progressive rash in a fatty area distribution. Prompt referral to Dermatology is recommended so that biopsy can be obtained early. Pain control and early goals of care discussion should be prioritized in patients with this incurable disease. REBOUNDING PTH AND PERSISTENT HYPERCALCEMIA FOLLOWING RESECTION OF A SUSPECTED PARATHYROID ADENOMA Kireem Nam1; Sarah Jones2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2General Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4272056) CASE: A 71-year-old man with hypertension, type II diabetes, and chronic kidney disease presented to the hospital after routine labs revealed calcium of 14.2. He noticed forgetfulness in recent months but otherwise was asymptomatic. Vital signs notable for BP 167/103; physical exam was unrevealing. He was not taking thiazide diuretics or hypercalcemia-inducing medications. Crystalloid fluids improved hypercalcemia and memory. Parathyroid hormone (PTH) was elevated to 650, highly suggestive of primary hyperparathyroidism (PHPT). CT neck and sestamibi scan demonstrated a nodule in the left thyroid lobe concerning for a parathyroid adenoma. He underwent left parathyroid exploration with resection of the adenoma, as well as discovery and dissection of an additional inferior adenoma. Calcium was trended twice daily to monitor for post-op hypocalcemia. Notably, calcium remained elevated to 11.5 and PTH levels rebounded from 28.3 to 209 within two days post-op. Given these findings, the patient was suspected to have multi-gland hyperplasia rather than a solitary adenoma. Re-exploration focusing on the right parathyroid glands was recommended; however, the patient declined repeat procedure while admitted and elected clinic follow up for further discussion. IMPACT/DISCUSSION: Understanding PHPT is crucial for clinicians given its prevalence, which makes up 80-90% of chronic hypercalcemia cases. Diagnostic workup includes PTH and 24-hr urine calcium measurement if familial hypocalciuric hypercalcemia (FHH) is suspected. Of note, urine calcium may be inaccurate with chronic kidney disease, vitamin D deficiency, thiazide diuretics, and lithium. Parathyroidectomy is first line treatment and recommended for patients with hypercalcemia, skeletal involvement (i.e. fracture or bone mineral density by T-score ≤ -2.5), renal involvement (eGFR or CrCl < 60 mL/min), or young age < 50. Imaging is obtained not for diagnosis but for operative planning, and can be done via ultrasound, CT with contrast, or sestamibi scan to locate the abnormal parathyroid glands. However, imaging may be less effective in detecting multi-gland hyperplasia as in this case. Distinguishing a solitary adenoma (80% of PHPT cases) from multi-gland hyperplasia (15-20%) determines whether to perform a limited parathyroidectomy vs more extensive, bilateral neck exploration. A solitary adenoma would likely lead to atrophy of the remaining parathyroids. Thus, persistent hypercalcemia following removal would be unlikely, and one should instead suspect multi-gland parathyroid hyperplasia, which can be seen in multiple endocrine neoplasia.

-Hypercalcemia and elevated PTH are highly suggestive of PHPT, due to parathyroid adenoma or multi-gland hyperplasia -Diagnostic workup of PHPT includes PTH and 24-hr urine calcium if FHH is suspected while imaging is for surgical planning -Persistent hypercalcemia following resection of a parathyroid adenoma should prompt consideration of the alternate diagnosis of multi-gland hyperplasia and MEN RECOGNITION AND TREATMENT OF NEUROPSYCHIATRIC INVOLVEMENT IN A FLARE OF SYSTEMIC LUPUS ERYTHEMATOSUS Chumeng Wang1; Riti Kotamarti1; Bryanna Mantilla2. 1Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; 2Department of Internal Medicine, Division of Rheumatology, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4267102) CASE: A 46-year-old woman with a history of systemic lupus erythematosus (SLE) presented with two weeks of worsening lower extremity weakness and pain with new altered mental status. She presented off of immunomodulatory medications. Vitals were notable for hypertension (173/108 mmHg) and tachycardia (106 bpm). Exam demonstrated a thin woman in distress with bilateral wrist and foot drop, symmetrical distal and proximal muscle weakness in extremities, and absent knee and ankle deep tendon reflexes. Labs demonstrated hypocomplementemia, proteinuria, elevated sedimentation rate, and creatinine of nearly three times baseline (2.91 mg/dL). Contrast brain and spine MRI was unrevealing with no cord or white matter abnormalities. Lumbar puncture showed normal WBC, protein, and glucose. After rheumatology consultation, the patient was noted to have a SLEDAI-2K score of 32, indicating very high disease activity with renal and neurologic involvement. Pulse dose steroids were recommended but initially delayed. Eventually, the patient received five days of methylprednisolone 1000mg. Subsequent renal biopsy demonstrated class IV+V diffuse proliferative and membranous lupus nephritis with focal lupus vasculitis. Additional serologies showed markedly elevated anti-dsDNA antibodies, as well as positive anti-Smith and anti-SSA antibodies. The patient was started on hydroxychloroquine and low-dose EUROLUPUS cyclophosphamide protocol, and her steroid dosage was tapered. On follow up post-discharge, her mentation and renal function had returned to baseline and she experienced partial improvement in limb weakness. IMPACT/DISCUSSION: Both renal and neurologic involvement are considered severe manifestations of SLE. Current understanding of neuropsychiatric SLE (NPSLE) is limited; presentation is heterogeneous, with symptoms including confusion, psychosis, seizures, or neuropathy (Schwartz 2019). This wide range makes attribution of neurologic symptoms to SLE challenging. Imaging is not reliable, as 50% of patients with NPSLE have nonsignificant MRI results, and lumbar puncture is often normal (Moore 2021). As such, current guidelines recommend evaluating the patient’s overall SLE activity and placing the development of any new neurological symptoms in this context. This case illustrates the importance of recognizing systemic activity of SLE in order to attribute new neurological symptoms to active lupus rather than an alternative diagnosis. Timely identification and appropriate management of SLE is crucial to prevent morbidity and mortality. Early consultation with a rheumatologist can be an important tool for hospitalists in these challenging cases.

Consultation with rheumatology should be early and often in lupus patients due to the heterogeneous and systemic nature of SLE. Clinicians should maintain a high index of suspicion of NPSLE for patients with a history of SLE who present with unexplained neurological symptoms. CSF and MRI often cannot confirm the attribution of neurologic symptoms to SLE. RECOGNIZING A COMMON RASH IN AN UNCOMMON HOST Luisa Nilan1; Jennifer O. Spicer1; Sheetal Kandiah1; Mariam Assi1; Laura D. Aspey2. 1Department of Medicine, Emory University School of Medicine, Atlanta, GA; 2Department of Dermatology, Emory University, Atlanta, GA. (Control ID #4267366) CASE: Mrs. A is a 78-year-old female with COPD who was transferred from another hospital for evaluation of a new, diffuse, vesicular rash. Six days prior, she had presented to the ED for an earache and was prescribed methylprednisone and cefdinir; she denied other new medications. Three days later, she awoke with a new rash that started on her right forehead and spread to her lips, buccal mucosa, chest, abdomen, back, bilateral arms and legs, groin, and palms over the next 3 days. The rash was painful, pruritic, and associated with numbness. The rash was initially erythematous, but then developed into small vesicles with yellow-brown drainage that crusted over in various stages of healing. The patient reported an allergy to penicillin, a history of primary varicella as a child, and shingles on her forehead one year ago. She tested negative for HIV. The primary treating team was initially concerned for a drug-related rash, but from the history and presentation, the dermatology and infectious disease teams quickly identified it as disseminated herpes zoster (DHZ); the diagnosis was confirmed via a VZV PCR from one of her vesicles. She was treated with 10 days of IV acyclovir with gradual resolution of her rash. IMPACT/DISCUSSION: Disseminated herpes zoster (DHZ) is a condition that is often under-recognized and therefore warrants a high index of suspicion in elderly patients who present with a diffuse, vesicular rash, even among those without obvious risk factors. The condition occurs in about 2% of the general population, with an incidence of 10-40% in the immunocompromised. The incidence in immunocompetent hosts is not well known, but some studies estimate it at about 0.5%. In the immunocompetent, a careful history can elicit other risk factors such as older age, a history of primary varicella or shingles, or exposure to even a short course of steroids, the likely culprit in this case. The diagnosis of DHZ requires more than 20 vesicles outside of the initial 1-2 adjacent dermatomes that are affected in shingles. The characteristic presence of an initial, localized rash that then becomes diffuse can also help distinguish it from primary varicella. While the treatment of shingles is a 7-day course of a PO antiviral such as valacyclovir or famciclovir, treatment of DHZ requires IV acyclovir 10 mg/kg q8h for 10-14 days because patients are at risk of developing visceral organ involvement (most often hepatitis, pneumonitis, or encephalitis), which can be life-threatening.

● DHZ is under-recognized in immunocompetent patients; older age and steroid use are two important risk factors. ● DHZ is diagnosed in the presence of more than 20 vesicles outside of the initial 1-2 adjacent dermatomes that are affected in shingles. ● While shingles can be managed outpatient, treatment of DHZ requires inpatient management with IV acyclovir for 10-14 days. RECURRENT ASEPTIC MENINGITIS WITH WIDESPREAD LYMPHADENOPATHY - A RARE CASE OF KIKUCHI DISEASE Kevin Soon Hwee Teo1; Isaac K. Ng2; Ming Ying Gan2; Amy May Lin Quek1. 1Neurology, National University Hospital, Singapore, Singapore, Singapore; 2Department of Medicine, National University Hospital, Singapore, Singapore, Singapore. (Control ID #4245215) CASE: A young woman in her twenties presented with recurrent episodes of fever, headache with neck stiffness and cervical lymphadenopathy. The first episode followed her return from an overseas holiday. Gadolinium-enhanced MRI showed extensive leptomeningeal enhancement without any enhancing parenchymal lesions or abscess seen. Lymphopenia was identified on full blood count, and lumbar puncture revealed a raised opening pressure of 40cm H2O with lymphocyte-predominant pleocytosis (white blood cell count 358). CSF protein was mildly elevated at 0.53g/L and the CSF glucose to serum glucose ratio was 0.48. Infective workup with blood cultures, CMV, EBV, retroviral, and leptospira serologies returned negative. CSF FilmArray polymerase chain reaction panel, acid-fast bacilli smear and cultures, bacterial cultures, and cryptococcal antigen also returned negative. CSF flow cytometry and cytology were negative for lymphoproliferative disorder or maligancy. The patient's symptoms spontanoeusly improved without antibiotics and she was diagnosed with viral meningitis and discharged with early follow-up. The patient returned to hospital 2 weeks later with recurrent symptoms. Repeat CSF studies once again identified aseptic lymphocytic meningitis. Anti nuclear antibodies returned positive with a titre of 1:320 without positive ds-DNA titres or other systemic manifestations of systemic lupus erythematosus. Serum angiotensin converting enzyme levels were normal and serum IL-2 receptor levels were within the normal range. IgG4 levels were normal and TB quantiferon was negative. A whole-body CT showed prominent supraclavicular, axillary, and periportal nodes. An excision biopsy of a left cervical lymph node revelaed reactive histiocytic lymphadenitis consistent with the diagnosis of Kikuchi disease. IMPACT/DISCUSSION: Kikuchi disease is a rare self-limiting immune-mediated condition characterised by cervical lymphadenopathy and fever. Neurologic manifestations are increasingly recognised and include aseptic meningitis and cerebellar syndrome. Diagnosis is through histopathological examination of lymph nodes with typical findings of necrosis and histiocytic cellular infiltration. Biopsy is recommended to exclude other serious conditions requiring aggressive therapy such as tuberculosis or lymphoma. Symptoms of Kikuchi disease typically resolve within one to four months, however patients with severe or persisting symptoms have been treated with glucocorticoids or other forms of immunosuppression with some reported benefit. Recurrences may occur for many years and there is a risk of evolution into systemic lupus erythematosus, particularly in cases with a positive antinuclear antibody test.

This was a case of Kikuchi disease presenting with recurrent aseptic meningitis with widespread lymphadenopathy. Histopathological diagnosis is vital as other potentially more serious conditions such as tuberculosis or lymphoma may mimic its clinical presentation RECURRENT METASTATIC CERVICAL CANCER PRESENTING WITH TUMOR EMBOLISM, ENDOBRONCHIAL OBSTRUCTION, AND GROUP V PULMONARY HYPERTENSION Sagar Patel1; Libby Niehoff1; Deepika Razia1; Jaya Raj2,1. 1Medicine, Creighton University School of Medicine, Phoenix, AZ; 2Medicine, St. Joseph's Hospital & Medical Center, Phoenix, AZ. (Control ID #4241462) CASE: A 36-year-old woman with a history of Stage IIIb squamous cell carcinoma (SCC) of the cervix, in remission for six years after chemoradiation, presented with hemoptysis and chest pain. Three months earlier, she was hospitalized for a right upper lobe (RUL) cavitary lesion and pneumothorax requiring chest tube placement. Despite negative microbiologic studies and outpatient follow-up, her symptoms persisted. On admission, physical exam revealed jugular venous distension and decreased right lung breath sounds. Chest CT showed eccentric occlusion of the right main pulmonary artery (PA), an enlarging RUL cavitary lesion, and right pleural effusion. Pleural fluid analysis was exudative, with negative cytology and microbiology. Pulmonary angiography identified right main PA stenosis with absent distal flow. Bronchoscopy revealed a 3.1 × 2.9 cm mass encasing the bronchus intermedius; biopsy confirmed metastatic SCC positive for high-risk human papillomavirus (HPV). PET imaging showed hypermetabolic activity in the RUL, pleura, and liver. The patient was diagnosed with stage IV non-resectable cervical cancer and treated with paclitaxel, carboplatin, and bevacizumab, followed by maintenance bevacizumab for one year. IMPACT/DISCUSSION: This case highlights a rare and complex presentation of recurrent metastatic cervical cancer manifesting as tumor embolism, endobronchial obstruction, and Group V pulmonary hypertension. While pulmonary metastases are common in cervical cancer, the occurrence of these specific complications is exceptionally unusual, posing significant diagnostic and management challenges. The case emphasizes the importance of advanced imaging, bronchoscopy, and histopathology in diagnosing rare metastatic mechanisms and demonstrates the effectiveness of systemic therapy with paclitaxel, carboplatin, and bevacizumab in alleviating symptoms and reducing tumor burden. This report contributes to the limited literature on rare metastatic complications of cervical cancer and underscores the aggressive metastatic potential of squamous cell carcinoma. It highlights the importance of recognizing tumor embolism and vascular compression as causes of pulmonary hypertension and the value of a multidisciplinary approach in managing complex metastatic patterns. These insights serve to improve clinical understanding and enhance patient outcomes in similar cases.

This case underscores the complexity of diagnosing and managing recurrent cervical cancer with unusual metastatic patterns and highlights the need to consider tumor embolism and extrinsic compression as causes of group V PAH. Early multidisciplinary intervention is crucial for optimizing patient outcomes. RECURRENT RUPTURED ASCENDING AORTIC ANEURYSM IN A YOUNG ADULT. IS THERE AN UNDERLYING EXPLANATION? Ilgizar Hart2; Grace Suppa3; Brian Houston1. 1Cardiology, Medical University of South Carolina, Charleston, SC; 2Internal Medicine, Medical University of South Carolina, Charleston, SC; 3Rheumatology, Medical University of South Carolina, Charleston, SC. (Control ID #4270622) CASE: A 40-year-old female with postpartum cardiomyopathy was diagnosed with a fusiform aneurysm of the ascending aorta, diameter of 4.2 cm, and severe aortic insufficiency. She underwent aortic valve and ascending aorta replacement, which was complicated by presumable endocarditis of the aortic valve and ascending aorta. During surgery, pericardium adhesion to the ascending aorta and periaortic reaction were observed. Pathology showed inflammation of the media and adventitia of aorta. On follow-up CT chest, contrast extravasation was found. She had another aortic root and valve replacement with a bypass to the left main coronary artery. Blood cultures grew B. Subitilis. Mycoplasma IgM and Karius H. Pylori were positive. She finished daptomycin and ceftriaxone and transferred to doxycycline. Then, she presented with NSTEMI and cardiogenic shock. CTA of the chest noted an ascending aorta pseudoaneurysm with a diameter of 11 cm with contrast extravasation. Circumferential diffuse thickening of the thoracic aorta and four-vessel aortic branches were noted. A pseudoaneurysm compressed the bypass graft. TTE revealed a newly reduced EF to 20%. Troponin peaked at 20 000. She was treated with ACS protocol and milrinone. Her inflammatory markers CRP, ESR, IL-6 were significantly elevated. The infection workup was negative. Pulse dose steroids improved inflammatory markers. A cardiac PET scan a week after steroid treatment showed a mild inflammatory component of the aorta and post-infarct myocardium inflammation. After almost a month of high-dose steroid immune suppression, she had 3rd sternotomy and arch replacement with Bentall and CABG. She was discharged in stable condition. Tocilizumab was started, and steroids tapered off. IMPACT/DISCUSSION: This was a challenging case to diagnose large vessel vasculitis. It was revealed that she had symptoms back in 2017, including night sweats, weight loss, and shortness of breath. Her age and gender put her at risk for Takayasu arteritis. However, it is more associated with stenosis and limb claudication than pseudoaneurysm. Despite receiving treatment for presumed endocarditis, she had persistent inflammation of the aorta, and subsequent infection workup was negative. A cytokine panel showed elevated IL-6, which is a target for Tocilizumab. No level of immunosuppression could repair the damage already done. She had an occluded graft in the left main coronary artery, which resulted in a large area of myocardial infarction and led to ischemic cardiomyopathy. This significantly affected her overall prognosis.

This case is challenging due to the patient's history of previous instrumentation and recurrence, putting her at high risk for surgical interventions on re-admission. Aggressive treatment with steroids helped with decreasing inflammation, allowing an attempt for third aortic root surgery. The use of steroid-sparing agents or immunosuppression would not preclude her from a possible future heart transplant. REFRACTORY COLLAGENOUS COLITIS INDUCED BY PEMBROLIZUMAB IN A PATIENT WITH METASTATIC RENAL CELL CARCINOMA: A CASE OF IMMUNE-MEDIATED COLITIS RESISTANT TO MULTIPLE STEROID THERAPIES Chaitanya V. Nimmagadda, Harmony Zimmerman, Carlos Contreras, Diba Atar. College of Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #4267124) CASE: An 82 year-old-male with a history of renal cell carcinoma (RCC) and collagenous colitis (CC) presented to a VA ED in the Northeast U.S. with 7-14 daily episodes of diarrhea and weakness over several days. 4 months prior at a nearby academic medical center, he received 4 rounds of pembrolizumab 200 mg every 3 weeks for treatment of RCC. He developed profuse diarrhea after his 5th dose. A colonic biopsy from that admission showed CC, thought to be secondary to immunotherapy. He received a course of methylprednisolone 125 mg and a 3-month prednisone taper, which improved his diarrhea. Diarrhea resumed after the taper and he was readmitted to the academic center, where his symptoms improved with, and he was discharged on, budesonide 9 mg. He then presented to the VA, where a physical exam showed dry mucous membranes and increased bowel sounds. A stool microorganism panel was negative. He was started on loperamide 4 mg q6h; budesonide 9 mg was switched to methylprednisolone 125 mg daily. This regimen initially controlled his symptoms, but diarrhea resumed on day 5. The team then restarted his budesonide 9 mg daily and added 40 mg of prednisone daily. He received 19 days of budesonide and 20 days of prednisone, but diarrhea persisted. The patient continues to follow with the VA internal medicine, oncology, and gastroenterology teams for ongoing management. IMPACT/DISCUSSION: Microscopic colitis (MC) is characterized by chronic, watery, non-bloody diarrhea, with normal gross mucosa on colonoscopy but abnormal histology. Risk factors include certain medications, with the strongest evidence for NSAIDs. Pembrolizumab, used in solid and hematologic malignancies, can sometimes cause immune-mediated MC with an incidence of 1.3%-2.9%, and usually happens 5-10 weeks after the 2nd or 3rd treatment cycle. MC often resolves by stopping the offending drug, or with low-dose corticosteroids (budesonide being first-line). Steroid-refractory cases may require second-line biologics such as infliximab and vedolizumab. Our patient is notable for developing MC late, after his 5th treatment cycle of pembrolizumab. He is also unique in that his MC was initially responsive to methylprednisolone but later became refractory after multiple rounds of budesonide. Earlier initiation of biologics and defined timelines for steroid trials, facilitated by prompt interdisciplinary collaboration between oncology and gastroenterology, could have optimized management and reduced the prolonged use of ineffective treatments.

Despite multiple attempts with first-line corticosteroids, this patient’s pembrolizumab-induced MC remained refractory, challenging us to expand individualized treatment plans to include other biologic immunomodulators. REFRACTORY HYPERCALCEMIA SECONDARY TO SQUAMOUS CELL CARCINOMA OF THE BUCCAL MUCOSA WITH RARE SKELETAL MUSCLE METASTASES: A CASE REPORT Walaa Hasan, Ahad Qasim, Manthan Pandya. internal medicine, Trinitas Regional Medical Center, Elizabeth, NJ. (Control ID #4242596) CASE: Hypercalcemia of malignancy (HCM) is a serious complication seen in up to 30% of cancer patients, often associated with poor prognosis. Parathyroid hormone-related peptide (PTHrP) is a common mediator, particularly in squamous cell carcinomas (SCC). Distant metastasis to skeletal muscle is exceedingly rare in SCC of the buccal mucosa, with few cases documented in the literature. A 55-year-old Hispanic male with SCC of the left buccal mucosa presented with altered mental status, diffuse abdominal pain, and right thigh pain. He had previously undergone modified DCF chemotherapy with an excellent response, followed by a partial maxillectomy with negative lymph nodes. However, adjuvant radiation therapy was incomplete. On physical examination, he had a tender, hard 3 × 4 cm mass in the right thigh. Imaging revealed multiple intramuscular lesions, including a 7.9 cm mass in the vastus lateralis. Biopsy confirmed metastatic high-grade carcinoma. Initial laboratory studies showed a corrected calcium of 15.5 mg/dL, suppressed parathyroid hormone (PTH) of 3 pg/mL, low vitamin D (13 ng/mL), and elevated PTHrP (3 pg/mL), consistent with humoral hypercalcemia of malignancy. The patient was treated with intravenous fluids, calcitonin, zoledronic acid, and steroids, achieving temporary improvement in calcium levels to 10.7 mg/dL. He was discharged with outpatient follow-up. The patient was readmitted four weeks later with worsening mental status and a corrected calcium level of 17.7 mg/dL. Despite advanced treatment with denosumab, calcitonin, and bisphosphonates, his hypercalcemia remained refractory. Given his poor prognosis and advanced disease, the patient’s care was transitioned to comfort measures, and he subsequently succumbed to his illness. IMPACT/DISCUSSION: SCC of the buccal mucosa, a subset of head and neck cancers, rarely metastasizes to skeletal muscle, with distant metastases occurring in less than 1% of cases. Hypercalcemia of malignancy, predominantly mediated by PTHrP secretion, occurs in 10-20% of SCC cases, often signaling advanced disease and resistance to therapy. Most PTHrP-mediated hypercalcemia is responsive to bisphosphonates; however, the fact that this patient returned with refractory hypercalcemia within four weeks highlights the aggressive nature of his malignancy. This emphasizes the need to consider alternative therapies, such as denosumab, which may offer better outcomes in similar cases. The transient response to standard interventions underscores the challenges in managing paraneoplastic syndromes in late-stage malignancies.

This case demonstrates the rarity of skeletal muscle metastases in SCC of the buccal mucosa and the clinical complexities of refractory hypercalcemia. It highlights the importance of early recognition of paraneoplastic syndromes and the need for timely integration of palliative care in advanced malignancies to improve patient quality of life. RESISTANT HYPONATREMIA AND HEART FAILURE EXACERBATION CAUSED BY ADRENAL INSUFFICIENCY FROM EXOGENOUS EXPOSURE TO DEXAMETHASONE IN ARTRI KING Enat Arega1; Hana Arega3; Lindsey Ward1; Inderpreet Saini2. 1Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 3University of Washington, Seattle, WA. (Control ID #4272668) CASE: The patient is a 58-year-old female with a past medical history of heart failure with preserved ejection fraction, BMI of 56, hypertension, hyperlipidemia, type 2 diabetes mellitus, coronary artery disease, and atrial flutter. She presented to the emergency room with progressively worsening leg swelling and shortness of breath over the past two weeks. The patient’s initial vitals were heart rate of 61, blood pressure of 156/71, and oxygen saturation 100% on 2L nasal cannula. On a physical exam, the patient looked overtly volume overloaded with bilateral basilar crackles, and 3+ pitting edema to the knee. The pateint’s initial labs were notable for Hb of 10.6, Na of 133, BUN of 35, Cr of 1.4, and glucose of 235. The patient was admitted for acute decompensated heart failure and was started on IV diuretics, supplemental oxygen, and fluid restriction. Her hospital course was complicated by increased oxygen requirements, hemodynamic instability, and worsening hyponatremia with Na of 125 while on IV diuretics, requiring an intensive care unit upgrade. Given the worsening hyponatremia while on IV diuretics, the patient was further evaluated for secondary causes of the hyponatremia such as hypothyroidism and adrenal insufficiency. She was found to have central adrenal insufficiency, with 8 AM cortisol and ACTH levels of 0.8 and <2, respectively. The patient's 11 AM cortisol level was 10 after cosyntropin stimulation. On further interviewing, the patient revealed that she has been taking Artri King, an over-the-counter pill containing diclofenac and dexamethasone, to relieve her arthritic pain. The patient was started on prednisone 20mg BID and IV lasix 80 mg; and her hyponatremia and hemodynamic instability, likely due to adrenal crisis, started improving instantly. IMPACT/DISCUSSION: Hyponatremia is a common manifestation of heart failure, occurring in up to 25% of patients admitted for heart failure exacerbation. In patients hospitalized for heart failure, hyponatremia is linked to longer hospital stays, a 19% increase in in-hospital mortality, a 10% increase in early post-discharge mortality, and an 8% increase in readmission for each 3 mmol/L decrease in admission serum sodium below 140 mmol/L. Given hyponatremia is a strong prognostic marker for poor outcomes in patients with heart failure, this case illustrates the need to investigate for secondary causes of hyponatremia before a diagnosis of advanced heart failure is made. Furthermore, this case underscores the importance of asking about non-prescription medications during medication reconciliation. It also highlights the importance of educating patients about non-FDA-regulated drugs and their potential serious side effects.

This case highlights the critical role of thorough work-up for hyponatremia in patients with worsening heart failure. It also emphasizes the importance of comprehensive medication reconciliation, including review of over-the-counter medications and non-FDA-regulated drugs. RHEUMATOID ARTHRITIS WITH OVERLAP MYOSITIS MASQUERADING AS STEMI Matthew Utset1; Kevin Stanko2. 1Alix School of Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4273041) CASE: A 56-year-old female with seropositive rheumatoid arthritis diagnosed 1 week prior on a tapering course of prednisone presented to the emergency department with chest pain, dyspnea, peripheral edema, and fatigue. Initial laboratory workup was notable for troponin T 563 ng/L, AST 387 U/L, ALT 285 U/L, and NT-Pro BNP 1973 pg/mL. Electrocardiogram demonstrated ST-segment elevations in the inferolateral leads concerning for STEMI. She was taken for emergent cardiac catheterization which demonstrated non-obstructive coronary disease. Upon admission, laboratory workup showed an elevated creatine kinase at 2905 U/L and a urine myoglobin greater than 3000 mcg/L. On physical exam, new mild proximal muscle weakness was noted without pain or distal weakness. Rheumatology and Neurology recommended electromyography, which showed active myopathy with evidence of rhabdomyolysis and progression of a length-dependent sensorimotor peripheral neuropathy. Further laboratory evaluation was notable for positive SS-A and Jo-1 antibodies of >8.0 as well as an ANA of 1:160. PET-CT demonstrated diffusely increased muscle activity in the upper and lower extremities suspicious for myositis; subsequent muscle biopsy showed perivascular inflammation with perifascicular pathology consistent with antisynthetase syndrome or overlap myositis. She was initiated on prednisone 80 mg daily and rituximab. Although she experienced improvement in chest pain, the etiology of her symptoms remained unclear. Transthoracic echocardiography was unremarkable, and cardiac MRI was notable for a small region of 75% subendocardial enhancement in the apical inferior wall. Aspirin, atorvastatin, and metoprolol were initiated. She was discharged home in stable condition. IMPACT/DISCUSSION: Idiopathic inflammatory myopathies (IIM) are a rare group of diseases affecting 0.55 to 25 per 100,000 people characterized by clinical manifestations of progressive muscle weakness and histopathologic findings of inflammatory infiltrates in muscle tissue. This case demonstrates an atypical presentation where a patient diagnosed with inflammatory arthritis in the absence of myositis features developed abrupt-onset inflammatory myositis. Notably, the prevalence of IIM in patients with rheumatoid arthritis is rare, with studies citing a co-occurrence in <1% of patients with IIM. This case further illustrates the increased risk of cardiac disease in patients with IIM, thought to be driven by inflammation of the myocardium and accelerated coronary atherosclerosis. This patient’s radiographic findings and symptoms of exertional dyspnea, chest pain, and fatigue were concerning for concurrent myocardial infarction with non-obstructing coronaries versus focal myocarditis.

This case demonstrates the heterogeneous presentation of IIM and the multidisciplinary approach to its identification and treatment. For patients with known IIM, providers should be aware of the increased risk of cardiac insults, including myocardial infarction and myocarditis. RHOMBENCEPHALITIS IN THE IMMUNOCOMPROMISED: A CASE OF CMV AND LISTERIA COINFECTION Mai Hamaad1; Jairah Shaikh2; Ali Yusuf3; Sayma Yaqub4; Fatema Mahjabeen5; Mahmoud Elbadrawy6; Abhijit Gutal2. 1Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; 2Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 3internal medicine, Texas Tech university health science center Amarillo, Amarillo, TX; 4Internal Medicine , Texas Tech University Health Science Center Amarillo, Amarilo, TX; 5Internal medicine , Texas tech university health sciences center amarillo, Amarillo, TX; 6Internal medicine, Texas Tech University Health Sciences Center, Lubbock, TX. (Control ID #4273383) CASE: A 25-year-old male-to-female transgender individual presented with a 5-day history of progressive abdominal discomfort, nausea, diarrhea, headaches, blurred vision, confusion, and ataxia. She was recently diagnosed with anal squamous cell carcinoma but had not initiated treatment. Additionally, she had untreated HIV with a viral load of 147,000 copies/mL and a CD4 count of 73, placing her at high risk for opportunistic infections. On presentation, she was febrile, hypotensive, tachypneic, and hypoxic. She developed acute hypoxic hypercapnic respiratory failure requiring intubation. Initial CT of the brain was unremarkable. Lumbar puncture revealed CSF pleocytosis (WBC 25, 64% neutrophils), elevated protein (71 mg/dL), and glucose of 50 mg/dL. CSF PCR was positive for CMV. Blood cultures confirmed Listeria monocytogenes. MRI findings included bilateral ill-defined enhancing lesions in the brainstem, predominantly in the pons, with linear enhancement extending into the left dorsolateral medulla and upper cervical spinal cord at the C1-C2 level. Vasogenic edema was evident in the cerebellum and cerebellar peduncles. Initial broad-spectrum antibiotics were adjusted to ampicillin, gentamicin, and trimethoprim-sulfamethoxazole, while antiviral therapy included ganciclovir and Biktarvy. The patient’s condition improved gradually over the following week in the ICU, with extubation and discharge in stable condition. IMPACT/DISCUSSION: Rhombencephalitis refers to an inflammatory disease of the hindbrain, encompassing the brainstem and cerebellum. Its etiologies include infections, autoimmune conditions, and paraneoplastic syndromes. Among infectious causes, Listeria monocytogenes and Cytomegalovirus are significant, particularly in immunocompromised hosts. Listeria-associated rhombencephalitis is rare, with a predilection for the brainstem and a biphasic course, an initial flu-like syndrome of headache, fever, nausea, and vomiting, progressing over days to cranial nerve palsies, ataxia, decreased consciousness, seizures, and hemiparesis. CSF findings can be non-specific, making blood cultures a more reliable diagnostic tool. Advanced diagnostics like multiplex PCR targeting the hly gene are essential for rapid identification of Listeria in CSF. MRI typically shows enhancing lesions in the brainstem, cerebellum, and medulla, confirming the diagnosis. This case highlights dual infections (CMV and Listeria) in an immunocompromised patient, where early targeted therapy with antibiotics and antivirals was lifesaving. Without prompt treatment, mortality rates for Listeria rhombencephalitis approach 50%.

This case underscores the diagnostic and therapeutic challenges of rhombencephalitis in immunocompromised patients with dual infections. Advanced imaging, culture-independent diagnostics, and timely therapy are essential for managing infections like Listeria and CMV. The patient's recovery emphasizes the need for a multidisciplinary approach and high clinical vigilance. ROBOTIC WHIPPLE PROCEDURE AND THE RISK OF PORTAL VEIN THROMBOSIS A CALL FOR OPTIMIZED GUIDELINES Kopal Kotak1; Ayushi Garg1; Pranav Chalasani1; Wadid Sirry1; Zain Kulairi2. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4273295) CASE: A 69-year-old female with hypertension, hyperlipidemia, and pancreatic adenocarcinoma presented with mild abdominal pain and fullness for two weeks. Six weeks prior, she had undergone chemotherapy and radiation therapy, followed by a robotic Whipple procedure with pancreatic duct stent placement and three weeks of post-operative anticoagulation. On admission, she reported postprandial left-sided abdominal pain, fatigue, chills, and poor oral intake. Vital signs revealed a fever of 101.3°F and tachycardia. Labs showed leukocytosis (35.6 Thous/mcL) and elevated transaminases. A CT scan of the abdomen revealed acute occlusive right portal vein thrombosis (PVT) and post-Whipple changes. She was started on a heparin infusion and intravenous piperacillin-tazobactam to manage the thrombus and suspected infection. Although blood cultures showed no growth, systemic signs of infection resolved with antibiotics. The patient was discharged on long-term oral anticoagulation with follow-up imaging planned. IMPACT/DISCUSSION: Portal vein thrombosis (PVT) is a rare yet serious complication following major abdominal surgery, with significant implications for morbidity and mortality. In the context of pancreatic surgeries such as the Whipple procedure, PVT incidence can reach up to 21.2%, underscoring the vulnerability of this population. This case highlights the multifactorial nature of PVT, likely attributed to perioperative anticoagulation insufficiency, vascular manipulation, and extensive dissection near the portal vein during the robotic approach. While robotic surgeries offer minimally invasive benefits, they may inadvertently increase the risk of vascular injury, particularly in oncological procedures involving complex vascular anatomy. Current guidelines emphasize thromboprophylaxis in high-risk patients undergoing oncological surgery, yet they lack specificity for Whipple procedures. This gap in evidence-based recommendations leaves patients at risk of complications like PVT. Early recognition of clinical signs, supported by imaging, is essential for timely management to prevent thrombus progression and embolic events. The resolution of systemic signs of infection with antibiotics in this case further underscores the importance of comprehensive postoperative care, as infection can exacerbate thrombotic processes. This case calls attention to the pressing need for tailored perioperative anticoagulation protocols for individuals undergoing pancreatic surgery.

This case underscores the critical importance of perioperative anticoagulation in preventing and managing PVT following complex surgeries like the Whipple procedure. Developing evidence-based guidelines tailored to pancreatic surgery patients is essential to reduce thrombotic risks while balancing bleeding concerns, ultimately improving patient outcomes. RUPTURED HEPATIC ARTERY PSEUDOANEURYSMS WITH ABDOMINAL COMPARTMENT SYNDROME AND SHOCK – A RARE BUT CATASTROPHIC ADVERSE EFFECT OF NIVOLUMAB AND IPILIMUMAB CHECKPOINT INHIBITOR THERAPY Sharon M. Thomson1; Alexander Yerkan1,3; Daniel Weber1,3; Josephine T. Fisher1; Kelly A. Kieffer1; Kevin Kerin2. 1Internal Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH; 2Rheumatology, Dartmouth Hitchcock Medical Center, Lebanon, NH; 3Dartmouth College Geisel School of Medicine, Hanover, NH. (Control ID #4271397) CASE: A 67-year-old female with anaplastic metastatic thyroid cancer status post total thyroidectomy and nivolumab/ipilimumab immune checkpoint inhibitor (ICI) therapy, internal jugular vein thrombus (on apixaban), and chronic adrenal insufficiency, presented with abdominal pain. An abdominal computed tomography (CT) scan revealed large intrahepatic arterial pseudoaneurysms for which she was transferred to a tertiary care center. On arrival, she was in hemorrhagic shock due to progressive hemoperitoneum. Interventional radiology (IR) performed a mesenteric arteriogram which revealed persistent opacification of the aneurysms necessitating coil embolization of the common hepatic artery. She later underwent emergent decompressive laparotomy for abdominal compartment syndrome resulting from massive transfusion protocol resuscitation. Autoimmune and hepatitis panels sent given the visceral aneurysms were unremarkable except for low C3 and C4 levels for which Rheumatology recommended pulse dose steroids with prolonged taper. On day 5, broad-spectrum antibiotics were started due to intrahepatic air and necrosis on CT. On day 12, IR drained a recurrent hemoperitoneum that grew Escherichia coli and Pseudomonas aeruginosa. The species’ subsequent development of meropenem resistance led to septic shock by day 43 and three drains were needed for source control. Although the patient survived the index hospitalization and was discharged to a rehabilitation facility on day 49, she had seven consecutive, prolonged hospitalizations in the next twenty months. She ultimately passed away after transition to comfort care. IMPACT/DISCUSSION: Although ICIs have been linked to cardiovascular immune-related adverse events (irAEs), the focus has been on inflammatory and ischemic events rather than structural abnormalities. Current literature highlights one report (Pang et al., 2023) which directly associates atezolizumab and bevacizumab with a gastric artery pseudoaneurysm managed with transarterial embolization. We posit that this patient, with low complement levels, developed intrahepatic pseudoaneurysms due to an immune-complex mediated vasculitis syndrome. To our knowledge, this is the first reported association and should be a critical consideration in risk-benefit discussions of ICI therapy.

This case highlights life-threatening irAEs of ICIs in the form of intrahepatic arterial pseudoaneurysms causing hemorrhagic and septic shock. To develop evidence-based guidelines for prophylaxis in patients who receive anti-CTLA4 and anti-PD1 immunotherapies, we need additional studies to identify markers that may predispose patients to developing such complications. As ICIs become ubiquitous in our clinical arena, it is key for internal medicine clinicians to recognize the extensive complications that may arise from its use. SALMONELLA PARATYPHI A IN A TRAVELER TO INDIA Joseph Reitano2; Melanie Prestidge1. 1Hospital Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Medicine, The Ohio State University College of Medicine, Columbus, OH. (Control ID #4271345) CASE: A 40-year-old woman presented with 4 days of fevers 3 weeks after returning from a 1-week trip to India. She reported mosquito bites during her trip but avoided local cuisine and unbottled drinks. She also endorsed new onset, non-bloody diarrhea, which she self-treated with loperamide. Other associated symptoms included fatigue, headache, neck stiffness, and appetite loss. She denies any prophylactic vaccines or treatments before travel. Vitals showed T 99.8 (Tmax 103.2), BP 108/56, HR 85, RR 16. Her exam was largely benign. CBC was notable for downtrending Hgb (14 > 12) and platelets (309 > 133) compared to prior to travel. CRP was 93.79 and LDH was 298. LFTs, haptoglobin, ESR, procalcitonin, and reticulocytes were within normal limits. Malaria blood smears, dengue fever antibodies, and acute hepatitis panel were negative. During her stay, she had ~5 episodes of non-bloody, watery diarrhea daily. Blood cultures drawn were positive for Salmonella species, resistant to fluoroquinolones. Speciation was sent to the Dept. of Health, yielding Salmonella paratyphi A. She was treated with 5 days of ceftriaxone with >24 hours without fevers, decreasing diarrheal episodes, and negative blood cultures. She was discharged to complete a course of oral TMP-SMX. IMPACT/DISCUSSION: Enteric fever is used to describe both typhoid and paratyphoid fever, which are generally clinically indistinguishable. Enteric fever consists of a 1–4 week incubation period followed by gradually increasing fever severity with relative bradycardia. Shortly after, headaches, anorexia, malaise, and diarrhea commonly develop. The classic rose-colored maculopapular rash is typically only seen in 1/3 of cases. Morbidity is notability 10-30% for those with enteric fever, with lower rates in those infected with paratyphoid strains. In the US, ~500 cases of enteric fever are diagnosed per year, with >80% found in recent travelers to endemic areas, commonly South Asia. Paratyphoid fever incidence, especially paratyphi A, has been increasing over the past few decades. Although there are vaccines for typhoid fever, none currently exist for paratyphoid species. In addition, although genomic similarities, current typhoid vaccines don’t confer immunization to paratyphi A. Also, unlike other common transmittable infectious diseases found in South Asia, including dengue, malaria, and hepatitis, there is no prophylaxis to paratyphoid fever. Clinical trials are ongoing for paratyphoid vaccination aimed at decreasing the disease burden.

Enteric fever is rare in America, classically seen in travelers to endemic areas. Although morbidity is lower for paratyphoid fever, an increasing incidence further emphasizes the need for immunization. Enteric fever should be considered in patients returning from endemic areas, regardless of vaccination status. SALMONELLA SEPTICEMIA COMPLICATED BY PROSTHETIC MITRAL VALVE SEWING RING ENDOCARDITIS Fatiah Joseph, Sana Ahmed, Franklyn Fenton. Internal Medicine , New York Presbyterian Brooklyn Methodist Hospital, Brooklyn , NY. (Control ID #4273129) CASE: A 72-year-old male with multiple cardiac comorbidities including a history of rheumatic fever status post mitral and aortic valve replacement and recent history of septic shock secondary to multi drug resistant salmonella bacteremia of unclear source presenting a month later with colicky epigastric pain associated with nausea, vomiting and fevers. Physical examination was significant for a systolic murmur on auscultation of the heart and abdominal tenderness with guarding. Labs showed mild normocytic anemia, thrombocytopenia, hyponatremia, acute kidney injury, direct hyperbilirubinemia and elevated liver enzymes. Blood cultures were positive for salmonella species. TTE showed elevated gradient across the aortic and mitral mechanical prosthesis. TEE revealed a mobile vegetation attached to the mitral prosthetic sewing ring. Cardiothoracic surgery was consulted who deemed the patient as not a surgical candidate considering the patient’s history of multiple valvular surgeries. Decision was made to treat with intravenous antibiotics for 6 weeks followed by lifelong suppressive therapy with oral antibiotics for recurrent bacteremia. Repeat blood cultures showed no growth. The patient continues to improve with no recurrent salmonella bacteremia and has remained asymptomatic for 5 months after discharge. IMPACT/DISCUSSION: Cardiac valve repair and replacement are lifesaving treatments for patients with rheumatic heart disease who need them, however, the prosthetic material can become a nidus for infection. Infective endocarditis is associated with significant morbidity and mortality even with appropriate antibiotic therapy. This is further complicated in the presence of prosthetic valves which often require surgical intervention in addition to antibiotics for superior outcomes. In addition, some patients may require chronic suppressive oral antibiotics after an appropriate intravenous antibiotic course is completed to control infection and prevent complications. There are very few cases reported of prosthetic valve endocarditis caused by salmonella species that was medically managed with chronic suppressive oral antibiotic therapy.

Prosthetic valve endocarditis caused by salmonella species require prompt diagnosis and treatment. Culture sensitive antibiotics therapy must be completed for an appropriate duration and surgical intervention considered for patients who are candidates to improve prognosis. In addition, it is important for clinicians to confirm negative blood cultures after treatment of salmonella bacteremia to prevent complications such as prosthetic valve endocarditis. In cases where patients have prosthetic endocarditis from recurrent salmonella septicemia and are a poor surgical candidate, chronic antibiotic suppression therapy may be considered to control the infection and to reduce mortality, however, close follow up of patients is needed to determine the efficacy of management. SALT IN THE WOUNDS: THE ROLE OF SALT RESTRICTION IN ACUTE DECOMPENSATED HEART FAILURE Conor Rork1; Athina Vassilakis2. 1Medical Education, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 2Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4270019) CASE: A 50-year-old woman with a history of heart failure with reduced ejection fraction, housing instability, and substance use disorder presents with subacute-onset chest pain and shortness of breath. Lower extremity edema and elevated jugular venous pressure on exam were concerning for acute decompensated heart failure (ADHF), with non-ischemic EKG, vascular congestion on chest films, and negative troponin confirming the diagnosis. The treatment team initiated diuresis and ordered a diet with fluid and salt restriction. After her poor response, the team found that the patient, unable to tolerate the newly restrictive diet, supplemented with vending machine items such as sodas, energy drinks, and chips to manage hunger and thirst. Counseling regarding the impact of diet on her disease did not change her dietary behaviors and resulted in conflict with the team. Eventually, the team removed fluid and salt restriction and adjusted treatment for appropriate diuresis. Two days later, she was discharged home with improvement of her symptoms and volume status. IMPACT/DISCUSSION: There remains controversy around dietary intervention in ADHF. While randomized trials are limited, the SODIUM-HF trial and a recent systematic review and meta-analysis suggest that sodium restriction <2g is associated with increased mortality. These diets also cause patients to suffer from increased thirst, as in this vignette. Sodium consumption in excess of 3g, however, does increase the risk of heart failure exacerbation. Despite newer data available, current practice often includes sodium restriction in the treatment of ADHF. This vignette highlights how conflict between patients’ values and management plans produces sub-optimal care. Collaborative approaches such as motivational interviewing have improved medication adherence and response to symptoms for patients with heart failure, and may promote dietary change as shown by the diabetes literature. Exploring exacerbation frequency and utilizing rapid diet screening tools may offer starting points for these conversations with patients. After discharge, this patient was not readmitted for months in part due to the collaborative dietary counseling she received.

Sodium restriction has long played a role in the management of acute decompensated heart failure. However, recent evidence shows that sodium restrictive diets lead to decreased patient quality of life and may increase mortality. A renewed focus on patient-centered, motivational interviewing approaches to dietary behavioral change has the potential to improve hospitalized patients’ experiences and reduce the risk of rehospitalization. SARCOIDOSIS BEYOND THE LUNG: RARE MULTIORGAN INVOLVEMENT INCLUDING BRAIN, BONE, EXOCRINE GLANDS, JOINTS, MUSCLE AND SKIN. Niurka Liranzo Tejera1,2; Shu Min Lao3,4. 1Mount Sinai West Medical Center, New York, NY; 2Mount Sinai Morningside Hospital, New York, NY; 3Rheumatology, Mount Sinai Health System, New York, NY; 4Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4241136) CASE: A 34-year-old African-American female admitted in July 2023 with severe parotid/lacrimal gland swelling, bilateral eye dryness, jaw pain, myalgias, skin nodules, loss of smell and taste and amenorrhea. Physical examination significant for painful/enlarged parotid glands, dry mucous membranes, diffuse arthralgias, bilateral periorbital swelling and multiple skin hypopigmented nodules in arms and back. Laboratory findings significant for ACE 156 U/L, CRP 6.1mg/L, ESR 116mm/hr, Estradiol <24pg/mL, FSH 0.4MIU/mL, LH 0.5MIU/mL, TSH 0.31uIU/mL, and negative SSA/SSB and anti-dsDNA. Imaging with evidence of multiorgan sarcoid involvement and a positive skin biopsy suggestive of sarcoidosis granulomata. The patient was treated with high dose steroids and Mycophenolate Mofetil (which was later discontinued due to oral sores), also required hormone replacement therapy and Levothyroxine due to disease involvement of pituitary gland. More recently Desmopressin was added, as patient developed signs of central diabetes insipidus. Given worsening clinical condition, Infliximab infusion was started with improvement of symptoms. IMPACT/DISCUSSION: The pituitary gland is among the least commonly affected sites in neurosarcoidosis, comprising only 13.6% of cases involving the nervous system. Sarcoidosis affecting the parotid gland remains a rare manifestation. Our patient displayed bilateral involvement, which is considered the least predominant presentation, as unilateral involvement accounts for most cases. Skin involvement has been described as an early finding and requires biopsy. Our patient exhibited lupus pernio with hypopigmented nodules/granulomas. Musculoskeletal involvement in sarcoidosis in uncommon and highly unpredictable, often challenging to diagnose due to its resemblance to other conditions.

Sarcoidosis is a multisystem disease of unknown cause, marked by granuloma formation. Involvement of more than three organ systems is rare, with an unpredictable clinical course. Diagnosis relies on compatible clinical and radiological findings, histological evidence of non-necrotizing granulomas, and exclusion of other causes of granulomatous disease. The multilevel localization of disease in the brain, bone, exocrine glands, muscle, and skin represents rare extrapulmonary manifestations. Isolated involvement of these tissues is exceptionally uncommon, with this specific pattern rarely coexisting with other systemic symptoms. Notably, multiple organ involvement occurs in approximately 20% of cases (three or more organs), 7% (four or more), and 2% (five or more). Various treatment modalities are available, tailored to the affected organs and disease severity. In this case, the patient’s symptoms have improved following Infliximab infusion therapy. SCALING UP OUR UNDERSTANDING OF SKIN DISEASE Mohad Awan, Andrew Bryant. Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. (Control ID #4229983) CASE: This case is a 63 y.o. male with a history of Darier disease, PVD, stroke, HTN, and HLD who presented to OSH for diffuse rash. 10 days ago, he went outside and developed an erythematous eruption on his legs that progressed to involve his head, trunk, and all extremities, covering roughly 80% of BSA. He thinks it is from falling in poison sumac. The rash was painful with 8/10 severity, making ambulation difficult. Pruritis was present but described as not too bad. His Darier disease was diagnosed 10-15 years ago, but he has not received systemic treatment. He does not see a dermatologist. His medications include amlodipine, aspirin, atorvastatin, and clopidogrel. At the OSH he was started on empiric acyclovir, piperacillin-tazobactam, and vancomycin. The physical exam was notable for diffuse, confluent erythroderma and scale on the scalp, trunk, and upper and lower extremities with scattered hemorrhagic crusting, white plaques present on soft palate, and linear red streaking of the right 2nd fingernail with potential V-nicking of the distal nail plate. Dermatology was consulted to evaluate and manage the eruption. Tissue biopsies, swabs, and cultures were obtained. Swabs were positive for HSV-2, and cultures grew GPC and GPR. Biopsy did note mites, but no evidence of scabies. Biopsy was consistent with erythrodermic Darier disease. The diagnosis was made of erythrodermic Darier disease exacerbation complicated by eczema herpeticum and bacterial impetiginization. Treatment with empiric antibiotics and acyclovir for HSV-2 was continued. Acitretin for Darier exacerbation, ivermectin for mites, and topical emollients for symptomatic relief were added. His calcium channel blocker was also discontinued. He had marked improvement in scale and erythema, stably discharged on hospital day 7 with dermatology follow-up. IMPACT/DISCUSSION: Darier disease is a rare autosomal dominant disease with hyperpigmented, keratotic, crusted papules with a greasy texture presenting mainly between the ages of 6 and 20. The distribution of lesions is in the seborrheic areas with involvement of the hands common. The nails show red longitudinal bands and sandwiching of these bands, often with a V-shaped nick at the free margin of the nail. Pruritis is the most common symptom along with malodor and appearance change. All these changes were present in the patient. Common findings not noted in this patient are cobblestone appearance of white papules with central depression in the oral, anogenital or esophageal mucosa. Exacerbations triggers include infection, calcium channel blockers, heat, excess sweating, mechanical irritation, and UV light. Many of these triggers were present in the patient.

In Darier disease, acute exacerbations can present with striking physical exam findings due to a combination of infection, mechanical irritation, and medications. SCARRED FROM THE INSIDE: A CASE OF SCLEROSING MESENTERITIS Miguel Gomez, Kevin Stanko. Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4270899) CASE: This is an 80-year-old female Jehovah’s witness who was admitted to a medicine service for progressive dyspnea in the setting of acute on chronic normocytic anemia. Her labs were notable for anemia with a hemoglobin of 7.3 g/dL (decreased from 8.1 g/dL three months prior). CT abdomen pelvis demonstrated soft tissue thickening and calcifications of the central bowel mesentery concerning for sclerosing mesenteritis complicated by acute on chronic ischemia of the jejunum, superior mesenteric vein (SMV) occlusion and ascites. Gastroenterology performed an upper endoscopy and colonoscopy, which demonstrated LA grade C esophagitis and Cameron erosions without active hemorrhage. IgG4, HIV, celiac serologies, ANA, and ENA were unremarkable. Surgical biopsy was deferred given underlying anemia. She was treated with IV iron sucrose and erythropoietin given she was a Jehovah’s witness and was discharged on proton-pump inhibitor therapy. She was readmitted soon after for worsening anemia, diarrhea, and progressive abdominal swelling. Ascitic fluid studies were consistent with portal hypertension, thought to be secondary to mechanical obstruction of the SMV. Ascitic fluid cultures grew multi-drug-resistant E. coli, for which she completed a course of ertapenem. She was initiated on diuretic therapy for rapidly accumulating ascites and prednisone and tamoxifen for sclerosing mesenteritis. Repeat CT abdomen pelvis following paracentesis demonstrated bowel perforation in the ascending colon with progressive jejunal thickening. She transitioned to comfort care and passed away. IMPACT/DISCUSSION: Sclerosing mesenteritis is a rare, non-neoplastic inflammatory and fibrotic disease affecting the mesentery. Complications include bowel obstruction, obstructive uropathy, chylous ascites, and chronic mesenteric ischemia. There are reports of portal hypertension and ascites secondary to sclerosing mesenteritis, though this is an uncommon complication rarely reported. The pathogenesis is idiopathic but autoimmune disease and multiple abdominal surgeries can increase risk of developing the disease. Although biopsy used to be the definitive way to diagnose, CT abdomen pelvis is more common now due to its less invasive nature. Treatment with prednisone and tamoxifen may be considered due to their antifibrotic properties, though this has not been shown to improve prognosis or prevent progression. Thus, the primary goal of treatment is symptom relief.

1) Sclerosing mesenteritis can sometimes be idiopathic but other causes should be explored including autoimmune disease, infectious causes and trauma. 2) Treatment options include prednisone and tamoxifen due to their antifibrotic properties. However, there is limited data on their ability to improve prognosis. SEEING BEYOND NORMAL IMAGING: A CASE OF RAPID COGNITIVE DECLINE WITH PARANOIA AND VISUAL HALLUCINATIONS Sydney Gropack1,2; Jennifer Kish1,2; Lily Cao1,2; Amanda Klinger1,2. 1Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY; 2Department of Internal Medicine, New York City Health and Hospitals Bellevue, New York, NY. (Control ID #4271160) CASE: A 76-year-old male patient with a past medical history of diabetes, hypertension, metastatic prostate cancer with bony metastases presented to a public hospital with two months of rapidly progressive cognitive decline, paranoia, and auditory/visual hallucinations. 3 months prior to admission he was cognitively intact. 2 months ago, he began to have short-term memory loss, followed by paranoia and auditory/visual hallucinations. He was initially admitted to another hospital 1 month prior to this admission for acute altered mental status. Laboratory work up was negative and a brain MRI showed chronic microvascular changes. Routine EEG demonstrated slowing, concerning for a seizure disorder, for which he was started on levetiracetam. The patient was discharged to subacute rehab with a diagnosis of dementia with behavioral disturbance. Two days later, the patient was sent to our hospital for worsening paranoia and visual hallucinations. He was intermittently agitated or crying but oriented to self. He was a Vietnam veteran and reported seeing hallucinations of friends who had died in the Vietnam War. Physical exam was notable for urinary retention, for which a foley catheter was placed. Labs were unremarkable. Head CT and Brain MRI were negative for acute pathology. Despite treatment for possible UTI, his mental status deteriorated further. Due to the time course of his deterioration (less than 3 months), the decision was made to perform a lumbar puncture. CSF studies showed WBC 35 with 71% lymphocytes, protein of 60, and positive antibody to glial fibrillary acidic protein (GFAP) with a titer of 1:8, consistent with a GFAP astrocytopathy. He was treated with a 5-day course of IV methylprednisolone with improvement. Further work up completed in a subsequent admission found a new colonic adenocarcinoma. IMPACT/DISCUSSION: We present a case of paraneoplastic encephalitis in the setting of known metastatic prostate and new colon cancer. GFAP astrocytopathy is a rare immune-mediated encephalitis first described in 2016 with only several small case series in the literature. This disease is associated with neoplasms (found in over 1/3 of patients) and post-viral infections. While most patients have abnormal MRI findings, up to 20% of MRIs will be normal. Patients have a good response to high dose corticosteroids (70-80%). Our case teaches that autoimmune encephalitis should be on the differential diagnosis of someone presenting with rapidly progressive dementia, and that negative imaging does not rule out the possibility of autoimmune etiologies.

Internists must maintain a high degree of suspicion for alternative diagnoses in rapid onset cognitive decline or psychosis. In patients with active malignancy, consider paraneoplastic encephalitis as a cause of altered mental status, even if imaging findings are negative. Lumbar puncture should be performed for diagnosis as it can change clinical management. SEIZURES IN DISGUISE: A CASE OF HYPERGLYCEMIA AND BILATERAL OCCIPITAL LOBE INVOLVEMENT Jonathon M. Monroe1; Simosenkosi Nkomboni3; Abisola Oso2; Carolyn G. Brooks2; Babar Junaidi2; Annie Massart2. 1Medical Scientist Training Program, Emory University School of Medicine, Atlanta, GA; 2Department of Medicine, Emory University School of Medicine, Atlanta, GA; 3Doctor of Medicine Program, Emory University School of Medicine, Atlanta, GA. (Control ID #4269006) CASE: A 59-year-old female with history of type 2 diabetes mellitus (T2DM) and migraines presented with 1 week of worsening occipital headaches refractory to sumatriptan accompanied by “disco light” visual disturbances in her peripheral visual fields. Glucose upon arrival was 559 mg/dL (HbA1c >14%) with a normal anion gap, and an insulin drip was initiated. Vitals and physical exam were normal except for hypertension and peripheral visual field deficits. Neuro-ophthalmic evaluation noted a left homonymous superior quadrantanopia and a right homonymous inferior quadrantanopia localizing to the bilateral occipital lobes. Magnetic resonance imaging showed no signs of a demyelinating process or abnormal optic nerve pathology but revealed a subtle cortical restricted diffusion in the left occipital lobe. A lumbar puncture produced a negative inflammatory/infectious work-up. Given the stereotyped and recurrent symptoms described by the patient, an electroencephalogram was conducted and detected electroclinical focal seizures in the biposterior region. Levetiracetam was initiated, and the patient’s symptoms resolved. IMPACT/DISCUSSION: Despite inadequate long-term DM management and hyperglycemia upon presentation, it was unclear whether the patient's visual symptoms were attributable to her blood glucose, a distinct etiology (e.g., infectious/inflammatory), or a combination of both. Hyperosmolar hyperglycemia state more commonly results in focal motor seizures than occipital seizures.1,2 Mechanisms associated with hyperglycemia-induced neuro-excitability include disruptions in metabolic/osmotic homeostasis1 and downregulation of Na-K ATPase channels in response to elevated extracellular potassium levels.3 Regardless, neurologic manifestations may serve as a clue of undiagnosed or poorly controlled DM, particularly for those without conventional risk factors. Although her body habitus was unknown at the time of T2DM diagnosis as a young adult, her current healthy BMI (23.9 kg/m2), small waist circumference, and no apparent risk factors lacked the typical phenotype for T2DM. These observations suggest the consideration of monogenic diabetes, which is frequently misdiagnosed as T1DM or T2DM4,5 and remains unexplored as it relates to seizures. However, misdiagnosis of monogenic diabetes may lead to higher rates of complications given the need for genetic variant-specific treatment.6 We hope this case informs providers to consider unique hyperglycemia-induced manifestations and ensure adequate outpatient care—especially in patients with atypical diabetic phenotypes.

● Although common in hyperglycemia, visual disturbances warrant a broad differential diagnosis. ● Hyperglycemia-induced seizures are not restricted to focal motor seizures. ● Atypical diabetic phenotypes should prompt evaluation for monogenic diabetes to guide precise treatment. SEMAGLUTIDE AND THYROID DISORDERS Cecile McGarvey, Celeste M. Newby. Tulane University School of Medicine, New Orleans, LA. (Control ID #4272889) CASE: A 70 y/o man presented with a two-day history of neck swelling. He denied fevers, palpitations, recent weight loss, excessive sweating, or change in bowel movements. He reported a similar episode of neck swelling that resolved spontaneously after a few days and had occurred 2 months prior to current presentation. Past medical history was significant for uncontrolled DMII, HTN, HLD, prior MI, prior CVA, and obesity. Patient denied history of tobacco use or previous radiation therapy. Family history was significant for “throat surgery” in mother, further details unknown to patient. He initially presented hypertensive with BP of 207/101mmHg, pulse 86bpm, RR 20, and temperature of 97.7oF. Patient was breathing comfortably on room air, oxygenation 100%. Physical exam was remarkable for bilateral nodular thyromegaly associated with mild tenderness. Initial lab studies showed TSH 1.28 uIU/mL, free T4 0.66 ng/dL, TSH receptor antibody <1.10 IU/L (WNL), TPO antibodies 1.2 IU/mL (WNL), CRP 0.9 mg/dL, and a largely unremarkable CBC and CMP. CT of the neck demonstrated a heterogeneously enlarged thyroid gland with mass effect on the trachea. US of the thyroid demonstrated bilateral lesions measuring 6.3 x 5.7 x 3.5cm in the right lobe and 7.5 x 5.2 x 6.3cm in the left lobe. TI-RADS risk score was 4, prompting further evaluation with FNA. FNA was negative for malignancy, consistent with diagnosis of nontoxic multinodular goiter. Upon further questioning, patient was taking semaglutide when the original neck swelling episode occurred two months prior to hospital presentation. IMPACT/DISCUSSION: With the rise in prevalence of GLP-1RA medication use, it is important for internists to recognize the less well-known side effects of these medications. There is conflicting data regarding the association between GLP-1RAs and thyroid disorders, specifically medullary thyroid carcinoma. A case-control analysis reported a 58% increased risk of any thyroid cancer and 78% increased risk of MTC specifically with the use of GLP-1RAs. Studies have demonstrated GLP-1R expression in thyroid tissue with a proposed pathway of GLP-1RA induced hyperplasia predisposing to carcinoma. Our patient used semaglutide for three months before discontinuing the medication two months prior to this presentation. With a concurrent metabolic disorder and an unclear family history, it was necessary to rule out thyroid carcinoma with an FNA biopsy. FNA confirmed diagnosis of nontoxic multinodular goiter. This case calls attention to the clinical significance of monitoring thyroid function in patients on GLP-1RAs with risk factors for thyroid pathology.

Given the increasing use of GLP-1RAs, it is important for internists to recognize presentations of their less common side effects including thyroid dysfunction. SERENDIPITOUS PROTECTION? GUAVA TEA IN AN ACCIDENTAL TYLENOL OVERDOSE CASE Veronika Berg1; Prasana Ramesh1; Christine Bryson2. 1Internal Medicine, Baystate Medical Center, Springfield, MA; 2Internal Medicine, Baystate Medical Center, Florence, MA. (Control ID #4273114) CASE: A 60 year old female with past medical history of HTN, type 2 DM and obesity presented with acute onset confusion and serum glucose >500. She endorsed a headache treated with Tylenol, NyQuil, Dayquil and guava leaf tea. Labs showed HAGMA; liver and coagulation panels were normal. Serum APAP was 54. The patient became hypotensive to 68/42 6.5 hours after last known well and was fluid resuscitated. Transaminitis began soon after, when glucose was 200s, and NAC protocol was begun. Serum APAP was 24 about 1.25 hours later. Six hours after transaminitis began, platelet count dropped from 214k to 7k and INR and PT increased; ammonia level was 13, increasing to 35 about 32 hours later. AST peaked at over 12k, ALT at 5.6k and bilirubin at 3.0. AMS slowly resolved and NAC protocol was stopped after 61 hours due to 50% decrease in AST and ALT and INR <2. At discharge, AST was 118, ALT was 920 and INR was 0.6. IMPACT/DISCUSSION: This case emphasizes the necessity of considering all possible events that can lead to liver dysfunction. Her LFT levels were normal when serum APAP was highest. An unexplained hypotensive episode prompted repeat labs showing transaminitis that peaked about 36 hours after last known well (last APAP dose unknown), greater than the 20 hours seen in ischemic hepatitis but less than the 72 hours in APAP-induced hepatitis. A platelet drop can also be seen in severe ALF cases. This suggests perhaps both hypotension and APAP contributed to her liver dysfunction, representing a mixed picture that was noticed due to consideration of liver function after hypotension, not just after significant clinical status change. Her liver injury’s limited severity may in part be due to an interaction between guava leaf and APAP. Guava is used in subtropical regions for ulcers, GI ailments, HTN, HLD, inflammation, pain and as an antiseptic and antioxidant; Japan’s Ministry of Health, Labor and Welfare recommends it for pre-T2DM. APAP overdoses increase reactive oxygen species causing hepatocyte necrosis. Mouse studies show guava leaf decreases hepatic reactive oxygen species and lessens oxidative stress after APAP exposure. Combined, they may have counteracted each other’s effects. This case also shows the importance of patient education. About 70% of American households have APAP and consider it safe despite it causing 46% of all acute liver failure in the United States (2000-3000 annual ALF diagnoses, 30% die within 3 months if no transplant). Nyquil and Dayquil have 325mg APAP, Nyquil Severe is 650mg and Tylenol has 325mg and 500mg options. They warn users to limit APAP but rarely name other sources, possibly contributing to people combining them and achieving our patient’s APAP level. It’s vital to educate patients about the active drugs in OTC medication.

Guava leaf consumption is part of many cultures and may have benefits supported by clinical and mouse studies Educating patients about what is in OTC medications is vital since many do not know how to combine them safely SEVERE AMMONIA ELEVATION IN A CIRRHOTIC PATIENT DUE TO KLEBSIELLA BACTEREMIA Joshua Clason1; Nathan T. Douthit2; Jordan Nickols2; Sameer Khan1. 1Internal Medicine Residency Program, East Alabama Medical Center, Opelika, AL; 2Internal Medicine, East Alabama Medical Center, Opelika, AL. (Control ID #4271720) CASE: A 45-year-old female with PMH of alcoholic cirrhosis, autoimmune hepatitis, ascites, and pyoderma gangrenosum on mycophenolate mofetil and prednisone presented to the emergency department after a fall the prior day. On evaluation, the patient was in significant distress and pain. Initial vitals were significant for tachycardia and tachypnea. Physical exam revealed a jaundiced, obese, middle aged women with significant wounds on her right leg and ecchymosis across the lower abdomen. Presenting labs were pertinent for: bicarbonate 5 mmol/L; anion gap 31; glucose 51 mg/dl; BUN 78 mg/dl; creatinine 4.4 mg/dl; ammonia 300 μmol/L; lactic acid 17 mmol/L; hgb 6.8 gm/dl; plt 78000 mcl; wbc 2200 mcl; INR 3.3; +3 bacteria on UA. Imaging was noncontributory. Fluid bolus was given and piperacillin-tazobactam was started. Two hours after admission, the patient suddenly became hypotensive and was transferred to the ICU. Due to worsening encephalopathy the patient was intubated, antibiotics were changed to vancomycin, cefepime, and metronidazole, and vasopressors were started. Due to worsening ecchymosis on the patient’s abdomen suspicious for purpura fulminans and DIC, additional lab work was performed that showed fibrinogen 40 mg/dl, INR 4.8, D-Dimer 7733 ng/ml, and plts 22000 mcl. Blood cultures returned positive for Klebsiella Pneumonia by rapid PCR. Dilated pupils, unresponsive to light, were then noted which led to concerns of increased ICP and a OBJ repeat ammonia level and mannitol infusion was ordered. The family decided to withdraw care 16 hours after presentation to the ED. Following the withdraw of care, the repeat ammonia was noted to be 1700 μmol/L. IMPACT/DISCUSSION: Ammonia induced encephalopathy occurs in up to 40% of cirrhotic patients. In individuals without cirrhosis, elevated serum ammonia, although uncommon, can be caused by drugs such as valproate and masked urea cycle defects. Infections with urease-producing bacteria, such as klebsiella, can cause encephalopathy or coma in non-cirrhotic patients due to increased ammonia production in the urinary tract. In cirrhotic patients with concurrent urease-producing bacterial infection, hyperammonemia can occur by decreased ammonia conversion due to hepatocellular damage and increased ammonia production due to increased enzymatic breakdown of urea into ammonia by bacterial urease in the urinary tract or theoretically, the blood stream. These mechanisms can lead to a rapidly increasing ammonia level that may appear to be an error. The requirement for ammonia blood samples to be on ice and be processed in a short amount of time are meant to prevent false positive elevations. However, at room temperature, ammonia tends to increase linearly by 5-10 μmol/L and not by the hundreds as seen in our patient.

Rapidly increasing ammonia can be multifactorial in cirrhotic patients. Infections with urease producing bacteria should be considered when assessing encephalopathic cirrhotic patients. SEVERE CHEMOTHERAPY-INDUCED MUCOSITIS IN A PATIENT WITH EXTRAGONODAL PULMONARY YOLK SAC TUMOR: A CASE REPORT Reem Matar1; Rosalyn Marar2; Lionel Aurelien Kankeu Fonkoua2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Hematology and Oncology, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4273342) CASE: A 78-year-old male with a yolk sac tumor of extragonadal pulmonary origin, treated with ACE chemotherapy (dactinomycin/cyclophosphamide/etoposide), presented with dysphagia, dysphonia, and delirium. His medical history includes complete heart block with a biventricular pacemaker, type 2 diabetes, heart failure with mildly reduced ejection fraction, hypertension, chronic kidney disease stage 3, depression, and giant cell arteritis. He was seen in the oncology clinic and diagnosed with mucositis in the setting of chemotherapy-induced neutropenia. Later that day, he was brought into the emergency department (ED) with worsening symptoms and fever to 38.3 °C. Laboratory results revealed severe neutropenia (absolute neutrophil count <0.03 x 109/L), thrombocytopenia (platelets 16x109/L), and mildly elevated creatinine. Blood cultures were positive for gram-positive cocci and gram-negative bacteria. He was started on cefepime for neutropenic fever and fluconazole for possible candidiasis. He was subsequently transferred to Mayo Clinic for further management. Following transfer, blood cultures grew Streptococcus agalactiae and Escherichia coli, thought to be secondary to translocation in the setting of severe mucositis, prompting a switch from cefepime to meropenem. ENT evaluation revealed a right vocal cord nodule and a biopsy of tongue confirmed necrosis of skeletal muscle. Over the course of twenty days, the necrotic tongue tissue detached with healing, and the patient’s symptoms improved. The patient was discharged with close follow-up with both medical and radiation oncology. IMPACT/DISCUSSION: Chemotherapy-induced mucositis (CIM) is a frequent and challenging complication of cancer treatment affecting about 30-40% of cancer patients. CIM can severely impair a patient's quality of life, leading to pain, dysphagia, poor nutrition, and increased risk of aspiration pneumonia. This case highlights the severe complications of CIM, including mucosal necrosis, neutropenic fever, and secondary infections. It underscores the importance of early recognition and intervention in patients at high risk for CIM, particularly those undergoing multi-agent chemotherapy. The translocation of pathogens due to mucosal injury is a key risk factor for life-threatening infections in this population. Effective management requires multidisciplinary care, incorporating oncological, infectious disease, and supportive interventions.

CIM represents a debilitating complication of chemotherapy, particularly in elderly patients with comorbidities. Early intervention and vigilant monitoring are critical to mitigating morbidity and mortality. Further research into preventive and therapeutic strategies for CIM is essential to improving outcomes in this vulnerable population. SEVERE CMV POLYRADICULOMYELOPATHY (PRAM) IN AIDS: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE Noorine Plumber, Abdelrahman Yakout, Zubia Menaaz Ahmed, Phillip Gross, Merin Varghese. Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4272018) CASE: Cytomegalovirus (CMV) polyradiculomyelopathy (PRAM) is a rare condition, affecting individuals with advanced immunosuppression, such as those with acquired immune deficiency syndrome (AIDS). Although precise statistics on CMV PRAM are limited, CMV infections occur in approximately 30-40% of people with untreated AIDS. Among these, neurological complications, including PRAM, account for less than 2-5% of cases. CMV can affect the spinal cord and nerve roots, resulting in bowel and bladder dysfunction, areflexia, sensory loss, and ascending muscle weakness. This case report discusses a 48-year-old female diagnosed with CMV PRAM in the setting of AIDS. She presented with many symptoms including confusion, urinary retention, and generalized weakness. The patient’s medical history was notable for pneumonia treated a month earlier at another hospital. Further examination revealed dysarthria, bilateral lower extremity paralysis, and hypotension. Laboratory evaluations revealed significant hyponatremia, anemia and elevated ferritin. Blood cultures and chest radiographs were normal. Initial imaging, including brain and spine MRI, showed no abnormal findings. A moderately distended bladder was noted on the CT scan. Cerebrospinal fluid (CSF) analysis noted turbid fluid with white blood cell (WBC) of 13,250/uL red blood cell (RBC) of 6,000/uL, protein of 249 g/dL and meningitis/encephalitis panel detected CMV DNA. Further work up led to a diagnosis of HIV, with CD4 count of 4 cells/mm3, and viral load of greater than 3 million copies/mL. Serum CMV viral load was 11,400 IU/mL. As CMV-associated polyradiculopathy was suspected, the patient was started on intravenous (IV) ganciclovir. Due to continued bilateral lower extremities paralysis, saddle hyperesthesia, and urinary retention, a trial of intravenous immunoglobulin (IVIG) and corticosteroids were administered at the guidance of neurologist. Unfortunately, her neurological symptoms did not improve. IMPACT/DISCUSSION: The progressive nature of the patient’s condition despite treatment raises important considerations about the timing and effectiveness of therapeutic interventions for CMV-related neurological diseases in the setting of untreated AIDS. While CMV PRAM has become rare due to the widespread use of antiretroviral therapy (ART), additional research is necessary to develop more effective treatments and improve outcomes for those affected by this severe complication.

This case highlights the rare, but severe complication of CMV PRAM in a patient with untreated HIV/AIDS. The development of CMV PRAM is a rare manifestation commonly seen in severely immunocompromised individuals. The case underscores the challenges of managing advanced AIDS-related complications particularly when neurological involvement is severe and refractory to standard therapies. SEVERE COVID-19 ASSOCIATED MYOCARDITIS SUCCESSFULLY MANAGED WITH HIGH DOSE STEROIDS: A CASE REPORT Abhishek Pant1; Shruti Gupta1; Patrick Kicker1; Barney Soskin2; Lela Ruck1. 1Internal Medicine, Texas Tech University Health Sciences Center El Paso Paul L Foster School of Medicine, El Paso, TX; 2Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX. (Control ID #4241672) CASE: A 74-year-old female with underlying HTN and severe aortic stenosis S/P TAVR presented with epigastric pain radiating to the left jaw. She denied cough, dyspnea, or palpitations. She tested positive for COVID-19 four days prior and was prescribed Nirmatrelvir-Ritonavir. On arrival, she was afebrile, tachycardic, and saturating 95% on room air. On examination, lungs were clear and heart rhythm was irregularly irregular. CXR showed b/l patchy lower lobe infiltrates. EKG revelaed A-fib with a rapid ventricular rate. Pertinent labs on admission showed- BNP 38 pg/ml, high-sensitivity Troponin-I 9108 pg/ml, CRP 23.1 mg/dl, CK 2160 IU/L, IL-6 334.0 pg/ml, Procalcitonin 1.5 ng/ml. Echo and LHC revealed LVEF 50-55% with inferior wall hypokinesis and mild diffuse disease of LAD without significant stenosis, respectively. GDMT for NSTEMI was started along with a 5-day course of Remdesivir and low-dose dexamethasone. Troponin continued rising to a maximum of >25000 pg/ml between day 1 and day 6 along with progressive pleuritic chest pain and dyspnea. By day 3, she developed acute respiratory failure, requiring a high-flow nasal cannula. Therefore, on day 3, low-dose dexamethasone was stopped and switched to a high-dose Methylprednisolone 500 mg/day in divided doses. Following 5 days of treatment, CRP normalized (CRP 3.12 mg/dl), Troponin-I downtrend (Troponin-I 13,000 pg/ml) and she was weaned off the oxygen. She was discharged with a 4-week oral prednisone taper with serial troponin within normal limits upon completion of therapy (Troponin-I 38 pg/ml). IMPACT/DISCUSSION: A CDC study noted a higher prevalence of myocarditis, 150/100,000 in COVID-19 patients versus 9/100,000 in non-COVID patients, from the same timeline. The ACC and ESC advocate for supportive treatment of myocarditis while leaving the use of immunosuppression to expert consensus. Elevated IL-6 and troponin have been strongly and independently associated with increased severity and in-hospital mortality. Alarming lab values and clinical deterioration warranted intervention in our patient. Although the role of immunosuppression in virus-negative myocarditis is well established by the landmark TIMIC trial and a 20-year follow-up of the study, immunosuppression in virus-positive myocarditis is still controversial. Among COVID-19 patients, the RECOVERY trial showed that using dexamethasone was associated with decreased 28-day mortality. A systematic review of 14 case reports of COVID-19-related myocarditis by Sawalha et al. revealed a high survival rate of 85% with steroids. Another review of 18 case reports by Kamarullah et al. reported clinical improvement in 72% of cases using steroids. The dose, duration, and choice of steroid remain physician-dependent.

While the milder forms may respond to supportive treatment, patients with severe acute myocarditis may benefit from immunosuppression therapy. This case advocates for further studies to define the role of immunosuppression in COVID-19-associated myocarditis.SEVERE HYPERBILIRUBINEMIA DUE TO CLENBUTEROL ILLICIT USE: A CASE REPORT Adrian Sarita1; Athena Guo1; Valerie Cluzet2. 1Internal Medicine, Nuvance Health, Lagrangeville, NY; 2Medicine/Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4234308) CASE: A 27-year-old male bodybuilder with no medical history presented with subacute progressive jaundice, nausea, and generalized pruritus. He reported recent clenbuterol use. On presentation, he was hemodynamically stable with good saturation on room air. Physical exam was notable for prominent jaundice and icteric sclerae. The rest of the exam, including abdominal exam, was normal. Initial work up showed total bilirubin of 31.8 mg/dL (direct bilirubin >20 mg/dL), elevated ALT (101 U/L), AST (60 U/L), alkaline phosphatase (160 U/L), mildly elevated creatinine (1.39 mg/dL), normal platelet (294 x10(9)/L), INR (0.9), APTT (32.1 second), PT (11.1 second), and negative viral hepatitis panel. Imaging with ultrasound, CT, and MRI of the abdomen was unrevealing. Additionally, hemolytic panel, EBV panel, CMV and HSV serologies, serologies for autoimmune hepatitis (anti-smooth muscle and anti-mitochondrial antibodies), alpha1 antitrypsin, and ceruloplasmin were all negative. He eventually underwent liver biopsy with findings of mild chronic hepatitis, mild periportal inflammation and focal interface changes, negative for malignancy or fibrosis/cirrhosis. The patient’s nausea and pruritus were treated supportively with hydration, antiemetic, and diphenhydramine. The patient remained hemodynamically stable but had persistent hyperbilirubinemia of 30 mg/dL and persistently mildly elevated transaminases. The care team suggested transfer to a facility capable of liver transplant given that he had a MELD score of 23. However, the patient declined and, unfortunately, left against medical advice. IMPACT/DISCUSSION: Clenbuterol is used primarily as an anabolic and lipolytic agent in livestock husbandry and, for these exact reasons, it is an enticing substance for bodybuilders and athletes. As it is not approved for use in humans, standardized dosing is not available for this substance, so it is difficult to ascertain at which doses adverse effects will occur. The pathophysiology of clenbuterol toxicity is not well understood. Reported adverse effects include cardiovascular toxicity, such as supraventricular tachycardia, atrial fibrillation, myocardial injury, myocarditis, cardiomyopathy, hepatomegaly, hyperglycemia and death.1 Not only has clenbuterol shown cardiac toxicity2, but there have also been case reports showing that jaundice3 and liver congestion were noted on autopsy in patients who used clenbuterol for bodybuilding, and clenbuterol was also present in the post-mortem bile specimen.4 At present, there is no known antidote for clenbuterol toxicity and treatment is supportive.

The anabolic effect of clenbuterol is appealing to bodybuilders and fitness enthusiasts. Unfortunately, its ingestion can lead to potential catastrophic consequences. This case illustrates the sequalae of unregulated clenbuterol abuse, leading to fulminant liver failure. Education and regulation are crucial to prevent such cases. SEVERE HYPERCALCEMIA-INDUCED ACUTE PANCREATITIS IN PRIMARY HYPERPARATHYROIDISM Beatriz Feijo1; Calen Frolkis2. 1Medical Student, Case Western Reserve University School of Medicine, Cleveland, OH; 2Internal Medicine, MetroHealth Medical Center, Cleveland, OH. (Control ID #4260731) CASE: A 34-year-old female presented with a one-week history of chills, myalgias, headache, cough, and lightheadedness. She also reported abdominal pain, poor appetite, vomiting, and diarrhea on the day of admission. Her past medical history included vitamin D deficiency but was otherwise unremarkable. She denied excessive alcohol consumption and had no personal or family history of gallstones, hypercalcemia, hypertriglyceridemia, pheochromocytoma, parathyroid disorders, autoimmune disease, or genetic conditions associated with pancreatitis. On arrival, she was afebrile and well-appearing. Physical examination revealed slight epigastric tenderness without peritonitis and mildly dry mucous membranes, with all other systems unremarkable. Laboratory results revealed a serum calcium level of 16.0 mg/dL, ionized calcium of 1.91 mmol/L, phosphate of 1.4 mg/dL, 25-hydroxyvitamin D level of 13.3 ng/mL, and a lipase of 466 IU/L. A CT scan of the abdomen and pelvis identified acute pancreatitis and right pyelonephritis. The patient was then admitted to the step-down unit and treated with intravenous fluids, calcitonin, and zoledronate. Further diagnostic workup revealed a significantly elevated parathyroid hormone (PTH) level of 189 pg/mL and undetectable parathyroid hormone-related peptide (PTHrP). Her significantly elevated PTH, hypercalcemia, suppressed PTHrP, and negative history for other causes of pancreatitis supported primary hyperparathyroidism as the underlying cause of her acute pancreatitis. IMPACT/DISCUSSION: This case highlights primary hyperparathyroidism (PHPT) as a rare but notable cause of acute pancreatitis. Studies have shown that PHPT accounts for pancreatitis in approximately 0.4% of cases; however, in patients with PHPT and resulting hypercalcemia, the incidence of pancreatitis is significantly higher, occurring 10 to 20 times more often than in the general population. The proposed mechanism is thought to involve hypercalcemia-induced accelerated intrapancreatic conversion of trypsinogen to trypsin, leading to pancreatic damage. This case adds to the existing literature by illustrating an uncommon presentation of PHPT with severe hypercalcemia and pancreatitis. Most cases of PHPT-associated pancreatitis present with a mean serum calcium level of 12.24 ± 2.79 mg/dL, whereas this patient presented with a markedly elevated calcium level of 16 mg/dL. This highlights the variability in clinical presentations of PHPT and the need for a high degree of suspicion to diagnose the condition, particularly in atypical cases.

- Severe hypercalcemia can occur in primary hyperparathyroidism and requires prompt identification and management. - Comprehensive diagnostic evaluation is necessary to rule out other causes of severe hypercalcemia, such as malignancy, to ensure appropriate management. - Acute pancreatitis is a rare but serious complication of severe hypercalcemia that warrants close monitoring and treatment. SEVERE INTERSTITIAL LUNG DISEASE IN ANTI-MDA5 POSITIVE DERMATOMYOSITIS: A CASE OF RAPID DETERIORATION Ozan Soyer1; Hasti Taghados2,1; Ganeem Juneja2,1; Juan F. Martinez Ortega1; Krishna Kishore Anne1; Pamela H. Feliz1; Esther Adedibu1; Nehad Shabarek1. 1Internal Medicine, Lincoln Medical Center, New York, NY; 2Medicine, St George's University, St George's, St George's, Grenada. (Control ID #4217488) CASE: A 66-year-old woman with hypertension, hyperlipidemia, and Chronic Obstructive Pulmonary Disease (COPD) presented with violaceous skin plaques. She reported a 20-pound unintentional weight loss and decreased appetite over the past couple months. On exam, she had violaceous papules on her scalp, thighs, arms, chest, elbows, and legs, with ulcerated lesions on her arms and bilateral upper and lower muscle weakness (4/5). Despite normal creatinine kinase levels, elevated aldolase and a positive anti-MDA-5 antibody suggested dermatomyositis, confirmed by skin and muscle biopsies. She was initially started on prednisone 50 mg daily. During her hospital stay, hypoxia worsened, necessitating increased oxygen support. A CT scan revealed diffuse ground-glass opacities with fibrotic features, raising concern for rapidly progressing interstitial lung disease (ILD). She was treated with intravenous methylprednisolone 500 mg for 3 days, followed by prednisone 50 mg daily, with Bactrim added for Pneumocystis jirovecii pneumonia prophylaxis. Imaging also found a breast mass and thyroid nodules. Her condition rapidly declined, requiring high-flow nasal cannula and additional treatment with cyclophosphamide 500 mg per square meter and tacrolimus 0.075 mg/kg/day. Despite these efforts, she progressed to respiratory failure, requiring intubation and mechanical ventilation. Unfortunately, she succumbed due to respiratory failure unresponsive to standard care. IMPACT/DISCUSSION: Dermatomyositis is a rare idiopathic inflammatory myositis characterized by muscle weakness and distinctive skin rashes. It can be complicated by ILD, especially in the presence of anti-MDA5 antibodies, where despite minimal muscle involvement, it causes severe pulmonary issues. Anti-MDA5-positive dermatomyositis is aggressive and often resistant to standard treatments, with progression leading to respiratory failure and high mortality. Anti-MDA5 antibodies trigger dysregulated immune responses, causing widespread lung inflammation and fibrosis. Early diagnosis and aggressive treatment—using corticosteroids, immunosuppressive agents, or biologic agents—are crucial. Adjunctive therapies, such as intravenous immunoglobulin (IVIG), anti-fibrotic agents, and JAK inhibitors, are emerging options. Anti-MDA5-positive ILD often has poor outcomes, with high hospitalization rates and up to 50% six-month mortality in untreated cases. This case underscores the rapid disease progression despite aggressive treatment, highlighting the need for further research in this field to improve survival and quality of life for these patients

The detection of anti-MDA5 antibodies is crucial for identifying dermatomyositis patients at high risk for rapidly progressive ILD. Given the poor prognosis, a multidisciplinary approach is vital. This case underscores the importance of early diagnosis, aggressive immunosuppressive therapy, and ongoing reevaluation in managing high-risk autoimmune diseases. SEVERE MEDICATION-INDUCED ELECTROLYTE ABNORMALITIES: A CAUTIONARY TALE FOR LONG-TERM PROTON PUMP INHIBITOR USE Kathryn Thompson, Viniya Patidar, Anup Patel. Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4271164) CASE: A 71-year-old female with a history of systolic heart failure and gastroesophageal reflux disease presented with two days of right-sided chest pain and diffuse body cramping. She denied fevers, shortness of breath, abdominal pain, diarrhea, vomiting, tobacco use, alcohol use, and drug use. Her pertinent home medications included furosemide 40 mg every other day and omeprazole 40 mg daily which she had been on for many years. She was afebrile, normotensive, bradycardic with heart rate in the 50’s, and her oxygen saturation was 97% on room air. She had a negative Chvostek sign, normal cardiopulmonary exam other than bradycardia, and an intact neurologic exam. Her initial lab values included sodium 143 mmol/L, potassium 3.4 mmol/L, calcium 6.9 mg/dL (ionized calcium 0.76 mmol/L), magnesium 0.6 mg/dL, and high-sensitivity troponin 8 ng/L. Her electrocardiogram showed sinus rhythm with no ST-T changes. Her electrolytes were repleted and her home omeprazole and furosemide were held which led to electrolyte correction and symptom resolution. Urine electrolyte testing was completed to evaluate renal versus extrarenal electrolyte losses but it was completed after electrolyte repletion. Her fractional excretion of magnesium (FeMag) was 3% (less than 2% is typically indicative of extrarenal losses) and her fractional excretion of potassium (FeK) was 7.4% (less than 10% is indicative of extrarenal losses). Labs for work-up of malabsorption showed she had iron and vitamin B12 deficiency, but her celiac serologies, intrinsic factor antibody, and other vitamin deficiency testing were negative. IMPACT/DISCUSSION: The differential diagnosis for hypomagnesemia, hypokalemia, and hypocalcemia included proton pump inhibitor (PPI) use, diuretic use, or an undiagnosed cause of malabsorption. Hypomagnesemia is known to cause hypokalemia and hypocalcemia, and both hypomagnesemia-induced hypokalemia and hypocalcemia can only be corrected with magnesium repletion. Though her urine electrolyte testing was completed after electrolyte repletion, her FeMag was borderline for determining renal versus extrarenal loss, but FeK was low indicative of extrarenal loss which points to PPI-induced hypokalemia. Given resolution of electrolyte abnormalities with repletion while holding home omeprazole and furosemide, her electrolyte abnormalities were attributed to long-term PPI use with concomitant diuretic use.

This case demonstrates the risk of severe, potentially life-threatening electrolyte abnormalities caused by long-term PPI use, especially when used with diuretics. Urinary electrolyte testing can potentially help determine the etiology of severe electrolyte abnormalities, but clinicians should rely on the patient’s history and medications to help make the diagnosis. SEVERE MUSCLE RIGIDITY IN EHRLICHIOSIS MIMICKING TETANUS: A CASE COMPLICATED BY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) Ester Masati1; Mohammed Menofy2; Vincent Riesgo3; Anna Brady3. 1Internal Medicine, Medical University of South Carolina, Charleston, SC; 2Neurology, Medical University of South Carolina, Charleston, SC; 3Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC. (Control ID #4272402) CASE: A 37-year-old male with hypothyroidism presented to the ED with fever for one week. He endorsed fevers to 104 F, night sweats, myalgias, nausea, emesis and diarrhea. He also noticed reduced urine output. He denied sick contacts, travel, alcohol, or drug use. He lived in a rural, wooded area and noted a possible bug bite. He also had a nail injury to his thumb while working in the attic. In the ED, he was hemodynamically stable, though ill-appearing. No abnormal findings were noted on physical examination. Labs were remarkable for hemoglobin 12.2, platelets 77, creatinine 5.5 from 1.3, lactate 2.6, AST 295, ALT 104, ferritin 115,000, procalcitonin 16.7, ionized calcium 0.56 and CK 5,600. TSH was normal. CT chest revealed opacities concerning for pneumonia and CT abdomen showed splenomegaly. He was admitted to medicine, infectious workup was sent, and vancomycin and cefepime were started. Overnight, the patient was transferred to the ICU for ongoing fevers, hypotension, and new encephalopathy. He developed severe, diffuse, muscular rigidity and spasms with facial grimacing and rising CK to 16,400. Within 24 hours in ICU, he required renal replacement therapy and intubation with brief neuromuscular blockade due to ventilator dyssynchrony from muscle rigidity. Infectious workup was initially unrevealing including blood cultures, urine cultures, HIV, and GI panel. Lumbar puncture was consistent with aseptic meningitis. Infectious Disease was consulted, and doxycycline was added given concern for rickettsial disease. Given tetany on exam and unknown immunization status, he received tetanus immunoglobulin and metronidazole. He was also given IV calcium supplementation. On hospital day nine, Karius returned positive for Ehrlichiosis. Hematology was consulted due to concern for Hemophagocytic Lymphohistiocytosis (HLH), which was confirmed on bone marrow biopsy. IMPACT/DISCUSSION: This patient presented with vague infectious symptoms with rapid clinical deterioration and a negative broad infectious workup. Karius testing, a next-generation sequencing-based assay, was instrumental in identifying Ehrlichia chaffeensis as the infectious agent that ultimately triggered HLH and multiorgan system failure. Tick-borne diseases can be difficult to diagnose due to non-specific presenting symptoms and unreliability of serologic testing. Further complicating the picture in this patient was his severe tetany, raising suspicion for tetanus infection and prompting treatment.

Tick-borne infections can present a diagnostic challenge, making it crucial to maintain a high level of suspicion when patients present with flu like symptoms, recent exposure to wooded areas, and nonspecific lab abnormalities. While mild muscle rigidity can occur in tick-borne illnesses, severe muscle rigidity, spasms, and facial grimacing are more indicative of tetanus, which should remain on the differential due to its high mortality. Karius testing can be helpful when standard infectious workups are inconclusive. SEVERE REFRACTORY HYPONATREMIA IN CIRRHOSIS REQUIRING A NUANCED APPROACH Austin Carlen2; Matthew Yoder2; Philip Huang2,1. 1Internal Medicine, The Ohio State University, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH. (Control ID #4271535) CASE: A 38-year-old woman with a past medical history of alcoholic cirrhosis complicated by ascites with severe hyponatremia (lowest 118 mmol/L) and hepatopulmonary syndrome presented with shortness of breath and volume overload. Imaging revealed pulmonary edema and effusions. This improved with diuretic therapy, but she then developed severe hyponatremia. As she remained volume overloaded on exam, diuresis was continued with 80mg IV furosemide twice daily. The serum sodium level (sodium) initially improved to 134 mmol/L but trended down over several days to 122 mmol/L. At this time, she was now euvolemic on exam. Urine chemistry revealed Na 33 mmol/L, Cl <15 mmol/L, and K 23 mmol/L. In consultation with nephrology, we then started tolvaptan 15mg daily with free water restriction 1.5 L/day. Unfortunately, the sodium remained ~125 mmol/L. Hypertonic 3% saline was then started at 45 ml/hour. This raised the sodium above 130 mmol/L. However, after stopping hypertonic saline, the sodium again began to decline. We then trialed urea 15 grams TID. Sodium then improved above 130 mmol/L. During this hospitazliation, we also discussed urgent liver transplant evaluation given the degree of hyponatremia, but we encounterd significant concerns regarding social support and compliance with medical therapy and follow up care. As we planned for discharge, we encountered one final challenge of affording an outpatient supply of urea due to its OTC status. Fortunately, we were able to wean to once daily dosing which proved affordable. IMPACT/DISCUSSION: Hyponatremia is a common complication of cirrhosis, with 21% of cirrhotic patients having moderate to severe hyponatremia. Treatment can be difficult, and severe hyponatremia (< 120 mmol/L) can cause significant morbidity. Physical exam with serum and urine chemistry testing can guide treatment. Most cases respond to fluid and salt restriction, diuretics, and lactulose; however, in severe or emergent cases, albumin, vaptans and hypertonic saline may be used. Albumin and vaptans are relatively expensive, and vaptan use carries a risk of hepatotoxicity. Urea can be effective with lower overall cost but may have higher out of pocket cost after discharge. Urea also carries risk for hepatic encephalopathy. Finally, referral for liver transplant should be completed in all cases of cirrhosis as the underlying pathophysiology will only progress over time.

Hyponatremia in cirrhosis can be severe and recurrent. Evaluation requires close monitoring of physical exam and serum and urine lab studies. Treatment most often requires lifestyle change with fluid and salt restriction and volume management with furosemide and lactulose. Refractory cases require consideration for liver transplant and may respond to urea. SEVERE THROMBOCYTOPENIA PRESENTING AS AN ATRAUMATIC SUBDURAL HEMORRHAGE IN THE SETTING OF LUPUS Anha Islam1; Aala Dweik1; Virginia Velez Quinones2; Michel Vulfovich2. 1Internal Medicine, Memorial Healthcare System, Hollywood, FL; 2Hematology/Oncology, Memorial Healthcare System, Hollywood, FL. (Control ID #4272790) CASE: A 51-year-old female with a history of SLE, lupus nephritis, ESRD on peritoneal dialysis, and hypertension was admitted for progressively worsening headache, nausea, and vomiting for 1 week. On admission, CT brain revealed an acute subdural hematoma (SDH) on the left cerebral convexity with significant mass effect and a 4 mm midline shift. Laboratory findings showed severe thrombocytopenia (<2 x 103/mm3), pancytopenia (hemoglobin 8.8 g/dL and WBC 3.1 x 103/mm3), and elevated haptoglobin and PTT. B12, folate, anti-PF4, LDH, bilirubin, fibrinogen, and PT/INR were within normal limits. Her Von Willebrand antigen, Factor assays, and flow cytometry were normal. Hematology/Oncology and Neurosurgery were consulted for further management. She was diagnosed with immune thrombocytopenic purpura (ITP), and treatment with IVIG (1g/kg), IV Decadron (40 mg), platelet transfusions, PRBCs, FFP, and cryoprecipitate was initiated. She remained hemodynamically and neurologically stable. Repeat CT scan showed no significant progression of the SDH, and she was discharged on hospital day 3 with a platelet level of 66 x 103/mm3. Ten days later, she returned with headache, nausea, vomiting, and left-sided facial droop. Brain CT an increase in SDH size with a 7 mm left-to-right midline shift. Laboratory results revealed similar values to initial work-up and a platelet count of 12 x 103/mm3. She was admitted to the NICU and received another round of IVIG (1g/kg for 2 days), romiplostim (1 mcg/kg subcutaneously), Decadron, and underwent left middle meningeal artery embolization. She was discharged in stable condition on day 5 with a plan for continued weekly romiplostim and outpatient follow-up. IMPACT/DISCUSSION: SDH in ITP is rare, with limited cases reported in the literature. Unlike traumatic SDH, which often damages brain parenchyma, ITP-related SDH is typically confined to the subdural space, enabling conservative management in stable patients. The pathophysiology involves capillary leakage and microvascular bleeding due to profound thrombocytopenia, with coagulation abnormalities compounding the risk. Management focuses on stabilizing platelet counts and addressing the underlying ITP. Steroids and IVIG, are first line treatments. If bleeding persists or reoccurs, thrombopoietin receptor agonists may be used. Middle meningeal artery embolization also offers a minimally invasive alternative for refractory bleeding in patients who are poor surgical candidates. Surgery is generally reserved for cases with significant mass effect or SDH thickness >10 mm.

This case illustrates the importance of early recognition, multidisciplinary management, and individualized treatment strategies for ITP-associated SDH, especially in patients with comorbid conditions such as SLE. Close monitoring and timely interventions are essential to optimize outcomes. SGLT2-INHIBITOR INDUCED EUGLYCEMIC KETOACIDOSIS IN A NON-DIABETIC PATIENT Sarah Strandholm1,2. 1Internal Medicine, University of South Carolina School of Medicine - Greenville, Taylors, SC; 2Internal Medicine, Prisma Health, Greenville, SC. (Control ID #4229184) CASE: A 72-year-old, non-diabetic (A1c 4.9) male with history of coronary artery disease, atrial fibrillation, new heart failure with reduced ejection fraction (HFrEF), and alcohol abuse presented for acute on chronic encephalopathy after 1 week of GI symptoms and poor appetite. During a previous admission for stroke workup one month prior, he was started on empagliflozin, carvedilol, and sacubitril-valsartan when echo showed EF 20-25%. Vitals were within normal limits, neurologic exam was non-focal, but he was oriented only to self. Labs showed anion gap metabolic acidosis (HCO3 17, anion gap 23), β-hydroxybutyrate 1.8, pH 7.29, and lactate 8.8. Glucose was 155 with normal C-peptide and fructosamine. CT head, infectious workup (CBC, blood cultures, syphilis, HIV), B12, folate, thiamine, TSH, ammonia, UDS, and ethyl alcohol were all normal. Patient received 1 L fluid bolus and was started on D5 + insulin infusion at 150 ml/h for 3.5 hours. He received approximately 2 units of insulin before acidosis resolved, lactate cleared, anion gap closed, and mental status returned to baseline. Empagliflozin was discontinued. IMPACT/DISCUSSION: In 2022, the American Heart Association recommended SGLT2i for treatment of HFrEF based on large clinical trials demonstrating reduced major adverse cardiac events in both diabetic and non-diabetic patients. Euglycemic DKA is a known adverse effect of SGLT2i. Potential triggers include major illness, dehydration, peri-operative states, and acute gastroenteritis. Euglycemic ketacidosis is exceedingly rare in non-diabetic patients taking these medications for heart failure alone. Two other cases have been described in the literature, and each was precipitated by diminished oral intake. Ketoacidosis occurs in the setting of absolute (Type 1 diabetes) or relative insulin deficiency. With SGLT2i use, carbohydrate loss through glucosuria creates relative insulin deficiency, leading to reduced glucose utilization, increased lipolysis, and hepatic ketogenesis. SGLT2i may also reduce renal tubular clearance of ketones and exert natriuretic and osmotic diuretic effects. Our patient’s presentation was less severe than previously documented cases, and lactate contributed to metabolic acidosis. His acidosis and encephalopathy corrected rapidly with fluids and insulin. Although rare, prevalence of SGLT2i-associated euglycemic ketoacidosis in non-diabetic patients will likely increase. In addition to cardiovascular benefit, recent research shows mortality benefit and safety in CKD patients with and without type 2 diabetes. Since introduction to the market, Medicare coverage has increased substantially, and use of SGLT2i is likely to expand.

--Maintain a high index of suspicion for euglycemic ketoacidosis in patients taking SGLT2i presenting with anion gap metabolic acidosis. --It is critical to hold SGLT2i during acute illness or anticipated decrease in oral intake, and to diligently counsel patients about parameters for holding these medications. SHOT THROUGH THE HEART, AND WITHDRAWAL IS TO BLAME - TAKOTSUBO GIVES OPIOIDS A BAD NAME Nikhil R. Gangasani, Amanda Overstreet. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4270652) CASE: A 47-year-old female with history of scleroderma on a chronic opioid pain regimen and pulmonary arterial hypertension on ambrisentan presented to the emergency department with chief complaint of abdominal cramping, nausea, and vomiting. She noted increased use of her home opioid regimen of morphine sulfate 60 mg three times daily with morphine IR 30 mg prn for breakthrough pain over the past week and ran out completely two days prior to presentation. She was found to be hypoxemic to 89%. Physical exam was notable for digital amputation of multiple fingers without JVD and leg swelling. Laboratory evaluation was significant for BNP 2357 pg/mL and high sensitivity troponin 76 ng/L. EKG demonstrated normal sinus rhythm with prolonged QTc at 555 ms. TTE demonstrated newly reduced ejection fraction (EF) of 35% with global LV hypokinesis, worst in the apex, with normal RV function. Her EF on TTE four months prior was 61%. Left heart catheterization was performed 3 days later demonstrating normal coronary arteries. GDMT for HFrEF was started and advanced imaging obtained. Cardiac MRI now showed normal LV function. GDMT was discontinued on discharge and the patient was encouraged to continue treatment for pulmonary hypertension. IMPACT/DISCUSSION: Takotsubo cardiomyopathy is a transient left ventricular dysfunction due to akinesis of left mid-apical segments in the absence of critical coronary artery stenosis. This condition is classically precipitated by intense physical or emotional stress. While the pathophysiology is not completely understood, a surge in catecholamines and resulting sympathetic overstimulation is thought to result in stunning of the myocardium, leading to left ventricular dysfunction with wall motion abnormalities. Abrupt withdrawal of opioids in a patient on chronic therapy, like this patient, can result in a highly adrenergic state due to loss of sympathetic antagonism with cessation of opioid therapy. Common symptoms include tachycardia, altered mental status, nausea, and dyspnea. Diagnostic testing frequently reveals an abnormal EKG with common features being T wave inversions, ST elevations, and QTc prolongation. Elevated troponin, elevated BNP, and reduced ejection fraction on initial echocardiogram are also common. Pharmacological management of opioid withdrawal is the mainstay of therapy although beta-blockers and a2-agonists have also been used. Patients usually recover cardiac function within days to weeks.

Takotsubo cardiomyopathy is an uncommon complication of opioid withdrawal that is transient in nature. The pathophysiology involves catecholamine excess in the setting of an abrupt cessation of opioids, leading to myocardial stunning and transient LV dysfunction. Addressing opioid withdrawal is the mainstay of therapy. Internists should be mindful of the risk and features of Takotsubo cardiomyopathy when treating patients on chronic opioid therapy while being assured that the condition has a good prognosis with management of withdrawal. SILENT INVASION EXTENSIVE PULMONARY TUMOR EMBOLISM FROM HEPATOCELLULAR CARCINOMA Constangela Matos Noboa, Ushna Jawwad Awan. Internal Medicine, Montefiore Wakefield Campus, New York, NY. (Control ID #4272788) CASE: A 65-year-old woman with history of cirrhosis complicated by multifocal HCC, two years post transarterial chemoembolization (TACE) presented with abdominal pain. She did not have respiratory symptoms. Of note, she did not have recommended biannual screening labs and imaging following TACE. Admission labs were notable for elevated liver enzymes: aspartate aminotransferase 448 U/L, alanine aminotransferase 61 U/L, alkaline phosphatase 286 U/L, bilirubin 4.7 mg/dL, alpha-fetoprotein (AFP) 90,466 ng/mL, all significantly increased from prior. CT abdomen/pelvis revealed innumerable hepatic masses, multiple metastatic lung nodules, and tumor thrombosis (TT) of the portal and left hepatic veins extending into the inferior vena cava (IVC) to right atrium (RA). CT chest was then performed, which revealed pulmonary nodules and a filling defect in the distal left main pulmonary artery extending into left lobe and lower lobe proximal segmental branches, representing PTE. Given poor prognosis, palliative chemotherapy was offered. IMPACT/DISCUSSION: HCC is the most common primary liver malignancy. According to the World Health Organization, it is the 4th leading cause of cancer-related death worldwide and has a five-year survival rate of 18%. HCC is characterized by its aggressive nature and propensity for vascular invasion, contributing to its poor prognosis. TT formation in the IVC and RA with PTE is a rare but serious complication, associated with advanced disease and poor prognosis due to limited therapeutic options. There have been only four cases reported in the literature. The risk of vascular invasion is notably higher in cases with larger tumors, with studies reporting incidence up to 82% in patients with tumor diameters exceeding 5 cm and AFP levels greater than 1,000 μg/L. PTE has poor prognosis, with survival typically ranging from three to 12 months. Our patient missed biannual screening and was asymptomatic, demonstrating the consequences of missed screening in high-risk HCC and highlighting the importance of vigilance for this rare fatal complication. Clinicians should maintain a high index of suspicion for PTE, particularly in patients with advanced HCC who are at risk of vascular tumor involvement, even when asymptomatic, as this can significantly impact prognosis and management strategies.

High-risk HCC can be complicated by PTE. Having a high index of suspicion in patients with tumor diameters greater than 5 cm and AFP levels greater than 1,000 μg/L is key for timely diagnosis. Biannual screening is essential for early recognition of new lesions, tumor growth, and complications; missed screening can delay diagnosis of complications, significantly increasing the morbidity and mortality for these patients. SILENT SUSCEPTIBILITY: INFECTIVE ENDOCARDITIS IN A YOUNG MALE WITH AN UNDIAGNOSED BICUSPID AORTIC VALVE Caroline Horne1; Natalie J. Reed2; Nirja Sutaria1; Lindsey Whitesides3. 1Internal Medicine, Atrium Health, Charlotte, NC; 2Internal Medicine, Carolinas Medical Center, Charlotte, NC; 3Atrium Health Carolinas Medical Center, Charlotte, NC. (Control ID #4271663) CASE: A 27 year old male presented with 3 months of night sweats, fatigue, dyspnea, 30-lb weight loss, and a resting heart rate of 120-130 bpm per his smartwatch. He denied fevers, sick contacts, or recent travel, but reported consumption of unpasteurized milk, followed by 3 days of vomiting before symptom onset. His history included a dental cleaning 2 months prior to symptom onset, but no significant medical, surgical, or family history. He denied tobacco, alcohol, or recreational drug use and worked a corporate job with no occupational exposures. He was evaluated by his PCP who noted microcytic anemia and referred him for EGD and colonoscopyp; both were unremarkable. Follow up CT abdomen/pelvis noted splenic infarcts prompting hospital admission. Initial vitals in the hospital included fever of 102°F, blood pressure 110/45, and heart rate of 110 bpm. Physical exam revealed diaphoresis and a diastolic murmur. Labs confirmed microcytic anemia and an otherwise normal CBC, CMP, PT/INR, aPTT, troponin, BNP, TSH, and EKG. Blood cultures were obtained. CT angiogram of the chest was normal. He was started on empiric antibiotics. Given the new murmur, a transthoracic echocardiogram (TTE) was ordered and revealed a bicuspid aortic valve, large aortic valve mass (1.8 cm x 1.5 cm), severe aortic regurgitation with holodiastolic flow reversal, large mass on the anterior mitral valve leaflet, and moderate to severe mitral regurgitation. Blood cultures grew Streptococcus parasanguinis (viridans group). Antibiotics were de-escalated based on susceptibilities. MRI Brain noted multiple tiny acute infarcts of the bilateral posterior subcortical white matter and left thalamus consistent with septic emboli from endocarditis, though the patient had no neurologic symptoms. He underwent mechanical mitral and aortic valve replacements and left atrial appendage occlusion with cardiothoracic surgery. Postoperatively, he was started on warfarin for mechanical valve anticoagulation and discharged with 6 weeks of outpatient parenteral antibiotic therapy. IMPACT/DISCUSSION: This case highlights infective endocarditis in a young patient without clear risk factors apart from an undiagnosed bicuspid aortic valve. The likely sources were dental cleaning or unpasteurized milk. Current guidelines from American Heart Association and European Society of Cardiology do not recommend antibiotic prophylaxis for dental procedures in patients with known bicuspid aortic valves; however, this case raises questions regarding the current prophylactic recommendations.

This patient experienced significant morbidity from indolent endocarditis with septic emboli affecting multiple organs and requiring dual valve replacement. This case underscores the need to consider whether screening for bicuspid aortic valves or revising prophylaxis guidelines could prevent similar outcomes. Additionally, given the association between S. viridans bacteremia and colon cancer, colonoscopy remains an important part of the evaluation. SILENT THREAT: ABDOMINAL AORTIC ANEURYSM RUPTURE IN A FEMALE PATIENT Mumta Essarani1; Gurshan Kaur2. 1Internal medicine, Bayhealth Medical Center, Dover, DE; 2Internal medicine, University of Washington System, Boise, ID. (Control ID #4270369) CASE: A 72-year-old female with history of abdominal aortic aneurysm (AAA) who was discharged earlier in the day for pneumonia, presented back to the ED for lower abdominal pain ongoing for a week. She reported that the non-radiating pain was worse with palpation and was accompanied by diarrhea for the past few days (negative for C. difficile in the last hospitalization). Prior CT abdomen and pelvis showed infrarenal abdominal aortic aneurysm, measuring up to 6.2 cm. She advised to follow-up for AAA upon discharge. Repeat CT imaging during this admission revealed a new retroperitoneal hematoma around aneurysm most prominent at the pancreas level, consistent with rupture. Our patient was taken for an emergent endovascular aneurysm repair. IMPACT/DISCUSSION: Abdominal aortic aneurysm (AAA) is a focal, full-thickness dilation of the aorta that is more than 50% greater than its standard diameter. With dilation, the aortic wall becomes thinner and is susceptible to rupture and life-threatening hemorrhage. The prevalence of AAA in males is approximately 4-8% compared to females with prevalence of 1-1.3%. Women are more likely to have a worse prognosis with rupture secondary to under surveillance. Current guidelines from the Society of Vascular Surgery (SVS), the European Society for Vascular Surgery, and the United States Preventive Services Task Force (USPSTF) include implementing screening by ultrasonography for men aged 65-75 years who have ever smoked. USPSTF reports there is insufficient evidence to assess the balance of benefits and harms of the surveillance for women aged 65-75 years who have smoked. Our patient was not screened by ultrasonography due to insufficient demographic evidence according to USPSTF guidelines. The patient was incidentally diagnosed with AAA during her previous hospital admission. Per surveillance guidelines, surgical consultation was necessary for elective repair since her AAA measured >5.4 cm. Though our patient was advised to follow-up with vascular surgery outpatient, she did not receive in-patient consultation. This case highlights the importance of not only screening appropriate female patients with ultrasonography and close follow-up but also the importance of prompt treatment for AAA in female patients.

1. There is need for review of current screening guidelines for AAA in women with history of smoking. 2. Implementing screening physical examinations for AAA in an outpatient clinical setting for those who do not qualify for ultrasonography. SIMULTANEOUS ACUTE ISCHEMIC STROKE AND INFERIOR STEMI: A CASE OF DOUBLE JEOPARDY Sanjay V. Pujar. Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #4272845) CASE: 37-year-old man presented with right-sided weakness and dysarthria that started two hours ago. On exam, he had right-sided facial droop, numbness in the right upper extremity, and 4/5 strength in the right upper and lower extremities. The National Institute of Health Stroke Scale (NIHSS) score was 4 upon arrival. Blood work was mostly normal, except for HbA1c of 7.8. His LDL was at 136 and total cholesterol at 200. Troponins were normal. A CT scan of the head (CTH) revealed small infarcts in both basal ganglia, while an MRI of the brain showed an acute to subacute infarct involving the left lenticulostriate distribution. Patient denied thrombolysis. Echocardiogram with a bubble study and CTA of the head and neck, were unrevealing. Two hours later, ST elevations were noted in leads II, III, aVF, V4, V5, and ST depression in V2. A multidisciplinary team comprising neurology, cardiology, and critical care specialists reached a consensus that thrombolysis would be the most appropriate choice for this patient. The patient agreed and received tenecteplase. An EKG repeated an hour later showed complete resolution of the prior ST elevations, and his symptoms of stroke also resolved. IMPACT/DISCUSSION: The pathophysiological link between AIS and STEMI lies in their common underlying etiology of atherosclerosis and thrombosis. Atherosclerosis is a systemic disease process that can affect multiple vascular territories, predisposing patients to both cardiovascular and cerebrovascular events. In this case, the patient's risk factors, including smoking, morbid obesity, and abnormal lipid levels, likely contributed to the development of both AIS and STEMI. Thrombolysis with tenecteplase (TNK) was chosen in this case, as the patient was within the time window for thrombolysis and the benefits were deemed to outweigh the risks. The successful outcome in this case underscores the importance of a coordinated and timely approach involving neurology, cardiology, and critical care teams. Communication and collaboration among these specialties are essential for making informed decisions and optimizing patient outcomes. Safety considerations are paramount in the management of acute cardio-cerebral infarction. Careful monitoring for potential complications, such as bleeding, is essential. In this case, repeat imaging studies ruled out bleeding complications, and the patient's symptoms resolved after thrombolysis.

The above unique presentation, termed acute cardio-cerebral infarction, requires a multidisciplinary approach. Thrombolysis was chosen in this case as it e"ectively addresses both emergent conditions, while cardiac catheterization posed a significant risk due to the concurrent stroke. DAPT and a high-intensity statin were initiated to reduce the risk of recurrent events. SLOW BUT DEADLY: MULTIPLE-VALVE ENDOCARDITIS PRESENTING AS BRADYCARDIA AND COMPLETE HEART BLOCK Harsh Jha, James Barefield. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4272381) CASE: A man in his late sixties with a past medical history of coronary artery disease requiring coronary artery bypass grafting, and aortic stenosis requiring prosthetic aortic valve replacement, presented to our Emergency Department with bradycardia. He had been discharged from the hospital recently with antibiotics for a Streptococcus sanguinis blood stream infection that originated from an infected tooth. The patient had completed his antibiotic course of ceftriaxone and had not yet undergone dental extraction. While his fevers and sweats had initially resolved, he continued to have back pain that came in waves and did not localize to any vertebral level. The man denied any history of intravenous drug use. On initial evaluation, the patient was afebrile, normotensive, and bradycardic. Physical examination pertinently revealed a necrotic appearing lower molar, a systolic murmur best heard at the sternal border, and a catheter with no erythema or site breakdown. The patient’s initial lab work showed a mild leukocytosis of 11.6 K/uL, and blood cultures which grew no organisms at five days. Electrocardiography in the emergency department revealed a left bundle branch block and third-degree atrioventricular block. Initial transthoracic echocardiography revealed nonspecific abnormality of the prosthetic aortic valve. A subsequent transesophageal echocardiogram revealed a possible aortic valve abscess in addition to anterior mitral leaflet vegetation consistent with endocarditis. The patient was resumed on intravenous ceftriaxone upon readmission to the hospital. Further evaluation by an Infectious Disease physician resulted in empiric initiation of intravenous gentamicin while awaiting echocardiography. The patient underwent pacemaker implantation two days into admission. Once the diagnosis of multiple-valve endocarditis was confirmed on ultrasonography, evaluation by a cardiothoracic surgeon was obtained. The patient was consented for a possible bypass graft revision, prosthetic aortic valve replacement, aortic root repair, and mitral valve repair or replacement. IMPACT/DISCUSSION: In this clinical vignette, conventional initial diagnostics for endocarditis were negative. A higher degree of clinical suspicion for endocarditis was maintained given the electrocardiography findings and patient risk factors. This led to more invasive testing for endocarditis, which made the diagnosis of multiple-valve endocarditis and cardiac abscess. As such, we were able to obtain cardiac surgery for this patient.

There are few cases reported in the literature of infective endocarditis involving the mitral valve presenting as bradycardia from a third-degree heart block, and increased awareness of these cases may reduce delays in appropriate diagnosis and medical therapy. Multiple-valve endocarditis and prosthetic valve endocarditis have poorer prognoses than single native valve endocarditis, and a higher index of suspicion should be maintained for endocarditis in these patient populations SMELLING A RAT: A CASE OF SUPERWARFARIN TOXICITY Hannah Hugo1; Harleen Sidhu1; Aparna A. Rathnam1; Thanushiree Sivalingam1; Mohamed Abdelghffar1; Oikigbeme Oikeh2. 1Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; 2Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY. (Control ID #4273387) CASE: A 46-year-old man with diabetes mellitus presented with gingival bleeding and hematuria for one week. He had no prior similar episodes or infectious symptoms. He was not taking any medications or alcohol. His family history was unremarkable. Exam revealed gingival bleeding and upper extremity ecchymosis. Initial labs showed hemoglobin of 13.4 g/dL, activated partial thromboplastin time (aPTT) 129 seconds (normal: 25-35 seconds), D-dimer 363 ng/mL (<230 ng/mL), fibrinogen 558 mg/dL (200-393 mg/dL), Factor VIII 397% (50-150%), von Willebrand factor 390% (42-176%) and Factor IX 6.8% (65-150%). Prothrombin time (PT) and INR were unmeasurably high. Additional hemolysis labs and TEG platelet studies were normal. Imaging revealed an occluded left renal artery. After administering 10 mg of IV vitamin K, aPTT decreased to 71.8 seconds, PT to 94.3 seconds, and INR to 8.2. Factors II, VII, and X were also low. Further investigation revealed that the patient had encountered rats in his building, and his landlord frequently applied rat poison to kitchen surfaces. An anticoagulant (AC) poisoning panel was positive for brodifacoum, a superwarfarin used in rodenticides. Initially, the patient received 10 mg of IV vitamin K daily, leading to normalization of INR; however, repeat labs showed an INR rise to 15. He was transitioned to 30 mg of oral vitamin K three times daily, and PT and INR normalized. A repeat AC panel three weeks later still detected brodifacoum, necessitating a gradual taper of vitamin K over months. IMPACT/DISCUSSION: Bleeding disorders can be inherited or acquired. Common inherited causes include Von Willebrand disease and hemophilias. Acquired causes include cirrhosis, AC use, and the development of inhibitory factors of the coagulation cascade due to autoimmune or paraneoplastic processes. Warfarin and superwarfarins inhibit vitamin K epoxide reductase (VKOR), disrupting the synthesis of vitamin K-dependent coagulation factors (factor II, VII, IX, and X, protein C, and protein S). This impairs clotting and increases the risk of spontaneous bleeding. Additionally, they can cause paradoxical thrombosis due to initial reductions in protein C and S, which may explain our patient’s renal artery thrombosis. The AC effect of coumarins can be reversed with vitamin K1 (phytonadione) which bypasses VKOR. Due to brodifacoum’s long half-life (15-62 days) and stronger VKOR binding, patients require significantly higher doses of vitamin K. Our patient initially required 90 mg of vitamin K daily for a week, followed by a slow taper over months. Discharge planning for these cases includes addressing the high cost of vitamin K and ensuring the environment is cleared of rodenticides.

Clinicians should always inquire about potential environmental exposures, such as rodenticides in patients presenting with unexplained bleeding. In cases of suspected AC poisoning, timely vitamin K administration is crucial, with dosages tailored to the patient's INR and clinical status. SOMETHING’S AFOOT: PANCYTOPENIA OF UNKNOWN ORIGIN Shreya Bandlamudi, Rebecca Steinberg, Marcus W. Moses, Dylan M. Baker. Department of Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4273102) CASE: A 23-year-old with no significant past medical history presented to the hospital with 5 days of worsening right foot pain and an overlying bullous lesion. On initial exam, vitals were significant for a temperature of 101.5F and right foot edema and erythema with a 2 cm tense bullae. The patient had no past medical, surgical, social, or family history. He had immigrated from Guatemala 4 years ago and had not seen a doctor regularly. On admission, he was found to have streptococcus bacteremia, pancytopenia, and neutropenic fever of unclear etiology. Labs were otherwise notable for low absolute reticulocytes at 14. Blood smear was normal. CT and MRI of the abdomen and pelvis was negative. After 7 days of antibiotics, repeat blood cultures were negative, and the patient transitioned to an oral antibiotic course. However, the patient continued to have pancytopenia and fevers. A bone marrow biopsy was performed and was consistent with aplastic anemia. Hemoglobin electrophoresis revealed elevated fetal hemoglobin, elevated alpha-feto protein levels, and chromosome analysis revealed an abnormal karyotype with a net gain of 1q consistent with bone marrow clonal neoplasm and Fanconi Anemia. Treatment was initiated inpatient for 4 days with anti-thymocyte globulin infusion and methylprednisone. He was stably discharged to outpatient hematology-oncology on cyclosporine to stimulate bone marrow production. Outpatient chromosomal breakage studies revealed increased chromosome breakage and homozygous BRIP1 mutations—a DNA repair gene—diagnostic of Fanconi Anemia. IMPACT/DISCUSSION: Fanconi Anemia (FA) is a rare inherited bone marrow failure syndrome characterized by improper DNA repair and cell cycle dysregulation. It has variable presentation including congenital anomalies, skin findings (café-au-lait spots), and hematologic manifestations like cytopenias and bone marrow failure (BMF). FA is diagnosed age 6-9 on average, however it can present later in life. FA portends a higher risk of developing other myeloproliferative disorders or hematologic malignancies such as acute myeloid leukemia. This case illustrates the potential of an acute infectious process to unmask FA in the absence of physical manifestations. Because of the long-term and potentially fatal consequences of FA and at times atypical presentation, it is crucial to maintain a broad differential when considering pancytopenia, even in adult patients. This becomes especially important in cases of patients without adequate access to healthcare in childhood, like in this case.

Fanconi Anemia is a chronic diagnosis not exclusive to pediatric populations. It can present variably and without the classic physical findings, so keeping a broad differential is crucial to long-term patient success. SPINAL EPIDURAL HEMATOMA POST CERVICAL EPIDURAL STEROID INJECTION - IDENTIFYING THE RECIPE FOR A POSITIVE PATIENT OUTCOME Krishna R. Suresh2; Ayra Kathuria3; Samir Desai1; Jeffrey T. Bates1. 1Medicine, Baylor College of Medicine, Houston, TX; 2Stanley Medical College, Chennai, TN, India; 3The University of Buckingham Medical School, Crewe, England, United Kingdom. (Control ID #4272831) CASE: The patient is a 48-year-old man with a history of rheumatoid arthritis and degenerative cervical spine disease who presented with severe neck pain, bilateral numbness, and acute lower extremity weakness after a cervical epidural steroid injection (ESI). Initial physical examination showed significant tenderness from C7 to T1. In the left leg, dorsiflexion strength was 2/5 in the foot with loss of fine touch; dorsiflexion strength in the right foot was 1/5. Symptoms worsened rapidly over one hour, with progressive sensory loss, bilateral leg paralysis, and urinary retention. Lab results showed leukocytosis (WBC 15,200/mm3) with normal coagulation studies. Non-contrast computed tomography showed hyperdense fluid in the epidural space, confirming a large hematoma measuring approximately 17.6 cm in length with a maximum thickness of 1 cm from C3 to T2. MRI confirmed an epidural hematoma, and the patient underwent emergent cervical hemilaminectomy (C3-T2) with successful evacuation of the hematoma. Postoperatively, he was monitored in the intensive care unit and given midodrine and norepinephrine to maintain a mean arterial pressure > 85 mmHg. He required catheterization for urinary retention. Over the next week, the patient showed significant neurological improvement; by hospital day 6 he was ambulating independently; by hospital day 7 strength had returned to 5/5 throughout. He was discharged home with the urinary catheter, which was subsequently removed 1 week later. IMPACT/DISCUSSION: ESIs have become increasingly prevalent as a therapeutic intervention for managing spinal pain; over 9 million are performed annually in the United States. Despite their widespread use, ESIs are not without associated risks. Causes of acute neurological deficits post ESI include epidural hematoma, intravascular administration resulting in air emboli and stroke, intrathecal administration, and direct damage to the spinal cord. Late-onset complications include epidural abscess, meningitis, and discitis. Epidural hematomas are rare (1 in 150,000) in healthy patients. They are more common in patients with underlying coagulopathy; use of antiplatelets agents, non-steroidal anti-inflammatory drugs, or anticoagulants; multiple injections; or a history of previous ESIs. In this case, the epidural hematoma was likely caused by puncture of the epidural venous plexus. Rapid detection and intervention were crucial, as studies show that surgical intervention within 12 hours leads to better neurological outcomes. This patient achieved a full recovery without any lasting neurological deficits within 7 days of surgery, highlighting the importance of timely, multidisciplinary care.

This case underscores the importance of vigilant monitoring and prompt response to neurological deficits in patients who undergo spinal procedures. The positive outcomes after complications highlight the critical role of early diagnosis and intervention. SPINAL SCHWANNOMA CAUSING CAUDA EQUINA SYNDROME: A MALIGNANT PRESENTATION OF A BENIGN TUMOR Dhairya Salvi1; Emecheta Ajaero1; Pranav Chalasani1; Vamsi Krishna Lavu1; Ayushi Garg2; Parshva Salvi1; Zain Kulairi3. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI; 3Internal Medicine, Ascension Providence Rochester Hospital, Rochester, MI. (Control ID #4273597) CASE: A 50-year-old male with past medical history of uncontrolled hypertension presented to the hospital for left posterior thigh pain radiating down to the leg with numbness and tingling for the last couple of years, worsening in recent days. He also endorsed difficulty emptying his bladder despite straining for the previous week. On arrival, he was found to have a blood pressure of 260/144 mm Hg and a heart rate of 70bpm. Further exam revealed a positive straight leg test, reduced sensation in the left lower extremity, without any associated extremity weakness or saddle anesthesia, and had urinary retention with a post-void residual volume >900cc. The above features were concerning for spinal cord compression. He was started on intravenous antihypertensive and a Foley catheter was placed. Magnetic resonance imaging revealed an enhancing intradural mass with heterogenous composition adjacent to cauda equina/filum terminale at the level of L4/L5 along with crowding of cauda equina nerve roots from the level of L2/L3 to just above the level of L4/L5. Physical examination along with imaging findings were consistent with early Cuada Equina syndrome. Resection of the intradural extramedullary tumor was performed and the histopathological exam was consistent with Schwannoma IMPACT/DISCUSSION: Spinal Schwannoma is a benign, slow-growing, intradural extramedullary tumor that develops from the nerve sheath of spinal nerve roots and is mostly asymptomatic. Symptoms usually develop when the tumor grows large enough to put pressure on the spinal cord or nearby nerves. Early symptoms are often nonspecific, which include back pain and radicular sensory changes. However once a tumor reaches a critical size, it can cause spinal cord compression and severe neurological deficits which may present as Cauda Equina Syndrome. Therefore, it is crucial that clinicians perform a thorough evaluation of patients with back pain, including magnetic resonance imaging, and are aware of the potential correlation between spinal schwannoma and cauda equina syndrome.

Timely identification and management of a spinal schwannoma that leads to neurological symptoms can enhance patient outcomes. SPLENIC INFARCTION; PFO AS A RARE CAUSE Tabeer T. Ahmed. Internal Medicine, Montefiore Wakefield Campus, New York, NY. (Control ID #4215012) CASE: A 28-year-old woman with a history of Anemia presented to the emergency department with nine days of left upper quadrant (LUQ) abdominal pain, low grade fever, and vomiting. Systemic review was notable for fatigue and palpitations. She denied any trauma, travel history or unusual food intake. There was no personal or family history of venous thromboembolism or prothrombotic disorders. She denied taking any medications at home. Physical exam revealed LUQ tenderness and splenomegaly. A CT Abdomen with IV contrast demonstrated muliple splenic infarcts and hepatosplenomegaly. Labs were notable for a hemoglobin of 6.9 mg/dl and normal PT, PTT. Other autoimmune workup revealed normal complement levels, negative antiphospholipid antibody syndrome screen. Sickle cell disease was also considered and an Hb electrophoresis was done which was normal. Given the hepatosplenomegaly, serologies for HIV, EBV and CMV were sent and were unremarkable. A Transthoracic echocardiogram (TTE) showed no valvular vegetations suggestive of infective endocarditis. Her abdominal pain improved with oxycodone and she was discharged, however, one week later she returned with worsening pain. A TTE with bubble study identified a patent foramen ovale (PFO). The PFO was determined to be the likely cause of the splenic infarct and a PFO closure was performed. IMPACT/DISCUSSION: Splenic infarction is an uncommon condition with various etiologies. A systemic approach is essential to evaluate patients with a splenic infarction. A comprehensive hypercoagulable workup is crucial, including tests for thrombophilias like Protein C & S deficiency and Factor V Leiden mutation. Malignancy, as a hypercoagulable state must be ruled out with age appropriate cancer screening. Hematological disorders like sickle cell disease and myleproliferative disorders should be considered. Moreover, thorough infectious work up should be performed to rule out other causes. Cardioembolic causes, such as atrial fibrillation or infective endocarditis are prevalent in older patients, whereas hematological causes are often found in younger patients. However, this case highlights the importance of considering PFO as a potential etiology in younger patients with unexplained splenic infarction. In our young patient, a PFO was initially overlooked but later identified on a TTE with bubble study. Splenic infarcts arising from PFOs are exceedingly rare. Upon literature review, only four reported cases of splenic infarction were attributed to PFO, most common embolic sites from PFO were the extremities and brain.

Beyond standard evaluations for autoimmune, infectious, and hematologic causes, clinicians should consider PFO as a possible etiology for splenic infarction. Early identification through TTE with bubble can prevent delays in diagnosis, allowing for prompt treatment. Moreover, this case underscores the need to integrate PFO evaluation into diagnostic algorithms for younger patients with splenic infarction. SPLENIC INFARCTION AS THE GATEWAY TO DIAGNOSING ANTIPHOSPHOLIPID SYNDROME Jordan Selep1; Rose Sanchez Rosado1; Ashley Wong2; Mario Pita3; Brenden Cabana1. 1Internal Medicine, The George Washington University, Washington, DC; 2Internal Medicine, The George Washington University Department of Medicine, Washington, DC; 3The George Washington University, Washington, DC. (Control ID #4273457) CASE: We present a 60-year-old female with a past medical history of diabetes mellitus and Graves' disease who presented to the emergency room with progressive, intractable periumbilical pain that radiated to the back for 5 days. On arrival, she was afebrile, hypertensive, tachycardic, and tachypneic. Labs were significant for creatinine of 3.2mg/dL (baseline of 0.7md/dL), anion gap 26mmol/L, and lactic acid 3.3mmol/L. She received fluids with normalization of lactate; however, her anion gap persisted with unknown etiology. Given this presentation, the differential included mesenteric ischemia, obstruction, and euglycemic diabetic ketoacidosis. CT angiogram of the chest, abdomen, and pelvis was negative for any evidence of ischemia or intra-abdominal pathology. Although the patient’s abdominal pain and metabolic acidosis initially improved with intravenous hydration, later in the hospital course, the patient developed new flank pain. A CT abdomen was performed that revealed multiple splenic infarcts and anticoagulation was initiated. This finding prompted the evaluation for cardioembolic, infectious, and coagulopathic disorders as source of the thrombi. A hypercoagulable workup revealed elevated beta2-glycoprotein I (GPI) antibodies and anticardiolipin antibodies, raising suspicion for antiphospholipid syndrome (APS). During a 12-week follow-up, the patient had persistently elevated anti-beta2 GPI IgM and anticardiolipin antibodies, confirming the diagnosis of APS. IMPACT/DISCUSSION: We present a case of APS presenting as splenic infarct. While splenic infarct is an uncommon cause of abdominal pain, when diagnosed, work-up should be broad, with exploration into etiologies including cardioembolic sources, infection, and other hypercoagulable disorders.1 Careful consideration should be given when ordering a hypercoagulable workup in acute thrombosis as results can be falsely positive during periods of acute inflammation. For this reason, serologic testing should be repeated in 12 weeks to confirm the diagnosis and guide appropriate treatment.2 Furthermore, autoimmune diseases are often associated with secondary APS; and although this is most commonly seen with Lupus, it is important to consider the possibility of a less common culprit – Graves' Disease - as seen in this patient.3,4 This case is significant in that it presents splenic infarction as a rare initial manifestation of APS, emphasizing the importance of comprehensive investigation, with special consideration in patients with pre-existing autoimmune disorders.

Splenic infarction is a rare presentation that should prompt a broad workup. The diagnosis of APS can be difficult due to false positive results during periods of acute inflammation but should be considered in patients with thrombosis and known auto-immune diseases including Lupus and Graves' disease. SPONTANEOUS ESOPHAGEAL PERFORATION FOLLOWING WATER INGESTION Brandon Gordon, Essam Rashad. Hospital Medicine, Parkview Health, Fort Wayne, IN. (Control ID #4273438) CASE: A 66-year-old female presented with abdominal pain after drinking water, reporting sharp, stabbing pain radiating between abdomen, back and throat. Computed tomography with angiography (CTA) of the chest showed extensive pneumomediastinum with apparent wall thickening in the esophagus along with edema in the posterior mediastinum. Labs showed leukocytosis of 33k. Barium esophagogram demonstrated extraluminal extravasation of contrast in the distal third of the esophagus, consistent with esophageal perforation complicated by mediastinitis. Treatment was initiated with broad spectrum antibiotics. The patient's hemodynamics remained stable. Interventional gastroenterology performed an upper endoscopy, noting a 4.3 cm esophageal perforation at the gastroesophageal junction (GEJ) with white exudates proximally. Two interrupted sutures were placed endoscopically. While initial intraoperative esophagram showed no extravasation, persistent chest pain prompted repeat imaging showing ongoing leak. Two additional endoscopies were required, with the second showing migrated mattress sutures. Finally, a longer stent with two interrupted sutures achieved successful repair, enabling discharge shortly afterwards. IMPACT/DISCUSSION: Esophageal perforation, also known as Boerhaave syndrome, is a rare yet deadly condition that occurs due to sudden, steep rise of intraesophageal pressure which when combined with negative intrathoracic pressure produces a full thickness tear. Risk factors include malignancy, caustic ingestion, Barrett's esophagus and following balloon dilation of esophageal strictures. The most common anatomical location is at the left posterolateral wall of the lower third. This case highlights how minimal precipitating factors can cause Boerhaave syndrome through sudden increases in intraesophageal pressure. Traditionally, esophageal rupture has been associated with trauma or underlying malignancy. Common presentations like chest pain and vomiting may mimic acute coronary syndrome, esophagitis, perforated ulcer or pulmonary embolism. This case highlights spontaneous rupture as an important consideration in unexplained chest pain, warranting thorough investigation including contrast esophagram.

Although rare, spontaneous esophageal rupture is an important condition to consider in patients presenting with severe chest pain and signs of respiratory distress, as early identification and intervention can be life-saving. A heightened awareness of this diagnosis can lead to more appropriate imaging, prompt consultation with surgical specialists, and better patient outcomes. Serial monitoring and repeat procedures may be necessary despite initial technical success. SPONTANEOUS INTRAMUSCULAR HEMORRHAGE IN ANTI-MDA5 DERMATOMYOSITIS Pooja Parekh1; Ethan Molitch-Hou2. 1Internal Medicine Residency Program, The University of Chicago, Chicago, IL; 2Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4240740) CASE: A 44 year-old male with a history of gout presented with bilateral hand swelling, muscle weakness, fatigue, rash, and shortness of breath. The symptoms progressed over 6 months with new development of a chest wall rash 2 weeks prior to admission. Vitals on arrival are notable for hypoxia to 84% requiring 10 liters of oxygen by nasal cannula but otherwise hemodynamically stable. Physical exam was notable for scattered crackles throughout lung fields, an erythematous maculopapular rash across the chest wall, and heliotrope-pattern rash. CT of the chest had findings suggestive of interstitial lung disease (ILD) associated with mixed connective tissue disease in a non-specific interstitial pneumonia pattern. Initial labs revealed ferritin elevated at 4606 ng/mL, lymphopenia to 640 cells/uL, negative antinuclear antibody, antineutrophil cytoplasmic antibody, rheumatoid factor, and anti-cyclic citrullinated peptide. A myomarker panel was positive for anti-melanoma differentiation-associated protein-5 (MDA5) antibody. He was diagnosed with anti-MDA5 dermatomyositis (DM) with rapidly-progressive ILD and treated with methylprednisolone and tacrolimus. One week into hospitalization, CT Abdomen and Pelvis was notable for a left retroperitoneal hematoma and diffuse intramuscular iliopsoas hemorrhage with layering effect suggestive of active bleeding. The patient developed hemorrhagic shock and unfortunately passed from multiorgan failure. IMPACT/DISCUSSION: Anti-MDA5 DM is a subtype of DM characterized by a unique clinical spectrum of rapidly-progressive ILD, skin manifestations (ulcerations, alopecia, Gottron papules, heliotrope rash, or shawl rash), inflammatory arthropathies, and a lower incidence of muscle involvement compared to other forms of DM. While there are no formal diagnostic criteria or treatment guidelines, serologic testing should be considered in those with rapidly-progressive ILD and notable skin findings. Treatment with a combination of high-dose glucocorticoid, cyclophosphamide, and calcineurin inhibitors has been shown to improve survival and pulmonary function compared to a step-up regimen. Respiratory failure is a common cause of death, but there has been emerging evidence of spontaneous intramuscular hemorrhage as a cause of mortality, with development of deep tissue hemorrhage associated with 50-60% mortality rate in retrospective analyses occurring in the first month after diagnosis. Risk factors for mortality include presence of ILD, elderly age, male gender, anti-MDA5 positivity, lymphopenia, hyperferritinemia, and elevated creatine kinase. The first 4 of these factors have also been associated with spontaneous intramuscular hemorrhage, as well as high dose steroid and heparin use.

This case highlights the clinical features of anti-MDA5 DM as well as a rare complication of spontaneous intramuscular hemorrhage. Early identification of the disease and awareness of leading causes of mortality is prudent to help prolong survival. SPONTANEOUS SUBDURAL HEMATOMA IN RED YEAST RICE-INDUCED LIVER FAILURE Javier Garcia2,1; Benjamin Cipion2; Rafael Aldaya Bourricaudy2; Chengcheng Zheng2,1; John Pennington3,2. 1Department of Anesthesiology, University of Florida, Gainesville, FL; 2College of Medicine, University of Florida, Gainesville, FL; 3Community Health Family Medicine, University of Florida College of Medicine, Gainesville, FL. (Control ID #4273249) CASE: We report a 38-year-old male with hyperlipidemia, gastroesophageal reflux disease, hypothyroidism, obstructive sleep apnea, anxiety, and significant tobacco dependence (10 cigarettes/day and 1 can/day chewing tobacco for 23 years) presented with abdominal pain, pruritus, and dark red urine. He had been taking RYR (2000 mg/day) for three months. Initial laboratory evaluation showed transaminitis (AST 459 U/L, ALT 1492 U/L), hyperbilirubinemia (total bilirubin 3.8 mg/dL, direct bilirubin 2.1 mg/dL), and elevated alkaline phosphatase (248 U/L). Imaging demonstrated splenomegaly and lymphadenopathy. Hepatology recommended cessation of RYR, supportive care, and a liver biopsy, which revealed resolving drug-induced liver injury (DILI). The patient’s symptoms and liver function improved, and he was discharged. Two weeks later, he presented with an excruciating headache, right arm numbness, and dysarthria. A non-contrast head CT revealed a left acute SDH (6 mm without midline shift). Coagulation studies and platelet counts were normal, and the patient denied any trauma. Neurology and hematology evaluations ruled out coagulopathy, vascular anomalies, and other secondary causes, concluding the SDH was spontaneous, likely linked to transient coagulopathy secondary to liver dysfunction from RYR. Neurosurgery performed a craniotomy for hematoma evacuation due to worsening neurological symptoms. Postoperatively, he received supportive care, with resolution of neurological deficits except mild aphasia and right-sided weakness. IMPACT/DISCUSSION: RYR-induced hepatotoxicity mimics statin-induced liver injury, with risks amplified in smokers due to oxidative stress and inflammation. The impaired hepatic synthesis of clotting factors predisposes to spontaneous bleeding. This case underscores the potential for severe complications from unregulated supplement use, especially in patients with risk factors like smoking. The concurrent use of statins or other hepatotoxic agents with RYR further increases the risk of liver failure and coagulopathy. Spontaneous SDH, although rare, is a significant complication associated with severe liver dysfunction.

- Red yeast rice (RYR)-induced hepatotoxicity should be considered in patients presenting with liver dysfunction, particularly those with compounded risk factors like smoking. - Early recognition and a thorough history can prevent complications, such as coagulopathy and spontaneous subdural hematoma (SDH). - Tailored management emphasizing patient education, supplement cessation, and multidisciplinary care is essential for optimal outcomes and quality of life. SPORADIC LYMPHANGIOLEIOMYOMATOSIS PRESENTING AS SPONTANEOUS RECURRENT PNEUMOTHORAX Benjamin J. Lasota1; Robert Madden1; Sulaiman Karim2; George Rodenko4; Rebecca Mantsch5; Barath Rangaswamy3. 1Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Odessa, Odessa, TX; 2school of Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 3internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX; 4Radiology, Medical Center Hospital, Odessa, TX; 5Pathology, Medical Center Hospital, Odessa, TX. (Control ID #4272535) CASE: A 35-year-old white female with a history of allergic rhinitis presented to the ER with dyspnea and right flank pain. She had similar symptoms 3 weeks prior due to a pneumothorax that resolved with a pigtail catheter, and a 2 month history of progressive cough and wheezing. Her vitals were notable for an elevated BP of 133/88 mm Hg and an oxygen saturation of 98% on room air. Physical exam revealed absent breath sounds in the right upper lung field and diminished sounds in the right lung base. A chest x-ray confirmed the pneumothorax, which resolved after a chest tube was placed. A CT scan of the chest showed diffuse thin-walled radiolucencies in the bilateral lung parenchyma suggestive of lymphangioleiomyomatosis (LAM), and subsequent CT of the abdomen and pelvis did not show any renal angiomyolipomas (AML). Serologic studies revealed an elevated VEGF-D and a positive ANA. Due to persisting symptoms, the patient underwent video-assisted thoracoscopic surgery (VATS) for mechanical pleurodesis and lung biopsy. The subsequent pathology report had positive staining with HMB-45, desmin, and podoplanin, which confirmed early-stage LAM. She clinically improved after VATS, and chest x-ray on her 3 week follow up did not show recurrence of pneumothorax. IMPACT/DISCUSSION: LAM is a rare systemic, progressive lung disease that affects mostly women of childbearing age. Congenital cases occur at a younger age with mutations in the TSC1/TSC2 genes, while sporadic cases comprise 60% of LAM patients and occur later in life with fewer complications. As with our patient, sporadic LAM commonly presents with primary spontaneous pneumothorax. On CT chest, findings include bilateral, diffuse, thin-walled, round pulmonary cysts. Further CT imaging of the chest, abdomen, and pelvis should be performed to identify the extent of disease and extrapulmonary manifestations, such as renal AMLs. Serologic studies such as connective tissue disease screen, alpha-1-antitrypsin, serum VEGF-D levels are also recommended. In our patient, early-stage LAM was confirmed based on the pathological specimen after VATS. Management of LAM is multi-disciplinary, and pharmacotherapy includes sirolimus, which is an mTOR inhibitor with anti-proliferative properties. Patient education includes smoking cessation, avoiding air travel, and seasonal vaccinations. Routine imaging and PFTs should be used to monitor disease progression, and a lung transplant can be considered in advanced cases.

Clinicians should consider sporadic LAM in the differential diagnosis of spontaneous pneumothorax in females of childbearing age High Resolution CT is recommended for identifying lung cysts, and a lung biopsy is the gold-standard for definitive diagnosis of LAM Early diagnosis and multifaceted management prevent disease progression SPOTTING THE SYSTEMIC SIGNS: A CASE REPORT ON THE DIAGNOSIS OF AL AMYLOIDOSIS Kathlyn Zhuang. Internal Medicine, Washington University in St Louis, St Louis, MO. (Control ID #4273264) CASE: We report a case of a 59-year-old man who presented to the emergency department with fatigue, orthostasis, weight loss, nausea, vomiting, and diarrhea, who was subsequently diagnosed with systemic AL amyloidosis with GI involvement. His early work up was notable for a positive C. difficile stool toxin, and so his initial symptoms were attributed to volume losses from profuse diarrhea. However, his diarrhea, nausea, vomiting, and weight loss persisted and progressed despite treatment with fidaxomicin. He underwent an EGD and flexible sigmoidoscopy, for which Congo red staining was positive for amyloid. Further work up revealed a peak NT-pro-BNP of 6,920 pg/mL and a urine protein/creatinine ratio of 2,681, raising suspicion for systemic amyloidosis (Mayo stage III). The patient was treated with cyclophosphamide, bortezomib, and dexamethasone but was unable to complete a full course of treatment because of recurrent hospitalizations, and he passed away less than a year after diagnosis. IMPACT/DISCUSSION: AL amyloidosis is a rare disease with only 1,275 to 3,000 cases diagnosed annually in the United States [1]. Commonly affected organs include the heart, GI tract, kidneys, and nervous system. In patients with amyloidosis with GI involvement, the most prominent symptoms are weight loss, followed by diarrhea [2].

Overall, early diagnosis is an important factor in improved survival [3, 4]. Early identification and initiation of treatment for AL amyloidosis is key to favorable patient outcomes; therefore, amyloidosis should be considered in the differential diagnosis for patients with evidence of systemic dysfunction. Sources: 1 Baker KR. Light Chain Amyloidosis: Epidemiology, Staging, and Prognostication. Methodist Debakey Cardiovasc J. 2022 Mar 14;18(2):27-35. doi: 10.14797/mdcvj.1070. PMID: 35414848; PMCID: PMC8932379. 2 Madsen LG, Gimsing P, Schiødt FV. Primary (AL) amyloidosis with gastrointestinal involvement. Scand J Gastroenterol. 2009;44(6):708-11. doi: 10.1080/00365520902783717. PMID: 19242859. 3 Schulman, A., Connors, L. H., Weinberg, J., Mendelson, L. M., Joshi, T., Shelton, A. C., & Sanchorawala, V. (2020). Patient outcomes in light chain (AL) amyloidosis: The clock is ticking from symptoms to diagnosis. European journal of haematology, 105(4), 495-501. 4 Muchtar E, Gertz MA, Kumar SK, Lacy MQ, Dingli D, Buadi FK, Grogan M, Hayman SR, Kapoor P, Leung N, Fonder A, Hobbs M, Hwa YL, Gonsalves W, Warsame R, Kourelis TV, Russell S, Lust JA, Lin Y, Go RS, Zeldenrust S, Kyle RA, Rajkumar SV, Dispenzieri A. Improved outcomes for newly diagnosed AL amyloidosis between 2000 and 2014: cracking the glass ceiling of early death. Blood. 2017 Apr 13;129(15):2111-2119. doi: 10.1182/blood-2016-11-751628. Epub 2017 Jan 26. PMID: 28126928; PMCID: PMC5391625. STEALTHY VIRUS: UNLOCKING THE ENIGMA OF RECURRENT NON-BLEEDING ANEMIA Esravila A. Wibisono, Mabel Lopez, Shahab Jazayeri. Department of Medicine, Saint Mary's Hospital, Waterbury, CT. (Control ID #4273362) CASE: An 88-year-old previously healthy woman was referred to the emergency department for recurrent, significant drops in hemoglobin (Hb) without signs of bleeding. One month prior to admission (PTA), she was found by her primary care physician (PCP) to have Hb of 7.3 g/dL (12-16), a mean corpuscular volume of 97.3 fl, and vitamin B12 level of 104 pg/mL (160-950), treated with high-dose parenteral vitamin B12. Two weeks PTA, she was hospitalized for fatigue and presyncope episodes with an acute drop in Hb to 5.2 g/dL. A fecal occult blood test and computerized tomography scan of the abdomen and pelvis were unremarkable. She was transfused two units of packed red blood cells (PRBCs). Workup, including renal and thyroid function, coagulation profile, iron and folate level, hemolysis panel, babesiosis, Hepatitis B and C serologies, Epstein-Barr Virus, and Human Immunodeficiency Virus, was unremarkable. Colonoscopy and esophagogastroduodenoscopy showed no bleeding source. This admission, her Hb dropped again to 5.7 g/dL with reticulocytopenia of 0.3% (0.5-2.5). Bone marrow biopsy with fluorescent in situ hybridization showed no evidence of myelodysplasia, leukemia, or lymphoproliferative disorders. Upon further questioning, the patient admitted to have self-resolved flu-like symptoms and arthralgia without any skin rash, approximately 1.5 months PTA. Serologies revealed positive Parvovirus B19 IgG of 7.38 and IgM of 1.28. Weekly Hb monitoring and supportive transfusion therapy were initiated for of pure red cell aplasia secondary to parvovirus B19. IMPACT/DISCUSSION: Anemia is a common medical presentation that can be driven by multiple etiologies, including renal failure, gastrointestinal pathologies, malignancies, endocrine disorders, hemoglobinopathies, nutritional deficiency, and hemolysis. Without a clear source, primary bone marrow abnormality like pure red cell aplasia induced by parvovirus-B19 infection should be considered in recurrent anemia with reticulocytopenia. Parvovirus B19 has a direct cytotoxic effect on the erythroid progenitor cells and is primarily transmitted through respiratory droplets. In adults, it is usually self-limiting and presents with flu-like illness. In our case, most likely, the patient was infected by it when she had the newly recognized flu-like symptoms 1.5 months PTA.

Clinicians should be aware that Parvovirus infection is one of the common causes of sudden and recurrent anemia in previously hematologically healthy individuals with intact immunity and no signs of bleeding. Patients should be managed symptomatically until their hematopoiesis is restored, and regular follow-up is vital for detecting recurrence and treating it promptly. STICKY BUGS IN STICKY PLACES: A SEVERE CASE OF INVASIVE PNEUMOCOCCAL DISEASE Shun Toyota1; Keita Hibako1; Wissam Harmouch3; Samuel Stephenson3; Koki Kikuchi2; Tetsuya Hoshi1. 1General Internal Medicine, Teine Keijinkai Byoin, Sapporo, Hokkaido Prefecture, Japan; 2Infectious Diseases, Teine Keijinkai Byoin, Sapporo, Hokkaido, Japan; 3Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX. (Control ID #4271684) CASE: A 41-year-old male with a history of atopic dermatitis presented with five days of fever and debilitating right-sided back pain. He was initially evaluated at an outside hospital, where a full-body CT scan showed no abnormalities, and was discharged. Persistent symptoms led to his transfer to our hospital for further evaluation. On admission, his temperature was 38.4°C, and hemodynamic parameters were stable. Examination revealed tenderness over the right lumbar paraspinal muscles without neurological deficits. Initial laboratory findings showed elevated inflammatory markers, with a white blood cell count of 19×103/μL, C-reactive protein (CRP) of 26.7 mg/dL, and an erythrocyte sedimentation rate (ESR) of 66 mm/hr. MRI demonstrated nonspecific edema in the right paraspinal muscles without infection in the vertebrae or discs. Antibiotics were withheld initially. On hospital day 4, blood cultures identified pan-susceptible Streptococcus pneumoniae, and ceftriaxone was initiated. Repeat imaging revealed destructive arthritis of the L3-L4 facet joint, which was determined to be the primary site of infection, along with an L3-L4 epidural abscess and a paraspinal abscess. Surgical drainage of the abscesses was performed on day 8. The patient completed a six-week antibiotic course (four weeks of intravenous ceftriaxone followed by two weeks of oral amoxicillin) and recovered fully without recurrence. IMPACT/DISCUSSION: This case underscores the importance of recognizing lumbar facet joint septic arthritis as a rare but serious manifestation of IPD. Streptococcus pneumoniae is an uncommon cause of musculoskeletal infections, which are typically associated with respiratory or neurologic presentations. This case highlights the critical need for repeat imaging to identify the progression of infection when initial studies are inconclusive. The successful management of this patient underscores the importance of timely diagnosis and intervention in preventing long-term complications. By considering facet joint infections as a potential origin, clinicians can ensure earlier intervention in similar cases.

1. Recognize lumbar facet joint septic arthritis as a rare but critical presentation of IPD, which can progress to epidural and paraspinal abscesses if not promptly diagnosed and treated. 2. Prioritize repeat imaging in patients with persistent fever and back pain to identify evolving musculoskeletal infections. 3. Maintain a high index of suspicion for atypical presentations of IPD to enable timely diagnosis and treatment. STILL STILL’S DISEASE WITH LEUKOPENIA? A DIAGNOSTIC CHALLENGE IN ADULT ONSET STILL’S DISEASE Adam Alnihmy, Enat Arega, Edward Lee, Katherine Bracamontes. Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4273480) CASE: The patient was a 25-year-old man with a history of positive SSA antibodies and chronic prostatitis presenting with one day of fever, chills, tachycardia, and transient joint pain. He had a two-year history of chronic prostatitis with a recent PICC line placed for IV vancomycin. Patient reported high fevers, a salmon-toned rash, and ferritin >80k ng/mL a year ago. He was seen by rheumatology and work-up revealed only positive SSA antibodies, and his symptoms resolved with NSAIDs. The patient’s initial vitals were T 38.2°C, HR 122, BP 124/82, RR 29 and O2 sat 99% room air. Exam was notable for diaphoresis, sinus tachycardia, and normal joint and skin exam. Initial labs showed WBC 3.31, ESR 9, CRP 0.4, ferritin 435, AST 41, ALT 48. Labs 3 days later showed leukopenia 2.13, ESR 14, CRP 1.4, Ferritin 869, AST 79, and ALT 118 in the setting of worsening fever of 39.4°C, diffuse salmon color rash, and transient arthralgia. Extensive infectious work-up and repeat rheumatologic serologies were unrevealing. Despite leukopenia countering a major Yamaguchi criteria, the constellation of quotidian fevers, diffuse macular rash, transaminitis, and transient arthralgia raised concern for an intermittent AOSD pattern. Dermatology was consulted and a skin biopsy was performed with results consistent with AOSD. IMPACT/DISCUSSION: AOSD is a rare, systemic autoinflammatory condition characterized by recurring high fevers, arthritis, a transient salmon-pink rash, and systemic features such as lymphadenopathy, hepatosplenomegaly, and elevated ferritin. Yamaguchi diagnostic criteria requires ≥ 5 criteria met, with ≥ 2 major criteria and exclusion of infections, malignancies, and other rheumatic diseases. AOSD is inherently challenging due to its nonspecific symptoms and similarity with other conditions. While elevated ferritin in the presence of neutrophilia and quotidian fever is classic, AOSD is a diagnosis of exclusion that requires thorough evaluation to exclude infections, drug reactions, malignancies, and vasculitides. A salmon-pink macular rash also raises suspicion for AOSD. However, it is important to note that skin biopsy findings such as interface dermatitis at the dermal-epidermal junction and lymphocytic vasculitis are also nonspecific and may occur in other conditions including drug reactions, viral exanthems and autoimmune diseases. Nonetheless, the absence of eosinophils, granulomas, or other defining histological markers excluded alternative diagnoses like hypersensitivity reactions or vasculitis syndromes.

While skin biopsy lacks specificity, it remains valuable in narrowing the differential and supporting the clinical suspicion of AOSD. The diagnostic ambiguity of AOSD highlights the need for heightened clinical suspicion and integrating histological findings with the clinical presentation and laboratory data to arrive at the diagnosis. STILL WITH US: AN ATYPICAL PRESENTATION OF MACROPHAGE ACTIVATING SYNDROME IN ADULT ONSET STILL DISEASE Marie Ehrhardt1; Daniel Cooper2; Carlie Stein2. 1The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; 2Medicine, UAB, BIrmingham, AL. (Control ID #4242880) CASE: A 22-year-old female initially presented with encephalopathy with diaphoresis and seizure-like activity. Drug regimen on presentation included anakinra (due to adverse effects of other antirheumatologics) and glucocorticoids. She was intubated until electroencephalography demonstrated no seizures. She was transferred to the floor and discharged on a higher dose of Anakinra with close follow-up. Five days following discharge, she experienced fever, headache, and tremors and returned to the hospital after 5 days. She was found to be in cardiogenic shock secondary to pericardial effusion, and despite maximal efforts, eventually passed away. After extended resuscitation efforts, the patient’s family elected to cease efforts and be with her in her final moments. IMPACT/DISCUSSION: Adult Onset Still Disease (AOSD) is a rheumatologic illness of innate and adaptive immunity comprised of indolent fevers, arthralgias, and a maculopapular rash. Treatment includes glucocorticoids for acute flares, monoclonal antibodies, and immune modulators, such as interleukin antagonists like anakinra. Some flares can lead to macrophage activation syndrome (MAS), a type of hemophagocytic lymphohistiocytosis (HLH). MAS has been found in up to 15-23% of AOSD cases. While MAS is a dangerous sequela of rheumatologic phenomena, there are no official guidelines to steer treatment. The H score is utilized to quantify the patient's possiblity for developing HLH. The H score is a compilation of a patient’s lab values and clinical findings which yield a composite score helpful for assessing the patient's likelihood of HLH.

The patient's H score was 164, suggesting 40-54% probability of HLH, versus 184 on secondary presentation. Possible etiologies of HLH/MAS include inadequate DMARD dosing, undertreatment, inadequate therapy length, illness superimposed on immunosuppression, and malignancy. In pediatric literature, glucocorticoid pulse therapy is the mainstay treatment for MAS, but approximately 50% of adults are unresponsive. Use of the H score served as an aid and decision point in starting high-dose steroids and increasing the dose of anakinra in this patient. This patient’s story highlights the importance of immune-modifying pharmacotherapy, the devastating effects of MAS with rare cardiac tamponade, and honoring a grieving family’s final wishes. STORM-PROOFING TREATMENTS: THE IMPORTANCE OF ALTERNATE ROUTES OF ADMINISTRATION FOR THYROID STORM MEDICATIONS Zoya Khan, Aqeel A. Khanani, Taylor Karns. Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4234758) CASE: A 39-year-old male with untreated hyperthyroidism presented with acute onset dysphagia, right-sided weakness and facial droop. He was in atrial fibrillation with rapid ventricular response (AF with RVR), with heart rates reaching 137 beats per minute (bpm). Physical exam showed facial sensory loss, impaired tongue protrusion and right-sided motor deficits. CT Imaging identified a large middle cerebral artery (MCA) territory infarct with occlusion of the left MCA branch, for which he received tissue plasminogen activator (tPA) for an acute ischemic stroke. The patient failed the swallow evaluation due to neurologic deficits and nasogastric tube (NGT) was contraindicated given the bleeding risk from tPA administration. Further evaluation confirmed thyroid storm, with an undetectable TSH (<0.005 uIU/L), elevated T3 (629.0 ng/dL), T4 (32.2 mcg/dL) and a Burch-Wartofsky score of 50. Unable to tolerate oral therapy and lacking intravenous options, the patient received rectal propylthiouracil (PTU) via foley catheter enema along with rectal potassium iodide and intravenous hydrocortisone. By hospital day 2, he showed marked improvement in clinical status, neurologic function and thyroid hormone levels, with T3 of 175.9 ng/dL, and T4 of 16.1 mcg/dL. After passing a repeat swallow evaluation, he was transitioned to oral methimazole, potassium iodide, and propranolol, and discharged with appropriate follow-up. IMPACT/DISCUSSION: Thyroid storm is a severe, life-threatening exacerbation of hyperthyroidism leading to a hypermetabolic state. It can precipitate arrythmias due increased metabolic demand on the heart, most commonly atrial fibrillation (AF). Treatment strategies, which include oral thionamides to inhibit thyroid peroxidase, should be initiated at the suspicion of diagnosis due to the high mortality rate. This case of thyroid storm, complicated by AF and an acute stroke, required an innovative inpatient approach due to the inability to utilize oral anti-thyroid medications, and unavailability of intravenous or intramuscular preparations. Administration of rectal PTU and potassium iodide allowed effective stabilization, as evidenced by improvements in thyroid function tests and clinical status. This case portrays the need for flexibility within treatment strategies when standard options are impractical, and adds to literature by demonstrating a novel approach to managing thyroid storm.

- Rectal thionamide administration highlights the need to adapt treatments to patient-specific needs in critical situations. - This case shows the importance of using available resources and finding innovative solutions when standard treatments are unavailable. STREP GOES STEALTH: ABSCESS PRECIPITATES WARM AUTOIMMUNE HEMOLYTIC ANEMIA Kush Patel, Dee W. Ford. Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4270354) CASE: An 80-yo man was found to have epidural abscesses from T11-L4 and osteomyelitis/discitis of L2-L3 and started on broad-spectrum antibiotics. He underwent incision and drainage and L1-L5 decompression on hospital day 2. Intraoperative cultures grew Streptococcus anginosus/constellatus/intermedius, so his antibiotics were transitioned to ceftriaxone. On hospital day 6, he acutely decompensated with new onset tachycardia and tachypnea. His hemoglobin dropped to 4.8 g/dL from 7.6, and his platelets decreased to 91,000/cumm from 221,000 the day prior. He had lactate >20 mmol/L, WBC 78,000/cumm (up from 19,000 the day prior), reticulocyte count 13%, AST 7323 U/L (up from 25 on admission), ALT 3747 U/L (up from 16), total bilirubin 7.7 mg/dL (up from 0.6), ferritin 78,408 ng/mL, triglycerides 219 mg/dL, LDH 8150 U/L, haptoglobin undetectable, IL-2 receptor 4622 pg/mL, and CXCL9 6464 pg/mL. Serum and urine protein electrophoresis had no abnormal monoclonal protein signals. Peripheral blood smear was without blasts. Peripheral blood flow cytometry was negative for any abnormal B or T-cell populations. Direct Coomb’s test was positive for IgG and C3D. Serologic evaluation for autoimmune disease was unremarkable with ANA 1:80, negative ENA, negative dsDNA, negative C and P-ANCA. C3 and C4 were low (45.2 and 5.5 mg/dL, respectively). His serum EBV load was 562 IU/mL. SARS-CoV-2, HBV, HCV, and HIV tests were negative. IMPACT/DISCUSSION: Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by fever, cytopenias, organomegaly, and hyperferritinemia. To diagnose HLH, patients need to have 5 of the following: fever, splenomegaly, bicytopenia, hypertriglyceridemia, hemophagocytosis on biopsy, low/absent NK-cell activity, elevated ferritin, elevated soluble IL-2 receptor. Our patient met 4 criteria, but he notably was getting Tylenol which could mask fever. His Hscore, a score for the likelihood of secondary HLH, corresponded to a 40-54% chance of HLH. As far as etiologies, there were no signs of malignancy. His low EBV viral load was thought to be reactive in the setting of critical illness. Serologies for other viruses were negative. Further, he had definitive evidence of warm autoimmune hemolytic anemia (AIHA) with signs of hemolysis, positive direct Coomb’s test, and normal cold agglutin titer. Both HLH and warm AIHA are typically associated with malignancy, autoimmune conditions, or certain viral infections, but our patient did not seem to have any of these. He was treated for warm AIHA with steroids and IVIG. His inflammatory and hemolysis markers improved gradually.

This warm AIHA was most likely secondary to bacterial peri-spinal abscess. While the likelihood of HLH is low, it is still a possible sequala of this patient’s abscess. There have been case reports of Streptococcus infection precipitating HLH, but there are no reported cases found that link Streptococcus anginosus/constellatus/intermedius to any autoimmune hemolytic anemia. STROKE AS THE INITIAL PRESENTATION OF ADVANCED TAKAYASU ARTERITIS Hannah Hugo, Harleen Sidhu, Alexander Conant. Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY. (Control ID #4273293) CASE: A 55-year-old man with no known past medical history presented with left facial droop, left hemiplegia, and dysarthria for over 48 hours. CT of the head showed a right middle cerebral arterial (MCA) ischemic infarct. Patient was not a candidate for thrombolysis or thrombectomy and was treated with dual antiplatelet therapy. During admission, the patient had repeated episodes of orthostatic hypotension refractory to fluids and midodrine. Adrenal insufficiency was ruled out with a cosyntropin stimulation test. The patient was noted to have a difference of 30 mmHg in systolic blood pressure between his upper and lower extremities. Due to concern for bilateral arterial stenosis, whole body CT angiography was obtained. It demonstrated severe stenosis of the great vessels originating from the aortic arch including the right brachiocephalic artery. The imaging confirmed diagnosis of Takayasu arteritis, which was also determined to be the cause of his stroke. Inflammatory markers were negative at that time. Patient was started on monthly infusions of tocilizumab, a monoclonal antibody targeting interleukin-6 receptors. Repeat imaging showed no progression of disease. IMPACT/DISCUSSION: Takayasu arteritis (TA) is a form of granulomatous large-vessel vasculitis affecting the aorta and its large branches. The disease typically manifests in young women; its mechanism and cause are unknown to this day. Important clinical findings are ischemic symptoms of affected organs secondary to arterial stenosis, thrombus formation, and, in rare cases, dissection or ruptured aneurysms. Our patient’s age and gender are atypical for TA. Additionally, stroke as initial presentation of vasculitis is not common. Studies show a prevalence of stroke in only 6-13% in TA patients. In around half of these cases, a stroke led to initial diagnosis of TA. The MCA was the most frequently involved artery. Interestingly, studies report the absence of systemic inflammatory markers in TA patients presenting with stroke, as seen in this patient. The clinical presentation of TA is diverse, and thus a high index of suspicion is needed to avoid misdiagnosis. Atypically in this case, there was no asymmetric blood pressure between the upper extremities. Instead blood pressure was disconcordant at the brachial and femoral sites. Blood pressure should be measured in all limbs when there is suspicion for TA. Exam findings suggesting vascular disease in patients with minimal risk factors should raise suspicion for vasculitis, and blood pressure should be measured in all limbs when evaluating for TA.

TA has a highly variable presentation and may initially manifest as stroke. The diagnosis should be considered in patients with apparent vascular disease, especially those with minimal vascular risk factors. Differential blood pressure readings between the upper and lower extremities may provide an important clue to a vascular abnormality. SUBACUTE COMBINED DEGENERATION OF THE SPINAL CORD SECONDARY TO CHRONIC NITROUS OXIDE ABUSE Ayush Kaushish1; Ginu Kurian1; Brenda Queen2. 1Internal Medicine, Virginia Commonwealth University Department of Internal Medicine, Richmond, VA; 2Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA. (Control ID #4269945) CASE: A 20-year-old female presented to Student Health with one month of numbness and tingling of her hands and feet, unsteady gait, and frequent falls. Her symptoms were not progressive in severity, but were constant and debilitating. She denied dizziness, confusion, gastrointestinal symptoms, rashes, or fevers. Her medical history included ADHD, anxiety, and depression. Her medications included fluoxetine and methylphenidate. Her social history was significant for use of marijuana, cocaine, vape pens, and nitrous oxide (N2O). She denied any family history, including any demyelinating disorders. Patient was sent to the Emergency Department (ED) for further evaluation. In the ED, vital signs were unremarkable and physical examination demonstrated intact, but diminished sensation of bilateral upper extremities up to mid-forearms and bilateral lower extremities up to mid-calves. Her gait was normal and Romberg testing was negative. Labs showed a hemoglobin of 11.7 g/dL, MCV of 95.2 fL, serum vitamin B12 level of 449 pg/mL (normal 213 – 816 pg/mL), and serum methylmalonic acid (MMA) level of 4256 nmol/L (normal 0 – 378 nmol/L). Neurology and toxicology were consulted and expressed concern for vitamin B12 deficiency in the setting of chronic N2O toxicity. Patient was empirically started on 1000 mcg intramuscular (IM) cyanocobalamin. An MRI of the brain and spinal cord was obtained, which showed a long segment of increased T2 signal within the dorsal columns, extending from C2 to T11. This was suggestive of subacute combined degeneration (SCD) of the spinal cord. Patient was discharged with plans to complete 14 days of IM cyanocobalamin, followed by 500 mcg oral vitamin B12 daily until symptom resolution. She was advised to avoid further use of N2O. IMPACT/DISCUSSION: SCD is a neurological disorder primarily caused by vitamin B12 deficiency. Symptoms include paresthesia, gait instability, and weakness. If left untreated, symptoms can become progressive and irreversible. A less frequent cause of vitamin B12 deficiency is chronic N2O use, which is becoming more common, particularly among young adults participating in recreational use. Chronic N2O use can cause a functional vitamin B12 deficiency by creating an inactive form of the vitamin. Serum vitamin B12 level are often within normal ranges. However, other markers such as elevated MMA and homocysteine levels can be used to make the diagnosis.

Clinicians should have a high index of suspicion for vitamin B12 deficiency when evaluating neuropathies. Serum vitamin B12 level is neither a sensitive nor specific test and a normal value has limited diagnostic utility. Elevated homocysteine and MMA levels are useful in making a diagnosis of vitamin B12 deficiency in the setting of N2O toxicity. Prompt treatment of vitamin B12 deficiency is crucial in preventing irreversible and long-term neurological deficits. SUCCESSFUL MEDICAL MANAGEMENT OF A RARE CASE OF EMPHYSEMATOUS GASTRITIS Brian J. Haimerl1; Kathryn M. Welp1; Juan Pablo Arroyo2,1. 1Internal Medicine, Vanderbilt University Medical Center, Nashville, TN; 2Nephrology, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4271092) CASE: A 79-year-old male with a history of type 2 diabetes, coronary artery disease, and atrial fibrillation presented with left lower extremity cellulitis and was started on cefazolin. On hospital day five, the patient developed severe vomiting refractory to anti-emetics. A CT of the abdomen and pelvis (CT A/P) demonstrated gastric distention and large stool burden, but no obstruction. Symptoms improved after a bowel movement. However, on day nine, he became increasingly somnolent and hypotensive, with more nausea and vomiting. A repeat CT A/P with contrast revealed gastric mural gas and marked gastric distention, consistent with emphysematous gastritis, as well as minimal left portal venous gas, but no free air concerning for perforation. He was started on broad-spectrum antibiotics and a full infectious workup was initiated. General surgery was consulted and placed a nasogastric tube for decompression. CT angiogram revealed a patent celiac axis and branch vessels. Overall the patient had a benign abdominal exam and serum lactate remained within normal limits. The decision was made to proceed with medical management and avoid surgery. The patient was started on a proton pump inhibitor and seven day course of piperacillin-tazobactam. His blood cultures remained negative and his diet was advanced as tolerated. On day fourteen, a follow-up CT A/P demonstrated marked improvement in the emphysematous changes. Given risk of perforation, an EGD was deferred to the outpatient setting. The patient was ultimately discharged, having successfully recovered with conservative management. IMPACT/DISCUSSION: Emphysematous gastritis (EG) is a rare and life-threatening condition, with less than 100 reported cases in the literature. It is characterized by gastric intramural air on CT and patients have nonspecific symptoms such as abdominal pain, nausea, vomiting, fever, and chills, but often no signs of an acute abdomen. A range of organisms have been implicated in the pathogenesis of EG, including gram-negative, gram-positive, and candida Sp. Given the rarity of EG, there is limited evidence regarding management. While surgical intervention was previously a pillar of treatment, recently, management has shifted to more conservative measures including bowel rest, intravenous fluids, and broad-spectrum antibiotics, with antifungal use determined on a case-by-case basis. Overall, this shift, as well as earlier recognition, have led to a significant improvement in mortality. This case highlights the vague presentation of EG and demonstrates the successful application of conservative medical management.

- EG has a nonspecific clinical presentation and is associated with high mortality if not detected early - Medical management should be considered as a viable treatment option for EG. SUDDEN CARDIAC DEATH IN CARDIAC AMYLOIDOSIS: A CASE STUDY FOLLOWING TREATMENT INITIATION Natalie J. Reed1; Caroline Horne2. 1Internal Medicine, Carolinas Medical Center, Charlotte, NC; 2Internal Medicine, Atrium Health, Charlotte, NC. (Control ID #4273507) CASE: A 43 year old male presented with two weeks of dyspnea, lower extremity edema, and chest pain. Exam was notable for bilateral 2+ pitting lower extremity edema and jugular venous distension raising concern for heart failure. Further work up revealed mild pulmonary edema and transthoracic echocardiogram (TTE) with left ventricular ejection fracture (LVEF) of 45%, grade 3 diastolic dysfunction, and abnormal average global longitudinal strain pattern with apical sparing. Given the TTE findings and new onset heart failure in a patient with minimal other medical comorbidities, there was concern for cardiac amyloidosis. Cardiac MRI was then completed, showing diffuse subendocardial late gadolinium enhancement of the bilateral ventricles and atria. Further labs revealed an IgG kappa monoclonal protein on immunoelectrophoresis and elevated free kappa light chains with kappa/lambda ratio of 120. Eventually, right heart catheterization with right ventricle biopsy confirmed AL kappa type amyloidosis. The patient was initiated on treatment with daratumumab with close monitoring in the cardiac ICU given extensive cardiac involvement and high risk for arrythmias. A hematopoietic cell transplantation was not pursued due to patient preferences and advanced cardiac and renal involvement. While the initial dose was tolerated well, he had a poor response to monotherapy and an escalated regimen of CyBorD-DARA (cyclophosphamide, bortezomib, and dexamethasone with daratumumab) was initiated in the outpatient setting. Unfortunately, this was following by an out of hospital cardiac arrest two days later and the patient died as a result. IMPACT/DISCUSSION: This case features a patient with AL kappa type cardiac amyloidosis with a fairly classic initial presentation. Tissue biopsy has historically been the gold standard for diagnosis of cardiac amyloidosis, but advancements in echocardiography and cardiac MRI’s have enhanced diagnostic capabilities in these patients. A high index of suspicion in appropriate cases with timely diagnosis can be critical for improvement of outcomes and highlights the importance of awareness of this condition for general medicine practitioners.

Cardiac amyloidosis is a rare but serious cause of new onset heart failure that carries a high morbidity/mortality burden. Nearly half of deaths from cardiac amyloidosis are due to sudden cardiac death. Treatment options are progressing, but this case highlights the risk of adverse outcomes despite high acuity monitoring with initial treatment. SUDDEN LOSS OF CONSCIOUSNESS FOLLOWING PSILOCYBIN INGESTION Fletcher Bell2,1; Marlene Tai1; Joshua Woolley1; Amanda Downey1. 1Psychiatry, University of California San Francisco, San Francisco, CA; 2Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4231522) CASE: Mr. K is a 45yoM with no past medical or psychiatric history who enrolled in a clinical trial evaluating the effects of psilocybin combined with psychotherapy in healthy adults. He was not taking any medications. Mr. K ingested 25mg of psilocybin. Approximately 20 minutes later, while supine, he experienced acute onset dizziness followed by a guttural vocalization and loss of consciousness. He developed generalized rigidity with arching of the back, upward eye deviation, and pallor. No rhythmic movements were observed. After several minutes, he regained consciousness with normal muscle tone. BP was 91/56 mmHg and HR was 60 bpm. He was alert and oriented but fatigued, unable to recall the event. There were no signs of tongue biting or incontinence. He denied chest pain. He was taken to the ED where he received IV fluids and symptomatic treatment for headache and nausea. ECG showed normal sinus rhythm. Initial labs were notable for lactate of 2.3 mmol/L which normalized to 1 mmol/L within a few hours. He spent the remainder of his “trip” in the ED and was discharged home with a provisional diagnosis of syncope. IMPACT/DISCUSSION: Psilocybin-related syncope is documented in recreational settings (Kopra et al.) but remains poorly understood due to its rare occurrence. It is crucial to highlight psilocybin’s lesser-known adverse effects. The most common known side effect of psilocybin ingestion is transient hypertension and tachycardia (Wsol). However, there is a diversity of vascular responses to 5-HT depending on concentration (Wsol). Theoretically, acute hypertension due to activation at 5-HT2A and increased chronotropy due to activation at the 5-HT4 receptor could lessen ventricular filling time and cause decreased CO (Salvucci et al., Wsol). Seizure has been reported following psilocybin ingestion (Kopra et al.), but the patient’s rapid return to neurological baseline is consistent with syncope. Differentiating syncope from seizure can be challenging, but key symptoms help. Syncope's prodrome often includes lightheadedness, nausea, sweating, or visual disturbances, unlike the sensory "aura" (e.g., specific smell or taste) that may precede seizures (Sheldon et al.). Syncope involves brief loss of consciousness with rapid recovery, while seizures involve longer unconsciousness with post-ictal confusion and fatigue (Strickberger et al.). Motor activity in syncope usually has fewer, less rhythmic jerks than the frequent, synchronized jerks in seizures. The "10/20 rule" states fewer than 10 jerks suggest syncope, while over 20 suggest a seizure (Shmuely et al.).

Given the growing interest in psilocybin-assisted therapy, transparency about adverse effects is critical. Strategies for patient safety are essential both to ensuring the responsible implementation of psilocybin therapy in clinical settings and to support people who may need urgent medical attention after recreational use. SUPERIOR MESENTERIC ARTERY SYNDROME UNVEILED- AN UNUSUAL COMPLICATION OF CYCLIC VOMITING SYNDROME IN A YOUNG FEMALE Mazhar Shapoo1,2; Jing Wang3; Anusha McKay4; America Silva5; Amir Iqbal1. 1Internal medicine, Wayne State University, Detroit, MI; 2Detroit Medical Center, Detroit, MI; 3Internal Medicine, Division of Gastroenterology, Wayne State University School of Medicine, Detroit, MI; 4Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 5Internal Medicine, Wayne State University, Detroit, MI. (Control ID #4273357) CASE: A 28-year-old woman with a history of cyclic vomiting syndrome (CVS) diagnosed two years ago, untreated H. pylori infection and GERD presented with a three-day history of worsening epigastric abdominal pain, nausea, and vomiting. She reported multiple episodes of non-bloody, non-bilious emesis, acute weight loss, and decreased oral intake. She denied fever, chills, sick contacts, or recent travel. She reported occasional marijuana use, last used two weeks prior but reports no improvement in symptoms with hot showers. On admission, the patient exhibited signs of dehydration, tachycardia, and her BMI was 19.8. Labs revealed acute kidney injury, anion gap metabolic acidosis, lactic acidosis, and ketonuria, all resolving with intravenous fluids. Urine drug screen was positive for marijuana. CT abdomen and pelvis without contrast revealed an acute SMA angle of 16 degrees, a narrowed aortomesenteric distance, and severe distension of the stomach and proximal duodenum, suggestive of SMA syndrome(SMAS) secondary to mesenteric fat pad loss. Conservative management was initiated, including antiemetics, proton pump inhibitors, and pain control, resulting in symptomatic improvement. Prior EGD from a year before revealed H. pylori gastritis, with unclear treatment status. A repeat EGD showed mild duodenal narrowing without overt obstruction. Biopsies were positive for H. pylori, and bismuth-based quadruple therapy was initiated. An upper gastrointestinal series with small bowel follow-through demonstrated thickened gastric folds but no obstruction; however, the study was limited by pain and emesis. Surgical consultation deemed obstruction unlikely and recommended conservative management. The patient tolerated a full liquid diet with ensure supplementation and was told to advance diet as tolerated. Her home amitriptyline for CVS was restarted. Symptoms resolved, and a regular diet was tolerated prior to discharge. The patient and family received counseling on weight gain and nutritional supplementation, given the likely association of SMAS with weight loss. Cannabis cessation was also advised. IMPACT/DISCUSSION: SMAS secondary to CVS is rare, with limited published cases. Our patient's history of CVS, with monthly symptoms coinciding with menstruation, likely contributed to significant weight loss and subsequent mesenteric fat pad loss, predisposing her to SMAS. Chronic cannabis use and potential cannabis hyperemesis syndrome(CHS) could have further exacerbated symptoms and weight loss. Physicians should be aware of the possibility CVS and CHS leading to SMAS particularly when a patient has significant weight loss or is underweight.

This case underscores the need for heightened awareness of SMAS, especially in patients with CVS who present with nausea, vomiting, and abdominal pain. While CVS management is important, a broader diagnostic approach is necessary to identify and address SMAS promptly. Early recognition and intervention can significantly improve patient outcomes. SUPERIOR OPHTHALMIC VEIN THROMBOSIS IN THE SETTING OF COVID-19 INFECTION AND MRSA BACTEREMIA Robert Vargas1; Shalini Atluri2; Shuvani Sanyal1. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Rush University Rush Medical College, Chicago, IL. (Control ID #4267334) CASE: A 53-year-old female with insulin-dependent type 2 diabetes presented with worsening headache, facial pain, and fevers following an upper respiratory tract infection (URI). Exam found right eye ptosis, chemosis, and pain with right-sided extraocular movements. CT head and subsequent CT orbits showed left maxillary sinus mucosal thickening and slightly enlarged hypoenhancing right superior ophthalmic vein concerning for thrombus. Patient was admitted, and ophthalmology, ENT, and infectious disease were urgently consulted. Infectious work-up was positive for COVID-19, and methicillin-resistant staphylococcus aureus (MRSA) bacteremia. An initial TTE only noted trivial mitral regurgitation. Subsequent TEE revealed small, filamentous vegetations on the mitral valve consistent with infectious endocarditis (IE). Patient was treated with 6 weeks of intravenous vancomycin for MRSA orbital cellulitis complicated by bacteremia and IE. She received prolonged steroids, with dexamethasone to prednisone taper, for partial cranial nerve III and VI palsy. Additionally, she was started on therapeutic anticoagulation with enoxaparin and transitioned to rivaroxaban before discharge for superior ophthalmic vein thrombosis (SOVT). At outpatient follow-up, the patient had marked improvement in her ocular and neurologic symptoms. IMPACT/DISCUSSION: With an incidence of 3 to 4 million cases per year, SOVT is a rare condition. It classically presents in the context of cavernous sinus pathology with facial swelling, unilateral vision loss, and ophthalmoplegia. SOVT has septic and aseptic etiologies including infection, hypercoagulability, and orbital neoplasms. Case reports have described SOVT in patients with hypercoagulability related to COVID-19 infection and in patients with orbital cellulitis. Our patient had multiple risk factors for SOVT including hypercoagulability from COVID-19 infection, superimposed MRSA rhinosinusitis, orbital cellulitis with subsequent bacteremia and endocarditis. This case highlights the multidisciplinary collaboration between ophthalmology, ENT, infectious disease, hematology, and neurology that is necessary to manage risk factors and sequelae of SOVT. Urgent ophthalmologic evaluation is critical to avoid vision-threatening complications. Treatment requires the use of empiric antibiotics and anticoagulation to manage underlying risk factors. Surgical management may be indicated if abscess or sinus disease is present.

This case uniquely demonstrates both septic (MRSA orbital cellulitis and bacteremia) and aseptic (hypercoagulability of COVID-19) etiologies of SOVT, and emphasizes the broad differential that must be considered when evaluating for underlying causes. The low overall incidence and difficulty in identifying an etiology requires the collaborative efforts of multiple consultants to diagnose, evaluate, and treat SOVT. SURPRISE! IT’S TIME FOR A NEW VALVE: LOSS OF CONSCIOUSNESS IN A PATIENT WITH BICUSPID AORTIC VALVE Charissa Bloom, Megan Cavrak, Tanya Nikiforova. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4271316) CASE: A 39-year-old man with a history of coarctation of the aorta, congenital bicuspid aortic valve (BAV), hypertension, stroke, cerebral aneurysm status-post coiling, and seizure history was admitted after an unwitnessed episode of loss of consciousness (LOC) while unloading items from his truck. He completed a 20-hour drive with little fluid intake the day before. He collapsed after experiencing no prodrome and awoke with bowel and urinary incontinence, confusion, and lightheadedness. Exam on presentation revealed normal vital signs and neurologic exam, and a 3/6 systolic murmur. Electrolytes and troponin were normal. CTA chest was negative for PE. MRI brain was normal. EKG and telemetry did not show ischemic changes or arrhythmia. Orthostatic vitals were negative and EEG was normal. TTE revealed preserved EF and severe aortic stenosis (AS) (valve area 0.7cm2, mean gradient 58mmHg). His AS was felt to be the cause of his syncope, so CT surgery evaluated and performed mechanical aortic valve replacement the next week. IMPACT/DISCUSSION: LOC can occur due to seizure and syncope. Seizure and structural neurologic issues were quickly ruled out with brain imaging and EEG. The differential for syncope includes vasovagal, orthostatic, and cardiac causes. Cardiac syncope classically presents with no prodrome, as in this case, while vasovagal and orthostatic syncope often presents with prodromal symptoms. Obtaining TTE is unnecessary for every presentation of syncope. AHA guidelines recommend obtaining TTE as a class IIa recommendation only when valvular disease, hypertrophic cardiomyopathy, or left ventricular dysfunction are suspected immediate causes for syncope, as in this scenario. Patients with BAV should undergo lifelong serial TTEs to monitor the aortic root and valve, and should be educated on how early and rapidly AV disease can progress. Indications for valve replacement in AS include: symptomatic severe high-gradient AS, asymptomatic severe AS with LVEF <50%, and symptomatic low-flow low-gradient severe AS. Options for AV replacement include mechanical and bioprosthetic valves. Patients under 50 experience high lifetime rates of bioprosthetic valve deterioration and typically receive mechanical valves. The role of transcatheter aortic valve implantation (TAVI) for individuals with BAV is being studied. Recent data suggests that the rate of paravalvular leak with TAVI is no different in patients with BAVs and trileaflet valves, thus TAVI may be become a future option.

Structural cardiac causes of syncope should always be considered, even in young patients. TTE should be selectively used in syncope work up. Patients with BAV should be closely monitored with serial imaging, as valvular disease may become severe at an early age requiring aortic root repair or valve replacement. SWALLOWING THE RARE - A UNIQUE PRESENTATION OF NECROTIZING EPIGLOTTITIS Nathan D. Nyanjom, Inae Park. Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4273284) CASE: A 39 year-old man presented with pain in the left jaw and throat for the past two days. His symptoms began at work, and he attributed them to an impacted left wisdom tooth. On his first day of symptoms, he took Ibuprofen which provided some relief. The following day, he woke up with increased pain in the left jaw, along with a fever, cough, neck swelling, drooling, hoarseness and dysphagia. Ibuprofen did not provide relief, and he presented to the hospital. He did not endorse dyspnea, chest pain, palpitations, vomiting, cough or congestion. He denied any sick contacts, or recent dental work. He is an active smoker and heavy drinker of alcohol. He has no significant past medical history and is on no medications. Physical exam showed a swollen anterior neck, with tender anterior lymphadenopathy bilaterally. There was fullness of the submandibular area, with posterior oropharyngeal erythema. There was full range of motion of the neck, with no tonsillar exudates or swelling. Obtained labs showed an elevated white blood count of 26.8 k/uL. Chest X-Ray showed bilateral hazy opacities compatible with edema. CT of the neck showed marked epiglottic edema, thickening, and internal foci of gas that tracked into the body of the epiglottis from the base of epiglottis, suggesting necrotizing epiglottitis. Subsequent flexible laryngoscopy showed an erythematous epiglottitis with significant edema and left-sided purulence. The patient was given IV steroids and started on Vancomycin, Ceftriaxone and Clindamycin, and was admitted to the Intensive Care Unit for observation. Repeat flexible laryngoscopy showed slight improvement with multiple small white plaques, however Diphtheria antitoxoid was found to be in normal range. His white blood cell count continued to normalize, and he was continued on Ceftriaxone and Clindamycin. The Patient’s throat pain improved daily, and after a course of three days, the patient was downgraded to the general medicine floor in stable condition. He was then discharged home one day later on oral Cefdinir and Clindamycin to be taken for ten days. IMPACT/DISCUSSION: Necrotizing epiglottitis (NE) is an even more rare and severe variant of acute bacterial epiglottitis. As of 2018, only seven cases of NE had been reported in medical literature, with six of these cases occurring in immuno-compromised individuals. We present here an immuno-competent patient who was diagnosed with NE, and who was ultimately successfully treated with antibiotics in lieu of surgical intervention. Unique in this case, the causal infectious agent was never identified, as respiratory cultures never resulted. Antibiotics alone proved sufficient in treating this case of necrotizing epiglottitis.

-Necrotizing Epiglottitis should never be excluded from your differential diagnosis, even in the immuno-competent -Broad-spectrum Antibiotics alone can be sufficient in management of NE -Identifying the causal infectious agent, while ideal, is not necessary to treat NE SWALLOW YOUR PRIDE: A CASE REPORT AND REVIEW OF THE DIAGNOSIS, MANAGEMENT, AND MULTIDISCIPLINARY APPROACH TO DEGLUTITION SYNCOPE Huu Bao Huy Pham1; Alec T. Harrington2; Konner Feldhus3; Ernie Arnouts3; Thien-Dang Vu3; Jennifer Adams1. 1School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 2Rocky Vista University College of Osteopathic Medicine, Parker, CO; 3Internal Medicine Residency, National Jewish Health Saint Joseph Hospital, Denver, CO. (Control ID #4255671) CASE: This case involves a 59-year-old Vietnamese-speaking male with hypertension, hiatal hernia, and partial vocal cord paresis who presented with recurrent syncopal episodes, primarily triggered by swallowing liquids of extreme temperatures. Initial evaluations, including CT imaging and an esophagram, showed no structural abnormalities. During hospitalization, telemetry monitoring revealed sinus bradycardia, Mobitz type II AV block, and sinus pauses, particularly during ingestion. Provocation tests confirmed deglutition syncope as bradycardia and asystole were reproducible with ingestion of hot or cold fluids. A video fluoroscopic swallow study ruled out aspiration or anatomical anomalies. Electrophysiology consultation recommended pacemaker placement due to high-risk bradycardic events, but the patient deferred definitive treatment in favor of outpatient management. IMPACT/DISCUSSION: This case demonstrates the potentially life-threatening consequences of deglutition syncope, a rare condition often misdiagnosed due to its vague and intermittent symptoms. Identifying swallowing as the trigger requires careful history-taking and targeted testing. The detailed telemetry findings and provocation testing emphasize the need for precise diagnostic evaluations in patients presenting with swallowing-associated syncope. Effective management often requires collaboration among cardiology, gastroenterology, and speech-language pathology to address the multifaceted nature of this syndrome. Even though a pacemaker is a definitive treatment for preventing life-threatening arrhythmias in severe cases of deglutition syncope, the patient’s decision to defer pacemaker placement underscores the importance of incorporating shared decision-making into clinical care. The patient’s presentation of deglutition syncope aligns with cases documenting vagal hyperactivity and syncope during swallowing, and collectively, these studies support a multi-disciplinary diagnostic and therapeutic approach to deglutition syncope, with a focus on electrophysiological evaluation and the potential role of pacemaker therapy in preventing recurrent syncopal episodes.

Deglutition syncope should be considered in patients with unexplained swallowing-associated syncope. Telemetry and provocation testing are critical for diagnosis. Pacemaker placement is a definitive treatment option but requires patient-centered discussions to address preferences and compliance. SWEET WARNING SIGNS: DIABETES AND PANCREATIC CANCER Wilson G. Goh1; Isaac K. Ng2; Jason W. Tho3; Desmond B. Teo4. 1Infectious Diseases, National University Health System, Singapore, Singapore, Singapore; 2Medicine, National University Hospital, Singapore, Singapore, Singapore; 3Ministry of Health Holdings Pte Ltd, Singapore, Singapore; 4Medicine, Alexandra Hospital, Singapore, Singapore, Singapore. (Control ID #4245528) CASE: A 75-year-old Chinese male, with no significant medical history, presented with a 2-month history of intermittent, dull epigastric pain, associated with bloating, loss of appetite, and 9kg weight loss. On examination, he was clinically stable, with no jaundice/pallor, and his abdomen was soft, non-tender, with no organomegaly. Initial blood tests showed completely normal blood counts, renal and liver function, and lipase level. However, a point-of-care glucose test detected an elevated random glucose of 15.3 mmol/L (reference range 4-11.1 mmol/L). A HbA1c was sent which came back as 9.9% (reference range < 7%), suggestive of newly diagnosed diabetes mellitus (DM). In view of his constitutional symptoms, a computed tomography scan of the thorax, abdomen and pelvis was arranged which revealed a pancreatic body mass with upstream pancreatic ductal dilatation but without overt lung or liver metastases. Carbohydrate antigen (CA) 19-9 was elevated at 5870 U/ml (reference range < 37 U/ml). An endoscopic ultrasound-guided biopsy of the pancreatic mass showed moderate to poorly differentiated pancreatic adenocarcinoma on histopathology. He was diagnosed with locally advanced pancreatic body adenocarcinoma. He was referred to a medical oncologist, and commenced on palliative mFOLFIRINOX chemotherapy. IMPACT/DISCUSSION: Pancreatic cancer is a malignancy with dismal prognosis, because it often presents in advanced stages due to lack of evidence-based screening modalities, insidious clinical manifestations, and an overall aggressive tumour biology, and has also a lack of effective systemic treatment options that can greatly prolong survival. In recent years, new-onset DM has been recognised as a possible early sign of underlying pancreatic cancer which is known to be associated with a specific pancreatogenic subtype (type 3c) of DM. Postulated hypotheses include destruction of insulin producing cells, insulin resistance and inflammation with oxidative stress by the tumour cells. Early recognition of this association is crucial for timely diagnosis and intervention. While DM screening may offer early clues for pancreatic cancer, challenges include cost-effectiveness and timing of DM onset as it may be a late sign of pancreatic cancer. A targeted approach, focusing on high-risk individuals such as family history of malignancy, genetic mutations, or unexplained weight loss could be more effective. Integrating additional biomarkers and establishing a clear follow-up protocol could improve screening specificity and outcomes without overwhelming the healthcare system.

There should be a high index of suspicion for pancreatic malignancy with new onset DM or worsening DM control from previously stable disease in the older adults. Targeted DM screening in high-risk individuals may provide early detection of pancreatic cancer while maintaining cost effectiveness. SYNCOPE: AN UNCOMMON CAUSE Amber Roberts1; Malinda Gong2; B. Cameron Webb1. 1Internal Medicine, University of Virginia, Charlottesville, VA; 2School of Medicine, University of Virginia, Charlottesville, VA. (Control ID #4272217) CASE: The patient is a 54 year old female with a past medical history of lupus nephritis, HTN and HFrecEF who presented to the hospital for a 72 hour fast. Prior to presentation, the patient had a 2-month history of multiple syncopal events without prodrome that were associated with severe hypoglycemia (blood glucose as low as 20). The episodes were confirmed to be non-cardiac in nature and therefore consistent with neuroglycopenia. Her symptoms improved with correction of her blood glucose (BG), making them consistent with Whipple’s Triad. Of note, the patient lacked any history of diabetes mellitus, significant weight loss, gastric bypass surgery, adrenal insufficiency, thyroid disease or cancer. The fast was conducted by making the patient NPO and checking her BG every 2 hours until her BG was <70, at which point the BG was checked every 30 minutes with close monitoring for symptoms and additional labs were obtained (BMP, proinsulin, insulin, BHB, oral hypoglycemic agent screen and C-peptide). The fast is concluded once the patient has symptoms+BG<55, no symptoms+BG<45 or at 72 hours, whichever is first. Our patient quickly reached severe hypoglycemia with glucoses <45 on BMP x3 without associated symptoms. She was found to have elevated C-peptide (7.3), proinsulin (36) and insulin (28.2) levels, consistent with an endogenous insulin source such as an insulinoma. Her initial imaging evaluation with a CT A/P and MRI did not reveal evidence of a lesion. She was considered for PET imaging but this could not be obtained during admission, so she subsequently underwent EGD with EUS which revealed a 16mmx15mm mass in the body of the pancreas. Biopsy revealed a well-differentiated neuroendocrine tumor, confirming that the patient indeed had an insulinoma. The patient underwent distal pancreatectomy and splenectomy for definitive management. Her postoperative course was complicated by an intraabdominal abscess which was managed without issue. She has been doing well without any recurrence of her symptoms. IMPACT/DISCUSSION: Clinicians must be able to maintain a wide differential when presented with a patient with unexplained syncope, as it may be the presentation of an etiology of endogenous hyperinsulinemia. Hypoglycemic unawareness is rare in patients without a history of diabetes and decreases in BG are usually accompanied by a series of physiologic autonomic responses such as tremors or diaphoresis prior to neuroglycopenic symptoms. However, as it was in this patient’s case, the lack of autonomic symptoms with pure neuroglycopenia has been noted to be a more common presentation of an insulinoma as opposed to other causes for hypoglycemia.

Our patient had to undergo an extensive amount of lab testing plus invasive and noninvasive imaging modalities, further complicating the course to an official diagnosis. Our case demonstrates a common presentation of a rare etiology of hypoglycemia, insulinoma, and how extensive obtaining diagnostic clarity can be. SYPHILIS-INDUCED TRANSVERSE MYELITIS: A RARE NEUROLOGICAL MANIFESTATION Sagel P. Ejantkar1; Amber Peterson2. 1Osteopathic Medicine, Western University of Health Sciences, Pomona, CA; 2College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA. (Control ID #4270008) CASE: A 29-year-old sexually active male presented with progressive bilateral lower extremity weakness, incontinence, and muscle spasms. Two months prior, he experienced sudden-onset imbalance, requiring cane-assisted ambulation. Initial spinal MRI revealed hyperintensity from C7 to T11, consistent with transverse myelitis (TM). A 5-day course of IV methylprednisolone (1 g/day) provided partial improvement, and he transitioned to rehabilitation. Shortly after discharge, his symptoms worsened, necessitating readmission. Diagnostic evaluation confirmed syphilis with positive RPR and Treponema pallidum antibody tests. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis and elevated protein but a negative VDRL. A 14-day IV penicillin G course and plasma exchange therapy (PLEX) were initiated without clinical or radiological improvement. Subsequent MRI showed progression of spinal cord hyperintensity, now extending from C3 to T11. The patient began a 5-day course of intravenous immunoglobulin (IVIG, 0.4 mg/kg), resulting in significant functional improvement, enabling ambulation with a walker. However, repeat high-dose IV methylprednisolone led to a rapid decline in muscle strength and function. This had a profound effect on the patient's ability to perform activities of daily living and his mental health. A follow-up MRI revealed persistent hyperintensity from T2 to T9. He remained in rehabilitation, and a second round of PLEX was under consideration in an effort to improve function. IMPACT/DISCUSSION: This case underscores the diagnostic and therapeutic challenges of syphilitic transverse myelitis (TM). TM typically presents with acute paraparesis, sensory changes, and autonomic dysfunction. Syphilis-induced TM is rare, often requiring serologic testing for RPR and Treponema pallidum antibodies, alongside supportive CSF findings. Treatment strategies for TM involve high-dose corticosteroids to mitigate inflammation, IVIG for immune modulation, and PLEX to remove autoantibodies. While IVIG provided temporary improvement, subsequent therapies showed diminishing returns, highlighting the refractory nature of the disease in this case. Timely recognition and early intervention are critical to improving outcomes, as delayed diagnosis may lead to irreversible neurological damage. This vignette contributes to the literature by emphasizing the importance of considering syphilis in atypical TM presentations. Given the limited evidence for syphilitic TM management, further studies are needed to refine therapeutic approaches and explore novel immunomodulatory agents.

Recognize syphilis as a rare cause of transverse myelitis in patients with unexplained neurological symptoms. Early diagnosis and prompt initiation of both antimicrobial and immunomodulatory therapies are critical for optimizing outcomes. Refractory cases of TM require a multidisciplinary approach, emphasizing individualized treatment strategies and ongoing research into innovative therapies. SYSTEMIC LUPUS ERYTHEMATOSUS PRESENTING AS ASEPTIC MENINGITIS Sathish Krishnan, Faizan Shaikh. Pulmonary and Critical Care, Community Health Network Inc, Indianapolis, IN. (Control ID #4272480) CASE: A 46-year-old male presented to the Emergency Department with a 10-day history of fever, headache, skin rashes, and bilateral hand pain. Vital signs were notable for a temperature of 101.8°F and a heart rate of 118/min. Physical examination revealed neck stiffness and erythematous, annular plaques on the trunk and extremities. Urinalysis showed non-nephrotic range proteinuria. A CT (computed tomography) of the head and an MRI (Magnetic Resonance Imaging) of the brain were unremarkable. A lumbar puncture was performed, and the patient was empirically started on vancomycin, ceftriaxone, and acyclovir. Despite broad-spectrum antibiotics and antiviral therapy, the patient continued to have persistent fevers. A CT of the chest, abdomen, and pelvis revealed bilateral small pleural effusions. Blood cultures were negative. A thoracentesis confirmed exudative pleural fluid that was culture negative. Cerebrospinal fluid (CSF) analysis showed a white blood cell count of 188/μL (<6/μL) with 61% lymphocytes, protein of 294 mg/dL (12–60 mg/dL), and glucose <20 mg/dL (40–70 mg/dL). CSF bacterial and fungal cultures were negative. PCR testing for bacterial, viral, and fungal pathogens was also negative. Serological testing revealed a positive ANA with a titer of 1:1280 and a speckled pattern. CRP was elevated at 13.8 mg/dL (<1 mg/dL), and anti-Smith antibody was positive. Anti-dsDNA, anti-Ro/SSA, anti-La/SSB, and anti-U1RNP antibodies were undetectable. Pleural fluid cultures were negative. After a multidisciplinary discussion involving the infectious disease and rheumatology teams, a diagnosis of aseptic meningitis secondary to systemic lupus erythematosus (SLE) was established. Treatment with systemic steroids and hydroxychloroquine was initiated. Antibiotic and antiviral therapies were stopped. At a 6-month follow-up, the patient successfully tapered off prednisone and was maintained on hydroxychloroquine with significant improvement in skin rashes and arthralgia. IMPACT/DISCUSSION: SLE is an autoimmune connective tissue disorder that can affect various organs, including the nervous system. Neurologic and psychiatric symptoms, collectively termed neuropsychiatric SLE, can manifest in diverse ways. Aseptic meningitis is a rare neuropsychiatric SLE manifestation, with its exact prevalence remaining unknown. It can occur as an isolated feature or alongside other SLE manifestations. CSF analysis is essential for diagnosis, helping to differentiate aseptic meningitis from infectious causes. Typical CSF findings include pleocytosis, elevated protein levels, and low or normal glucose levels.

This case underscores the importance of considering systemic lupus erythematosus (SLE) in the differential diagnosis of aseptic meningitis, particularly in patients with systemic symptoms such as rash, arthralgia, and serositis. Early recognition and diagnosis of SLE are crucial for timely initiation of immunosuppressive therapy. TAKING A DIFFERENT ROUTE TO CHEST PAIN: A CASE OF ABERRANT RIGHT SUBCLAVIAN ARTERY Chandora Akshay1; Robert DeStefano2; Kapil Chandora3; Joshua Stephens1; Aaron Teklesenbet1; Dokun Dairo1; Justin Choi1. 1Medicine, Morehouse School of Medicine, Atlanta, GA; 2Emory University, Atlanta, GA; 3Internal medicine, Morehouse School of Medicine, Atlanta, GA. (Control ID #4272471) CASE: A 22 year old female with a history of cholelithiasis and multiple emergency department visits for chest pain presented to the hospital for chest pain, cough and associated shortness of breath for 1 day. Her chest pain was squeezing in nature,substernal, and radiated to her stomach and was worsened with cough, and lying flat. She denied odynophagia, palpitations, or numbness but noted occasional swallowing difficulties and feelings of her “heart bursting”. Her vitals were significant for maximum temperature of 103 F, tachycardia, and tachypnea. She tested positive for COVID-19 and was started on Paxlovid for treatment. Her chest x-ray demonstrated hilar prominence. Subsequent imaging with computed tomography of her chest with intravenous contrast demonstrated an Aberrant right subclavian artery (ARSA). Formal transthoracic echocardiogram showed normal ejection fraction and was without congenital cardiac abnormalities. Cardiothoracic surgery (CTS) was consulted given concern that the patient's chest pain was related to ARSA and she was scheduled for congenital CTS follow up and further management in the outpatient setting. IMPACT/DISCUSSION: ARSA affects less than 1% of the population and can have life threatening complications, such as aortic dissection and aortic aneurysm. The condition predominates in women and symptoms include dysphagia, chest pain, and dyspnea. Clinician's could attribute her chest pain to the COVID infection given her acute duration or even cholelithiasis given her history, both of these differentials would indicate anchoring biases. However, her unique presentation of chronic intermittent swallowing difficulties with feelings of intense chest pain were likely attributable to her right subclavian abnormally routing posterior to her esophagus. Given the paucity of ARSA, no consensus exists with treatment guidelines for these patients. Patients with ARSA should be evaluated and routinely followed for surgical interventions such as bypass.

Clinicians should keep congenital abnormalities on their differential and understand the patient’s specific anatomy for presentations of chest pain in young adults. ARSA if left untreated has a high risk for life-threatening aortic dissection and death. As chest pain carries a broad differential and is commonly encountered by the internist, clinicians should keep congenital abnormalities in their purview. TAKOTSUBO CARDIOMYOPATHY IN AN 83-YEAR-OLD FEMALE Daniel Pastan1; Linda Baier2; David A. Feldstein2. 1Internal Medicine, University of Wisconsin-Madison, Madison, WI; 2Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI. (Control ID #4270748) CASE: An 83-year-old female with aortic stenosis, chronic obstructive pulmonary disease, and atrial fibrillation presented with a week of worsening dyspnea. She was hypoxemic with a respiratory rate of 34. Vitals were significant for BP of 105/72 and SPO2 of 86%. She denied recent chest pain or palpitations. Her exam was notable for diffusely coarse breath sounds, elevated jugular venous pulsation, and pitting edema of her bilateral lower extremities. Labs included leukocytosis, a mildly elevated troponin, and an elevated brain natriuretic peptide level. An ECG showed diffuse T-wave inversions. A transthoracic echocardiogram revealed a newly reduced ejection fraction of 40% with globally reduced left ventricular function and apical akinesis. She denied recent emotionally stressful or traumatic experiences. She was started on an aggressive diuretic regimen and goal-directed medical therapy. Prior to discharge, a nuclear stress test was negative for ischemia. Eight weeks after hospitalization, repeat transthoracic echocardiogram revealed left ventricular ejection fraction recovery to 60% and she reported that her symptoms had resolved. IMPACT/DISCUSSION: Approximately 90% of patients diagnosed with Takotsubo cardiomyopathy (TC) are female, most of whom are over age 65. TC is often triggered by emotional and/or physical stress, but in a third of cases no preceding incident is identified. Numerous viable diagnostic criteria are available. Diagnosis using the Mayo Clinic criteria requires: echocardiographic evidence of transient left ventricular systolic dysfunction beyond a single vascular distribution; absence of obstructive coronary disease or evidence of acute plaque rupture; new electrocardiographic abnormalities; and absence of pheochromocytoma or myocarditis. Typically, TC patients are treated supportively. Those who experience complications of reduced ejection fraction are treated with diuretics and goal-directed medical therapies including beta-blockers and an ACE or ARB. In-hospital mortality for patients with TC is thought to be 3-4%, and risk of recurrence is estimated at 1-2% annually. Most who survive the acute illness phase will have return of regular ventricular function within one month. TC patients appear to experience increased all-cause mortality, particularly in the year following diagnosis. This case served to remind me that TC is not an uncommon diagnosis – it should be carefully considered when evaluating new-onset cardiopulmonary symptoms, especially in older female patients.

- TC is a non-ischemic cardiomyopathy that most commonly presents in older female patients - A preceding emotional or physical trigger is common, but is not a prerequisite for diagnosis - TC patients are likely to survive the acute phase of illness and experience return of left ventricular function within one month TAKOTSUBO CARDIOMYOPATHY POST DENTAL EXTRACTION: A CASE REPORT. Jill Bhavsar1; Kamal Naser1; Merry D. Balcha1; Aashu Bhavsar2; Seham AlHaddad1. 1Internal medicine, WellStar Cobb Hospital, Austell, GA; 2MK shah medical college and research center, Ahmedabad, Gujarat, India. (Control ID #4272800) CASE: A 73-year-old female with a past medical history significant for hypertension, hyperlipidemia, and a family history of premature coronary artery disease. She presented to the emergency department after developing an abrupt onset of central chest pain. She described the pain as an “elephant sitting on my chest," 10/10 in intensity, radiating to the left arm and associated with shortness of breath. She reported undergoing dental work two weeks prior to her presentation with extraction and upper and lower post implants pending dentures with sutures still in place and was in significant pain due to it. She reported no other stressors. In the emergency department, she was noted to have an elevated troponin of 181 on admission trending to 534, with a delta of 353. Her EKG was of normal sinus rhythm with non-specific T-wave flattening. The patient was admitted to the hospital and was started on a heparin drip for suspected myocardial infarction along with aspirin and statin. She underwent urgent left heart catheterization, which showed normal coronaries. The heparin drip was discontinued. A subsequent echocardiography showed a severely decreased ejection fraction of 31-35% and abnormal left ventricular diastolic function with severe hypokinesis of the mid and distal anteroseptal wall and apical wall of the left ventricle. The patient was started on empagliflozin 10 mg and metoprolol succinate 25 mg and discharged under stable conditions with follow-up transthoracic echocardiography (TTE) in 6 weeks. IMPACT/DISCUSSION: Between 2% to 3% of all patients and 5% to 6% of all women who present with what looks like an acute coronary syndrome (ACS) actually have an acute reversible left ventricular dysfunction without coronary artery obstruction, a phenomenon known as Takotsubo cardiomyopathy (TCM), which is presumed to happen due to extreme catecholamine surge from a trigger, provoking multi-vessel epicardial spasms, coronary microvascular dysfunction, and apical ballooning. Triggers usually include panic, fear, anger, anxiety, grief, natural disasters, financial problems, and happy heart syndrome. However, this case demonstrates that dental procedures with poorly controlled pain can develop TCM due to pain-induced high catecholamine surge. Patients present with signs and symptoms similar to acute myocardial infarction, such as typical chest pain, dyspnea, electrocardiographic abnormalities, and elevated biomarkers. Healthcare providers need to recognize this condition early, and they often recommend healthy coping techniques with the usual pharmacotherapy of left heart failure, such as diuretics, angiotensin-converting enzyme inhibitors (ACE), and beta blockers. Most of the patient population fully recovers; however, 20% go on to develop heart failure.

Thus, healthcare practitioners must recognize the importance of adequately controlling a patient’s pain post procedures, including dental procedures, which can otherwise lead to conditions such as takotsubo cardiomyopathy. TAXANES & TOXICITIES: A CASE OF SEVERE TAXOL-INDUCED PNEUMONITIS Natalie J. Reed1; Caroline Horne2; Yaffa Badi Ali3. 1Internal Medicine, Carolinas Medical Center, Charlotte, NC; 2Internal Medicine, Atrium Health, Charlotte, NC; 3Wake Forest University School of Medicine, Winston-Salem, NC. (Control ID #4273471) CASE: A 76 year old female with stage IIIB non small cell lung cancer who completed curative intent concurrent radiation therapy and carboplatin/paclitaxel (Taxol) two weeks prior presented to the Emergency Department with a several week history of diarrhea and shortness of breath. She was noted to be hypoxic upon initial evaluation requiring 2 L supplemental oxygen. Computed tomography (CT) of the chest revealed a necrotic 4.1 x 2.4 cm right lower lobe lung mass and interval development of septal thickening and honeycombing within both lungs. She was admitted for further management with an unfortunate rapid decline following admission. She was started on high dose methylprednisolone, as needed diuresis, and empiric antibiotics with vancomycin and piperacillin/tazobactam, but continued to worsen requiring intubation on admission day 5. Repeat chest CT was done revealing idiopathic interstitial pneumonia with evidence of honeycombing, paraseptal emphysema, and acute superimposed bilateral ground glass disease. Initial differential diagnosis included radiation pneumonitis, pulmonary edema, aspiration pneumonia, and taxane induced pneumonitis. Upon detailed review of her imaging as well as bronchoscopy studies that were unrevealing, the extensive ground glass opacities and fibrosis outside of the radiation fields made the latter diagnosis of taxane induced pneumonitis most likely. After three days, she was extubated to high flow nasal cannula, which was initially tolerated well. However, unfortunately on day two of support with high flow nasal cannula, oxygen requirements continued to escalate to max settings with recurrent desaturations. Following several days of aggressive treatment with steroids and antibiotics, she continued to worsen and her family ultimately opted for comfort directed care prior to her dying approximately two weeks after initial presentation. IMPACT/DISCUSSION: Taxane induced pneumonitis is a relatively rare (1-5% incidence in patients receiving taxanes), potentially life-threatening adverse effect of taxane based chemotherapy regimens. It is believed to be due to an immune mediated hypersensitivity reaction that occurs within days to weeks of taxane based treatment. The mainstay of treatment for severe cases is taxane discontinuation, systemic glucocorticoids, and evaluation/treatment of other potential etiologies.

This case report features a severe occurrence of taxane induced pneumonitis refractory to standard treatments. It is important for general medicine providers to be mindful of this diagnosis in patients with cancer receiving taxane based chemotherapy, as it is less commonly seen than radiation pneumonitis and other etiologies but can be very severe. Early recognition/treatment and avoidance of the offending agent can be instrumental for recovery in these patients, though it presents heterogeneously overall with varying manifestations and severity. TESTOSTERONE TROUBLE: FROM MUSCLE BOOST TO WILD RIDE OF ARRHYTHMIA AND CARDIOMYOPATHY Sameer Lohana1; Mohammad Hazique1; FNU Kalpana2; Sheraz Anjum1. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4273460) CASE: A 28-year-old male bodybuilder presented with progressive dyspnea, orthopnea, and symptoms of fluid overload, including nocturia and peripheral edema. Physical examination revealed elevated jugular venous pressure, lung crackles, an S3 gallop, and significant edema. Investigations showed erythrocytosis, atrial fibrillation on EKG, and an ejection fraction <30% with global hypokinesis on echocardiography. JAK2 mutation was negative, and ischemic causes and pulmonary embolism were ruled out. Exogenous testosterone use was identified as the likely cause, and treatment included cardioversion, therapeutic phlebotomy, GDMT, and catheter ablation, leading to significant recovery. IMPACT/DISCUSSION: This case highlights a rare but important association between exogenous testosterone use and cardiovascular complications, including atrial fibrillation and nonischemic cardiomyopathy. Anabolic steroids, commonly used among athletes and bodybuilders, have been linked to myocardial remodeling, fibrosis, and arrhythmogenesis. Elevated testosterone levels also contribute to erythrocytosis, increasing blood viscosity and cardiac workload. This case shows us the importance of a thorough history and evaluation in younger patients presenting with arrhythmias and heart failure symptoms. Early recognition and targeted intervention, including cessation of anabolic steroids and guideline-directed medical therapy, were critical for recovery. This case emphasizes the need for public awareness and clinician education on the cardiovascular risks of performance-enhancing supplements. Long-term management, including catheter ablation, ensured sustained rhythm control and improved outcomes.

This case signifies the critical need to recognize exogenous testosterone use as a potential cause of atrial fibrillation and nonischemic cardiomyopathy, particularly in young athletes. Prompt identification and targeted treatment, including cessation of anabolic steroids, cardioversion, and guideline-directed therapy, led to significant recovery. It highlights the importance of patient education and clinician vigilance regarding the cardiovascular risks of performance-enhancing supplements. Early intervention can prevent long-term complications and improve outcomes. THE AIR WE BREATHE: A DIAGNOSTIC CHALLENGE OF ACUTE HYPOXIC RESPIRATORY FAILURE Caleb D. Cohen. Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4272362) CASE: A 62-year-old female with a history of hypertension, chronic opioid use disorder on methadone, and recent T4-T10 fusion presented with 2 days of generalized weakness and shortness of breath that led to a fall at home. She was admitted to medicine for evaluation and treatment of acute hypoxic respiratory failure. Pertinent ROS included + rhinorrhea and pleuritic chest pain. Admission vitals were pertinent for HR 101, RR 18, and O2 saturations between 70-90% requiring 4L of O2 via NC. Physical exam showed obesity, decreased breath sounds to bilateral lung bases and trace lower extremity edema. Admission labs were notable for normal WBC (8.54) and absolute eosinophils (0.11), elevated CRP/ESR, elevated BNP, and negative RVP and procalcitonin. CT imaging was notable for negative PE, multifocal bilateral extensive ground-glass opacities, and a small left pleural effusion. She was started on antibiotics for CAP treatment and finished 5 days of therapy. She underwent diuresis with concerns for volume overload, with TTE showing normal systolic/diastolic function. She also underwent a negative autoimmune and non-invasive infectious work up. Despite the above treatment, her hypoxia did not improve. On day 6 of her hospitalization, she developed persistent eosinophilia and was found to have elevated IgE concerning for acute eosinophilic pneumonia (AEP) with her other clinical findings. She was started on empiric steroids with bronchoscopy completed on day 4 of steroids with BAL showing 14% eosinophils, consistent with a diagnosis of AEP. Her clinical status improved with initiation of steroids, and she was discharged on a steroid taper. IMPACT/DISCUSSION: This case illustrates the difficulty of diagnosing acute eosinophilic pneumonia, as it is an uncommon cause of acute hypoxic respiratory failure. It demonstrates the importance of thinking of new differentials after ruling out more common diagnoses for hypoxic respiratory failure, including pneumonia, PE, and heart failure. Normal eosinophil levels at admission may complicate the presentation, which may subsequently develop peripheral eosinophilia. Given the exclusion of other causes in combination with clinical/radiographic findings, AEP was at the top of our new differential. A definitive diagnosis is made with BAL eosinophilia >25% or lung biopsy. Our case was complicated by high oxygen requirements requiring a safe bronchoscopy and BAL that needed to be completed after steroids were already initiated. Despite bronchoscopy completed on day 4 of steroids, BAL still showed significant eosinophilia consistent with AEP.

-Peripheral eosinophilia typically develops after the initial presentation -Acute eosinophilic pneumonia is an uncommon cause of acute hypoxic respiratory failure that clinicians should be concerned about in setting of bilateral lung opacities and peripheral eosinophilia THE ART OF DIAGNOSIS: POEMS SYNDROME IN A PATIENT PRESENTING WITH DYSPNEA Sarah Shidid1,3; Ananna N. Kazi2. 1Internal Medicine, Montefiore Health System, Bronx, NY; 2Internal Medicine, Montefiore Medical Center, New York, NY; 3Hematology Oncology, Montefiore Medical Center, New York, NY. (Control ID #4273347) CASE: A 67-year-old female, with HTN, HLD, CAD, hypothyroidism, presented with worsening dyspnea associated with significant functional decline for two weeks. CT chest showed a large right pleural effusion with an incidental finding of hepatosplenomegaly and sclerotic bone changes. Despite thoracentesis, she continued to decline throughout her hospital stay. Patient was also noted to have new distal axonal sensory polyneuropathy. Physical exam was significant for hyperpigmented skin changes on her lower extremities with 3+ pitting edema bilaterally and right axillary lymphadenopathy. Her labs were significant for an elevated TSH (7.95), monoclonal gammopathy (SPEP M Spike of .36 g/dL, 5.7%.) and an elevated VEGF (360). A Bone marrow biopsy showed 20% plasma cells. She met several criteria which were concerning for syndromic disorder called POEMS syndrome. She was placed on a chemotherapy regimen and had outpatient oncology follow up with plans for a transplant. IMPACT/DISCUSSION: Patient presented with progressive dyspnea and was found to have constellation of symptoms concerning for POEMS syndrome, a paraneoplastic syndrome that arises from a plasma cell neoplasm. The diagnosis of POEMS (Polyneuropathy, Organomegaly, Endocrinopathy, M protein, and Skin changes) syndrome is confirmed when both mandatory major criteria (polyneuropathy, monoclonal plasma cell-proliferative disorder), one of the three other major criteria (Castleman disease, sclerotic bone lesions, VEGF elevation) and one of six minor criteria (organomegaly, extravascular volume overload, pleural effusion skin changes) are present. There is no clear, definitive management given the rarity of the condition. Treatment can range from radiation therapy, alkylator based therapy, and corticosteroids. In the case of this patient, she was treated with CyBord (Cyclophosphamide, Bortezomib and Dexamethasone) with plans for high-dose chemotherapy with peripheral blood stem cell transplant. Prompt recognition, supportive care, and multidisciplinary management result in best outcomes.

1. Early Recognition is Key!: multiple new or unexplained presenting complaints accompanied with dyspnea should prompt a high degree of clinical suspicion for syndromic conditions such as POEMS syndrome. A comprehensive workup and physical exam with multidisciplinary team ensures optimal management. 2. CT Imaging can be a useful tool in identifying idiosyncrasies outside of the cardiopulmonary system to identify non pulmonary causes of subacute shortness of breath. THE BITE OF DEATH: HORSE BITE INDUCED VENTRICULAR TACHYCARDIA AS A RARE INITIAL PRESENTATION OF ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Bibek Saha1; Allison A. Reinhardt1; William Mundell2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Hospital Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4272610) CASE: A 40-year-old female equestrian presented to an outside hospital after she was bitten by her horse and subsequently developed chest palpitations, dyspnea, dizziness, and blurry vision. She was found to have sustained ventricular tachycardia (VT), with a heart rate of 247 bpm and a blood pressure of 100/57 mmHg. She was managed with amiodarone, metoprolol, and cardioverted. TTE revealed a mildly enlarged right ventricle (RV). She had recurrent episodes of VT but non-sustained, prompting transfer to our center. At our center, the patient was asymptomatic. However, she reported intermittent chest palpitations for the last few years but denied syncopal episodes. Family history was negative for sudden unexpected death, and myocardial infarction. She denied smoking, heavy alcohol and illicit drug use. She was overall vitally stable, and cardiovascular examination was normal. Labs including CBC, CMP, magnesium, and TSH were all unremarkable. EKG showed normal sinus rhythm but a prolonged Qtc (490). TTE demonstrated no LV abnormalities (LVEF=58%) but revealed a mild-moderately enlarged RV chamber with a mildly reduced RV systolic function. RV regional wall motion abnormalities including dyskinesis were also observed. Given VT in a younger patient with RV abnormalities, arrhythmogenic right ventricular cardiomyopathy (ARVC) was suspected prompting a cardiac MRI, 12-lead Holter monitor, and electrophysiology (EP) consult. MRI demonstrated regional RV dyskinesia, enlargement, and reduced RVEF (37%). There was no evidence of infarction, scarring, inflammation, or an infiltrative process. A diagnosis of definite ARVC was made with subsequent genetic workup revealing PKP2 mutation heterozygosity. The patient underwent dual-chamber ICD placement for management. She declined anti-arrhythmics leading to nadolol initiation. On 3-month follow-up, Holter revealed non-sustained VT prompting VT ablation. IMPACT/DISCUSSION: ARVC is an autosomal dominant genetic disorder characterized by fibrofatty infiltration of the RV myocardium. It classically presents in the 2nd-4th decade with ventricular arrythmias originating in the RV, and contributes to 20% of sudden cardiac death cases in those <35 years old. We present a rare case of a young female who experienced sustained VT after a horse bite and was subsequently found to have ARVC. The differential in our case included cardiac sarcoidosis, RV trauma leading to scar tissue, and hypertrophic cardiomyopathy all of which were unlikely given the diagnostic workup. The diagnosis of ARVC is difficult to make but when suspected, should prompt cardiac MRI and EP consultation.

●VT alongside abnormalities of the RV in a younger patient should prompt the workup for ARVC ●Specific triggers for ventricular arrythmias in those with underlying ARVC can be unpredictable THE CHAOS OF THE HEMATOLOGY-RHEUMATOLOGY BORDER: ADULT-ONSET STILL DISEASE (AOSD)- ASSOCIATED MACROPHAGE ACTIVATION SYNDROME (MAS) Yadana Oo1; Liana Srisawitri3; Min Zaw Thein2. 1Internal Medicine, Baptist Health Floyd, New Albany, IN; 2University Of Medicine 1, Yangon, Myanmar; 3Indiana University School of Medicine, Indianapolis, IN. (Control ID #4221700) CASE: A 37-year-old Caucasian female with a history of epilepsy and uterine fibroids was admitted with sepsis from pneumonia and pelvic abscess from a recent hysterectomy. She reported diffuse arthralgia and pruritic generalized maculopapular rash for seven months before admission. She also had a family history of SLE. She developed acute hypoxic respiratory failure requiring intubation, cardiac arrest, and acute kidney injury. Her labs showed WBC of 14.5 K, hemoglobin of 6.2, and platelet of 191. PT/INR, PTT, Fibrinogen, and complements were normal. Haptoglobin was less than 6 mg/dL, and Coombs was negative. D-dimer of 29,700 ng/ml, LDH of 1092 units/L, and ferritin of 42,800 ng/mL. AST of 233 U/L, ALT of 66 U/L, ALP of 289 U/L, total bilirubin of 2.0 mg/dL, and triglycerides of 312 mg/dL. ANA, anti-dsDNA, and RF were negative. The infection workup was negative. CT abdomen was negative for hepatosplenomegaly. The skin biopsy showed neutrophil margination, endothelial swelling, perivascular monocyte-like cells, no hemophagocytosis, and consistent with AOSD. The liver biopsy showed nonspecific acute hepatitis. The patient was started on IV methylprednisolone as there was concern for MAS in the setting of possible AOSD. Anakinra was started, followed by etoposide and cyclosporin in later days. With the starting of these medications, the D-dimer and Ferritin trended down significantly. She clinically improved and was extubated successfully. On discharge, she was prescribed mycophenolate 500 mg twice daily with a plan of discontinuing cyclosporine after 5 days of being on mycophenolate and a tapered dose of steroids. IMPACT/DISCUSSION: MAS is a potentially life-threatening complication of rheumatic diseases like systemic juvenile idiopathic arthritis, AOSD, and SLE. MAS is also considered a type of secondary hemophagocytic lymphohistiocytosis (HLH). AOSD has dysregulated immune responses and can trigger MAS. The over-activation of T lymphocytes and macrophages leads to a cytokine storm, which can lead to multiorgan failure. MAS can present as persistent fever, lymphadenopathy, hepatosplenomegaly, cytopenias, increased inflammatory markers, hypofibrinogenemia, transaminitis, hypertriglyceridemia, and extreme hyperferritinemia. The poor prognostic factors in AOSD-associated MAS are thrombocytopenia, high serum ferritin levels, reduced fibrinogen levels, splenomegaly, and liver dysfunction. MAS is a significant cause of death in AOSD patients per the multi-center retrospective analysis conducted in China. The first-line medications crucial in MAS treatment are high-dose intravenous corticosteroids with cyclosporin, intravenous immunoglobulin (IVIg), and anakinra, a recombinant IL-1 receptor antagonist.

Early recognition, timely treatment initiation, and a multidisciplinary approach are crucial in reducing mortality in AOSD-associated MAS. THE COAGULATION ENIGMA: ACQUIRED HEMOPHILIA A (AHA) IN POLYAUTOIMMUNITY Nanno Dandi, Jinal Patel, Alefiya Al-Qamari. Rush Medical College, Rush University Graduate College, Chicago, IL. (Control ID #4270557) CASE: Patient is 66-year-old female with a history of Sjogren’s disease, vasculitis, membranoproliferative glomerulonephritis who presented for progressive left arm pain, ecchymosis, and swelling extending to the left neck after cutting her finger while cooking 10 days prior to arrival. Patient denied fevers, chills, decreased sensation, prior bleeding episodes, and anticoagulation medications. Prior to presentation, her PCP ordered an upper extremity ultrasound which was negative for clots. Exam showed multiple ecchymoses on right arm and a large hematoma at the site of IV placement. Labs showed normal CMP and CBC, CRP 19.6, ESR 41. CT Angiogram of neck and upper extremity showed soft tissue stranding and swelling of left neck and ventral left arm. PT and INR were normal but PTT was high at 82.2. Hematology was consulted. A Factor 8 level was low, a mixing study did not correct the PTT, and a Factor 8 Bethesda assay was elevated to 20. Patient’s symptoms were presumed to be bleeding from acquired hemophilia A due to Factor 8 inhibitor in the setting of extensive autoimmune disease. Patient was treated with prednisone, Rituximab, and recombinant Factor VIIa. Emicizumab was considered but not initiated due to lack of insurance coverage. Patient’s PTT decreased and ecchymosis and swelling improved. Patient was discharged with outpatient hematology follow up. IMPACT/DISCUSSION: This case unmasks the presentation of an uncommon bleeding disorder in the setting of polyautoimmunity. Differential diagnoses included vasculitis, cellulitis, thromboses, and compartment syndrome. Initially, bleeding disorder was thought to be unlikely as the patient is older and previously never had uncontrollable bleeding. Acquired Hemophilia A is defined by autoantibodies against Factor 8. The incidence of AHA is biphasic with one peak in females of reproductive age and another peak in adults >60 years associated with autoimmunity or malignancy. In contrast, genetic Hemophilia A presents in early childhood and is X-linked recessive. Both genetic and AHA present with elevated PTT, but AHA has a mixing study that will not correct the PTT. A Bethesda assay quantifies autoantibodies in AHA. This case also showcases treatment challenges due to insurance constraints. Eradication of autoantibodies is achieved by immunosuppression with steroids, Rituximab, or cyclophosphamide. Bleeding control is achieved with Emicizumab, recombinant Factor VIIa (to bypass intrinsic pathway in coagulation cascade), or activated prothrombin complex concentrate. Considering each patient’s insurance and financial situation is important in determining which therapies to implement.

AHA should be one of the differnetial in patients with polyautoimmunity presenting with ecchymosis and coagulopathy. Management and treatment options for AHA may be guided by insurance limitations. THE CURIOUS CASE OF THE SWOLLEN CHEEK: GRANULOMATOSIS WITH POLYANGIITIS MASQUERADING AS PAROTITIS Mridula Sree Naagendran, Abigail Immanuel, Jason Carrese. Internal Medicine, UConn Health, Farmington, CT. (Control ID #4229135) CASE: 38 year old male presented with a myriad of symptoms following a visit to an indoor water park. His only significant past history was chronic allergic rhinitis. Shortly after the water park visit, he developed left ear pain and swelling necessitating multiple urgent care , primary care provider and ENT outpatient visits. He received multiple antibiotics topically and systemically including oral steroids for a month before his first hospital admission with bilateral parotitis abscess necessitating drainage. A day after discharge, he again presented to the emergency room again with increasing bilateral facial swelling, serosanguinous drainage from the left cheek at the site of prior abscess aspiration with ipsilateral facial weakness.He had mild elevation in temperature with labs notable for normal WBC, CRP with elevated ESR. Imaging studies including CT and MRI were notable for inflammatory changes involving the parotid gland and chronic sinusitis findings.Tests including ACE, vitamin D, RPR, Bartonella,Lyme, Mumps were negative. He underwent left myringotomy with tympanostomy tube placement, left maxillary antrostomy, and left parotid incisional biopsy. Intraoperatively, he had significant purulence of left middle ear and necrosis of the parotid gland. Intraoperative tissue cultures and gram stain from neck, paranasal and maxillary sinuses were all unremarkable. However, serological tests revealed c-ANCA titer >1:40 and PR-3 antibodies were positive which was concerning GPA vasculitis. Biopsy was notable for granulomatous necrotising inflammation. Consequently, we started him on high dose Solu-Medrol intravenously which was transitioned to oral prednisone at the time of discharge. IMPACT/DISCUSSION: Granulomatosis with polyangiitis (GPA) is a small to medium-sized vasculitis and is characterized by granulomatous inflammation and necrotizing vasculitis.This case illustrates an unusual presentation of GPA manifesting as isolated parotid swelling, initially mistaken for benign parotitis or a neoplastic process. Differential diagnosis of parotid swelling includes inflammatory, neoplastic, and infectious causes. The absence of conventional GPA symptoms, such as hematuria, nasal crusting, or pulmonary involvement, further complicated the clinical picture.The patient's significant clinical improvement with administration of corticosteroids and immunosuppressive medications highlights the importance of identifying unusual presentations of systemic illnesses.

Early recognition of this unusual manifestation of GPA is crucial, as timely diagnosis and appropriate intervention can significantly improve patient outcomes reducing systemic involvement and long-term morbidity. This case hightlights the need for heightened clinical awareness and expanded diagnostic considerations,contributing valuable insights into the spectrum of GPA presentations. THE CURIOUS KARIUS: USING METAGENOMIC NEXT-GENERATION SEQUENCING TO IDENTIFY A RARE CASE OF ENDOCARDITIS Lanerica Rogers, Rachel Michalowski, Barbara Okeke, Fred Buckhold, Alexis Stensby. Internal Medicine, Saint Louis University, St. Louis, MO. (Control ID #4271467) CASE: A 78-year-old female with a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia presented to the emergency department after a syncopal episode and ground-level fall, resulting in a scalp laceration. A CT of the head revealed a small volume subarachnoid hemorrhage. During her evaluation, a 2D transthoracic echocardiogram (TTE) showed a large, irregularly shaped, pedunculated echodensity on the atrial side of the tricuspid valve, raising suspicion for infective endocarditis. Though blood cultures remained negative, the patient was empirically started on ceftriaxone. Further investigation revealed that the patient had a tooth extraction four weeks before presentation without receiving prophylactic antibiotics. Further imaging with transesophageal echocardiography (TEE) revealed a small vegetation on the aortic valve and a vegetation on the tricuspid valve. Given the suspicion for infectious endocarditis, continuous negative blood cultures prompted the team to explore alternative diagnostic methods. The patient underwent a Karius blood test, which uses metagenomic next-generation sequencing (mNGS) to rapidly and accurately detect microbial cell-free DNA in plasma. The test revealed Prevotella melaninogenica and Alloscardovia omnicolens as the causative pathogen. The patient was subsequently discharged on four weeks of intravenous ceftriaxone with plans for follow-up TTE to monitor the vegetation. IMPACT/DISCUSSION: While culture-negative endocarditis is not rare, using the Karius blood test in patients with culture-negative endocarditis to isolate a pathogen of interest to tailor antimicrobial treatment is underutilized. A 2022 systematic review found that the average turnaround time for mNGS was 3.2 days, significantly faster than traditional PCR (11 days). This rapid diagnosis allows for more targeted antimicrobial therapy, which is particularly beneficial in culture-negative cases, where broad-spectrum antibiotics are often initially administered. Despite its advantages, the Karius test is not widely available due to its cost and accessibility, particularly in rural or low-resource areas. While initially, this test may be more expensive, considering the cost of suboptimal or unnecessary treatment regimens, using the Karius test to eliminate these treatment challenges could prove more cost-effective in the long term.

The next step is to identify clear guidelines for the use of mNGS in diagnosing culture-negative endocarditis. The new 2023 Duke—ISCVD Infective Endocarditis criteria now recognize a positive mNGS result as a major criterion for diagnosing infective endocarditis. By integrating mNGS into diagnostic protocols, clinicians can improve pathogen detection, optimize antimicrobial therapy, and ultimately enhance patient outcomes in cases of challenging endocarditis. THE ERUPTION DEDUCTION: THE RASH, THE CAT SCRATCH, AND THE BROAD DIFFERENTIAL Olivia Steczko1; Christine Li2; Nicolette Corrao2; Shiromini Herath2. 1PCIM, University of Connecticut School of Medicine, Farmington, CT; 2Medicine, UConn Health, Farmington, CT. (Control ID #4271754) CASE: A 53-year-old man with no prior medical history presented to the ED with a disseminated rash. Symptoms began 3 days prior at the site of a cat scratch on his left arm accompanied by fever of Tmax 102F. The rash spread from the primary site to his torso, buttocks, scalp, and extremities including his fingers with relative sparing of palms and soles. It was pustular, nonpainful, non-pruritic. He was scratched by a cat 8 days prior to admission. Three weeks prior to admission, he had 1 week of fever, myalgia and malaise which resolved before recurring. He denied other symptoms or sick contacts, substance use, travel, medication change, tick bite or sexual or occupational exposure. In the ED he was febrile but hemodynamically stable. Exam was without lymphadenitis. Studies revealed WBC 1.2 thousand/uL, ANC 300/uL, hemoglobin 9.9 g/dL, platelets 100000/uL, ESR 115 mm/h, CRP 198 mg/L, PT 17.5s, INR 1.6, fibrinogen 585 mg/dL, triglycerides 57 mg/dL and unremarkable CMP. Iron studies showed anemia of chronic disease; B9, B12, LDH and reticulocytes were normal, and haptoglobin was mildly elevated. CT showed mild mediastinal lymphadenopathy, splenomegaly and a small splenic infarct. He was started on doxycycline, cefepime, and azithromycin. Infectious disease and hematology/oncology were consulted. He underwent extensive infectious workup which returned negative for monkeypox, tick panel, HIV, HAV, HBV, HCV, VZV, CMV, toxoplasma, acute parvovirus or EBV. Bartonella, gonococcal, HSV and treponemal studies were negative. Blood, tissue, fungal and acid fast bacilli cultures were unrevealing. Dermpath showed superficial perifollicular dermal neutrophilic infiltrate with hemorrhage and no definitive vasculitic nor infectious features, nor definitive immunofluorescence or immunostaining. Given negative findings, antibiotics were deescalated to doxycycline and he was discharged with close followup. Ultimately, marrow biopsy revealed hairy cell leukemia (HCL) but no skin involvement. He later started cladribine-rituximab therapy. Rash resolved over weeks with doxycycline and was attributed to pustular Sweet syndrome. IMPACT/DISCUSSION: Rashes may present a diagnostic challenge, particularly if presentation is atypical or if an uncommon agent is the culprit. Pustular or disseminated skin changes may be caused by many infectious agents as well as by pathologies such as thrombocytopenic purpura, malignancy with skin involvement, or immuno-inflammatory causes such as vasculitis, pustular psoriasis or Sweet syndrome. Pustular and herpetiform cases of Sweet syndrome have uncommonly been described in the literature. Our patient was found to have Sweet syndrome based on diagnostic criteria including skin changes, pathology, pyrexia, underlying malignancy and exclusion of other causes. Workup in our patient unveiled HCL.

Sweet syndrome is a rare disorder that often occurs in association with other pathologies such as hematologic malignancy and warrants further evaluation for underlying causes. THE EYES HAVE IT- DIAGNOSING FAT EMBOLISM SYNDROM (FES) WITH A DILATED FUNDUS EXAM Valerie Gao1; Samantha Rosen3; William Levin2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2General Internal Medicine, University of Pittsburgh Medical Center, Gibsonia, PA; 3N/A, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4250637) CASE: The patient is a 47-year-old male with a past medical history of spina bifida with paraplegia and hydrocephalus with VP shunt who presented with acute onset encephalopathy and lethargy. The day prior to presentation, the patient had fallen onto his knees and dragged himself a distance before calling for help. He then began having episodic lethargy and confusion, visual disturbances (“floaters” and “sparkles”), and headaches prompting presentation to the ED. On arrival he was nonverbal and unable to follow commands. He was mildly tachycardic (106), tachypneic (30), hypoxemic (90%), and febrile (101F) without leukocytosis or other lab abnormalities. CT head revealed slit-like ventricles concerning for over shunting although the patient was found to not have shunt dysfunction. X-rays revealed bilateral distal femur fractures. CT chest/abdomen/pelvis showed only patchy airspace opacities in the right lower lung. Brain MRI and EEG were without acute abnormalities. He was treated empirically with antibiotics for suspected infection. CSF sampling was discussed but deemed to be high risk. His reported visual disturbances prompted a dilated fundus exam which revealed Purtscher’s retinopathy consistent with a diagnosis of FES. His antibiotics were stopped and he rapidly improved on IV methylprednisolone with fading of cotton wool spots and hemorrhages on retinal exam. He was discharged on a steroid taper with outpatient follow-up. IMPACT/DISCUSSION: Acute encephalopathy is a common hospital presentation with a broad differential. Our case highlights the importance of a systematic workup and thorough review of the history. We immediately ruled out stroke, shunt malfunction, and subdural hemorrhage and treated empirically for meningoencephalitis. When the patient failed to improve on antibiotics, we revisited the initial history and broadened our differential. FES was initially not high on our differential given lack of significant respiratory failure, petechial rash, and normal MRI brain. However, the patient’s visual symptoms in the setting of recent long bone fractures led us to pursue evaluation of rare manifestations of FES leading to discovery of Purtscher’s retinopathy. FES is a clinical diagnosis of exclusion. The pathogenesis of Purtscher’s retinopathy as related to FES was first described in 1989 in the British Journal of Ophthalmology and since then the literature has mostly been limited to case reports. Here, we present a case of acute encephalopathy secondary to FES manifested by Purtscher’s retinopathy as proven by systematic exclusion of other conditions and robust response to steroid therapy.

- FES classically presents as respiratory insufficiency, cerebral involvement, and petechial rash. Purtscher’s retinopathy is a rare visual manifestation. - FES should be considered in patients with recent orthopedic trauma and visual symptoms. THE FORGOTTEN DISEASE: A CASE OF SEVERE LEMIERRE SYNDROME Sai Patel1; Bharath Peddibhotla1; Alisha Sharma2; James O'Connor2; Lisa Brath2. 1Internal Medicine, Virginia Commonwealth University, Richmond, VA; 2Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA. (Control ID #4267619) CASE: A 27 year-old previously healthy male presented with a 1-week history of progressive dyspnea, fever, and chest pain that was preceded by a sore throat. Initial physical exam was notable for fever, tachycardia, tachypnea with absent pharyngeal erythema, lymphadenopathy, or neck tenderness. Laboratory workup revealed leukocytosis (WBC 22.1 x 109/L) and thrombocytopenia (36x109/L). Computed tomography (CT) of the chest showed diffuse pulmonary nodules suspicious for septic emboli, bilateral lower lobe consolidations and a loculated right sided pleural effusion. Blood cultures revealed Fusobacterium necrophorum. Despite lack of oropharyngeal and neck physical exam findings, CT neck with contrast was obtained due to clinical suspicion for Lemierre syndrome. It revealed a nonocclusive thrombus of the right internal jugular (IJ) vein along with small, rim-enhancing collections in the right sternocleidomastoid which were too small to be drained. A right sided chest tube was placed with instillation of intrapleural fibrinolytics for empyema. Despite IV antibiotics, the patient had persistent fevers and leukocytosis, and after multidisciplinary discussion with vascular surgery, pulmonary and infectious disease, he was initiated on anticoagulation. He ultimately improved and was discharged on a 4-week course of metronidazole along with an 8-week course of anticoagulation. IMPACT/DISCUSSION: Lemierre syndrome, aptly referred to as ‘the forgotten disease’ is rare with an annual incidence of 3.6 cases per million. It is characterized by septic thrombophlebitis of the IJ vein with septic emboli, most commonly caused by Fusobacterium necrophorum. It is frequently preceded by pharyngitis, as seen in our patient. Pulmonary involvement is reported in almost 85% of cases with complications including septic emboli and empyema as seen in our case. Our patient improved with chest tube placement and intrapleural fibrinolytics; however surgical intervention with thoracotomy and decortication is often needed. Additionally, while antibiotics and drainage of fluid collections are key components of management, there are no established guidelines for the role of anticoagulation. It is uncertain whether anticoagulation reduces the thrombus propagation or embolic events but is widely considered safe and efficacious in cases with disease progression despite appropriate antimicrobial therapy.

This case highlights the importance of maintaining a high index of suspicion for Lemierre syndrome in patients with a history of pharyngeal infection and septic emboli even in the absence of physical exam findings. Management is complex and requires a multidisciplinary approach particularly when determining the need for anticoagulation. THE GREAT IMITATOR: CUTANEOUS T CELL LYMPHOMA (CTCL) MISDIAGNOSED AS ECZEMA Melissa Gunchenko1; Ramkumar Narendran1; Jessica Igiede2; Yolla Haibe3; Seo-Hyun Kim3. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Rush Medical College, Rush University Rush Medical College, Chicago, IL; 3Hematology/Oncology, Rush University Medical Center, Chicago, IL. (Control ID #4272936) CASE: A 42 year old female with a 5-year history of biopsy-proven eczema presented with two weeks of worsening body pain and skin ulcerations. Six months prior to presentation, topical steroids and Dupixent were started without significant improvement. Two months prior to presentation, worsening eosinophilia was noted. On arrival, she was febrile to 101.8 F and tachycardic. Laboratory studies showed WBC 11.4 K/uL, absolute eosinophil count 1.74 K/uL, lactate 2.5 mmol/L, and human T-Cell lymphotropic virus (HTLV) 1 and 2 negative; blood cultures and a wound swab grew methicillin-sensitive staphylococcus aureus (MSSA). Broad spectrum antibiotics were initiated. Chest x-ray was unremarkable. Transthoracic echocardiogram (TTE) was negative for vegetation. Due to persistent fevers and eosinophilia, there was concern for underlying malignancy. Blood flow cytometry showed 50% CD4+ T cells with complete loss of CD7 suggesting a T-cell neoplasm. Sezary smear showed no Sezary cells, and peripheral smear was negative for dysplastic cells. Skin and inguinal lymph node biopsies confirmed mycosis fungoides. Bone marrow biopsy showed no evidence of T cell lymphoma. Positron emission tomography (PET) demonstrated extensive superficial soft tissue hypermetabolic lesions and multiple hypermetabolic lymph nodes representing diffuse lymphomatous involvement. Treatment with gemcitabine was started and, in combination with routine wound care, resulted in gradual clinical improvement. IMPACT/DISCUSSION: Mycosis fungoides (ΜF) is one of the most common subtypes of cutaneous T cell lymphoma (CTCL). MF is a mature T cell non-Hodgkin lymphoma with a heterogenous cutaneous presentation, including patches, plaques, generalized erythroderma, alopecia, and tumors that can involve any body surface; extracutaneous disease can include the lymph nodes, blood, and viscera. While eczema does not progress to MF, the clinical and histological characteristics are often very similar and frequently result in misdiagnosis; this is often compounded by the low incidence of MF and its indolent course. Eosinophilia can occur in both severe eczema and CTCL, as both conditions involve significant skin inflammation. Patients with eczema typically have a relapsing-remitting course, and the presence of B symptoms and/or refractory lesions should prompt investigation for a malignant process.

MF is a subtype of CTCL and shares clinical and histological features with common benign skin conditions, such as eczema and psoriasis, often resulting in delayed diagnosis. High suspicion for CTCL should be maintained in patients with treatment-refractory eczema and/or associated B symptoms. Lastly, a multidisciplinary approach is often essential in establishing the diagnosis and coordinating treatment. THE HEART'S SILENT STRUGGLE: CONGESTIVE HEART FAILURE INDUCED BY TKI THERAPY Aymen Baig, Christian Peña, Ting-Wei Lu. Internal Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4270403) CASE: A 36-year-old male with a past medical history of chronic myelogenous leukemia with the T315I resistant mutation and multiple relapses treated with single agent ponatinib presented to the ED with complaints of pleuritic chest pain and shortness of breath. Exam was notable for mid neck jugular venous distention and mild crackles in bilateral lung bases. Pertinent labs included a WBC 78 K/mcL with neutrophilia, EKG showed nonischemic pattern with normal troponins, and a B-type natriuretic peptide of 600. Chest x-ray showed pulmonary vascular congestion. His echo showed a severely depressed left ventricular systolic function of 10% with global longitudinal strain severely depressed at -5% and severe global hypokinesis. Last echo from 2021 showed an ejection fraction of 40-45%. Left heart catheterization at an outside hospital earlier in the year was consistent with nonischemic cardiomyopathy. Cardiology was consulted and he was started on guideline-directed medical therapy with recovery in ejection fraction to 25% within two months of discontinuing ponatinib. IMPACT/DISCUSSION: While 90% to 95% of chronic myeloid leukemia (CML) patients possess a reciprocal translocation of t(9;22) which constitutively activates tyrosine kinase, some carry mutations that confer resistance to tyrosine kinase inhibitors (TKIs). For those with the T315I mutation, which is resistant to the first and second generation TKIs, third-generation TKIs are preferred with ponatinib considered first given its effectiveness in T315I-mutated CML. Ponatinib however, is associated with substantial cardiovascular toxicity, higher than that reported with other tyrosine kinase inhibitors. In this study, we describe a case of ponatinib-induced heart failure leading to ventricular fibrillation arrest in the setting of severe cardiomyopathy.

While the mechanism of cardiac toxicity from ponatinib is unclear, data reveals that ponatinib is the most cardiotoxic agent among all TKIs. In our patient with no prior history of heart disease, hyperlipidemia, diabetes, hypertension, or family history of coronary artery disease, the decision to start ponatinib was made given his T315I mutation, for which ponatinib is the only inhibitor with activity against. Although he did fine initially, he endorsed progressively severe fatigue and dyspnea with minimal exertion raising the concern for cardiac dysfunction. While his heart failure symptoms were initially managed with GDMT, recurrent hospital admissions since diagnosis for heart failure exacerbations necessitated the discontinuation of this drug. This case underscores the importance of further investigation in minimizing the adverse effects associated with CML-TKIs, as well as developing interventions for managing ponatinib-induced cardiotoxicity in the hospital setting. As opposed to our patient, early recognition of TKI-induced cardiac dysfunction and prompt drug cessation could’ve helped prevent his recurring symptoms requiring hospitalization. THE HIDDEN CULPRIT: UNMASKING PARANEOPLASTIC PEMPHIGUS Shaw-Ming Lin, Felicia R. D'Souza, Katherine Oakden. Hospital Medicine, Penn Medicine, Philadelphia, PA. (Control ID #4268387) CASE: A 34-year-old male presented with sores on his oral mucous membranes, body rash, and significant weight loss due to pain associated with eating. He was seen by various providers in the outpatient setting and took courses of valacyclovir, azithromycin and steroids without improvement. On initial presentation, there were extensive ulcerations on his lips, buccal mucosa and tongue, as well as blanching erythematous macules and papules (on trunk more than extremities). An intraoral biopsy of a mucosal lesion showed lichenoid mucositis. Punch biopsies of his body rash showed interface dermatitis. The patient was started on IV steroids, mucositis mouthwashes, and topical steroid creams, but his rash and sores did not improve. Given his significant weight loss, there was concern for malignancy, and a pan-CT showed marked retroperitoneal lymphadenopathy. A PET/CT confirmed hypermetabolic lymphadenopathy in the abdomen and mesentery. Surgical oncology performed an excisional biopsy of a mesenteric lymph node with results revealing follicular lymphoma. The patient was ultimately diagnosed with paraneoplastic pemphigus (PNP) and he was initiated on chemotherapy for lymphoma. IMPACT/DISCUSSION: PNP is a rare and highly fatal autoimmune blistering disease. It is characterized by severe oral lesions with cutaneous and systemic involvement, specifically in the lungs as bronchiolitis obliterans. Its skin lesions are similar to SJS/TEN, erythema multiforme, drug reactions and pemphigus vulgaris, making a PNP diagnosis difficult. PNP is commonly associated with malignancy, especially lymphoproliferative diseases, with a mortality rate as high as 80%. Autoantibodies, triggered by the tumor, attack the epithelial and mucosal layers of the skin and respiratory tract, manifesting as blisters/ulcers and respiratory distress respectively. Treatment of PNP involves treating the malignancy itself with resection of the tumor leading to a better prognosis. Systemic steroids and immunosuppressive agents, such as rituximab, can also be used.

A blistering or desquamating rash can be confusing and difficult to diagnose as a provider due to the heterogeneity and infrequency of its presentation. An early consultation with Dermatology can help ensure a correct diagnosis. Treatment of a blistering rash usually involves ordering antimicrobials for infections, such as HSV or VZV, or steroids if the infection is autoimmune in nature. However, it is important to look at the overall clinical picture and not focus only on treating the rash itself as an underlying malignancy can be overlooked. A timely diagnosis and removal of the tumor can lead to an improved outcome for PNP. THE INTERSECTION OF INTRACRANIAL CAROTID STENOSIS, CIRRHOSIS, AND TRANSPLANTATION: A MULTIDISCIPLINARY DILEMMA Kidus Shiferawe2; Misa Ito3; Jessica McFarlin4; Hirotaka Kato1. 1Internal Medicine, University of Kentucky College of Medicine, Lexington, KY; 2College of Medicine, University of Kentucky College of Medicine, Lexington, KY; 3MedPeds, University of Kentucky, Lexington, KY; 4Division of Palliative and Supportive Care, University of Kentucky, Lexington, KY. (Control ID #4272367) CASE: A 63-year-old female with hepatitis C cirrhosis, variceal bleeding, hepatic hydrothorax s/p TIPS, and end-stage renal disease, was admitted for dyspnea and intolerance of chronic dialysis due to syncopal episodes. She had been removed from the simultaneous liver-kidney transplant list due to recent tunneled line infection and incidentally found right vertebral and left intracranial carotid artery stenosis. Initial workup revealed SpO2 of 89% on 2L nasal cannula and chest x-ray with pleural effusion. Oxygen requirement returned to baseline after thoracentesis, and she tolerated inpatient dialysis. Brain imaging revealed known intracranial stenosis and a new, small lacunar stroke. A multidisciplinary approach was used to determine how to best optimize this patient for transplant in this setting. The transplant surgery team requested either stenting or best medical therapy to reduce her stroke risk associated with carotid stenosis. However, the neurology and neurosurgery teams determined her strokes were related to small vessel disease and would not benefit from stenting. Typically, intracranial stenosis and small vessel disease are best treated medically with 90 days of dual antiplatelet therapy (DAPT). However, her history of esophageal varices and thrombocytopenia made this high risk for life threatening hemorrhages. Her poor prognosis without a rapid transplant made a 90-day treatment course unlikely to be achievable. This interdisciplinary discussion resulted in a recommendation for medical management with aspirin and a statin. IMPACT/DISCUSSION: Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, with an estimated 20 to 40 per 100,000 individuals experiencing a stroke annually. Such symptomatic ICAD poses a higher stroke risk, and decompensated cirrhosis complicates clinical decision-making due to its hypercoagulable state and increased bleeding risk. Stenting for ICAD has not been shown to reduce stroke risk, as both SAMMPRIS and CASSISS trials demonstrated no benefit of adding stenting to DAPT in reducing stroke for symptomatic or high-risk ICAD. Limited evidence exists comparing stroke versus hemorrhage risks in these high-risk patients who may be candidates for DAPT, making individualized treatment decisions essential. This case underscores the need for multidisciplinary approaches and individualized assessments of ICAD severity and stroke etiology in guiding transplant decisions.

ICAD in patients with decompensated cirrhosis requires a multidisciplinary approach. Accurate assessment of its severity, symptoms, and stroke risk is essential in guiding transplant teams to make informed decisions regarding transplant eligibility, ensuring that patients are not prematurely excluded from consideration. THE INTERSECTION OF ONCOLOGY AND CARDIOLOGY: COLLABORATIVE APPROACHES TO PATIENT CARE Alina Sehar1; Hope C. Lackey1; John Fanning2; Ahmed Abdelhaleem2. 1Internal Medicine, The University of Alabama at Birmingham, Birmingham, AL; 2Internal Medicine, The University of Alabama at Birmingham School of Medicine Huntsville, Huntsville, AL. (Control ID #4236492) CASE: An 87-year-old male with a history of coronary artery disease, heart failure, chronic kidney disease and metastatic renal cell carcinoma (RCC) on nivolumab and ipilimumab presented with worsening shortness of breath. He had history of recurrent pleural and pericardial effusions requiring multiple thoracenteses in the preceding months. At admission, patient was hemodynamically stable but required 5 L/min of supplemental oxygen. Physical examination revealed decreased breath sounds bilaterally and lower extremity edema. Laboratory findings included elevated Pro-BNP (4,476 pg/mL), creatinine (2.6 mg/dL). Chest X-ray showed moderate-large bilateral pleural effusions, while echocardiography demonstrated an ejection fraction of 65–70% and a moderate pericardial effusion without evidence of tamponade. Initial diuretic therapy with minimal relief. Bilateral thoracenteses drained 2.0 L and 1.5 L of fluid, analyses consistent with transudative process. Despite temporary improvement, dyspnea persisted, prompting right heart catheterization, revealing high-output heart failure. Further workup yielded no definitive cause. Given lack of improvement, literature review suggested potential immune-mediated reaction from immune chceckpoint inhibitors (ICIs). Nivolumab and ipilimumab were discontinued, and patient was started on methylprednisolone 80 mg. Symptoms improved, imaging showed stable moderate bilateral pleural effusions. The patient discharged on corticosteroids and continued to show symptom improvement on follow-up, requiring no further thoracentesis. IMPACT/DISCUSSION: Nivolumab and ipilimumab are widely used ICIs for treatment of RCC. By enhancing immune response, these therapies may induce immune-related adverse events (irAEs), including rare cardiotoxic effects such as pericardial and pleural effusions. These effusions are often diagnoses of exclusion, requiring differentiation from tumor progression, pseudo-progression, infection. Clinical and pathological findings are critical in distinguishing irAEs from other etiologies. Pseudo-progression resolves spontaneously or with continued ICI therapy, while irAEs necessitate discontinuation of ICIs and immunosuppressive treatment. Diagnostic imaging, biopsy, and fluid analysis can provide clarity. In our case, biopsy findings and symptom resolution following ICI discontinuation confirmed an immune-related etiology. Management involves stopping ICIs and initiating corticosteroids. Additionally, pericardiocentesis or thoracentesis, may be necessary in severe cases. Prompt recognition and treatment can lead to rapid and complete resolution of symptoms.

While ICIs are effective in cancer treatment, they are associated with irAEs, which often affect the gastrointestinal system or skin. However, cardiac toxicities, such as myocarditis, pericarditis, and effusions, remain rare. Reports of ICI-related pericardial or pleural effusions are particularly limited, highlighting the need for further study in this area. THE MANAGEMENT OF R ON T PHENOMENON IN REFRACTORY ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE Aram Aslanian, Samra Iqbal, Ali Yusuf, Jairah Shaikh, Obaidah Adi, Tarek Naguib. Internal Medicine, Texas Tech University Health Sciences Center - Amarillo, Amarillo, TX. (Control ID #4269872) CASE: A 62-year-old male with metastatic end-stage prostate cancer, cachexia, coronary artery disease (CAD), atrial fibrillation (AF), and pathologic vertebral fractures presented with worsening shortness of breath due to recurrent malignant pleural effusions. Echocardiography showed a left ventricular ejection fraction of 65-70%. He then developed AF with rapid ventricular response (RVR) that failed multiple trials of intravenous (IV) metoprolol and diltiazem. Despite feeling comfortable, he was transferred to the ICU and diltiazem drip was instituted. Subsequently, telemetry revealed an “R on T” phenomenon. Immediate administration of IV magnesium sulfate and amiodarone were begun instead of diltiazem drip. Labs showed magnesium 2.3, potassium 4.3, and troponin 42, with frequent need for electrolyte replacement throughout hospitalization. The heart rate and rhythm were more effectively controlled and he remained hemodynamically stable with no further episodes of R on T or other significant arrhythmic events. IMPACT/DISCUSSION: AF with RVR can be a challenging condition to manage. The presence of systemic illness, poor nutritional status, and electrolyte abnormalities complicates management of AF, often failing standard treatments like diltiazem and beta blockers. The R on T phenomenon is a dangerous finding in this context, as it can lead to life-threatening arrhythmias, such as ventricular tachycardia or fibrillation. R on T occurs when a premature ventricular contraction falls on the vulnerable portion of the T-wave, which can result in sustained arrhythmias. The prompt use of magnesium sulfate may have contributed to stabilize the myocardium in preventing further arrhythmic events. Amiodarone is a key agent in controlling refractory AF, especially in cases where patients are unresponsive to agents like diltiazem or beta blockers. The interplay between cancer cachexia, electrolyte imbalances, and the systemic effects of malignancy complicated arrhythmia management. Additionally, the development of the R on T phenomenon further illustrates the importance of continuous telemetry monitoring and the need for swift intervention in such high-risk cases.

This case emphasizes the importance of recognizing and managing the R on T phenomenon in critically ill patients with refractory AF. Continuous telemetry monitoring allowed for the swift detection and management of a potentially fatal complication. The use of magnesium sulfate and the switch to amiodarone may have played a role in stabilizing the patient’s heart rate and preventing potentially fatal arrhythmias. Further research into optimal arrhythmia management in this population is warranted to improve outcomes and guide therapeutic strategies. THE MASQUERADE OF THROMBOCYTOPENIA Ian Lorang. Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4268582) CASE: This case describes a 75-year-old male who was hospitalized for significant thrombocytopenia, platelets 18,000. Presenting symptoms included cough, dizziness, anorexia and non-bloody diarrhea for a few weeks with one day of subjective fever and night sweats. Comorbidities included severe aortic stenosis and prior alcohol use disorder. Pertinent lab findings included leukopenia at 2.1, AST and ALT elevations 90-100 , normal bilirubin, and hyponatremia to 122. GI pathogen panel was positive for Shiga toxin E coli. Initial etiology of thrombocytopenia was unclear but included Immune Thrombocytopenic Purpura (ITP) vs Shiga toxin induced. Peripheral smear did not show schistocytes or platelet clumping. Since the patient was not bleeding, steroids were held initially given concern for infection. This was thought to also be supported by hyponatremia secondary to diarrhea and poor oral intake completing a Shiga toxin infectious picture. Clinical history was re-visited revealing the patient had a tick bite two weeks prior to admission while hunting. Tick-borne pathogen panel returned positive for Anaplasma. Unfortunately, patient developed AFib with RVR during fluid resuscitation for hyponatremia and was transferred to the ICU. In the setting of acute illness, both steroids and doxycycline were initiated. Platelets recovered to normal range in the 200,000’s after four days of dexamethasone 20mg and doxycycline (100mg twice daily for 10 days). Patient was discharged home in stable condition. IMPACT/DISCUSSION: This case highlights a complicated diagnosis of thrombocytopenia with multiple potential etiologies at play. The most likely diagnoses is Anaplasma given the co-occurring leukopenia and transaminitis. Shiga toxin initially was of concern but seemed less likely with resolving diarrhea and no signs of hemolytic uremic syndrome. ITP is a diagnosis of exclusion but given improvement on steroids it cannot be ruled out. While this poses an interesting diagnostic dilemma, it highlights the importance to avoid grounding and for a provider to remain flexible during a workup as the clinical situation changes. A thorough history should never be overlooked! Other pearls are that Anaplasma has a 1-2 week incubation period (fits this cases timeline) and treatment is with doxycycline. ITP usually needs immediate steroid treatment if the patient is bleeding or if platelets are severely low (<20K). Also, ITP usually occurs with isolated thrombocytopenia. Tick borne illness is not a cause of secondary ITP.

-Treat Anaplasma with doxycycline for 7-10 days. Steroids are not needed to correct the thrombocytopenia, treating the infection alone should suffice. -Suspect Anaplasma as the diagnoses of thrombocytopenia with a tick bite in the past 1-2 weeks, and laboratory studies consistent with leukopenia and transaminitis. -ITP is a diagnosis of exclusion. Unless platelets are critical or the patient is bleeding there is time to consider other causes and hold on steroids treatment. THE MYSTERIOUS BUG - DISSEMINATED EXTRA-GENITAL UREAPLASMA UREALYTICUM INFECTION IN THE SETTING OF IMMUNOSUPPRESSION Dania S. Hasan, Heather Kissel. internal medicine, Virginia Mason Franciscan Health, Tacoma, WA. (Control ID #4273028) CASE: We present an interesting case of a systemic ureaplasma infection occurring in the setting of immunosuppression. A 51-year-old female with a medical history of multiple sclerosis on Ocrelizumab was admitted to the hospital with sepsis secondary to acute sigmoid diverticulitis. Her condition was refractory to conservative management with IV antibiotics, necessitating an exploratory laparotomy with sigmoidectomy and end colostomy. Her post-operative course was significant for rectal stump leak and ongoing pelvic and intra-abdominal abscesses and infections, which were managed with intra-abdominal drainage and antibiotic therapy. Throughout this period, the patient consistently had negative cultures from both blood and abscess samples. Despite broad-spectrum antibiotic therapy including cefepime and metronidazole, the patient continued to have clincial deterioration. The hospital course was further complicated by left clavicular osteomyelitis and a fluid collection in the right hip joint. Fluid and bone samples were sent for 16S rRNA testing, which revealed Ureaplasma urealyticum in the abdominal fluid, left clavicle bone, and right hip fluid collection. Accordingly, her antibiotic regimen was adjusted to incorporate coverage for Ureaplasma with levofloxacin and doxycycline. Following the modification of her therapy, the patient began to show signs of clinical improvement. Further review of the patient’s medical records revealed a prolonged history of unresolving culture-negative vaginal infections prior to admission, which had been unresponsive to multiple courses of antibiotic therapy. The patient had a benign looking pelvic ultrasound at that time. The disseminated disease in this case was thought to have originated from the patient’s unresolved vaginal infections. The patient was ultimately discharged after being hospitalized for slightly over six months. IMPACT/DISCUSSION: Ureaplasma urealyticum is a fastidious bacterium that lacks a cell wall, making it incapable of growing on standard culture media. It typically requires a special culture media to grow, a urea containing agar, or molecular testing. It is recognized as part of the normal urogenital flora. While extragenital infections are less common in immunocompetent adults, they may lead to more severe disease in immunocompromised patients. Beta-lactams and vancomycin tend to be ineffective for ureaplasma infections as the bacteria lack a cell wall. It is essential to maintain a high index of suspicion for Ureaplasma in the setting of non-resolving, culture-negative infections, particularly in immunocompromised patients.

1. Having culture negative non-improving pelvic/gential infections should raise suspicion for ureaplasma infection 2. Utilize gene sequencing tools, such as 16S rRNA analysis, to evaluate unresolving culture-negative infections. 3. Early detection of ureaplasma infection could prevent systemic disease especially in immunocompromised patient THE NEED FOR FURTHER RESEARCH IN PML TREATMENT Melony Mody, Mumta Essarani, Enrique Cortez Bernal, Muhammad Syed. internal medicine, Bayhealth Medical Center, Dover, DE. (Control ID #4273472) CASE: This is a 69-year-old male with a past medical history of hypertension, hyperlipidemia, supraventricular tachycardia, and COPD. He was brought to the emergency department by his wife due to confusion and forgetfulness. Initial CT imaging was unremarkable, while an MRI of the brain revealed multiple areas of signal abnormalities. Subsequent lumbar puncture was positive for JC virus. Further workup identified newly diagnosed HIV infection, with a CD4 count of 83. The patient was started on highly active antiretroviral therapy (HAART) consisting of darunavir, cobicistat, emtricitabine, and tenofovir alafenamide, along with Bactrim prophylaxis, and was discharged home. Eight days later, the patient returned to the emergency department with progressively worsening cognitive function, failure to thrive, and now being nonverbal. There was concern for immune reconstitution inflammatory syndrome (IRIS) following the initiation of HAART. The patient was started on a tapering regimen of Decadron over 10 weeks, beginning at 4 mg daily. Unfortunately, the patient passed away a few days later while on comfort measures. IMPACT/DISCUSSION: Progressive multifocal leukoencephalopathy (PML) is a fatal disease with a high mortality rate, especially within the first few months after diagnosis (30-50%). JC virus, the causative agent, targets myelin in immunocompromised individuals, leading to progressively worsening neurological deficits that can become debilitating within weeks to months. Diagnosis of PML typically requires either a biopsy or evidence of white matter lesions on brain MRI, in addition to the detection of JC virus in cerebrospinal fluid (CSF). A review published in JAMA Neurology (2019) examined the role of immunomodulators, such as interleukin-2 (IL-2) and interferon-alpha (IFN-α), in the treatment of PML. While some studies showed a reduction in JC viral load, there was limited improvement in clinical outcomes. Additionally, the use of these agents increased the risk of IRIS. A study published in Clinical Infectious Diseases (2018) explored the use of plasmapheresis as an adjunctive therapy for PML in AIDS patients. Some studies showed clinical improvement with plasmapheresis; however, the evidence remains weak, and its use is generally reserved for severe cases. A small cohort study published in Neurology (2021) evaluated the use of natalizumab, a monoclonal antibody, in AIDS patients with PML. The study found a reduction in disease progression, but the risk of immune suppression and associated complications was increased.

The cornerstone of treatment for PML remains the early initiation of HAART. There may be a role for plasmapheresis in cases with severe CNS involvement. This case highlights the importance of early diagnosis and intervention. THE PARADOX OF HEALING: STILL’S DISEASE IN THE ERA OF HIV TREATMENT Wilson G. Goh1; Isaac K. Ng2; Nicholas J. Chan1. 1Infectious Diseases, National University Health System, Singapore, Singapore, Singapore; 2Medicine, National University Health System, Singapore, Singapore. (Control ID #4269628) CASE: A 21-year-old Chinese male, with background of Human Immunodeficiency Virus (HIV), presented with daily fevers for 3 months associated with significant unintentional weight loss. He had migratory joint pains involving large and small joints with rashes over his upper and lower limbs. He did not report any localising infective symptoms, alopecia, oral ulcers or conjunctival injection. He had no recent sexual activity and did not have any personal/family history of tuberculosis, autoimmune diseases or malignancies. He did not have any recent travel history, insect bites or animal exposures. He was diagnosed with HIV 6 months ago with absolute CD4 count 346 cells/uL (17%) and HIV viral load 24,1000 copies/mL on initial diagnosis. He was started on Biktarvy (bictegravir, emtricitabine, tenofovir alafenamide) and his absolute CD4 count rose to 534 cells/uL and HIV viral load was undetectable 1 month prior to his symptom onset. Physical examination revealed urticated plaques over bilateral elbows, hands and feet. He had symmetrical swelling and tenderness over bilateral humeral, metacarpophalangeal, proximal interphalangeal, radiocarpal, knee and ankle joints with no overlying erythema. Examination of the cardiorespiratory and abdominal systems were unremarkable. He did not have any lymphadenopathy, vertebral tenderness or oral thrush. Full blood count showed leucocytosis 16 x 109/L with 87.3% neutrophilia and haemoglobin 12.8 g/dL. His C-reactive protein and erythrocyte sedimentation rate were elevated, together with lactate dehydrogenase and ferritin. His liver function test showed transaminitis. Epstein-Barr Virus, Cytomegalovirus polymerase chain reaction and Hepatitis B, C and parvovirus serologies returned negative. Anti-nuclear antibody, anti-double stranded DNA and anti-cyclic citrullinated peptide antibody were negative. Computed tomography of his thorax, abdomen and pelvis did not reveal any abnormalities. He was diagnosed with adult-onset Still’s disease based on the Yamaguchi criteria. He was treated with non-steroidal anti-inflammatory medications and corticosteroids with excellent clinical response. IMPACT/DISCUSSION: The exact cause of adult-onset Still’s disease remains unknown. Genetic, environmental and infectious factors have been implicated. Emerging evidence points to a T-cell driven mechanism. Given the significant immune dysregulation, particularly T-cell abnormalities seen in HIV infection, there may be a potential link between the two conditions. Additionally, initiating antiretroviral therapy can induce immune reconstitution inflammatory syndrome (IRIS), which may manifest as Still’s disease. This is thought to occur due to imbalance in T-cell subsets resulting from increased CD4 and CD8 T cell counts and cytokines levels following antiretroviral therapy initiation.

As antiretroviral therapy continues to improve the lives of those living with HIV, it is critical to be aware of the potential risks associated with immune recovery. THE RAVEN BEFORE THE STORM: ADULT-ONSET ASTHMA AND RASH AS HARBINGERS OF EGPA Nivedita Ravi1; Athina Vassilakis2. 1Vagelos College of Physicians and Surgeons, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 2Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4271424) CASE: A 74 year old female with newly diagnosed asthma developed a rash covering her arms, legs, and abdomen. The rash was presumed urticarial and effectively treated with solumedrol and famotidine, then recurred for ten days monthly, resolving without treatment each month. Three months later, she developed left leg and right hand weakness and numbness requiring walker and leading to difficulty writing and holding cutlery. She was treated for gout flare without response. Four months after symptom onset, she was admitted for ongoing rash, left leg and right hand weakness and numbness, and fifty-pound weight loss over two months. Exam was notable for non-blanching, large, erythematous plaque on abdomen, wheal on right leg, and purpura on both arms and legs. She had inspiratory and expiratory wheezes with normal heart exam. Labs were significant for WBC 5.12, eosinophils 11.9%/0.61, ESR 47, and CRP 68. CXR showed bilateral pleural effusions, and CT chest also showed pericardial effusion. Rheumatology, dermatology, neurology, and neurosurgery were consulted to reveal positive p-ANCA, mononeuritis multiplex on EMG, and skin and nerve biopsies with eosinophilic vasculitis. Chronic viral infections and hematologic malignancies were ruled out. She was treated for eosinophilic granulomatosis with polyangiitis with IV methylprednisolone 500 mg for 3 days with prompt resolution of rash and mononeuritis multiplex. She received an initial dose of rituximab prior to discharge on a steroid taper. IMPACT/DISCUSSION: Eosinophilic granulomatosis with polyangiitis (EGPA) is an ANCA-associated small-vessel vasculitis. The clinical symptoms of EGPA manifest in prodromal, eosinophilic, and vasculitic phases. The prodromal phase is characterized by new-onset asthma. The eosinophilic phase presents with eosinophilia and lung infiltrates, and the vasculitic phase with palpable purpura and peripheral neuropathy. In 2022, the American College of Rheumatology proposed weighted, point-based diagnostic criteria with positive points for asthma, nasal polyps, mononeuritis multiplex, eosinophilia, and biopsy-based extravascular eosinophilia, and negative points for hematuria and c-ANCA/PR3 antibodies. The multisystem symptomatology of EGPA presents a diagnostic challenge. In this case, the primary team obtained prior history, recognized the constellation of symptoms, and facilitated collaboration among specialists to select and interpret studies for rapid diagnosis. Unfortunately, existing criteria recognize the final, vasculitic phase of EGPA, leading to late diagnosis and progressive organ involvement requiring longer hospitalizations, higher steroid doses, and more immunosuppressive agents. Recognizing adult-onset asthma and non-blanching rash as early alarm symptoms could lead to more timely diagnosis.

Systemic symptoms in the setting of new-onset asthma should raise suspicion for EGPA. Promoting chest imaging for adults with newly diagnosed asthma and non-blanching rash may lead to earlier diagnosis. THE ROLE OF THE PRIMARY TEAM IN ADVANCING WORK-UP AND MANAGEMENT IN A CASE OF SEVERE DYSPHAGIA Ayush Kaushish, Jason Pecorella. Internal Medicine, Virginia Commonwealth University Department of Internal Medicine, Richmond, VA. (Control ID #4271033) CASE: A 73-year-old female with IgA lambda multiple myeloma (MM) on chemotherapy presented with difficulty swallowing for several months. She described a sensation of solids and liquids getting stuck in her chest, which began around the time she was diagnosed with MM and acutely worsened. She had 10-15 pounds of unintentional weight loss during this time. She denied odynophagia, chest pain, diarrhea, or oral lesions. Her medical history also included hypothyroidism and GERD, both well-controlled with levothyroxine and pantoprazole. Family and social histories were non-contributory. Gastroenterology (GI) was consulted and the patient underwent an upper endoscopy, which did not show any abnormalities. Subsequently, GI recommended outpatient follow-up with the possibility of a gastric tube if symptoms persisted or worsened. Speech therapy was consulted and did not recommend any additional inpatient evaluation. The patient’s symptoms remained debilitating, and as a result, the primary team ordered a fluoroscopic esophagram. This demonstrated severe diffuse esophageal dysmotility with stasis of contrast in the middle and distal esophagus, with associated tertiary contractions and proximal escape, as well as severe reflux to the level of the thoracic inlet. The etiology was hypothesized to be secondary to her MM and she was started on nifedipine XL 30 mg daily. Within 24 hours, her oral intake increased to include >75% of her meals. She was discharged home with outpatient GI follow-up, who noted that patient has had near complete resolution of her dysphagia several months later. IMPACT/DISCUSSION: This case highlights the important role primary teams have in patient advocacy. This patient presented with severe dysphagia, limiting her quality of life. Her diagnosis was not established until a provider on her primary team decided to obtain an esophagram. While specialist recommendations are valuable, responsibility for patient care ultimately falls on primary teams, who should feel empowered to advance work-up and management in complex cases. Another interesting aspect of this case was the extreme response to pharmacologic treatment. Although calcium channel blockers (CCB), like nifedipine, are routinely used to treat dysmotility disorders, their response is often temporary, variable, and complicated by side effects. However, this patient has responded well to daily use of CCB with near complete resolution of symptoms several months later, demonstrating a unique response to treatment.

Esophageal dysmotility disorders have many etiologies, and work-up includes dynamic imaging such as barium esophagram and manometry. Symptomatic response to CCBs is variable, but can provide long-term resolution in rare cases. When diagnostic uncertainty arises, physicians should feel empowered to advocate for their patients by advancing work-up and management. THESE AREN'T THE RHEUMATOID YOU’RE LOOKING FOR Asbah Rahman, Zarif Kazi, Haseeb Moiz, Aastha Randhawa, Vikash Ramtahal. Internal Medicine, Maimonides Medical Center, Brooklyn, NY. (Control ID #4242523) CASE: A 62-year-old man with a history of hypertension, psoriasis, and chronic back pain with 2 spinal fusions presented with shortness of breath, generalized muscle spasms, and a 60 pound weight loss over the past year. One year prior, he developed kyphoscoliosis which impaired his mobility and he underwent spinal surgery with fusion. He had been bed bound since his surgery due to his weakness but denied any prior joint pain. He had a 35 pack-years smoking history and quit 5 years ago. He worked as a doorman until he was limited by the back pain. Family history was notable for rheumatoid arthritis in the patient's mother, sister, and maternal aunt, as well as an unspecified autoimmune disease in his father. On physical examination, he had decreased range of motion in the hips and knees associated with pain and contractures. There was no synovitis or warmth in his joints. Crepitus was noted in the knees without effusion. His blood work was unremarkable. There was a concern for malignancy due to the severe weight loss and an abdominal CT was performed revealing thickening of the gastric wall at the fundus. Endoscopy with biopsy only showed H. pylori infection. Tumor markers were within normal limits. Due to the history of autoimmune disease, inflammatory and immune markers were done and revealed an elevated ESR, CRP, rheumatoid factor, and anti-CCP. A CT chest was done for the dyspnea and showed multiple nodules at the lung bases, a small left thick walled pleural effusion, trace right pleural effusion and honeycombing at the lung bases with bullous changes, with a usual interstitial pneumonia pattern. He was diagnosed with Caplan syndrome but was not started on immunomodulators due to the fact that there was no active synovitis. IMPACT/DISCUSSION: There was considerable delay in diagnosis of our patient’s rheumatoid pneumoconiosis for several years, likely because weight loss was the main complaint and he denied ever having joint pains. Even with severe, rapidly progressive symptoms that necessitated spinal surgery before the age of 65, no cause was worked up. His strong family history was not explored as a cause, and it took approximately three years for a diagnosis. He did not have typical risk factors for caplan syndrome such as exposure to silica or coal. Symptoms such as intermittent dyspnea should have been further explored and the extensive lung changes may have been prevented.

Rheumatoid arthritis can have a vague presentation without any risk factors and varied extra-articular manifestations. Diagnosis can be difficult when arthralgia is not the main complaint. Thorough history taking is needed in a difficult diagnostic case such as this so important diagnoses are not missed. THE SILENT FUNGAL INVASION: ASPERGILLUS BRAIN ABSCESS IN AN IMMUNOCOMPETENT ELDERLY PATIENT Jamie Therese Abad, Amanda Darzi, Kashmira Wani, Jasmine Omar. Internal Medicine, Henry Ford Hospital, Detroit, MI. (Control ID #4257276) CASE: An 84-year-old male with Alzheimer's disease, hypertension, coronary artery disease, atrial fibrillation and heart failure with preserved ejection fraction, presented with fever and headache after a fall. CT head showed a right frontal lesion with a differential including trauma, infarction, infection, or neoplasm. After being discharged with outpatient follow-up, the patient re-presented with confusion, prompting imaging that confirmed a persistent frontal lesion. He underwent craniotomy and drainage, confirming an abscess, with cultures growing Aspergillus. Notably, he had no preexisting lung conditions or lung pathology. He was discharged on prolonged voriconazole therapy. Despite treatment, he returned with persistent fever (up to 104.2° F) and new symptoms including ptosis, blurry vision and right eye drainage. Laboratory workup revealed leukocytosis, renal impairment, positive urinalysis with cultures growing Pseudomonas and negative blood cultures. MRI brain showed right post-craniotomy changes, multiple intra-axial brain abscesses, and possible cavernous sinus extension, indicating an unresolved empyema. Endophthalmitis was ruled out. Given poor prognosis, and extensive infection, Neurosurgery deemed surgical intervention unfeasible. Infectious Disease recommended continued voriconazole, vancomycin, metronidazole. Without source control, complete resolution was unlikely. His mentation declined, and he was discharged to hospice for comfort measures. IMPACT/DISCUSSION: This case highlights a rare and challenging presentation of an Aspergillus brain abscess in an elderly immunocompetent patient. Brain abscesses caused by Aspergillus are typically seen in immunocompromised individuals, often due to hematogenous spread from primary pulmonary or sinus infections. However, this patient, despite his advanced age and comorbidities, lacked a primary lung or sinus infection to suggest the typical pathophysiologic route. Aspergillus brain abscesses are notoriously difficult to diagnose early, often presenting with nonspecific symptoms such as headache, fever, and neurological deficits, delaying diagnosis. The patient’s condition deteriorated despite voriconazole therapy, which typically offers effective coverage for Aspergillus infections. The presence of multiple abscesses, subdural fluid collections, and the involvement of critical structures such as the cavernous sinus likely contributed to the difficulty in achieving source control. This case emphasizes the need for heightened awareness and early intervention in managing fungal brain infections, especially in patients with significant comorbidities.

- Consider brain abscess in elderly with fever, headache, and neurological changes, even in immunocompetent patients with no typical risk factors. - Early multidisciplinary consultation is essential for complex cases and poor prognosis. THE SILENT MIMIC: UNMASKING PHEOCHROMOCYTOMA IN A PATIENT WITH UNCONTROLLED HYPERGLYCEMIA AND INTERMITTENT FEVERS Brianna Smith, Yuqing Wang, Ayotunde I. Buremoh, Mylene Vista, Saira Akhtar. Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4272864) CASE: A 56-year-old man with type 2 diabetes and hypertension presented to the ER with uncontrolled blood sugars, intermittent nausea, vomiting, fevers, and a 15-pound unintentional weight loss over one month. He was recently hospitalized with similar symptoms, started on insulin, and evaluated for fevers with negative blood and urine cultures, which were attributed to a viral illness. At presentation, labs showed severe hyperglycemia, leukocytosis, elevated creatinine, and troponin, but infectious testing including urinalysis and chest X-ray was unremarkable. A transthoracic echocardiogram revealed diffuse left ventricular hypokinesis with an ejection fraction of 40-44%, prompting initiation of metoprolol. Despite increasing insulin, hyperglycemia persisted. A CT scan of the abdomen and pelvis was performed to evaluate for malignancy, revealing a solid cystic mass in the left adrenal gland measuring 8 x 7 x 9.3 cm. The patient developed hypertensive crises with systolic BP reaching 200 mmHg, alternating with orthostatic hypotension, requiring IV fluids. Suspecting pheochromocytoma, metoprolol was discontinued and phenoxybenzamine was started. Biochemical tests confirmed pheochromocytoma with elevated plasma metanephrine (950 pg/mL), urine metanephrine (7614 mcg/g creatinine), and plasma normetanephrine (875 pg/mL). He underwent left adrenalectomy and nephrectomy due to left renal vein involvement. Postoperatively, his glucose normalized, fevers resolved, and insulin was discontinued. Pathology confirmed the diagnosis of pheochromocytoma. IMPACT/DISCUSSION: Pheochromocytomas are rare adrenal tumors secreting excess catecholamines, leading to variable presentations. This case illustrates the challenges in diagnosing pheochromocytoma, when presentations deviate from the classic triad of headache, palpitations, and diaphoresis. The patient's severe hyperglycemia, intermittent fevers, and weight loss initially raised suspicion for infection or malignancy. However, labile severe hypertension alternating with orthostatic hypotension, combined with the imaging findings, pointed toward pheochromocytoma, with the diagnosis confirmed by elevated catecholamine metabolites and adrenal mass on imaging. Catecholamine surges, triggered by changes in tumor pressure or blood flow, explain hypertensive episodes and orthostatic hypotension. Hyperglycemia results from suppressed insulin, increased glucagon, and insulin resistance. Fevers may stem from catecholamine-induced IL-6 release, though occult infection must be excluded. Post-resection, catecholamine normalization resolves systemic effects.

Pheochromocytoma should be considered as a differential diagnosis for patients with atypical symptoms, particularly when unexplained hyperglycemia, intermittent fevers, and unintentional weight loss are present. Early diagnosis is crucial, as pheochromocytomas carry significant morbidity and mortality if left untreated. THE SILENT SPIRAL: MITRAL VALVE ENDOCARDITIS WITH SYSTEMIC EMBOLI IN A YOUNG PATIENT Charu Hasini Vasa, Yasitha Kakarlapudi, Rishika Trivedi, Pantoja Celia Rojas. Internal Medicine, DHR Health, Edinburg, TX. (Control ID #4272534) CASE: A 46-year-old male with uncontrolled diabetes mellitus presented with two weeks of worsening left second toe pain, purulent discharge, and systemic symptoms. On admission, he was hypothermic (T 94°F), tachycardic, and hypoxic on 5L nasal cannula. Examination revealed Janeway lesions, splinter hemorrhages, cyanosis of the right third finger, erythema with induration of the left shoulder extending to the chest wall, and scattered skin vesicles. Blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA), and echocardiography revealed a large mobile mitral valve vegetation (3.0 x 1.4 cm) with preserved ejection fraction (60%). MRI brain identified a right cerebellar hematoma with surrounding vasogenic edema, attributed to septic emboli. Persistent bacteremia despite IV oxacillin raised concerns for systemic embolization. The patient underwent surgical amputation of the left second toe for MRSA osteomyelitis. Progressive left shoulder pain prompted MRI, revealing osteomyelitis, septic arthritis of the AC/glenohumeral joints, and surrounding abscess/phlegmon. Cerebral edema was managed with hypertonic saline. Multidisciplinary collaboration, including infectious disease, neurosurgery, cardiology, and orthopedics, determined the need for urgent mitral valve replacement. The patient was stabilized and transferred to a tertiary center for surgical intervention and orthopedic washout. IMPACT/DISCUSSION: This case highlights the devastating complications of mitral valve infective endocarditis, including persistent bacteremia, systemic emboli, and multiorgan dysfunction. The patient’s rare presentation with skin vesicles and septic arthritis underscores the importance of recognizing atypical endocarditis manifestations. Laboratory findings revealed persistent MSSA bacteremia, leukocytosis (WBC 16,100/mm^3), and elevated inflammatory markers (CRP 32.5 mg/L, ESR 120 mm/hr). Imaging confirmed multiorgan involvement: large mitral valve vegetation (3.0 x 1.4 cm), a right cerebellar hematoma with vasogenic edema, osteomyelitis of the humeral head and distal clavicle, and bilateral renal/vertebral infarctions. The case demonstrates the necessity of timely surgical intervention to prevent irreversible complications from large vegetations. Effective communication between infectious disease, neurosurgery, cardiology, and orthopedics ensured stabilization and transfer for definitive care. It highlights the importance of recognizing embolic signs, strong antibiotic stewardship, and multidisciplinary collaboration.

- Uncommon manifestations of IE, such as skin vesicles and septic arthritis, require prompt recognition for timely management. - Early surgical intervention for large vegetation prevents catastrophic systemic complications. - Multidisciplinary coordination is vital in managing complex cases involving persistent bacteremia and systemic embolization. THE SILENT THREAT: FATAL OUTCOME OF BABESIA MICROTI AND BORRELIA BURGDORFERI CO-INFECTION DUE TO FULMINANT LIVER FAILURE Aya Elalfy, Igor Dumic, Tatjana Gavrancic. Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4272019) CASE: A 77-year-old male with a history of type II diabetes, stage IV chronic kidney disease, and heart failure with preserved ejection fraction (HFpEF) presented to an academic medical center in the Mid-West region with a two-week history of worsening dyspnea, dry cough, and bilateral lower extremity edema. The physical exam revealed jugular venous distension, crackles, and 3+ bilateral pitting edema without erythema. Chest X-ray showed bilateral pulmonary congestion and pleural effusions. Laboratory results indicated elevated pro-BNP and a creatinine level of 4 mg/dL (baseline 2.5 mg/dL), with normal electrolytes and liver enzymes. The patient was diagnosed with acute decompensated HFpEF and cardiorenal syndrome. Despite treatment with intravenous furosemide, he became oliguric and required hemodialysis. The next day, the patient became lethargic and developed acute liver failure (total bilirubin 6.8 mg/dL, direct bilirubin 4.2 mg/dL, AST 2656 U/L, ALT 1421 U/L), new thrombocytopenia (platelet count 95 x10^9/L), acute anemia (hemoglobin 7.7 g/dL), and an INR of 3.5. Viral hepatitis, drug-induced liver injury, and ischemic hepatitis were ruled out. Abdominal ultrasound and Doppler studies excluded cholecystitis and biliary obstruction and confirmed patent portal veins. The patient became hypotensive, prompting empiric therapy with ceftriaxone, vancomycin, and doxycycline for SIRS with an undetermined source of infection, followed by septic shock, requiring norepinephrine, vasopressin, phenylephrine, and dobutamine. Despite these efforts, the patient died. Postmortem analysis revealed intraerythrocytic inclusions consistent with Babesia microti, confirmed by blood PCR, and PCR-positive Lyme serology. IMPACT/DISCUSSION: Babesiosis and Lyme disease are tick-borne illnesses that can present with multi-organ involvement, including acute kidney injury (AKI) and encephalopathy. At admission, both infections were likely near the end of their incubation period, with symptoms emerging during heart failure treatment, making diagnosis challenging. It is unlikely that babesiosis caused the AKI, as the patient did not exhibit hemolysis or cast nephropathy. Although ceftriaxone covered both Lyme disease and neuroborreliosis, the absence of hemolysis delayed timely suspicion and treatment for babesiosis. Co-infection likely contributed to the poor outcome, as patients co-infected with Borrelia burgdorferi and Babesia microti often experience more severe and prolonged symptoms. In animal models, co-infection exacerbates Lyme disease symptoms, although its effect on Babesiosis symptoms is variable. Studies have shown that Babesia infection can attenuate the immune response, potentially enhancing the severity of Lyme disease.

-Tick-borne illnesses should be considered in patients with multi-organ dysfunction in endemic regions, even in the absence of erythema migrans or hemolysis. -Co-infection with Borrelia burgdorferi and Babesia microti can lead to more severe and prolonged illness. THE SPLEEN IS MORE USEFUL THAN WE THINK Brianna Skaff, Margaret Geertz, Mohammad Baseem Shaikh. Internal Medicine, University of Kentucky Medical Center, Lexington, KY. (Control ID #4232896) CASE: A 24-year-old female with immune thrombocytopenia (ITP) and splenectomy presented to emergency department with one month duration of vomiting and daily fevers. She recently completed a course of amoxicillin for treatment of Strep throat without improvement. She denied intravenous drug use but endorsed daily alcohol use. Initial workup was significant for white blood cell count 44.35, 85% neutrophils, lactate 1.2, ESR 67, and CRP 172, and no murmur heard on physical exam. Peripheral smear revealed red blood cell schistocytes and echinocytes. Blood cultures were positive for Streptococcus pneumoniae. Transthoracic echocardiogram (TTE) revealed a mitral valve vegetation. Imaging of brain showed acute infarction of right middle cerebral artery from septic emboli. She was treated with four weeks of the appropriate antibiotics. Given her history of splenectomy, she was advised to receive vaccinations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Repeat TTE after antibiotic completion revealed that her mitral valve vegetation had increased in size from the study one month prior. She underwent mitral valve vegetation removal due to high risk of repeat embolism. Transesophageal echocardiogram (TEE) post-operatively did not reveal perforation, prolapse, or other structural abnormalities. IMPACT/DISCUSSION: Streptococcus pneumoniae is a rare causative agent for infective endocarditis (IE) that accounts for about 1.2% of cases. Risk factors for pneumococcal endocarditis include extremes of age, alcoholism, immunosuppression, malnutrition, and prior valvulopathy. Our patient’s risk factors included splenectomy and alcohol use. The spleen plays an important role in IgM memory B cells, and without it, patients are at higher risk of developing infections with encapsulated bacteria. Our patient received vaccinations against these bacteria since her chances of IE, pneumonia, and meningitis were higher. TTE is useful in detection of vegetation, but TEE is more beneficial in discovery of complications such as valvular perforations and abscesses, which were not seen after TEE in our patient. Early surgery may be necessary for patients with the complications mentioned or persistent bacteremia despite appropriate antimicrobial therapy. As seen in our patient, her mitral vegetation rapidly grew in just the one month between presentation and surgery, necessitating prompt surgical intervention as extremely important.

Infective endocarditis caused by Streptococcus pneumoniae is very rare, however, the incidence may be higher in patients with splenectomy due to the lack of defense against encapsulated organisms. Patients with splenectomies should be educated to receive vaccinations against encapsulated organisms for prevention. THE STEROID EFFECT: RARE CASE OF ISOLATED ABDOMINAL NOCARDIOSIS Raya N. Abbasi1; Mumta Essarani2; Syed Nazeer Mahmood3. 1Internal Medicine, Bayhealth Hospital Kent Campus, Dover, DE; 2Internal medicine , Bayhelth Medical Center, Charlotte, NC; 3Pulmonary and Critical Care Medicine, Bayhealth Hospital Kent Campus, Dover, DE. (Control ID #4273160) CASE: A 63-year-old male with advanced chronic obstructive pulmonary disease (COPD) with recurrent exacerbations requiring multiple courses of prednisone over the last two years presented to the hospital with abdominal discomfort and urinary retention. CT abdomen and subsequent MRI of the abdomen and pelvis demonstrated a 5.4 x 6.3 x 7.2 cm pelvic mass along the right sidewall, suspicious for an abscess. Patient underwent CT guided pelvic drain placement with 75 ml of purulent drainage. Drain cultures were positive for Nocardia Farcinica. Further imaging did not reveal any thoracic or brain lesions. He was started on a three-week course of Bactrim with plans for prophylactic dosing given chronic steroid use. He was then discharged home with the pelvic drain with removal planned as outpatient, which was removed one week later (earlier than anticipated) due to significant discomfort. The patient was re-hospitalized one week later for COPD exacerbation and complaints of persistent abdominal pain. Repeat CT demonstrated re-accumulation of abscess, which was not amendable to drainage due to small size. Antibiotics changed to Linezolid and Doxycycline due to hyperkalemia. He was discharged with a plan to complete six weeks of Linezolid. IMPACT/DISCUSSION: Norcardia spp are gram-positive bacteria often found in soil, decaying vegetation, and aquatic environments. Transmission to humans occurs usually via inhalation or inoculation of the skin. Nocardiosis commonly affects immunocompromised hosts, particularly those with cell-mediated immunosuppression. One of the major risk factors being glucocorticoid therapy, which confers up to a five-fold increase in infection risk. Other risk factors include patients with solid organ malignancies, organ transplant, HIV infection, and primary immunodeficiencies. Nocardiosis typically presents as a pulmonary or central nervous system disease. Abdominal nocardiosis, however, is very rare. There have been approximately 39 cases of intra-abdominal and retroperitoneal nocardiosis, of which 12 were related to peritoneal dialysis. Treatment for Nocardiosis treatment can vary based on susceptibilities but empirically patients can be started on trimethoprim-sulfamethoxazole, amikacin, imipenem, or third-generation cephalosporins. Abdominal nocardiosis abscess also requires percutaneous drainage and follow-up imaging to assess for resolution of the fluid collection. Our case highlights a rare case of opportunistic infection due to prolonged use of steroids therapy in an end-stage COPD patient. It also highlights the need for close follow-up in an outpatient setting for COPD patients to prevent hospitalizations and to limit steroid use.

1. Chronic steroids are a risk factor for opportunistic infections . 2. Abdominal nocardiosis is a rare infection and can be considered as one of the differentials in an immunocompromised patient. THE THREAT WITHIN: ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY PRESENTING AS CARDIAC ARREST Mohamed Bassiony1; Alena Gonzalez1; Avery Hum1; Ariela Baur1; Pedro Rafael Vieira de Oliveira Salerno1; Colin Carpenter1; Tanuj Gupta2; Arun Mahtani3; Ayesha Samad4; Apurva Sharma2. 1Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2SUNY Downstate Health Sciences University, New York, NY; 3Virginia Commonwealth University, Richmond, VA; 4Hackensack Meridian Hackensack University Medical Center, Hackensack, NJ. (Control ID #4272116) CASE: Background: Arrhythmogenic Cardiomyopathy (ACM) is a complex form of cardiomyopathy with a prevalence of around 1 in 2,000 to 5,000 in the general population. It is characterized by genetic inheritance and structural changes in the myocardium, leading to electrical instability and potential sudden cardiac death. It can affect either the left or the right ventricle, with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) being one variation characterized by progressive loss of right ventricular myocardium and its replacement by fibrofatty tissue. Case: A 23-year-old Hispanic male with no previous medical history was brought to the emergency department after experiencing ventricular fibrillation (VFib) arrest while eating lunch. Following successful resuscitation, ECG showed sinus rhythm with anteroseptal ST elevation and a QTc of 452. A Transthoracic Echocardiogram (TTE) revealed an LVEF of 50% with RV dilatation. Left heart catheterization revealed normal coronaries. Cardiac MRI (cMRI) revealed an LVEF of 64%, an RVEF of 34%, micro-aneurysms of the mid-to-apical RV free wall, and late gadolinium enhancement (LGE) of the right ventricular inferior wall and free lateral wall, consistent with ARVC. Genetic testing was positive for PKP2 variant. The patient received an implantable cardioverter-defibrillator (ICD) and was started on metoprolol for management of ARVC. IMPACT/DISCUSSION: Decision-making: Around 10% of deaths in individuals under 65 from undiagnosed cardiac disease are due to ARVC. Diagnosing ACM is challenging due to its nonspecific features and phenotypic variations. Task Force Criteria have been developed to aid in diagnosis, using family history collection, ECG findings, recognition of phenocopies, and various echocardiographic and cMRI parameters. Treatment includes limiting physical activity, using antiarrhythmic medications, catheter ablation, secondary prevention with ICD, and potential evaluation for cardiac transplantation in refractory cases.

Conclusion: This case emphasizes the importance of maintaining clinical suspicion for ARVC in cases of VFib in young male patients. Advanced diagnostic techniques allow for accurate diagnosis but require keeping ACM on the differential. THE TRIPLE THREAT: EXPLORING HIGH-GRADE FEVER WITH CYTOPENIA AND SPLENOMEGALY Abijha Boban1; Moyan Sun2; Vikas Kilaru1. 1Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 2Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4271633) CASE: 28-year-old male with no past medical history presented with abdominal pain, fever, nausea and vomiting for 2 weeks. Patient had a fever of 100.4, white count 1.8, platelet count 28, bilirubin 10 elevated AST and ALT, AKI with creatinine of 1.3. RUQ showed hepatomegaly. CT chest, abdomen pelvis showed splenomegaly and herniated appendix, but no signs of any malignancies or infection. He was hypotensive despite 3 L of isotonic fluid bolus, started on norepinephrine 5 mcg, He was also started on empiric antibiotics Zosyn and vancomycin. Patient was admitted with similar complaints 6 months ago, with workup showing positive EBV antigen, and mildly positive dengue fever IgG, but negative histoplasma, blastomycosis, gold QuantiFERON, peripheral smear for Malaria and was discharged on antibiotics, infectious disease was consulted. Infectious disease recommended heme onc consulted due to concern for HLH. Patient became tachycardic and tachypneic requiring mechanical ventilation followed by pressor support for hypotension. On Heme Onc evaluation, the patient had a H score of 254, making him 99% likely to have Hemophagocytic lymphohistiocytosis (HLH). He was started on biweekly Etoposide and Decadron. Autoimmune workup showed decreased complement levels and ANA positive. Infectious disease workup was positive for parvovirus and EBV virus, with EVB quantitative titers at 236,000, for which he was started on weekly Rituxin. The patient improved within 3 days, was extubated, came off all pressor support and was transferred out of the ICU. IMPACT/DISCUSSION: HLH has been shown to be familial, or secondary to infection, autoimmune conditions (i.e. SLE), or malignancy. Diagnosis can be made if triad of high-grade fever, cytopenia, splenomegaly are present followed by confirmation via the H score. HLH-94 comprising of Etoposide and Decadron, has been the favored treatment regimen. In refractory, recurrent or progressive diseases, Emapalumab, has been used with up to 73% survival at 12 months. In EBV induced HLH, Rituxin is typically as it has been shown to reduce viral outcomes.

It is imperative to be aware of the triad as prompt treatment could make a difference in mortality. THE TURBULENCE OF A BROKEN HEART: A CASE OF TAKOTSUBO CARDIOMYOPATHY-INDUCED VENTRICULAR FIBRILLATION James Pollock, Susan A. Feldman, Chandler Richardson, Logan Carlyle. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4273456) CASE: A 65-year-old female with past medical history significant for hypertension, obstructive sleep apnea, and gastroesophageal reflux disease was brought to the emergency department via ambulance with complaints of chest pain that began while she was at a movie theater. She received sublingual nitroglycerin and aspirin while en route, but her heart rhythm degenerated into ventricular fibrillation which successfully broke with one-time defibrillation. She did not lose consciousness and did not require intubation nor cardiopulmonary resuscitation. Initial rhythm after defibrillation was sinus bradycardia. Upon arrival to the hospital, she was administered an amiodarone bolus and started on amiodarone infusion. Initial high-sensitivity troponin was 17 ng/L. EKG was negative for ischemic changes. CT angiogram of the chest was negative for acute abnormalities. Transthoracic echocardiogram (TTE) was significant for a left ventricular ejection fraction (LVEF) of 50% with apical ballooning. Overnight, her troponin rose as high as 517 ng/L and she experienced recurrence of spasm-like chest pain rated 10/10 in severity. Repeat EKG was significant for ST-segment elevation in leads V2, V3, I, and aVL. Patient was taken for immediate left heart catheterization, and she was found to have mild-to-moderate coronary disease of the distal right main coronary artery and left anterior descending artery without critical lesions. Upon returning to the floor, she denied ongoing chest pain and an EKG showed no ST-segment elevations. Routine labs, including daily basic metabolic panels, magnesium, and phosphorus, were negative for electrolyte abnormalities. Cardiac MRI revealed normal left ventricular size and systolic function with an LVEF of 54%. Late gadolinium enhancement imaging was negative for myocardial fibrosis and infiltrative myocardial disease. Follow up conversation with the patient revealed that she had recently experienced two separate traumatic losses in the weeks prior to presentation. Given the findings on TTE and lack of other explanatory etiology, this patient most likely experienced acute stress-induced cardiomyopathy with complicating ventricular fibrillation. Dual-chamber ICD was implanted for secondary prevention prior to discharge. IMPACT/DISCUSSION: Physiological stress can induce a profound catecholamine release that causes regional myocardial stunning, resulting in a stress-induced cardiomyopathy (or Takotsubo cardiomyopathy). While this variety of cardiomyopathy is typically reversible, the acute pathologic state can rarely complicate with lethal arrhythmias like ventricular fibrillation, as occured in the described case. Understanding the potential for this complication may help prevent future mortality in affected patients.

This case highlights the potential for secondary arryhthmias in patients with acute stress-induced cardiomyopathy and the need for providers to be vigilant in monitoring for such complications to mitigate the risk of further mortality. THE UNEXPECTED HEARTBREAK: STRESS-INDUCED MIDVENTRICULAR TAKOTSUBO CARDIOMYOPATHY Mazhar Shapoo2; America Silva1; Amir Iqbal1. 1Internal Medicine, Wayne State University, Detroit, MI; 2Internal medicine, Wayne State University, Detroit, MI. (Control ID #4273141) CASE: A 51-year-old woman with a past medical history of mitral valve prolapse, mitral annulus disjunction, intermittent palpitations status post Medtronic loop recorder and hypothyroidism who presented for a scheduled dobutamine stress test to evaluate for structural cardiac disease. Prior interrogation of the loop recorder showed several episodes of atrial tachycardia with bigeminy and atrial fibrillation. During the dobutamine stress test, at peak dose there was preserved apical and basal function with hypokinesis of mid-segments and the ejection fraction (EF) declined to 35-40%. In the recovery period, the relative preserved apical and basal segment contractility with an EF of 30%. The patient was admitted for overnight monitoring and a repeat transthoracic echocardiogram (TTE) was obtained. It showed a left ventricular EF of 35-40% with apical and basal segment contractility relatively preserved, compared to mid segments that appeared akinetic/dyskinetic. This regional dysfunction is consistent with Takotsubo cardiomyopathy, the mid-ventricular variant type. During the test, the patient reported head heaviness but denied dyspnea and dizziness. The patient remained stable during overnight monitoring and was ultimately discharged with close follow-up for another repeat TTE outpatient. IMPACT/DISCUSSION: Midventricular Takotsubo cardiomyopathy is an uncommon variant, representing approximately 14.6% of all TTC cases. Common triggers include intense emotional or physical stress, resulting in a surge of catecholamines. In this case, the patient's stress test likely induced excessive catecholamine release, precipitating the midventricular TTC. Diagnosing TTC can be challenging due to its similarity in symptoms and electrocardiogram findings to acute coronary syndrome. It is estimated that TTC accounts for 2% of suspected ACS cases. However, TTE can provide strong evidence for TTC, often revealing akinesis or dyskinesis of the mid-anteroseptum, mid-inferoseptum, mid-inferior wall, mid-anterior wall, and the mid-anterolateral wall. This pattern aligns with the presentation observed in our patient's midventricular TTC. Typically, TTC is a transient condition managed conservatively with supportive care, including stress reduction. However, clinicians must remain vigilant as some patients may develop acute decompensated heart failure and subsequent cardiogenic shock. Therefore, awareness of this condition is critical for physicians to ensure appropriate diagnosis and management.

This case presents a rare instance of stress-induced midventricular Takotsubo cardiomyopathy during a dobutamine stress test. It highlights that physiological stress can precipitate TTC, even without overt emotional distress. This transient mid-ventricular dysfunction with preserved apical and basal function emphasizes the diverse presentations of TTC. Careful evaluation during stress testing is crucial. The case illustrates the typically benign and reversible nature of TTC with conservative management. THE UNUSUAL SUSPECT: LEMIERRE'S SYNDROME FROM ARCANOBACTERIUM HAEMOLYTICUM Chanan R. Batra1; Nicholas Litsky3; Husayn F. Ramji2; Farheen Surtie4. 1Internal Medicine, Tulane University School of Medicine, New Orleans, LA; 2Internal Medicine, Tulane University School of Medicine, New Orleans, LA; 3Tulane University School of Medicine, New Orleans, LA; 4Pulmonary and Critical Care, Tulane University School of Medicine, New Orleans, LA. (Control ID #4273057) CASE: A 20-year-old female presented with a 5-day history of flu-like symptoms, emesis, shortness of breath, and decreased oral intake due to non-radiating neck pain. On arrival, she was tachycardic, tachypneic, and hypoxic to 92% on room air. Examination revealed retropharyngeal erythema and left uvular deviation. Labs showed leukocytosis and anion gap metabolic acidosis. Imaging revealed bilateral tonsillitis, left internal jugular (IJ) vein thrombosis, retropharyngeal edema, and bilateral pulmonary septic emboli likely originating from the IJ thrombus. Cultures were obtained and empiric broad-spectrum antibiotics were started. Despite initial treatment, her respiratory status worsened, requiring bilevel positive airway pressure and admission to the medical intensive care unit (MICU) for acute hypoxic respiratory failure. She progressed to septic shock, necessitating pressors, intubation, and the addition of azithromycin to her antibiotic regimen. Blood cultures on MICU day two grew Arcanobacterium haemolyticum. With an IJ thrombus, pulmonary septic emboli, and bilateral pleural effusions in the setting of an acute anaerobic oropharyngeal infection, the patient was diagnosed with Lemierre’s syndrome. Pleural effusions noted on initial imaging continued to grow, prompting Interventional Radiology consultation for bilateral thoracenteses that were subsequently converted to chest tubes for a right-sided empyema and left-sided parapneumonic effusion. Following over two liters of purulent fluid drainage and ten days of intubation, the patient was extubated and transitioned to high-flow nasal cannula, later stepping down to the medicine floor for continued treatment. IMPACT/DISCUSSION: Lemierre’s syndrome is septic thrombophlebitis of the internal jugular vein, typically following anaerobic oropharyngeal infections. It is a rare cause of septic pulmonary emboli and can result in acute respiratory failure with high mortality. While Lemierre’s is most commonly caused by Fusobacterium necrophorum, this case highlights a rare instance of A. haemolyticum as the pathogen, with only one other reported case in the literature. Studies on A. haemolyticum antibiotic susceptibility are limited, though a regimen that includes penicillins and macrolides appears effective. The rapid progression of this patient’s disease underscores the importance of timely source control and tailored antibiotic therapy. Empyemas are difficult to treat with antibiotics alone, and chest tube placement was crucial in resolving our patient’s systemic inflammation. Following drainage, a regimen of ceftriaxone, azithromycin, and piperacillin-tazobactam effectively addressed her infection.

This case highlights A. haemolyticum as a rare but important pathogen in Lemierre’s syndrome, emphasizing the need for early recognition, source control, and appropriate antibiotic therapy. Having a high clinical suspicion for A. haemolyticum is imperative as treatment necessitates the addition of a macrolide. THE WEIGHT OF A SIDE EFFECT: RHABDOMYOLYSIS AND SEMAGLUTIDE Patrick G. Smith1; Anila Mehta1; Meenu Singh2. 1Internal Medicine, University of Utah Health, Salt Lake City, UT; 2Internal medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4272593) CASE: This case involves a 36-year-old male with Class I obesity who presented with bilateral thigh pain and subjective leg weakness. He recently attended a spin class and initially attributed his leg pain to muscle soreness. Unfortunately, this pain progressively worsened and did not improve with acetaminophen. He also reported dark-colored urine, which appeared to improve with increased hydration. His only home medication was semaglutide, which he started a month prior for weight loss. The patient denied history of seizures, recent falls, trauma or physical exertion out of norm for him. Besides bilateral quadricep tenderness and limited ambulation due to pain, physical examination was unremarkable with intact strength, sensation, and reflexes. Labs revealed an elevated CK level of 16,202 U/L, AST of 279 U/L, and ALT of 77 U/L. Creatinine was within normal range. Urinalysis revealed myoglobinuria (proteinuria, hematuria without red blood cells). The patient was admitted for further laboratory monitoring and aggressive intravenous fluid resuscitation for rhabdomyolysis. His CK peaked at 26,000 U/L, declining to 5,000 U/L post-resuscitation. The patient was subsequently discharged. Semaglutide was considered the likely trigger for rhabdomyolysis given significantly elevated CK levels and no other clear etiologies. His dosing history involved titration from 0.5mg to 2.4mg weekly over 4 weeks, with the first 2.4mg dose administered a week before presentation. IMPACT/DISCUSSION: Only one prior case of semaglutide-associated rhabdomyolysis has been reported involving a 47-year-old woman receiving semaglutide 1.7 mg weekly. She presented with myalgia, weakness, and fatigue, with subsequent diagnosis of rhabdomyolysis. Our patient exhibited similar features, meeting rhabdomyolysis diagnostic criteria with elevated CK, subjective muscle weakness, dark urine and myoglobinuria in absence of traditional causes (trauma, crush injury, compartment syndrome, immobilization). The exact mechanism by which GLP-1 agonists such as semaglutide may induce rhabdomyolysis remains unclear. GLP-1 receptors, while primarily found in the pancreas, also exist in skeletal muscles, potentially linking overstimulation at higher doses to side effects.

The utilization of GLP-1 agonists continues to grow due to their demonstrated benefits in weight loss, glycemic control and cardiorenal function. While gastrointestinal side effects remain the most frequently reported adverse event, emerging case reports continue to identify additional, rare side effects. This case highlights an important association between semaglutide and rhabdomyolysis. Clinicians should be vigilant for rhabdomyolysis when prescribing GLP-1 agonists and investigate any concerning symptoms. THE WORLD’S UNLUCKIEST HEART: A CASE OF COMMOTIO CORDIS IN THE PRESENCE OF HYPERTROPHIC CARDIOMYOPATHY. Colin Carpenter, Alena Gonzalez, Ariela Baur, Samantha Lo, Avery Hum, Mohamed Bassiony, Pedro Salerno. Medicine, Mount Sinai Health System, New York, NY. (Control ID #4271806) CASE: A 30-year-old man with no significant medical history was brought to the ED for a ventricular fibrillation (VF) arrest after he was hit in the chest by a soccer ball during a game. After successful resuscitation, exam was notable for a 3/6 systolic murmur heard in the 5th intercostal space at the left sternal border. Electrocardiogram showed left ventricular hypertrophy with ST elevations in V1 and V2. Echocardiogram revealed severe left ventricular hypertrophy, diastolic dysfunction, and systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction and a gradient of 111 mmHg. A dual-chamber AICD was placed prior to discharge. Metoprolol and disopyramide were started for HCM management. The patient tolerated the procedure well; he was discharged home with outpatient cardiology follow up and continues to do well five months later with no further cardiac events. IMPACT/DISCUSSION: Commotio cordis (CC) is the second most common cause of sudden cardiac death in young athletes behind hypertrophic cardiomyopathy (HCM). When comparing HCM and CC, both cause ventricular fibrillation(VF), but their mechanism of action is different. For example, the immediate trigger for VF in CC is likely a focal phenomenon induced by direct impact, similar to a premature ventricular contraction seen in electrophysiology labs or cardiac catheterization procedures. Alternatively, it could be an afterdepolarization induced by changes in current flow, similar to the R-on-T phenomenon observed in acute ischemia or in long-QT syndrome. On the other hand, in HCM , the obstruction is dependent on contractility and loading conditions and may lead to ventricular arrhythmias and sudden death due to increased myocardial ischemia.

In this case, although the history was suggestive of CC as a cause of the VF, the accidental discovery of HCM introduces ambiguity to accurately identify the primary cause of the VF. HCM has not been posited as a risk factor for CC, but given the lack of consensus around the mechanism of CC, it is difficult to state with certainty that there is no association between these two rare cardiac conditions. THINK TWICE ABOUT ASTHMA Jordan Nunnelee, James Utz. Internal Medicine, Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4231956) CASE: A 67-year-old woman with a medical history of osteopenia and childhood asthma presented to her local clinic with progressive dyspnea, wheezing, and fatigue. Chest x-ray demonstrated a right lower lobe opacity on initial evaluation. She was treated with antibiotics as well as inhalers without improvement. Follow-up CT revealed nearly collapsed right lower lobe with dense bronchial material and left lower lobe central bronchiectasis. Previously active, she now experienced dyspnea after 300 steps and subsequently presented to the emergency department. She arrived normotensive, with normal oxygen saturations on room air. There were decreased breath sounds in the right lower lung fields, though no abnormal breath sounds or increased work of breathing at rest. Laboratory tests showed mild leukocytosis (12.8x10^9) with hypereosinophilia (1.92x10^9). Histoplasma and Blastomyces antigens were negative. Bronchoscopy demonstrated significant mucous impaction of the right lung below the right upper lobe takeoff. Copious rubbery mucous was aspirated, some forming casts. Anti-Aspergillus IgE and IgG were elevated, and bronchial washings cultures were positive for Aspergillus fumigatus and Aspergillus niger complex. She was diagnosed with allergic bronchopulmonary aspergillosis (ABPA) and treated with prednisone and posaconazole, resulting in improved exercise tolerance. IMPACT/DISCUSSION: This case demonstrates a classic case of allergic bronchopulmonary aspergillosis (ABPA), though with an absence of a characteristic lifelong chronic, refractory asthma history. She did have childhood and more recent recurrent asthma symptoms not responsive to inhalers. Our patient met diagnostic criteria for ABPA through her predisposing asthma, positive serum anti-Aspergillus fumigatus IgE and elevated total IgE >1000 IU/mL (both required), hypereosinophilia, elevated serum anti-Aspergillus IgG, and CT imaging demonstrating typical findings of mucoid impaction leading to bronchial obstruction and central bronchiectasis. Bronchoscopy confirmed stiff mucoid bronchial material characteristic of ABPA. The Infectious Diseases Society of America recommends antifungal treatment upfront to reduce long-term steroid use. Our patient was started on posaconazole due to her osteopenia and significant disease burden. ABPA is not an invasive Aspergillus infection, but rather a reactive process thought to be a Th2-mediated response to inhaled Aspergillus antigen. A delay in diagnosis can lead to irreversible bronchiectasis due to recurrent inflammatory response.

It is important to consider ABPA in a patient with history of refractory asthma, even if asthma symptoms are only recently recurrent. ABPA should be suspected when acute infection has been ruled out. Bronchoscopy can be helpful to identify and remove mucoid bronchial material, which is diagnostic and therapeutic in cases of bronchial obstruction. THROMBOLYSIS IN CRISIS: NAVIGATING PULMONARY EMBOLISM LEADING TO CARDIAC ARREST Serafino LaGalbo1; Nicole C. Nowak2; Sarah Van Dorin1; Hilary Faust1. 1Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; 2Internal Medicine, Rush University Rush Medical College, Chicago, IL. (Control ID #4271800) CASE: A 32-year-old male with a pertinent medical history of alcohol use disorder was transferred from an outside hospital after presenting with dyspnea, pleuritic chest pain, and a recent fall while intoxicated. Upon initial presentation, the patient was mildly hypotensive with response to IV fluids, tachycardic to 126 bpm, tachypneic and satting 91%. Labs were notable for platelet count of 179, INR of 1.7 in addition to elevated lactate and troponin I. CTPE revealed a saddle pulmonary embolism (PE) with right ventricular (RV) strain and septal bowing. Imaging of the patient’s head was unremarkable. Given concern for recent head trauma and elevated INR in the setting of an intermediate-high risk PE, systemic tPA was deferred and the patient was started on a heparin drip prior to being transferred with plans for mechanical thrombectomy. On arrival, the patient continued to be hypotensive and tachypneic and was intubated prior to thrombectomy. Shortly thereafter, the patient suffered asystolic cardiac arrest and CPR was initiated. During resuscitation, the decision was made to administer tPA at ½ the typical dose (50mg bolus) given concern for coagulopathy. Return of spontaneous circulation was achieved shortly thereafter, however the patient again suffered v-tach arrest with eventual ROSC. An additional 50 mg tPA was administered at this time to achieve full dose lytic therapy after discussion with cardiology, and the patient was stabilized with eventual extubation in the succeeding days. IMPACT/DISCUSSION: This case underscores the complex decision-making involved in the management of massive PE in the setting of hemodynamic instability and coagulopathy. This patient initially presented with several risk factors for poor prognosis including RV dysfunction and tachycardia, however the patient remained relatively stable hemodynamically after IV fluid challenge prior to transfer. Relative contraindications to tPA such as concern for coagulopathy and trauma further complicated the decision to initially withhold systemic thrombolysis. Given the acuity of cardiac arrest secondary to obstructive shock, tPA was ultimately the most effective method of treatment. An additional consideration in cases such as this is the variation in thrombolytic dosing during scenarios involving cardiac arrest compared to standard dosing protocols. While current guidelines recommend administration of 100 mg of tPA as an infusion over 2 hours for hemodynamically stable patients, recommendations surrounding cardiac arrest suggest a more aggressive approach which was employed in this case.

Management of pulmonary embolism in the setting of hemodynamic instability and coagulopathy requires careful risk stratification involving both the patient’s clinical status and the risks of thrombolytic therapy. Standard thrombolytic dosing protocols differ significantly from those recommended during cardiac arrest secondary to PE, where a more aggressive approach to systemic thrombolysis is indicated. THYROTOXICOSIS COMPLICATED BY IATROGENIC CARDIOGENIC SHOCK: A CASE OF MISSED CARDIAC FAILURE Vasiliki Tasouli-Drakou1; Jasmine Dugal1; Ryan Shao2; Divyansh Sharma2. 1Internal Medicine, University of Nevada Las Vegas Kirk Kerkorian School of Medicine, Las Vegas, NV; 2Cardiovascular Medicine, University of Nevada Las Vegas, Las Vegas, NV. (Control ID #4272603) CASE: Thyrotoxicosis-induced cardiomyopathy represents a rare, yet life threatening form of dilated cardiomyopathy. In addition to tremors, sweating, and weight loss, patients with thyrotoxicosis-induced cardiomyopathy may also demonstrate severe clinical features, such as arrhythmias, shock, and pulmonary edema. Delayed recognition and mismanagement of these symptoms, especially when coupled with postponed echocardiographic evaluation, can potentially precipitate the disease progression and increase the risk of adverse outcomes, including mortality. We present the case of a 49-year-old male with no past medical history who presented with dyspnea, cough, and palpitations, one week after developing fever. Initial evaluation revealed atrial fibrillation with rapid ventricular response (AFib RVR), a heart rate of 146 BPM, a TSH level of <0.008 IU/L, and a T4 level of 2.99 NG/DL, consistent with severe hypothyroidism. In the emergency department, he received an IV diltiazem bolus, followed by a diltiazem infusion for rate control, and oral propranolol for treatment of thyroid storm. A transthoracic echocardiogram (TTE) was ordered but not yet performed. Although heart rates improved, shortly thereafter, he became hemodynamically unstable with development of cardiogenic shock. TTE showed a severely reduced left ventricular ejection fraction of 20-25%. Medications were discontinued and the patient was upgraded to ICU where he received vasopressor infusions, methimazole for thyrotoxicosis, and Continuous Renal Replacement Therapy for acute renal failure. After resolution of cardiogenic shock, he underwent a successful cardioversion for atrial fibrillation and was discharged in sinus rhythm on methimazole and metoprolol. IMPACT/DISCUSSION: Thyrotoxicosis-induced cardiomyopathy is a potentially fatal condition. Initiating rate-control medications such as diltiazem for AFib RVR and propranolol to address hyperthyroid symptoms without first evaluating the patient’s cardiac function can precipitate severe complications. These interventions may lead to florid iatrogenic cardiogenic shock by impairing myocardial function in an already compromised state.

Early and comprehensive evaluation is critical to guide appropriate treatment and mitigate risk. This case demonstrates the importance of utilization of point-of-care ultrasound and the avoidance of medications that could precipitate symptoms of heart failure in the setting of thyrotoxicosis. TIKTOK HELPS AN ANCIENT APHRODISIAC POISON MAKE A COMEBACK Caroline Burley. Department of Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4273177) CASE: A 55-year-old male patient with a history of hypertension, hyperlipidemia, tobacco use disorder, and erectile dysfunction presented to the hospital with hematemesis. Patient reported earlier that night he had taken a "Blue chew" (Sildenafil 30 mg chewable tablet) and 5-6 drops of "Bluestone Drops for Men.” He purchased both products on Amazon after learning about them through TikTok. Patient noted the recommended dosage of the drops was 1 drop, but he increased the dose to ensure efficacy. He initially felt normal, but 2 hours later woke up and started coughing up blood and mucous. A short time later, his partner reported he started projectile vomiting blood and stomach contents. When the vomiting stopped, the patient appeared diaphoretic, closed his eyes and slumped over. He was briefly unresponsive, at which time EMS arrived. They found the patient only responsive to pain and disoriented with BP 197/112. In the hospital vitals were remarkable for tachypnea and hypertension. Patient was altered but able to follow commands. Imaging was unremarkable. Labs showed a mild troponin elevation, without ischemic EKG changes. He was treated with IV PPI and isotonic fluid infusion. He had no further episodes of emesis or hematemesis after hospital arrival, and confusion and drowsiness resolved after about 2 hours. Patient reported it was his first time taking the drops. The only medical problems he noted were a chronic cough and erectile dysfunction over the last year. He rarely sees doctors and had not consulted a doctor for his erectile dysfunction. Patient was discharged after observation for toxic ingestion causing hematemesis complicated by likely vasovagal syncope and elevated troponin due to demand ischemia. Further research revealed the “Bluestone drops” the patient ingested contained “Spanish Fly” (Lytta vesicatoria), which is known to cause hematemesis. IMPACT/DISCUSSION: Lytta vesicatoria (“Spanish Fly”) are beetles that secrete cantharidin, which has been used for over 2,000 years as both an aphrodisiac and abortifacient. Cantharidin is a vesicant and is thought to cause priapism in men and pelvic organ engorgement in women via genitourinary inflammation. If ingested it is toxic in a dose-dependent manner. Cases of toxicity are rare in the literature, but the most common symptoms in case reports were mucosal irritation, dysphagia, nausea, hematemesis, gross hematuria, and dysuria. Treatment is supportive care. Testing for cantharidin is not available, and diagnosis is solely based on history and symptoms.

Cantharidin, colloquially called “Spanish Fly,” is present in some herbal supplements for sexual dysfunction, which have recently gained greater visibility on TikTok. If ingested, it can cause gastrointestinal and genitourinary tract bleeding, which is managed with supportive care. It is important to screen for use of over-the-counter formulations and herbal supplements to treat sexual dysfunction, and educate patients on the risks of these readily available products. TO CLOSE OR NOT TO CLOSE: A HYPOXIC PFO Bernita V. Sidhu, Alyssa Heric, John M. Clark. Internal Medicine, Lankenau Medical Center, Wynnewood, PA. (Control ID #4272412) CASE: A 77-year-old female with COPD, cutaneous lupus erythematosus, CHB with a BiV pacemaker, hypertension, and hypothyroidism, presented to an emergency department in Mexico while on vacation found to be hypoxic, suspected of having pneumonia and was treated with antibiotics. Unresolving, she presented to our facility hypoxic to 86%, tachypneic, normotensive, afebrile with unrevealing labs. Chest X-ray (CXR) showed mild bilateral pleural effusions. She remained hypoxic despite BiPAP. During a rapid response for worsening hypoxia, she was intubated for acute hypoxic respiratory failure. EKG showed paced rhythm, and CTA Chest was negative for pulmonary embolism. Echocardiogram showed biventricular dysfunction with myocardial appearance and strain pattern suspicious for cardiac amyloidosis. Bubble study revealed early, high volume agitated saline moving within 3 beats of injection from the right heart to the left heart, suggesting PFO with right-to-left shunting. Despite optimization with low positive-pressure ventilation through PEEP reduction and paralysis, she remained hypoxic requiring continuous bagging. Her PFO was closed with a 30 mm Amplatzer device and her hypoxia resolved entirely, with a subsequent TEE showing no immediate impact on cardiac function. However, 2–3 hours after the PFO closure, she developed hypotension. Despite initiation of dobutamine, TTE showed worsened biventricular function. A right ventricular assist device (RVAD) using a Protek Duo catheter was placed to provide cardiac support. Repeat CXR revealed pulmonary edema prompting IV diuresis. A Swan-Ganz catheter was placed for hemodynamic monitoring, revealing CVP 18, PA 32/19, PCWP 18, and MVO2 60. RVAD was ultimately weaned and removed. Repeat TTE showed an EF of 45-50% with moderately reduced RV dysfunction. Despite support, her prognosis remained poor, and family pursued comfort care. IMPACT/DISCUSSION: Closing a PFO can improve oxygenation and reduce the risk of paradoxical embolism, but it also carries potential risks, especially for patients with compromised right heart function. The closure of a PFO removes a low-resistance pathway that the heart may rely on to relieve pressure, which can worsen right ventricular function in those with underlying strain or elevated pulmonary pressures. In such cases, PFO closure can exacerbate right heart strain, potentially leading to cardiogenic shock. In our patient, there were also signs of likely infiltrative disease impacting biventricular cardiac function. However, due to her persistent acute hypoxic respiratory failure with no other identifiable cause, the decision was made to close the PFO.

Currently, there are no established guidelines for PFO closure outside of cases involving cryptogenic stroke. Decision-making is largely extrapolated from published ASD closure experiences. This case is presented to contribute to the existing evidence on the considerations and potential complications of closing a long-standing, reversed shunt. TO DOAC OR NOT TO DOAC: EXAMINING THE DISCHARGE MANAGEMENT OF A YOUNG ADULT WITH VENOUS THROMBOEMBOLISM Jennifer John1; Yazmin Rustomji2; Ginu Kurian3; Shuvani Sanyal2. 1School of Medicine, A T Still University - Arizona Campus, Mesa, AZ; 2Internal Medicine, Rush University Medical Center, Chicago, IL; 3Internal Medicine, Virginia Commonwealth University, Richmond, VA. (Control ID #4272965) CASE: A 23-year-old female with obesity and hypothyroidism presented with chest pain, cough, and leg pain following a recent flu-like illness. She had discontinued her OCPs a few months earlier. In the ED, she was tachycardic but saturating well. CBC, CMP, TSH, troponins, and a CXR were unremarkable. A bilateral lower extremity US revealed a partially occlusive DVT in the left common femoral and deep femoral veins. A CTPE confirmed multifocal acute pulmonary emboli. She was started on heparin and then admitted. TTE showed no right heart strain. She denied any personal or family history of autoimmune conditions, pregnancy losses, or prior VTEs. The patient’s young age and multiple sites of venous thrombosis prompted further evaluation for hypercoagulable disorders. Given her risk factors of recent viral illness, morbid obesity, and previous oral contraceptive use, she was transitioned to rivaroxaban at discharge. One week later, she returned to the ED with heavy menstrual bleeding. During this visit, her antiphospholipid antibody panel was found to be triple positive. She was readmitted, started on a heparin-warfarin bridge, and discharged after stabilization. Additional autoimmune workup was negative. Twelve weeks later, follow-up testing confirmed persistent triple-antibody-positive antiphospholipid syndrome (APS). IMPACT/DISCUSSION: APS is a rare and critical cause of unprovoked VTE. Although it can be associated with autoimmune diseases, idiopathic APS occurs without a secondary systemic disorder. The incidence of APS is estimated to be around 2 to 5 new cases per 100,000 persons per year. Triple-antibody-positive APS portends a higher thrombotic risk and emphasizes the importance of interim anticoagulation strategies. Although direct oral anticoagulants (DOACs) such as rivaroxaban are convenient, they are not recommended for APS, particularly in triple-antibody-positive patients. Low molecular weight heparin (LMWH) is an effective bridge to long-term therapy, such as warfarin, and should be considered for patients discharged while awaiting diagnostic results. This case raises broader questions about discharge practices for unprovoked VTE: Should patients with risk factors for hypercoagulable conditions initially be prescribed LMWH? While the benefits include flexibility and enhanced efficacy in hypercoagulable states, barriers such as cost, injection-related discomfort, and patient compliance must be weighed. Ultimately, shared decision-making with patients is essential.

In cases of high clinical suspicion for APS, providers should consider discharging patients with suspected hypercoagulable states on LMWH until the diagnosis is confirmed. Despite the convenience of DOACs, such as rivaroxaban, they are not ideal for patients with triple-antibody-positive APS. LMWH is preferred as an interim anticoagulant, bridging to long-term therapy with warfarin. TOO BASIC TO HANDLE: A CASE OF ALKALEMIA LEADING TO DIALYSIS Jeemin Kwon1; Ghadi Ghanem1; Priyanka Moolchandani1,2. 1University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4267188) CASE: A 31-year-old male with history of gastroesophageal reflux disease and alcohol use disorder presented to the emergency department (ED) with diffuse muscle cramps and a week of excessive post-prandial nausea and vomiting for which he was taking calcium carbonate every 4 hours. He endorsed drinking 750 mL of liquor daily for 2 months, with his last drink being the day of admission. In the ED, his vitals were only notable for a heart rate of 115. His physical exam was unremarkable and without signs of alcohol withdrawal. His labs were notable for an anion gap of 27.5 mmol/L, sodium 124 mmol/L, potassium 2.5 mmol/L, chloride 55 mmol/L, bicarbonate 42 mmol/L, BUN 63 mg/dL, creatinine of 7.1 mg/dL (baseline of 0.85), calcium 9.8 mg/dL, lactate 4.3 mmol/L, pH of 7.63 and pCO2 of 36 mmHg on venous blood gas. EKG showed U waves. Nephrology initially recommended aggressive fluid and potassium repletion. After 4 liters of normal saline, his tachycardia resolved and lactate normalized, but the pH on arterial blood gas only slightly improved to 7.57. Given the refractory severe alkalemia, the patient underwent one session of hemodialysis (HD) with improvement of his pH to 7.47, bicarbonate to 30 mmol/L, and creatinine 3.38 mg/dL. He was monitored for one day with continued improvement of his metabolic derangements and discharged to a substance use rehabilitation facility. IMPACT/DISCUSSION: This patient presented with hypokalemic and hypochloremic metabolic alkalosis most likely in the setting of intractable vomiting. The significant volume losses led to severe prerenal acute kidney injury which impaired renal bicarbonate excretion, worsening the metabolic alkalosis. The patient’s excessive ingestion of calcium-carbonate was considered as a contributor to the degree of alkalemia, but the normal calcium level was inconsistent with calcium-alkali syndrome. Severe alkalemia, most consistently defined in the literature as pH > 7.55, is an extremely rare indication for inpatient HD and is associated with increased mortality. The treatment of metabolic alkalosis is often targeted towards the underlying cause and increasing renal bicarbonate excretion, usually through fluid and electrolyte repletion. However, in the case of severely reduced renal function, renal bicarbonate excretion is impaired which also limits the utility of acetazolamide. In this case, because his pH remained >7.55 despite aggressive fluid resuscitation, the decision was made to undergo HD. After, his metabolic derangements improved and kidneys recovered.

● Heavy alcohol use can precipitate severe vomiting with subsequent alkalemia and pre-renal AKI. ● Acetazolamide has limited utility in correcting metabolic alkalosis in severe renal injury. ● Refractory metabolic alkalosis with pH>7.55 and underlying renal impairment may merit consideration of HD. TOO SWEET: A CASE OF LICORICE-INDUCED HYPOKALEMIA, RHABDOMYOLYSIS AND LOWER EXTREMITY WEAKNESS IN AN INPATIENT SETTING Charlotte Gopinath1; Juanita Gyamera1; Omar Yaghi1; Senayt Alemu1; Shazia Samanani2. 1Graduate Medical Education: Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Medicine, The George Washington University, Washington, DC. (Control ID #4273608) CASE: A 64 year old male with no past medical history presented to the emergency department with 5 days of bilateral lower extremity weakness resulting in a fall. He was hypertensive with physical exam showing mild proximal lower extremity weakness. Labs were notable for potassium of 1.8 mmol/L, bicarbonate of 37 mmol/L and CK of 7,693 U/L which peaked at 15,004 U/L, concerning for rhabdomyolysis with metabolic alkalosis. EKG showed a prolonged QT interval. On further questioning, he reported 6 weeks of excessive ingestion of licorice extract in tea, as he enjoyed the taste. He underwent aggressive IV potassium repletion and fluid resuscitation, with resolution of hypokalemia and rhabdomyolysis in 8 days. IMPACT/DISCUSSION: Licorice induced hypokalemia is a rare but potentially life-threatening condition. The incidence is difficult to quantify as more research is needed; licorice is widely used as flavoring and as a natural remedy, and there is not an established safe level of consumption. Glycyrrhizin causes licorice’s sweet taste. Glycyrrhizic acid is hydrolyzed to glyrrhetinic acid (GA) in the intestine. GA inhibits 11-b-hydroxysteroid dehydrogenase, which normally converts cortisol to cortisone in the kidney, therefore increasing the amount of cortisol. When cortisol binds to the mineralcorticoid receptor, it causes pseudo-hyperaldosteronism, suppressing plasma renin and aldosterone levels. Sodium is reabsorbed and potassium is secreted. The clinical picture of hypokalemia, hypertension, and metabolic alkalosis is consistent with increased mineralocorticoid receptor activation due to persistent cortisol. Patients with severe hypokalemia require inpatient admission for aggressive IV potassium repletion and management of complications including hypertension, life-threatening cardiac arrhythmias such as torsade de pointes, rhabdomyolysis, acute tubular necrosis, metabolic alkalosis, encephalopathy, and paralysis. Patients typically respond well to aggressive IV repletion and can expect a good prognosis within days. Our case demonstrates the importance of obtaining a complete dietary supplement history in patients with hypokalemia. Without instructions to discontinue the causative licorice extract on discharge, our patient would have been at risk of adverse outcomes. A review of the literature suggests that licorice contained in chewing gum, herbal medicines, tea, sweets, tobacco and marijuana has been associated with toxicity.

Although rare, excessive licorice consumption can cause severe hypokalemia. Obtaining a thorough medication and supplement history is essential to identifying the cause of hypokalemia and preventing future episodes. TOUGH TO SWALLOW: PHARYNGEAL-CERVICAL-BRACHIAL VARIANT GBS MIRRORING MYASTHENIA GRAVIS Frank Cassavell1; Aparna Iyer1; Inessa Bronshteyn2; Carmine Gianatiempo2; Tanganyika Barnes1. 1Internal Medicine, Englewood Health, Englewood, NJ; 2Englewood Hospital and Medical Center, Englewood, NJ. (Control ID #4272086) CASE: A 74-year-old female with a history of GERD, vertigo, osteoporosis, and traumatic subdural hematoma s/p left parietal craniotomy presented with persistent diplopia, dysphagia, dysarthria, bilateral ptosis, and upper extremity weakness. MG was considered but ruled out based on negative MG antibodies, non-diagnostic EMG with reduced amplitude of the right median motor nerve at the wrist and below but no change with repetitive stimulation, and no treatment response to pyridostigmine or three doses of IVIG. Botulism was also ruled out. ENT evaluation showed arytenoid and supraglottic edema, treated with dexamethasone and NG tube placement. Mechanical ventilation was not required. Workup at an outside hospital included a lumbar puncture with cerebrospinal fluid showing protein of 48 mg/dL but normal WBC and differential, negative ganglioside Ab including Gq1b, and normal MRI brain. MRI spine showed chronic severe T5 compression fracture with ventral cord compression. Barium swallow revealed irregular deviation of the proximal esophagus. She was diagnosed with PCB variant GBS and underwent plasma exchange with improvement in her symptoms. IMPACT/DISCUSSION: Guillain-Barré Syndrome (GBS) is an acute immune-mediated polyneuropathy with an incidence ranging from 0.4 to 1.7 cases per 100,000 population, primarily affecting the elderly. Serial nerve conduction studies suggest that the pharyngeal-cervical-brachial (PCB) variant is a localized subtype of GBS, often presenting as axonal rather than demyelinating neuropathy, and is frequently misdiagnosed as brainstem stroke, myasthenia gravis, or botulism. In the absence of identified alternative diagnoses, PCB can be diagnosed if the patient has symmetric muscle weakness of the oropharynx, neck and upper limbs with areflexia or hyporeflexia and no ataxia or prominent leg weakness that develops between 12 hours and 28 days then reaches a clinical plateau. Features that strongly support the diagnosis include preceding infectious symptoms, CSF with elevated protein (>45 mg/dL) and a normal CSF WBC count, evidence of neuropathy with electrophysiological findings showing decreased amplitude of motor (and possibly sensory) responses with normal conduction velocities, and the presence of antiganglioside antibodies. Though antiganglioside antibodies were negative, the patient’s symptoms and workup were most consistent with PCB variant GBS and she responded well to treatment with plasmapheresis. Like stroke, MG and botulism, PCB variant GBS should be considered in patients with primary upper limb and oropharyngeal weakness.

Early diagnosis and treatment of neurologic conditions such as GBS can greatly improve patient outcomes. Consider PCB variant GBS in patients presenting with proximal arm weakness, dysphagia, and diplopia. Given the involvement of oropharyngeal and cervicobrachial muscles in PCB variant GBS, it is important to consider using a nasogastric tube and mechanical ventilation based on the patient's clinical presentation. TOXIC ORIGINS : ACUTE PANCREATITIS CAUSED BY ORGANOPHOSPHATE INGESTION Juan Urraca1; Aparna A. Rathnam1; Bibhuti Adhikari2; Harleen Sidhu1; Jean Singh1. 1Internal Medicine, NYC Health and Hospitals Elmhurst, Queens, NY; 2Internal Medicine, Elmhurst Hospital Center, Queens , NY. (Control ID #4273343) CASE: A healthy 30 year old man was brought in by EMS after an ingestion of 100 ml of insecticide (a 2,2 dichlorovinyl dimethyl phosphate) after an argument with his wife. Patient reported severe abdominal pain and several episodes of non bilious vomiting. On exam, he was somnolent but arousable and had drooling, miosis, and hyperlacrimation, as well as epigastric and suprapubic tenderness. Labs revealedWBC 19.9/mcl (4.8-10.8/mcl) lipase of 1,295 U/L (10-140 U/L), triglycerides of 200 mg/dl (<150 mg/dl), and ethanol <10 mg/dl. US and CT abdomen were performed with no evidence of gallstones, bile duct dilation or edematous enlargement of the pancreas. Poison control center recommended monitoring the patient for 24 hours and starting atropine 3-5 mg IV if symptoms worsen. The patient was provided supportive management with IV fluids, opioids and antiemetics. After 24 hours, he was able to tolerate a solid diet and was discharged after consultation with poison control center and psychiatry IMPACT/DISCUSSION: Organophosphate (OP) poisoning commonly causes bradycardia, bronchospasm, bronchorrhea, miosis, hypersalivation, lacrimation, urination, diarrhea, vomiting and diaphoresis, but can rarely lead to acute pancreatitis. The acetylcholinesterase enzyme is inhibited by the organophosphate leading to Sphincter of Oddi contraction increasing the internal pressure in the pancreas. Exocrine secretions from the pancreas are also found to be increased during organophosphate poisoning (2) Our patient ingested (2,2-dichlorovinyl dimethyl phosphate) and lacked other plausible causes of pancreatitis, such as ethanol or medication use, gallstones, and hypertriglyceridemia.. Normally, the treatment of OP poisoning is atropine, which blocks the activity of acetylcholine by decreasing the internal pressure in the pancreas. Although our patient had a prompt recovery with supportive care, recognition of acute pancreatitis due to organophosphate poisoning can be critical for appropriate management in more severe cases

Although OP induced pancreatitis is rare and not well documented in the literature, having a systemic approach to ruling out other common causes can aid its early identification. Once recognized, it is imperative to contact poison control center and in more severe cases, to start atropine and pralidoxime in order to avoid potentially fatal complications. TREATING CAMPYLOBACTER SPECIES INFECTIONS NEAR THE AIRWAY IN A TIME OF DEVELOPING RESISTANCE Lahari Ramagiri2; Philip Huang2,1. 1Internal Medicine, The Ohio State University, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH. (Control ID #4271470) CASE: A 70-year-old woman presented to a local ED on 11/1/24 with progressive swelling of her right jaw and neck following a fall while bowling. Given concern for Ludwig’s angina, she was emergently transferred to our academic medical center. On arrival, she was overall in stable condition, but had associated trismus, hoarseness, and dysphagia. She did not have any clear respiratory distress. Initial labs revealed WBC 14.17 with left shift. Imaging was then pursued emergently, with CT neck on 11/1 demonstrating a acute abscess of the right floor of the mouth with submandibular cellulitis. There was initial concern for Ludwig’s angina, but the patient remained stable while in the ED for a few hours after starting Unasyn (amp/sulbactam). After evaluation by otolaryngology (ENT), she was then admitted to the floor with plans for urgent incision and drainage of the abscess with necrotic tooth extraction. On HD 1, ENT was successful with draining the abscess. Blood cultures from the outside hospital later returned negative. Preliminary abscess cultures then grew multiple microbes, including Campylobacter species. We consulted infectious disease, who requested send out susceptibilities of the Campylobacter species and recommended IV ertapenem (HD 5-8) due to possible resistant organisms in a sensitive location. She remained in stable condition, and we ultimately discharged her with close outpatient follow-up on 7 additional days (14 day total course) of amoxicillin-clavulanate 875 mg PO BID and levofloxacin 750 mg PO daily on HD 8. After discharge, the Campylobacter species was identified as C. rectus. IMPACT/DISCUSSION: ENT infections are often caused by organisms covered by Unasyn. However, if suspicion is high for a complicated infection such as Ludwig’s angina or osteomyelitis, it is crucial to select the correct antibiotic given the high risk of failure. Treatment of polymicrobial infections should then be personalized based on clinical stability, antimicrobial susceptibility, risk of developing resistance, and ability to determine speciation of the bacteria. If Campylobacter species is identified, broad-spectrum coverage including carbapenems such as ertapenem may be considered, as many strains have developed drug resistance in recent years to fluoroquinolones (FQ) and macrolides. Moreover, Campylobacter species requires a prolonged incubation period in anaerobic conditions. Fortunately, the most common species, C. rectus, remains broadly sensitive to antibiotic including penicillins and FQs, with some variability. Further study may aid in identification and antibiotic selection of infections involving Campylobacter species.

Infections of the oral cavity such as Ludwig’s angina or osteomyelitis can have severe consequences and require prompt medical and possibly surgical treatment. Unfortunately, Campylobacter has a prolonged incubation period with rising resistance requiring a multidisciplinary conversation to create a personalized treatment plan. TREATING THE UNSEEN CHALLENGE: EFFECTIVE MALODOR MANAGEMENT IN UNUSUAL FUNGATING LESIONS WITH TOPICAL METRONIDAZOLE Kidus Shiferawe2; Lakshmi Naidu1; Hirotaka Kato1. 1Internal Medicine, University of Kentucky College of Medicine, Lexington, KY; 2College of Medicine, University of Kentucky College of Medicine, Lexington, KY. (Control ID #4272298) CASE: A 44-year-old man with a history of craniotomy for a brain mass complicated by hydrocephalus status post ventriculoperitoneal shunt presents to the emergency room for evaluation of pelvic pain, mass, and drainage. The patient noticed the mass 12 years ago diagnosed as genital condyloma treated with topical therapy. Since then lesions progressed significantly extending to bilateral groin and mons. The lesions were very painful and associated with bleeding and copious drainage. On presentation, his vitals were stable, and his physical examination was remarkable for fungating masses covering bilateral groins and mons. The patient was admitted, and the biopsy of this lesion confirmed condyloma acuminatum without high grade dysplasia. Despite proper wound care, this fungating lesion continued to produce severe malodor, prompting our decision to apply crushed metronidazole to it. The odor drastically improved within 24 hours of the application with improved satisfactions for both the patient and the providers. After discharge, the patient eventually had an extensive surgical resection and reconstruction by urology and plastic surgery. IMPACT/DISCUSSION: Condyloma acuminate is anogenital warts due to human papillomavirus which can result in extensive fungating lesions. Treatment is required when lesions become symptomatic, large, or longstanding. Even though topical medications, cryotherapy, and surgical resection are typical options, unpleasant odor is often untreated despite its distressful impact on quality of life, psychological discomfort, and embarrassment among patients and clinicians caring for patient. The fetid odor associated with such chronic lesions or wounds is attributable to a combination of factors such as necrotic tissue and biofilm formation with bacterial colonization. Anaerobic bacteria, such as Bacteroides and Fusobacterium species, contribute to release of unpleasant odor. Wound malodor may be addressed using direct or indirect approach. Direct approach, such as charcoal and its derivative activated carbon, focuses on absorbing the volatile organic compounds that create malodor. Indirect approach like metronidazole, silver, iodine, or Manuka Honey products seeks to reduce odors by lowering bacterial bioburden in the wound. Metronidazole is a nitroimidazole antibiotic available as concentrated gel (or we can crush the tablet) used as off-label topical agent. Past studies reported significant reduction in odor and pain by day 7 in cancerous and non-cancerous chronic wounds.

Malodor from a fungating mass is a distressing symptom and often left untreated. When the wound care approach does not control the odor, it’s vital to consider topical metronidazole that drastically reduces the odor regardless of etiologies of the lesion, including condyloma acuminatum. TREATMENT-INDUCED DIABETIC NEURALGIA LEADING TO DIABETIC THORACIC POLYRADICULOPATHY Fidel A. Vazquez1; brittney carman1; Michael Quarton1; Austin Burkenstock1; Kristin Bateman2. 1Internal Medicine, Tulane University SOM, New Orleans, LA; 2Medicine, Tulane University, New Orleans, LA. (Control ID #4272629) CASE: A 32-year-old man with recently diagnosed type 1 diabetes (T1DM) presented with acute onset of severe sharp left-sided abdominal/flank pain, associated with hyperalgesia and allodynia. Exam was notable for pain distribution in a T10-T12 dermatomal pattern, with no rash, guarding, or costovertebral angle tenderness. Laboratory studies were notable for mild hyperglycemia and hemoglobin A1C (HbA1C) 7.3, improved from 14 six months prior at time of T1DM diagnosis. Renal ultrasound and CT abdomen/pelvis revealed no abnormalities. Electromyography showed sensory axonal neuropathy with radiculopathy of the 9th-11th intercostal nerves, consistent with diabetic thoracic polyradiculopathy. Despite a multimodal pharmacologic regimen, his pain remained poorly controlled. Patient underwent interventional cryoablation of the left 9th-11th intercostal nerves, which produced significant improvement in pain control. IMPACT/DISCUSSION: Although diabetic neuropathy is a common complication of diabetes, diabetic thoracic polyradiculopathy remains a rare clinical syndrome that is characterized by pain and sensory disturbances in the thoracic and abdominal distributions. It is usually seen in patients with poorly controlled diabetes. Treatment-induced diabetic neuralgia is a rare iatrogenic small fiber neuropathy that occurs when patients with chronic hyperglycemia experience a significant and rapid reduction in HbA1c, typically defined as ≥2% points over 3 months. Absolute risk of developing treatment-induced diabetic neuralgia with a reduction of HbA1c of greater than 2% and greater than 4% within 3 months has been demonstrated to be 20% and 80%, respectfully. While the pathophysiology is poorly understood, treatment-induced diabetic neuropathy is thought to be due to blood glucose levels being corrected faster than microvascular changes occurring during the hyperglycemic period can be restored. These changes result in endoneural ischemia and the formation of axonal regeneration zones that produce ectopic depolarizations and pain when reverting to a normoglycemic state. Treatment for chronic diabetic neuropathy is typically managed with gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, or anti-epileptics. Given the acute onset and severity of the pain in our patient, who required intravenous opioids for pain control, we opted to pursue a nerve block for rapid onset of action and to minimize long-term opioid use.

Awareness of diabetic thoracic polyradiculopathy is crucial for the internist, as internists are the frontline for patient management of chronic complications of T1DM. It is important to recognize the clinical syndrome, risk factors, and identify new treatment options for localized radiculopathy. TRIPLE THREAT: ACUTE CHIKUNGUNYA WITH EBV AND CMV CO-INFECTIONS IN AN IMMUNOCOMPETENT FLORIDA TRAVELER Chidozie Igbonagwam1; Camila Villacreses4; Daniela Carralero-Somoza3; Michael Sabina2; Danish Narula2. 1GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2Internal Medicine - GME, Lakeland Regional Medical Center Inc, Lakeland, FL; 3Internal Medicine Residency, Lakeland Regional Medical Center Inc, Lakeland, FL; 4Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4273479) CASE: A 39-year-old female presented with two weeks of cyclical fevers, generalized weakness, headaches, and neck stiffness following a trip to the Florida Keys, where she experienced mosquito bites. She denied gastrointestinal symptoms, rash, or joint pain. After failing to improve on a 3-day doxycycline course, she sought emergency care. An infectious workup included tests for mosquito-borne diseases like Chikungunya, dengue, and malaria. CT imaging of the head showed no acute findings, and lumbar puncture ruled out meningitis and encephalitis. Elevated liver enzymes were attributed to chronic cholecystitis with biliary dyskinesia. Infectious disease consultation suspected a mosquito-borne viral illness, recommending symptomatic management. The patient was discharged in stable condition with follow-up care instructions. Subsequent outpatient testing confirmed acute infections with Chikungunya virus (CHIKV), Cytomegalovirus (CMV), and Epstein-Barr virus (EBV). Both CMV and EBV IgM levels indicated acute infections despite the patient being immunocompetent, with normal IgG levels and no evidence of HIV. Elevated liver enzymes were likely due to CMV, as imaging showed no obstruction or gallstones. IMPACT/DISCUSSION: Florida's climate makes it susceptible to mosquito-borne diseases like CHIKV. Locally acquired Chikungunya cases were first reported in 2014, following a Caribbean outbreak. Since then, sporadic outbreaks have occurred, especially in southern counties like Miami-Dade and Broward. From 2014 to 2020, approximately 200 locally acquired CHIKV cases were reported annually, with fluctuations corresponding to mosquito activity. However, Florida’s incidence remains lower than in the Caribbean and South America, where the virus is endemic. The co-infection with EBV and CMV in this case is noteworthy. Both viruses typically establish latency in immunocompetent individuals and can reactivate under stress or immunosuppression. The simultaneous acute infections with EBV, CMV, and CHIKV, in the absence of immunosuppression, is unusual. CHIKV induces a strong inflammatory response with elevated pro-inflammatory cytokines and chemokines, potentially disrupting immune balance and increasing vulnerability to additional infections.

The case emphasizes maintaining a broad differential diagnosis in patients with prolonged cyclical fevers and recent travel to endemic areas. It underscores the need for systematic diagnostic approaches, particularly as climate change and travel patterns influence the spread of vector-borne diseases. Dual positivity for EBV and CMV IgM, increasingly recognized due to antibody interference, complicates interpretation, highlighting the importance of comprehensive clinical evaluation. Further research is needed to understand the interplay between arboviruses like CHIKV and other latent viruses during co-infections. TRIPLE THREAT: RENAL DYSFUNCTION, COAGULOPATHY, AND A PALPABLE PURPURIC RASH Bailey Will1; Pranav Shah2. 1College of Medicine, Medical University of South Carolina, Charleston, SC; 2Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4273403) CASE: A 65 year-old male with pertinent past medical history of diabetes mellitus, atrial fibrillation on warfarin and septic arthritis complicated by methicillin susceptible staphylococcus aureus (MSSA) bacteremia presented with a new rash on the bilateral upper and lower extremities. The rash was described as scattered petechiae and palpable purpura on the left palmar surface, bilateral upper arms, dorsal feet, ankles, and anterior/posterior axillary folds. Notably the abdomen, back, groin, and mucosal surfaces were spared. 5 days prior, patient was admitted for MSSA bacteremia secondary to a septic knee joint. A joint aspiration and washout was completed and a peripherally inserted central catheter (PICC) was placed with a plan for 4 weeks of cefazolin. Labs on readmission were notable for an international normalized ratio (INR) of 9.5, Creatinine (Cr) of 1.93 mg/dL (baseline of 0.97 mg/dL), erythrocyte sedimentation rate of 113 mm/hr, and C-reactive protein of 13mg/dL. Due to a high level of concern for a drug interaction between cefazolin and warfarin, both medications were discontinued. Dermatology performed a skin biopsy showing leukocytoclastic vasculitis with direct immunofluorescence demonstrating granular deposition of IgA, IgM, and C3 in the superficial dermal vessel consistent with IgA vasculitis. An autoimmune and infectious work up was notable for a positive antinuclear antibody (1:80). The patient received three days of pulse dosed steroids (500mg intravenous methylprednisolone) before transitioning to oral prednisone with a taper according to Pexivas protocol on discharge. The rash improved and he began to have renal recovery. Despite prolonged abstinence from warfarin his INR remained elevated following multiple doses of oral vitamin K and fresh frozen plasma. This delayed obtaining a renal biopsy. The patient was then given intravenous vitamin K which reversed his INR to 1.2. His Cr continued to uptrend to 3.66 mg/dL before down trending. IMPACT/DISCUSSION: IgA vasculitis is an uncommon disease in the adult population but is often found to be more severe with increased risk of renal failure. This case demonstrates key features of IgA vasculitis including palpable purpura, concomitant renal involvement, and colicky abdominal pain. This case was also notable for prolonged elevations in INR and Cr despite appropriate treatment and improving cutaneous symptoms. The systemic inflammation caused by IgA vasculitis also limited the effectiveness of oral therapies. Recognition of IgA vasculitis and subsequent IgA nephropathy is crucial to guide proper therapy and prevent progression to renal failure.

This case illustrates the difficulty of distinguishing IgA. Palpable purpura, renal involvement, coagulopathy, and colicky abdominal pain should prompt further investigation into IgA vasculitis. TRUST YOUR EXAM: A NEAR MISS APPENDICITIS WITH NORMAL(?) CT Afia Khan, Matthew T. Cerasale. Medicine, The University of Chicago Division of the Biological Sciences, The University of Chicago Division of the Biological Sciences, Chicago, IL, US, academic/gen, Chicago, IL. (Control ID #4271471) CASE: A 32-year-old man with no past medical or surgical history presented to the emergency department (ED) with 12 hours of crampy generalized abdominal pain which began after eating fast food. He also endorsed inability to tolerate oral intake, nausea, and 1 episode respectively of emesis and loose stool. His vitals were normal but he had left lower quadrant (LLQ) tenderness to palpation (TTP) without rebound or guarding. Complete blood count, liver function tests, lipase, and urinalysis were normal except WBC differential showing neutrophilia (WBC 10.9/μL). No abnormality was noted on CT Abdomen/Pelvis. He was admitted for pain control with the presumptive diagnosis of acute gastroenteritis. On his second morning, his symptoms had improved; he tolerated meals and only needed acetaminophen for pain. However, new findings included tachycardia, RLQ TTP, and leukocytosis, now raising concerns for appendicitis. Radiology was reconsulted to overread the initial CT, and found appendiceal dilation to 2.0 cm, altogether consistent with appendicitis. He underwent laparoscopic appendectomy that evening, revealing pelvic ascites and an inflamed appendix adherent to the pelvic sidewall. IMPACT/DISCUSSION: Appendicitis typically presents with nonspecific periumbilical pain that localizes to the right lower quadrant within 24 hours. Fever and leukocytosis are also common. Appendicitis was nearly missed in this case due to normal labs and vitals on admission, LLQ TTP on exam, and subtle imaging findings which were overlooked during the first radiology assessment. He also began feeling better after 24 hours despite worsening objective findings. In retrospect, the initial misdiagnosis of gastroenteritis was less likely given the lack of commonly characteristic diarrhea. Secondly, while his admission WBC count was not above reference range, elevation over 10/μL is a risk factor in standardized scores for appendicitis diagnosis. Since this lab was obtained soon after symptom onset, it likely reflected the ongoing inflammatory process. Appendiceal enlargement was initially missed, but itself is not diagnostic of acute appendicitis. In this case, the patient’s evolving subjective and objective findings, along with the imaging reread, cued the providers that appendicitis best explained his condition.

Imaging and laboratory findings must be interpreted within the broader context of the patient’s changing clinical presentation. Appendicitis and other acute abdominopelvic conditions can present atypically. It is important to regularly reassess patients, especially because initial findings may be subtle or misleading. TUBERCULOUS SPONDYLITIS: A RARE CASE OF POTT DISEASE WITH RECURRENT RIGHT PSOAS ABSCESS IN A PATIENT WITH AIDS Omar Zuhdi1; Camila Villacreses1; Juan Rivera-Martinez1; Paola Campillo2; Chidozie Igbonagwam1. 1Internal Medicine , Lakeland Regional Health Medical Center, Tampa, FL; 2Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4272681) CASE: The patient is a 45-year-old female, with history of AIDS, who initially presented to the emergency department due to lower back pain and right hip pain for the last two weeks. During that time, the patient reported fevers and shortness of breath. During her previous admission one month ago, the patient was treated for vertebral osteomyelitis secondary to tuberculosis with psoas abscess. RIPE therapy (rifampin, isoniazid, pyrazinamide, and ethambutol) had been initiated and the patient had been following with the health department since discharge. During this admission, the CT of the abdomen showed evidence of osteomyelitis of the L3 vertebral body with 1.8 x 2.5 x 3.5 cm abscess in the right psoas muscle at the level of the L3 vertebral body. The patient was started on RIPE therapy and piperacillin-tazobactam empirically due to concern over possible secondary bacterial infection. CT guided percutaneous needle aspiration of the right psoas abscess was performed and cultures were obtained which previously came back positive for tuberculosis. Patient had a CD4 count of 70/mcL. Patient was started on dolutegravir, emtricitabine, and tenofovir for the treatment of AIDS. Rifampin was switched to rifabutin due to decreased interaction with the HIV regimen. Over several days, patient had resolution of her symptoms and was discharged on outpatient antituberculous therapy with close monitoring by the department of health. IMPACT/DISCUSSION: Skeletal tuberculosis is an extrapulmonary manifestation of tuberculosis which includes tuberculous spondylitis (Pott disease), tuberculous arthritis, and extraspinal tuberculous osteomyelitis. Diagnosis of skeletal tuberculosis can pose as a significant challenge as there is no evidence of active pulmonary tuberculosis in the majority of cases of skeletal tuberculosis. Especially in regions which are not endemic to tuberculosis, diagnosis of skeletal tuberculosis, including Pott disease, may be delayed resulting in further complications of the disease, including bone collapse and neurological compromise requiring surgical intervention. Pott disease most commonly affects the lower thoracic and upper lumbar regions of the spine, however, it may also be seen in the cervical and upper thoracic regions. Patients often present with localized pain at the site of the spondylitis. Systemic symptoms including fever and weight loss may be seen in less than half of patients. The treatment for musculoskeletal tuberculosis involves antituberculous therapy similar to that of pulmonary tuberculosis.

Initiation of anti-tuberculous therapy in a timely manner is essential in the hospital setting as diagnosis is often delayed especially non-endemic TB areas, such as the United States. This can prevent complications including neurological deficits and cord compression requiring surgical intervention. TWIST OF FATE: VERTEBRAL OSTEOMYELITIS LINKED TO POSSIBLE YOGA STUDIO EXPOSURE Suzanna E. Coyne1; Ramkumar Narendran2; Alefiya Al-Qamari2. 1Rush Medical College, Rush University Rush Medical College, Chicago, IL; 2Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4270486) CASE: A 58-year-old woman with psoriatic arthritis on Etanercept, chronic urinary incontinence, and intermittent syncope due to progressive supranuclear palsy presented with 6 months of worsening radicular neck pain unresponsive to methylprednisolone and tizanidine for suspected cervical myelopathy. Cervical MRI showed a paravertebral soft tissue mass with epidural extension, raising concern for malignancy. Further imaging confirmed vertebral osteomyelitis (VO) at C6-C7 and an epidural abscess from C2-T1, causing cord compression. Fluid collections were noted in the thoracic and lumbar spine, with possible leptomeningeal extension. ESR was 66 mm/hr, and CRP was 162.4 mg/L. CT-guided biopsy was performed. The patient noted a yoga classmate recently recovered from MSSA VO, prompting an investigation into potential infection sources at the studio. Environmental exposures, including a recent dental cleaning, recreational canoeing, and her work as a death doula in nursing homes, were considered. Despite broad-spectrum antibiotics, the patient developed urinary retention and persistent left arm numbness. Cultures grew MSSA, and urgent surgical intervention (C6 corpectomy, C6-7 discectomy, laminectomy, and spinal fusion) was performed due to neurological deterioration. She was discharged after 6 days to complete a 6-week course of IV cefazolin. IMPACT/DISCUSSION: Vertebral osteomyelitis (VO) results from hematogenous bacterial spread, with risk factors like immunosuppression, chronic conditions, and environmental exposures. In this case, etanercept, a TNF-α inhibitor, increased infection risk by impairing immune response. Psoriatic arthritis with skin lesions and joint damage provided entry points for MSSA, the most common VO pathogen. Non-specific symptoms, like neck pain, complicate early diagnosis. Environmental exposures, including a yoga classmate with MSSA VO, recent dental cleaning and work in nursing homes, further increased infection risk. Epidural abscesses complicate VO in IVDU and non-IVDU cases. Image-guided biopsy is crucial to guiding targeted therapy and timely surgical intervention, especially when non-invasive tests are inconclusive, ESR is elevated and epidural collection is seen on MRI. Early diagnosis, surgical intervention, and long-term antibiotics were essential in this case, emphasizing the importance of considering the patient-specific and environmental risk factors of VO.

This case highlights the importance of detailed social histories, as the patient’s connection to a yoga classmate with MSSA VO was key to the diagnosis. Despite the absence of IVDU, risk factors like psoriatic arthritis with skin lesions and etanercept use increased her risk of epidural abscesses. Early diagnosis and prompt surgical intervention were critical in preventing further neurological deterioration and improving outcomes. TWO RELATIVES WITH SEVERE OCULAR VASCULITIS LEADING TO GLOBE RUPTURE Matthew Ross, Ethan Loftspring, Michael LoCurcio. Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4266888) CASE: A 48-year-old man from Chile with previously diagnosed granulomatosis with polyangiitis (GPA) presented with subacute, progressive bilateral blurry vision, eye redness, and eye pain. Eight years prior, during a hospitalization for similar symptoms, he was diagnosed with serine proteinase 3 (PR3) vasculitis. During the index hospitalization, he was treated with rituximab with complete symptom resolution. However, during insurance-related lapses in rituximab therapy, he experienced central serous retinopathy, right-sided tinnitus with hearing loss, epistaxis, peripheral mononeuropathy, polyarticular synovitis, and chilblains-like lesions on his fingertips. He denied any pulmonary or renal involvement. Strikingly, his mother was diagnosed with GPA at age 48, too. Her manifestations included chronic scleritis complicated by globe rupture. Her disease progressed despite chronic steroid use, and she died at age 55. Upon presentation, our patient had bilateral scleral injection with enlarged scleral vasculature, scleral melt, and punctate epithelial erosions. Initial labs were unremarkable. On the first night of admission, he had a traumatic left globe rupture urgently repaired via scleral patch and amniotic membrane graft. He received broad-spectrum antibiotics and pulse-dose steroids but experienced progressive vision deterioration. He then received rituximab and cyclophosphamide, which markedly improved his scleritis. He was discharged with poor but stable vision. The medical team is working with the patient to obtain genetic testing for him and his adult children. IMPACT/DISCUSSION: GPA is a potentially lethal systemic illness that commonly impacts the airways, kidneys, and blood vessels. About one-third of patients with GPA have eye involvement, with vision loss and scleritis being common manifestations. Among patients with eye involvement, approximately 10 percent have necrotizing scleritis, which can lead to globe rupture. GPA is associated with anti-neutrophil cytoplasmic antibodies (ANCA), with PR3 positivity being most common. Despite case reports of familial clusters, GPA is not considered a heritable illness. GPA is theorized to be multifactorial and polygenic and has been associated with alleles including HLA DPB1*04:01, SERPINA1, and PRTN3. Other reports involving familial clusters have suggested environmental etiologies involving prior sensitization to neutrophilic cytoplasmic antigens such as PR3. This case, however, is the first reported familial case of GPA with similar manifestations of severe scleritis causing globe rupture. Further research is warranted to explore the potential familial associations in GPA and better characterize its pathophysiology.

Though not classically considered a hereditary condition, GPA vasculitis is presented here as a case of a mother and her son both with predominantly scleral manifestations. This case report emphasizes the importance of considering familial patterns, particularly in patients with unusual clinical presentations. UNCHECKED IMMUNITY TO UNLEASHED ANARCHY: HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS FOLLOWING COMBINATION IMMUNE CHECKPOINT INHIBITOR THERAPY Sunil Dommaraju, Gavin Hui, Alexandra Drakaki. Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4243967) CASE: A 42-year-old female with a 5-month history of clear cell renal cell carcinoma status-post left radical nephrectomy with eventual recurrence in the nephrectomy bed and new local/liver metastases presented to the ED with 6 days of fever (max 39.6 C), foul-smelling urine, and pruritus one week after her second cycle of the immune checkpoint inhibitors (ICIs) ipilimumab and nivolumab (ipi/nivo). She had a recent hospitalization for C. difficile colitis. Exam revealed tachycardia (141 bpm) and erythematous patches. Labs showed normal WBC, stable anemia (Hgb 9.1 g/dL), declining platelets (244 k/uL, baseline 448 k/uL), lactic acidosis (lactate 37mg/dL, CO2 15 mmol/L), and new transaminitis (ALT 308 U/L, AST 242 U/L, ALP 192 U/L, normal bilirubin). CT abdomen/pelvis revealed mild bowel wall thickening, progression in hepatic metastases, and new splenomegaly. Fluids and empiric antibiotics for presumed urosepsis or colitis were started but discontinued after 48 hours when broad infectious work-up was negative. New watery diarrhea on day 2 prompted stool studies which confirmed recurrent C. difficile infection, so oral fidaxomicin was started. Persistent fever (max 39.5 C) and tachycardia (110-120 bpm) on day 3 led to evaluation for hyperimmune activation. Labs showed ferritin of 3,659 ng/mL (from 13 ng/mL), high soluble IL-2 receptor level (7,005 U/mL), low Natural Killer cell activity, mildly elevated triglycerides (224 mg/dL), and normal fibrinogen. Meeting five of nine diagnostic criteria, she was diagnosed with hemophagocytic lymphohistiocytosis (HLH) secondary to ipi/nivo. Fevers resolved on day 4 upon initiation of methylprednisolone 0.8mg/kg IV daily. Ferritin, CRP, and LDH trended downward, so bone marrow biopsy was deferred. She was discharged on day 6 with prednisone 80mg daily, which was increased to 150mg the next week in clinic given recurrence of fevers and worsening transaminitis and ferritin. Over two months, symptoms and labs improved, steroids were tapered, and she transitioned to lenvatinib and everolimus. IMPACT/DISCUSSION: Immunotherapy has modernized cancer treatment, but detecting and managing immune-related adverse events (irAEs), such as HLH, remains challenging. The patient’s sepsis-like presentation, absence of multiple cytopenias, and mild transaminitis confounded by liver metastases initially made an irAE unlikely. Non-revealing infectious work-up and persistent fever prompted HLH investigation. Among only 22 reported HLH cases secondary to ICIs, fever, cytopenias, and elevated ferritin were the most common findings. Treatment was successful in 19 cases, but 3 were fatal. Retrying ICIs after HLH resolved was successful in 3 cases. This case adds to evidence regarding features of HLH due to ICIs and supports steroids as an effective treatment.

- HLH should be suspected in patients recieiving ICIs who have unexplained fever, cytopenia, and transaminitis - HLH is largely treatable, but the safety of rechallenging patients with ICIs remains unclear UNCOMMON CAUSE OF ABDOMINAL PAIN AND NAUSEA: OVARIAN VEIN THROMBUS IN A DIABETIC WOMAN Melissa Gunchenko1; Ramkumar Narendran1; Yolla Haibe2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Hematology and Oncology, Rush University, Chicago, IL. (Control ID #4273346) CASE: A 40-year-old (G3P2102) female with a past medical history of type 2 diabetes, hypertension, obesity, and iron deficiency anemia secondary to abnormal uterine bleeding (AUB) presented with intractable nausea and vomiting after starting dulaglutide. On arrival, she was afebrile and hemodynamically stable. Initial exam and laboratory studies were unremarkable. CT abdomen/pelvis demonstrated an enlarged right ovary and enlarged right gonadal/ovarian vein with central hypointense filling defect concerning for ovarian vein thrombus (OVT). CT venogram confirmed a partially occlusive right OVT extending to the level of the inferior vena cava (IVC) confluence. A transabdominal/transvaginal ultrasound showed normal vascularity within the ovarian parenchyma bilaterally and mild endometrial thickening. An endometrial biopsy (EMB), performed one month prior to admission for AUB, was normal. She was started on a heparin infusion, and gynecology was consulted. A pelvic exam revealed no abnormalities. Additional laboratory studies were notable for a negative trichomonas vaginalis antigen, chlamydia/gonorrhea RNA probe, and bacterial vaginosis screen. The patient was transitioned to apixaban and subsequently discharged in stable condition. IMPACT/DISCUSSION: OVT is a rare and potentially life-threatening condition that classically presents with fever, pelvic pain, and a right-sided abdominal mass. It is unclear whether this patient’s symptoms were related to her OVT or dulaglutide use. Fortunately, the healthcare team avoided diagnostic error by not anchoring on this patient’s medication history. Given her non-specific presentation, abdominal/pelvic imaging was essential in establishing the diagnosis of OVT. There is currently no consensus on which imaging modality is most sensitive for OVT; both magnetic resonance imaging and CT have been recommended. OVT has been associated with the postpartum period, malignancy, pelvic inflammatory disease, inflammatory bowel disease, and recent pelvic or abdominal surgery. This patient’s recent EMB may triggered her OVT, particularly in the setting of diabetes and obesity, which are risk factors for thrombosis. Because OVT can resolve spontaneously, the need for anticoagulation (AC) is debated. While no treatment guidelines exist, three months of AC is typically recommended for provoked OVT extending to the renal veins or IVC. If thrombophlebitis or pelvic infection is suspected, antibiotic therapy is indicated. Delayed diagnosis and treatment can lead to life-threatening complications, such as pulmonary embolism, ovarian infarction, and septic thrombophlebitis. A high index of suspicion is essential, especially in patients with recent pelvic procedures or thrombosis risk factors.

OVT is a rare condition that presents with non-specific symptoms and is diagnosed via imaging. Treatment with AC may be required. A high index of suspicion should be maintained in patients with recent pelvic procedures, pelvic infections, and/or malignancies. UNCOMMON MONONUCLEOSIS: A RARE CASE OF EPSTEIN-BARR VIRUS CEREBELLITIS IN A MIDDLE-AGED ADULT Yuma Takeda3; Takaaki Kobayashi2; Hiroki Matsushita3; Yuka Ogata3; Kazuki Sogawa1; Akihito Yoshida3. 1Neurology, Kameda Medical Center, Kamogawa, Chiba, Japan; 2Internal Medicine, University of Kentucky, Lexington, KY; 3General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan. (Control ID #4270398) CASE: A 54-year-old man with asthma and chronic kidney disease presented with subacute fever, dizziness, and dysarthria. His symptoms began three weeks prior with mild fever, headaches, and throat pain, progressing to slurred speech, dizziness, and gait instability. Examination revealed tender cervical lymphadenopathy and cerebellar signs, including ataxic dysarthria, impaired tandem gait, and dysmetria. Neurological findings were otherwise intact. Laboratory workup showed elevated inflammatory markers, liver enzymes, and atypical lymphocytes. Positive EBV-VCA IgG and IgM with negative EBNA confirmed primary EBV infection. CT imaging revealed reactive lymphadenopathy, while brain MRI, head CT and cerebrospinal fluid (CSF) EBV-PCR were negative. Mild lymphocytic pleocytosis in CSF suggested aseptic meningitis. Despite negative imaging and CSF results, clinical findings supported EBV cerebellitis. Neurologist recommended two courses of steroid pulse therapy with methylprednisolone 1,000 mg/day for three days, respectively, leading to significant improvement in dysarthria and ataxia. IMPACT/DISCUSSION: Primary EBV infections in young children are often manifested as nonspecific illnesses. infectious mononucleosis (IM) most commonly affects those who have primary Epstein-Barr virus (EBV) infection during 15 to 24 years of age. EBV transmission occurs through exposure to infected saliva. Common clinical features of IM include fever, pharyngitis, lymphadenopathy, and malaise. Neurologic complications occur in 1 to 5% of IM. Cerebellitis is a rare complication among adults and commonly occurs one to three weeks after symptoms of mononucleosis emerge. The literature search in Pubmed only revealed seven cases of cerebellitis associated with primary EBV infection in adults. Most of the adult cases develop in their 20s, and no cases above 50 years of age have been reported. Some earlier reports have revealed that EBV DNA may result negative in cerebrospinal fluid analysis, as in this case, suggesting that not only direct viral neuronal invasion but also immunotoxicity is involved in the pathophysiology of EBV cerebellitis. MRI may also result negative; thus, physical findings are essential in suspecting the disease. Although many reports stress the self-limiting nature of the disease, corticosteroids, plasmapheresis, and intravenous immunoglobulins have been empirically used and might decrease the severity and duration of illness and improve quality of life.

EBV cerebellitis is a rare complication of IM in adults. A meticulous clinical evaluation is critical for diagnosis when imaging and CSF analyses are inconclusive. UNCOVERING AN INSIDIOUS SOURCE OF REFRACTORY HYPERFIBRINOLYSIS Nicole M. Clark2; Xiaomei Meng1. 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH. (Control ID #4265005) CASE: A 36 year old female with history of myocarditis, ventricular tachycardia, and alcohol use presents to ED for sudden onset altered mental status with hemoglobin 2.7g/dL, INR 5.4, lactate 6.7mmol/L, total bilirubin 4.7mg/dL, PTT 180s, albumin <1.5g/ml and fibrinogen <60mg/μL (normal 220-410), D-dimer 10.3mcg/mL (normal <0.5) without significant signs of bleeding. Normal AST/ALT and global coagulopathy suggest DIC. Additional labs included +ANA with anti-SMA. Coagulation workup showed normal protein C & S, antithrombin III 59% (normal 85-118) and severely low factors II, X, VII and IX with mildly elevated factor VIII. Doppler ultrasound showed a cirrhotic liver with sequela of portal hypertension. She required 30 units cryoprecipitate and FFP over 20 days to maintain fibrinogen >100mg/dL. Given progressive elevation of bilirubin to 28mg/dl and unresolving fibrinolysis, she received a liver transplant 20 days after admission. Biopsy of native liver showed cirrhosis with lymphoplasmacytic infiltrate, compatible with autoimmune hepatitis. Coagulation labs normalized 1 day post-transplant and no more blood products were required. She then developed bilateral pulmonary emboli, right atrium thrombosis and colonic ischemia, requiring anticoagulation. She was discharged after 3 months and is doing well on follow-up. IMPACT/DISCUSSION: While this patient’s labs initially suggested DIC, unsuccessful treatment with clotting factor replenishment presented a rare case of refractory hyperfibrinolysis, highlighting an approach to identify an uncommon source of coagulopathy. Severe liver disease has been associated with low grade DIC but the key to this patient’s diagnosis was factor VIII. While most clotting factors are synthesized in the liver, factor VIII is also produced by endothelial cells throughout the body. Thus, normal levels amidst depletion of all other coagulation factors suggests reduced hepatic synthesis of clotting factors rather than peripheral depletion. Post liver transplant, coagulation labs quickly normalized, supporting liver failure-induced hyperfibrinolysis. Notably, this patient developed multiple post-surgical thrombi. With reduced synthesis of procoagulants and increased anticoagulant factors, patients with severe liver failure can reestablish hemostasis, though it may be affected by the different half-lives of these factors, causing temporary post-surgical hypercoagulopathy, worsened by autoimmune status and post-surgical status.

Hepatic dysfunction leading to hyperfibrinolysis in patients with advanced liver disease may be mistaken for DIC. Normal factor VIII with otherwise decreased clotting factors in hyperfibrinolysis suggest a hepatic source of coagulopathy. UNCOVERING SYSTEMIC LUPUS ERYTHEMATOSUS: A RARE PRESENTATION WITH SEVERE PANCYTOPENIA, IDIOPATHIC THROMBOCYTOPENIC PURPURA AND PERICARDIAL EFFUSION Nour Aldaoud1; Ayushi Garg2; Vamsi Krishna Lavu3; Joiven Nyongbella4; Wajahat Khan5. 1Internal Medicine Residency, Wayne State University School of Medicine, Detroit, MI; 2INTERNAL MEDICINE, Wayne State University School of Medicine, Detroit, MI; 3Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 4Internal medicine, Wayne State University School of Medicine, Detroit, MI; 5Oncology, Henry Ford Health System, Detroit, MI. (Control ID #4273171) CASE: A 33-year-old female with Raynaud's phenomenon presented with four days of chest heaviness, dyspnea, coffee-ground emesis and melena, along with three weeks of heavy menstrual bleeding. Examination revealed subconjunctival hemorrhages, bruises and purpura along with sinus tachycardia on Electrocardiogram. Laboratory tests showed severe pancytopenia with a hemoglobin of 4.1 g/dL, white blood cells of 2.8 Thous/mcL and platelets of 2 Thous/mcL, and elevated troponins (0.43 and 0.48 ng/mL). Bedside ultrasound revealed pericardial effusion with right ventricular collapse during diastole as an early sign of tamponade. A pericardial window was promptly done, evacuating 500 mL of blood-tinged fluid, which was negative for malignant cells. Viral testing for Human immunodeficiency, hepatitis B and C and Epstein-Barr viruses was only positive hepatitis B surface and total core antibodies. Computed tomography revealed no splenomegaly. Bone marrow biopsy demonstrated hyperplastic marrow with trilineage hematopoiesis and increased megakaryocytes. Studies showed antinuclear antibodies titer of 1:1280, with elevated cardiolipin immunoglobulin G, histone, ribonucleoprotein and Smith antibodies. Other than low vitamin B12 (196 pg/mL), further anemia, coagulation and autoimmune work-up was unrevealing, warranting the diagnosis of Systemic Lupus Erythematosus (SLE) and associated Idiopathic thrombocytopenic purpura (ITP). Management included multiple blood transfusions, intravenous immunoglobulin (IVIG) and steroids. Platelet count remained critically low at 3 Thous/mcL despite three days of treatment prompting the initiation of Rituximab. With subsequent improvement of platelet count to 37 Thous/mcL and stabilization of her hemoglobin level, she was discharged on a steroid taper with hematology and rheumatology follow ups for immunosuppressive therapy and long-term SLE management. IMPACT/DISCUSSION: This case highlights a rare initial presentation of SLE manifesting as severe pancytopenia, ITP, profound bleeding and pericardial effusion with early signs of tamponade. SLE is a multisystem autoimmune disease with a wide range of manifestations. Life-threatening pericardial effusion is an unusual but reported presenting sign. Rapid recognition and treatment, including pericardial window placement, are essential to prevent fatal outcomes. Steroids and IVIG are first-line therapy for ITP. If these fail to achieve a safe and stable platelet count, Rituximab, other immunosuppressive agents and thrombopoietin receptor agonists are second-line treatments. Tailored therapy and a multidisciplinary approach are crucial for favorable outcomes and long-term management.

This case underscores the importance of maintaining a high index of suspicion for autoimmune diseases as SLE in patients with multisystem involvement, including hematologic and cardiac complications. Early diagnosis and intervention in a multidisciplinary approach are vital for patient survival and optimizing long-term outcomes. UNDERAPPRECIATED AND UNDIAGNOSED CHRONIC ADRENAL INSUFFICIENCY IN LOW RESOURCE SETTINGS Emma Brezel1; Joseph H. Stephens2. 1Medicine, New York University Grossman School of Medicine, New York, NY; 2General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4271705) CASE: A 65 year old female with a remote history of hypothyroidism subsequently untreated presented to a rural Ugandan hospital with profound fatigue for 24 years. Previously healthy, she eventually became unable to leave home except for church – the 15 minute walk taking 2 hours and developed cold intolerance, weight gain despite anorexia, chest heaviness, constipation, arthralgias/myalgias, and clouded thinking. PE was notable for normal orthostatic vitals, unremarkable thyroid, hyperpigmented skin, hair loss, psychomotor slowing, and decreased reflexes. Labs notable for Na 129 mEq/L, elevated TSH, low T4, morning cortisol <0.5 mcg/dL, negative TB and HIV tests, and normal CXR. Further testing and imaging were unavailable. Given her signs/symptoms with elevated TSH, low T4 and remarkably low AM cortisol, a clinical diagnosis of primary hypothyroidism and chronic AI was made, likely autoimmune. She was given levothyroxine and prednisone. In follow up, symptoms improved. IMPACT/DISCUSSION: Even in high income settings, up to 20% of patients with AI go undiagnosed for over 5 years since symptoms are gradual in onset and nonspecific. Rural Africa presents further diagnostic and management challenges: symptoms overlap with more common chronic infections; provider awareness is limited as is patient understanding of chronic disease; access to facilities with diagnostic capacity is poor and limited by poverty, and when diagnosed, the urban follow-up required is arduous and expensive. Likely, many undiagnosed patients spend years with AI before succumbing, usually to infection and acute adrenal crisis. Most AI is caused by TB in Africa, however autoimmune disease may be as prevalent as in resourced countries. Clinicians should have high suspicion for concurrent AI in patients with hypothyroidism as it may be up to 100-fold more common in this population. Skin hyperpigmentation and hyponatremia, in addition to hypotension, concentrated urine, hypoglycemia, salt craving, and weight loss raise concern. Given the lethality of adrenal crisis, AI should be considered in patients with shock, altered mental status, or severe abdominal pain. Concern should be high in patients with HIV/AIDs or TB – the most common causes of AI in Africa. In resource limited settings where serum ACTH, stimulation tests, and adrenal CT are unavailable, clinicians rely upon clinical features and biochemical clues for diagnosis. A comprehensive search for present or past TB is important. Personal/family history of autoimmune conditions, and/or concurrent endocrine disease, raise suspicion for autoimmune AI.

Autoimmune conditions including AI often go undiagnosed in low resource settings due to non-specific symptoms and focus on infectious diseases. It is important to maintain a high level of suspicion for AI in patients with other autoimmune disorders or evidence of TB. Hyperpigmentation, hyponatremia and other clinical cues can aid in diagnosis. UNDIAGNOSED AND DISSECTING: A MISSED AORTIC DISSECTION CAUSING BASILAR ARTERY OCCLUSION. Stephen A. Akinfenwa1; John Huston2,3. 1Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Pulmonary Critical Care, Hartford HealthCare Corporation, Hartford, CT; 3Pulmonary Critical Care, UConn Health, Farmington, CT. (Control ID #4271771) CASE: A 46-year-old female with a history of anxiety, depression, and hypertension presented to the emergency department (ED) with hypotension, bradycardia, nausea, and dizziness, suspected a presentation to be due to chemical exposure at work. She had reported four weeks of intermittent chest pain and tingling in her right fingers that she attributes to her anxiety and GERD. The initial workup revealed unremarkable lab results aside from a mildly elevated lactate level of 3.2. Despite receiving 4 liters of intravenous fluids and ICU consultation, her blood pressure only minimally improved, and lactate level was not rechecked. She was subsequently discharged after observation in the ED. Four days later, she was found unresponsive in her apartment hallway. EMS noted severe hypertension and unresponsiveness to Narcan administration. Upon arrival at the hospital, she was intubated for airway protection. Further investigation, including a CT angiography, revealed a Stanford Type A aortic dissection with extension into the proximal innominate and left subclavian arteries and occlusion of the basilar artery. A hyperacute MRI showed a massive posterior circulation stroke involving the whole pons, bilateral thalami, and cerebellum. Given the severe stroke burden, thrombectomy was not feasible. The patient was transitioned to comfort measures only after a discussion with family and subsequently passed away. IMPACT/DISCUSSION: Aortic dissection is relatively rare and often presents as a catastrophic illness with hemodynamic compromise. The clinical triad of acute severe chest or abdominal pain, blood pressure and/or pulse variation, and mediastinal widening on imaging account for 96% of acute aortic dissection presentation. This case highlights the challenges in diagnosing aortic dissection, mainly when initial presentations are atypical or could be attributed to other causes. The initial hypotension associated with mild lactate elevation and bradycardia, coupled with mild symptomatology, may have diverted focus from a more critical underlying pathology. The subsequent hemodynamic and neurological compromise, indicated by the massive posterior circulation stroke, highlights the potential for rapid deterioration and catastrophic complications in undiagnosed aortic dissection cases. The delay in diagnosis emphasizes the need for heightened clinical suspicion and comprehensive evaluation in patients presenting with cardiovascular instability and atypical symptoms.

Aortic dissection can present with varied and atypical symptoms, leading to potential misdiagnosis or delayed treatment. This case illustrates the importance of considering aortic dissection in differential diagnosis, particularly in patients with risk factors such as hypertension and atypical presentations. Thorough clinical assessment and early imaging are crucial for the timely diagnosis and management of this life-threatening condition and its complications. UNILATERAL BREAST MASS: A RARE PRESENTATION OF BURKITT’S LYMPHOMA Anirban Ganguly2; Naseeruddin Naseem1; Jordan Sztejman3; Jeffrey G. Wiese5; Chancellor Donald4. 1Internal Medicine , Tulane University, New Orleans, LA; 2Internal Medicine, Tulane University School of Medicine, New Orleans, LA; 3Tulane University, New Orleans, LA; 4Hematology/Oncology, Tulane University School of Medicine, New Orleans, LA; 5Internal Medicine, Tulane University, New Orleans, LA. (Control ID #4273341) CASE: A 34-year-old HIV+ woman presented to an outside hospital (OSH) with four weeks of a progressive unilateral breast mass, fever, chills, night sweats, nausea, and weight loss. Family history included an aunt who died of breast cancer. Social history included smoking. Exam included her left breast four times larger than right with tight, indurated, purple skin and left axillary adenopathy. Labs showed a mild normocytic anemia with lymphopenia and acute kidney injury. CT showed a heterogeneous 11x9x9 cm left breast mass with 9x6x11 cm mass in left axillary tail, calcified mediastinal and right hilar lymph nodes, and moderate left hydronephrosis. Surgery obtained a core needle biopsy. Within the week, the patient presented to the hospital with increased left breast swelling and pain. She was admitted for further workup. CT showed a new finding of a large infiltrative retroperitoneal (RP) mass involving the left kidney with severe hydronephrosis. Biopsy (bx) of RP mass resulted in aggressive B-cell lymphoma (CD10+, BCL6+, C-MYC+, Ki-67 very high (>95%.) BCL2-). The following day, the breast bx from the OSH resulted in aggressive B-cell lymphoma as well. Burkitt Lymphoma was confirmed with FISH on RP bx resulting in t(8;14) MYC/IGH translocation. The patient was treated with 6 21-day cycles of R-EPOCH and intrathecal methotrexate per NCCN guidelines. Post-C3 PET scan showed partial response. Post-C6 PET scan is pending. IMPACT/DISCUSSION: Burkitt’s Lymphoma (BL) is a rare, aggressive form of NHL, the fastest growing human tumor, and can be immunodeficiency related. This form typically presents in the abdomen, less commonly in the head/neck, and even less commonly elsewhere . BL is diagnosed with immunophenotyping and karyotype +/- FISH testing. It is treated with chemotherapy, including DA-REPOCH, which has been validated in a multicenter phase II trial and improves on cost, toxicity, and complexity over other regimens. We describe an unusual case of HIV-associated BL in a woman with a family history of breast cancer who presented with a massive breast mass. This mass rapidly proliferated over several weeks. A retroperitoneal mass was later found. Biopsies showed histopathological and FISH findings consistent with BL. The patient was treated with DA-REPOCH with intrathecal methotrexate leading to partial response. The aggressive course of this illness demonstrates the importance of recognizing, diagnosing, and treating BL urgently.

- Burkitt’s Lymphoma (BL) is a rare, aggressive form of NHL that should be suspected in HIV+ patients with concern for malignancy - BL is diagnosed with immunophenotyping and karyotype +/- FISH testing of mass biopsy - NCCN guidelines describe multiple chemo regimens for BL including DA-REPOCH UNMASKING ACUTE HEPATITIS: A CASE OF APETAMIN-INDUCED LIVER INJURY Nirja Sutaria, Justin Shaw, Tony Dang. Internal Medicine, Atrium Health, Charlotte, NC. (Control ID #4271755) CASE: A 38-year-old female with hypertension and depression presented with nausea, non-bloody emesis, malaise, and yellowing of her skin. She reported binge drinking, consuming two-fifths of liquor over 1-2 days, multiple times per month. On physical exam, she had jaundice and mild right upper quadrant tenderness. Initial labs showed total bilirubin 14.7 mg/dL (0.3-1 mg/dL), direct bilirubin 3.9 mg/dL (<0.3 mg/dL), AST 1726 U/L (13-39 U/L), ALT 1427 U/L (7-52 U/L), ALP 258 U/L (38-120 U/L), and INR of 2.0. A CT scan revealed a severely heterogeneous liver, raising concern for acute hepatitis. Although alcoholic hepatitis was initially suspected, the degree of transaminase elevation prompted further workup. The patient was started on IV solumedrol, N-acetylcysteine (NAC), and Vitamin K. A comprehensive workup for autoimmune, viral, hereditary, and metabolic causes was unrevealing. Phosphatidyl ethanol levels were markedly elevated at 844 ng/mL (>20 abnormal), confirming significant alcohol use. Doppler ultrasound showed a normal liver with patent vasculature. Throughout the hospitalization, liver enzymes improved with NAC and corticosteroid therapy. Upon further questioning, the patient revealed daily use of Apetamin, a weight gain supplement, for several months. A transjugular liver biopsy demonstrated cholestatic liver injury with lymphocytic and neutrophilic inflammation, rare plasma cells, and mild steatosis, consistent with DILI. No history of liver disease, autoimmune disorders, or other risk factors were identified. The patient’s liver enzymes and symptoms improved with treatment. She was discharged with a steroid taper, hepatology follow-up, and counseling on alcohol and Apetamin discontinuation. IMPACT/DISCUSSION: Apetamin, an unregulated supplement containing cyproheptadine, has been promoted on social media for figure augmentation purposes. This case highlights a rare instance of DILI from Apetamin in a patient with chronic alcohol use. Diagnosing acute hepatitis can be challenging, but markedly elevated transaminases and negative workups should prompt consideration of less obvious etiologies. Although liver injury from Apetamin has been reported, literature on DILI specifically caused by Apetamin is limited. This case emphasizes the importance of taking a thorough history, including over-the-counter supplement use, in the workup of acute hepatitis.

- The rise in popularity of over-the-counter supplements like Apetamin necessitates increased vigilance for DILI - Even when risk factors such as alcohol use are evident, it is crucial to consider non-prescription supplements in the differential for acute hepatitis - Early identification and cessation of these substances are key to optimizing patient outcomes UNMASKING AMYLOIDOSIS: A COMPLEX CASE OF MULTI-SYSTEM INVOLVEMENT IN KAPPA LIGHT CHAIN MULTIPLE MYELOMA: A CASE REPORT Jacklyn Huhn2; Brianna Graham1; Jeffrey Anderson1; Gabrielle Gillow1; Nadia D. Ali3; Carly Fabrizio4; Vikranth R. Induru1. 1Internal Medicine, Temple University Hospital, Philadelphia, PA; 2Temple University Lewis Katz School of Medicine, Philadelphia, PA; 3Hematology, Temple University Health System Inc, Philadelphia, PA; 4Cardiology, Temple University Health System Inc, Philadelphia, PA. (Control ID #4272678) CASE: A 78-year-old female with a medical history of hyperlipidemia and pre-diabetes presented with a three-month history of progressive lower extremity edema, fatigue, and diarrhea. A recent colon biopsy performed as part of the workup for her diarrhea revealed positive Congo Red staining, raising suspicion for amyloidosis. On admission, the patient was hemodynamically stable but demonstrated significant volume overload. Chest X-ray showed cardiomegaly and pulmonary edema, while laboratory testing revealed an elevated BNP of 1,629 pg/mL. Transthoracic echocardiography (TTE) demonstrated heart failure with diastolic dysfunction and biatrial enlargement but preserved left ventricular function. An amyloidosis workup was initiated. Serum protein electrophoresis revealed an M-spike of 0.06 g/dL, elevated kappa light chains, and an increased kappa-to-lambda light chain ratio. This diagnosis of kappa light chain multiple myeloma was confirmed via bone marrow biopsy. The patient started chemotherapy, including pulse-dose steroids and bortezomib. Further evaluation for cardiac involvement included a PYP scan, which was negative for transthyretin amyloidosis. However, due to high clinical suspicion for AL amyloidosis, cardiac MRI was performed, showing diffuse amyloid deposition in all cardiac chambers. Mass spectrometry of the colon biopsy subsequently confirmed AL kappa subtype amyloidosis. IMPACT/DISCUSSION: Amyloidosis can manifest as a wide variety of symptoms resulting from a deposition of protein fibrils in various organ systems. One such protein is a derivative of circulating immunoglobins leading to AL amyloidosis. This case of multiple myeloma, presented primarily with sequela of amyloidosis in two organ systems. Secretory diarrhea and decompensated heart failure prompted further work-up into the etiology of these seemingly unrelated conditions, leading to the diagnosis of multiple myeloma. The work-up involved a multidisciplinary team, assisted in large part by a colonic biopsy positive for Congo-red staining raising suspicion for amyloid, and a cardiac MRI confirming cardiac amyloid.

Multiple myeloma may present with symptoms of amyloidosis, rather than more typical “CRAB” symptoms (hypercalcemia, renal dysfunction, anemia, bone lesions) Consider amyloidosis as a unifying diagnosis for multiple end organ syndromes. UNMASKING CEFTAZIDIME NEUROTOXICITY: NEUROLOGICAL DECLINE IN A PATIENT WITH MULTI-ORGAN DYSFUNCTION Erfan Tasdighi, Naana Kena, Aysha Hussain, Manasa S. Ayyala. Medicine , Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4268317) CASE: A 58-year-old woman with a history of decompensated liver cirrhosis, heart failure with preserved ejection fraction, type 2 diabetes, and a recent episode of septic shock secondary to cholecystitis status post laparoscopic cholecystectomy was transferred to our institution for management of a corneal ulcer in the left eye. The ulcer was suspected to be secondary to Pseudomonas infection associated with intermittent contact lens use. The patient was initiated on intravenous ceftazidime at 2 g every 12 hours, and vancomycin ophthalmic solution. Despite treatment, she developed new-onset somnolence, confusion, and myoclonic jerking of the upper extremities and cheeks. These neurological symptoms were in the setting of recurrent hypotension and worsening renal function. Ceftazidime neurotoxicity was suspected, prompting the discontinuation of the antibiotic on day 15 of therapy. Following the cessation of ceftazidime, the patient’s neurological symptoms improved significantly. There was a gradual resolution of her myoclonic jerking and encephalopathy. IMPACT/DISCUSSION: Ceftazidime, remains a cornerstone in the management of Pseudomonas infections. However, its neurotoxic potential is well known in patients with renal impairment. This case is notable because the patient had no prior renal dysfunction but developed acute kidney injury during treatment, amplifying her susceptibility to neurotoxicity. Antibiotic-associated encephalopathy (AAE), frequently observed with beta-lactam antibiotics, occurs through well-characterized neurotoxic mechanisms. The proposed mechanism for ceftazidime-induced neurotoxicity is that ceftazidime has structural similarity to gamma-aminobutyric acid (GABA) allowing it to competitively bind to GABAA receptors, inhibiting normal neurotransmission. This inhibition can manifest as encephalopathy, confusion, hallucinations, and seizures. Type 1 AAE, commonly associated with cephalosporins, typically presents with electroencephalographic (EEG) abnormalities and unremarkable magnetic resonance imaging (MRI) findings, often emerging within days of therapy initiation. This patient’s case highlights the dual neurotoxic and nephrotoxic risks associated with ceftazidime, particularly in the setting of multi-organ dysfunction. While dose adjustments based on renal function are standard practice, this case underscores the importance of close monitoring for signs of neurotoxicity and prompt intervention in patients who develop acute kidney injury during ceftazidime therapy.

Ceftazidime-associated neurotoxicity, while documented, remains an under-recognized complication of treatment, particularly in critically ill patients with multi-organ dysfunction. This case underscores the need for heightened clinical vigilance, regular monitoring of renal function, and early dose adjustments in patients at risk. Prompt recognition and management of ceftazidime neurotoxicity can prevent severe neurological and renal complications, improving patient outcomes. UNMASKING CHOLANGIOCARCINOMA - A HIDDEN DIAGNOSIS IN THE SHADOW OF OPIOID WITHDRAWAL AND VIRAL HEPATITIS Avan Chu1; Sean P. Carroll1; Charles Hughes1; Saumya L. Karne2; Ankit Hanmandlu2; Lubna Fatiwala2. 1School of Medicine, Wayne State University School of Medicine, Detroit, MI; 2Department of Internal Medicine, Detroit Medical Center, Detroit, MI. (Control ID #4254138) CASE: An underinsured 71-year-old male with history of opioid use disorder was admitted with acute on chronic abdominal pain for over 6 months associated with nausea, bilious emesis, and diarrhea. He used heroin the day prior, said this felt like his previous withdrawal episodes, and requested medication assisted therapy. Although his symptoms improved with buprenorphine, his pain persisted, and further imaging revealed an 18 centimeter right hepatic lobe mass with mass effect causing extrinsic narrowing of the inferior vena cava and right main portal vein branch with possible thrombus or infiltration. Prior viral serologies had revealed laboratory evidence of exposure to hepatitis B, and hepatitis C (viral load 409,926 International units/milliliter (mL)) that was untreated. Further workup showed an elevation in alpha-fetoprotein (AFP) of 516 nanograms (ng)/mL, total bilirubin of 3.55 milligrams (mg)/deciliter (dL), alanine aminotransferase (ALT) of 57 units (U)/liter (L), aspartame aminotransferase (AST) of 154 U/L, and alkaline phosphatase (ALP) of 246 U/L. A liver biopsy was performed and showed a malignant neoplasm with high-grade features and cytologic features consistent with cholangiocarcinoma (CCA) with neuroendocrine features. Unfortunately, prior to undergoing planned treatment, the patient was admitted with signs of worsening obstructive jaundice in the setting of malignant strictures, and after a prolonged hospitalization complicated by septic shock, ultimately decided to pursue hospice care. IMPACT/DISCUSSION: Patients presenting with CCA pose a diagnostic challenge, especially if the patient displays risk factors for hepatocellular carcinoma (HCC) such as well-circumscribed hepatic mass on MRI, mass localization near hepatic vasculature on computed tomography (CT), and severely elevated AFP such as in our patient's case. Moreover, the patient was admitted with severe opioid withdrawal symptoms, further clouding suspicion for CCA. Lastly, the patient’s socioeconomically disadvantaged status delayed earlier presentation, integration into the healthcare network, and regular follow-up. Interestingly, this case was also complicated by co-existing hepatitis B and hepatitis C infections. The CCA:HCC incidence ratio is 17:233 in patients positive for both viruses, demonstrating the lower frequency of CCA compared to HCC. However, the risk remains, as one theory of oncogenesis is thought to be attributed to hepatocyte transdifferentiation into cholangiocyte precursors, but further research is required to elucidate the precise mechanisms. This case highlights the importance of considering CCA in patients with chronic liver disease, even in the presence of opioid withdrawal and complex comorbidities. It emphasizes a greater need for vigilance in diagnosing hepatobiliary malignancies, especially in vulnerable populations.

CCA should be considered even in the presence of overlapping symptomology. Greater vigilance is required in socioeconomically vulnerable populations. UNMASKING CLOZAPINE-INDUCED MYOCARDITIS: A CASE OF EARLY DETECTION AND INTERVENTION Ahmed Raza2; Saman Razzaq1; Niamat Ali3; Usman Ahmed4; Shoaib F. Sher5; Muhammad Shaheer Ul Islam5. 1Pulmonary Disease and Critical Care Medicine, Stony Brook University Hospital, Stony Brook, NY; 2Internal Medicine, Yale New Haven Hospital, New Haven, CT; 3Orthopedic, Lahore General Hospital, Lahore, Punjab, Pakistan; 4Medicine, Jinnah Hospital, Lahore, Punjab, Pakistan; 5Medicine, Allama Iqbal Medical College, Lahore, Punjab, Pakistan. (Control ID #4270488) CASE: A 34-year-old male with history of obsessive-compulsive disorder, autism spectrum disorder, and anxiety was admitted to inpatient psychiatry for management of psychosis and possible drug-induced parkinsonism caused by Zyprexa which was tapered off. Clozapine was initiated and titrated to 350 mg nightly with resultant improvement in psychosis. Routine monitoring revealed elevated troponin levels (111 ng/L) and C-reactive protein (CRP) at 24.3 mg/L and the patient developed non-radiating chest pain that occurred at rest. Further testing revealed peripheral eosinophilia, normal electrocardiogram (EKG) and transthoracic echocardiogram (TTE) findings. However, cardiac magnetic resonance imaging (MRI) demonstrated patchy mid-myocardial late gadolinium enhancement (LGE) and myocardial edema, suggestive of myocarditis. Infectious and autoimmune etiologies were ruled out. Clozapine was immediately discontinued, and the patient was transitioned to quetiapine for psychosis management. The patient’s cardiac symptoms resolved with supportive care, troponin levels trended down, and he was discharged with close cardiology follow-up. IMPACT/DISCUSSION: Clozapine, an effective antipsychotic for treatment-resistant schizophrenia, carries a rare but serious risk of myocarditis. It typically occurs within 3–4 weeks of starting clozapine and symptoms may mimic viral infections, leading to delayed diagnosis. It is thought to result from a hypersensitivity reaction involving eosinophilic infiltration of the myocardium and peripheral eosinophilia can act as an early warning marker. Early detection is vital, as untreated cases can have a mortality rate of 10%–20%. Routine monitoring of troponin and CRP levels during the initial weeks is important, because these markers often rise before symptoms in 90% of cases. Our patient had elevated biomarkers and peripheral eosinophilia on labs prior to developing symptoms. Although his EKG and TTE were normal, cardiac MRI revealed evidence of myocarditis.

This case emphasizes the importance of routine cardiac monitoring in patients initiated on clozapine. Clozapine induced myocarditis can have fatal consequences if not detected early. Routine monitoring with serial troponin and CRP levels and a high degree of suspicion can aid in early diagnosis and timely intervention. UNMASKING HEPATITIS C-INDUCED CRYOGLOBULINEMIC VASCULITIS: A RARE CASE OF NEUROPATHY WITH OVERLAPPING IMMUNE AND HEMATOLOGIC CLUES Doan Ngoc Chau Nguyen1; Mohamed Sleem2; Viet Nghi Tran3; Mai Hamaad4; Anum Farid1; Rahul Chandra5. 1Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX; 2Internal Medicine, Texas Tech University Health Science Center/Amarillo, Amarillo, TX; 3Dept. of Internal Medicine, Resilience Healthcare - Weiss Memorial Hospital LLC, Chicago, IL; 4Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, Amarillo, TX; 5Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX. (Control ID #4271163) CASE: A 59-year-old Caucasian male welder presented with six months of progressive bilateral lower extremity pain and weakness. Exam revealed stocking-pattern sensory loss and absent ankle reflexes. Initial workup revealed normal HbA1c and vitamin B1, B6, and B12 levels, with negative HIV, syphilis, and heavy metal screens. Cerebrospinal fluid analysis showed albuminocytologic dissociation, and electromyography confirmed mononeuritis multiplex with severe axonal neuropathy. Vasculitis markers (ANCA, ANA) were negative, and serum C4 was normal. Further tests showed elevated IgM (270 mg/dL), a kappa/lambda ratio of 1.81, and an M-spike of 0.2 mg/dL. Bone marrow biopsy revealed a small kappa-restricted B-cell population (<1%), consistent with IgM monoclonal gammopathy of undetermined significance (MGUS). A month later, he developed right-hand arthritis and lower-extremity livedo reticularis. Imaging showed no joint destruction. Urinalysis revealed >20 RBCs, and CRP was elevated. Rheumatoid factor (RF), type II mixed cryoglobulins, and hepatitis C RNA were positive. Diagnosed with hepatitis C-induced cryoglobulinemia (HCIC), treatment with prednisone, rituximab, and antiviral therapy improved arthritis and neuropathic pain. IMPACT/DISCUSSION: Mixed cryoglobulins (MCs) are a common extrahepatic manifestation in patients with hepatitis C, whereas overt cryoglobulinemic vasculitis develops in only 5–10% of cases. This report details a complex case of HCIC presenting as severe peripheral neuropathy, initially mistaken for chronic inflammatory demyelinating polyneuropathy (CIDP) and IgM MGUS. The patient’s peripheral neuropathy with CSF albuminocytologic dissociation initially suggested CIDP. Normal calcium/creatinine, elevated serum IgM, an increased kappa/lambda ratio, and <10% plasma cells on bone marrow biopsy indicated possible IgM MGUS, where neuropathy is uncommon. The subsequent onset of arthralgia, synovitis, livedo reticularis, and hematuria raised suspicion for HCIC, which was later confirmed as type II MCs with overt cryoglobulinemic vasculitis. Type II MCs arise when HCV binds to CD81 on B cells, inducing clonal proliferation and production of autoantibodies (IgM with RF activity targeting anti-HCV IgG). This process elevates free kappa light chains and the kappa/lambda ratio. Electrophoresis reveals mixture of polyclonal hypergammaglobulinemia and monoclonal Ig, typically IgM-kappa. Neurological manifestations of HCIC range from sensory axonopathy to mononeuritis multiplex, often presenting as distal sensory or sensory-motor polyneuropathy. Low C4 is a key marker of MC disease activity.

IgM monoclonal gammopathy in patients with peripheral neuropathy is not limited to lymphoproliferative disorders like IgM multiple myeloma or MGUS. This case highlights the complexity of diagnosing overlapping hematological and immunological features, emphasizing the importance of a comprehensive evaluation, including a workup for type II HCIC. UNMASKING OCCULT GIANT CELL ARTERITIS: A CASE OF ISOLATED OCULAR INVOLVEMENT Hannah Hugo, Harleen Sidhu, Aparna A. Rathnam, Juan Urraca, Mohamed Abdelghffar. Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY. (Control ID #4273432) CASE: A 79-year-old woman with Parkinson's disease, diabetes mellitus with neuropathy, and hypertension was admitted following a mechanical fall. She denied experiencing dizziness, loss of consciousness, head trauma, headaches, and chest pain. She reported blurry vision in her right eye following another fall eight days prior, during which she struck her head. The patient did not use assistive devices and denied alcohol and illicit drug use. On examination, she had right eyelid ecchymosis, pupils were reactive to light bilaterally, extraocular movements were intact and she had no focal deficit. Initial labs were only notable for urinalysis showing 23 WBCs. CT head revealed no acute findings. The patient’s recurrent mechanical falls were attributed to a recent increase in carbidopa-levodopa dose. IV Ceftriaxone was started for presumed urinary tract infection. On hospital day two, the patient’s right eye blurry vision progressed to acute bilateral vision loss, prompting a stroke code, but workup for acute stroke was negative. The patient experienced no headache, jaw claudication and had no temporal artery tenderness on exam. Further investigation revealed CRP 77.8 mg/L (normal: <10 mg/L) and ESR 88 mm/hour (0 to 20 mm/hour). CSF studies and vascular imaging were normal. Ophthalmologic exam showed bilateral optic disc edema. The patient was started on methylprednisolone 1 g/daily for 3 days. Temporal artery biopsy was performed, and steroids were tapered after the completion of the pulse-dose regimen. IVIG was initiated for corticosteroid unresponsive optic neuritis but was discontinued after the biopsy results confirmed giant cell arteritis (GCA). Despite treatment, the patient had no improvement in vision and was ultimately discharged to a skilled nursing facility for further care on methotrexate, a steroid-sparing agent. IMPACT/DISCUSSION: GCA is the most common primary systemic vasculitis in individuals over 50 years of age. This condition primarily affects large and medium-sized arteries, especially branches of the external carotid artery. Symptoms vary, but often include cranial symptoms such as headache, scalp tenderness, and jaw claudication, as well as constitutional symptoms. Occult GCA is a variant of GCA in which ocular involvement is the primary manifestation, but the typical systemic manifestations are absent. This often results in delayed or missed diagnosis. Temporal artery biopsy remains the gold standard diagnostic test, though it is commonly biopsied due to its accessibility, and is not the only site of disease involvement.

In clinical practice, GCA should be strongly suspected in patients over 50 presenting with unexplained blurry vision, particularly when no other diagnosis is apparent. Early diagnosis and treatment of GCA is crucial, as a shorter interval between onset of vision loss and initiation of therapy has been shown to significantly improve outcomes and prevent irreversible vision loss. UNMASKING PJP PNEUMONIA: A DELAYED DIAGNOSIS Hannah Fuson1; Rosemary B. Falama2; Andrea Smeraglio3. 1School of Medicine, Oregon Health & Science University, Portland, OR; 2Department of Medicine, Oregon Health & Science University, Portland, OR; 3Internal medicine, Oregon Health & Science University, Portland, OR. (Control ID #4271114) CASE: An 82-year-old woman with steroid-treated giant cell arteritis (GCA) and heart failure with preserved ejection fraction presented with dyspnea. Her medications included prednisone tapered from 80mg to 20mg over 2-months without PJP prophylaxis. On exam, she was afebrile, on 2L of O2, with elevated JVP, bilateral crackles, irregular heart sounds, and lower extremity edema. Initial laboratories were unremarkable. Chest X-ray revealed patchy bilateral lung opacities. She was treated for an acute heart failure exacerbation, achieving euvolemia within four days. Despite this, her oxygen requirements increased to 4L/min causing consideration of a broader differential diagnosis. A chest CT showed worsened patchy ground glass opacities and mosaicism compared to 1-year ago. Pulmonology was consulted and performed a bronchoalveolar lavage (BAL). She was restarted on high dose steroids with concern for rapidly progressive interstitial lung disease after infectious workup was initially negative including a PJP smear. Eight days after BAL, Beta-D-glucan resulted positive, and PJP PCR from BAL resulted positive the following day. The patient was started on treatment dose Bactrim with clinical improvement. IMPACT/DISCUSSION: This case highlights PJP pneumonia in a patient with confounding factors leading to delayed diagnosis including initial heart failure presentation and send out labs with lengthy waiting periods. In addition, there was hesitancy to start empiric PJP treatment due to conflicting literature on PJP prevalence in this population. Finally, clinicians incorrectly anchored on a low-sensitivity negative PJP stain, further delaying treatment initiation. It took 18 days to reach a diagnosis and initiate treatment. On review of PJP diagnostics, it is important to note that stains for PJP have a sensitivity as low as 31%, whilst PCR offers a sensitivity of 97-99%. Unfortunately, the stain results nearly immediately while PCR can take 1-2 weeks. Serum Beta-D-glucan (sensitivity 91-95%, specificity 75%) can improve diagnostic accuracy but also can take 1-2 weeks to result. These challenges in PJP diagnostics are compounded by the lack of consensus about risk of PJP in patients on high dose steroids. PJP is rare in GCA patients on steroids, with recent literature reporting only 30 cases within a 24-year analysis period. Due to low incidence, prophylaxis is not routinely used unless a secondary immunocompromising medication or condition exists.

PJP should be considered in the differential in any patient on high dose steroids with hypoxia. Understanding the diagnostic characteristics of PJP testing is important given the lengthy delays between testing and results. A low threshold should be given to starting initial treatment while pending results. UNMASKING THE MYSTERY: HIGH-GRADE B-CELL LYMPHOMA PRESENTING AS EPIGASTRIC PAIN IN A YOUNG FEMALE Jordan Selep1; Joyce Chen1; Shazia Samanani2. 1Internal Medicine, The George Washington University, Washington, DC; 2Medicine, The George Washington University, Washington, DC. (Control ID #4271321) CASE: A 26-year-old female with no past medical history presented with two weeks of persistent epigastric pain, nausea, vomiting, weight loss, and loss of appetite. Prior to presentation, she had been diagnosed with Helicobacter Pylori (H.Pylori) outpatient and had started pantoprazole with mild improvements in her symptoms but ongoing abdominal pain. In the emergency room, the patient was tachycardic to 120 beats per minute. Labs were notable for a lipase of 3754 U/L, but lactate, white blood cell count, and electrolytes were within normal limits. CT abdomen revealed a large 15x12x9cm gastric mass with invasion into the liver, spleen and pancreas. Esophagogastroduodenoscopy with aspiration of the mass revealed atypical lymphocytes. The specimen was sent for flow cytometry with markers consistent with high-grade B-cell lymphoma (HGBL). IMPACT/DISCUSSION: We considered a wide differential in this young female patient with minimal alcohol or anti-inflammatory use presenting with epigastric, postprandial pain and positive H.Pylori testing. Dyspepsia, peptic ulcer disease, gastritis, and pancreatitis all began high on the differential, with lymphoma less likely given lack of lymphadenopathy. Given the persistence of her symptoms despite pantoprazole with red flag symptoms of weight loss and appetite loss, further imaging was pursued. The gastric mass with pancreatic involvement seen on imaging helped elucidate the etiology of her pancreatitis while opening a broader differential including GIST (gastrointestinal stromal tumors), gastric cancers, and lymphomas. In the setting of her untreated H.Pylori and newfound mass, MALT (mucosa-assisted lymphoid tissue) lymphoma was highly suspicious. Given her young age and absence of lymphadenopathy, HGBL was an unexpected diagnosis. HGBL is an aggressive subtype of Non-Hodgkin’s lymphoma mostly seen in older adults around 70 years old.1 HGBL has similar features to diffuse large B cell lymphoma and Burkitt lymphoma and can also present at nodal or extranodal sites, with one third of cases found outside the lymphatic system.2 The gastrointestinal tract, bone marrow, and central nervous system are several common locations for extranodal involvement.3,4 It is crucial to keep extranodal lymphoma on the differential for epigastric pain to allow for appropriate diagnosis and treatment.

-In a young patient with epigastric, postprandial pain with positive H.Pylori testing, it is crucial to keep a broad differential and pursue imaging if "red flag" symptoms including weight loss or loss of appetite are present. -Extranodal HGBL is a subtype of Non-Hodgkin’s lymphoma that is important to keep on the differential for epigastric pain to ensure prompt workup and treatment given the disease's poor outcome. UNRAVELING AN UNSUAL CASE OF IG4 RELATED DISEASE Jorge Aboytes2,1; Jose J. Loayza Pintado2,1; Guillermo A. Obregon3,1. 1Internal Medicine, Valley Regional Medical Center, Brownsville, TX; 2Internal Medicine, The University of Texas Rio Grande Valley, Brownsville, TX; 3HNI healthcare, The University of Texas Rio Grande Valley McAllen, McAllen, TX. (Control ID #4273158) CASE: A 35-year-old woman with history of metabolic associated fatty liver disease (MASLD) presented with progressively worsening nausea, vomiting, abdominal pain, and generalized weakness that started two weeks prior to admission. She denied fever, chills, cough, dysuria or diarrhea. Intially she was difficult to arouse, but was able to cooperate and follow commands. Toxicology panel was negative for drugs of abuse, ethylene glycol and acetaminophen. Other laboratory work up found her to be in acute renal failure and a blood gas analysis indicated high anion gap metabolic acidosis. Abdominal ultrasound suggested cirrhosis which was later confirmed with a subsequent computed tomography. During hemodialysis she became acutely encephalopathic, lethargic and unable to protect her airway. Hence, requiring intubation and transfer to ICU. There was concern for decompensated liver cirrhosis that progressed from MASLD. However, besides presence of hyperammonemia and imaging, albumin, platelets and INR were normal. Additionally, initial physical exam did not reveal stigmata of liver disease. We concluded elevated ammonia levels were consistent with the inability to remove urea products due to acute kidney failure. Autoimmune workup then reported elevated IG4 levels prompting initiation of intravenous steroids. Two additional hemodialysis sessions were required before renal function improved. IMPACT/DISCUSSION: In a small case series, 82% IG4-RD patients were found to have IG4-related kidney disease (IG4-RKD). Approximately 30% of these showed no abnormalities on CT imaging, conversely, other studies suggest that around 70% of such patients exhibit abnormalities. Despite multiple hemodialysis sessions and first-line treatment with steroids, this patient had a slow recovery and response to treatment. This may be attributed to the severity of the disease at presentation, rapid decompensation, and ultimately delayed diagnosis. Saeki et al. reported that while steroid therapy led to rapid improvement in renal function for patients with an estimated glomerular filtration rate (eGFR) below 60 mL/min before treatment, a complete recovery was not always achieved. In our case, the initial eGFR was 1 mL/min, potentially explaining her limited early response. Additionally, a series of 41 cases of IG4-RKD noted that serum IgG levels exceeded 1,800 mg/dL in over 90% of cases and 3,000 mg/dL in more than 50%. Only two cases in their study involved IG4-RKD, as IG4-RD typically affects three to four organs simultaneously. In contrast, our case featured a serum IgG level of 1544 mg/dL with disease limited to the kidneys.

Our patient's marked uremic symptoms, imaging findings and delayed response to therapy highlights the variability in clinical presentation of rare cases of IG4-RKD. The complications of severe renal dysfunction emphasize the importance of early recognition, steroid treatment to optimize outcomes and the benefit of multidisciplinary approach in managing complex presentations of IG4-RD. UNSHACKLING PULMONARY EMBOLI: AN UNDERAPPRECIATED RISK FACTOR FOR IN-HOSPITAL THROMBOSIS Owen Cooper2; Mark Spencer1. 1General Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2Emory University, Atlanta, GA. (Control ID #4264926) CASE: A 28yo with schizoaffective disorder was admitted from jail with abdominal pain and diagnosed with diabetic ketoacidosis. He remained shackled to his bed with an arm and leg metal cuff around the clock. After two days of enoxaparin prophylaxis, acute thrombocytopenia led to its discontinuation. Days later, he experienced sudden hemodynamic collapse with refractory hypotension and tachycardia. He was diaphoretic and lightheaded but without hypoxia. CT revealed a massive saddle PE. Lower extremity doppler did not reveal a DVT. He received thrombolytic therapy and was placed on long-term anticoagulation. A second case involved a 64yo with a history of opioid and tobacco use who was admitted from jail for opioid withdrawal. He was likewise shackled to his hospital bed. DVT prophylaxis was withheld due to downtrending hemoglobin in the setting of an upper GI bleed. H. pylori-associated gastric ulcers were identified on endoscopy and treated. Days later, he developed sudden dyspnea and chest pain. CT showed extensive bilateral Pulmonary emboli. Doppler ultrasound found no DVT. He underwent thrombolysis and was eventually discharged on a direct oral anticoagulant. IMPACT/DISCUSSION: In addition to the documented physical and psychological harms of shackling patients, the practice significantly reduces mobility, a known risk factor for VTE. When pharmacologic prophylaxis is contraindicated, the prolonged immobility imposed by shackles may contribute to an incomplete risk assessment by healthcare providers. Both cases underscore a potentially preventable pattern of life-threatening PE in shackled patients, where conventional VTE risk stratification such as Padua or IMPROVE-VTE scores may fail to account for the unique constraints posed by forced immobilization. Compounding this issue, the absence of hospital guidelines, nursing protocols, or EMR alerts for managing shackled patients may enhance patient risk. Therefore, it is important that all hospital systems begin with a thorough analysis of in-hospital DVT/PE, comparing unshackled to shackled patient rates. Policies should be established for prolonged removal of shackles in certain circumstances. If prolonged removal is not possible, protocols should be in place for shackle rotation, allowances for out-of-bed mobility, and systematic documentation of shackle use to mitigate patient harm.

While the direct evidence connecting shackling to increased VTE risk is limited, the established link between immobility and thromboembolism provides a compelling rationale for considering shackling as a significant contributing factor. While reasons already exist to strongly consideration significantly curtailing the use of shackles in hospital settings, this risk is another to be taken into consideration for all hospitalized incarcerated patients. Further investigation to compare relative event rates of shackled and non-shackled inpatients are needed as are policy reforms to ensure the safety and dignity of all incarcerated patients. UNTANGLING THE ROOTS OF HEART BLOCK: LYME, SARCOID, OR BOTH? Ashish Tripathi1; Sanjana Arsha1; Elliot Levine2; Chhaya A. Gupta2. 1Internal Medicine, Westchester Medical Center Health Network, Valhalla, NY; 2Cardiology, Westchester Medical Center Health Network, Valhalla, NY. (Control ID #4273476) CASE: A 56-year-old woman with hypertension, previously noted LBBB and a remote history of treated Lyme disease presented with several days of dizziness and exertional dyspnea. An EKG in her cardiologist’s office revealed a new complete heart block, prompting referral to the ED. Initial evaluation showed heart rate of 39 bpm, with stable blood pressure and normal oxygenation. Labs showed elevated proBNP 2160 pg/mL, hs troponin of 16 ng/L, and CT chest imaging revealed patchy infiltrates, mediastinal lymphadenopathy, and heterogeneous thyroid, raising suspicion for sarcoidosis. She was then transferred to our center for further workup. Despite transient dopamine support, she remained bradycardic (HR 36 bpm), and EKG showed complete heart block with ventricular escape beats. She underwent an endomyocardial biopsy with the placement of temporary transvenous pacing (TVP) due to continued conduction defects, which was later upgraded to a semi-permanent pacemaker. Endomyocardial biopsy did not reveal evidence of myocarditis or granulomatous infiltration. Transbronchial lung biopsy revealed non-necrotizing granulomas consistent with pulmonary sarcoidosis. Subsequently, Lyme serologies (IgM 3/3 bands and IgG 10/10 bands) were positive, and IV ceftriaxone was initiated, though conduction did not improve. Cardiac PET scan showed focal FDG uptake in the basal septum, suggestive of possible cardiac sarcoid involvement, but the diagnosis remained uncertain due to concurrent Lyme infection. Given persistent AV block and no response to antibiotics, a permanent pacemaker was placed. She was discharged with outpatient follow-up, cardiac MRI, completion of Lyme-targeted doxycycline, and close cardiopulmonary monitoring. IMPACT/DISCUSSION: This case highlights the diagnostic challenge when a patient presents with high-grade AV block and findings suggestive of an infiltrative process like sarcoidosis while also testing positive for Lyme disease. Although Lyme carditis can cause AV block, the lack of improvement after appropriate antibiotic therapy raised suspicion for another underlying pathology, possibly cardiac sarcoidosis. Diagnosing cardiac sarcoid can be difficult without definitive biopsy findings, and imaging findings may be subtle. This case underscores the importance of a broad differential, a multidisciplinary approach, and the judicious use of advanced diagnostics in patients with complex conduction abnormalities.

Sarcoidosis and Lyme disease can both present with high-degree AV block, complicating the diagnostic process. Noninvasive imaging and tissue biopsy may be inconclusive, requiring careful clinical judgment. Persistent AV block, despite targeted therapy, may prompt permanent pacing and ongoing multidisciplinary follow-up. UNVEILING A HIDDEN CAUSE: RECURRENT PANCREATITIS SECONDARY TO PANCREAS DIVISUM Jose Duran, Priscilla Abate, Jake Debroff, Bharati Dev, Luis G. Rendon-Rodriguez. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272006) CASE: A 49-year-old male with recurrent pancreatitis of unknown etiology presented with epigastric abdominal pain radiating to the back, associated with nausea and vomiting. He reported multiple similar episodes, most recently three years prior. He denied alcohol, tobacco, or drug use. Previous evaluations included an unremarkable MRCP showing interstitial pancreatitis with no structural abnormalities and normal autoimmune panels. On admission, vital signs were stable. Physical examination revealed epigastric tenderness with guarding. Labs showed elevated alkaline phosphatase but normal lipase, AST, ALT, and triglycerides. CT of the abdomen revealed acute interstitial pancreatitis without collections. Ultrasound showed no biliary abnormalities. A repeat MRCP revealed pancreas divisum without biliary dilation or choledocholithiasis. The patient was managed with intravenous fluids and pain control. His symptoms improved, and he was discharged with gastroenterology follow-up to consider endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla sphincterotomy. IMPACT/DISCUSSION: Pancreas divisum, the most common congenital pancreatic anomaly, affects 10% of the population, but only 5% develop symptoms such as recurrent acute pancreatitis. The pathophysiology involves impaired drainage through a narrow minor papilla, leading to increased intraductal pressure and inflammation. This case highlights key challenges in diagnosing recurrent pancreatitis. Normal lipase levels complicated the initial diagnosis, emphasizing the importance of correlating clinical findings with imaging. The initial CT did not identify pancreas divisum, underscoring the value of MRCP in cases of unclear etiology. While pancreas divisum is often asymptomatic, it should be considered in recurrent pancreatitis, particularly when other causes are excluded. Management is typically conservative, but therapeutic options such as ERCP with minor papilla sphincterotomy or dorsal duct stenting may benefit selected patients. This case contributes to the literature by emphasizing the need for thorough evaluation and advanced imaging in recurrent pancreatitis.

● Acute pancreatitis may present with normal lipase levels; diagnosis requires careful correlation with clinical and imaging findings. ● MRCP is an invaluable diagnostic tool in recurrent pancreatitis cases, particularly when initial imaging is inconclusive. ● Pancreas divisum, though often asymptomatic, should be considered as a potential cause of recurrent pancreatitis, prompting further evaluation for appropriate management. UNVEILING MITRAL ANNULAR DISJUNCTION: A POST-OPERATIVE DISCOVERY IN A YOUNG PATIENT Carson Oprysko1; Shreya Arvind2; Ghalib Shaikh2; Madura Saravanan3. 1Department of Medicine, University of Connecticut, Storrs, CT; 2Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; 3Medicine, UConn Health, Farmington, CT. (Control ID #4273694) CASE: A 27-year-old female with a history of recurrent pituitary macroadenoma, diabetes insipidus, and electronic cigarette use disorder presented to the hospital for an elective transsphenoidal resection of residual pituitary tumor. While being monitored post-operatively in the neuro-intensive care unit, she was noted to have frequent runs of premature atrial contractions as well as ventricular bigeminy. Laboratory workup was within normal limits. A transthoracic echocardiogram showed a severely myxomatous mitral valve with leaflet prolapse, posterior mitral annular disjunction, and a mildly dilated left atrium. Following her post-surgical recovery, a cardiac MR was performed, which showed the myxomatous mitral valve leaflets, moderate mitral regurgitation, and MAD with a 1.3 cm separation during systole. No areas of abnormal late gadolinium enhancement (LGE) were appreciated. IMPACT/DISCUSSION: Mitral annular disjunction (MAD) is a structural abnormality where the mitral valve leaflets insert into the atrial wall instead of their usual location. Usually associated with mitral valve prolapse (MVP), the presence of MAD often serves as an arrhythmogenic focus and can lead to malignant arrhythmias and sudden cardiac death. Though it's unclear if MAD is a byproduct of MVP or perpetuates it, the arrhythmogenic risk is thought to be related to the repetitive, exaggerated stretch of the mitral annulus, leading to fibrosis. Identification of MAD through advanced imaging plays a clinically significant role in determining the role of interventions. Though the timing of interventions remains a challenge, several options exist, and some such as surgical mitral valve replacement can be potentially curative. In the absence of sustained ventricular arrhythmias and LGE, as in our case, there is a lower risk of sudden cardiac death and patients can often be observed in the outpatient setting.

MAD can lead to malignant arrhythmias and sudden cardiac death. The use of advanced imaging techniques carries prognostic value and can help determine further steps in mangement UNVEILING THE SIGNIFICANCE OF WELLENS SYNDROME: A CASE SERIES DEMONSTRATING CRITICAL LAD STENOSIS AND IMPLICATIONS FOR TIMELY INTERVENTION Saad Malik, Kunwardeep Singh Arora, Sanjay V. Pujar, Patel Dipaben, Vaseem Ahmed. Internal Medicine, Texas Health Resources, Arlington, TX. (Control ID #4272688) CASE: Introduction: Wellens Syndrome is a critical clinical entity characterized by biphasic or deeply inverted T waves in V2-V3, accompanied by a history of recent chest pain that has resolved. This syndrome is highly specific for identifying critical stenosis of the left anterior descending artery (LAD). (1,2)

We present a case series of four patients who presented with resolved chest pain, demonstrated a biphasic T-wave pattern in V2-V3 during a pain-free state and exhibited normal or slightly elevated. cardiac markers. Urgent left heart catheterization confirmed significant LAD stenosis ranging from 80% to 100%. Patient 1: A 60-year-old male with a history of heart issues experienced mild right arm pain. Evaluation revealed an 80-90% blockage in the LAD (left anterior descending artery). He underwent a successful PCI (Percutaneous Coronary Intervention). Patient 2: A 75-year-old female with a history of various health conditions presented with chest pain that was sharp, moderate in intensity, and radiated to both arms. She underwent PCI due to a 99% blockage in the LAD. Patient 3: A 74-year-old male complained of left-sided chest pain aggravated by exertion and associated with shortness of breath. Evaluation revealed a 99% blockage in the LAD. He underwent a successful PCI. Patient 4: A 70-year-old male with a history of GERD experienced chest pain, initially mild but later severe with exertion and shortness of breath. He exhibited EKG changes consistent with LAD occlusion. Urgent catheterization showed a 95% blockage in the LAD, and he underwent PCI. IMPACT/DISCUSSION: The biphasic T-wave pattern seen in our patients' pain-free state aligns with the diagnostic criteria for Wellens Syndrome. Timely recognition of this pattern on electrocardiograms (ECGs) is crucial as it indicates impending risk of extensive anterior wall myocardial infarction. Despite being pain-free at the time of presentation, these patients were found to be at an elevated risk for subsequent myocardial infarction within days to weeks. Due to the unstable nature of critical LAD stenosis, medical management is often insufficient, necessitating invasive therapy such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). (1-4) In addition, our study aligns with previous research indicating that Wellens Syndrome may be an important precursor to non-ST-segment elevation myocardial infarction (NSTEMI). Wellens' sign was observed in 8.8% of NSTEMI patients, with the majority involving LAD culprit. lesions. Sensitivity and specificity of Wellens' sign for predicting LAD culprit lesions were found to be 24.6% and 96.2%, respectively. (6)

Our case series highlights the importance of serial ECGs in patients presenting with chest pain, as the characteristic T-wave changes of Wellens Syndrome may not be evident during episodes of ischemic chest pain. The findings also emphasize the need for urgent intervention to prevent catastrophic outcomes like cardiac arrest . URINARY BLADDER FUNGAL BALL MISDIAGNOSED AS COLOVESICAL FISTULA IN A DIABETIC PATIENT Shanmukha Priya Peddireddy2; Kishan Patel1; Bauer Timothy3. 1Internal Medicine, Nuvance Health, POUGHKEEPSIE, NY; 2Internal Medicine, Nuvance Health, POUGHKEEPSIE, NY; 3NEUROLOGY, Nuvance Health, POUGHKEEPSIE, NY. (Control ID #4272546) CASE: A 71-year-old male with hypertension, hyperlipidemia, benign prostatic hyperplasia, chronic venous insufficiency with non-healing wounds, insulin-dependent diabetes mellitus (previously on an SGLT2 inhibitor, recently discontinued), atrial fibrillation, and a chronic Foley catheter for urinary incontinence was admitted with worsening suprapubic pain for a month. His history includes hospitalization for a Candida urinary tract infection (UTI) treated with micafungin. Initial CT of the abdomen and pelvis showed moderate right and mild left hydroureteronephrosis, with suspicion of a colovesical fistula and soft tissue gas near the right hip. He was diagnosed with sepsis secondary to UTI, raising concerns about a colovesical fistula. Blood and urine cultures grew Candida glabrata, and treatment was initiated with micafungin, fluconazole, and intravesical amphotericin B. A CT urogram failed to fill the bladder with contrast, prompting a colonoscopy to evaluate the suspected colovesical fistula; the results were negative. The patient experienced repeated Foley catheter clogging, leading to urinary retention. Repeat CT imaging with oral and IV contrast showed no significant changes. Cystoscopy revealed a diffusely inflamed bladder and a 5 cm fungal ball. A second cystoscopy removed multiple fungal balls, and continuous bladder irrigation was started for hematuria, which resolved during his hospital stay. The hospital course was complicated by Pseudomonas bacteremia, treated with a 10-day course of meropenem. He was discharged to a rehabilitation facility on a 4-week course of oral fluconazole after source control. IMPACT/DISCUSSION: Urinary tract fungal balls, though rare, can cause recurrent UTIs, obstruction, and distress. They are most common in patients with diabetes, immunosuppression, chronic illnesses, or indwelling catheters. This patient’s diabetes and prior SGLT2 inhibitor use increased his risk for urinary mycotic infections. While SGLT2 inhibitors are linked to urinary mycotic infections, evidence of their association with fungal ball formation is limited and warrants further study. In this case, a fungal ball was misdiagnosed as a colovesical fistula, delaying treatment. This underscores the importance of including fungal balls in the differential diagnosis of recurrent UTIs, especially in patients with chronic candidiasis or catheter use. CT urograms and cystoscopy are essential for accurate diagnosis and management.

Urinary tract fungal balls are diagnostically challenging and often mistaken for other conditions like colovesical fistulas, leading to delayed treatment. Clinicians managing recurrent UTIs in diabetics or patients with chronic catheters should maintain a high index of suspicion for fungal infections. Early recognition and urological intervention, including cystoscopy, are critical for effective treatment. UTILITY OF POINT-OF-CARE ULTRASOUND (POCUS) TO EVALUATE FOR ACUTE CHEST SYNDROME IN SICKLE CELL ANEMIA Varsha Venkatakrishna. Internal Medicine, Lenox Hill Hospital, New York, NY. (Control ID #4273413) CASE: A 49 year old female with history of sickle cell disease presented with progressively worsening bilateral lower extremity and low back pain, pleuritic chest pain, dyspnea, productive cough, and subjective fever. On admission, the patient had a temperature of 100.6 °F that resolved without intervention, blood pressure of 130/87, heart rate of 77, respiratory rate of 18, and oxygen saturation of 100% on room air. Pulmonary auscultation revealed decreased air movement and an otherwise unremarkable exam. Chest X-ray (CXR) showed a possible retrocardiac consolidation and bilateral linear opacities. The patient was started on fluids, pain control, and empiric ceftriaxone and azithromycin for pneumonia. Soon after, the patient developed hypoxia requiring 2L NC. Concerned for ACS, a point-of-care ultrasound (POCUS) was performed to further evaluate for retrocardiac consolidation. Pulmonary POCUS revealed mild, bilateral static air bronchograms consistent with atelectasis and no consolidation. A two-view CXR later confirmed the absence of retrocardiac consolidation as noted on sonography. Due to the absence of fever, mild respiratory symptoms, and unremarkable imaging, the patient was continued on treatment for acute sickle cell pain crisis and community acquired pneumonia. The rest of her hospital course was unremarkable, and the patient was discharged home 2 days later. IMPACT/DISCUSSION: While the pathogenesis of ACS is poorly understood, it is hypothesized that prothrombotic sickled red blood cells result in vasoocclusion of pulmonary vasculature, leading to hypoxia and inflammation that further promote vasoocclusion. If left untreated, this becomes a vicious cycle that can lead to elevated pulmonary artery pressure and right heart failure. Clinicians may struggle to differentiate between ACS and pneumonia due to similarities in clinical presentations. While clinicians must remain watchful for ACS, minimal and stable oxygen requirements and the absence of fever can lead against the diagnosis of ACS in cases with indeterminate radiography. Furthermore, POCUS can be a rapid, effective tool in assessing for pulmonary consolidations without the radiation exposure associated with traditional computed tomography (CT). Static air bronchograms, or linear reverberations that do not move with respiration, may indicate atelectasis while dynamic air bronchograms, or linear reverberations synchronous with respiration, are pathognomonic for consolidation. Pulmonary POCUS should be used to aid in risk stratification in patients with suspected ACS.

- POCUS should be utilized as a risk stratification tool to identify pulmonary consolidations in patients with suspected ACS and indeterminant radiography. - Static air bronchograms are linear reverberations that do not move with respiration and are associated with atelectasis or early consolidation. Dynamic air bronchograms are linear reverberations in synchrony with respiration and are pathognomonic for consolodation. VACATION BLOCKED: A CASE OF LYME CARDITIS WITH ATRIAL VENTRICULAR ARRHYTHMIAS Amy E. Hockman, Pranav Shah. Internal Medicine, Medical University of South Carolina, Charleston, SC. (Control ID #4269749) CASE: A 29-year-old male with a history of anxiety presented to the emergency department with complaints of fever, rash, arthralgias, and an irregular heartbeat. He reports being in South Carolina on vacation for the past week and chose to seek medical attention for his heart concerns. He reported a two-week history of symptoms, including fever up to 103°F and chills, followed by the development of an ovoid erythematous rash that spread across his torso and limbs. Initially evaluated in Massachusetts two weeks prior, he had a negative Lyme test and was diagnosed with flu-like symptoms. Upon presentation for further evaluation of his irregular heartbeat, a comprehensive examination revealed widespread joint pain and an oval rash. Diagnostic workup indicated a positive Lyme IgM immunoblot and a transthoracic echocardiogram (TTE) showing an ejection fraction of 64% with no valvular abnormalities. EKG showed sinus bradycardia with first degree AV block with progression to 2nd degree AV block with a period of 2:1 AV conduction. Given the history, AV block on EKG and positive Borrelia serology, the patient was diagnosed with Lyme carditis and subsequently underwent leadless pacemaker placement and was started on a 21-day course of intravenous ceftriaxone. IMPACT/DISCUSSION: Lyme disease, caused by the spirochete Borrelia burgdorferi, can lead to a variety of clinical manifestations, including Lyme carditis, an uncommon but serious complication that may require cardiac intervention. This case highlights an unusual presentation of Lyme disease complicated by cardiac arrythmias. This may occur in patients with cardiac involvement and manifest as 1st or 2nd degree heart blocks. Furthermore, the degree of AV block can fluctuate rapidly within minutes. Telemetry and EKG findings may help to identify these arrythmias on the inpatient setting and may require prompt intervention if found. Fortunately, these arrythmias are often transient and the initiation of antibiotics can lead to quick resolution. A leadless pacemaker was a favorable choice for this patient to ensure a safe transition of care back to Massachusetts once his vacation was completed.

This vignette illustrates a patient with progressive heart block, evolving from first-degree AV block to second-degree Mobitz type I block, identified through EKG and telemetry monitoring. This progression prompted further diagnostic testing to investigate Lyme disease as the underlying cause. VANCOMYCIN-INDUCED ANAPHYLAXIS DESPITE PREVIOUS EXPOSURES Jad M. Achkar, Chloe Hill, Amanda Sidley, Charles Peng. Internal medicine, University Hospitals, Cleveland, OH. (Control ID #4273538) CASE: A 69-year-old male with a past medical history of cervical spondylosis status post right iliac bone harvest, complicated by MSSA osteitis, and nephrolithiasis presented for an elective right ureteral stone cystoscopy with laser lithotripsy. Pre-procedural urine cultures revealed staph epidermidis. Due to a reported penicillin allergy (hives), he was initiated on intravenous vancomycin as surgical prophylaxis. Minutes after starting the vancomycin infusion, the patient developed acute respiratory distress, wheezing, and profound hypotension 80/50 mmHg. The infusion was immediately discontinued, and the patient received DuoNeb, IV fluid bolus, diphenhydramine, dexamethasone, and ondansetron. He was placed on 2L of supplemental O2 via NC. Initial laboratory workup revealed an elevated serum tryptase level of 15.7 μg/L, consistent with mast cell activation. The patient’s symptoms improved in PACU and transferred to the ICU for observation. Upon arrival, he denied any ongoing symptoms and had no recollection of the event. Physical examination revealed persistent wheezing. He received intravenous fluids and steroids. Morning labs showed a normalization of serum tryptase to 6.7 μg/L and mild leukocytosis. The patient remained stable, was discharged on doxycycline and rescheduled the procedure. Notably, a review of his medical record confirmed prior uneventful daily use of IV vancomycin for one month. Pharmacokinetic modeling using InsightRx verified appropriate vancomycin dosing and infusion rates during the current administration, ruling out an anaphylactoid reaction due to rapid infusion. IMPACT/DISCUSSION: Anaphylaxis is a severe, IgE-mediated type I hypersensitivity reaction, whereas anaphylactoid reactions involve non-immune-mediated mast cell and basophil degranulation or complement activation. Both present with overlapping clinical features, including erythema, edema, hypotension, bronchospasm, tachycardia, pruritus, and angioedema. However, distinguishing between the two is critical, as management and future antibiotic options differ. Serum tryptase measurement is a valuable diagnostic tool that remains underutilized. In anaphylaxis, serum tryptase levels rise rapidly and return to baseline within 6 to 24 hours. In this case, elevated tryptase levels during the acute event, coupled with normalization in subsequent testing, confirmed the diagnosis of vancomycin-induced anaphylaxis rather than anaphylactoid reaction.

Prompt identification and treatment of anaphylaxis with known previous exposure to medication are critical to patient safety. Further research and development of diagnostic tools are necessary to improve diagnostic accuracy and guide future antibiotic use in patients with a history of severe reactions. VEINS OF FATE: UNRAVELING THE INTRACEREBRAL MYSTERY Allison Isabelli1; Emil Joseph1; Omair Syed1; Sheel Dalal2; Samee Farooqi1; Torrie Hook1; Mitali Roy1. 1Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL; 2internal medicine, Advocate Christ Medical Center, Oak Lawn, IL. (Control ID #4273217) CASE: More than 795,000 people in the U.S. suffer from an acute stroke each year. Most ischemic strokes are caused by known risk factors such as uncontrolled hypertension, hyperlipidemia, and diabetes; however, about 10% of ischemic stroke patients have a co-morbid malignancy. We present a case where an acute ischemic event led to the diagnosis of Endometrial Adenocarcinoma. A 55 y/o female with a past medical history of HTN presented to Trinity Hospital for one day of difficulty speaking and altered mental status. She was speaking to her friend who told her she sounded confused, which prompted her to go to the ED. CT Head revealed a left temporal intracerebral hemorrhage (ICH) with a 2 mm midline shift. She was transferred to ACMC for a higher level of care. MRI Brian w/wo con revealed a large occlusive thrombus throughout the left transverse and sigmoid sinus and left proximal internal jugular vein. The ICH seen on initial imaging was due to her extensive occlusive thrombus, therefore, she was started on a heparin infusion for a significant cavernous sinus thrombosis. She had no obvious risk factors for a thrombotic event and CVA risk factors including hyperlipidemia and diabetes were largely controlled (Total Cholesterol 159 and HBA1C 5.4). Hematology/oncology was consulted for evaluation of suspected hypercoagulable state. CT Pelvis with contrast revealed heterogeneous thickened endometrium raising concerns for malignancy. Gynecology performed an endometrial biopsy which confirmed endometrial adenocarcinoma FIGO grade 1. Her expressive aphasia drastically improved throughout her hospital course and the patient was discharged home on Eliquis with plans for a total hysterectomy 6 weeks after her admission. IMPACT/DISCUSSION: The connection between acute CVA incidents and solid tumor malignancies such as lung, colorectal, and brain cancers is well established however, the link between gyencologic cancers and strokes has not been well explored. Gynecologic cancers are associated with elevated estrogen levels. Estrogen causes a prothrombitic state at baseline due to increased production of coagulation factors. Patients with gynecologic cancers such as endometrial adenocarcinoma therefore, may relay a higher risk of stroke and other embolic complications.

Endometrial adenocarcinoma (EA) is one of the most common reproductive malignancies affecting post-menopausal women. Our patient presented with persistent vaginal bleeding that had been misdiagnosed as her typical menstrual cycle. It was only in the setting of her acute CVA that further investigations around her vaginal bleeding were completed. EA is a pro-estrogen malignancy and could cause in increased risk of stroke development given its underlying increased thrombotic state. Our case demonstrates the importance of understanding the connection between estrogen driven cancers and risk of stroke in patients with well controlled cardiac risk factors. VENTRICULAR TACHYCARDIA CARDIAC ARREST AS A RARE COMPLICATION OF RIGHT MIDDLE CEREBRAL ARTERY INFARCT Ghalib Shaikh1; Carissa Monterroso2,3. 1Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Pulmonary and Critical Care, Hospital of Central Connecticut at New Britain, New Britain, CT; 3University of Connecticut School of Medicine, Farmington, CT. (Control ID #4273510) CASE: A 79-year-old female with multiple sclerosis complicated by neurogenic bladder, hypertension, and atrial fibrillation on flecainide and rivaroxaban initially presented to the emergency department after inadvertent removal of her suprapubic catheter during a tube flush at her facility, with staff unable to replace the catheter. Family and social history were limited as the patient had recently moved from out of state and did not have consistent medical care. Several hours after admission, the patient was fully alert and oriented at the time of nursing shift change but suddenly developed shaking with lateral tongue bite and then PEA cardiac arrest. During the code, she developed pulseless ventricular tachycardia (VT) and was defibrillated and given amiodarone. In total, she received 5 rounds of cardiopulmonary resuscitation and 3 doses of epinephrine before return of spontaneous circulation. Initial non-contrast CT head was negative but repeat with contrast after 24 hours revealed new right posterior middle cerebral artery (MCA) infarct suspected to be the etiology of her seizure and arrest. The patient was later stabilized before experiencing hemorrhagic conversion of her stroke around 1 week later and transitioned to comfort measures. IMPACT/DISCUSSION: Cardiac arrest is a known but uncommon complication of stroke. This case presents a rare instance of a right MCA stroke causing an ultimately shockable cardiac arrest with pulseless VT. Research is limited but suggests that infarcts to the right insular cortex (supplied by the MCA) can cause autonomic dysfunction, which can lead to different types of cardiac arrest depending on the areas and mechanisms affected. However, there does not appear to be consensus about which arrest rhythms are most common, making this presentation a unique and unexpected stroke distribution for a cardiac arrest with VT. While seizure can be considered as a cause of her arrest, it is less likely in this case due to its apparent brief duration before pulses were lost.

MCA infarcts (and strokes more generally) can be a cause of cardiac arrest depending on the territories involved and the functions of those sections of the brain. VT is an unusual presentation of right MCA infarct-induced cardiac arrest. The insular cortex may be implicated in stroke-induced cardiac arrest involving MCA infarcts. VIBRIO VULNIFICUS LEADING TO DIC, MULTIORGAN FAILURE AND BACTEREMIA IN LESS THAN 48 HOURS: A CASE REPORT Drashti Desai1; Enrique J. Ramirez-Merced1; Arianne Bennett-Venner2,3. 1Internal Medicine, HCA Healthcare Inc, Nashville, TN; 2Pulmonology/Critical Care, HCA Healthcare Inc, Nashville, TN; 3Pulmonology, University of Central Florida, Orlando, FL. (Control ID #4271619) CASE: A 70-year-old female with a history of breast cancer in remission, cirrhosis, and chronic alcohol use presented to the ED after a fall, generalized weakness, diarrhea, and lower extremity pain. She displayed evidence of septic shock and acute hypoxic respiratory failure. Despite initial aggressive resuscitation, she rapidly progressed to a cardiac arrest and was successfully resuscitated requiring mechanical ventilation and vasopressors. Physical exam revealed hemorrhagic bullae, cyanosis, and pitting edema in the extremities. Labs showed thrombocytopenia, leukopenia, lactic acidosis, transaminitis ,acute kidney injury, and signs of disseminated intravascular coagulation(DIC). She was diagnosed with septic shock with multiorgan failure. Sepsis protocol was continued with fluid resuscitation, broad-spectrum antibiotics, and vasopressor support, but her condition worsened. Blood cultures grew gram-negative rods. The family chose to withdraw care, and two days later, blood cultures confirmed Vibrio vulnificus, linked to raw oyster consumption just one evening ago. The entire clinical course occurred within 48 hours. IMPACT/DISCUSSION: Vibrio vulnificus is a rare but highly lethal pathogen in the USA, with mortality rates exceeding 50% in individuals with risk factors and over 90% if septic shock develops. This case highlights its clinical impact, especially in patients with liver disease, chronic alcohol use, and immunocompromised states. The infection progresses rapidly, often within 24-48 hours, with symptoms like lower extremity pain, gastroenteritis, and hemorrhagic bullae, leading to multi-organ failure and disseminated intravascular coagulation. Infection typically manifests 24 hours after consuming raw oysters, as seen in a 2002-2007 FDA study tracking 75 cases. Early recognition and prompt intervention are crucial, as blood cultures may be too slow. PCR provides faster diagnosis, within 8-12 hours. Treatment requires aggressive antibiotics (doxycycline or fluoroquinolones with ceftriaxone) and debridement for early lesions. This rare infection posed a diagnostic challenge, confirmed postmortem, emphasizing the need to consider Vibrio vulnificus in differential diagnoses for rapid-onset cellulitis, gastroenteritis, and raw seafood exposure. Public health efforts should educate at-risk populations to prevent infections.

Vibrio vulnificus can progress in 24-48 hours, causing symptoms like lower extremity pain, gastroenteritis, and hemorrhagic bullae, leading to multi-organ failure, DIC, and septic shock without early treatment. Prompt treatment with doxycycline/fluoroquinolones and ceftriaxone, early debridement is essential. PCR can diagnose within 8-12 hours. Individuals with liver disease, alcohol use, or immunocompromised states are at higher risk. VITAMIN B12 DEFICIENCY IN DISGUISE - A CASE REPORT OF PSUEDO THROMBOCYTIC MICROANGIOPATHY Katherine Wells1; Mark Troyer2. 1Internal Medicine, The Ohio State University, Columbus, OH; 2Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4224060) CASE: A 59 year old man presented to the emergency department due to progressive weakness and fatigue with eventual syncopal episode. The patient also noted significant weight loss of approximately 40 lbs. In the emergency department, the patient was noted to have severe, microcytic anemia with a hemoglobin of 4.5 g/dl and MCV of 75. The patient's platelet count was also significant decreased to 38,000. The patient was transfused with 2 units of packed red blood cells and admitted for further work-up. Admission labs were notable for elevated lactate dehydrogenase, normal fibrinogen, decreased reticulocytes, and elevated lactate. Patient was without signs of any other end organ damage. Patient did, however, have notable B12 deficiency. Hematology was consulted to rule out other causes of TMA such as thrombotic thrombocytopenic purpura (TTP). Further work-up was notable of negative ADAMST13 level, elevated methylmalonic acid level, and positive intrinisic factor antibody. These findings supported patient's presentation being in the setting of his pernicious anemia. The patient was started on aggressive Vitamin B12 repletion with improvement in symptoms and lab work. IMPACT/DISCUSSION: This case illustrates a rare but well documented presentation of vitamin B12 deficiency. The pathophysiology behind this presentation of vitamin B12 deficiency is due to the larger red blood cell fragments and reduced platelet production in combination with the accumulation of byproducts and metabolites. An important differentiator between vitamin B12 deficiency and TTP can be seen in reticulocyte counts. Vitamin B12 deficiency is notable for decrease in substrates of DNA synthesis so this leads to suppression of the production of hematopoietic cells, while TMAs do not have this this presentation. It is important to be aware of this presentation as the work-up of TMAs can be extensive and expensive. Empiric treatment of TMAs can also be invasive, so this is another reason to consider B12 deficiency on the differential for thrombocytopenia.

1.Vitamin B12 deficiency can rarely present with lab work mimicking that of TMAs. 2.Vitamin B12 deficiency usually presents with more severe anemia, higher LDH levels, and lower reticulocyte counts. Differentiating between Vitamin B12 deficiency and causes of TMAs, such as TTP, is important for appropriate treatment 3.Differentiating between Vitamin B12 deficiency and causes of TMAs, such as TTP, is important for appropriate treatment VITAMIN C IN DAPSONE-INDUCED METHEMOGLOBINEMIA AND HEMOLYSIS Jasmine Shrestha1; Swathi Reddy Rajula1; Asis Shrestha2. 1Internal Medicine, Mercy Hospital Fort Smith, Fort Smith, AR; 2University of Arkansas for Medical Sciences, Little Rock, AR. (Control ID #4242973) CASE: We present a case of 56-year-old female with a history of mucous membrane pemphigoid (MMP) and depression, presented to ED from outpatient oncology for elevated creatinine and shortness of breath. Patient reported worsening shortness of breath over a month associated with fatigue. AKI resolved with mild hydration, but the patient was requiring 2 l/min oxygen to maintain oxygen saturation above 90%. Hemoglobin was 9.8g/dl with MCV 104.3fl. BNP, troponin, EKG, Chest x-ray, COVID-19, CT angiogram chest was negative. Overnight patient continued to worsen with oxygen saturation 85%, which did not improve even with high flow oxygen. ABG showed PaO2 of 154mmHg indicating discordance between PaO2 and SpO2. Patient reported ongoing dapsone therapy of 100mg daily over a year for MMP, thus methemoglobinemia was suspected. Additional lab work showed LDH 351U/L, haptoglobin <20mg/dl, reticulocyte count of 5.8%, suggesting hemolysis. Peripheral blood smear revealed bite cells and Heinz bodies confirming hemolytic anemia due to oxidative stress. G6PD levels and direct antiglobulin tests were normal. Methemoglobin level was 18.1 % confirming methemoglobinemia. Patient was treated with IV ascorbic acid 1500mg and folic acid to counter oxidative stress. Patient’s home medications also included amitriptyline and escitalopram. Given the reported risk of serotonin syndrome with methylene blue administration in patients taking serotonergic agents and considering the patient’s clinical improvement with vitamin C, methylene blue was not administered. Patient was eventually weaned off oxygen with reduction in methemoglobin level to 3.9%. IMPACT/DISCUSSION: Dapsone has been shown to be the major cause of drug-induced acquired methemoglobinemia. Hydroxylated amine metabolites produced in the oxidation reactions have been hypothesized to cause dapsone's hematologic adverse effects, including hemolytic anemia and methemoglobinemia. The diagnosis of methemoglobinemia is based on clinical symptoms and laboratory testing, especially ABG-analysis. Methylene blue is best known as an antidotal treatment for acquired methemoglobinemia. Vitamin C is a potential alternative to methylene blue for treating mild symptomatic methemoglobinemia due to its ability to scavenge free radicals. It aids in recycling alpha-tocopherol in erythrocyte membrane and acts as a cofactor for NADP reductase required for glutathione metabolism which can directly reduce methemoglobin level.

Physician should remain vigilant for the association between dapsone use and methemoglobinemia or hemolytic anemia. Comprehensive ABG analysis including methemoglobin levels is essential for unexplained hypoxia in a patient on dapsone therapy. Methylene blue should be used cautiously due to the risk of serotonin syndrome when combined with serotonergic agent. High-dose vitamin C is a safe and promising alternative for treating methemoglobinemia. WEST NILE VIRUS MYOCARDITIS: A RARE CAUSE OF ACUTE CARDIOPULMONARY DECOMPENSATION " Anum Farid1; Samra Iqbal1; Muna Osman2; Mahmoud Elmahi3; sharmin faizia4; Fatema Mahjabeen4; Jairah Shaikh5; Tanzina Afroze6; Sayma Yaqub4. 1Internal Medicine, Texas Tech University Health Sciences Center Amarillo, Amarillo, TX; 2Internal medicine, Texas Tech University System, Lubbock, TX; 3Internal medicine, TTUHSC amarillo, Amarillo, TX; 4Internal medicine , Texas tech university health sciences center amarillo, Amarillo, TX; 5Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 6Internal Medicine, Texas Tech University Health Sciences Center School of Medicine Amarillo, Amarillo, TX. (Control ID #4272536) CASE: A 62-year-old female with no significant past medical history presented with altered mental status. Workup confirmed West Nile encephalitis by positive West Nile virus IgM antibodies in CSF. Three days later, she developed acute hypoxic respiratory failure requiring oxygen, exhibiting tachypnea and tachycardia up to 130 bpm. Chest X-ray showed cardiomegaly, vascular congestion, and bilateral pleural effusions. EKG showed nonspecific ST segment abnormalities. Arterial blood gas (ABG) indicated acute uncompensated respiratory alkalosis with hypoxemia. CT angiogram ruled out pulmonary embolism but noted mild cardiac enlargement and lung infiltrates. Echocardiogram (ECHO) showed reduced ejection fraction (EF) of 40–45%, trace mitral and aortic regurgitation, and right ventricular systolic pressure (RVSP) of 20-30 mmHg. Troponins were 106, and BNP was 182. Due to worsening hypoxia, she was placed on high-flow nasal cannula, then BiPAP. Despite this, oxygen saturation dropped, and her blood pressure decreased. Repeat ABG showed worsening hypoxemia. She was intubated, improving her blood pressure without pressors. After diuresis with IV Lasix, her chest X-ray showed better aeration. After 36 hours of intubation, she passed a spontaneous breathing trial and was successfully extubated. Follow-up ECHO on Day 10 showed EF improvement to 60–65%, grade 1 diastolic dysfunction, and mild tricuspid regurgitation. A Lexiscan stress test on Day 15 revealed no myocardial ischemia, with EF stabilizing at 59%. She improved hemodynamically and was discharged in stable condition. IMPACT/DISCUSSION: West Nile virus (WNV) infection can rarely cause myocarditis due to direct viral invasion leading to myocardial injury and reduced EF, as seen in this patient. The diagnosis was supported by elevated troponins, BNP, abnormal chest X-ray findings, nonspecific EKG changes, and reduced EF on ECHO.Timely intubation likely reduced myocardial stress, enabling cardiac recovery, with EF improving from 40–45% to 60–65%. Persistent tachycardia highlighted the need for cardiovascular monitoring. There is no specific antiviral therapy for WNV myocarditis. Management is supportive, focusing on hemodynamic stabilization, oxygenation, and reducing cardiac stress. Timely intubation and diuresis were critical in this case. Further research is needed to better understand the pathophysiology and optimal management of WNV-induced myocarditis.

This case highlights the importance of considering cardiac involvement in WNV patients with cardiovascular symptoms. Early recognition, intensive care management, and close follow-up are essential for improving outcomes in this potentially life-threatening condition. WET OR DRY BERI BERI? Beatrice Carpo, Emily Robertson, Zachary Wright, Diana L. Sewell. Internal Medicine, University of Connecticut School of Medicine, Farmington, CT. (Control ID #4269919) CASE: Our patient is an 89-year-old male with a history of chronic kidney disease, hypertension and heart failure who presented to the emergency department with 1 week of generalized weakness, poor oral intake, and worsening exertional dyspnea. His physical exam revealed a thin frail, elderly man, with very dry mucous membranes and faint crackles in the left lung base, but no jugular venous distention or peripheral edema. Initial workup revealed an acute kidney injury and elevated BNP. His chest x-ray revealed interstitial pulmonary edema. An echocardiogram was obtained and revealed an ejection fraction of 15-20% from a baseline of 35%. The patient’s renal function did not improve with IV fluids. Cautious diuresis with furosemide was initiated given concern for slight volume overload. Over the next several days, BNP and creatinine improved modestly, but never returned to the patient’s baseline. A thiamine level was obtained given the patient’s weakness in the context of acutely reduced ejection fraction, history of alcohol use, and recent poor oral intake, and was found to be low at 3nmol/L. Thiamine was prescribed. IMPACT/DISCUSSION: Beri beri is a clinical syndrome caused by thiamine (vitamin B1) deficiency and is classified as either “wet” or “dry” depending on the systems affected and associated symptoms. Wet beri beri primarily involves the cardiovascular system and is typically associated with heart failure caused by systemic vasodilation. Common symptoms include and signs of volume overload such as edema, dyspnea, crackles in the lungs, and jugular venous distension. In contrast, dry beri beri primarily affects the nervous system and is characterized by peripheral neuropathy and symmetric muscle wasting, often presenting with weakness or paralysis, numbness and tingling in extremities. In this case, the patient presented with an atypical form beri beri: cardiorenal syndrome secondary to heart failure with reduced ejection fraction. Uniquely, there were no physical exam findings of volume overload, which would typically be expected in classic wet beri beri. This highlights a rare and subtle presentation of thiamine deficiency in a patient who appeared "dry" on examination.

Beri beri is rare in the United States because most foods, particularly grains, are fortified with thiamine. Thiamine deficiency is therefore primarily seen in populations at risk of malnutrition, including elderly individuals, alcoholics, and patients with chronic illnesses or malabsorptive conditions. In elderly patients with poor nutritional intake or signs of malnutrition, it is important to consider thiamine deficiency as a possible cause of heart failure. Wet beri beri, although uncommon, can present atypically without overt signs of fluid overload. Recognizing and treating thiamine deficiency promptly with supplementation is crucial, as it can lead to significant clinical improvement. WHAT IS MAKING THIS MAN-GO? MULTIDRUG-RESISTANT S. TYPHI Aidan Flanagan1; Brenda Queen2. 1Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA; 2Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA. (Control ID #4269368) CASE: Typhoid fever is an acute febrile illness caused by Salmonella enterica serovar Typhi (S. Typhi), primarily transmitted via the fecal-oral route through contaminated food and water. Endemic in many low- and middle-income countries, the disease thrives in areas with inadequate water, sanitation, and hygiene infrastructure. The pathogenesis involves bacterial translocation across the intestinal epithelium, entry into the bloodstream, and dissemination to systemic and intracellular sites, resulting in a systemic infection. Clinical manifestations include prolonged, stepwise fever, abdominal pain, constipation or diarrhea, and the characteristic maculopapular rash known as "rose spots." First-line treatments include fluoroquinolones and third-generation cephalosporins. This case highlights a patient requiring antimicrobial escalation due to multidrug-resistant S. Typhi. A 31-year-old Indian male with a history of Dengue virus infection in 2012 presented after a recent trip to Hyderabad, India. He reported consuming street cart mangoes and subsequently experienced three weeks of stepwise, escalating fevers reaching 40°C, accompanied by headaches. During the week before presentation, he developed liquid brown diarrhea. Physical examination was unremarkable. Laboratory studies revealed serum creatinine 1.26 mg/dL (baseline 0.77), AST 81 U/L, ALT 112 U/L, total protein 9.1 g/dL, globulin 5.2 g/dL, CRP 7.6 mg/L, ESR 113 mm/hr, ferritin 1,653 ng/mL, and mild anemia (Hb 12.6 g/dL). A comprehensive infectious workup was negative for Leptospira, Aeromonas stool culture, HIV, SARS-CoV-2, EBV, heterophile antibody, hepatitis A and B, and malaria/parasitic blood smears. However, the gastrointestinal pathogen panel identified Salmonella, and CT imaging revealed irregular mural thickening of the cecum and ascending colon with multiple right lower quadrant lymph nodes. Infectious disease consultation led to the initiation of ceftriaxone, but the patient continued experiencing fevers of 39°C every 12 hours. Therapy was escalated to meropenem and the fevers resolved soon thereafter. The patient was discharged on a 10-day course of levofloxacin based on sensitivities. At follow-up, all symptoms had resolved. IMPACT/DISCUSSION: The emergence of antimicrobial-resistant S. Typhi poses a significant challenge, particularly in Southeast Asia, where multidrug-resistant strains (resistant to ampicillin, cotrimoxazole, and chloramphenicol) and extended drug-resistant strains (resistant to fluoroquinolones and third-generation cephalosporins) are alarmingly prevalent at rates of 14.7% and 43.4%, respectively, according to Imran et al. This case underscores the need for effective antimicrobial stewardship and to preserve the efficacy of existing treatments.

This case highlights challenges of multidrug-resistant S. Typhi, emphasizing antimicrobial stewardship to combat resistance in endemic regions. Effective treatment required prompt escalation, underscoring the need to preserve existing therapies. WHEN ACUTE HEART FAILURE MASQUERADES AS VASCULITIS, A CASE OF NITROFURANTOIN-INDUCED CUTANEOUS VASCULITIS Paul Holden, Joshua L. Dejoya. Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4273469) CASE: 73 year-old gentleman with systolic heart failure, COPD on 4L oxygen, and atrial fibrillation on apixaban presenting with subacute fatigue, arthralgias, dyspnea, and a non-blanching palpable purpuric rash on his extremities. Initially presented to clinic three weeks prior with dysuria, diagnosed with cystitis and started on nitrofurantoin. Soon after, he developed a rash on his extremities. He was switched to amoxicillin-clavulanate but his rash persisted with progressive fatigue, joint pains, and increase in his chronic cough. Presented to the hospital, found to be afebrile, hypertensive (167/89), and saturating well (98%) on his home 4L oxygen. Exam otherwise notable for scattered crackles on lung auscultation, no jugular veinous distention, and a palpable, purpuric rash on his extremities with coalescence around the knees. Initial labs notable for hyperkalemia (6.1), acute kidney injury (creatinine 2.9, baseline 1.1-1.2), pro-BNP >76,000, mild leukocytosis (9.4, 0% eosinophils), anemia (8.8), and a hepatocellular injury (total bilirubin 1.8, AST 761, ALT 677, alkaline phosphate 210). He was started on diuresis with furosemide. Additional autoimmune work-up was notable for ANA reactive (1:80), C3 71 (reference: 88-201), c4 23 (reference: 15-45), negative HAV, HBV, HCV. Later results included negative ANCA, Anti-chromatin, RHF, dsDNA, syphilis, dsDNA, Chromatin, Liver Kidney Microsomal (LKM-1) Antibody, Anti Smooth Muscle Antibody, RA factor, Cryoglobulins, and anti-GBM. Skin biopsy results had negative staining for IgG, IgM, IgA, C3, Fibrin. H&E staining showed purpura consistent with early leukocytoclastic vasculitis. Ultimately felt to be most consistent with acute on chronic systolic heart failure exacerbation in the setting of missed diuresis with concomitant nitrofurantoin cutaneous vasculitis. He tolerated diuresis well and his symptoms gradually resolved off the nitrofurantoin. IMPACT/DISCUSSION: This case initially mimicked systemic vasculitis with multiorgan involvement, but the primary issue was acute-on-chronic heart failure due to missed home diuresis. It highlighted two key cognitive biases: anchoring bias, as clinicians focused on unifying diagnoses for the rash and systemic findings, and base rate fallacy, where common presentations of heart failure were overlooked due to distracting findings like the rash. Nitrofurantoin-induced vasculitis that affect the skin is rare and includes two forms: cutaneous vasculitis, which is skin-limited, and ANCA-associated vasculitis, which primarily affects the lungs and kidneys. Prevalence is unknown, but case reports suggest cutaneous vasculitis is less common.

Nitrofurantoin-induced cutaneous vasculitis is a rare adverse effect of a commonly used drug. This case highlights that a common clinical syndrome, such as heart failure, occurring alongside an unrelated rare drug reaction, can sometimes be the correct diagnosis rather than a single unifying explanation. WHEN A FIGHTER MEETS HIS MATCH: A CASE OF HEMORRHAGIC PHEOCHROMOCYTOMA Yuqing Wang, Mylene Vista, Ayotunde I. Buremoh, Brianna Smith, Wenyuan Li, Huixian Zhou, Kristin A. Swedish. Medicine, Division of General Internal Medicine, Montefiore Medical Center, New York, NY. (Control ID #4272475) CASE: A 39-year-old active MMA fighter with hypertension and type 2 diabetes mellitus presented with 1 day of crampy, left-sided abdominal pain and multiple episodes of vomiting. He reported episodic dizziness, flushing, headache, and rises in blood pressure (BP) over the prior two years. He denied recent trauma. On admission, BP and glucose were elevated. Exam revealed left upper quadrant tenderness without palpable masses. A Computed Tomography (CT) scan of the abdomen and pelvis with contrast showed a left adrenal gland mass hemorrhaging into the retroperitoneum. Magnetic Resonance Imaging (MRI) confirmed a large intra-adrenal hemorrhage measuring 8.5x7x8.4 cm extending to the retroperitoneum. Urine and serum metanephrines and normetanephrines were elevated. Adrenal Surgery was consulted, and a plan was made for resection of the tumor. After transitioning to phenoxybenzamine for BP control, he underwent laparoscopic adrenalectomy. Pathology confirmed pheochromocytoma. One month after the surgery, his BP and diabetes were controlled without medication and repeat metanephrines and normetanephrine normalized. Given the patient’s large tumor and young age, he underwent genetic testing for hereditary cancer syndromes associated with pheochromocytomas, which returned negative. IMPACT/DISCUSSION: Spontaneous hemorrhage within a pheochromocytoma, causing retroperitoneal or intraperitoneal bleeding, is a rare but life-threatening event with a 30% mortality rate. Here, we present a rare case of spontaneously hemorrhaging pheochromocytoma in young adults with early onset hypertension and diabetes who presented with abdominal pain. Patients with massive bleeding or hemodynamic instability require emergency surgery, which carries a high mortality rate of 40-45%. In our case, the patient was hemodynamically stable, allowing for elective surgery and an uneventful recovery. Approximately 40% of affected individuals have a hereditary predisposition, and many have bilateral tumors; however, genetic testing in our patient was negative. In terms of diagnosis, both CT and MRI can be helpful, and all patients with hemorrhagic adrenal masses should undergo a hormonal assessment to exclude hormonally active tumors. Alpha-adrenergic receptor (AR) blockers are the first-choice medications in the preoperative management of pheochromocytoma. The potential risk factors for hemorrhage are difficult to establish, as demonstrated in our case. After the operation for hemorrhagic pheochromocytoma, careful life-long follow-up of the patients seems to be the most appropriate.

This case emphasizes the importance of lowering the suspicion threshold for pheochromocytoma in young patients with hypertension and diabetes who present with abdominal pain and vomiting. It is important to maintain a broad differential to avoid premature closure on a diagnosis. Although uncommon, pheochromocytoma is a critical diagnosis to consider, as missing it can result in severe complications and a high risk of mortality. WHEN A RASH ISN'T JUST A RASH: HERPES ZOSTER MASQUERADING AS DECUBITUS ULCERS AND ELSBERG SYNDROME Junya Yamada1; Akihito Yoshida1; Takaaki Kobayashi2; Satomi Kawamura1; Sanami Doi3; Tadashi Eguchi1. 1General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan; 2Internal Medicine, University of Kentucky, Lexington, KY; 3Dermatology, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan. (Control ID #4270283) CASE: A 90-year-old woman residing in a nursing home and requiring a walker for ADLs presented with a 1.5-month history of intermittent falls. Two days before admission, she had been lying down more frequently, and on the day of admission, she was unable to stand and was hospitalized. On admission, her temperature was 38.7°C. Physical examination revealed a skin rash in the sacral area, initially presumed to be pressure ulcers. A CT scan identified significant urinary retention. Closer examination of the sacral lesions revealed circular lesions with post-rupture findings, including petechial rashes, blisters, and purpura. A varicella-zoster virus (VZV) antigen swab test was positive, confirming a diagnosis of S1-S2 herpes zoster. Neurological examination demonstrated weakness of the internal anal sphincter, consistent with cysto-rectal dysfunction. The patient’s urinary retention was attributed to sacral herpes zoster, complicated by a secondary urinary tract infection (UTI). Following treatment with ceftriaxone and valacyclovir, the patient achieved spontaneous voiding without catheterization. IMPACT/DISCUSSION: Elsberg Syndrome describes acute or subacute bilateral lumbosacral neuritis or myelitis, typically caused by an infectious mechanism. While classically associated with HSV, it can also result from VZV infection. Key symptoms include sensory disturbances in the lower extremities (80%), urinary retention (76.7%), lower extremity weakness (50%), sacral region sensory changes (50%), constipation (43.3%), urinary incontinence (23.3%), and fecal incontinence (10%). Herpes zoster typically presents as a painful, vesicular rash along dermatomes, progressing through pre-rash, rash, and chronic phases. However, its clinical manifestations vary depending on the site of reactivation. For instance, facial involvement may result in Ramsay Hunt syndrome. Risk factors include advanced age, immunosuppression, and chronic comorbidities such as diabetes. Treatment for Elsberg Syndrome due to VZV involves antiviral therapy, symptomatic management, and, potentially, steroids. Early diagnosis and intervention improve outcomes. Atypical presentations of VZV, such as zoster sine herpete (herpes zoster without a rash), may delay recognition.

This case highlights the diagnostic challenge of distinguishing herpes zoster from decubitus ulcers. In cases of acute urinary retention with sacral lesions, herpes zoster and sacral nerve root involvement should be considered. Recognizing infection-triggered lumbosacral neuritis or myelitis as Elsberg Syndrome is essential for timely management and improved outcomes. WHEN COVID-19 STRIKES THE VESSELS: A CASE OF SYSTEMIC CAPILLARY LEAK SYNDROME Danielle Uibel, Faiqa Amin, Madihah Alam, Modupe Oluya. Internal Medicine, Bayhealth Medical Center, Dover, DE. (Control ID #4273230) CASE: A 73 year old female with a history of Jo-1 antisynthestase syndrome with myositis and interstitial lung disease, tachy-brady syndrome (post pacemaker), paroxysmal atrial fibrillation, and hypothyroidism who presented with bilateral lower extremity edema. She was admitted for management of anasarca, pericardial effusion, and pleural effusion. Her symptoms began two months prior, during active COVID-19 infection, with bilateral leg swelling. Cardizem was also started at that time. Echocardiogram revealed a stable moderate to large pericardial effusion and no findings to suggest heart failure. The patient was not a candidate for pericardiocentesis or pericardial window. On further work up, there was no evidence of proteinuria, renal pathology, overt cirrhosis, ascites or malignancy. Rheumatology recommended initiation of steroids. The patient's edema persisted despite switching Cardizem to metoprolol. Due to preload dependent pericardial effusion, the patient was started on gentle diuresis. She soon developed increased work of breathing and orthopnea. Repeat CT chest showed worsening bilateral pleural effusions. She was diagnosed with COVID-19 induced systematic capillary leak syndrome with plans for IVIG therapy. IMPACT/DISCUSSION: Systemic Capillary Leak Syndrome (SCLS) is a rare idiopathic disorder of immune-mediated endothelial dysfunction and microvascular leakage. This leads to fluid accumulation in the third spaces such as peripheral edema, pleural effusions and pericardial effusions. SCLS is often secondary to viral infections, autoimmune diseases or rarely, myositis flare. In this case the timing of the patient’s symptoms following her COVID-19 infections suggests that SCLS was triggered by the viral infection with no signs of active myopathy. Treatment of SCLS remains challenging as there is no standardized approach. However, IVIG has shown benefit in some cases, though managing volume overload requires close monitoring. IVIG is particularly risky in such patients with significant fluid retention. To balance this, she received her IVIG inpatient to allow for careful fluid management and active diuresis. She continued prednisone and mycophenolate at an increased dose to manage her autoimmune conditions.

COVID-19 can cause a variety of atypical sequelae some of which can present weeks to months after initial infection. Systemic Capillary Leak Syndrome is an idiopathic but serious condition that presents with symptoms of fluid accumulation including edema and effusions. Although IVIG shows promise in treating patients with SCLS, it requires careful administration in patients with volume overload. In this case, early recognition of SCLS with critical to initiating appropriate treatment. The patient’s clinical course indicates the importance of maintaining appropriate fluid balance while providing effective therapy for SCLS. WHEN CPAP FALLS SHORT: MANAGING HIGH NOCTURNAL CARBON DIOXIDE IN SEVERE OBESITY AND SLEEP APNEA Ginu Kurian, Ayush Kaushish, Evan M. Ritter. Internal Medicine, Virginia Commonwealth University Department of Internal Medicine, Richmond, VA. (Control ID #4272363) CASE: A 67-year-old woman with obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS) presented to the emergency department with worsening shortness of breath and a productive cough. On examination, she was somnolent but responsive to voice. Venous blood gas (VBG) analysis revealed pH 7.23, pCO2 109 mmHg, pO2 62 mmHg, and HCO3 46 mmol/L, findings consistent with compensated respiratory acidosis. Due to her declining mental status, bilevel positive airway pressure (BPAP) was initiated. However, her condition worsened with slow respirations and hypotension, necessitating intubation. After one day of mechanical ventilation, she was successfully extubated to BPAP. After 24 hours she was weaned off daytime BPAP due to marked improvement in her respiratory status. Despite continuing her home nocturnal continuous positive airway pressure (CPAP), she remained hypercapnic, with a CO2 level >50 mmHg measured shortly after awakening. A trial of nocturnal BPAP was initiated, resulting in significant improvements in both hypercapnia and mental alertness. She was discharged on nocturnal BPAP therapy. IMPACT/DISCUSSION: Patients with OSA and OHS are at high risk for chronic hypercapnic respiratory failure (CHRF), especially when managed solely with nocturnal CPAP. These conditions exacerbate hypoventilation, leading to persistent hypercapnia, ventilation-perfusion mismatch, and reduced respiratory drive. The absence of specific inpatient guidelines for transitioning to nocturnal BPAP can delay optimal management, contributing to prolonged hospital stays and poorer outcomes. Managing CHRF in OSA and OHS is particularly challenging in settings lacking resources like polysomnography. While outpatient recommendations typically advise BPAP to reduce CO2 levels below 45 mmHg, inpatient transitions are often reserved for cases of noninvasive positive pressure ventilation (NPPV) intolerance or palliative care. This case highlights how inpatient BPAP titration targeting CO2 reduction can improve both respiratory function and sleep quality, emphasizing the need for clear inpatient protocols. Studies have shown BPAP to be more effective than CPAP at lowering PaCO2 in obesity-related hypoventilation, particularly in patients with comorbid obstructive conditions like chronic obstructive pulmonary disease (COPD). Although this patient did not have COPD, these findings support BPAP’s broader applicability. Additionally, evidence from OSA-COPD overlap studies identifies daytime hypercapnia and nocturnal hypoxia as predictors of early CPAP failure, reinforcing the importance of timely adjustments in ventilation strategies to optimize outcomes.

Nocturnal BPAP should be considered for OSA/OHS patients with persistent hypercapnia, demonstrating significant improvements in CO2 levels and mental status. The absence of inpatient-specific BPAP guidelines highlights the need for evidence-based protocols, particularly in resource-limited settings. WHEN MELANOMA STRIKES THE HEART: A CASE OF RIGHT VENTRICULAR METASTASIS PRESENTING AS SYNCOPE Amy Courtney1; Matthew Genelin1; Lucas Smith1; Brittany Bertaux2; Melissa McNeil1. 1Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI; 2University of New England College of Osteopathic Medicine, Biddeford, ME. (Control ID #4273079) CASE: A 74-year-old man with recently diagnosed metastatic melanoma initiated on pembrolizumab and without known cardiac history presented with syncope. The patient denied any prodromal symptoms prior to sudden collapse and transfer to the hospital. He was newly hypoxic and on CT angiogram was found to have several small segmental pulmonary emboli and a large right ventricular mass, which was thought to be a clot provoked by his underlying malignancy. The mass was 8.6 cm and largely filled the right ventricle; there was associated RV dilation and reduced systolic function along with right atrial enlargement. After evaluation with echocardiogram and cardiac MRI, the mass was determined to be a metastasis from his known metastatic melanoma. The syncope and hypoxia were due to right ventricular outflow obstruction from the mass. Although the pulmonary emboli could have reflected tumor emboli, he was started on apixaban. Cardiac surgery was not in line with goals of care; the patient was thus referred to his oncologist. Decision was made to not pursue further treatment and patient died 1 month after his initial presentation. IMPACT/DISCUSSION: Symptomatic cardiac metastases from metastatic melanoma occur in <2% of patients. Symptoms are widely variable. Tumors may affect the electrical conduction system of the heart, lead to tamponade, acute coronary syndrome, or cause heart failure symptoms from outflow tract obstruction. Syncope has been uncommonly reported due to a large right ventricular mass. A high index of suspicion is required for patients with a history of melanoma, metastatic or otherwise, presenting with new cardiac complaints. When cardiac metastases are suspected, echocardiogram should be obtained as it can characterize size and hemodynamic impact. Contrast echocardiography may clarify the etiology as it can characterize tissue perfusion and can help differentiate hypervascular metastatic tumor tissue from clot or sparsely vascular benign cardiac tumors. Cardiac MRI may be beneficial for surgical planning or to better characterize the composition of a tumor. Surgery may have a role for symptom palliation and can prolong survival, however death often occurs within months despite surgery. Radiation and immunotherapy may be used in place of surgery or as an adjunct to surgery.

Cardiac metastases are not uncommon in metastatic melanoma (autopsy studies report ranges as high as 64%), but these are often asymptomatic and only diagnosed post-mortem. The frequency of symptomatic cardiac metastases may increase as survival from metastatic melanoma improves due to advanced therapy which dramatically prolongs survival. Advanced imaging should be obtained to aid in diagnosis if cardiac metastasis is suspected, yet prognosis is poor. WHEN MENINGOENCEPHALITIS AND TICKS DON’T EQUAL LYME Vanessa Gipson1; Maria F. Sanes Guevara1; Andrea Carter2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2Medicine, UPMC, Pittsburgh, PA. (Control ID #4272731) CASE: 73-year-old man with a history of seizures and meningioma presented with 1 day of gait ataxia, confusion, somnolence and fevers. He reported multiple tick bites 3 weeks prior and intermittent headaches. On admission, he was febrile to 39.4°C. Neurological exam showed hypoacusis, mild dysmetria and truncal ataxia without nuchal rigidity. Lab tests revealed an elevated CRP (14.2), normal CBC/basic chemistry, and negative Lyme. MRI of the brain and cervical spine had no acute findings. He empirically started on ceftriaxone, vancomycin, and acyclovir for presumed meningoencephalitis. A lumbar puncture on day 2 revealed: WBC 1 (61% lymphocytes), RBC 2, glucose 62, and protein 114. During hospitalization, he had high fevers, headaches, and developed thrombocytopenia (48,000), leukopenia (2,400) and hepatocellular injury (AST 346, ALT 176). A broader tick-borne disease (TBD) workup was initiated, and doxycycline, atovaquone and azithromycin were added. Peripheral smear was negative for inclusions. His fevers subsided and neurologic symptoms improved significantly. After additional CSF results, all other intravenous antimicrobials were discontinued, and he was discharged on day 6 with triple antibiotics. A few days post discharge, Anaplasma serum PCR returned positive, and doxycycline continued for 14 days IMPACT/DISCUSSION: Human Anaplasmosis (HA) incidence has risen in the last decade. While classic presentation includes fever, headache, elevated liver enzymes, and thrombocytopenia, initial symptoms may be non-specific, and empiric treatment should be driven by epidemiological risk factors: residence in areas with Ixodes ticks (Northeast, Upper Midwest, Pacific Northwest), outdoor activity, known tick exposure, and warm seasons. Central nervous system (CNS) involvement in HA is uncommon, but can manifest as meningoencephalitis or neurologic symptoms, like facial diplegia or brachial plexopathy. PCR testing is the most sensitive diagnostic tool for detecting Anaplasma phagocytophilum DNA in blood or CSF, especially in early infection. Serology and peripheral smear are less sensitive. Treatment is doxycycline for 10 days or at least 3 days post fever resolution. Delayed treatment can lead to severe complications, such as acute respiratory distress syndrome, disseminated intravascular coagulation, organ failure and rarely hemophagocytic lymphohistiocytosis.

- HA is an emerging TBD diagnosed by a combination of patient history (tick exposure), symptoms (Fever, headache, rare neurological involvement), and supportive labs - PCR is the most sensitive test to diagnose in blood or CSF, while other modalities are less sensitive. WHEN MOVING FURNITURE TURNS AIR EMBOLISM Lawrence Stawkowski, Bharani Pusukur. Internal Medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4272827) CASE: A 32-year-old male with no past medical history was moving his sofa and fell onto his chest wall causing significant pain. He was evaluated in the emergency department with a chest x-ray, which was negative for any acute findings and discharged. Due to persistent chest pain not amenable to over-the-counter medications he was evaluated again. During his visit, he was noted to be splinting and had severe tenderness over his left lateral ribs and upper quadrant. A cat scan of his abdomen and chest found a moderately sized air embolism in the left axillary and innominate veins which was caused by iatrogenic administration of venous contrast. Management included placing the patient into the left lateral decubitus position and transferring to the medical intensive care unit (MICU) for a higher level of care. After an uneventful 24 hours, he was discharged from the hospital. IMPACT/DISCUSSION: Air embolism can occur from trauma, diving, childbirth or from iatrogenic causes. They are rare, occurring 2.65 in 100,000 hospitalizations. Animal and human studies have shown that 20-50 mL of air can increase central venous pressure, decrease pulmonary and systemic arterial pressure, and can inflame and rupture pulmonary endothelium at the capillary level. The most feared complications include end organ ischemic injury and stroke, with 200-300 mL of air being lethal. As imaging becomes more prevalent and accessible in our society, it is pertinent that providers recognize this complication and its management. Management includes placing patients into the left lateral decubitus and Trendelenburg's positions. This aids in keeping the air embolism out of the pulmonary circulation. Hyperbaric oxygen treatment (HBOT) is another effective solution. HBOT is beneficial as it works on both arterial and venous air embolisms, but availability is limited depending on the location of the patient. In our case, the patient was asymptomatic with a moderately sized venous air embolism. He was kept in the left lateral decubitus position and monitored for 24 hours. He had no ill effects and was safely discharged home.

●Large air embolisms cause high morbidity and mortality. ●Treatment strategies include placing patients in left lateral decubitus and Trendelenburg’s positions along with HBOT when able. ●Take safe and systematic approaches to procedures, maintaining Trendelenburg's position when able. WHEN SHOULDER PAIN FEELS UNUSUAL : RECOGNIZING REFERRED PAIN AND THE IMPORTANCE OF COMPREHENSIVE EVALUATION. HOKUTO HIMENO1; Akihito Yoshida2; Takaaki Kobayashi3. 1general internal medicine, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan; 2General Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan; 3Internal Medicine, University of Kentucky, Lexington, KY. (Control ID #4270662) CASE: A 33-year-old previously healthy man presented with acute right shoulder pain of one day’s duration. During the interview, he reported mild epigastric discomfort persisting for two weeks. He denied any history of trauma, appetite loss, weight loss, hospitalizations, or medication use. On physical examination, vital signs were normal. The right shoulder exhibited no redness, warmth, swelling, tenderness, or pain during active or passive movement. A whole-body examination, prompted by the atypical presentation of musculoskeletal pain, revealed liver tenderness. Referred pain from the diaphragm, potentially related to liver lesions, was suspected. Blood tests showed elevated liver enzymes. Contrast-enhanced abdominal computed tomography revealed multiple irregular liver masses with delayed peripheral enhancement and thickening of the sigmoid colon wall. Colonoscopy and biopsy confirmed a diagnosis of colon cancer. Despite two courses of chemotherapy, the patient passed away due to multiple organ failure caused by tumor lysis syndrome. IMPACT/DISCUSSION: Referred pain occurs when sensory nerve fibers from different anatomical regions converge on the same spinal cord segments, causing pain to be perceived in a location distant from its source. Diaphragmatic afferents from the third and fourth cervical dorsal root ganglia also innervate the shoulder and lower neck, explaining why diaphragmatic irritation can manifest as shoulder pain. While shoulder pain often stems from localized causes such as inflammation, trauma, or structural abnormalities of the shoulder, tendons, or ligaments, referred pain may originate from sources like cervical spine pathology, diaphragmatic irritation, intra-abdominal tumors, or liver capsule expansion. Tumor-related visceral pain syndrome, associated with gastrointestinal and gynecological malignancies, can result in shoulder pain through diaphragm irritation caused by liver capsule stretching. Referred pain differs from localized shoulder pain in its lack of association with joint movement, range of motion limitations, or tenderness. A detailed history and thorough physical examination are essential for identifying referred pain and prompting further evaluations such as laboratory testing and imaging studies.

When shoulder joint pain cannot be explained by local structural causes, referred pain from internal organs should be considered, even in young and otherwise healthy individuals. A comprehensive evaluation, including targeted diagnostic testing, is critical for identifying serious underlying conditions. WHEN THE AIRWAY STRIKES BACK: SEVERE STATUS ASTHMATICUS COMPLICATED BY PNEUMOTHORAX AND ASPERGILLUS Danny Aiti1; Ameed Bawwab2; Abdallah Masri3. 1Internal Medicine, Canton Medical Education Foundation, Canton, OH; 2Internal Medicine, Cleveland Clinic Mercy Hospital, Canton, OH; 3Department of Cardiology, Aultman Hospital, Canton, OH. (Control ID #4267194) CASE: A 37-year-old female with severe persistent asthma, anxiety, and tobacco use presented with progressive dyspnea, productive cough, and worsening status asthmaticus over two weeks. Initial outpatient steroid therapy provided no improvement. Upon emergency department admission, she exhibited acute hypercapnic respiratory failure (pH 7.13, pCO2 102) and required mechanical ventilation after failing non-invasive support. Complications during the ICU course included right apical pneumothorax secondary to barotrauma from elevated ventilatory pressures, necessitating small-bore chest tube placement. Persistent bronchospasm and significant auto-PEEP made ventilatory management challenging, requiring deep sedation, neuromuscular blockade, and permissive hypercapnia. Further deterioration prompted bronchoscopy, revealing Aspergillus infection, likely exacerbated by high-dose steroid use. Infectious workup also identified Staphylococcus aureus. The patient developed critical illness myopathy and neuropathy, extending her need for ventilatory support and prompting tracheostomy placement. IMPACT/DISCUSSION: This case underscores the complexity of managing severe status asthmaticus compounded by barotrauma, secondary infection, and critical illness sequelae. Barotrauma leading to pneumothorax is a known risk in status asthmaticus patients receiving mechanical ventilation due to elevated airway pressures and breath-stacking. Additionally, the development of Aspergillus infection highlights the importance of surveillance for fungal superinfections in patients receiving prolonged high-dose steroids and mechanical ventilation. Key interventions included tailored antifungal therapy (Voriconazole and Cresemba), careful ventilatory management to minimize further lung injury, and multidisciplinary collaboration with pulmonology, infectious disease, and critical care teams. This patient’s course required balancing permissive hypercapnia with strategies to address ventilatory challenges such as auto-PEEP and bronchospasm, while managing superimposed complications.

Severe status asthmaticus may progress to critical illness complicated by barotrauma, secondary infections, and prolonged ventilatory dependence. This case highlights the importance of meticulous ventilatory management, early identification of superinfections, and a multidisciplinary approach to optimize outcomes for critically ill asthma patients. WHEN THE COAGULATION CASCADE FAILS: METASTATIC PROSTATE CANCER PRESENTING AS DIC Aala Dweik1; Nyein Theik1; Shivani Dalal2; Elizabeth Rubin2; Ali Ansari-Lari3; Matthew P. Salzberg2. 1Internal Medicine, Memorial Healthcare System, Hollywood, FL; 2Hematology/Oncology, Memorial Healthcare System, Hollywood, FL; 3Anatomic and Clinical Pathology, Memorial Healthcare System, Hollywood, FL. (Control ID #4273435) CASE: A 62-year-old man with a past medical history of type II diabetes mellitus and hypertension presents with generalized malaise. Physical exam was remarkable for decreased lung sounds of the bilateral lung bases and +1 bilateral lower extremity pitting edema. Initial labs showed microcytic anemia (Hemoglobin 12.7 g/dl and MCV 78.9 fL), normal white blood cell count (8.2 x 10^3/mm3), low-normal platelet count (153 x 10^3/mm3), and elevated prothrombin time (PT) 13.6 s. CT imaging revealed a small right parietal sub-galeal hematoma, bilateral pleural effusions and mediastinal and hilar lymphadenopathy. On hospital day 3, the patient developed gross hematuria and by day 6, hemoglobin fell to 8.3 g/dl. He then developed anemia refractory to daily packed red blood cell transfusions. An explorative cystoscopy found no primary bladder tumor. By day 14, lab investigations showed low platelet count (102 x 10^3/mm3), low fibrinogen (118 mg/dl), prolonged PT (15.3 s), and prolonged PTT (38 s). Bone marrow biopsy was performed revealing metastatic adenocarcinoma of the prostate. Initial PSA was 403 ng/mL. Hospital course was complicated by an acute subarachnoid hemorrhage, requiring transfer to the ICU, along with hemoptysis and oral bleeding. He received Casodex for 5 days prior to inpatient treatment with Androgen Deprivation Therapy and Docetaxel. Coagulopathy normalized with treatment, coinciding with drop in PSA. IMPACT/DISCUSSION: DIC is a clinical diagnosis and results as a complication of an underlying cause. In advanced prostate cancer, DIC is the most common coagulation disorder, occurring in 0.4% to 1.65% of patients, though it is rarely symptomatic. Consequently, DIC is seldom the initial manifestation of prostate cancer but when it does occur, it is often associated with poor prognosis and high mortality risk. Early detection of the underlying malignancy and prompt treatment with anti-androgen therapy can help prevent significant morbidity and mortality.

The rare and challenging presentation of advanced prostate cancer manifesting initially as DIC, can lead to severe, life-threatening complications such as hematuria, hemorrhagic manifestations, and multiorgan involvement. Early recognition and appropriate intervention with androgen deprivation therapy resulted in stabilization of the coagulopathy and a reduction in tumor burden. This case highlights the importance of a comprehensive work-up for unexplained coagulopathy, especially in patients presenting with bleeding that does not respond to standard treatments, as it can be a harbinger of an underlying malignancy. WHEN THE FIRST MAGNETIC RESONANCE IMAGING LIES: THE CRITICAL ROLE OF REPEAT IMAGING IN DIAGNOSING PYOGENIC SPONDYLITIS Nae Itagaki1; Takaaki Kobayashi2; Shunsuke Koga3; Akihito Yoshida4. 1General Internal Medicine, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan; 2Internal Medicine, University of Kentucky, Lexington, KY; 3Orthopedics, Kameda Medical Center, Kamogawa, Chiba Prefecture, Japan; 4General Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan. (Control ID #4270289) CASE: An 81-year-old man with diabetes mellitus and lumbar hernia presented to the emergency department with worsening back pain, fever (more than 40 degrees celsius), low blood pressure, and altered mental status. Physical examination revealed abdominal varicosities but no other significant findings. Laboratory tests showed leukopenia (1300/μL) and elevated C-reactive protein levels (9.47 mg/dL). Urinalysis was negative. Initial contrast-enhanced pan-computed tomography and magnetic resonance cholangiopancreatography revealed no source of infection. Escherichia coli was isolated from multiple blood cultures, prompting intravenous ampicillin-sulbactam therapy. A non-contrast lumbar spine MRI on day 4 showed no abnormalities. Despite treatment, the patient had continued bacteremia, raising concerns for an endovascular infection. However, transthoracic echocardiography was negative. On day 12, a repeat non-contrast lumbar spine MRI revealed short TI inversion recovery (STIR) hyperintensity in the L1 and L2 vertebral bodies, confirming pyogenic spondylitis. Antimicrobial therapy was continued for over six weeks after blood cultures turned negative, leading to clinical improvement. IMPACT/DISCUSSION: Pyogenic spondylitis is rare, with an incidence of 0.4–2 cases per 100,000 annually, but its frequency is increasing due to longer life expectancy and chronic illnesses. Staphylococcus aureus is the most common causative organism, followed by Gram-negative bacilli and streptococci/enterococci. While E. coli bacteremia is typically associated with urinary (50%), biliary (11–27%), and intra-abdominal infections (4–48%), pyogenic spondylitis as a source is rare. Mortality rates for pyogenic spondylitis range from 2–20%, and delays in diagnosis can lead to complications such as spinal deformity and dysfunction. MRI is the gold standard for diagnosing pyogenic spondylitis, with T1-weighted images showing reduced vertebral signal intensity and T2/STIR sequences revealing increased signal intensity from edema. However, MRI may be negative in early disease. Cases have been reported where repeat MRI, performed 2–4 weeks after initial imaging, confirmed the diagnosis despite earlier negative results. This emphasizes the importance of persistence in diagnostic imaging when clinical suspicion remains high.

This case highlights the need to consider pyogenic spondylitis as a potential cause of E. coli bacteremia, particularly when initial diagnostic tests are inconclusive. Early and repeat MRI play a crucial role in achieving timely diagnosis and effective intervention, ultimately reducing the risk of severe complications. WHEN THE PARTY’S OVER: A TRIPPY TALE OF KETAMINE-INDUCED CHOLANGIOPATHY Bibhuti Adhikari. Internal Medicine, Elmhurst Hospital Center, Queens , NY. (Control ID #4270476) CASE: A 31-year-old man with history of substance abuse, including the daily use of high doses of ketamine, presented with a week of weakness, fatigue, and abdominal pain. Physical examination revealed general abdominal tenderness, most pronounced in the lower abdomen. Laboratory tests indicated significantly elevated alkaline phosphatase of 1, 200 U/L, and mildly elevated alanine transaminase of 69 U/L implicating likely cholestatic liver injury. Imaging studies, including ultrasound, did not show hepatic steatosis, cholelithasis, or gallbladder wall thickening. Notably, the CT scan also revealed moderate bilateral hydroureteronephrosis to the level of the bladder with no evidence of moderate to large biliary abnormality to suggest primary sclerosing cholangitis. Given the absence of other explanation for the patient's cholestatic liver injury, the patient was given a presumptive diagnosis of ketamine-induced cholangiopathy. Despite initial treatment, the patient’s liver function worsened during hospitalization. He was discharged with the expectation of improvement upon discontinuing ketamine use. However, he failed to return for follow-up. IMPACT/DISCUSSION: Ketamine use can cause neuropsychiatric impairment, ulcerative cystitis, or uropathy. While urinary bladder dysfunction due to ketamine is well-known, its effects on the hepatobiliary system have been less well-defined. The mechanism by which daily ketamine use leads to cholestasis and biliary dilatation remains unclear. Ketamine is primarily metabolized into norketamine by the liver through nitrogen demethylation. Approximately 90% of metabolite is excreted in urine, where it exerts cytotoxic effects on urothelial cells via an apoptosis-inducing pathway, while the remaining 10% is eliminated through bile. Forensic investigations have confirmed the presence of norketamine in human bile following ketamine poisoning. It is hypothesized that the pathology could be due to direct toxic injury to surface epithelium, similar to urothelial injury. Alternatively, studies have shown that injecting NMDA into the dorsal motor nucleus of the vagus, which has efferent fibers to the gallbladder, increases gallbladder motility, and this effect can be abolished by ketamine or norketamine leading to gallbladder dysmotility. Strong consideration to the diagnosis should be given in cases of cholestatic liver injury in the setting of ketamine use, whether therapeutic or recreational, with unremarkable imaging or imaging showing only bile duct dilation. Although at this time reports of ketamine-induced cholangiopathy are sparse, the diagnosis may become increasingly common as new roles for ketamine emerge in the treatment of psychiatric illnesses and with greater awareness of the disease.

At this time it is unclear if the risk of biliary or hepatic pathology is dose related or idiosyncratic; however it has been observed to be potentially reversible in abstinent patients. WHEN THE SKIN FIGHTS BACK: A COMPLEX CASE OF PYODERMA GANGRENOSUM IN A CHRONICALLY ILL PATIENT Luke Ciminera2; Sidratul Baizeed2; Wali Kamran3; Jeffery A. Debuque1. 1Internal Medicine, Lehigh Valley Hospital - Cedar Crest, Allentown, PA; 2Internal Medicine, Lehigh Valley Health Network, Allentown, PA; 3Internal medicine, Lehigh Valley Health Network, Allentown, PA. (Control ID #4271747) CASE: A 71-year-old female with a history of Takayasu arteritis on chronic prednisone, Charcot foot, diffuse alveolar hemorrhage and recent hospitalization at another facility for pulmonary embolism presented for evaluation of worsening chronic right lower extremity (RLE) wounds. On arrival, CT angiography revealed patent arteries but a medial calf fluid collection. Initial management with IV vancomycin and cefepime ended as Infectious Disease and Dermatology felt bacterial infection was unlikely. Pseudomonas isolated from cultures was deemed colonization. Attempts at image-guided drainage were aborted after the fluid collection spontaneously resolved. Rheumatology and Dermatology suspected pyoderma gangrenosum (PG). A punch biopsy confirmed a neutrophilic dermatosis without vasculitis, consistent with PG. Concurrent hemoptysis, likely diffuse alveolar hemorrhage, prompted pulse-dose IV steroids. Vascular surgery recommended a possible above-knee amputation, but the patient declined, opting for a conservative approach. Without fever or active infection, antibiotics were discontinued, and she was started on a structured steroid taper, with prophylactic trimethoprim-sulfamethoxazole to prevent opportunistic infections. Physical and occupational therapy evaluations deemed the patient safe for discharge home with home health support. She departed with close rheumatology follow-up and local wound care arrangements. IMPACT/DISCUSSION: In this patient with long-standing vasculitis and chronic immunosuppression, PG presented as a challenging diagnostic puzzle. Initial presumptions of infection and vascular compromise proved incorrect. Collaboration among Rheumatology, Dermatology, Infectious Disease, and Vascular Surgery, alongside tissue biopsy and vascular imaging, clarified the diagnosis. High-dose steroids addressed both PG and pulmonary complications. Avoiding unnecessary surgery and prolonged antibiotics, the team adopted a patient-centered, minimally invasive strategy.

This case highlights the complexities of diagnosing and managing PG in a patient with extensive comorbidities and decades of immunosuppression. The patient’s dissatisfaction with medical recommendations and refusal of multiple interventions limited her therapeutic options. Further complicating care was presentations across a range of health systems. Frequent evaluation, multidisciplinary input, and biopsy confirmation averted invasive interventions. Respecting the patient’s wishes, the team implemented a careful steroid taper, prophylaxis, and wound care support at home. Ultimately, this approach underscores the necessity of flexibility, communication, and individualized care in complex inflammatory conditions. WHEN THE TONGUE SPEAKS: A DECADE-LONG SILENT THREAT OF UNILATERAL TONGUE EDEMA FROM ACE INHIBITOR-INDUCED ANGIOEDEMA Mizuki Seki1; Takaaki Kobayashi2; Akihito Yoshida3. 1Emergency and Trauma, Kameda Medical Center, Kamogawa, Chiba, Japan; 2Internal Medicine, University of Kentucky, Lexington, KY; 3General Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan. (Control ID #4270631) CASE: An 84-year-old Japanese woman with a history of hypertension and myocardial infarction presented to the emergency department with a progressive, isolated left-sided tongue swelling that had developed over several days. Her vital signs were unremarkable, and physical findings revealed non-tender, localized swelling of the left side of the tongue without erythema, induration, or other signs of inflammation. The patient denied dyspnea, dysphagia, or any symptoms suggestive of airway compromise. She also reported no recent changes in diet, medications, allergen exposure, sick contacts, or travel history. The patient had been taking enalapril, an angiotensin-converting enzyme inhibitor (ACE-I), for hypertension management for over 10 years. Based on her clinical presentation and the exclusion of other potential etiologies, ACE-I-induced angioedema was strongly suspected. Enalapril was promptly discontinued, leading to complete resolution of the tongue edema within 48 hours, confirming the diagnosis. IMPACT/DISCUSSION: ACE-I-induced angioedema is an uncommon but potentially serious adverse reaction, with an incidence of 0.1–1%. ACE-Is, along with NSAIDs and β-lactam antibiotics, remain significant causative agents of drug-induced angioedema. This condition is mediated by bradykinin accumulation due to ACE inhibition, leading to increased vascular permeability and localized edema. Unlike histamine-mediated angioedema, which manifests as transient superficial swelling, bradykinin-mediated reactions are characterized by deep swelling involving the dermis, subcutaneous tissues, and submucosa. The typical clinical presentation of ACE-I-induced angioedema involves diffuse lip or facial swelling. Isolated unilateral tongue edema is rare, with only several similar cases reported in the literature. Additionally, the onset of ACE-I-induced angioedema is highly variable, ranging from days to over a decade after starting therapy. This delayed onset often complicates diagnosis, especially in long-term users. Management requires immediate discontinuation of the ACE inhibitor, which is usually sufficient to resolve symptoms. Severe cases with airway involvement may necessitate advanced airway management, such as intubation or tracheostomy. In this case, early detection and the absence of airway compromise allowed for conservative treatment with close monitoring.

ACE-I-induced angioedema may present in atypical localized forms, such as isolated unilateral tongue swelling, even after years of medication use. Awareness of these diverse presentations and timely drug discontinuation are critical to ensuring patient safety and preventing severe complications. WHEN THE VALVE IS THE CULPRIT - RARE CASE OF MYXOMATOUS DEGENERATION OF AORTIC VALVE CAUSING CULTURE NEGATIVE ENDOCARDITIS Albert Alexis A. Annan1; Victor Adenuga1; Alba L. Caceres Munoz2; Carolina Nadin De La Porte3. 1Internal Medicine, Texas Health Resources, Arlington, TX; 2Internal Medicine, Texas Health Resources University, Arlington, TX; 3Internal medicine GME, Texas Health Resources, Arlington, TX. (Control ID #4273612) CASE: A 67-year-old female presenting with chronic intermittent fevers of about 6 weeks' duration and exertional shortness of breath. She had presented to the emergency department 4 days prior to admission for the same complaints, however declined admission and was discharged with oral antibiotics. On admission patient had a fever of 100.1F, had significant leukocytosis with left shift (WBC 23,000), ESR 66 and CRP of 4.1. On physical examination, diastolic murmur was appreciated around left sternal border. Chest x-ray showed calcification of the thoracic aorta otherwise unremarkable. EKG showed normal sinus rhythm. Initial Transthoracic Echocardiogram (TTE) done to rule out vegetation due to concern of endocarditis showed normal systolic function with EF 50-55%,with moderate aortic regurgitation, however vegetation could not be ruled out. Transesophageal echocardiogram(TEE) showed 11 x 6 medium mobile echodensity on right coronary and non coronary cusp of aortic valve with severe aortic regurgitation. Blood cultures were negative, testing for atypical organisms including Brucella, Bartonella, Coxiella burnetti, legionella and typhus were negative. Immunologic testing including ANA, anti ds antibody, anti Jo 1, anti SSA and anti SSB were all negative. Patient was managed with IV Lasix given aortic regurgitation,IV antibiotics for culture negative endocarditis and CT surgery was consulted for valve replacement. Patient underwent aortic valve replacement with bioprosthetic valve as patient deferred chronic anticoagulation. Valve specimen was sent for microbiology including, Gram stain, Acid Fast bacilli and culture, fungal culture were negative and pathology showed focal myxoid degeneration. Patient was discharged with IV antibiotics for 4 weeks. IMPACT/DISCUSSION: Myxomatous degeneration (MD) is a non-inflammatory degenerative process leading to disruption of the fibrosa layer of the valve. This commonly affects the mitral valve leading to regurgitation, however, there are increasing reports of myxomatous degeneration of the aortic valve. Although less commonly affected than mitral valve, it is still a common cause of severe aortic valve regurgitation and can predispose to infective endocarditis especially if certain underlying cardiac conditions, such as a history of infective endocarditis, rheumatic heart disease, congenital heart disease and Marfan’s syndrome are present. This presented a diagnostic challenge as our patient did not have any of the above conditions but our multidisciplinary approach to this case solved this mystery.

MD can involve a previously normal aortic valve and can cause aortic insufficiency in the absence of valvular heart disease and predispose to varying complications including endocarditis. Early diagnosis is crucial to avoid these complications. Aortic valve replacement is the definitive treatment as myxoid degeneration is a progressive disease. WIDESPREAD RECURRENCE OF IGG4-RELATED DISEASE: A RARE LYMPHOMA MIMIC Allison A. Reinhardt1; Katlin Schmitz1; Bibek Saha1; Nick P. Steinauer1; Ray Qian2. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Hospital Internal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4273272) CASE: A 68-year-old male with history of IgG4-related autoimmune pancreatitis presented to the Emergency Department with a one-month history of generalized weakness and a 25 lb unintentional weight loss over the past three months. Labs were notable for elevated lactate (3.4 mmol/L), new thrombocytopenia (platelets 29 ×10^9/L), and a stage II AKI with creatinine 2.4 mg/dL compared to baseline 1.1 mg/dL. CT A/P showed widespread abdominopelvic lymphadenopathy and splenomegaly, concerning for hematologic malignancy. Hematologic work-up revealed a biclonal gammopathy with IgG kappa and IgG lambda M spikes (0.7 mg/dL and 0.8 mg/dL respectively). FDG PET/CT showed intensely FDG-avid lymphadenopathy above and below the diaphragm, compatible with a lymphoproliferative disorder. There was intense FDG uptake associated with opacities in the bilateral lung bases, concerning for involvement of “lymphoma” in the lungs. Lymph node biopsy was negative for hematologic malignancy; 10% of the plasma cells in the lymph node expressed IgG4. Bone marrow biopsy showed a minute population of monoclonal B cells, consistent with MGUS. Kidney biopsy showed IgG4-rich plasma cells with storiform fibrosis indicative of IgG4-related tubulointerstitial nephritis. Broad infectious work-up including Karius testing was negative. The patient was initiated on rituximab and steroids for widespread relapse of IgG4-related disease (IgG4-RD) with favorable clinical response including rapid improvement of his AKI and near resolution of lymphadenopathy on interval PET/CT three months after hospital discharge. IMPACT/DISCUSSION: IgG4-RD is an autoimmune fibroinflammatory disorder in which IgG4-secreting plasma cells invade various tissues, contributing to inflammation and scarring. Any organ system can be impacted by IgG4-RD, though salivary glands, lacrimal glands, and the hepatopancreaticobiliary system are most commonly involved. Correctly identifying IgG4-RD requires a high index of clinical suspicion. It is important to communicate this clinical suspicion to the reading pathologist to ensure immunohistochemistry for IgG4 is performed on the biopsy tissue. In our patient, diagnosis was delayed due to anchoring bias after initial CT A/P and subsequent PET/CT were read as highly concerning for lymphoma. Widespread relapse of IgG4-RD was not considered in the initial differential as the patient had limited health literacy, and his history of IgG4-related pancreatitis was not clearly documented in the Electronic Health Record (EHR). The rate of IgG4-RD recurrence is as high as 36% in the three years after initial diagnosis, and it is crucial for clinicians who will care for impacted patients in the future to be aware of this clinical history.

IgG4-RD should remain in the differential for patients with widespread FDG-avid lymphadenopathy. The relapse rate is nearly 40%, and this case highlights the importance of distinctly documenting a history IgG4-RD in the EHR to guide future clinicians. WITHDRAWAL WITHOUT AN EXIT: LESSONS IN CRITICAL CARE MANAGEMENT OF PRECIPITATED WITHDRAWAL FROM EXTENDED-RELEASE NALTREXONE Elijah T. Lustig1; Megan Heeney2,3; Monish Ullal2,1; Erik Anderson2,3. 1Internal Medicine, Alameda Health System, Oakland, CA; 2Addiction Medicine, Alameda Health System, Oakland, CA; 3Emergency Medicine, Alameda Health System, Oakland, CA. (Control ID #4267131) CASE: A 65-year-old male with a history of alcohol use disorder (AUD) and opioid use disorder (OUD) in remission for 25 years presented with symptoms of alcohol withdrawal after a relapse with heavy alcohol consumption. Extended-release naltrexone was administered for AUD management following the patient’s denial of recent opioid use. However, it was later revealed that the patient was on 270 mg of daily methadone maintenance therapy. Within 30 minutes of naltrexone administration, the patient experienced severe agitation, discomfort, and hypertensive urgency. Dexmedetomidine was initiated for symptom control but led to bradycardia and subsequent torsades de pointes (TdP), necessitating cardiopulmonary resuscitation. The patient was intubated in the intensive care unit (ICU), where a multimodal approach was employed for symptom control, including high-dose opioids (hydromorphone and fentanyl), ketamine, and benzodiazepine infusions. The hospital course was complicated by recurrent mucus plugging requiring bronchoscopy, sepsis secondary to pneumonia, and acute renal failure requiring hemodialysis. Persistent respiratory failure and oropharyngeal dysphagia necessitated tracheostomy and gastric feeding tube placement. After six weeks of ICU care, the patient was transferred to a long-term acute care facility for ongoing management. IMPACT/DISCUSSION: This case underscores the risks associated with using extended-release naltrexone in patients with unrecognized opioid dependence, particularly those on high-dose methadone. It highlights the critical need for comprehensive pre-treatment evaluation, including an in-depth assessment of opioid use history and tailored risk mitigation strategies. The case also illustrates the pharmacologic challenges posed by the high mu-receptor affinity of naltrexone, which limited the efficacy of opioid agonists and necessitated a multidisciplinary, multimodal approach to symptom management. While previous reports have described opioid withdrawal of varying severity from oral and extended-release naltrexone, this case is unique due to the exceptionally high methadone dose involved as well as the degree of complications. These insights contribute to better understanding of the clinical impact of opioid withdrawal precipitated by extended-release naltrexone and inform strategies to mitigate similar risks in future cases.

Comprehensive pre-treatment evaluation is essential before initiating extended-release naltrexone, particularly evaluating prior opioid exposure. Management of severe precipitated withdrawal requires a multidisciplinary approach and may necessitate advanced critical care interventions. Naltrexone’s high mu-receptor affinity poses unique challenges in cases of precipitated withdrawal and requires multimodal symptoms control. WORSENING HYPOCALCEMIA IN THE SETTING OF LOOP DIURETIC USE IN HYPOPARATHYROIDISM Mayura R. Kesara1; Kusum Joshi1; Drushik Gangasani2. 1Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY; 2Internal medicine, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4272528) CASE: A 78-year-old female with a medical history of hypothyroidism post-thyroidectomy, hypocalcemia secondary to postsurgical hypoparathyroidism, and cardiomyopathy presented to the hospital with worsening shortness of breath, lower extremity swelling, and generalized weakness. Despite being initiated on furosemide as an outpatient a few days prior, her symptoms had progressed. On presentation, the patient was in respiratory distress with signs of fluid overload and diffuse expiratory wheezing. She was admitted for management of a heart failure exacerbation. Initial laboratory results revealed hypocalcemia, with a serum calcium level of 7.5 mg/dL and normal Vitamin D level. The patient was started on intravenous furosemide for fluid management, and her home calcium carbonate supplements (500 mg thrice daily) were continued during her hospitalization. Her hospital course was complicated by worsening hypocalcemia. Calcitriol supplementation was initiated, resulting in an initial improvement in calcium levels. Nevertheless, a subsequent decrease in calcium levels was observed, prompting the discontinuation of furosemide, after which her calcium levels stabilized, and she was transitioned to spironolactone. The patient’s calcium levels eventually normalized, and she was discharged home with continued calcium supplementation. IMPACT/DISCUSSION: This case highlights the challenges of managing calcium homeostasis in patients with hypoparathyroidism, particularly in the setting of loop diuretic use. Furosemide, a loop diuretic, is known to increase calcium excretion in the urine, which can exacerbate underlying hypocalcemia in patients with hypoparathyroidism. This case underscores the importance of careful monitoring of calcium levels in such patients, especially when using diuretics like furosemide. The patient's initial response to calcitriol supplementation suggests that active vitamin D analogs may be necessary to support calcium absorption in the setting of hypoparathyroidism. However, the persistence of hypocalcemia despite these interventions led to the discontinuation of furosemide. The subsequent stabilization of calcium levels following the switch to a potassium-sparing diuretic (spironolactone) emphasizes the need to consider alternative diuretic options in managing fluid overload in these patients.

In conclusion, while detailed epidemiological data on furosemide-induced hypocalcemia in hypoparathyroid patients are limited, this case demonstrates the substantial risk associated with this combination, particularly in patients with already compromised calcium homeostasis. Clinicians should be vigilant in monitoring calcium levels and consider alternative therapies to prevent severe hypocalcemia in this vulnerable population. YERSINIA ENTEROCOLITICA INFECTION ASSOCIATED WITH ANCA-ASSOCIATED VASCULITIS Aaron D. Smith, Britney He, Yeshwanter Radhakrishnan, Jess Dreicer. Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA. (Control ID #4241187) CASE: A 63-year-old male with a history of hypertension initially presented with a 6-week history of severe nausea, vomiting, and diarrhea. He was found to have acute kidney injury (AKI) with creatinine elevated to 3.2 mg/dL from a baseline of 0.9 mg/dL. Urine microscopy showed dysmorphic red blood cells (RBC) and granular casts. Initial workup revealed low C3 and C4 levels, and elevated myeloperoxidase (MPO) antibody titers. A CT scan revealed terminal ileitis, suggestive of an infectious process, and stool testing identified Yersinia enterocolitica. The patient was treated with a seven-day course of doxycycline, which resolved his gastrointestinal symptoms. At a follow-up nephrology clinic visit, his creatinine remained elevated at 2.9 mg/dL, and repeat urine microscopy continued to show dysmorphic RBCs and RBC casts. The patient was directed to the hospital for further workup and biopsy. Histopathology demonstrated fibrinoid necrosis, crescents, and endocapillary hypercellularity on light microscopy, while immunofluorescence was negative and deposits were absent on electron microscopy. These findings, combined with positive MPO titers, were consistent with ANCA-associated vasculitis (AAV). The patient was treated with three days of intravenous methylprednisolone (1 gram daily), followed by a prednisone taper, complement component 5a receptor antagonist avacopan and rituximab infusions (1,000 mg) administered as 2 doses 2 weeks apart. His creatinine improved to 1.7 mg/dL at the last follow up. Complement levels normalized and urine microscopy did not show any red blood cells. IMPACT/DISCUSSION: This case illustrates a unique presentation of Yersinia enterocolitica infection occurring in conjunction with AAV raising the possibility of a causal link. Although Yersinia primarily causes gastrointestinal symptoms, it may incite autoimmune responses through mechanisms such as molecular mimicry or immune dysregulation. Similar associations have been documented with other pathogens like Bartonella, Coxiella burnetii and Staphylococcus aureus. Antigens from these infections may promote ANCA production, neutrophil activation, and endothelial injury, contributing to the development of autoimmune vasculitis. Recognizing infections as potential triggers for AAV has significant clinical implications, particularly in patients presenting with acute kidney injury during and after infections. Identifying the autoimmune component early allows for timely initiation of immunosuppressive therapy once infection is under control. Such an approach can optimize outcomes by addressing both the underlying autoimmune process and the infection contributing to disease pathogenesis.

While rare, Yersinia enterocolitica infections may act as potential triggers for ANCA-associated vasculitis through mechanisms akin to those seen with other bacterial pathogens. Greater awareness of this potential relationship may improve diagnostic accuracy and facilitate timely, targeted treatment in affected patients. Clinical Vignette - Medical Education and Training "AUTOIMMUNE FACTOR VIII DEFICIENCY (ACQUIRED HEMOPHILIA A): DIAGNOSTIC CHALLENGES, TREATMENT STRATEGIES, AND THE ROLE OF RITUXIMAB IN MANAGING REFRACTORY BLEEDING" Anum Farid1; Fatema Mahjabeen2; Jairah Shaikh3. 1Internal Medicine, Texas Tech University System, Amarillo, TX; 2Internal medicine , Texas tech university health sciences center amarillo, Amarillo, TX; 3Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX. (Control ID #4272578) CASE: 62-year-old female with a history of hypertension, recent ischemic CVA, and GI bleed due to a gastric ulcer presented with worsening right-hand pain, swelling, and abdominal bruising. CT of the hand showed a hematoma, and she underwent debridement for necrotic tissue. Post-surgery, she experienced persistent wound oozing. Labs revealed prolonged APTT (71.4) with PT (10.8) and INR (0.98) in the normal range. Fibrinogen was 626, D-dimers 6.29 (elevated), and lupus anticoagulant was negative. PTT-LA mix was 77 (elevated), suggesting an inhibitor. Factor VIII activity was undetectable, though factor IX was 160 and VWF activity/antigen were normal. Autoimmune Factor VIII deficiency was diagnosed. Treatment with prednisone, IVIG, cyclophosphamide, and vitamin K was initiated. Despite immunosuppression, Factor VIII remained undetectable, but bleeding ceased, and she was discharged on 40mg prednisone. She returned with active bleeding after two days, received coagulation factor VII (recombinant) that is Novoseven and rituximab. After two doses, Factor VIII levels became detectable. Her bleeding stopped, and she was discharged with a recommendation to complete four outpatient doses of rituximab. IMPACT/DISCUSSION: The diagnosis of autoimmune factor VIII deficiency was based on an elevated PTT, undetectable factor VIII, and failure of PTT correction with mixing studies. Initial therapies, including steroids, IVIG, and cyclophosphamide, were ineffective. The patient responded to rituximab while on prednisone, leading to detectable Factor VIII levels. This case highlights the role of rituximab in treating autoimmune factor VIII deficiency, also known as acquired hemophilia A (AHA). Rituximab acts as an immunosuppressive agent targeting B-cells responsible for producing autoantibodies against factor VIII, improving clotting function and reducing bleeding episodes. The underlying cause of autoimmune factor VIII deficiency in this patient remains unknown. Four months prior, she experienced a complicated hospital course, including recurrent CVA, GI bleeding, and MSSA bacteremia. It is unclear whether these events triggered the condition. Her autoimmune panel was negative, and prior treatments included ceftriaxone for MSSA bacteremia, clopidogrel and aspirin for stroke, and vancomycin. A direct medication-related trigger was not established. Monitoring Factor VIII levels after treatment initiation is essential, as persistent deficiency poses a risk of recurrent bleeding. Early consideration of rituximab in refractory cases may prevent life-threatening bleeds in AHA.

Autoimmune factor VIII deficiency (AHA) is a challenging condition to diagnose and manage. Despite initial resistance to standard therapies, the patient improved significantly with rituximab combined with prednisone. Given the potential for life-threatening bleeds, early use of rituximab in refractory cases is recommended. Regular monitoring of factor VIII levels and individualized treatment strategies remain essential. A CASE OF CARDIAC TAMPONADE: THE FIRST CLUE TO UNVEILING A HIDDEN MALIGNANCY Kathryn Johnston1; Nathan T. Douthit2,1. 1Medical Education, Edward Via College of Osteopathic Medicine - Auburn Campus, Auburn, AL; 2Internal Medicine, East Alabama Medical Center, Opelika, AL. (Control ID #4272282) CASE: 65-year-old male with a medical history of type 2 diabetes, hypertension and schizophrenia presented to the emergency department with bilateral leg pain. Patient is a current smoker. Vital signs revealed patient was hypotensive at 75/59 mmHg, afebrile and pulse of 121 bpm. Physical exam revealed increased heart rate with irregular rhythm. Lower extremities and feet revealed diminished pulses and trace edema bilaterally. Labs revealed sodium of 128 mg/dL, potassium of 5.2 mg/dL, AST 881 U/L, ALT 954 U/L, lactic acid 3.8 mmol/L, B12 >15,00 mcg, creatinine 2.1 mg/dL, D-dimer of 2,243 mg/L, calcium of 11.4 mg/dL and hemoglobin of 8.6 g/dL. EKG revealed atrial fibrillation with RVR. Chest XR showed enlarged mediastinal and cardiac silhouettes with clear lungs. Echocardiogram revealed circumferential pericardial effusion, compressing the right ventricle. Pericardiocentesis procedure produced 1275cc of sanguineous fluid. Patient’s cardiac and obstructive shock was treated with normal saline. Lactic acidosis and acute kidney injury improved over the course of the patient’s stay. Cytology results from pericardiocentesis sample revealed immunochemistry +p40, +CK7, -CK20, -TTF1, -calretinin. These markers equate to metastatic squamous cell carcinoma. No evidence of malignancy was found in chest and abdominal CT. Primary site of patient’s cancer is still unknown. Due to +CK7 marker, it is suggested that primary site is in the head or neck. Patient was discharged to oncology’s care. The oncologist advised against chemotherapy or surgery due to metastasis and the high burden of pericardial involvement. Hospice care was recommended. IMPACT/DISCUSSION: In patients with pericardial effusions, only 7-10% of patients develop cardiac tamponade. Those who go on to develop cardiac tamponade are at imminent risk of organ damage and death if left untreated. The pericardial effusion compresses the chambers of the heart, leading to reduced diastolic filling causing global hemodynamic instability. Cardiac tamponade has a wide range of acute and chronic etiologies. In patients who have an established diagnosis of malignant neoplasms, only 5-20% had malignant involvement of the pericardium. Initial presentation of metastasis due to incidence of cardiac tamponade is substantially low. Cancers adjacent to the heart are most likely to spread by direct extension, such as lung or breast cancer. Cytology fluid is a crucial pathway to discovering the origin of the pericardial effusion through immunohistochemical testing. However, certain cases may require a biopsy of the pericardium to determine etiology. Prompt diagnosis and treatment of the malignancy is essential to improve patient outcomes and hopefully remedy the grim prognosis of this presentation.

- Recognize neoplasm as a potential cause of cardiac tamponade - Manage cardiac tamponade in order to quickly assess, treat, and prevent the associated end organ damage. - Evaluate for primary site in metastatic malignancy of unknown origin. ACUTE CORONARY THROMBOSIS MIMICKING LUPUS MYOPERICARDITIS - A CASE REPORT AND CALL FOR VIGILANCE Hussain Majeed1; Fardeen Faiz2. 1Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 2Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4273016) CASE: Systemic lupus erythematosus (SLE) is a complex autoimmune disorder associated with complications like thromboembolism and pan-carditis. Thromboembolism in SLE is linked to hypercoagulability, platelet dysfunction, inflammation, and inadequate anticoagulation. This report describes a near-fatal case of lupus-associated myopericarditis presenting with chest pain due to right coronary artery thrombosis. A 41-year-old woman with SLE, cervical cancer, recurrent pulmonary emboli on enoxaparin, myopericarditis, and nonobstructive coronary artery disease presented with chest pain radiating to her shoulders and neck, similar to prior lupus pericarditis episodes. She was compliant with colchicine, hydroxychloroquine, and mycophenolate but had not seen a rheumatologist for two years. Vitals were normal, and labs revealed platelets 151 k/uL, troponin 3,736 ng/L, erythrocyte sedimentation rate 36 mm, and C-reactive protein <0.4 mg/dL. The electrocardiogram showed sinus bradycardia with inferior-lateral ischemia. Intravenous steroids were started for suspected myopericarditis flare. Her echocardiogram showed reduced right ventricular function and a newly reduced left ventricular ejection fraction of 35-40%. IMPACT/DISCUSSION: With ongoing chest pain and troponin rising to 34,603 ng/L, coronary angiography revealed 99% right coronary artery stenosis. Percutaneous coronary intervention with thrombectomy and stent placement was successful. She received tirofiban, prasugrel, aspirin, and increased enoxaparin. A hematology workup revealed low protein S, and she was discharged with follow-up in cardiology, hematology, and rheumatology.

Lupus-associated myopericarditis can mask coronary thrombosis, delaying diagnosis and treatment. SLE elevates thrombosis risk through vasculopathy and antiphospholipid syndrome (APLS). Prophylactic enoxaparin may be inadequate, and early catheterization should be considered. If APLS is confirmed, warfarin with a higher INR target (3.0) is advised. Outpatient follow-up, cancer screening, and nephrotic syndrome evaluation are essential for managing hypercoagulability and ensuring long-term care. ATRIAL MYXOMA PRESENTING WITH MULTIORGAN EMBOLIC INFARCTS Satya H. Manda1; Anunaya Aashish2. 1Internal medicine, Texas Health Resources, Arlington, TX; 2GME, Internal medicine residency program, THR HEB/Denton, Texas Health Resources, Arlington, TX. (Control ID #4272991) CASE: A 61-year-old African American man with a past medical history of uncontrolled hypertension, type 2 diabetes mellitus, morbid obesity, transient ischemic attack, acute ischemic stroke (cryptogenic) without residual deficits, hypothyroidism and generalized anxiety disorder, was brought to the emergency department (ED) by wife with complaints of confusion, slurred speech, and a fall. Upon arrival at the ED, his symptoms resolved, and his vitals were stable with an NIH score of 0. Basic lab workup was unremarkable. EKG showled normal sinus rthythm. CT head revealed chronic stable infarcts in the left parietal and occipital lobes, along with new findings of age-indeterminate ischemic changes in the posterior right frontal lobe and left frontal corona radiata white matter. CTA Head/Neck ruled out large vessel occlusion, aneurysmal dilatation, and acute dissection raising suspicion of multifocal ischemic stroke of cardioembolic origin. TTE (transthoracic echocardiogram) with bubble study showed normal EF and a mobile echogenic structure in the left atrium. Later TEE (transesophageal echocardiogram), showed a large (3cmx1cm) left atrial mass, suggesting thrombus vs cardiac tumor. Subsequently, therapeutic anticoagulation was initiated with heparin. CT chest, abdomen and pelvis done during a prior admission demonstrated multiple bilateral wedge shaped hypoattenuation and small bowel wall thickening suggestive of infection vs ischemia. These findings heightened concerns for multiple embolization episodes from the left atrial mass. Cardiothoracic surgery was consulted and they excised the left atrial mass. Histopathology confirmed it as an atrial myxoma. Postoperatively, the patient was managed with Eliquis and aspirin. He remained stable at discharge; no new symptoms/signs were noted on the 3-month follow-up visit. IMPACT/DISCUSSION: 75% of Myxomas originate in the left atrium in association with the interatrial septum. A higher incidence of embolization is associated with smaller size (<4.5cm) and soft gelatinous tumors. Although both TTE and TEE are sensitive in detecting myxomas, poor acoustic windows on TTE secondary to obesity, lung disease, etc., might limit its diagnostic value. Surgical resection of the tumor is the mainstay of treatment as it prevents further thromboembolic events. Post excision mortality rates and chances of recurrence are low.

Although cardiac myxomas are rare, they should be considered in individuals presenting with multiple embolic events and investigated further. Diagnosing myxomas can be challenging due to their variable presentations and the technical challenges of visualizing the tumor on echocardiography. TEE is the gold standard as it provides more accurate anatomical details such as the site of attachment of the tumor, extension, and hemodynamic effects. BUMPS IN THE ROAD: A CASE OF CUTANEOUS T-CELL LYMPHOMA Ana L. Bermudez, Alfred Rabinovich. Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #4224828) CASE: A 66-year-old Hispanic female with a medical history of low-grade lymphoma diagnosed in 2016 with transformation to diffuse large B-cell lymphoma (tDLBCL) in 2017, now in remission status post R-CHOP and Rituximab, presented to an outpatient Internal Medicine clinic for one month of recurrent right forehead bumps. The bumps were initially present two months prior to presentation but resolved on their own. Initial concern was for cystic acne and so a combination of Doxycline 100mg twice for 14 days, plus twice a day benzoyl-peroxide was prescribed. Patient returned to clinic 11 days later with growth of forehead lesions and was referred to Dermatology. Patient underwent skin biopsy that revealed Alk-negative CD30+ T-cell lymphoproliferative disorder and patient was diagnosed with primary cutaneous anaplastic large cell lymphoma. PET scan at the time was negative for systemic lymphoma. Patient began radiation treatment. IMPACT/DISCUSSION: ALK-negative primary cutaneous anaplastic large cell lymphoma (ALK-negative PTCL) is a rare type of non-Hodgkin lymphoma that is more common in men than women with an average age at presentation of 60 years old. Risk factors for development of ALK-negative PTCL include HIV infection, post-transplant immunosuppression, and chronic lymphedema. It most often presents with a localized reddish-brown nodule or papule, either isolated or in cluster. Disseminated lesions are rare but do occur in approximately 20% of patients. Treatment for the condition often includes surgery and/or radiation. The disease has a risk of reoccurring within 5 years of treatment, at which point systemic therapy like chemotherapy or methotrexate can be used. ALK-negative PTCL has a 10-year survival of 90%, although age over 60 years old at time of diagnosis is associated with a poorer prognosis.

The differential for ALK-negative PTCL is broad and includes benign conditions such as folliculitis and insect bites to conditions with a less favorable prognosis such as mycosis fungoides, systemic large cell lymphoma, and Hodgkin lymphoma with skin involvement. Given this broad differential, a high index of suspicion and low threshold for biopsy is necessary when evaluating rapidly progressing nodular lesions or lesions that do not resolve with standard therapy for more benign skin conditions. CASE REPORT ON PURPURA FULMINANS IN MULTI-ORGANISM SEPTIC SHOCK Branavan Ragunanthan1; basmah khalil1; Aadil Maqsood2. 1Department of Infectious Disease, University of Toledo Department of Medical Education, Toledo, OH; 2Medicine, The University of Toledo Medical Center, Toledo, OH. (Control ID #4216375) CASE: A 66-year-old male with a history of psoriasis on methotrexate and golimumab presented to the ED with a chief complaint of back pain and mechanical falls for days. VS in ED showed BP 71/34, temperature 36.6C, HR 97, RR 20, SpO2 95% on room air, and physical exam positive for multiple, slow-growing, patchy, erythematous, and violaceous lesions throughout his skin with areas of necrosis along with skin sloughing. Initial workup was notable for an unremarkable full-body CT scan, AKI with creatinine of 6.39mg/dL, WBC of 0.27 x 103/μL, Hemoglobin of 6.6g/dL, Platelet count of 19 x 103/μL, Lactate of 5.0 mmol/L, arterial pH of 7.16. The patient was admitted to the MICU for pressor support, renal replacement therapy, and mechanical ventilator needs; initial treatment entailed IV vancomycin, IV piperacillin/tazobactam, and fluid resuscitation. On infectious disease consultation, complement levels, aspergillus galactomannan antigens, 1-3 beta-D glucan levels, fungal antigens, and hepatology labs were obtained and were all unremarkable. Blood culture yielded Staphylococcus Aureus, Klebsiella Pneumoniae, Streptococcus Agalactiae. A TTE completed was unremarkable for acute endocarditis. Given his enlarging wounds, the patient underwent a skin biopsy revealing deep necrosis, bacterial colonies, and capillary thrombi consistent with sepsis mediated cutaneous damage in the form of purpura fulminans. Unfortunately, despite maximum supportive care, the patient had worsening lactic acidosis and hypotension leading to his arrest. IMPACT/DISCUSSION: This case exemplifies the rare phenomenon of purpura fulminans, an acute purpuric rash induced by coagulation of microvasculature leading to cutaneous necrosis and hemorrhage. Of the various forms of purpura fulminans, acute infectious purpura fulminans occurs in severe sepsis usually with endotoxin producing gram-negative bacteria producing a procoagulant state through acquired deficiency of protein C and S. The pro-coagulative state leads to thromboses of cutaneous vessels and manifests initially with erythema progressing to black hemorrhagic necrosis as seen in this case. Clinically, infectious purpura fulminans is not frequently encountered, and its rarity can lead to a delay in diagnosis and treatment with broad-spectrum antibiotics and surgery, thus increasing risk of mortality. This case provides some educational impact on healthcare providers to expand their assessment of the physical exam to correlate with underlying disease processes like sepsis. To date, purpura fulminans remains a relatively under-reported disease state with most of its understanding stemming from individual cases. This case aims to expand the limited literature on a frequently underdiagnosed, and complex pathological condition.

Infectious purpura fulminans is a hematological emergency that warrants prompt diagnosis and emergent implementation of antibiotic therapy to prevent mortality. ENDOCRINE CRISIS IN CKD: A CASE OF MYXEDEMA COMA IN A HEMODIALYSIS PATIENT Anum Farid1; Ali Yusuf2; Doan Ngoc Chau Nguyen3. 1Internal Medicine, Texas Tech University System, Amarillo, TX; 2internal medicine, Texas Tech university health science center Amarillo, Amarillo, TX; 3Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX. (Control ID #4273493) CASE: A 47-year-old male with type 1 diabetes mellitus, CKD on hemodialysis, and hypertension presented to the ER sedated, intubated, and on mechanical ventilation. He was found unresponsive and sweating in a chair at home after missing three dialysis sessions due to fatigue. EMS intubated him on-site. On arrival, he was hypertensive (BP 170/100), bradycardic (HR 45), and hypothermic (33.5°C). Exam revealed sedation, generalized swelling with facial puffiness, and bilateral edema. Labs showed Hemoglobin 10.4 (MCV 93), glucose 100, sodium 134, potassium 4.9, bicarbonate 19, corrected AG 13.8, BUN 80, creatinine 13.1, AST 205, ALT 190, bilirubin 0.34, phosphorus 9.4, procalcitonin 1.9, BNP 5000, troponin 34.4, glucose 48.Cortisol level was 13 , TSH was found to be 330 μIU/mL with free T4 0.19 ng/dl.CXR showed cardiomegaly and mild interstitial pulmonary edema. ABG revealed metabolic acidosis. Nephrology was consulted, and immediate dialysis was performed. IV levothyroxine and liothyronine were initiated, leading to mental status improvement. Hemodialysis was administered for three consecutive days. After two days, intravenous thyroid medication was replaced with oral thyroid replacement, which was continued afterwards.Hemodialysis was also resumed on scheduled days. IMPACT/DISCUSSION: This case highlights myxedema coma in a patient with CKD undergoing hemodialysis. Hemodialysis was initiated one year prior following a decline in kidney function, with baseline creatinine increasing from 1.9 mg/dL (GFR 44 mL/min) to 13 mg/dL (GFR 4 mL/min) over two years, likely due to longstanding hypertension and type 1 diabetes. Six months earlier, TSH was 4.89 μIU/mL with a free T4 of 1.15 ng/dL, though T3 levels were not assessed. CKD progression likely worsened underlying subclinical hypothyroidism through mechanisms including reduced peripheral T4-to-T3 conversion, altered hypothalamic-pituitary axis due to uremia causing a delayed TSH response, and impaired renal iodine clearance. Among thyroid abnormalities in CKD, low T3 is most common, followed by subclinical hypothyroidism. Regular thyroid panel assessments in CKD patients are critical. Regular T3,T4 and TSH monitoring is essential, with a low threshold for initiating thyroid hormone replacement in subclinical hypothyroidism to prevent severe hypothyroidism and myxedema coma. Timely hormone replacement may in return slow CKD progression by improving cardiac output, reducing fluid retention, enhancing BP control, and alleviating renal strain.

This case underscores the complex interplay between CKD and thyroid dysfunction, emphasizing regular thyroid monitoring in CKD patients. Early identification and management of hypothyroidism can prevent life-threatening complications, improve cardiovascular stability, and potentially slow CKD progression. A multidisciplinary approach involving nephrology and endocrinology is essential for optimal outcomes. FROM RECURRENT UTIS TO A LIFE-ALTERING DIAGNOSIS: AN ATYPICAL PRESENTATION OF PANCREATIC CANCER Kristina Patel1; Akintunde Oyedeji2; Rubela Ray3; Quratul Ain R. Ghori4. 1Internal Medicine, China Medical University, China Medical University, Shenyang, Liaoning, CN, academic/medsch, Shenyang, Liaoning, China; 2Meharry Medical College, Nashville, TN; 3Bankura Sammilani College, Bankura, WB, India; 4Jinnah Sindh Medical University, Karachi, Sindh, Pakistan. (Control ID #4271200) CASE: A 44-year-old African American female with no significant medical history presented with recurrent urinary tract infections over several months. Her anxiety, linked to job insecurity, further complicated her clinical picture. During an initial telemedicine visit, symptoms resolved after treatment with nitrofurantoin. However, two weeks later, she developed pruritus, yellowing of the skin and urine, and worsening fatigue, which she attributed to medication side effects and stress. On examination, she appeared pale, with scleral icterus and mild jaundice. Her abdomen showed mild diffuse tenderness but no severe pain. Laboratory tests revealed elevated total bilirubin, predominantly indirect, while the complete blood count and metabolic panel were otherwise normal. Urinalysis confirmed hematuria but no signs of infection. Autoimmune markers, including ANA, anti-mitochondrial antibodies, and ANCA, were negative. An abdominal ultrasound showed no abnormalities. Despite inconclusive findings, her persistent fatigue and jaundice necessitated further workup. A contrast-enhanced abdominal CT scan revealed a mass in the head of the pancreas. Tumor markers CEA and CA-19-9 were elevated. The diagnosis of pancreatic cancer was confirmed, and the patient was referred to MD Anderson Cancer Center for further management. IMPACT/DISCUSSION: Pancreatic cancer rarely presents in younger individuals, yet African Americans face a significantly higher risk of early-onset disease and worse outcomes. This case shows the diagnostic challenge of non-specific symptoms like jaundice, fatigue, and pruritus, which were initially overshadowed by anxiety and a history of UTIs. In this case, the patient’s lack of classic risk factors, such as smoking or alcohol use, further complicated clinical suspicion. Persistent symptoms despite treatment and initial negative findings highlight the importance of systematic follow-up and imaging. A broad differential diagnosis is crucial, particularly in high-risk populations. For African American patients, who experience disparities in pancreatic cancer incidence, clinicians must remain vigilant and avoid anchoring bias.

This case highlights the importance of a systematic evaluation for persistent, vague symptoms like jaundice and fatigue. Clinicians must maintain a broad differential diagnosis, particularly for high-risk populations such as African Americans, to recognize pancreatic cancer early. Timely diagnosis remains crucial in improving outcomes for this aggressive disease. HEART FAILURE EXACERBATION PRESENTING WITH RIGHT UPPER QUADRANT PAIN Jason Shiau1; Zaven Sargsyan2. 1Internal Medicine, Baylor College of Medicine, Houston, TX; 2Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4270070) CASE: A 52-year-old man with coronary artery disease and heart failure with reduced EF presented to the emergency department with 3 days of severe right upper quadrant (RUQ) abdominal pain. The pain was associated with decreased appetite and bloating, and exacerbated by food. Vital signs were normal. He had marked tenderness to light palpation in the right upper abdomen, and ultrasound showed gall bladder wall thickening (0.55 cm) and a 0.5 cm gallstone at the gallbladder neck (Fig). His serum aminotransferases, bilirubin, and leukocyte concentrations were within normal range. He was admitted to the general surgery service with a diagnosis of cholecystitis. Given his cardiac history, the general medicine consult service was called for perioperative risk stratification and optimization. Revisiting his history revealed that he had last been well until 3 weeks ago, when he began to have lower extremity edema, orthopnea, and weight gain, acutely worsening 3 days prior. His jugular venous pressure was 16 cm water. The lungs were clear to auscultation. There was marked tenderness over the right upper quadrant of the abdomen. In addition to the laboratories mentioned above, the B-natriuretic peptide level was 2750 pg/mL (Normal <100 ug/mL). The cholecystectomy was deferred to treat the patient’s decompensated heart failure prior to surgery. The post-prandial pain continued despite the absence of fevers, leukocytosis, bilirubin, or alkaline phosphatase elevation. This discordant finding prompted a hepatobiliary iminodiacetic acid (HIDA) scan, which demonstrated a patent cystic duct, ruling out acute calculous cholecystitis. We discussed with our surgical colleagues, and surgery was cancelled, antibiotics were discontinued. IV furosemide was initiated, and the patient’s RUQ pain and tenderness improved day by day along with his orthopnea and edema. He was discharged on hospital day 7 with an optimized regimen for his heart failure. His cholelithiasis has been managed with observation. IMPACT/DISCUSSION: This case demonstrates that heart failure exacerbation may rarely present with right upper quadrant pain and gallbladder edema that mimics acute cholecystitis. In two observational studies of patients with heart failure exacerbation, 6-31% of patients had localized abdominal pain. Data are scant on right upper quadrant pain specifically in this population. In a small study from 1955, 8% of patients had “hepatic pain”, but no more recent cohort studies were found for RUQ pain. What made this diagnosis challenging was that patients with acute cholecystitis may not have fever or leukocytosis. In an observational study of 198 cases with positive HIDA and cholecystectomy in the ED, fever was present in only 32% of patients, and leukocytosis was present in 61% of cases. 31% of patients had neither fever nor leukocytosis.

Heart failure may rarely present with right upper quadrant pain Right upper quadrant ultrasound may be falsely positive for cholecystitis HELP, DOC! I CAN’T SEE STRAIGHT! Ha Mieu Ho1; Nicole Gamboa2; Bernice Ruo2; Jessica Chen2. 1Internal medicine, University of California San Diego School of Medicine, La Jolla, CA; 2Medicine, University of California San Diego, La Jolla, CA. (Control ID #4271448) CASE: A 75-year-old female with a history of hypertension, hyperlipidemia, bronchiectasis, allergic rhinitis, and ulcerative colitis presented with acute progressive diplopia over two weeks. She initially noticed double vision with episodes of dizziness and unsteadiness with head motion. She had had left eye cataract surgery two months ago. Patient denied any recent trauma, fever, chills, rash, hearing loss, facial numbness, or headaches. On physical exam, her blood pressure was 128/72, pulse 81, and BMI 17.9 kg/m2. Neurological exam showed intact cranial nerves II-XII. Sensation and deep tendon reflexes were grossly normal. She had a normal gait and negative Romberg. The rest of the physical exam was normal. Hemoglobin A1c, thyroid stimulating hormone level, and comprehensive metabolic panel were within normal limits. Head MRI and MRA, and 24-hour Holter were unremarkable. Two weeks later, a repeat exam of the right eye demonstrated absence of lateral movement, consistent with cranial nerve VI palsy. The patient showed improvement a month later, with complete resolution in two and a half months without treatment. IMPACT/DISCUSSION: Cranial nerve VI palsy is a common cause of diplopia among older patients with vasculopathic risk factors such as diabetes or hypertension. The incidence is rare in the U.S., with roughly 15,000-37,000 new cases annually, with ischemic causes being the most common. Individuals over the age of 50 are at increased risk, and the highest risk is in those aged 60-75. This palsy can be isolated or non-isolated, and binocular or monocular. Non-isolated palsies are associated with other neurologic deficits. Isolated cranial nerve VI palsy may stem from congenital, traumatic, microvascular, inflammatory, iatrogenic, malignant, or idiopathic causes. Some specific causes may include diabetes, hypertension, systemic lupus erythematosus, migraines, multiple sclerosis, myasthenia gravis, thyroid disorder, or recent procedures with potential CSF leak. Thus, it is important to conduct a thorough history and physical exam to determine best next steps. In terms of management, all patients with an isolated cranial nerve palsy should first have imaging done to rule out intracranial lesions. Depending on underlying etiology, treatments can range from prism therapy to steroids or surgery. Typically, cranial nerve VI palsy in older adults requires minimal intervention, as it is generally not a life-threatening condition. The prognosis is good with full recovery in roughly 80% of all patients affected, with 74% recovering by 24 weeks. However, it is important to exercise due diligence by considering and ruling out other underlying causes.

- Cranial nerve VI palsy typically occur in older patients with microvascular risk factors and has a good prognosis. - Thorough history, exam, and imaging are important to rule out more dangerous etiologies and ensure prompt and appropriate treatments to better patient outcomes. HIDDEN IN PLAIN SYMPTOMS: A RARE CASE OF CUTANEOUS POLYARTERITIS NODOSA Asma cheema1; Ayesha Bibi3; Talha Aslam2. 1Internal Medicine, Montefiore Wakefield Campus, New York, NY; 2SUNY Downstate Health Sciences University, New York, NY; 3Montefiore Medical Center, New York, NY. (Control ID #4272799) CASE: A 62-year-old woman presented with a non-pruritic rash on bilateral lower extremities for the past six months. On examination, she was found to have non-tender erythematous polymorphous light eruptions, slightly palpable. She had no systemic signs or symptoms. Laboratory findings were negative for hepatitis B, C and Human immunodeficiency virus (HIV). When she had no relief with triamcinolone topical ointment, prompt histopathological testing was suggested. A punch biopsy taken from the left medial proximal pretibial region revealed leukocytoclastic vasculitis in sub-cutis artery consistent with cutaneous Polyarteritis Nodosa (PAN). Treatment with prednisone was initiated with improvement in rash. IMPACT/DISCUSSION: PAN is a systemic necrotising vasculitis that typically affects medium-sized vessels but may also involve small-sized vessels. It is a systemic disease affecting renal, gastrointestinal, cardiac, and central nervous system involvement, sparing the lungs. A rare form of the disease called cutaneous PAN affects small and medium-sized vessels of the dermis and subcutaneous tissue. It may present as subcutaneous nodules, livedo reticularis, digital gangrene, or subcutaneous ulceration, with rarer presentations include petechiae, purpura, and polymorphous light eruptions. Diagnosis relies on clinical features, confirmed by skin biopsy, which typically reveals leukocytoclastic vasculitis, with or without fibrinoid necrosis, resembling systemic PAN. Corticosteroids is the main stay treatment for both cutaneous and systemic disease. Our case presented with one of the rarest manifestations of cutaneous PAN characterised by polymorphous light eruptions without clinical or laboratory findings. Polymorphous light eruptions, commonly triggered by chronic sun exposure, present with diverse morphological patterns, including papular, vesicular, or erythematous plaque-like lesions commonly associated with photosensitivity disorders. Autoimmune conditions linked to such lesions include porphyria cutanea tarda and cutaneous lupus erythematous. Like our case, such chronic atypical lesions require prompt autoimmune workup and biopsy to rule out uncommon differentials, and immediate treatment to prevent recurrence and improve patient outcomes.

This case highlights the importance of recognizing uncommon manifestations of cutaneous PAN. It highlights the crucial role of histopathological examination in cases where lab and clinical findings are insignificant. Early diagnosis and identification of cutaneous PAN followed by appropriate treatment can prevent disease complications and recurrence and therefore significantly improve patient outcomes. IS NEUROLOGICAL DEFICIT A RARE SIDE EFFECT OF SKYRIZI (RISANKIZUMAB)? Zainab Khan. Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA. (Control ID #4245491) CASE: 44-year-old female with past medical history of nicotine dependence, anxiety, psoriasis who recently started taking Skyrizi (risankizumab) presented to the ED with sudden onset of left facial numbness, facial droop, dysphagia, dysarthria, aphasia and left-sided weakness. The diagnostic workup showed sodium of 138 millimoles/liter, potassium 3.5 millimoles/liter, chloride 111 millimoles/liter, creatinine 0.78 milligram/deciliter, troponin less than 3, white cell count 10.2, hemoglobin 13.9 g/dL. HbA1c 5.8%, cholesterol total 181 mg/dL, LDL direct 132 mg/dL, HDL 31.7 mg/dL, EKG with NSR; 85 beats/minute, normal axis and intervals, low voltage QRS, no acute ischemia. CT scan of the head with no acute intracranial process. CTA head and neck showed a 5 mm aneurysm arising from the supraglenoid right internal artery but no stenosis of cerebral vasculature. Initial NIHSS was 3, and code stroke was activated. The patient received TNK with partial resolution of her symptoms. Subsequent MRI of the brain was negative for acute intracranial abnormality. She was monitored in the hospital for 48 hours but continued to have residual left sided weakness, gait ataxia and mild dysarthria. She was discharged with recommendation to start taking aspirin and atorvastatin and to follow-up with neurology as outpatient. IMPACT/DISCUSSION: Skyrizi (risankizumab) is used to treat adults with certain types of plaque psoriasis, psoriatic arthritis, ulcerative colitis or Crohn’s disease, it works by targeting a specific protein in the immune system called interleukin-23 (IL-23). I present a case of neurological deficit in a young patient with psoriatic arthritis with no comorbidities including hypertension, positive family history of stroke, arrhythmia, metabolic syndrome and hypercholesterolemia. This patient started taking Skyrizi a few days prior to onset of neurological deficit. It is hypothesized that Skyrizi increases the incidence of cerebrovascular accidents and neurological defecits. Psoriasis and psoriatic arthritis have each been associated with cardiovascular risk factors and metabolic syndrome. It is important to perform risk assessment prior to prescribing Skyrizi.

In premarketing clinical trials; Skyrizi (risankizumab) was not associated with an increased risk of cerebrovascular accident (CVA) or neurological defecit in patients with plaque psoriasis. Very negligible incidence of CVA was observed in risankizumab-treated patients during clinical trials and the FDA-approved the drug without any warnings regarding increased CVA/TIA risk(1). Skyrizi can be related to increased risk of stroke, neurological defecits/TIA so further post marketing trial is required to explore any possible association between risankizumab and neurological defecits. 1. Li W, Ghamrawi R, Haidari W, Feldman SR. Risankizumab for the Treatment of Moderate to Severe Plaque Psoriasis. Ann Pharmacother. 2020 Apr;54(4):380-387. doi: 10.1177/1060028019885836. Epub 2019 Oct 31. PMID: 31672037 NAVIGATING LIFE WITH HYPOTHYROIDISM: UNVEILING SOCIAL CHALLENGES AND SOLUTIONS Mrudula Beesetty1; Sirish R. Pandey1; Valerie Cluzet2. 1internal medicine, Nuvance Health, Lagrangeville, NY; 2Medicine/Infectious Diseases, Vassar Brothers Medical Center, Poughkeepsie, NY. (Control ID #4271788) CASE: The patient is a 70-year-old female with past medical history of Graves' disease status post thyroidectomy, currently on levothyroxine, type 2 diabetes mellitus, gastroesophageal reflux disease (GERD)with Barrett's esophagus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, history of pulmonary embolism, previous abdominal compartment syndrome complicated by ischemic bowel with multiple bowel resections, history of morbid obesity status post gastric bypass, and iron and B 12 deficiencies who presented to outpatient procedure unit for port placement for iron transfusions, but was found have very elevated TSH and was sent to the ER for further evaluation. On arrival, she was afebrile and vital signs were normal except for hypertension (150/99).Initial labs are notable for TSH 180 mUI/ml, free T4 0.11mcg/dl. She reported generalized fatigue as well as hair loss and cold intolerance for many months. Upon further history taking, she revealed that she previously took IM levothyroxine 150mcg daily. However, was unable to get it for the past few months due to insurance issues and change of proper prescription when she changed endocrinologists. Instead, she was started on oral liquid levothyroxine by her new endocrinologist, which she did not tolerate and self-discontinued. She was then lost to follow up. She had been off levothyroxine for 9 months when she presented to the hospital. On admission, she was started on IV levothyroxine 50mcg daily. Unfortunately, her insurance denied refill of IM levothyroxine as she has been off that medication for several months. Therefore, after collaborative decision-making among the endocrinologist, hospitalist, and case management, a peripherally inserted central catheter was placed, and care was established with an infusion center with plan for patient to receive IV levothyroxine 100mcg three times/week IMPACT/DISCUSSION: About 70% of oral levothyroxine (LT4) is absorbed in the duodenum, jejunum, and ileum. Surgical procedures such as jejunostomy and bowel resection can significantly impair this absorption. Additionally, restrictive surgeries that increase gastric pH may negatively affect the drug's dissolution and solubility. Highly lipophilic drugs are especially affected, as they often depend on bile acids to enhance their solubility. As a result, patients may require dose adjustments and careful monitoring of thyroid hormone levels after surgery. While some studies have indicated improvements in TSH levels with the liquid form of levothyroxine, certain patients may still rely on intravenous or intramuscular levothyroxine for effective management.

Through this case, we highlight medical, social and financial issues that patients with hypothyroidism and malabsorption may encounter, as well as strategies for addressing these challenges PROSTATE CANCER DIAGNOSED WITH A PSA LESS THAN 1 NG/DL: A CLINICAL VIGNETTE. SORA CHEE, MD, PAULINE BAGATELAS, MD, GEORGE HANNA, MD AND TONY WU, MD Tony C. Wu. Medicine, Rhode Island Hospital, Providence, RI. (Control ID #4271779) CASE: Patient is a 77 year old male with a past medical history of GIST tumor, atrial fibrillation, who initially was diagnosed with Benign Prostatic Hypertrophy in 2017 as a 70 year old male. At that time he was started on Finasteride for BPH and had improvement in symptoms of Lower Urinary Tract Symptoms. His PSA level in 2017 prior to starting Finasteride was 1.2 NG/DL. In 2018, his PSA on Finasteride was 1.2 NG/DL with stable LUTS. In 2019 his PSA level had dropped to .55 NG/DL. In 2020 pt had a digital rectal exam which revealed an abnormal R side of the prostate gland which prompted an MRI of the prostate showing a lesion in the R base of the prostate gland. The patient’s PSA in 2020 was .47 NG/DL. He underwent a prostate biopsy which revealed a Gleason Score 3+4 Prostate Cancer in 2/16 core biopsies. After a short period of Active Surveillance, in 2021 his PSA had risen to 1.4 NG/DL. He underwent a subsequent biopsy in 2021 which revealed Gleason Score 3+3 Prostate Cancer both in R side and L side of the prostate gland. He then proceeded with radiation and androgen deprivation therapy and has done well since this treatment. IMPACT/DISCUSSION: The majority of prostate cancers diagnosed in the U.S. currently revolves around our screening practices using PSA. Major medical organizations recommend shared decision making for PSA screening. Prostate cancer remains the second most common malignancy diagnosed in the United States second to nonmelanoma skin cancer. There are cases of prostate cancer with a low PSA at the time of diagnosis. A majority of these are either diagnosed incidentally through procedures, or with some symptoms such as lower urinary tract symptoms and/or an abnormal digital rectal exam. The prognosis of prostate cancer diagnosed incidentally or through other means other than PSA screening is not as well known. Studies have suggested that with prostate cancers diagnosed with a PSA less than 4, the volume of prostate cancer within the gland is still directly correlated with the PSA value. So at very low PSA levels, the prostate cancer could still represent a very low volume and thus be clinically insignificant. We now present a case of a patient who through shared decision making was getting screened for prostate CA with a yearly PSA who was discovered to have a clinically significant prostate cancer with a PSA of .47 ng/dL at the time of diagnosis.

There are a small percentage of prostate cancers that can present with relative low PSA values at the time of diagnosis. These prostate cancers are cancers that are not necessarily diagnosed through traditional screening with PSA testing but rather diagnosed with signs and symptoms related to the prostate such as lower urinary tract symptoms or through an abnormal digital rectal exam. Although prostate cancers diagnosed with a relatively low PSA level at the time of diagnosis are not common, treatment and prognosis of this subset of prostate cancers remains uncertain in the era of PSA screening. SCLEROMYXEDEMA: AN ATYPICAL PRESENTATION OF A RARE CONDITION Joseph Jones1; Yasir Ahmed1; Harleen Sidhu2; Ayyaz Shah2; Henda Bouali2; Genadij Sienkiewicz2. 1Internal Medicine, United Health Services Hospitals Inc, Binghamton, NY; 2United Health Services Hospitals Inc, Binghamton, NY. (Control ID #4273425) CASE: A 73-year-old patient with hypertension, dyslipidemia, and hyperthyroidism was evaluated for small, white skin lesions over her posterior neck for one year. The patient denied other symptoms including pruritis. Examination revealed numerous, waxy, smooth, whitish colored papules measuring 0.1-0.3 cm across the posterior neck. The patient underwent three punch biopsies of lesions across the posterior neck, with pathology results showing papular mucinosis, also known as scleromyxedema, in all specimens. Because this condition is known to have an association with paraproteinemia, hematology/oncology was taken on board. Serum protein electrophoresis (SPEP), immunofixation delta and epsilon with immunoglobulin free light chains, 24-hour urine monoclonal protein quantitation, and anti-nuclear antibody (ANA) tests all resulted within normal limits. Additionally noted, a recent thyroid stimulating hormone (TSH) level resulted at 1.37 ulu/mL (reference range 0.27-4.20 ulu/ml). Since this condition is not a skin cancer, and laboratory work up showed no paraproteinemia, further work up was deferred. In the setting of having a limited, focal patch of skin lesions, without generalized skin thickening, no monoclonal gammopathy, and no neurologic or rheumatologic symptoms, it was thought that the patient must have a limited benign form of papular mucinosis. Because systemic therapy is not indicated, and there are no known topical or local treatments with proven efficacy, observation for worsening of symptoms was recommended. IMPACT/DISCUSSION: Papular mucinosis, also known as scleromyxedema, is a rare, idiopathic disorder of cutaneous mucin deposition. Cutaneous mucinoses are divided into primary cutaneous mucinoses (examples include scleromyxedema, lichen myxedematosus, scleredema, and mucinoses associated with thyroid disease) and secondary mucinoses, which are disorders associated with histologic deposition of mucin (examples include basal cell carcinoma, lupus erythmatosus, dermatomyositis, and mycosis fungoides). It has been noted that more than 80% of patient’s present with an associated paraproteinemia. Diagnosis of the disorder requires correlation of clinical, histologic and laboratory findings. Management strategies are largely guided by case reports and cases series, owing to the rarity of the disorder. Intravenous immunoglobulin (IVIG) is widely accepted as first line therapy for cutaneous and extracutaneous manifestations. Second line therapies include corticosteroids and/or thalidomide, which may be used in addition to IVIG when no contraindications exist.

The morphology of this patient’s skin lesions and the limited distribution demonstrate an atypical presentation of an already rare condition. It is important to recognize the condition and initiate workup for related conditions. SOMETHING IN THE WAY SHE MOVES A CASE OF COGNITIVE BIASES AND THEIR IMPACT ON MEDICAL DECISION MAKING Raeven A. Chung, Anne Polick. Medicine, University of Illinois Chicago, Chicago, IL. (Control ID #4272044) CASE: A 36-year-old woman with a PMH of schizophrenia with tardive dyskinesia was admitted for a 30lb weight loss with decreased oral intake.Patient resided at a mental health facility for the past five years and history was provided by an accompanying facility member. Physical exam is notable for ataxia and irregular rapid movements of the trunk, arms and legs on ambulation, fidgeting of the hands and intermittent jerking of the arms on rest.Nutrition and heavy metal labs were ordered; more patient history was sought; and neurology and psychiatry were consulted. She’d received LAI haloperidol prior, her benztropine was continued.Prior to 2024 admission, patient was referred to neurology for evaluation of dyskinesia in 2022 and was diagnosed with EPS from antipsychotic use.Labs, LP, MRI and EEG were unremarkable. Patient was discharged with updated nutrition regimen. Genetic testing revealed one Huntington Disease allele within full penetrance range and was diagnosed with Huntington Disease.Treatment has been optimized to olanzapine daily and she was transferred to a medical facility. IMPACT/DISCUSSION: Medical professionals are trained to utilize Bayesian statistical thinking, in which information is accumulated progressively and collectively analyzed to aid in decision making (1). Although this is beneficial for determining the most appropriate diagnosis, it can allow the base-rate fallacy cognitive bias to impact medical decision making.The base-rate fallacy occurs when information that is perceived as being of higher-relevance is dominant over low-relevance information (2,3).Such as in this case, base-rate fallacy in the clinical setting presents as health professionals favoring the most likely diagnosis over considering rare diseases.An inferred family history and subsequent social history was helpful: the patient was raised by her godfather, after her father died in his 40’s of a disease that rendered him unable to walk. She was halfway through nursing school without a psychiatric history, but was involuntarily admitted in 2019 after an episode of delusion and paranoia. The delay in diagnosis persisted because premature closure bias followed by base-rate fallacy reaffirmed her diagnosis of paranoid schizophrenia complicated by extrapyramidal symptoms from antipsychotic use.As symptoms progressed, anchoring bias was used, such as clinicians relying and seeking out information that solely supports her diagnosis (4).

Despite awareness and education on cognitive bias, the emphasis on rapid patient care and techniques to simplify medical decision making, can have negative impacts in patient care.Although cognitive biases are not apparent until a medical or diagnostic error occurs, physicians can minimize their impact by remaining aware of them and continuously questioning aspects that may not perfectly fit into diagnoses.This case should be used as a justification to remain curious and open-minded when evaluating and treating patients. SPHENOID SINUS MUCOCELE WITH SKULL BASE EROSION AND OPHTHALMIC INVOLVEMENT - A DIAGNOSTIC CHALLENGE Quresh Savliwala1; Vikas Kilaru2; Adeel M. Akhtar2; Hely Patel3; Jasmine Fung1; Kamyar Chong1; Austin Cat1; Hadia Ahmad2. 1Osteopathic Medicine, Touro College of Osteopathic Medicine Harlem Campus, New York, NY; 2Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 3Pediatrics, Emory University School of Medicine, Atlanta, GA. (Control ID #4272225) CASE: 81-year-old female with history of hypertension, type 2 diabetes, and atrial fibrillation presented with one week history of left temporal and frontal headaches. Physical exam including nasal and nare examination was unremarkable. Labs showed WBC of 12.8K/uL. CT of the head revealed opacification of the left sphenoid sinus, with partial calcification of posterior sphenoid chamber wall and sellar floor. Differential diagnosis included sphenoid sinusitis, mucocele, polyp, or mass. Otolaryngology (ENT) was consulted and recommended Augmentin for 7 days for presumed acute sinusitis. Headache improved and the patient was discharged after 48 hours. Two weeks later, the patient was readmitted and reported new-onset left eye visual disturbances, including double vision and difficulty with abduction. ENT recommended CT paranasal sinus protocol and MRI of the maxillofacial area and brain with contrast. Ceftriaxone and dexamethasone were started empirically. Imaging revealed bony erosion of the sphenoid septum and skull base, non-enhancing opacification, and no encephalocele. Erosion of the pituitary face and involvement of the clivus was noted, without involvement of the cavernous sinus. Neurology was consulted due to concern for a mass with invasion of the cavernous sinus. ENT elected to perform left sphenoidotomy with tissue removal, left maxillary antrostomy, and left ethmoidectomy. Headaches resolved with improved abduction of the left eye and the patient was discharged. IMPACT/DISCUSSION: Sphenoid sinus mucocele represents a rarer etiology of generalized symptoms of headaches and visual disturbances often mistakenly attributed to many causes, including sinusitis. This case highlights the challenge of diagnosing a mucocele due to its insidious onset and non-specific symptoms. Initial antibiotic treatment was appropriate based on CT findings and presentation, but worsening neurological symptoms should prompt urgent re-evaluation. Detailed imaging was crucial for final diagnosis and differentiating sinusitis from a mucocele. Imaging showed bony erosion and calcification consistent with a mucocele, while sinusitis shows soft tissue opacification. Timely diagnosis was essential to prevent further bony invasion or any potential metastasis. This case highlights the importance of thorough imaging for early intervention before symptoms worsen or mass effect, such as involvement of other sinuses, occurs. It is also a reminder of common neurological deficits and the need of thorough neurological examination for patients with an intracranial lesion within the differential.

Sphenoid sinus mucoceles are typically asymptomatic, but internists should be aware of the possibility when patients present with consistent localized headaches and visual disturbances alongside symptoms similar to sinusitis. Consultation with ENT and neurology are important when symptoms are not improving, especially in the case of mass which could be threatening critical structures such as the abducens nerve. TEMPOROMANDIBULAR JOINT DYSFUNCTION IN EARLY-ONSET RHEUMATOID ARTHRITIS: A CASE FOR ROUTINE SCREENING Caroline H. Lee, Christina Hermann, Hannah Salvucci. College of Medicine, Penn State College of Medicine, Hershey, PA. (Control ID #4267849) CASE: A 31-year-old African American woman presented to clinic with preauricular jaw pain. She endorsed chronic symmetric polyarthralgia and deformity of metacarpophalangeal (MCP), proximal interphalangeal (PIP), and knee joints since childhood. Insurance and access issues acted as barriers to medical care and prior diagnosis. Review of systems revealed fatigue, prolonged morning stiffness, shortness of breath, and chest pain. Physical exam showed bilateral ulnar deviation of the 2-5th MCP joints with mild swelling without tenderness, hyperextension of both thumbs, and tenderness of the left knee. Additionally, bilateral temporomandibular joint (TMJ) crepitus, stiffness, trismus, and tenderness to palpation was present. Labs showed positive rheumatoid factor (RF), positive antinuclear antibody with 1:2560 homogeneous pattern, positive anti cyclic citrullinated peptide (anti-CCP, 123.6 unit/mL), elevated C reactive protein (CRP, 2.69 mg/dL) and elevated erythrocyte sedimentation rate (ESR, 41 mm/hr). Right hand X-ray showed soft tissue swelling of the 2-4th PIP and MCP joints, loss of joint space, and subluxation without bony productive changes. Left hand showed similar findings most prominent at index PIP and MCP joints with swan neck deformity. She was diagnosed with rheumatoid arthritis (RA) with concomitant TMJ disorder. Patient started Hydroxychloroquine 200 mg oral daily, along with behavior modification, occlusal splints, and passive stretching exercises. Although she endorsed improvement of polyarthralgia, she still suffers from TMJ deformity as result of late diagnosis. IMPACT/DISCUSSION: The exact etiology and pathophysiology of RA is unknown. Certain genetic and environmental factors, such as anti-citrullinated antibodies and cigarette smoking, interact to trigger autoimmunity, which initiates and amplifies the inflammatory arthritis. Activated synovial innate immunity increases vascular permeability, increasing access of immune complexes to joint spaces, stimulating inflammation to cause symmetrical arthritis. Certain clinical features suggestive of RA include fatigue, morning stiffness greater than one hour, and painful symmetric swelling of primarily small joints such as MCP, metatarsophalangeal, and PIP joints with potential large joint involvement. Key lab findings include elevated ESR, CRP, and positive RF and anti-CCP. Chronic inflammatory arthritis causes cartilage and bone erosion leading to joint deformities. Undiagnosed and untreated RA can lead to loss of function and long-term disability.

Disease progression to involve the TMJ occurs in 50% of RA patients; risk increases with childhood onset. Diagnosis of TMJ involvement is challenging due to atypical presentation without classic inflammatory signs. Given these risks, it is crucial to consider TMJ involvement in RA patients to ensure early diagnosis and prevent progression to substantial joint dysfunction. This case highlights the need for TMJ assessment in the standard rheumatology exam. THE CURE OR THE CAUSE: EVALUATING CK ELEVATION IN A PATIENT ON BOTH STATIN AND CHECKPOINT INHIBITORS Madellena A. Conte1; Juan N. Lessing2; Joann Zell1. 1Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; 2Internal Medicine/Hospital Medicine Group, University of Colorado, Denver, CO. (Control ID #4272550) CASE: A 76-year-old woman presented with two weeks of progressive myalgias. She described aching in the hip girdle, shoulders and thighs impeding her ability to rise from a seat. Her medical history includes chronic hepatitis B (HBV) infection, T2DM, HLD treated with atorvastatin, and hepatocellular carcinoma (HCC), diagnosed 10 years ago, secondary to HBV. Due to progressive disease, her HCC treatment included dual checkpoint inhibitor therapy (anti-CTLA4 and anti-PD1), 2 years ago and discontinued 2 months prior. She had experienced several complications, most recently immune-checkpoint associated hepatitis 2 months prior. She was raised in Korea and lives with her daughter in Colorado. No drug use or supplements. Vital signs were within normal limits. She was lying in bed, in no acute distress. Pulmonary, cardiovascular, and abdominal exams were unremarkable. Musculoskeletal exam notable for symmetric muscle bulk, diminished strength in bilateral hip flexors and bilateral deltoids (4/5 bilaterally). No synovitis or rashes. A CBC and BMP were normal. AST 1,500, ALT 523, AlkPhos 614, Tbili 2.8 (direct 1.1), Albumin 3.9, INR 0.9, CK 29,000. ESR 57, CRP 9.1, INR: 0.9, Aldolase 56. Infectious work-up was negative. CTAP showed patient vasculature and no new hepatic lesions. AFP was normal. Patient was started on solumedrol. MRI without contrast showed diffuse intramuscular edema in the hamstring, representing multifocal myositis. Liver biopsy showed minimal inflammation without fibrosis. CK downtrended but plateaued at 24,000. Patient was given 1g IV solumedrol for three days, followed by improvement in the CK and her symptoms. On follow-up, she reported feeling at her baseline and CK was 32. Myositis antibody panel (including HMG-COA reductase) resulted negative. The diagnosis in this case was immunotherapy inducing an inflammatory myositis. Statin-induced elevated CK was made less likely with a negative HMG-COA reductase antibody. The elevated AST and ALT could have been a result of persistent hepatitis or secondary to myositis. IMPACT/DISCUSSION: This case highlights the complexity of evaluating elevated CK in a patient with multiple risk factors for myositis. Immune checkpoint inhibitors activate the immune system to treat cancer but can also attack on the body’s own cells, leading to autoimmune phenomenon. The highest risk for immune-related adverse effects (IRAE) is within 3 months of starting but IRAEs can happen at any time, even after treatment is completed. Treatment with two checkpoint inhibitors increases the risk for development of IRAE. Because statin-induced elevated CK can be associated with antibodies to HMG-COA reductase, persistent myositis can also continue even after the drug is stopped.

Checkpoint inhibitors, which activate the immune system to target malignancy, can lead to autoimmune syndromes. The highest risk for IRAE is within 3 months of starting immunotherapy but there are also delayed IRAE that develop after completion of treatment. THE FUNGUS THAT NEVER GAVE UP: A CASE OF CAVITARY ASPERGILLOMA NECESSITATING LOBECTOMY Payal Shukla1; Rakeshkumar Subramanian2. 1Internal Medicine, Parkview Health, Fort Wayne, IN; 2Pulmonary Critical Care Medicine, Parkview Health, Fort Wayne, IN. (Control ID #4257261) CASE: Introduction: Aspergilloma, a form of chronic pulmonary aspergillosis (CPA), often develops in cavitary lung disease patients, such as those with tuberculosis or COPD. Management of hemoptysis in aspergilloma cases typically involves BAE as a first-line intervention, with surgery as a secondary option. Case Presentation: A 65-year-old male with COPD and a history of smoking presented with recurrent, severe hemoptysis. Chest CT identified a cavitary lesion with a fungal ball (figure 1), confirmed as Aspergillus fumigatus via bronchoalveolar lavage. Despite antifungal therapy and tranexamic acid, the hemoptysis persisted. BAE was attempted but was unsuccessful due to small vessel size. The patient subsequently underwent a left upper lobectomy, experiencing postoperative complications including mucus plugging and septic shock, requiring ICU management. He was stabilized and discharged on antifungal therapy. IMPACT/DISCUSSION: Discussion: Hemoptysis in aspergilloma poses management challenges, with BAE and surgery offering varying success and risk profiles. Initial Management of Hemoptysis: For mild to moderate hemoptysis, antifungal therapy (e.g., voriconazole, posaconazole) and agents like tranexamic acid are used. However, in severe cases, BAE or surgery becomes necessary. Bronchial Artery Embolization (BAE): BAE achieves initial control in 70-90% of cases but has a recurrence rate of 15-45% within a year. Complications, including non-target embolization and spinal cord ischemia, occur in 5-10% of cases (3, 4). BAE’s efficacy can be limited by vascular anatomy, as seen in our patient. Surgical Resection: Reserved for refractory cases, surgical resection has a mortality rate of 5-10% and morbidity of up to 40% in high-risk patients (5). While it provides definitive bleeding control, it carries significant risks, including respiratory failure and infection, necessitating vigilant postoperative care.

Conclusion: BAE remains an effective first-line treatment for aspergilloma-associated hemoptysis, though anatomical challenges and recurrence can limit its long-term efficacy. Surgical resection is definitive but carries a higher risk profile, requiring a tailored approach to optimize outcomes. UNEXPECTED DISCOVERY OF CORONARY ARTERY DISSECTION ON CT ANGIOGRAPHY Keerthi Cedeno1; Sai A. Vanka1; Magued Haroun2; 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 #4272392) CASE: A 42-year-old man with history of COVID-associated pulmonary embolism (PE), presented with right-sided extremity tingling and numbness. His symptoms resolved by time of arrival to the unit and were attributed to transient ischemic attack following negative brain imaging. He did not complain of chest pain or retrosternal discomfort. Electrocardiogram (EKG) at admission was significant for pathological Q waves with T wave inversions in leads II, III and avF, unchanged from prior when he was diagnosed with COVID-associated PE. At that time, he had pleuritic chest pain that was attributed to PE; Transthoracic Eechocardiogram (TTE) was grossly normal. No further ischemic workup was pursued at the time. This admission, repeat TTE revealed inferior wall akinesis. CCTA subsequently revealed arterial dissection causing 50-60% stenosis of RCA with calcium score 0. Cardiology recommended outpatient follow up for further intervention. IMPACT/DISCUSSION: SCAD is separation of coronary arterial wall that presents as acute coronary syndrome or cardiac arrest, most commonly in young women, without atherosclerotic risk factors. When present in men, SCAD is more often due to atherosclerosis. Men have significantly more Circumflex artery than RCA (11%) dissections compared to women. Patients with SCAD usually have predisposing factors such as fibromuscular dysplasia or connective tissue disorders. Chest pain is the most common symptom of SCAD. A patient presenting without chest pain is very rare, often delaying the diagnosis and treatment, in which case ischemic EKG changes are key in triggering further work up. Invasive coronary angiography (ICA) is the gold standard for diagnosis of SCAD but poses the risk of propagating the dissection flap. Also, ICA often requires adjuvant tests such as Intravascular Ultrasound or Optical Coherence Tomography to verify diagnosis in complicated cases, which further increases the risk of dissection propagation. CCTA is an emerging diagnostic modality that has the advantage of being non-invasive and can quickly create a 3D reconstruction model. CCTA could be highly valuable in establishing diagnosis in stable SCAD cases with high pre-test probability and as a long-term surveillance tool to monitor for resolution of dissection. Nevertheless, the disadvantage of CCTA is that it can miss SCAD in small coronary vessels due to its low spatial resolution

SCAD rarely presents in men, especially involving RCA and even more rarely presents without symptoms. Physicians need to be vigilant when EKG findings suggest ischemic changes triggering further ischemic work up, especially in a rare presentation such as this case, and to utilize CCTA as a non-invasive diagnostic and follow up tool in stable SCAD cases. UNEXPECTED PNEUMONIA FROM ANTIBIOTIC USE: A CASE OF RECOVERY AFTER CESSATION Bushra Ghafoor1; Hassan Min Allah3; Nabil Mesiha2. 1internal medicine, Capital Health Regional Medical Center, Trenton, NJ; 2Capital Health, Trenton, NJ; 3Multan Medical & Dental College, New Multan, Pakistan. (Control ID #4232283) CASE: A 74-year-old male with history of dementia, osteomyelitis of the great toe and MRSA bacteremia refused amputation, so intravenous daptomycin was initiated. He was discharged but readmitted three weeks later with worsening mental status, hypoxia, fever, and respiratory distress. Physical examination revealed tachypnea and bilateral coarse crackles. Oxygen saturation was 84% on room air, requiring BiPAP support. Laboratory findings included leukocytosis without bandemia, normal procalcitonin, and mildly elevated eosinophils (7%). Creatinine kinase (CK) levels were normal. Chest CT revealed new bilateral infiltrates in the antero-apical segments of the upper and middle lobes, which were absent three weeks earlier. The location of these infiltrates were atypical for aspiration which raised suspicion for daptomycin-induced eosinophilic pneumonia. Daptomycin was immediately discontinued, and high-dose corticosteroids initiated. Over the next 24 hours, his respiratory status rapidly improved. He was weaned off BiPAP and repeat chest imaging showed marked resolution of infiltrates. The patient’s mental status also improved, aligning with his respiratory recovery. The rapid clinical response confirmed the diagnosis of DIEP. He was discharged seven days later with instructions for close follow-up. IMPACT/DISCUSSION: DIEP is a rare but critical condition to consider in patients developing respiratory symptoms while on therapy. Daptomycin’s poor penetration into lung parenchyma complicates its use in treating pneumonia, yet it can paradoxically trigger lung inflammation through eosinophilic infiltration. A systematic review found that daptomycin was the leading cause of DIEP, accounting for over half of reported cases. Onset of symptoms typically occurred between 2 to 4 weeks after initiating treatment. Another review of 35 confirmed cases revealed that most patients were male (83%) and elderly, with an average age of 65.4 years. These findings emphasize the importance of early detection in at-risk populations. While weekly monitoring of creatine kinase (CK) levels is widely recommended to mitigate the risk of rhabdomyolysis, routine screening for DIEP is not consistently practiced. Given the possibility of identifying early indicators, such as eosinophilia in the blood, implementing a similar strategy—weekly complete blood counts (CBC) with eosinophil counts—may facilitate the early identification of eosinophilic pneumonia.

Given the challenges in diagnosing DIEP and the typical onset within 2-4 weeks of initiating treatment, close monitoring for respiratory symptoms and eosinophilia could enhance early detection in at-risk patients. Routine weekly CBC and eosinophil counts may be beneficial in identifying early signs of DIEP. This approach could prevent progression to severe respiratory failure, ultimately improving patient outcomes in those undergoing daptomycin therapy. UNEXPLAINED FEVER IN AN ELDERLY FEMALE Somal Khan, Allison Kanakis. Internal Medicine, Lahey Hospital & Medical Center, Burlington, MA. (Control ID #4272380) CASE: An 81-year-old female with a medical history of hypertension, dyslipidemia, obesity (BMI 58.82), type 2 diabetes mellitus, chronic kidney disease stage 3a, chronic lymphedema, gout, and a chronic indwelling Foley catheter for neurogenic bladder (last changed 6 days ago before admission) presented with weakness and presyncope. Evaluation revealed an acute exacerbation of diastolic heart failure (LVEF 55-60% in 2022), complicated by a fever of 103.6°F. Despite an extensive infectious workup yielding negative results, imaging identified an acute pulmonary embolism (PE) involving several segmental and subsegmental branches on the right side. IMPACT/DISCUSSION: The patient exhibited vasovagal presyncope, weakness, and exacerbation of chronic dyspnea. She developed a high-grade fever (Tmax 103.6°F) on the evening of her emergency department presentation, lasting 4-5 hours. No tachycardia and hypoxia was noted, PE was low in the differential. Notably, there were no signs or symptoms indicative of infection: no cough, sputum production, gastrointestinal disturbances, mental status changes, or new skin lesions, making infectious etiologies less likely. Remarkably, the patient defervesced almost immediately once therapeutic anticoagulation with heparin was achieved. This case underscores that high-grade fever, though uncommon, can be associated with acute PE. Fever has been reported in up to 14% of PE cases, typically low-grade, but high fevers can occur. As per our literature search, there was no case reports of pulmonary embolism without coexisitng infeciton. Pathophysiology may involve inflammatory responses to pulmonary tissue injury or infarction.

Clinicians should maintain a high index of suspicion for PE in patients presenting with unexplained fever, especially when initial infectious evaluations are unremarkable, to ensure timely diagnosis and management. UNMASKING A RARE CASE OF EPSTEIN-BARR VIRUS-ASSOCIATED GASTRIC CARCINOMA WITH LYMPHOID STROMA Mujtaba Moazzam, Usman Bin Hameed, Ramona Berghea. Internal Medicine, Corewell Health, Royal Oak, MI. (Control ID #4273359) CASE: A 58-year-old woman presented with upper abdominal discomfort during a routine evaluation. Elevated liver function tests led to imaging studies. An abdominal ultrasound revealed a hypoechoic lesion in the left hepatic lobe near the stomach, raising concerns for an abnormal lymph node or a neoplasm. A CT scan identified a 5.4 cm exophytic gastric mass abutting the posterior hepatic lobe. Esophagogastroduodenoscopy (EGD) confirmed a malignant ulcerated gastric mass 3.5 cm x 3 cm, and biopsy revealed Epstein-Barr Virus (EBV)-associated gastric carcinoma with lymphoid stroma. Adjacent biopsies showed Helicobacter pylori-associated chronic active gastritis. The patient initiated H. pylori eradication therapy and awaits PET imaging, molecular studies, and oncology consultation for staging and treatment planning. IMPACT/DISCUSSION: Gastric cancer with lymphoid stroma (GCLS) is a rare subtype of gastric carcinoma classified under EBV-associated gastric cancers, comprising 1%–7% of all gastric carcinomas. Characterized by dense lymphocytic infiltration and a distinct immunological profile, GCLS often presents with nonspecific symptoms, requiring pathological examination for definitive diagnosis. The patient’s presentation of nonspecific upper abdominal discomfort highlights the need for thorough evaluation of routine symptoms. Diagnostic assessment confirmed EBV-GCLS, complicated by H. pylori infection. While Helicobacter pylori is less commonly associated with EBV-GCLS, it is present in 10%–20% of cases and contributes to tumorigenesis through chronic inflammation, immune disruption, epigenetic changes, and tumor microenvironment remodeling. Early Helicobacter pylori eradication therapy is crucial to mitigate oncogenic risks. GCLS is associated with a better prognosis compared to non-lymphoid gastric adenocarcinomas due to its robust anti-tumor immune response and reduced metastatic potential. In this case, preliminary imaging revealed no evidence of metastasis, consistent with favorable outcomes observed in GCLS. Biomarker testing, including HER2 status, microsatellite instability, and programmed cell death-ligand 1 (PD-L1) expression, is essential for guiding personalized treatment. Further molecular testing and a whole-body PET scan are planned for this patient to refine therapeutic decisions. Management of GCLS lacks consensus due to its rarity. Surgical options range from endoscopic mucosal dissection to subtotal gastrectomy. Emerging evidence suggests that these tumors exhibit a high expression of PD-L1 and other immune markers, making them prime candidates for immunotherapy but established guidelines are lacking.

The case emphasizes that routine symptoms can unveil rare and complex pathologies, such as GCLS. It highlights the critical role of early recognition, comprehensive diagnostics, and coordinated multidisciplinary care in achieving personalized treatment and better outcomes. The rarity of GCLS underscores the necessity of developing consensus-based guidelines. UNMASKING HEREDITARY ATTR AMYLOIDOSIS: A TUMOR IMPOSTOR MIMICKING GASTROINTESTINAL AND LIVER MASSES Anaiya Singh1; Shiva Jashwanth Gaddam2; Aditya Vyas3; Poornima Ramadas2. 1Internal Medicine, LSU Health Shreveport, Shreveport, LA; 2Department of Hematology/Oncology, Feist-Weiller Cancer Center, Shreveport, LA; 3Department of Gastroenterology, LSU Health Shreveport, Shreveport, LA. (Control ID #4272604) CASE: An 88-year-old woman with a history of vaginal squamous cell carcinoma (SCC) in remission presented with abdominal pain and rectal bleeding. A CT scan revealed a 6.1 cm mass in the ascending colon, lymphadenopathy, and hepatic lesions suspicious for malignancy. Colonoscopy showed a large, ulcerative colonic mass, but pathology revealed a tubular adenoma without high-grade dysplasia. Surgical resection of the colon and liver lesions showed amyloid deposition (vascular and interstitial) and confirmed transthyretin (ATTR) amyloidosis via mass spectrometry. Genetic testing identified the pathogenic TTR variant Val122Ile, linked to hereditary ATTR amyloidosis. Despite systemic potential, echocardiogram showed no cardiac involvement, and sural nerve biopsy revealed mild axonal neuropathy without amyloid. The patient experienced recurrent episodes of gastrointestinal (GI) bleeding managed with endoscopy, which revealed gastric ulcers, a duodenal bulb lesion, with pathology confirming amyloid deposits. IMPACT/DISCUSSION: Gastrointestinal (GI) manifestations are more common in systemic forms of amyloidosis and require biopsy-confirmed diagnosis. Among subtypes, GI involvement is most prevalent in immunoglobulin light chain (AL) amyloidosis, followed by transthyretin (ATTR) and serum amyloid A (AA) subtypes. Symptoms typically include weight loss, diarrhea, abdominal pain, and malabsorption. GI bleeding and isolated GI involvement is rare and often coexists with cardiac or nervous system manifestations. Our case is unique as this patient presented with recurrent gastrointestinal bleeding and was found to have a mass in the colon, initially suspected to be malignant given her past medical history of vaginal cancer. When amyloid deposits accumulate in organs such as the liver, gastrointestinal tract, or lymph nodes, their appearance on imaging can raise a strong suspicion of malignancy or metastatic disease. In our case, imaging revealed a mass in the colon causing recurrent gastrointestinal bleeding with multiple involved lymph nodes and bilobar hepatic lesions. Bleeding in amyloidosis is attributed to ischemia, infarction, and mucosal injury leading to erosions, hematomas, or ulcerations. Submucosal hematomas, seen along the GI tract, can rupture and cause severe bleeding, often necessitating surgical intervention or arterial embolization when endoscopic methods fail.

This case showcases the unique presentation of isolated gastrointestinal and hepatic amyloid deposits in the absence of more typical systemic involvement commonly associated with ATTR amyloidosis, such as cardiac or peripheral nerve involvement. Such a presentation is exceedingly rare, as ATTR amyloidosis typically manifests with multi-organ involvement. This case not only highlights the diagnostic challenge in differentiating isolated organ amyloid deposits from malignancy, but it also adds to the limited literature on isolated gastrointestinal and hepatic amyloid infiltration without any other systemic features. UNRECOGNIZED IGG4-RELATED DISEASE: EXPLORING A CASE OF PREOPERATIVE OVERSIGHT PRIOR TO A HEPATECTOMY Anam Adil1; Ummesalmah Abdulbaseer2; Wanna Zhang2; Jeehyun Lee2. 1Internal Medicine, Rush University Rush Medical College, Chicago, IL; 2Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4245847) CASE: A 74-year-old woman presented to her PCP with jaundice, right upper quadrant pain, and 40-pound weight loss. Labs showed bilirubin 7.5, ALP 952, AST 200, ALT 188. CA-19-9 was elevated to 190; AFP and CEA were normal. CT AP revealed irregular mass-like gallbladder with wall thickening and intrahepatic dilation, lymphadenopathy, and a lung nodule, suggesting metastatic gallbladder or biliary malignancy. She was admitted when she developed acute pancreatitis and acute renal failure thought to be tumor lysis syndrome. She was treated with aggressive hydration and allopurinol with improvement in renal function. Additional lab workup showed abnormal immunoglobulins with elevated kappa/lambda ratios IgG 1727 and IgM 389. She underwent planned Whipple Procedure with a right hepatectomy for presumed cholangiocarcinoma. Her post-operative course was complicated by new atrial fibrillation, deep vein thrombosis, ileus, biliary leak, and pleural effusions. Pathology unexpectedly revealed a non-malignant condition, IgG4 associated cholangitis (IAC). She was referred to Rheumatology after discharge and started on prednisone and rituximab for IgG4 disease. IMPACT/DISCUSSION: Malignancy was appropriately suspected based on the patient’s presentation. Over 80% of proximal biliary obstructions are due to hilar cholangiocarcinoma (HCCA). Diagnostic criteria include appropriate clinical presentation and imaging findings. While CA 19-9 is often elevated in HCCA, it has a 63% specificity and thus should only be used for additional confirmation. Given this presumed likelihood of malignancy, surgical intervention was rightfully pursued. However, pathology showed IAC, suggesting misdiagnosis. IAC often presents with obstructive jaundice and can mimic cholangiocarcinoma in both symptoms and imaging. IAC is associated with autoimmune pancreatitis, elevated IgG4 levels, and IgG4-positive cells in bile duct biopsy specimens. This patient had elevated serum IgG levels which were not appropriately evaluated with subsequent IgG subclass testing. If it had been considered, Hematology evaluation and the HISORt (Histopathology, Imaging, Serology, Other Organ Involvement, Response to Steroid Therapy) criteria could have led to a more targeted preoperative diagnostic evaluation. In these circumstances, an endoscopic ultrasound (EUS) with fine needle aspiration (FNA) or CT-guided biopsy may have been pursued to solidify the diagnosis. Furthermore, a trial of steroids could have been used to form a definite IAC diagnosis. This would have prevented unnecessary surgery and complications.

IgG4-associated cholangitis can masquerade as hilar cholangiocarcinoma. Further hematologic workup to assess for IAC here could have prevented unnecessary surgery and complications, thus suggesting need for more thorough preoperative evaluation in gallbladder malignancies. Clinical Vignette - Medical Ethics and Humanities BREAKING BOUNDARIES: A JEHOVAH'S WITNESS PATIENT'S CHOICE TO ACCEPT BLOOD TRANSFUSION Farooq Chaudhary1; Mostafa Elbanna1; Asma Tameez Ud Din2; Fady Makdisy1; NAGARAMAKRISHNA Tangirala1. 1Internal Medicine, Unity Hospital, Rochester, NY; 2St Guys & Thomas NHS Foundation Trust, London, United Kingdom. (Control ID #4270367) CASE: A 57-year-old Polish lady with no significant past medical history was referred from her primary care doctor to the ED due to low hemoglobin. Patient reported ongoing fatigue and dyspnea on exertion for last 2 months. She also reported occasional tarry black stools and 20 pounds weight loss in the last 6 months. Patient was not taking any routine medications and declined any NSAID usage. Patient had never had a screening colonoscopy. No smoking, alcohol or drug history. No family history of cancer or colonic issues. In the ED vital signs were stable and physical examination was significant for a palpable hard mass in the left side of abdomen. Further evaluation revealed a hemoglobin to be 5.7 g/dL (normal 11.5-16 g/dL), iron profile showing iron 7ug/dL (normal 50-170 ug/dL) and ferritin 4 ng/ml (normal 30-291ng/ml). CT scan showed infiltrative mass in the distal transverse colon with no evidence of metastatic disease. Patient confirmed that she is a Jehovah's Witness and declined packed cell transfusion. Patient started on IV iron daily and weekly epoetin alpha to build up her hemoglobin after discussion with hematology. Patient underwent a colonoscopy which revealed a circumferential ulcerated friable mass at the transverse colon which biopsy confirmed as adenocarcinoma. Colorectal surgery recommended open partial colectomy, however explained it was a high risk surgery due to its size and proximity to her spleen and recommended that her hemoglobin should be at least 10 g/dL prior to proceeding with the operation. Even though initially the patient had declined transfusion, however after having discussion with immediate family members/children, patient expressed her wish if she could have transfusion from her immediate family members. Red Cross was contacted to facilitate in this regards. Patient ultimately underwent transverse colectomy with partial omentectomy and received 2 packed RBCs that were donated from her family members. Post-surgery she had an uneventful recovery and was referred to Oncology after discharge. IMPACT/DISCUSSION: Jehovah's Witnesses are a religious group known for their unique beliefs and practices. They decline blood transfusions and opt for alternative medical treatments that do not involve blood products, even in life-threatening situations. We present here a case of a devout Jehovah's Witness who initially refused transfusion, however later on requested transfusion from close family members due to her critical condition.

This case emphasizes the significance of discussing sensitive matters like blood transfusions when the patients are alone so that they may feel more comfortable expressing their preferences/beliefs which can have a profound impact on the course of the medical treatment. Open and empathetic communication between doctors and patients during crucial moments is important to ensure that medical decisions align with the patient's values. DENIAL AND DECISION-MAKING: THE INTERSECTION OF PSYCHOSIS AND ONCOLOGY ETHICS Jigyasa Sharma1; Adam Richter1; Thomas J. Howe1; Lindsay R. Semler1,2; Harli Weber1; William Feldman1,2; Herrick Fisher1. 1Department of Medicine, Brigham and Women's Hospital, Boston, MA; 2Ethics Service, Brigham and Women's Hospital, Boston, MA. (Control ID #4271529) CASE: A 66-year-old woman with schizophrenia and dysphagia due to a mediastinal mass was found praying by a cemetery coatless in the cold. On hospital arrival by EMS, she was found to have psychosis, cachexia, and severe hypokalemia. She was deemed to lack capacity due to psychiatric illness and placed on a psychiatric hold. Administering antipsychotics required potassium repletion to avoid further QT prolongation but the patient refused, claiming potassium was poison. She also denied the presence of her mediastinal mass diagnosed six months ago. Per her long-term psychiatrist, the patient was in denial even when stable on antipsychotics and adherent to routine care two months prior. A multidisciplinary team including the ethics service met to consider pursuing court-appointed guardianship for hypokalemia and psychosis treatment, diagnostic imaging, and biopsy for this non-assenting patient lacking capacity with no surrogate decision makers. The group applied Rubin and Prager’s framework for contemplating medical intervention on a dissenting patient who lacks capacity: severity and imminence of harm without intervention, efficacy and risks of intervention, emotional impact of coercion, reasons for refusal, and logistics of treating over objection. Given the imminent and severe harm without these effective, low-risk interventions, the team pursued guardianship and obtained the guardian’s consent. Testing revealed a non-small cell lung cancer with a low chance of remission even with treatment. The team reapplied the framework and concluded that the low efficacy, high risks, and prohibitive logistics of treatment outweighed the severity and imminence of harm from no intervention. Thus, cancer treatment against the patient’s wishes was not pursued while other interventions continued such as placement of a gastrostomy tube with guardian consent and patient assent, though the patient later often refused tube feeds. Ultimately, with guardian consent and patient assent, she was transitioned to DNR/DNI and passed away peacefully. IMPACT/DISCUSSION: This case illustrates the dynamic ethical challenges of managing a critically ill, non-assenting patient who lacks capacity due to a psychiatric illness. Applying the same ethical framework at two key junctures resulted in different but ethically congruent decisions that balanced patient autonomy with beneficence and non-maleficence. This highlights the utility of ethical frameworks and multidisciplinary consultation in optimizing patient care.

1. Patients without decision-making capacity do not necessarily forfeit their autonomy; they may still retain the ability to assent or dissent to care, though these preferences may be overruled in some circumstances. 2. Overruling their preferences should rely on weighing other principles based on established ethical frameworks and involvement of ethics consultation when possible. IMPLICATIONS OF COURT-APPOINTED GUARDIANSHIP IN HEALTHCARE SETTINGS Dhivya Sridar1; Peggy B. Leung2; Shira Sachs1. 1Internal Medicine, Weill Cornell Medicine, New York, NY; 2Internal Medicine, New York Presbyterian/ Weill Cornell, New York, NY. (Control ID #4272878) CASE: Ms. J, a 65 year old female with SLE c/b lupus nephritis now on iHD and possible cerebral amyloid angiopathy c/b L parietal IPH with severe short term memory loss, is readmitted one day following percutaneous nephrostomy (PCN) tube placement with a dislodged PCN. She underwent PCN exchange, received antibiotics for a UTI, and was deemed medically ready for discharge in April 2024. However due to complications in discharge planning, Ms. J remained inpatient until November 2024. Despite medical recommendations for a skilled nursing facility or 24/7 home care, Ms. J refused, insisting on returning home. Though she was AxOx3, thorough cognitive assessment (MOCA 10/30) revealed significant decision-making impairment due to short-term memory loss, necessitating a court-appointed guardian to ensure safe discharge. For months, the interdisciplinary care team navigated complex legal processes, addressing court date delays, ineffective initial guardians, and family reluctance to take ownership of her care. Ultimately, Ms. J's brother was appointed her legal guardian, allowing her safe discharge home. IMPACT/DISCUSSION: This case illuminates the complexities of medical decision-making capacity assessment and court-appointed guardianship. While decision-making incapacity affects approximately 26% of inpatients, its evaluation remains nuanced. Capacity involves understanding risks and benefits of a treatment and its alternatives, applying these to oneself with reasoning, and communicating one’s decision. Any physician can assess decision-making capacity, often using a quick directed clinical interview. Formal tools for assessing medical decision-making capacity in more nuanced situations include the Aid to Capacity Evaluation, Hopkins Competency Assessment Test, and the MacArthur Competence Assessment Tool for Treatment. The guardianship process reveals significant systemic challenges. With limited judicial resources (e.g., just over a dozen judges overseeing guardianships for 17,411 individuals in New York City) and documented instances of court-appointed guardian misconduct (financial abuse and negligence), physicians must critically evaluate guardianship recommendations. Nationwide, data and oversight is lacking regarding court-appointed guardianship; more research is needed in this area. As physicians, we have a role in being more discerning regarding which of our patients we recommend for guardianship. We may also have a role in ensuring whether patients' guardians are adequately caring for patients. Finally, physicians may play a role in advocating for alternative solutions to court-appointed guardianship for patients who lack decision-making capacity.

Physicians play a crucial role in assessing medical decision-making capacity, using validated clinical tools to protect patient autonomy and safety. Court-appointed guardianship requires careful consideration, with needed advocacy for improved oversight, patient protection mechanisms, and potential alternative solutions. SELECTIVE REFUSALS AND SELECTIVE REQUESTS: ETHICAL CHALLENGES IN THE CARE OF A PATIENT AFTER TRAUMATIC SPINAL CORD INJURY Sophia Clark2; Meera Sury1,3. 1Pulmonary and Critical Care, University of Minnesota Medical School, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN; 3Center for Bioethics, University of Minnesota Twin Cities, Minneapolis, MN. (Control ID #4273522) CASE: A 31-year-old patient is admitted to the Surgical Intensive Care Unit after a high-speed motor vehicle accident. With his cervical spinal cord injury, he is dependent on the ventilator. His initial course is complicated by multiple cardiac arrests secondary to mucous plugging. He spent the majority of the following two years in the hospital, where patterns of care requests (specifically for bronchoscopies) and refusals (wound cares, airway clearance) emerged. Over the course of his care, clinical ethics teams have been involved to answer the following questions: 1) Do clinicians have an obligation to offer procedures that are not medically indicated? 2) Does a pattern of selective refusals, often resulting in critical illness, justify clinician-directed transition of code status to do not resuscitate, if his behaviors aren’t consistently aligned with his stated goal of prolonging life? 3) How can hospitals best support teams through the moral distress experienced in ethically complex cases? IMPACT/DISCUSSION: A particular complexity of this patient’s care is that his selective refusals are contradictory to his stated care goals and code status. While most patients have not experienced the full gamut of critical illness and resuscitation, he has the embodied knowledge of prolonged ICU stays, suggesting a robust understanding of full code status, should he re-arrest. Multidisciplinary meetings, both for providers and with the patient, have been the cornerstone of his care, and are an important mechanism to mitigating the moral distress associated with his patterns of requests and refusals. Multidisciplinary consensus has also served as a strong foundation to support clinicians in not offering medically unnecessary treatments, the provision of which we consider to be ethically inappropriate. For a patient with decision-making capacity, it is both ethically appropriate and necessary to set clear boundaries with the patient. Understandably, the question of medical futility has been raised since the cares declined have led to recurrent episodes of critical illness by way of mucous plugging and bacteremias. Though such a transition has not yet been made, a conversation has been initiated with the patient about a transition to comfort-focused cares if he continues to decline routine—but for him, life-sustaining—cares.

Ethics consultation and multidisciplinary teams can provide longitudinal support to providers and patients in complex cases where goals of care and patient behaviors are seemingly discordant. Including a decisional patient in developing and enacting boundaries is an important step in providing goal-concordant and quality care. “CUSHING” THE LIMITS: ETHICAL CHALLENGES IN TREATMENT OVER OBJECTION Holland M. Kaplan1,2. 1Section of General Internal Medicine, Baylor College of Medicine, Houston, TX; 2Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX. (Control ID #4269222) CASE: A 60-year-old woman with no medical history was admitted with progressive psychosis. Four months prior, the patient's daughter noticed worsening paranoia, which led to her fleeing home due to fears of being killed by government agents. She denied psychiatric or substance use history. After inpatient psychiatric evaluation, the patient was transferred to the hospital for tachycardia. At the hospital, the patient's paranoia led to intermittent refusal of medications, blood draws, and clinical assessments. Labs revealed hyperglycemia (439 mg/dl), hypokalemia (2.4 mmol/L), and elevated serum cortisol (57.9 μg/dl). A positive dexamethasone suppression test and elevated serum ACTH (204 pg/ml) confirmed ACTH-dependent hypercortisolism. An MRI revealed a pituitary adenoma, and inferior petrosal sinus sampling (IPSS) was recommended. The patient refused, concerned that the team would “inject toxins” during the procedure and “report her to the government.” Her daughter, stating she was “not in her right mind,” requested sedation for IPSS over the patient's objection. A formal assessment of decision-making capacity revealed that the patient was unable to state why she was hospitalized or the benefits of IPSS. Clinical ethics consultation was sought regarding coerced sedation for IPSS. After ethical analysis, IPSS was recommended and performed over the patient’s objection, demonstrating the pituitary adenoma as the cause of her hypercortisolism. The pituitary adenoma was resected, and her psychosis resolved. The patient retrospectively expressed appreciation for the treatment she received. IMPACT/DISCUSSION: In inpatient settings, patients with limited decision-making capacity often refuse recommended, non-emergent treatments, creating an ethical conflict between respecting autonomy and providing beneficent care. If treatment over objection (TOO) is being considered, its ethical risks must be carefully weighed, including loss of trust and violations of bodily autonomy. Despite the frequency and the distressing nature of these cases, guidance from the literature is limited. From our experience, key considerations for TOO include determining the proposed intervention’s necessity, assessing reversible causes of limited capacity, involving a surrogate decision maker, and attempting to address the patient’s reasons for refusal. In this case, the primary ethical justification for TOO was that treating the patient's Cushing’s disease could restore her ability to participate in decision making. These factors should be carefully considered when considering TOO.

1. TOO cases highlight conflicts between respecting autonomy and providing beneficent care. 2. Proceeding with TOO requires a high degree of ethical justification given the risk of losing trust and violating bodily autonomy. 3. If an intervention has the potential to restore a patient’s capacity, this could provide ethical justification for proceeding TOO. Clinical Vignette - Mental/Behavioral Health and Substance Use Disorders A CASE OF CLOZAPINE, CONSTIPATION, AND COMPRESSION FRACTURES Victoria H. Chen, Katherine Wrenn. Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4228941) CASE: A 64-year-old male with HFrEF s/p CRT-D, T2DM, HTN, schizoaffective disorder, and chronic constipation presented with severe back pain after an unwitnessed fall at home. Workup for his fall was unrevealing for secondary causes, including basic labs, orthostatic vitals, head imaging, and interrogation of his cardiac device. However, his CT torso was notable for acute lumbar compression fractures and severe dilation of the sigmoid colon with large stool burden. Upon further questioning, the patient reports missing doses of his home bowel regimen. Ultimately, the etiology of his fall was attributed to pre-syncope in the setting of severe, acute on chronic constipation causing a vagally-mediated event. A review of his home medications for constipating adverse effects was notable for clozapine, risperidone, and clonazepam. While admitted, he was treated with an aggressive bowel regimen with gradual improvement in stool burden. His back pain was managed with a multimodal analgesic approach including acetaminophen, NSAIDs, intranasal calcitonin, and minimal opioids to achieve adequate pain control without worsening his constipation. Extensive patient and family education was provided on the importance of continued constipation management after discharge. IMPACT/DISCUSSION: Clozapine-induced constipation and associated bowel complications are increasingly being recognized as serious adverse effects of the medication. It is important for providers to routinely screen for and actively manage constipation in patients taking clozapine. In contrast to agranulocytosis, which is a well-known but rare complication, constipation affects up to 80% of patients yet remains underrecognized. Severe constipation in this population has also been linked with highly morbid complications including bowel obstruction, perforation, and necrosis. This prompted the Food and Drug Administration to issue an updated drug safety communication in 2020. The constipation-related effects are due to the medication’s anticholinergic properties which promotes colonic hypomotility and exhibit a dose-dependent relationship. Therefore, treatment with non-bulk-forming laxatives is recommended. After the acute episode of constipation is resolved, clozapine can usually be continued in combination with an effective standing bowel regimen. In addition to bowel complications, chronic constipation has also been linked with increased frailty in older adults. As was hypothesized in this case, patients with inadequately managed constipation may be at increased risk for falls through a vagally-mediated pathway. This case emphasizes the importance of multidisciplinary care coordination between primary care and psychiatry, especially in medication management for patients taking clozapine.

- Routinely screen for and actively manage constipation in patients taking clozapine. - Non-bulk-forming laxatives are preferred given colonic hypomotility. - Clozapine can usually be continued with an effective standing bowel regimen. APPROACHING SENSITIVE EXAMS: AN EXAMPLE OF APPLYING TRAUMA INFORMED CARE Caroline Cao1; Rebecca Green2. 1General Internal Medicine, UPMC, Pittsburgh, PA; 2Medicine, Boston Medical Center, Pittsburgh, MA. (Control ID #4272922) CASE: A 42-year-old woman with no past medical history presented to the emergency department with one month of progressive back pain, abdominal pain, and abdominal distension. CT Chest Abdomen and Pelvis with IV Contrast revealed a 4cm infiltrative right breast mass with numerous liver and vertebral lesions suspicious for metastatic breast cancer. Labs were notable for hypercalcemia and a mixed hepatocellular and cholestatic liver injury suggestive of visceral crisis; Oncology was promptly consulted. Of note, the patient’s family relayed that she had noticed this mass two years ago but delayed seeking care. Originally, the patient refused examination of her breasts. Upon clarifying, she voiced general anxiety regarding hospitals and fear of being judged on the lesion’s appearance. To maximize comfort and control, the patient remained in street clothes during the admission. Through counseling and having a support person present, examination was completed. Prior to doing so, all steps were explained, and modifications were made to only perform necessary steps: examination of the left breast was observational; palpation was only utilized over the right breast and axilla. The patient dressed and undressed in private. Finally, all steps were re-verbalized in real time and examiner waited for consent before advancing. This instance served as the patient’s only breast exam. Providers verbalized recognition for her courage in seeking help. Unfortunately, as her work-up continued, the patient became obtunded. She was transferred to an inpatient Oncology floor where she transitioned to comfort measures only and passed away 1 week after presentation. IMPACT/DISCUSSION: Trauma informed care (TIC) is a model of care which reduces harm and builds resilience. Trauma refers to any physically or emotionally harmful or life-threatening experience. TIC is crucial because trauma negatively impacts health: it is associated with anxiety, insomnia, and negative coping behaviors in the short-term, and insulin resistance as well as increased risk of vascular and cardiac disease in the long-term. Additionally, a lack of TIC can prevent patients from seeking care, as the team suspected in our patient’s case. Because trauma is common and pervasive, TIC principles should be universally applied to minimize the risk of re-traumatization by asking for specifics. As in our patient’s case, the focus should be on maintaining psychological and physical safety: empower patients to collaborate in the exam by giving options and adjusting procedures when feasible. Maintain transparency by explaining each step. Finally, listen and validate patients’ emotions to create a supportive, patient-centered environment.

The principles of trauma informed care should be universally applied. Maximize safety by exploring patient preferences, maintaining transparency, collaborating when possible, and validating emotions. CHASING A PHANTOM: MEDETOMIDINE IN THE FENTANYL SUPPLY AND CHALLENGES IN WITHDRAWAL MANAGEMENT Olivia Oldridge1; Rachael Truchil2. 1Internal Medicine, Penn Medicine, Philadelphia, PA; 2General Internal Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4273061) CASE: A 42-year-old man with a history of opioid use disorder presented to the Emergency Department with nausea and vomiting. Prior to hospitalization, he was using one bundle of fentanyl intranasally daily. On admission he was hypotensive to 75/40. Three hours later, his blood pressure was 180/100 and he was tachycardic to 120. He was considered for ICU admission given labile vitals, however was admitted to Medicine, where his symptoms were managed with clonidine and antiemetics. He was successfully started on Suboxone. In subsequent weeks, he discontinued Suboxone given ongoing nausea, and returned to using approximately half a bundle of fentanyl daily. He established care at an addiction medicine clinic, where he attempted low-dose buprenorphine inductions multiple times. However, he was unable to tolerate therapeutic Suboxone as he had vomiting refractory to clonidine, ondansetron, famotidine, and quetiapine. He continued to use fentanyl to relieve his symptoms. Through shared decision making with his physician, he was referred back to the Emergency Department for inpatient withdrawal management and buprenorphine induction. IMPACT/DISCUSSION: A new contaminant, medetomidine, has recently been found in a majority of the illicit fentanyl supply in Pennsylvania. Medetomidine withdrawal occurs quickly and symptoms range from intractable vomiting to tachycardia, hypertensive emergency, and hypoactive delirium. This case demonstrates the challenges posed by medetomidine in the drug supply. First, it has become more challenging to initiate MOUD in the outpatient setting, as patients frequently return to use to mitigate withdrawal symptoms. Second, antiemetics are not sufficient to control nausea in some patients, and a combination of high dose alpha-2 agonists, antiemetics, and antipsychotics is currently being trialed in our practice. Finally, withdrawal can be so severe that patients require hospital or ICU admission. In our experience, some patients have required several days of intubation and sedation to successfully control vital sign abnormalities. This case highlights an emerging danger to patients with opioid use disorder.

1. Medetomidine, a veterinary sedative similar to xylazine, is a new contaminant in the fentanyl supply. Its closest analogue is dexmedetomidine, commonly used for ICU agitation. The concentration of medetomidine in the illicit supply is 1-2 orders of magnitude higher than any therapeutic dosage. 2. Medetomidine withdrawal can manifest as agitation, tachycardia, hypertension, and uncontrollable nausea and vomiting. In some cases, these symptoms can be managed outpatient with alpha-2 agonists, antiemetics, and antipsychotics. 3. Withdrawal can be so severe that it precludes outpatient MOUD initiation, and some patients require hospitalization or ICU admission for stabilization and withdrawal management. FACTITIOUS DISORDER: A LIFE-THREATENING PRESENTATION AND A CHALLENGING DIAGNOSIS Isna Khaliq, Richard C. Dwyer. Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4273185) CASE: A 43-year-old woman with a history of anxiety and epilepsy presented with her husband for an elective port exchange procedure. Postoperatively, she exhibited seizure-like activity without an obvious postictal state. Vitals and labs were unremarkable. Neurology determined that the seizure was likely psychogenic non-epileptic. The patient was subsequently admitted and experienced multiple episodes of hypoglycemia. On one occasion, her blood glucose level dropped below 20 mg/dL, accompanied by altered mental status (AMS). Treatment with IV dextrose corrected her hypoglycemia. An hour later, a repeat blood glucose test was 21 mg/dL, prompting an additional dose of dextrose. Further testing revealed high insulin and low C-peptide levels. There were now concerns of surreptitious exogenous insulin use and a one-to-one sitter was assigned. The sitter witnessed the patient's husband handling her something at the bedside, which she quickly concealed. The medical team discussed the situation with the patient, who immediately denied the event. Consequently, the patient’s husband was asked to leave the hospital, and the patient then adamantly demanded to leave against medical advice. A week later, she was admitted for AMS, requiring intubation, during which her husband revealed that she had been injecting non-prescribed insulin through her port. She remained hospitalized for over three weeks, during which she underwent an extensive negative workup. The patient and her husband returned to the clinic two months after discharge, where they disclosed that the patient had been getting insulin from another family member but had since stopped. She continues to have regular follow-ups with the same primary care provider (PCP) and has not had any further documented hypoglycemic episodes. IMPACT/DISCUSSION: Factitious Disorder (FD), or Munchausen syndrome, involves intentionally producing symptoms with unconscious motivation, and has an estimated prevalence of 0.1% to 8%. The unusual presentation of FD can pose significant diagnostic challenges. Our patient reported an undocumented history of ovarian cancer, and the reason for her port placement was unclear. Furthermore, her medication list from multiple providers in different states was discovered to have numerous discrepancies. These indicators and the objective data from low C-peptide during the admission warranted our careful attention and intervention. Undiagnosed FD can result in unnecessary healthcare resource consumption and, as seen in our patient, can lead to serious health issues, including death.

This case illustrates the recognition of a life-threatening manifestation of an underlying psychiatric condition. It highlights the importance of promptly diagnosing FD to prevent further harm to the patient's health. The goal is to identify deceptive symptoms, understand the triggers, address the symptoms without unnecessary testing, and develop healthier coping mechanisms. Regular follow-ups with the same PCP are beneficial. NEUROCYSTICERCOSIS, BEHAVIORAL SEQUELAE, AND LEGAL IMPLICATIONS: A CASE REPORT Jacklyn Samaha, Stephen N. Symes. Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4245168) CASE: A male in his fifties with a migration background (Haiti) presented with a history of seizures that began around age 18, progressively worsening despite Dilantin treatment. In his late twenties, he was hospitalized for a recurrent seizure. CT and MRI revealed a 2-cm multilobulated enhancing mass with surrounding edema in the left frontal lobe. A left frontal craniotomy was performed to remove what was presumed to be a tumor. Postoperative biopsy confirmed NCC in the cerebral parenchyma, with a larva identified at the center of the lesion. The surrounding brain tissue showed inflammation and fibrosis, findings characteristic of NCC. Post-surgery, he reported mild headaches, and there was visible swelling on his left scalp. In a follow up 10 days after his procedure, a CT without contrast showed persistent edema and hemorrhage. Since his craniotomy, he has not experienced any seizures but does report vertigo. He did not receive long-term medical or mental health care. The patient described behavioral changes post-craniotomy, such as reckless driving and larceny. Approximately a decade later, he was incarcerated for sexual misconduct. He reports that the onset of these impulsive behaviors began post-surgery and ceased during his time in prison. IMPACT/DISCUSSION: NCC is strongly associated with seizures and epilepsy, but the behavioral and psychological changes resulting from both the condition and its surgical treatment are less often discussed. Several case reports highlight cognitive decline, dementia, mania, and psychosis following NCC. While our patient’s seizures stopped after surgical treatment for NCC, he reported a noticeable increase in impulsive behaviors, including unsafe driving and larceny. Such impaired decision-making may have contributed to the crime he later committed. The lack of long-term mental health care post-surgery also raises concern over whether these behaviors may have been addressed sooner. Frontal lobe damage, often linked to executive functioning, can result in disinhibition, impulsivity, inappropriate behavior, and emotional dysregulation. These findings have implications for rehabilitation and highlight the potential risks associated with NCC-related brain damage. This case raises medical and legal questions about how left frontal lobe NCC affects decision-making. Though the patient has served his sentence and demonstrates no impulsive behaviors in recent years, he now faces potential deportation due to his crime.

1. Frontal lobe NCC and its surgical treatment can result in behavioral and psychological changes such as impulsivity and altered decision-making, emphasizing the need for long-term follow-up care. 2. This case highlights the intersection between post-NCC behavioral changes, legal challenges, and migration status. ONLY ABSTINENCE IS ENOUGH: NITROUS OXIDE-INDUCED SUBACUTE COMBINED DEGENERATION DESPITE CONCURRENT VITAMIN B12 SUPPLEMENTATION. Edison Jyang1; Kaili Du2. 1Internal Medicine, Cayuga Medical Center, Ithaca, NY; 2Department of Medicine, Cayuga Health System, Ithaca, NY. (Control ID #4273500) CASE: A 47-year-old male with a past medical history of depression and anxiety, presented to the emergency room for difficulty ambulating. He reported numbness and tingling below his trunk for 4 months, short-term memory loss, difficulty controlling his bladder, and balance issues with multiple falls. Social history reveals nitrous oxide (N2O) use for 20 years, with recent use of 6 canisters of 600 gram N2O per day. On exam he was alert and oriented, strength was 5/5 in his upper extremities but 2/5 in lower extremities with reduced sensation, absent plantar reflexes, and diminished vibration and proprioception at the great toes. CT of the head, neck, and lumbar spine ruled out an ischemic stroke or spinal fracture/pathology. The patient was admitted for a subacute onset of lower extremity weakness. Vitamin B12 level on admission was low-normal at 225 pg/mL, but elevated homocysteine and methylmalonic acid levels indicated a B12 deficiency. An outpatient B12 level 7 days prior was 137 pg/mL and he endorsed taking daily B12 tablets; his outpatient chart confirmed a prescription of twice-daily B12 500 mcg tablets for the past 4 months. He denied prior B12 deficiency or dietary restrictions. The patient underwent daily B12 1000 mcg IM injections for 7 days, followed by weekly 1000 mcg IM. On admission he required a stand assist lift for transfers due to weakness and imbalance, and ambulated with a rolling walker for only 20 ft. After 1 week, he could ambulate 170 ft with a RW and was discharged to an acute physical rehab unit. After 2 weeks in rehab, he was fully independent with transfers, and able to ambulate 150 ft without a walker. IMPACT/DISCUSSION: Nitrous oxide (N2O) remains a low-profile yet common recreational drug. A 2021 report from the Global Drug Survey showed 22.5% of respondents having tried N2O in their lifetime and 9.7% having used it in the past year. There is growing evidence that documents nitrous oxide-induced subacute combined degeneration (N2O-SCD), but only two case reports of N2O-SCD in patients also actively supplementing with vitamin B12. This case demonstrates N2O-SCD despite daily oral 1000 mcg B12 for the past 4 months. As seen in this case and other reports, N2O-SCD can occur with normal B12 levels. N2O causes cobalt oxidation in B12 leading to a functional B12 deficiency. Physicians and patients should be aware that active B12 supplementation does not prevent N2O-SCD. At this time, N2O abstinence is the best way to prevent N2O-SCD.

- N2O can cause a functional vitamin B12 deficiency via cobalt oxidation, inducing a subacute combined degeneration of the spinal cord (N2O-SCD). - Active N2O use with concurrent vitamin B12 supplementation does not reliably prevent N2O-SCD. - Physicians should inquire about a patient's history of N2O use routinely to prevent misdiagnosis of SCD. PERILOUS PICA Catherine W. Bennett2; Nathan Scheiner2; Lauren M. Gensler1. 1Internal Medicine/Psychiatry, Emory University School of Medicine, Atlanta, GA; 2Internal Medicine and Psychiatry, Emory University, Atlanta, GA. (Control ID #4269345) CASE: A 32-year-old female with a history of cocaine use was diagnosed with stuporous catatonia at an outside hospital and transferred to a combined internal medicine and psychiatry unit after 28 days to help clarify the diagnosis. Admission exam was inconsistent with catatonia; the patient had absent visual tracking, limited withdrawal to pain, grasp reflex, severe trismus, persistent autonomic instability, and poor response to lorazepam challenge. She also had a diffuse ichthyotic rash. Admission labs were notable for mild transaminitis, iron deficiency anemia, and elevated inflammatory markers. MRI of the brain suggested toxic encephalopathy. EEG was negative for seizure activity. Specialized labs, including serum autoimmune markers, infectious serologies, heavy metals as well as CSF studies, including basic labs, infectious studies, and autoimmune studies were negative. Subsequent collateral revealed ingestion of Bowl Fresh toilet bowl deodorizers for one year for unknown reasons. This product contains paradichlorobenzene (PDCB), a neurotoxic compound. Serum p-dichlorobenzene was elevated to 7.5 mcg/mL, and urine 2,5-dichlorophenol was elevated to 780 mg/L, confirming the diagnosis of PDCB toxicity-associated leukoencephalopathy. IMPACT/DISCUSSION: PDCB is an aromatic hydrocarbon that is volatile, easily aerosolized, and lipophilic. It is found in mothballs and toilet deodorizers. Usually, exposures are due to inhalation of aerosolized particles or via dermal exposures among factory workers. They have also occurred among people who live near facilities that make these products or near waste sites. Recent case reports suggest that these compounds can be used recreationally and do have abuse potential. There are also several case reports of patients with pica with PDCB toxicity, as was the case with our patient. The clinical features of PDCB toxicity consist of neurotoxicity, including encephalopathy, ataxia, and catatonia; anemia; multiorgan injury, including renal toxicity and hepatotoxicity; and ichthyotic rash. MRI brain often reveals symmetric periventricular white matter changes, consistent with our patient’s imaging. Prognosis of PDCB toxicity varies, but early nutrition can significantly improve outcomes. Through a process known as coasting, PDCB mobilizes from adipose tissues when they are broken down in response to starvation, resulting in higher serum levels and toxicity. Inadequate nutrition can lead to increased release of PDCB and worsening toxicity weeks after the last ingestion.

This case underscores the importance of thorough collateral when a diagnosis is unclear. It also demonstrates rare PDCB toxicity as a complication of compulsive or recreational household cleaner ingestion. Clinicians should keep PDCB toxicity on the differential diagnosis among patients with the constellation of symptoms of pica, unclear exposures, and encephalopathy. SEVERE ASYMPTOMATIC SINUS BRADYCARDIA WITH COMPETING JUNCTIONAL RHYTHM IN AN ADULT MALE PATIENT Rehnuma R. Khan1; Lisa Rucker2,1. 1Albert Einstein College of Medicine, New York, NY; 2Internal Medicine, New York City Health and Hospitals Jacobi, New York, NY. (Control ID #4271930) CASE: A 53 year-old-male with no past medical or surgical history presented to an academic center in the mid-Atlantic to establish care where he was found to have severe asymptomatic bradycardia. Pertinent negatives include lack of chest pain, palpitations, dyspnea, orthopnea, or syncope. He was not taking any medications. The patient had a physically active occupation and he was an avid basketball player. While he was a chronic, heavy marijuana smoker; he did not use any alcohol or cigarette/tobacco products. Physical examination was unremarkable except for significant bradycardia with regular rhythm. ECG demonstrated severe sinus bradycardia to the 30s with competing junctional rhythm. Cardiac work-up was otherwise negative and laboratory evaluation was within normal limits. After this visit, he was a victim in a motor vehicle accident and required emergent surgical intervention. His heart rate increased to the 70s, representing relative tachycardia. Subsequent cardiac evaluations with chest X-ray, echocardiogram, and ECG were normal, aside from persistently severe sinus bradycardia. IMPACT/DISCUSSION: Δ9-tetrahydrocannabinol (THC) is the main psychoactive cannabinoid in marijuana that agonizes the cannabinoid type 1 or 2 receptors (CB1/2-R). Cardiovascular effects of THC compounds are mediated through CB1-R with dose-dependent autonomic nervous system stimulation: low doses primarily stimulate a sympathetic response in contrast to chronic or high doses that innervate a parasympathetic response with sympathetic attenuation.1 Cannabinoid-induced sinus bradycardia has been studied in animals with scant case reports of symptomatic patients.1 Syncope, sinus arrest, asystole, and heart block have been reported complications due to severe bradycardia secondary to cannabinoid use.1 Marijuana is the most prevalent recreational drug worldwide with consistently increasing potency of contemporary strains and preparations, especially among youth. Our patient was asymptomatic with severe bradycardia incidentally discovered on evaluation dually attributable to marijuana use and athletic conditioning, unlike previously reported symptomatic cases. It possible that cannabis-induced sinus bradycardia is more prevalent and thus warrants further study. Additionally, it is important to increase physician awareness of cannabinoid-induced chronotropic and inotropic insufficiency given the severe side effects of heavy and/or chronic use. Citations 1Heckle, Mark R., et al. "Cannabinoids and symptomatic bradycardia." The American Journal of the Medical Sciences 355.1 (2018): 3-5.

1. CB1-R agonism elicits dose-dependent autonomic nervous system effects wherein low doses trigger sympathetic symptoms and high/chronic use stimulates parasympathetic effects. 2. Cannabis-induced cardiovascular complications range from asymptomatic sinus bradycardia to syncope, sinus arrest, or heart block. SEXUALLY TRANSMITTED…FENTANYL?: A CLINICAL VIGNETTE EXPLORING THE ETIOLOGY OF FENTANYL POSITIVITY IN A PATIENT ON BUPRENORPHINE THERAPY Cassandra L. Pasadyn1; Preston Williams2; Kelsey Schmuhl2; Cali Hazel2; Martin Fried2. 1Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; 2General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4267412) CASE: Patient A is a 30-year-old female with a 5-year history of opioid use disorder (OUD). During her 2021 pregnancy, she began treatment and delivered a healthy infant after residential care, reporting last fentanyl use in September 2021. The patient has been in sustained recovery since delivery with daily buprenorphine 8mg-naloxone 2mg therapy. Despite documented adherence to buprenorphine therapy and continuously reporting abstinence from fentanyl use, the patient intermittently tested positive for low levels of fentanyl in urine drug screens (UDS) through early 2023. When UDS results were discussed with Patient A she had a hypothesis about mechanism of exposure. Patient A’s fiancé, Patient B, is a 29-year-old male with a history of OUD (recent inhalational fentanyl). At the request of our index patient, Patient B established care in June 2023 and reported his pattern of use involves smoking fentanyl prior to intimacy with Patient A. Patient B noted he had not been as fastidious in cleaning hands and lips prior to intimacy. Together, both Patient A and B acknowledged the likeliest explanation of Patient A’s UDS results involves passive exposure across mucosal surfaces during sex. Patient A continued to have low levels of fentanyl and fentanyl metabolites on UDS until Patient B finally achieved complete abstinence in April 2024. IMPACT/DISCUSSION: There has been widespread criticism to the erroneous claims, mostly from law enforcement, about risk of overdose from passive cutaneous or inhalational exposure. We present the case of unintentional fentanyl ingestion from exposure between mucosal surfaces. While we do not intend to substantiate stigmatized misinformation, clinicians should not be glib about cutaneous exposure. This case highlights an under-recognized mechanism of fentanyl exposure—sexual transmission from a partner actively using the drug. Fentanyl's high lipid solubility prolongs presence in bodily fluids that may facilitate its transfer through intimate contact and may present as the metabolized form in the receiving partner. Clinicians should consider this possibility when evaluating unexplained positive drug screens in patients with robust adherence to treatment and no other sources of exposure.

Results of UDS do not indicate use disorder. Understanding unconventional routes of fentanyl exposure can help explain positive results, reduce stigmatization of patients in recovery, and prevent unnecessary modifications to treatment plans. Additionally, close analysis of drug screen results, specifically timing, relative concentrations, and metabolite profile, is critical for providers to understand the clinical context of tests. Lastly, patients may be more inclined to modify their own substance use patterns if they discover unintentional exposure to sexual partners. Further research is warranted to explore the pharmacokinetics of drug transmission through sexual activity and its implications for substance use recovery. SUBOXONE THERAPY FOR MANAGEMENT OF TIANEPTINE WITHDRAWAL SYMPTOMS Adam M. Taylor1; Alekses Clifton2. 1School of Medicine, University of Utah Health, Salt Lake City, UT; 2Internal Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4270897) CASE: A 36 y/o female with an extensive history including remote opioid use disorder s/p Suboxone wean 8 years ago presented to her PCP reporting worsening anxiety and depression no longer managed with Lexapro. Additionally, the patient expressed that she had been using Tianeptine for the past 13 months and was having cessation difficulty due to withdrawal symptoms. She initially began using Tianeptine to alleviate fatigue and chronic back pain, which began following a case of osteomyelitis. Due to her concern for withdrawal and the addictive nature of Tianeptine, the patient opted to start suboxone. The patient was switched from Lexapro to Fluoxetine to manage depression and anxiety symptoms better. The patient initiated Suboxone 4mg every 6 hours after an initial 2-day ramping phase. The patient discontinued Tianeptine use following initiation of suboxone and reported body aches were well controlled with Suboxone alone but endorsed increased fatigue. Around 7 weeks later the patient began to taper the Suboxone dose but due to increased withdrawal symptoms her dose was escalated back to 8mg BID with 4mg PRN. Around 6 months after initiation of Suboxone, the patient felt that her anxiety and depression had improved from her initial encounter and elected to discontinue her Fluoxetine. One year following the initial encounter, the patient continued on the same dose of suboxone and has had no relapse since initiation of Suboxone therapy. IMPACT/DISCUSSION: This case highlights the addictive nature of Tianeptine and the potential clinical benefits of using Suboxone to manage withdrawal symptoms. Tianeptine is an atypical TCA that is used in countries outside the US to treat depression but not currently FDA approved in the US. Its mechanism as an opioid receptor agonist creates a high potential for abuse, making it a significant public health concern. Tianeptine products are easily accessible for purchase in supplement form in retail spaces such as smoke shops and gas stations, further compounding the risk of misuse. The case illustrates the potential role of Suboxone in mitigating withdrawal symptoms associated with Tianeptine dependence. This case broadens its application to the cessation of substances like Tianeptine, emphasizing the flexibility of Suboxone in treating dependencies beyond traditional opioid use. Providers should be aware of the potential for Tianeptine misuse, particularly in patients with a history of substance use disorders or chronic pain conditions, who may turn to unregulated substances for relief. Finally, this case shows the need for increasing awareness of the risks associated with Tianeptine, which is marketed as a supplement but has properties that contribute to dependency.

1) Suboxone could be an effective tool for managing withdrawal symptoms associated with Tianeptine cessation. 2) Tianeptine is a readily available addictive substance that should have stricter regulations surrounding its distribution. TAINTED HIGHS, FATAL LOWS: AN ADULTERANT-ASSOCIATED OPIOID OVERDOSE IN A HIGH-RISK PATIENT Michelle Zhao, Elizabeth "Betty" Kolod. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273489) CASE: A 30-year-old woman with a history of bipolar disorder, anxiety, and polysubstance use was brought from her methadone clinic to the emergency department for lethargy that did not resolve with naloxone. Urine toxicology was positive for methadone, fentanyl, and cocaine. A local health department alert raised concern for medetomidine in the drug supply but testing was not performed. The patient’s home methadone, alprazolam, and gabapentin were held and she returned to her baseline within 48 hours. The patient had been undergoing significant psychosocial stressors, including losing parental rights over her daughter and her husband’s recent incarceration, but suicidality was ruled out. Her presentation was likely due to the use of cocaine adulterated with fentanyl in the setting of multiple prescribed sedating medications. The patient was discharged back on her home her home valproic acid, buspirone,gabapentin, alprazolam, dextroamphetamine, and methadone with with close outpatient follow-up. IMPACT/DISCUSSION: This case highlights the emerging role that adulterants play in overdose rates and strategies to mitigate its effects among patients with medical and psychosocial risk factors. Adulterants are pharmacologically active ingredients added to enhance or mask the effects, increase potency, or maximize profits of illicit drugs. Common adulterants include fentanyl analogs like nitazines, tranquilizers like xylazine or medetomidine, and benzodiazepines. Through various sedating mechanisms, they significantly increase the risk of opioid overdoses. The rising incorporation of adulterants has further exacerbated drug-associated overdoses and deaths – from 2019 to 2022, the percentage of illicitly manufactured fentanyl deaths from xylazine increased by 276% in the United States. It is important for providers to recognize and mitigate the effects of adulterants amongst high-risk populations. Advising patients of harm reduction strategies is crucial as non-opioid adulterants do not respond to naloxone. Examples include going to supervised consumption sites, starting with lower test doses of drugs, and using safer modalities of drug administration. Increasing funding for adulterant surveillance with policymaker collaboration will better inform prevention. Recognizing the medical and psychosocial conditions that affect the risk of overdose and providing tailored counseling is just as important. Providers should pay special attention to patients with substance use disorders who are prescribed multiple sedating medications. Optimizing the balance between harm reduction and symptom management is crucial to prevent further opioid morbidity and mortality.

Adulterants in the illicit drug supply exacerbate and complicate opioid overdoses in the United States. Harm reduction strategies, patient and provider education, and drug surveillance are all crucial in addressing this health hazard and preventing further drug overdose deaths. THE SILENT HEARTBREAK: OPIOID WITHDRAWAL-INDUCED TAKOTSUBO CARDIOMYOPATHY Anzi Salim, Rukshar Thapa, Srikrishna Malayala. Internal Medicine, Crozer-Chester Medical Center, Upland, PA. (Control ID #4272870) CASE: A 40-year-old female with a history of opioid use disorder presented to the Emergency Department with complaints of nausea and vomiting for the past 3 hours. Her last reported use of fentanyl was over 14 hours prior to presentation. The patient was prescribed Suboxone (8 mg/2 mg) twice a day but was not compliant with the medication. On admission, she was diaphoretic, actively vomiting, and in severe distress. Vitals showed blood pressure of 176/138 mmHg, pulse 52 bpm, and respiratory rate of 22/minute. Laboratory evaluation demonstrated hypokalemia (2.9 mmol/L), hypomagnesemia (1.5 mmol/L), and elevated troponin levels of 196 ng/L. Urine drug screen was positive for fentanyl and THC. Clinical Opioid Withdrawal Scale (COWS) score was calculated at 16. Subsequent troponin levels continued to rise, peaking at 4027 ng/L. Electrocardiography at that time revealed sinus tachycardia, and the patient remained free of chest pain. Chest X-ray did not identify any acute pathology. Transthoracic echocardiography demonstrated reduced left ventricular ejection fraction of 20%, with hyperkinesis of the proximal myocardial segments and the distal apex. Coronary angiography revealed non-obstructive and non-stenotic coronary arteries, with anterior akinesis and hyperdynamic basal segments consistent with a variant of Takotsubo Cardiomyopathy. Right heart catheterization showed mildly elevated pulmonary artery pressures. The patient was initiated on beta-blocker and ACE inhibitor therapy; however, further goal-directed medical therapy was limited due to episodes of hypotension. Buprenorphine was restarted during hospitalization, and the patient was subsequently discharged to a drug and alcohol rehabilitation center on buprenorphine 8 mg/2 mg twice daily. IMPACT/DISCUSSION: Given the rising opioid epidemic, Takotsubo Cardiomyopathy (TTC) should be recognized as a potential complication of opioid withdrawal in patients exhibiting cardiovascular symptoms. Stress-induced catecholamine release and adrenergic hyperactivation, leading to myocardial stunning, are key mechanisms in TTC. Although our patient did not exhibit clinical signs of heart failure, an elevated troponin level prompted us to perform an echocardiogram, which ultimately confirmed the diagnosis. It is possible that withdrawal-associated TTC is underdiagnosed due to limited awareness among clinicians. There should be high clinical suspicion and thorough history-taking in this regard. Early initiation of medications for opioid use disorder to treat withdrawal symptoms and implementation of goal-directed medical therapy may be associated with improved clinical outcomes.

This case highlights Takotsubo Cardiomyopathy as a rare but significant complication of opioid withdrawal. Prompt recognition and treatment of withdrawal-associated TTC are crucial for optimal outcomes. Increased awareness among clinicians is essential to ensure timely management and prevent underdiagnosis in this vulnerable population. WHEN WATER REPLACES FOOD: A RESTRICTIVE EATING DISORDER PRESENTING AS PRIMARY POLYDIPSIA Ashish Bibireddy, Irene Rahman, Alison Koransky. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273223) CASE: A 28-year-old male with a medical history of asthma, possible developmental delay, and possible obsessive-compulsive disorder was admitted to the hospital fifteen times this year due to hypoosmolar hyponatremia. Most recently, he presented with a sodium level of 104, resulting from his intake of 15-30 glasses of water daily. Upon admission, he was asymptomatic and did not show any signs of active suicidal ideation, auditory or visual hallucinations, or paranoia. He lives with his grandmother, works part-time in information technology, and plans to pursue a master's degree. Over the past year, his sodium levels progressively dropped despite multiple hospitalizations, weekly blood draws, and both inpatient and outpatient psychiatric involvement. The patient declined anti-psychotic medications due to concerns about potential weight gain. During each hospitalization, he received appropriate treatment, which included fluid restriction and DDAVP, under the guidance of the nephrology team. He required one-to-one nursing observation due to his continued water intake while in the hospital. Inpatient consultants recommended increasing his salt intake to enhance solute levels, but he declined to implement this as an outpatient. Given his frequent hospitalizations and disruptions in psychiatric care, the diagnosis of his condition was limited to primary polydipsia. Ultimately, after coordination with both inpatient and outpatient care teams, he was admitted to a psychiatric unit where he was diagnosed with a restrictive eating disorder. The patient revealed that after being told to lose weight three years earlier, he started drinking water to replace food intake. The patient was subsequently transferred to an inpatient eating disorder unit, where he has maintained stable sodium levels for two months and has plans to transition to outpatient care. IMPACT/DISCUSSION: Our patient’s goal of reducing caloric intake by consuming large amounts of water connects primary polydipsia with a restrictive eating disorder. While similar cases have been documented in the literature, this clinical vignette remains rare, and there are no established treatment recommendations. This case is particularly unique due to its chronic nature, as the patient remained asymptomatic despite dangerously low sodium levels. Though most cases are typically seen in adolescent females, our patient highlights that this issue can also affect other populations. The patient has started to show improvement with intensive therapy and careful coordination among their healthcare providers. However, the challenges in managing this case and the continued risk of recurrent hospitalizations emphasize the need for further research into treatment options for similar patients.

Restrictive eating disorders can manifest as primary polydipsia. Currently, there is no standard care for these patients. An interdisciplinary approach and a strong therapeutic alliance are essential for ensuring patient responsiveness to treatment. XYLAZINE ADULTERATION IN SUBSTANCE USE DISORDER: A CASE REPORT OF NECROTIC WOUNDS AND CELLULITIS Maisa Elbadawi, Polly D. Fraga. Internal Medicine, Lahey Hospital & Medical Center, Burlington, MA. (Control ID #4270460) CASE: A 30-year-old female with a history of intravenous polysubstance use disorder involving fentanyl combined with xylazine, amphetamines, and benzodiazepines for 11 years, recurrent MRSA cellulitis/abscesses, and anxiety/depression, presented with bilateral upper extremity non-healing ulcers. She complained of left upper extremity pain and swelling for 3 days, which led to the discovery of bilateral necrotic wounds. She admits to mixing xylazine into her drugs to potentiate the effect. On physical examination, she displayed no acute distress, had a non-toxic appearance, and was found sleeping but easily awakened. Bilateral forearm skin ulceration extended deep through the dermis with intermittent areas of less ulcer ated skin. The left hand appeared globally swollen, erythematous, and tender to palpation. Laboratory findings revealed abnormalities such as elevated CRP, low hemoglobin levels, and positive urine toxicology screen for fentanyl, amphetamines, and benzodiazepines. CT imaging of the bilateral upper extremities demonstrated cellulitis. The patient underwent Incision and Drainage of the left upper extremity abscess with plastic surgery and was initially treated with Vancomycin and Cefepime, later switched to Daptomycin. Despite some improvement, she continued to experience pain, jitteriness, anxiety, diaphoresis, and tremors, prompting her to leave against medical advice. Oral cefadroxil and doxycycline were prescribed upon discharge. IMPACT/DISCUSSION: Xylazine, an animal sedative and analgesic, is a potent alpha-2 adrenergic agonist often used as an adulterant in illicit drugs. This can lead to severe complications and present challenging management scenarios in clinical practice. The misuse of xylazine has become a concerning trend among individuals with substance use disorders. According to statistics from the Massachusetts Drug Supply Data Stream (MADDS), xylazine was detected in 28% of the 263 opioid samples tested in Massachusetts in 2022. Data from the Massachusetts Bureau of Substance Addiction Services and the Bureau of Health Professions Licensure also indicates that xylazine was present in 5% of opioid overdose-related deaths.Xylazine, when used in combination with other substances such as opioids and stimulants, can result in a myriad of adverse effects, including tissue necrosis, cellulitis, and abscess formation.

In this case, the patient was presented with bilateral necrotic wounds and cellulitis in the upper extremities, suggestive of the toxic effects of Xylazine adulteration. The presence of subcutaneous edema, skin thickening, and axillary adenopathy further underscored the severity of the soft tissue infection. Management of Xylazine-related complications pose a clinical challenge due to the limited understanding of its pharmacokinetics and toxic effects in humans. Treatment typically involves aggressive wound care, antibiotic therapy, and surgical intervention when necessary. “GAS STATION HEROIN” – THE RISING USE AND DANGERS OF CONVENIENCE STORE SUPPLEMENTS Kevin Wang1; Helen C. West2. 1Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; 2Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC. (Control ID #4273254) CASE: 33-year-old male with history of tobacco and cannabis use, anxiety, and depression presented with 1 day of severe agitation and visual hallucinations. His exam showed sinus tachycardia, diaphoresis, and normal pupils. Labs showed normal metabolic panel and blood counts, positive cannabinoid and opiate toxicology, and no intracranial pathology on imaging. Due to significant agitation, the patient required multiple doses of antipsychotics and benzodiazepines before ICU transfer for dexmedetomidine infusion and scheduled benzodiazepines. Discussion with family revealed no history of alcohol use, but 7 ED visits over the past 1.5 years all in relation to cessation of a legal supplement called Zaza Silver – a combination of tianeptine and phenibut. Opioid comfort medications and baclofen were initiated. Within 24 hours, he returned to his previous mental status. After discharge he established care with primary and addiction care, and initiated buprenorphine/naloxone in addition to baclofen, clonidine and gabapentin. He did not return to the ED and has been abstinent from tianeptine since. IMPACT/DISCUSSION: Tianeptine is an atypical antidepressant with mu-opioid agonism marketed as a supplement to boost mood, enhance concentration, and suppress appetite. Sold online and in stores as Zaza, Pegasus, Neptune’s Fury, and Tiana, it is nicknamed “Gas Station Heroin” for its easy access, euphoric effects, and use as a “natural” alternative to opioids. Tianeptine is frequently combined with phenibut – a GABA-B receptor agonist also sold to boost cognition and reduce anxiety. Tianeptine intoxication symptoms include agitation or lethargy, tachycardia, hypertension, nausea, and respiratory depression; phenibut intoxication varies between agitation and somnolence, tachy- or bradycardia, and mydriasis. Treatment is not standardized and includes supportive care with occasional benzodiazepine or antipsychotic use for agitation with either substance. Tianeptine-related respiratory depression has been successfully treated with naloxone as well. Withdrawal symptoms mimic those of opioids and GABAergic agents, with agitation, psychosis, and autonomic instability. For acute, severe withdrawal, antipsychotics, sedatives and GABAergic agents can be considered. For protracted withdrawal and ongoing cravings after acute treatment, opioid comfort medications like clonidine and medications for opioid use disorder can be considered.

- Tianeptine is a readily available supplement with mu-opioid activity often mixed with phenibut and marketed as an anxiolytic and cognition booster. - Intoxication from either substance has varying presentations and often requires supportive care and consideration of naloxone for respiratory depression. - Withdrawal from either substance can result in severe agitation and psychosis and may benefit from opioid and/or GABAergic agents if conservative management fails. Clinical Vignette - Quality Improvement and Patient Safety MINDING THE GAP: DISCHARGE PLANNING FOR COMPLEX PATIENTS Amanda Y. Wang, Manizha Kholmatov, Alice J. Tang. Internal Medicine, Weill Cornell Medicine Joan and Sanford I Weill Department of Medicine, New York, NY. (Control ID #4270165) CASE: A 45 year old woman with cirrhosis, CKD, HIV, h/o Steven Johnson Syndrome from sulfa-exposure was admitted to initiate hemodialysis (HD) due to ESRD. Throughout the hospitalization, the patient demonstrated significant distrust of the medical system and was reluctant to start any new medications or HD due to her history of SJS. On the day of discharge, she became overwhelmed upon learning of simultaneous nephrology and dialysis appointments across town, which conflicted with her limited Medicaid transportation and safety concerns about traveling in her neighborhood during evening hours. Ultimately, the discharge was delayed, and the patient did not attend her follow-up nephrology appointment. IMPACT/DISCUSSION: The discharge period is a particularly vulnerable time, with 1 in 5 patients experiencing an adverse event within 5 weeks. Yet, discharge planning, including coordination of follow up care, often fails to appropriately involve the patient due to time pressure or lack of resources. This patient exemplifies multiple complex risk factors for post-discharge complications, including medical complexity, limited social support, fractured healthcare relationships, and significant treatment transitions. Additional risk factors for adverse events at discharge include advanced age, disabilities, major illnesses or hospitalization within the past year, polypharmacy, and poor functional status. The discharge process revealed systemic failures in patient-centered care, highlighting critical gaps in communication, coordination, and individualized planning. The case underscores the necessity of a comprehensive, empathetic approach to discharge planning that goes beyond medical logistics. Key barriers included inadequate communication about follow-up requirements, lack of consideration for patient-specific transportation and safety constraints, and minimal patient engagement in care transition planning. Existing literature emphasizes these key components of a collaborative discharge with: empathetic language, anticipating patient needs, collaborative discharge planning, providing actionable information, and providing uninterrupted care with minimal handoffs. This patient would benefit from a more holistic, patient-centered discharge framework that considers individual social determinants of health, transportation limitations, and personal safety concerns. By proactively addressing these factors, healthcare teams can potentially reduce missed appointments, improve treatment adherence, and mitigate post-discharge complications.

Hospital discharge is a vulnerable time for patients, and discharge planning should involve a patient-centered approach, involving patients, caregivers and outpatient providers when possible. The key components of patient-centered discharge planning include empathetic language, anticipating patient needs, collaborative discharge planning, providing actionable information, and providing uninterrupted care with minimal handoffs. OPPORTUNITY FOR SYSTEM IMPROVEMENT: ACCIDENTAL IATROGENIC INSULIN OVERDOSE IN THE INPATIENT SETTING Haya Kaliounji, Katherine E. Zimmerman, Samantha King, Ivor Douglas. School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4271213) CASE: A 64-year-old male with a past medical history of chronic kidney disease, type 2 diabetes mellitus, and hypertension presented to the emergency room for a serum potassium of 6.1 mEq/L on outpatient labs. He was admitted to medicine for hyperkalemia. On hospital day three, the medical team ordered 10 units of intravenous (IV) regular insulin with 10% dextrose in water for potassium shifting. The patient’s nurse inadvertently drew up 10 mL of insulin, and a second nurse administered it, resulting in the patient receiving 1000 units of IV insulin. The error was immediately recognized, and a rapid response was called. The patient’s vital signs were stable at the time, and mental status was normal. He was immediately transferred to the medical intensive care unit (MICU) for central line placement and a continuous infusion of 50 % dextrose in water to maintain blood glucose levels above 100 mg/dl. Labs were frequently monitored to maintain potassium levels between 3.5 and 4.5 mEq/L. The dextrose drip was discontinued after approximately 15 hours with continued close continuous glucose monitoring. Although the patient’s blood glucose level dropped below 100 mg/dl once, he did not develop symptoms of hypoglycemia. IMPACT/DISCUSSION: This incident represents a clear medical error but also highlights several areas for system improvement. Upon debriefing with the care team, it was discovered that our hospital typically stocks IV insulin in 3 mL vials, but only had 10 mL vials in stock at the time due to supply shortage. Ten mL were inadvertently drawn instead of 10 units. The nurse responsible for drawing up the insulin was a new graduate, unfamiliar with the difference in vial sizes. In hopes of preventing similar errors in the future, there may need to be additional checks on high-risk medication administration. Given the risks of insulin overdose, a second check of proper dosing using either the electronic medical record or another nurse may be warranted. In addition, for protocolized doses of medications (such as in the case of insulin for shifting potassium), doses should be pre-packaged to prevent error. Despite the medical error, the patient did not experience any symptoms of hypoglycemia but still experienced a MICU upgrade, central line placement, more frequent lab draws, and additional days in the hospital.

Iatrogenic insulin overdoses, though rare, serve as an opportunity to reflect on clinical system gaps and implement changes to prevent further mistakes. Implementing specific changes, such as standardizing insulin vial sizes, could significantly reduce the likelihood of similar errors in the future. Fostering a culture of honesty and continuous improvement, rather than one of blame, is essential for ensuring patients receive timely, high-quality care in the event of a medical error REPEATING THE COLONOSCOPY: TRIALING NEW THERAPIES FOR TREATMENT OF IBD Madeline M. McCabe. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4273330) CASE: A 59-year old man with GERD, hypertension, and ulcerative colitis (UC) on upadacitinib who presented with 1 week history of bloody diarrhea and crampy abdominal pain. He was recently admitted 2 months ago and treated with a 5 day course of oral steroids for a presumed UC flare with incomplete resolution of symptoms. Vitals were stable. Labs were notable for leukocytosis to 11.3, C-reactive protein elevated to 13.2. Stool testing negative for infection, fecal calprotectin elevated to >8000. CT abdomen showed mild colitis. He was diagnosed with UC 15 years ago and was treated with mesalamine. He was largely able to maintain disease remission until first significant UC flare 5 years ago. Colonoscopy at this time showed severe pancolitis. Subsequently he was treated with adalimumab, tofacitinib, and vedolizumab, all without significant improvement in symptoms. He was started upadacitinib 2.5 years ago with initial 2 year remission of symptoms. There was no follow up colonoscopy. He was admitted to the medicine service and underwent a colonoscopy that showed severe extensive Crohn's colitis; mucosa was severely inflamed with deeply ulceration from the sigmoid to the hepatic flexure. The rectum was relatively spared with only mild disease present. Given severity of colonoscopy findings and diminished quality of life with recurrent UC flares, the patient elected for a total colectomy and was discharged home. IMPACT/DISCUSSION: This patient had originally been diagnosed with Crohn’s disease 15 years ago, however the diagnosis was later changed to UC. Based on the colonoscopy results during this presentation, the relative rectal sparing compared to severe disease process in sigmoid colon made the appropriate diagnosis unclear. Some diagnostic possibilities were discussed. Ulcerative colitis remains a possibility as the disease was limited to the colon; treatment with upadacitinib could have been more effective in the different parts of the colon with better disease control in the rectum than in the sigmoid colon. Conversely, with relative rectal sparing, the original diagnosis of Crohn’s disease may be more appropriate, and the patient should be counseled that colectomy may not be curative. Diagnosis remains conjecture as there was no follow up colonoscopy preformed during the patient’s 2-year remission in symptoms. Despite subjective history of clinical improvement, it is unknown if disease was ever well controlled with upadacitinib, and if the current presentation represents an acute flare versus a chronic 2-year progression of disease. Given severity of colonoscopy findings, chronic progression appears more likely.

- Appropriate follow-up for starting a new medication for IBD treatment involves a repeat colonoscopy after initiating treatment, regardless of subjective clinical improvement. - The diagnosis of Crohn’s disease and Ulcerative Colitis can change over a patient’s clinical course and should be revisited based on most recent clinical findings. Clinical Vignette - Social Determinants of Health A CASE OF LATE-DIAGNOSED PULMONARY HYPERTENSION Varsha Venkatakrishna. Internal Medicine, Lenox Hill Hospital, New York, NY. (Control ID #4273610) CASE: A 47 year old male with a history of HIV, obstructive sleep apnea (OSA), daily methamphetamine use, hypertension (HTN), and remote provoked pulmonary embolism (PE) presented for progressive dyspnea on exertion, fatigue, and weight gain. Patient was tearful on presentation, stating while symptoms were debilitating, prior emergency departments visits yielded unremarkable results. He expressed worry that his occupation as a sex worker was a barrier to adequate workup. Initial vital signs showed a temperature of 98.2, heart rate of 78, blood pressure of 121/84, respiratory rate of 18, and oxygen saturation of 95% on 2L via nasal cannula. Initial lab work revealed a complete blood count and metabolic panel entirely within normal limits, with the exception of total protein to 8.4. Chest X-ray and computed tomography angiography (CTA) of the pulmonary arteries were unremarkable. Physical exam was significant for itting edema in lower extremities, prompting concern for heart failure. Transthoracic echo (TTE) was performed, which revealed normal left ventricular size and function, mild right ventricular hypertrophy with normal function, and elevated pulmonary artery systolic pressure (PASP) of 43. Given the patient’s risk factors for pulmonary hypertension including HIV, OSA, and chronic methamphetamine use, the patient underwent a right heart catheterization (RHC) which revealed a PASP of 70 and a mean pulmonary artery pressure (mPAP) of 43. The patient was managed with diuresis and initiated on sildenafil for PH. IMPACT/DISCUSSION: PH is characterized by a mPAP greater than 20mmHg that is usually diagnosed on TTE and confirmed with RHC. PH is subclassified by etiology: Group I (including idiopathic, HIv, and OSA), Group II (left heart disease), Group III (lung disease, including OSA), Group IV (pulmonary artery obstructions), and Group V (unclear or multifactorial mechanisms). The patient in the present case likely had Group I and Group III PH due to his history of HIV, OSA, and chronic methamphetamine use. The diagnosis is often delayed, as the common presenting symptoms of dyspnea, fatigue, exertional chest pain, syncope, and weight gain are frequently misattributed to age and deconditioning. In the present case, bias against the patient’s race, HIV diagnosis, and history of drug use and sex work may have further contributed to misattribution of symptoms. As untreated PH is associated with extremely poor prognosis, it is important to consider this diagnosis in patients presenting with debilitating fatigue, dyspnea, and weight gain when they present with risk factors of PH.

- Clinicians should consider the diagnosis of pulmonary hypertension in patients with risk factors of PH such as HIV, OSA, and methamphetamine use. - Clinician should be aware of racial and sexual minority biases that may impact diagnosis of PH A CHALLENGING CASE OF NAVIGATING INSULIN DEPENDENT DIABETES Elizabeth D. Auckley1; Claire Bollinger3; Erin N. Marcus2. 1Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; 2University of Miami Miller School of Medicine, Miami, FL; 3The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4269837) CASE: A 48-year-old woman presented to a midwestern tertiary care endocrinology clinic for follow up of her poorly controlled type 2 diabetes mellitus, complicated by peripheral neuropathy, in August 2022. The patient reported that she was taking insulin aspart, insulin glargine, metformin, empagliflozin, and dulaglutide as prescribed. She used a continuous glucose monitor (CGM) to check her glucose and stated she had been getting alerts from it several times daily about hyperglycemia and hypoglycemia. She stated she wasn’t sure what alerts to believe, as she is “always hot and sweaty,” and was not sure if her diaphoresis represented a true glucose related symptom. POC A1C at this presentation: 7.2 POC A1C 3 months prior: 9.1 CGM report demonstrates successful use 20% of the time Further discussion revealed the patient had several episodes of diaphoresis, nausea, weakness, confusion, and fatigue associated with hypoglycemic alerts from her CGM. Alerts continued despite resuscitation with glucose. These episodes occurred during a recent heat wave with temperatures above 100F, when the patient was at home. She reports being unable to afford air conditioning in her rented apartment and using ice packs to cool herself during these episodes, including on her arm near the CGM. Her CGM report and symptoms were difficult to interpret as either device malfunction due to sweat and ice, or true hypoglycemia. Thus, medication adjustments were not made. IMPACT/DISCUSSION: Extreme weather events, like heat waves, are increasingly common and affect widespread geographical areas in this era of climate change. While CGMs are standard of practice for insulin dependent diabetes - and are known to significantly improve glycated hemoglobin, patient engagement, diabetes-related distress, and fear of hypoglycemia – they may pose an additional challenge for patients most vulnerable to climate change. Most CGM users will experience device disruption or malfunction at some point, which commonly lead to hypoglycemic events. It has been theorized that changes to skin perfusion, blood pressure, temperature, and medications may adversely impact the function of CGMs, and there is a need for more investigation of this topic. Environmental exposure is an important consideration when prescribing and counseling on CGM use for patients vulnerable to climate change.

-CGMs are standard of care for insulin dependent diabetes but can malfunction -Extreme weather events, such as heat waves, are increasingly common, and may cause unforeseen complications for economically vulnerable patients who rely on insulin and CGMs for diabetes management ATYPICAL INFECTIONS IN NEWLY ARRIVED MIGRANTS AND IMPLICATIONS IN TRANSITIONS OF CARE Pooja Parekh1; Ethan Molitch-Hou2. 1Internal Medicine Residency Program, The University of Chicago, Chicago, IL; 2Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4269417) CASE: In the last 3 years, the city of Chicago has seen a large influx of Hispanic immigrants as a safety net sanctuary state. Three cases of South American immigrants who resided in temporary housing highlight travel-related infections and challenges in post-hospitalization care. Case 1: A 30 year-old male presented with fevers, facial swelling, eye swelling and pain, and a whole body rash after migrating one week prior. He had exposure to a similar rash at his shelter. Physical exam noted vesicular and papular lesions of the face and upper body. He had proptosis and pain with extraocular movements of the right eye. Varicella was diagnosed by skin biopsy. Computed Tomography (CT) showed orbital cellulitis and abscess. Acyclovir was started and the abscess was drained. He remained hospitalized for 24 days until all lesions were crusted over due to shelter requirements. Case 2: A 27 year-old pregnant female presented for delivery after immigrating 3 months prior. Prenatal records showed a positive QuantiFERON gold test and a chest X-ray with left apical airspace opacities. Treatment was deferred until after delivery as she was asymptomatic, however, Chest CT this admission showed scattered micronodules in the apical lungs requiring treatment for active TB. She was isolated from her infant after delivery and discharged with airborne precautions to a shelter. Her infant was discharged after she completed 2 weeks of isolation while on TB treatment per shelter requirements. Case 3: A 27 year-old trans-female presented altered with seizures requiring intubation 2 months after immigrating. History was notable for chronic abdominal pain, diarrhea, and use of intranasal cocaine. She is sexually active with men and women with inconsistent condom use. Entamoeba Histolytica was positive on stool testing as well as new Human Immunodeficiency Virus (HIV) infection found on serologic testing. She was extubated after recovery from toxic-metabolic insults and follow-up at a non-profit clinic for the LGBTQ+ community was arranged. IMPACT/DISCUSSION: The large influx of immigrants causes strain on temporary housing with overcrowding and spread of infectious disease. Parasitic infections, hepatitis, and tuberculosis are commonly acquired. Varicella and measles infection in Chicago have doubled. Health disparities are compounded by lack of citizenship, financial and housing insecurity. Lack of health insurance, fear of deportation, and unfamiliarity with the healthcare system cause delayed identification and treatment of illnesses. Communicable disease must be controlled with collaboration between providers, hospital systems, and public health departments.

These cases underscore the complexities of managing travel-related infectious diseases with the limited resources and crowded living conditions in shelters. The underlying health and social vulnerabilities heighten risk for delayed diagnosis, treatment, and post-hospitalization care. BEHIND THE VEIL: HOW HIV-RELATED STIGMA HID A DIAGNOSIS IN PLAIN SIGHT Zoya Khan, Emma R. Weiland, Adriana Morales, Andrea Rodriguez Jimenez. Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4273243) CASE: A 38-year-old Caucasian male with no reported medical history presented with one-year history of progressive left leg swelling, a non-pruritic rash to his thigh, and worsening dyspnea over six months, with hemoptysis. He was evaluated for these symptoms one year prior and diagnosed with idiopathic lymphedema, with ineffective prior steroid and antibiotic treatment. Despite cachexia and temporal wasting, an HIV test was not performed until his hospitalization. Testing revealed HIV with a viral load of 498,000 copies/mL, CD4 count of 31 cells/mcL, and skin biopsy of the rash confirmed Kaposi sarcoma. Chest imaging identified a large right perihilar mass and pulmonary nodules, suggestive of disseminated KS. The patient was started on prophylactic antibiotics and referred for HAART initiation. IMPACT/DISCUSSION: HIV is a chronic retroviral infection that progresses to AIDS if untreated, predisposing individuals to opportunistic infections and malignancies such as Kaposi sarcoma. Early symptoms are often non-specific, contributing to misdiagnosis, especially in patients perceived as low-risk based on demographics or reported behaviors. This patient faced delays due to anchoring bias, such as fixation on idiopathic lymphedema and cellulitis, and confirmation bias regarding his perceived low-risk profile. Additionally, societal stigma surrounding HIV may have deterred the patient from disclosing risk factors. These biases delayed appropriate diagnostic testing, emphasizing the need for vigilance in evaluating patients with systemic symptoms. Early HIV testing and intervention with HAART are critical to preventing severe complications and improving patient outcomes.

This case recognizes the importance of overcoming implicit biases and stigma in diagnosing and managing HIV/AIDS. Unbiased and comprehensive evaluations can prevent delays in diagnosis, allowing timely initiation of HAART and reducing the burden of complications. It serves as a reminder to maintain a high index of suspicion for HIV/AIDS in patients presenting with unexplained systemic symptoms, regardless of the perceived risk. BEYOND THE MURMUR: A CASE OF UNDIAGNOSED SEVERE RHEUMATIC HEART DISEASE IN A SOCIOECONOMICALLY DISADVANTAGED PATIENT FROM THE UNITED STATES CHRISTINE REED MD, HELENE STRAUSS MD, PEGGY LEUNG MD Christine Reed, Helene Strauss, Peggy B. Leung. Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4272564) CASE: A 30-year-old American-born woman from a low socioeconomic background with a childhood history of an unspecified heart murmur underwent elective lumbar fusion for back pain after a motor vehicle accident. Postoperatively, she developed severe dyspnea and volume overload. Physical examination revealed a I/VI holosystolic murmur with a soft diastolic rumble at the apex, which had also been noted in pre-operative documentation. Transesophageal echocardiogram confirmed rheumatic mitral valve disease with severe stenosis and mild regurgitation. The patient was successfully treated with diuresis and subsequently underwent balloon mitral valvuloplasty. Initial monthly penicillin G intramuscular injections for secondary prophylaxis were modified to daily oral penicillin due to logistical challenges. IMPACT/DISCUSSION: This case illustrates how the perioperative period can unmask symptoms of undiagnosed valvular disease, underscoring the importance of preoperative evaluation. While many murmurs in asymptomatic young adults are benign, attention to specific features such as location, timing, and intensity differentiate potentially pathologic murmurs that should be investigated with echocardiography. This patient’s apical and diastolic murmur would have merited further preoperative identification with transthoracic echocardiography and likely prevented her postoperative complications. RHD, though rare in the United States with an incidence of less than 2 cases per 100,000 school-aged children, disproportionately affects socioeconomically disadvantaged populations. A 10-year U.S. multicenter review by De Loizaga et al. found 947 cases of pediatric acute rheumatic fever (ARF) and RHD, with most patients lacking travel to endemic regions. The study revealed a strong correlation between socioeconomic deprivation and increased disease incidence and severity, attributed to limited healthcare access and secondary prophylaxis barriers. Additionally of importance is recurrent ARF episodes increase the likelihood of developing severe chronic valvular disease. Guideline-directed standard secondary prophylaxis with monthly intramuscular penicillin injections for 10 years or until age 40 can be difficult to sustain. Recent American Heart Association guidelines suggest that daily oral prophylaxis may provide a more accessible alternative to monthly intramuscular injections, potentially improving long-term treatment adherence.

This case highlights the role of physical examination and echocardiography in pre-operatively diagnosing murmurs with pathologic features. It also underscores the need to consider RHD as a diagnosis, particularly among socioeconomically disadvantaged populations in high-income countries like the United States, and to address barriers to effective secondary prophylaxis. BRITTLE TRUTHS: SOCIAL AND STRUCTURAL DETERMINANTS IN A FRAGILE CASE OF SECONDARY HYPERPARATHYROIDISM Sarah Soniwala, Sarah B. Merriam. Internal Medicine, UPMC, Pittsburgh, PA. (Control ID #4271709) CASE: A 61-year-old long-time childcare worker with a history of low weight (BMI 16) presented with subacute onset of fatigue and bilateral rib pain exacerbated by movement following increased lifting/bending at work. She denied fevers, chills, night sweats, joint pain, other bony pain, change in weight/appetite, or mood symptoms. She is unmarried, not sexually active, and lives alone with little social support outside of coworkers. PHQ-9 screening was not concordant with mood disorder. Workup was notable for normal TSH, iron studies, A1c, and lipid panel. Celiac screen, HIV, and age-appropriate cancer screening were negative. A vitamin B12 level was 230 (L) and MMA 2954 (H). CMP was normal apart from ALP 277 (H) that prompted further evaluation with calcium (9.5), phosphorous (4.2), vitamin D (undetectable), and PTH (1433). DEXA with L1-L4 Z-score –3.4. Further history revealed the patient follows a vegan diet with transportation barriers limiting access to fresh produce. Her profound secondary hyperparathyroidism was treated with high-dose vitamin D supplementation with subsequent normalization of PTH and resolution of rib pain, which was ultimately attributed to osteomalacia. IMPACT/DISCUSSION: This case highlights a unique presentation of profound, minimally symptomatic, secondary hyperparathyroidism in the context of significant malnutrition. Primary hyperparathyroidism was unlikely given normocalcemia and phosphatemia, though these were closely monitored during nutritional supplementation to rule out masked hypercalcemia from hypovitaminosis D. Care required acknowledging and addressing social and structural determinants of health. Her job as an early childhood caregiver with low wages and little paid time off hindered her ability to access nutritious food and healthcare. Her neighborhood, a food desert, coupled with her dietary restrictions, made her reliant on highly processed options for sustenance. She also faced transportation insecurity, depending on multiple transfers on public transit to reach the few available grocery stores and primary care clinic. These factors compounded to impact her nutrition and healthcare access, perpetuating a cycle of disadvantage. Treatment required a holistic approach with interprofessional collaboration to identify community organization fresh produce drop points and transportation assistance.

Secondary hyperparathyroidism from vitamin D deficiency can present with bony pain from osteomalacia. When assessing for inadequate dietary intake of vitamin D, clinicians should evaluate for contributing social determinants of health such as economic stability, neighborhood, transportation, and access to nutritious foods and healthcare. Advocating to address these factors is critical to providing equitable care and reducing health disparities. CHALLENGES OF HONORING AND IMPLEMENTING ADVANCED DIRECTIVES FOR INCARCERATED PATIENTS Rachel Robbe1; Anna-Maria South2. 1Internal Medicine, University of Kentucky, Lexington, KY; 2Internal Medicine, University of Kentucky, Lexington, KY. (Control ID #4271692) CASE: A 70-year-old incarcerated nonverbal man without capacity was admitted several times over 2 years for sepsis due to diabetic foot ulcers and osteomyelitis. When he had capacity, he signed a notarized and witnessed advanced directive declining escalation of care. After the patient lost capacity, the prison requested a new advanced directive from his family, who wanted to honor the patient’s wishes. He had several amputations for osteomyelitis against his previous wishes. The inpatient team wanted to honor the advanced directive but the medical director at the prison wanted to continue treatment. The team honored the patient’s wishes, and he received inpatient comfort care. IMPACT/DISCUSSION: This case shows the challenges of honoring an incarcerated patient’s wishes, especially when they lose capacity to advocate for themselves. Common misconceptions and the best practices in caring for incarcerated patients are: 1. Advanced directives need to be updated regularly. - A living will is legally binding until a new document replaces it. Incarcerated patients can make their own decisions, including refusal of care and determining their own code status. 2. A warden can make medical decisions for an incarcerated patient. - This could be a conflict of interest. The patient’s advanced directive and the standard process for identifying a healthcare surrogate in their state needs to be followed. 3. Incarcerated patients cannot receive hospice. - Hospice care should be available for incarcerated patients. The core principles of medical ethics were violated in this case. The patient’s autonomy was violated due to the reversal of his advanced directive. Justice was violated when the inpatient team was unable to involve the patient’s family in decision-making due to his incarcerated status. The prison’s involvement impeded equitable treatment. Non-maleficence and beneficence were violated when the patient underwent invasive procedures against his wishes.

Our case shows the challenges with advanced directives in the incarcerated patient population and resulting violations of medical ethics. Advanced directives in the incarcerated patient population can be difficult to implement due to clinician lack of knowledge on the medical rights of incarcerated patients. Incarcerated patients are entitled to the same advanced directive and surrogate policies as patients who are not incarcerated. Clinicians need to become informed of and comfortable with advocating for the rights of incarcerated patients. CYTOMEGALOVIRUS RETINITIS: THE CONSEQUENCES OF DELAYED DIAGNOSIS & ACCESS TO HEALTHCARE Zachary McSween1,2; SAFAA KAMEL1,2; Jessica Madden1,2; Isabel Gossen1,2; Mahmudul Hassan1,2; Roxana E. Lazarescu3. 1St George's University, Saint George's, Saint George, Grenada; 2Internal Medicine, Wyckoff Heights Medical Center, New York, NY; 3Medicine, Wyckoff Heights Medical Center, New York, NY. (Control ID #4271414) CASE: A 26-year-old male arrived at the Emergency Department with a one-week history of generalized weakness, diarrhea, poor appetite, and oral thrush, and 50-pound weight loss over four months, raising concern for HIV. He recently immigrated to the U.S, and primarily spoke Spanish. He reported non-barrier sexual intercourse with female partners but denied prior STIs. His medical and family history were unremarkable, and he was not on any medications. Initial HIV test was nonreactive, prompting confirmatory testing. Clinical suspicion for AIDS led to treatment with oral nystatin and referral to infectious disease specialties. Subsequent tests confirmed HIV-1 infection with a CD4 count of 130 cells/μL and a viral load of 234,815 copies/mL. The care team initiated antiretroviral therapy along with prophylactic TMP-SMX. Three weeks later, he returned with pain above his left eyebrow and restricted visual fields. Fundus examination showed retinal vasculitis, necrosis, and hemorrhage, with macular sparing, and he was diagnosed with CMV retinitis. Treatment with ganciclovir and valganciclovir, resulted in significant improvement. His clinical course was complicated by disseminated Mycobacterium avium complex infection, Cryptococcal meningoencephalitis, anemia, acute kidney injury, and eosinophilia. Serologies were positive for HSV-1/2, while tests for syphilis and toxoplasmosis were negative. Despite treatment, poor ART adherence and unstable housing led to fluctuating CD4 counts between 109 and 157 cells/μL, leaving him at ongoing risk. IMPACT/DISCUSSION: This case presents CMV retinitis in a patient with a CD4 count of 130 cells/μL, challenging the <50 cells/μL threshold for diagnosis. In immunocompromised patients, CMV retinitis presents with blurry vision, floaters, and visual field defects, and early treatment is essential in preventing vision loss. It also highlights the importance of ophthalmologic screening for HIV patients, even those with CD4 counts above 100 cells/μL. The case also raises the possibility of immune reconstitution inflammatory syndrome, triggering latent infections after starting ART. This highlights the need for careful monitoring of newly diagnosed HIV patients. Poor ART adherence, additional HIV-related comorbidities, and social determinants of health hindered complicated his clinical course. This case suggests revisiting the threshold for ophthalmic screening in HIV patients, especially for those with late-onset diagnoses, while also emphasizing awareness of immune reconstitution inflammatory syndrome after ART initiation.

- Routine ophthalmic screening is essential for HIV patients, even those with CD4 counts >50 cells/μL, particularly with late-onset diagnoses. - Consider immune reconstitution inflammatory syndrome after ART initiation, as it can trigger opportunistic infections like CMV retinitis. DIFFERENTIATING LOOK-ALIKE DISEASES Patrick S. Potoczak1; Lizzie Luckashvili3; Nitu Kataria2. 1Lerner College of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; 2Internal Medicine, Cleveland Clinic, Cleveland, OH; 3David Tvildiani Medical University, Tbilisi, Tbilisi , Georgia. (Control ID #4272027) CASE: KR is a 63-year-old male who presented to clinic with an unintentional 50-pound weight loss over one-year, early satiety, and decreased appetite. He denied abdominal pain. His medical history included hypertension, hyperlipidemia, stage 3 CKD, anemia, alcohol use disorder, colon polyps, and hepatitis C. He lives alone with his dog, has limited social support, and transportation challenges. His family history is notable for pancreatic cancer in his father. He is a current smoker with a 50-pack-year smoking history, drinks four alcoholic beverages per week, and uses marijuana daily. He was not taking any medications. On examination, he was alert with a BMI of 21.8, down from 28.2 three years ago. His physical exam had normal cardiovascular, pulmonary, abdominal, and neurological findings. We ordered a basic metabolic panel, HbA1C, complete blood count, cancer screening tests (PSA, TSH, CA19-9, carcinoembryonic antigen, alpha-fetoprotein), colonoscopy, and imaging of the chest, abdomen, and pelvis. KR was advised to follow up in one month. KR returned five months later. Labs showed elevated triglycerides (327 mg/dL) and CA19-9 (102.0 U/mL). Carcinoembryonic antigen was borderline high (2.9 ng/mL), and CBC showed mild anemia (12.3 g/dL, 36.2%). Liver function tests revealed an elevated AST (59 U/L) with normal ALT and albumin. Sodium was slightly low at 131 mmol/L. HCV PCR was negative. He was counseled on the concern for pancreatic malignancy and encouraged to complete imaging. Subsequent imaging revealed diffuse pancreatic parenchymal calcifications consistent with chronic pancreatitis and a 1.7 mm cyst in the pancreatic head, likely a sequela of prior pancreatitis. Treatment was initiated with pancrelipase and thiamine. KR has since gained 4.5 kg. He is scheduled for a 3-month follow-up at the time of this report and referred to gastroenterology. IMPACT/DISCUSSION: This case underscores the importance of complete history taking when formulating a broad differential diagnosis, even when a specific disease is highly suspected. CA19-9 is an accurate diagnostic test, but relying solely on it can lead to a presumptive diagnosis of pancreatic carcinoma, influenced by cognitive biases like anchoring. This case highlights the overlapping features of pancreatic cancer and chronic pancreatitis while emphasizing the discriminating features. Internists who develop a thorough understanding of differences in look-alike diseases are better prepared to avoid diagnostic anchoring, minimize diagnostic delays, and improve patient safety.

The general internist should recognize that signs and symptoms of pancreatic cancer overlap with chronic pancreatitis. Though ruling out malignancy can bring a lot of relief to both the clinician and the patient, it is important to diagnose and manage the alternate pancreatic pathology and address patient concerns. This case highlights the importance of a complete social and medical history and to avoid anchoring on biomarkers of malignancy. ER ELOPEMENT WITH UNSTABLE ANGINA! WHO DOES THAT? Jessica Chen1; Maimuna Marenah2. 1Internal Medicine, University of California San Diego, San Diego, CA; 2School of Medicine, University of California System, Oakland, CA. (Control ID #4271251) CASE: A 61-year-old Chinese speaking only male with hypertension, hyperlipidemia, presented to emergency room (ER) for new onset heavy chest pressure with minimal exertion for two weeks, relieved by rest. He had not taken medication or seen physicians for years. He lived alone and his brother died from acute myocardial infarction at age 64. In ER, BP 171/103, P85. EKG showed inferior ischemia, and Troponins were trending up (20 -> 30 -> 35 ng/L). Patient was admitted to Cardiology for unstable angina versus NSTEMI but continued boarded in ER waiting for a hospital bed. Unfortunately, the patient eloped from ER without notifying staff due to “waiting too long (10 hours)” and “nothing was happening”. The patient later had a Chinese-speaking physician connected to the institution to review his ER medical record. He was emphatically advised to return to ER for unstable angina. He re-presented to ER and received urgent cardiac catheterization, which revealed three vessel coronary artery disease, including 99% stenosis of mid-right coronary (RCA). His chest pain was relieved after successful PCI of the RCA. IMPACT/DISCUSSION: Our 61-year-old patient who initially presented with unstable angina, initially eloped from the hospital before receiving necessary treatment. The patient’s decision was likely due to a combination of low health literacy and miscommunication because of language barrier. Personal health literacy is the extent the individuals can utilize information to make decisions about their health. Factors such as educational attainment, age, poverty, language and cultural context can impact health literacy and how individuals make decisions about their health. Health literacy and language are deeply linked. This patient with unstable angina returned to ER after finally understood his critical medical problem. Low health literacy is more common among elderly persons and among non-native English speakers. Ineffective communication related to language barriers is associated with more hospitalizations, greater use of emergency care, decreased use of preventive services, poorer health status, higher mortality, and higher health care costs. In 2022, an estimated 21.7 percent of the United States population aged 5 years or older spoke a language other than English at home. Communication of risk factors, treatment plans, and next steps can become obscured in the setting of language barriers. Patients who do not speak English proficiently may have difficulty having their questions answered or understanding information offered by medical providers.

1. Addressing language differences is an essential tool for improving health literacy, improving clinical outcomes, and is required by law. 2. Investment in timely and high-quality interpretation services, encouraging hiring of bilingual providers, and improving instruction for trainees and staff are important strategies for reducing healthcare outcomes for non-English speaking patients. NEUROCYSTICERCOSIS ACROSS BORDERS: A GROWING DIAGNOSIS IN THE U.S. Bernita V. Sidhu, Alyssa Heric, Samantha Watts. Internal Medicine, Lankenau Medical Center, Wynnewood, PA. (Control ID #4270898) CASE: A 44-year-old Spanish-speaking male from Honduras, who immigrated in 2006, presented with a week-long history of an occipital headache described as throbbing, accompanied by intermittent blurry vision and dizziness. He had no known medical history and reported trying his wife’s headache medication without relief. He denied taking any regular medications. On admission, his vital signs were stable. Lab results showed a sodium level of 135 mEq/L, blood glucose of 250 mg/dL, AST of 42 IU/L, ALT of 43 IU/L, normal WBC count, and stable hemoglobin. A head CT revealed no acute intracranial abnormalities but noted small, nonspecific cystic foci in the supratentorial brain. An MRI further identified several intracranial cystic lesions in varying stages consistent with neurocysticercosis, including a lesion in the right medial occipital lobe in the colloidal stage and others in the anterior interhemispheric fissure and left cranial vertex in the vesicular stage. The patient was diagnosed with neurocysticercosis and began a 48-hour course of dexamethasone before starting albendazole, praziquantel, and levetiracetam for seizure prophylaxis. Infectious disease consultation recommended an ophthalmologic evaluation to rule out ocular cysticercosis and tuberculosis screening. His headaches showed slight improvement with anti-inflammatories. Further testing revealed an HbA1C of 10.6, and he experienced frequent hyperglycemic episodes due to dietary indiscretions. Diabetes education and endocrinology were consulted to address insulin therapy, as the patient lacked health insurance. He completed neurocysticercosis treatment in the hospital and was discharged on insulin therapy for diabetes management. IMPACT/DISCUSSION: This case highlights the increasing incidence of neurocysticercosis in immigrant populations in non-endemic areas. Imaging and thorough history are essential, as symptoms might otherwise be misdiagnosed as primary headache disorders. Management requires a coordinated approach involving infectious disease, neurology, and ophthalmology teams. Treatment included antiparasitic agents (albendazole, praziquantel), corticosteroids (dexamethasone) to reduce inflammation, and levetiracetam for seizure prevention. Ophthalmologic evaluation ruled out ocular cysticercosis, which could alter treatment plans. The patient’s uncontrolled diabetes posed challenges, as hyperglycemia complicates infection recovery. Addressing this comorbidity was critical.

This case of neurocystericercosis underscores the need for accessible healthcare services for uninsured populations, especially in complex cases with multiple comorbidities, with the need for heightened clinical awareness, especially in non-endemic regions. Public health initiatives should focus on improving healthcare access, early diagnostics, and affordable treatment options for neurocysticercosis in immigrant communities to enhance outcomes. NO FRIENDS, NO FAMILY, NO COLONOSCOPY: LACK OF A CHAPERONE AS A BARRIER TO COLONOSCOPY COMPLETION Alice Zhao, Peggy B. Leung, Helene Strauss. Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY. (Control ID #4272644) CASE: Mr. G, a 66-year-old man with depression, was found to have new iron-deficiency anemia during routine lab work in 12/2022 with a Hg of 13.1, an iron level of 42, and an iron saturation of 11.9%. Having undergone a colonoscopy >10 years ago with inadequate preparation, he was referred to GI for endoscopic evaluation. Despite GI recommendations for EGD and colonoscopy, his procedures were cancelled twice due to a lack of a chaperone to accompany him after the procedure. Living alone without local family or friends, Mr. G experienced significant frustration. After his PCP provided information about a non-profit offering volunteer chaperones in 12/2024, Mr. G was placed on the waiting list at the non-profit and remained eager to schedule his procedures. IMPACT/DISCUSSION: Lack of a chaperone represents a critical barrier to essential medical procedures, particularly for vulnerable patient populations. Research indicates that up to 41% of individuals defer colorectal cancer screening due to transportation challenges, which disproportionately affect safety-net health systems. Proactive institutional interventions can meaningfully address these barriers. For example, endoscopy centers could implement direct communication protocols with primary care physicians when procedural cancellations occur, develop partnerships with non-profit organizations providing volunteer support, and explore innovative transportation solutions like rideshare collaborations (which some safety-net healthcare systems have already conducted pilot studies for). By creating structured support systems, healthcare institutions can directly address social determinants of health that impede medical care. Such strategies transform potential obstacles into actionable solutions, potentially reducing healthcare disparities and improving patient outcomes.

Lack of transportation and chaperone support are significant barriers to patient care. Proactive strategies can be developed to connect patients with community resources and support services. Institutional innovations can address social determinants of health. WHAT’S OLD IS NEW AGAIN: FOOD INSECURITY IN THE 21ST CENTURY Quinn Scallon1; Roshnee Raithatha2; Julie Knoeckel3,1. 1University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 2Internal Medicine Training Program, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 3Hospital Medicine, Denver Health, Denver, CO. (Control ID #4271433) CASE: A 69-year-old male patient presented to the Emergency Room with two months of progressive, non-traumatic, left leg bruising and swelling. His past medical history is significant for a right leg hematoma 5 months prior requiring incision and drainage. Review of systems revealed unintentional weight loss of 40 pounds over the last six months. He lives alone and walking has become increasingly difficult. Upon further review, his diet lacks variety due to difficulty accessing and transporting food and lack of a refrigerator in his home. Exam was notable for diffuse left lower extremity ecchymosis, temporal wasting, and corkscrew hairs over the forearms. There were no signs of mucosal bleeding or hemarthrosis. A CBC was notable for a hemoglobin of 6.8 g/dL. MCV was elevated at 104 fL and platelet count was within normal limits. Protime and INR were normal-to-high at 15.7 sec and 1.19 with a normal PTT. Homocysteine was elevated at 18 mmol/L and methylmalonic acid was within normal limits, with a low serum folate at 6.3 ng/mL and normal serum cobalamin. A left leg CT angiogram demonstrated diffuse left lower extremity edema without arterial occlusion, and an ultrasound was without deep vein thrombosis. Bone marrow biopsy was negative for signs of malignancy. The patient was empirically given thiamine, vitamin C, vitamin K, and multivitamin supplementation during his admission. His vitamin C level was later found to be undetectably low, confirming suspicion of vitamin C deficiency, commonly known as scurvy. Upon discharge he was connected with local food banks to increase his access to varied foods. He was advised to continue vitamin supplementation at discharge. At his outpatient follow-up appointment, he had complete resolution of his ecchymoses and myalgias. IMPACT/DISCUSSION: Bleeding and bruising are common presentations in internal medicine. This case report demonstrates that nutritional deficiencies should remain high on our differentials in patient populations at risk for food insecurity. Incorporating questions about diet and food access into our social histories is essential for identifying and treating nutritional deficiencies earlier.

Scurvy has an estimated prevalence of 6% among the general US population and most commonly presents with clotting abnormalities including purpura, hemarthrosis, muscular hematomas, and myalgias. Laboratory studies can demonstrate anemia with normal coagulation studies and a serum vitamin C level below 0.2 mg/dL. Risk factors for scurvy include a restrictive diet and excess alcohol/tobacco use. At-risk groups include males who live alone, elderly groups, those who are retired, low-income individuals, as well as refugee populations. It is imperative to evaluate for nutritional deficiencies in cases of abnormal bruising and bleeding. Clinical Vignette - Women’s Health, Sex, and Gender-Informed Medicine A BUMP AFTER THE BUMP: A CASE OF POST-PARTUM PREECLAMPSIA DIAGNOSED IN PRIMARY CARE Amy H. Farkas1; Jack Geiger2; Emmanuelle Yecies3. 1General Internal Medicine, Medical College of Wiscponsin, Milwaukee, WI; 2Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; 3Women's Health, VA Palo Alto Health Care System, Palo Alto, CA. (Control ID #4270833) CASE: A 29-year-old G1P1 woman with PMH of anxiety and latent TB, and 13 days post-c-section presented to PCP reporting shortness of breath. Three days postpartum (PP) she had been seen in the ED, where workup was notable for BP 157/101, BNP of 2000, and a CTA negative for PE but consistent with pulmonary edema. She was given labetalol and furosemide. Day 4 PP, BP remained elevated at OB follow-up, and labetalol was increased. At PCP visit on day 13 PP, she reported ongoing dyspnea with exertion and persistent swelling. PCP confirmed that patient had not received magnesium or cardiac work-up. A stat echocardiogram was notable for borderline concentric LVH with preserved EF. The patient was diagnosed with post-partum preeclampsia without cardiomyopathy. IMPACT/DISCUSSION: Post-partum preeclampsia is a highly morbid and underrecognized form of pre-eclampsia, a large contributor to maternal mortality. It can present between 2 days to 6 weeks post-partum and therefore it is critical for internists to recognize its features. In addition to above timeline, diagnostic criteria include elevated blood pressure (140/90) and evidence of end organ damage such as proteinuria, thrombocytopenia, renal insufficiency, transaminase elevation, pulmonary edema, headache, or vision changes. It is important to rule out other postpartum complications with overlapping features such as cerebral venous thrombosis, acute fatty liver of pregnancy, or peripartum cardiomyopathy. Management of post-partum preeclampsia focuses on reducing blood pressure to goal of <140s-150s/90s-100s mm Hg with labetalol or extended release nifedipine. Magnesium infusion for seizure prophylaxis should be used for patients experiencing neurological symptoms or other severe features (such as pulmonary edema). Diuresis can assist with volume optimization. Follow up within 1 week is recommended. Patients should be advised regarding interpregnancy intervals, recurrence risk in subsequent pregnancies, and long-term risks. Any hypertensive disorder associated with pregnancy increases risk for hypertension, diabetes, cardiovascular disease, and more throughout life. HDP history should be considered when assessing CVD risk at primary care visits.

Post-partum preeclampsia is an underdiagnosed condition with the potential for high morbidity, both during the post-partum period and later in life. Internists have an important role to play in recognizing and treating this disorder as well as counseling patients regarding their increased risk for HTN, DM, CVD, VTE, and kidney disease and helping them reduce this risk through preventive health measures. ATYPICAL STRESS CARDIOMYOPATHY ASSOCIATED WITH SEVERE ANEMIA: A CLINICAL VIGNETTE Emily Rodriguez, Rebecca Zeidman, Natasha Qureshi, Atul Bali, Miguel Alvarez Villela. Cardiology, Lenox Hill Hospital, New York, NY. (Control ID #4272364) CASE: A 46-year-old female with a history of ADHD (on dextroamphetamine), iron deficiency anemia, and menorrhagia (on norethindrone) presented with acute heavy vaginal bleeding and exertional dyspnea. She was tachycardic, anemic (Hb 6.1 g/dL), with AKI, pBNP 18k pg/mL, and elevated inflammatory markers. A TTE showed severely reduced LV ejection fraction (EF) 20-25%, global LV hypokinesis, biventricular dilation, moderate to severe tricuspid regurgitation, and pulmonary hypertension. She was hypervolemic, with evidence of end-organ dysfunction and cardiogenic shock requiring inotropes and diuresis. A cardiac MRI was performed after weaning off inotropes and revealed a borderline dilated LV with improving EF to 38% with the absence of late gadolinium enhancement. The patient soon showed normalization of EF with guideline-directed medical therapy. Additional work-up discovered an invasive cervical malignancy, the culprit for vaginal bleeding. IMPACT/DISCUSSION: We describe a case of atypical stress cardiomyopathy (SCM) presenting with cardiogenic shock following vaginal bleeding. SCM occurs due to a result of a catecholamine surge due to stress, which leads to temporary ballooning of the left ventricle (LV). This can present with atypical wall motion patterns or cardiogenic shock form severe LV dysfunction or dynamic left ventricular outflow tract obstruction. While many triggers have been described, to our knowledge, there are no reports due to severe vaginal bleeding. In this case, the inciting event may have been the stress response following acute blood loss and inflammation from a malignancy. Another possible factor is exogenous estrogen use which causes a sympatholytic effect with simultaneous down regulation of beta-adrenergic receptors (ß-AR) in cardiac cells, reducing contractility and cardiac output. Additionally, there is a sympathomimetic effect of dextroamphetamine, which modulates the catecholamines norepinephrine and dopamine, again stimulating the cardiac ß-AR’s and cardiac workload. Furthermore, it has been shown that patients with SCM have a higher prevalence of psychiatric disorders although more commonly seen in the typical variant compared to atypical SCM.

This case underscores the importance of considering atypical triggers for atypical SCM and the need for a multidisciplinary approach in managing such complex cases. BEHIND THE MASK OF URINARY RETENTION: THE CASE OF A BENIGN SPINAL TUMOR Abdul Arham1; Musfira khalid2; faheem javad3; Abira Khalid2; Abdul Waheed4; Muhammad Ahmed Khan5; Lauren Meade1. 1Internal Medicine, Baystate Health, Springfield, MA; 2Medicine, Fatima Jinnah Medical University, Lahore, Punjab, Pakistan; 3Al Nafees Medical College and Hospital, Islamabad, Islamabad Capital Territory, Pakistan; 4Post Graduate Medical Institute Ameer-ud-Din Medical College, Lahore, Punjab, Pakistan; 5Internal Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4270395) CASE: A 54-year-old female with systemic lupus erythematosus (SLE) and hypothyroidism presented to the emergency department with a three days of worsening abdominal pain and urinary retention. She had recently visited urgent care for dyschezia and was diagnosed with hemorrhoids. A CT scan of the abdomen revealed significant urinary retention and findings of pyelonephritis. A Foley catheter was placed and she was started on intravenous ceftriaxone. Urine cultures grew pan-sensitive Escherichia coli. A voiding trial was unsuccessful. Incidentally, while ambulating, the patient had an unperceived bowel movement, raising concern for potential neurogenic dysfunction. Given her immunosuppression from SLE, a broader differential diagnosis was considered. Lumbar MRI identified a 1.9 cm enhancing mass along the filum terminale. Neurosurgical consultation lead to urgent resection with pathology confirming myxopapillary ependymoma. Urinary retention is a common presentation, accounting for over 100,000 hospitalizations annually in the United States. While urinary retention can often occur secondary to urinary tract infection (UTI), this case illustrates the importance of exploring alternative etiologies such as neurogenic. The absence of low back pain initially obscured the diagnosis of an L1 spinal mass. Notably, the patient’s immunosuppressive state could have predisposed her to atypical presentations or masked classic symptoms, emphasizing the importance of vigilance in such populations. In females, urinary retention and bowel incontinence warrant prompt evaluation for lumbar spinal pathology, as mismanagement could lead to significant delays in diagnosis and treatment. This contrasts with the more straightforward diagnostic pathway often followed in males with presumed benign prostatic hyperplasia. IMPACT/DISCUSSION: Ependymomas are rare central nervous system (CNS) tumors, with an estimated prevalence of 0.05–0.08 per 100,000 individuals. These tumors can occur in both pediatric and adult populations, with intracranial ependymomas being more common than spinal ependymomas. Myxopapillary ependymomas, a subtype of spinal ependymoma, are most frequently located in the lumbosacral region and are often benign. Clinical manifestations may include back pain, radicular pain, urinary retention, and bowel incontinence, although subtle presentations can complicate timely diagnosis. The cornerstone of treatment is complete surgical resection while radiation therapy is reserved for recurrent or metastatic cases.

This case underscores the importance of considering occult spinal pathology in patients with urinary retention and bowel incontinence, particularly in the absence of back pain or other overt neurological symptoms. The presence of immunosuppressive conditions such as SLE can further obscure typical presentations. Early recognition and intervention are critical to preventing diagnostic delays and optimizing outcomes in patients with rare spinal tumors such as myxopapillary ependymoma. BREAKTHROUGH BLEEDING IN A NONBINARY INDIVIDUAL ON TESTOSTERONE HORMONE REPLACEMENT THERAPY Lily Ardente, Eric Kutscher. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273364) CASE: A 26-year-old nonbinary individual on weekly testosterone injections presented to primary care clinic with a recurrence of vaginal bleeding for 2 months. The patient had initially started gender affirming hormone therapy (GAHT) two years prior and had been amenorrheic for over a year. At the time of breakthrough bleeding, the patient was taking 40mg intramuscular (IM) testosterone cypionate weekly. Subsequent labwork showed a testosterone level of 501 ng/dL. Despite being within goal levels of 300-1000 ng/dL for GAHT according to WPATH (Costa et al.), the dose was increased to 60mg to address their symptoms. Notably, five months prior, the patient was taking 100mg weekly, however the dose was reduced to 40mg due to supratherapeutic testosterone levels and subsequent risk for adverse effects. Approximately 1 month after the dose increase to 60mg, the patient again achieved amenorrhea. Repeat labwork 3 months after showed a testosterone level of 769 ng/dL, which was again within goal. IMPACT/DISCUSSION: For transmasculine and other gender diverse individuals who previously experienced menstruation, amenorrhea is often a desired effect of initiation of testosterone GAHT and is typically accomplished within 6 months (Ahman and Leinung). However, occasionally trans individuals on testosterone have persistent or breakthrough bleeding beyond this timepoint, which can be dysphoric and lead to undue psychological harm. Although it has been shown that persistent bleeding has been associated with factors such as the use of testosterone gels/cream instead of injectables, higher BMI, and decreased testosterone levels in a limited number of studies (Zwickl et al.), there lacks a clear census on IM testosterone dosing and management of such menstrual symptoms. Furthermore, while it has been shown that increasing doses of testosterone helps to end menorrhea (Ahman and Leinung), there is a paucity of formal guidance on both treatment regimens to do so and appropriate testosterone levels to achieve amenorrhea while balancing side effects of testosterone. This is particularly true for nonbinary individuals who might not desire common side effects of increased testosterone in the body. Additionally, given testosterone’s effects on increasing hematocrit levels, this can serve as a limiting factor in ability to increase testosterone for desired symptomatic control. Due to this, after testosterone dose increases, next steps typically include progesterone, GnRH agonists, IUD, or hysterectomy. It is also important to note the teratogenic nature of testosterone and the need for simultaneous birth control use in patients who are on this GAHT.

GAHT requires a patient centered approach by practitioners. Management of hormone therapy requires discussion with the patient regarding their goals for treatment, how best to achieve these goals, and which medications and surgical specialties may be needed to do so. EGGS, TUBES, AND LIPID BLUES Stacy Tsai, Kenneth M. Fifer. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4267089) CASE: A 46 year old G3P3 with no significant medical history presents to the clinic desiring pregnancy. She reports unprotected intercourse with her partner for over a year without success. She has regular menstrual cycles. OB/Surgical history is notable for 3 C-sections and bilateral tubal ligation. Further history reveals she is seeing a fertility specialist. Current medications are clomiphene citrate, letrozole, and recombinant beta hCG injections. On exam she is well-appearing. Vitals are within normal range. BMI is 34.9. Labs reveal a fasting triglyceride level of 743. TSH, A1C, and metabolic panels were normal. She undergoes in-vitro fertilization without a viable pregnancy. She returns to clinic 6 months later for management of hyperlipidemia. Off medications, repeat lipid panel shows a fasting triglyceride level of 460. Initial severe hypertriglyceridemia is attributed to IVF and clomiphene citrate. IMPACT/DISCUSSION: 1 in 6 adults worldwide is affected by infertility, which is defined as the inability to achieve successful pregnancy with regular unprotected intercourse. Evaluation should be initiated at 12 months if under age 35 and at 6 months if over 35. One large cross-sectional study showed that patients engaged in healthcare had significantly lower odds of infertility. Particularly in settings with limited access to fertility specialists, internists play a critical role in initiating infertility evaluation while awaiting specialist consultation. Work-up of ovulatory infertility includes menstrual history, physical exam, and assessment of fallopian tube patency and uterine cavity with hysterosalpingography. FSH and AMH can be used to assess ovarian reserve, though this is not required for diagnosis. For patients with tubal occlusion, tubal reanastomosis is an option to restore fertility; however, in-vitro fertilization (IVF) is more effective for patients over 35. IVF is a treatment option for ovulatory infertility which involves ovarian stimulation, oocyte aspiration and fertilization, and embryo transfer. Medications used for ovarian stimulation include GnRH modulators and selective estrogen receptor modulators (SERMs) such as clomiphene citrate. SERMs cause a hyperestrogenic state which increases LDL production and reduces triglyceride clearance. To date, 9 case reports of IVF-induced hypertriglyceridemia and pancreatitis have been published, and 2 case reports attributing the complication to clomiphene citrate. Although rare, this potentially life-threatening complication has led fertility providers to obtain lipid panels prior to IVF in patients with risk factors for hyperlipidemia.

Internists play a crucial role in initial evaluation of ovulatory infertility. Internists should be aware of and monitor for metabolic complications of commonly utilized ovarian stimulating medications. HEART TO HEART: PRECONCEPTION CONSIDERATIONS IN HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY Alyssa Heric, Bernita V. Sidhu, Deepa Chellappa. Internal Medicine, Lankenau Medical Center, Wynnewood, PA. (Control ID #4245231) CASE: Patient is a 43-year-old female, G1P1001, who presented to establish primary care. She noted a strong family history of hypertension and had previously been treated herself for hypertension in Cote d’Ivoire but had not been on any medications since immigrating to the United States. During her first office visit, she reported exertional chest pain and dyspnea and was found to have a blood pressure of 211/109. ECG showed normal sinus rhythm, biatrial enlargement, and left ventricular hypertrophy with diffuse T-wave inversions; a repolarization abnormality concerning for hypertrophic cardiomyopathy (HOCM). Her hypertension was treated with nifedipine and valsartan with good response and she was referred to cardiology. A transthoracic echocardiogram revealed severe concentric left ventricular hypertrophy and hyperdynamic systolic function with LV wall thickness in the mid-cavity and apex up to 1.7 cm. There was complete obliteration of the apical and mid-cavity in systole. Cardiac MRI showed disproportionate increase in apical left ventricular wall thickness consistent with apical variant HOCM. During a follow up visit, the patient told her PCP that she was trying to conceive, and she was referred to a cardio-obstetrics specialist. Valsartan was replaced with labetalol and the patient was counseled on the risks associated with HOCM in pregnancy, including arrhythmia and pulmonary edema. As part of her workup, stress echocardiogram was attempted, but non-diagnostic as the patient developed chest pain, tachycardia and significantly elevated blood pressure with exertion. Of note, resting peak LVOT gradient was reassuring at 12 mmHg, though this could not be assessed during stress. Holter monitoring showed no evidence of sustained arrhythmia. She was referred for cardio-genetics counseling. IMPACT/DISCUSSION: Women of childbearing age often first present to their primary care doctor when attempting to conceive. Pregnancy poses significant hemodynamic challenges in women with pre-existing cardiomyopathies making pre-conception risk assessment essential. This should include a thorough history of cardiac symptoms, baseline electrocardiogram and echocardiogram, baseline exercise tolerance, elimination of medications that may cause adverse fetal events, and genetics referral. While most patients with HOCM fall into the Class II group of the World Health Organization maternal cardiovascular risk scheme, women with severe left ventricular outflow tract obstruction, symptomatic arrhythmia, and systolic left ventricular dysfunction are in the higher-risk Class III group. Functional status and signs of heart failure are especially important predictors of the ability to tolerate a pregnancy in this population.

This case illustrates the importance of early recognition of pre-existing cardiomyopathy and prompt workup for cardiovascular risk stratification in patients of childbearing age in order achieve the best chance of a successful and uncomplicated pregnancy. IGNORING RED HERRINGS: DIAGNOSING THE CAUSE OF PICA IN A VEGETARIAN, REPRODUCTIVE AGED WOMAN Megha Shankar, Jessica Chen. Medicine, University of California San Diego, La Jolla, CA. (Control ID #4270081) CASE: A 38-year-old G3P3 female presented with 2-3 months of fatigue and pica with intense craving to eat ice, associated with mild dyspnea on exertion, and dizziness. Patient denied abdominal pain, change in bowel movement or bleeding diathesis. She is a vegetarian since 13 years of age and through her three pregnancies. She has been amenorrheic after total abdominal hysterectomy 7 years ago for cervical carcinoma-in-situ. There is no history of recent travel, but remote travel to Costa Rica, Mexico, and India. Physical exam showed normal vital signs and mild pale conjunctiva. Diagnostic studies showed low hemoglobin 8.9 gm/dL (ref 11.2-15.7 gm/dL), low hematocrit 29.4 % (ref 34-45%), low MCV 69.3 (ref 79-95%), high UIBC 432 mcg/dL (ref 112-346 mcg/dL), low iron 25mcg/dL (ref 37-145 mcg/DL), and low ferritin 5 ng/mL (ref 13-150 ng/mL). FOBT was negative and vitamin B12 was normal at 882 pg/mL (ref 211-946 pg/mL). Stool ova and parasites were negative. Tissue Transglutaminase (tTG) Ab IgA was negative. EGD showed numerous Helicobacter organisms on stain and biopsy confirmed Helicobacter pylori (H Pylori) gastritis. After treatment for H pylori gastritis with quadruple therapy, patient’s anemia resolved. IMPACT/DISCUSSION: Pica is a compulsive eating disorder in which a person eats things that may or may not be food. In adult-onset pica, the most common cause is iron deficiency anemia. In a reproductive aged woman, the most common cause of anemia includes heavy menses, which causes iron deficiency, hence potential pica behavior. An individual who is vegetarian is at risk of vitamin B12 deficiency. However, in this patient who is amenorrheic, has normal vitamin B12 levels with a low MCV, and whose FOBT was negative with negative gastrointestinal symptoms, a broad differential is needed. Celiac disease, which can cause iron deficiency anemia, has been ruled out via Tissue Transglutaminase (tTG) Ab IgA and duodenal biopsy. H pylori infection can cause iron deficiency anemia, particularly in men and post-menopausal women. The pathophysiology includes chronic gastritis, H pylori taking up iron, increased hepcidin production with decrease iron absorption, and decreased stomach acid production (which is needed to absorb iron). EGD was the diagnostic study performed as a part of iron deficiency anemia work up to evaluate for gastrointestinal bleeding. In most cases, a H pylori stool antigen test is recommended over the blood antibody test, which will always be positive if the patient has had H pylori infection. Once H pylori infection was treated, this patient’s iron deficiency anemia resolved without recurrence.

It is important to recognize that H Pylori infection can be a potential cause of iron deficiency anemia and should be part of iron deficiency work up. MANAGING GENDER-AFFIRMING HORMONE THERAPY FOR A TRANSGENDER WOMAN WITH MIGRAINES WITH AURA Gabrielle E. Milner1; Eric Kutscher2. 1Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; 2Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273313) CASE: A 26-year-old transgender woman with migraines, tobacco use disorder, and obesity presented to establish primary care and gender affirming hormone therapy (GAHT) management. She reported starting GAHT at age 22 with estradiol injections 0.8mL biweekly, progesterone and spironolactone. She had undergone gender affirming surgery with a bilateral orchiectomy and discontinued spironolactone and progesterone. She reported a history of migraines 2-3 times per week lasting several hours characterized by nausea, photophobia, phonophobia, and eye pain preceded by an aura of visual changes including floaters and black spots. After starting GAHT she reported more frequent and worsening migraines. She reported that before starting estrogen she was not informed of increased stroke risk among cisgender women with migraines with aura who are prescribed estrogen-containing OCPs, and not informed of the possible increase in thrombosis risk when combined with progesterone. After a risk-benefit conversation, she decided to continue estrogen given its benefit in gender dysmorphia, but not the progesterone, and to modify other risk factors for clots including weight loss (prescribed metformin), smoking cessation (prescribed nicotine replacement therapy), and monitoring for blood pressure and cholesterol control. IMPACT/DISCUSSION: The case raises awareness of the importance of a comprehensive history to inform risk-benefit conversations when starting estrogen as GAHT for trans women with migraine with aura. It illustrates the value of care responsive to the health needs of transgender patients, as reflected in the patient-provider partnership and shared decision-making in discussions about thromboembolic risks in the setting of unknown data. Research investigating an association between migraines with aura, thrombosis risk, and prescribed estrogens for transwomen is limited. Existing studies demonstrate high rates of migraine with aura in transwomen on GAHT on par with that of cisgender women as well as worsened migraines when starting GAHT, as experienced by our patient. The optimal migraine management with GAHT is not known. Although cisgender women with migraines with aura are known to have increased stroke risk when prescribed estrogen containing OCPs, less is known about stroke risk for trans women with migraines with aura on GAHT. A cohort of transgender women on GAHT were found more likely to have ischemic stroke than matched cisgender groups. Obesity and smoking both are established to increase stroke risk, making these important modifiable risk factors.

1. The case illustrates incorporating evaluation of migraine with aura into management of transfeminine GAHT. 2. The case demonstrates an individualized approach to cerebrovascular risk factor modification for transgender women on GAHT with migraine with aura. MONTHLY MYSTERY: A CURIOUS CASE OF PROGESTERONE HYPERSENSITIVITY Amanda G. Rivas3; Carrie Bell4,5; Kathleen B. Dussan1,2. 1Internal Medicine, University of Michigan, Ann Arbor, MI; 2Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI; 3University of Michigan Medical School, Ann Arbor, MI; 4Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI; 5Women's Health, VA Ann Arbor Healthcare System, Ann Arbor, MI. (Control ID #4270646) CASE: A 34 year old Asian female g0 presented with a 10-year history of worsening cyclical, pruritic rash on her fingers and diffuse pruritus on her arms, thighs, and face, starting 9 days before menses, and resolving with bleeding onset. Symptoms, unresponsive to topical corticosteroids and antihistamines, intensified recently. Menstruation began at age 14, occurring every 28 days with 3–4 days of bleeding. Medical history includes asthma, eczema, anxiety, and iron deficiency anemia. She takes Docusate, Ferrous Sulfate, Hydroxyzine, Montelukast, Vitamin D3, and Loratadine. Family history is noncontributory. Denies tobacco use. Consumes alcohol 2-3 times/week. Physical exam: BMI 27.5. Normal vitals. No skin rash or lesions. Negative abdominal exam. Pelvic exam declined. Testing of CMP, CBC with differential, TSH were normal. Allergy consult recommended no testing. She trialed the etonogestrel/ethinyl estradiol vaginal ring, securing it on her arm for 3 days to confirm no reaction before vaginal placement. After insertion, pruritic symptoms improved but had 2 weeks of bleeding. After discussion, she switched to an ethinyl estradiol/norelgestromin patch, which resolved her premenstrual pruritus without further bleeding. IMPACT/DISCUSSION: Progesterone hypersensitive (PH) or autoimmune progesterone dermatitis (APD) is a rare allergic response to progestogens with about 200 published case reports. It occurs in reproductive age women during the luteal phase of menstruation, causing cutaneous urticaria, angioedema, and dermatitis to systemic reactions of bronchospasm and anaphylaxis. Triggers include endogenous and exogenous progesterone with hormonal contraception and fertility treatments potentially increasing cases. Diagnosis is by history, with skin biopsy or transdermal testing as options. There is no standardized progesterone test, often delaying diagnosis. Management includes symptom control, ovulation suppression (first-line with hormonal contraception), progesterone desensitization, omalizumab, GnRH analogs, tamoxifen. Severe cases resulted in bilateral oophorectomy. The history and shared decision making (SDM) were critical for diagnosis and treatment as it identified the cyclical nature of the rash and its association with progesterone surges. SDM was integral in understanding her previous medical therapies. Testing the ring on her skin prior to vaginal use included her directly in her care. Initial therapy led to improved pruritic symptoms with abnormal bleeding. SDM led to switching to the estradiol patch which resolved her rash and bleeding.

Consider PH in reproductive age women with luteal phase skin and/or respiratory symptoms. A detailed history and SDM support an accurate, timely diagnosis and promotes patient autonomy. Non-oral hormonal ovulation suppression contraception permits tolerance evaluation, side effect mitigation, and enhanced adherence. Empowering patients to actively participate in their care fosters collaboration and enhances clinical outcomes. NAVIGATING THE THERAPEUTIC DILEMMA: BALANCING GENDER-AFFIRMING HORMONE THERAPY AND VENOUS THROMBOEMBOLISM RISK IN TRANSGENDER WOMEN Ashley N. Urrutia. Internal Medicine, Emory University, Atlanta, GA. (Control ID #4271003) CASE: A 54 yo transgender woman with pre-diabetes and depression presented with 2 days of left lower extremity pain and swelling. Her medications included daily fluoxetine and spironolactone, and weekly IM estradiol. A venous duplex ultrasound showed a new non-occlusive thrombus within the left popliteal vein. She was started on rivaroxaban, her estradiol and spironolactone were discontinued, and she was advised to follow-up with her primary care provider. IMPACT/DISCUSSION: This case highlights a significant therapeutic dilemma in the care of transgender patients, where providers underestimate the importance of gender-affirming hormone therapy (GAHT) continuation. The insufficient integration of transgender health into medical curricula has left many providers ill-prepared to address the needs of transgender patients, leading to a failure to recognize the risks of discontinuing GAHT. Gender-affirming care is essential for the wellbeing of trans* identified patients, offering positive mental and physical health outcomes. Transgender individuals who access GAHT report decreased anxiety, depression, and suicidal ideation, along with better quality of life and self-esteem (Nguyen, 2019). Transgender women also have improvements in bone health and cholesterol with GAHT (Restrepo, 2014; Cochetti, 2021). Historically when transgender women have presented with a VTE, the decision to discontinue GAHT has been relatively universal, but this is not well supported by data. The mode of delivery of estradiol can affect VTE risk, with oral estradiol having the highest risk and transdermal estradiol having the lowest risk (Zucker, 2021). A meta-analysis by Khan et al. showed a VTE incidence rate of 2.3 per 1000 person-years for all forms of estradiol used in GAHT. Risk stratification and decisions regarding GAHT should be individualized and patient-centered. Appropriate evaluation should include discussing the risks and benefits of continuing GAHT, offering VTE treatment options, setting quality-of-life goals, and ensuring the plan aligns with the patient's gender journey (Arrington-Sanders, 2024). If the decision is made to stop GAHT, it is essential to have close follow-up with appropriate providers to monitor the patient’s well-being. If the decision is to continue GAHT, it is important to discuss reducing VTE risk, including using anti-coagulation, while continuing estrogen therapy, and continually re-evaluating goals and treatment plans at follow-up visits.

There is extensive evidence of positive changes with GAHT for trans*-identified patients including both mental and physical health. Commonly, providers are concerned about VTE risk with GAHT despite the overall risk being low. Due to these factors, there is limited evidence supporting stopping GAHT in the acute setting of VTE. Stopping GAHT can be life-altering for many patients. Providers should focus on a more patient-centered approach, supporting continuation of estradiol while addressing modes of reducing VTE risk. REDUCING HEALTH DISPARITIES IN EARLY PREGNANCY AS A GENERAL INTERNIST BY OFFERING PREGNANCY OPTIONS COUNSELING AND SCREENING FOR ECTOPIC PREGNANCY Rosymar Marcucci-Rodriguez, Mindy Sobota. Division of General Internal Medicine, Brown, Providence, RI. (Control ID #4272109) CASE: A 23y cis-female presents to her general internist with a positive home pregnancy test. Her last menstrual period (LMP) was 3.5w ago and 2w ago she took emergency contraception (levonorgestrel 1.5 mg orally) after a condom broke. She was counseled on her pregnancy options: continuing her pregnancy to parent or adopt, or ending the pregnancy with a pill or procedure. She wished to end the pregnancy with abortion pills, which we offer in our faculty-resident practice located in New England. She was screened for pelvic inflammatory disease (PID) and ectopic pregnancy. She reported no history of PID or ectopic pregnancy and no vaginal discharge or bleeding, but did endorse mild bilateral pelvic cramping. To rule out PID, a pelvic exam was performed and revealed uterine and right greater than left adnexal tenderness and no concerning discharge. To rule out an ectopic pregnancy, a serum quantitative human chorionic gonadotropin (hCG) and pelvic ultrasound were ordered and scheduled for the same day. The hCG was 76, consistent with a very early pregnancy. The pelvic ultrasound showed a 1.4 cm right adnexal mass discrete from the ovary highly suspicious for ectopic pregnancy. The patient was referred to the emergency department, where IM methotrexate was given and her hCG hormone levels were followed by gynecology. IMPACT/DISCUSSION: General internists in primary care or urgent care are situated to reduce health disparities for patients with early pregnancies because they are often the first point of contact with the health system. Referrals to prenatal care are often delayed, with first visits often in the late 1st or early 2nd trimester. Teaching general internists to counsel patients on pregnancy options is more critical than ever as options for abortion in the US are increasingly restricted (E.g., in Florida, abortions >6w from LMP are generally banned). A review of the literature shows that ectopic pregnancy is the leading cause of pregnancy-related maternal mortality with most ruptures occurring 6-8w after LMP, before most patients access prenatal care. Black Americans are 7x more likely to die compared to White Americans. General internists can reduce disparities by offering themselves as a resource if a patient becomes pregnant, whether they wish to continue or end the pregnancy and to offer pregnancy options counseling. Our patient presented very early, at a time when she may have dismissed her symptoms. By screening all pregnant patients for PID and ectopic pregnancy, we were able to identify a very early ectopic pregnancy and efficiently coordinate her care with gynecology.

General internists can offer themselves as a resource to patients should they become pregnant, whether they wish to continue or end the pregnancy Pregnant patients should be counseled on their pregnancy options, and screened for PID and ectopic pregnancy TAPPING INTO THE MYXEDEMA HEART; A CURIOUS CASE OF HYPOTHYROIDISM-RELATED PERICARDIAL EFFUSION Emmanuel Oundo. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4267111) CASE: We present a 77-year-old female with a medical history of hypothyroidism and breast cancer (in remission following chemotherapy/radiation 5 years prior)who presented to the emergency department with a one-week history of chest pain and progressive dyspnea on exertion. She was bradycardic, hypertensive, and had bilateral lower extremity edema. A cardiac examination revealed reduced heart sounds. EKG showed sinus bradycardia, but no evidence of ischemia. Troponin and Brain Natriuretic Peptide (BNP) were within normal limits. Hyponatremic - 130, TSH- 67.5, T4 < 0.4. CXR showed an enlarged cardiac silhouette consistent with pericardial effusion. Computed tomography pulmonary angiography (CTPA) showed no evidence of pulmonary embolism but revealed moderate pericardial effusion and trace bilateral pleural effusions. Lower extremity doppler ultrasound revealed occlusive left peroneal thrombus. Transthoracic echo (TEE) showed EF 70-75%, a large pericardial effusion, with early tamponade physiology. Colchicine and ibuprofen were started and pericardiocentesis was done. Anticoagulation with heparin for deep venous thrombosis was also started. The pericardial drain was persistently active, which was consistent with effusive pericarditis, and thus a pericardial window was performed. A cardiac MRI revealed myopericarditis. The pericardial fluid analysis was consistent with exudative effusion; it was also negative for malignancy and tuberculosis (TB). She also developed 2nd-degree heart block, and a permanent pacemaker was placed. Her levothyroxine dose was increased. Repeat TEE showed resolution of the effusion. She was discharged on ibuprofen, colchicine, increased dose of levothyroxine, and apixaban, and scheduled to follow up with cardiology as outpatient. IMPACT/DISCUSSION: Hypothyroidism is common in the US, with the most common cause being Hashimoto’s. Breast cancer is the most common cancer in the US with an estimated 313,510 new cases in 2024. These two are independently associated with an increased risk of developing pericardial effusion; their coexistence may have increased our patient’s risk. Some data shows a temporal association between pericardial disease and the severity of hypothyroidism. Most of these patients have TSH < 30; our patient was at 67.5. It is important to rule out other causes of an exudative nature of the effusion, especially in our patient who had been treated for breast cancer with chemotherapy and radiation. Her pericardial effusion showed no malignant cells and was negative for TB. Levothyroxine reverses the progression of pericardial effusion and can prevent tamponade; however, when a patient presents with tamponade, like ours, they require pericardiocentesis. With control of the hypothyroidism, complete resolution is expected within 4-26 weeks.

Our case highlights the importance of a broad differential for pericardial effusion. It also emphasizes the importance of throrough investigation of pericardial effusion and urgent pericardiocentesis. TITLE: PUSHING THE NEEDLE: INJECTABLE ESTRADIOL IN FEMINIZING HORMONE THERAPY Sarah K. Hall1,2; Eli Finer2. 1Primary Care, VA Salt Lake City Health Care System, Salt Lake City, UT; 2University of Utah Health, Salt Lake City, UT. (Control ID #4269525) CASE: A transgender woman in her early 60s was seen in her primary care physician’s office for routine care of diabetes, hypertension, obesity, and obstructive sleep apnea; she reported being in good health and asymptomatic at that time. Her vital signs, exam and labs were at goal (A1c 7.2%, estradiol 166pg/mL, testosterone <2.5ng/dL). Of note, she had used gender affirming hormone therapy for 20 years, including injectable estradiol valerate for the last 5 years. Five days after this visit, family called a wellness check due to lack of contact for 48 hours. Subsequently, she presented via ambulance to the emergency department obtunded and severely hypertensive at 240/110mmHg. Laboratory and imaging workup ultimately revealed bilateral proximal carotid artery emboli as well as bilateral middle cerebral artery infarcts. Mechanical thrombectomy was successful, but unfortunately, she suffered cardiopulmonary arrest following the procedure. IMPACT/DISCUSSION: - Ischemic stroke is a known risk of estrogen-based therapies; risk appears to increase with advancing age and duration of use. - There are no current recommendations for additional atherosclerotic cardiovascular disease screening or arrhythmia screening specific to patients on menopausal nor gender-affirming hormone therapy; however, clinicians should pay close attention to ASCVD risk factors in individuals on long term estrogen therapy and optimize risk reduction. - Chronic estrogen use potentially increases the risk of developing atrial fibrillation and consider lower testing threshold for patients with suggestive signs or symptoms. - Historical data on injectable estrogen preparations were limited and lacked generalizability; more recent literature among transgender and nonbinary patients using injectable estradiol for feminization indicate a more favorable risk-benefit profile.

- Bioidentical synthetic estradiol is widely used in patch and oral tablet form in the management of menopausal symptoms; these preparations are also recommended in the setting of gender-affirming hormone therapy. - Intramuscular and subcutaneous injectable estradiol prescriptions are increasingly popular in gender-affirming care and may assist in achieving testosterone suppression and patient embodiment goals; these are likely safe when used at low to moderate doses with appropriate monitoring. - Ultra long-term risks of injectable estradiol are unknown, and there are potential links to atrial fibrillation and cardiovascular disease in patients with additional risk factors. VISION LOSS DURING GAHT: CRAO IN A TRANSGENDER PATIENT WITH SICKLE CELL DISEASE swecha p. potharaj. Internal medicine, Alameda Health System, Oakland, CA. (Control ID #4272047) CASE: A 27-year-old transgender woman (designated male at birth) with a history of Hb-SS sickle cell disease presented with acute monocular vision loss in the left eye, which had persisted for 3 hours. The patient denied any eye trauma, photopsia, floaters, eye pain, or discharge. She reported no previous episodes of vision loss or history of strokes. The patient had been receiving gender-affirming hormone therapy for 3 years and was on the following medications: hydroxyurea 2000 mg, spironolactone 100 mg, progesterone 100 mg daily, and injectable estradiol valerate 40 mg every 2 weeks. On examination, vital signs were stable, and there were no focal neurological deficits. An ocular examination revealed a relative afferent pupillary defect (RAPD) in the left eye. Fundoscopic examination showed hyperemia, mild optic disc edema, tortuous veins, and "boxcarring" of the retinal vessels. Lab findings included 6 mg/dL of hemoglobin, 18.6% hematocrit, and a platelet count 404. Further evaluation for CRAO showed negative results for syphilis, antiphospholipid syndrome, and rheumatoid factor, with a normal lipid panel. Carotid Doppler imaging revealed 49% stenosis of the left internal carotid artery with normal antegrade vertebral artery flow. MRI of the brain and orbits, CT angiogram of the head and neck, and CT head with contrast showed no acute findings. The patient underwent an urgent exchange transfusion with no significant improvement in vision after. At this point, the patient opted to leave against medical advice to continue care at her usual healthcare facility. IMPACT/DISCUSSION: Risk mitigation plays a crucial role in the care of transgender patients, particularly when balancing the benefits of gender-affirming hormone therapy (GAHT)—such as improved quality of life and mental health—with the potential risks. In patients with sickle cell disease, like the one presented here, the risk of thrombosis is already elevated. Estrogen-containing therapies can further increase the risk of both arterial and venous thrombosis, making this an important consideration when initiating GAHT. Central retinal artery occlusion (CRAO) is a rare but serious thromboembolic complication in patients with sickle cell disease. The type and formulation of estrogen used may influence the degree of thromboembolic risk. Therefore, careful selection of GAHT agents and dosing, with input from a multidisciplinary team, is essential for optimizing patient safety. This approach will help ensure that the benefits of GAHT can be achieved while minimizing the risk of adverse outcomes.

Most gender-affirming hormone therapy (GAHT) takes place in a primary care setting. When considering GAHT for transgender patients with co-morbidities that increase the risk of adverse effects, such as sickle cell disease, a thorough discussion of risks and benefits is essential. It is crucial that their therapy includes close monitoring and involves a multidisciplinary care team. Innovation in Healthcare Delivery (IHD) - Ambulatory Medicine BP BASICS: ENHANCING HYPERTENSION CONTROL THROUGH POPULATION HEALTH OUTREACH IN A RESIDENT PRIMARY CARE PRACTICE Rebhi Rabah2,1; Qianjun Pan2,1; Afroza Sultana2,1; Gemonique Bowen2,1; Nadia A. Williams2; Melissa S. Lee2,1. 1Internal Medicine, SUNY Downstate Health Sciences University, New York, NY; 2Ambulatory Medicine, Kings County Hospital, Brooklyn, NY. (Control ID #4273518) STATEMENT OF PROBLEM/QUESTION: Hypertension (HTN) is a leading cause of stroke and heart disease. 30% of New Yorkers live with HTN; 44% are Black. Common treatment includes lifestyle modifications (weight loss, low salt diet, etc.) and medications. Yet 21% of patients living with HTN in our resident-run safety-net primary care practice in Central Brooklyn have uncontrolled blood pressure (BP). DESCRIPTION OF PROGRAM/INTERVENTION: Patients living with uncontrolled HTN were identified for outreach by resident primary care providers, utilizing a population health registry. 24 patients completed a baseline telephone survey. Despite living with uncontrolled BP, 83.3% of patients believe they are managing their BP “well” or “very well.” The most common barriers to BP control were too many medications (n=3, 13.6%), side effects (n=6, 27%), and difficulty picking up medications (n=4, 18.2%). A standardized phone script focused on assessing and improving patient understanding of HTN and its complications was developed. Patient beliefs and behaviors, including the importance of controlling BP, number of days taking medications in the past week, importance of medication adherence and motivation to take medication daily were measured using a Likert scale and compared pre- and post-intervention using the Wilcoxen signed-ranks test. Exact McNemar test was used to compare BP readings before and 3 months after the educational intervention. MEASURES OF SUCCESS: A brief, 5-minute educational tool improved patients’ ability to define hypertension and its complications, motivation to maintain BP at goal, medication adherence, and overall BP control. FINDINGS TO DATE: 45 patients were contacted (60% women, mean age 59.2 years). Knowledge of end organ damage (brain, kidney, heart, t(44)=-8.438, p<0.001), and complications (stroke, heart attack, renal failure, sexual dysfunction, vision loss, t(44) = -3.330, p<0.002) improved post-educational intervention. Wilcoxon signed-ranks test demonstrated a significant increase in patients' perception of the importance of BP control and medication adherence (Z = -5.142, p<.001 and Z=-5.475, p<.001, respectively). Blood pressure was evaluated at 3 months post-intervention in 31 patients. An exact McNemar's test determined that there was a statistically significant difference in the proportion of patients with controlled blood pressure pre- and post-intervention, p <0.001. KEY LESSONS FOR DISSEMINATION: In our primarily Afro-Caribbean safety-net practice, barriers to BP control include gaps in knowledge, beliefs, and behaviors around potential complications, access to healthcare, cost of medications, and concerns about side effects. Our data shows that patients’ knowledge of hypertension and motivation for medication adherence can be effectively improved through reproducible, cost-effective 5-minute teaching sessions. BREAKING BARRIERS: ADVANCING THE USE OF CONTINUOUS GLUCOSE MONITORS IN A COMPLEX DIABETIC PATIENT POPULATION TO ENHANCE SELF-EFFICACY AND IMPROVE OUTCOMES Jason Ehrlich1; Danielle Ezzo2,3; Teresa Cantilli4; Andrea Jainarine2; Karen Campbell2; Navneet Kaur2; Caitlyn Gordon1,3; Umar Bhatti2; Thandi Hannibal2; Daniel J. Coletti5. 1Medicine, Northwell Health, New Hyde Park, NY; 2Division of Internal Medicine, Northwell Health, New Hyde Park, NY; 3Pharmacy, St. John's University, Queens, NY; 4Medicine Specialties of Glen Oaks, Northwell Health, New Hyde Park, NY; 5Medicine, Northwell Health, Great Neck, NY. (Control ID #4270918) STATEMENT OF PROBLEM/QUESTION: Continuous Glucose Monitors (CGMs) are now standard in diabetes care, as they can help to empower patients’ self-management via real-time biofeedback and to aid providers in rendering more data-driven care decisions. Yet barriers persist to obtaining them, particularly among uninsured patients. We sought to increase access to and utilization of CGMs in this particularly challenging population. DESCRIPTION OF PROGRAM/INTERVENTION: The practice is an academic primary care center in an urban Northeast area serving diverse, mostly uninsured or underinsured patients who face challenges in diabetes management. An existing practice initiative aims to improve self-efficacy and diabetes knowledge among patients with poor glycemic control through enhanced support from an interprofessional team. New funding provides eligible, uninsured patients with 90-day CGM supplies. At onboarding, patients receive equipment and training, and complete surveys. HbA1C is measured pre- and post-intervention, with exit interviews at evaluation's end. MEASURES OF SUCCESS: ● Expansion of CGM access in target population. ● Rate of optimal CGM utilization among eligible patients. ● Patient implementation experience and impact upon quality of life. ● Patients’ diabetes management self-efficacy before and after intervention. ● Change in A1C from baseline to post-intervention. FINDINGS TO DATE: Our larger program currently has 218 active participants. Since program inception in April 2024 we have enrolled 23 uninsured patients, none of whom could access CGMs without our program’s support. 57% are male, with mean age 54.84 years (SD=10.98). 64% are non-English speaking; most primarily speak Spanish (n=12). Mean baseline Hba1c was 10.82 (SD=1.87). We observed a significant decline in A1C in the 14 patients who have completed their follow-up assessment to date; mean A1c post-intervention is 8.66 (SD=2.35, t=3.61, df=13, p<.01). In qualitative exit interview data, patients report CGMs are easy to use and improve diabetes-related quality of life and self-efficacy. KEY LESSONS FOR DISSEMINATION: Incorporating CGMs into practice transforms diabetes self-management but requires more than device provision. Education and support for patients, providers, and staff are critical for effective use. Having CGMs onsite reduces initiation barriers, enables hands-on training, and supports real-time monitoring with a clear data-sharing plan. Troubleshooting builds confidence and encourages consistent use, maximizing CGM impact. Addressing these elements can improve diabetes care and outcomes, particularly for uninsured patients disproportionately affected by complications, ED visits, and hospitalizations. At modest cost, preliminary data suggest we can significantly reduce burdens on both vulnerable patients and the healthcare system. BRIDGING THE GAP: HEART FAILURE TRANSITIONAL CARE MANAGEMENT TO REDUCE 30-DAY READMISSION RATE Lorna Devkota1; Dena Hayes2. 1Internal Medicine, NYU Langone Health, New York, NY; 2Cardiology, NYU Langone Health, New York, NY. (Control ID #4272386) STATEMENT OF PROBLEM/QUESTION: High readmission rates for patients admitted with congestive heart failure (CHF) in an urban community hospital with a large uninsured patient population. DESCRIPTION OF PROGRAM/INTERVENTION: Heart Failure Transitional Care Management (HF TCM) visit was developed as a way to ensure that patients discharged following CHF exacerbation were able to have timely post-discharge follow-up regardless of insurance status. Once a patient is nearing discharge, the internal medicine resident on the primary inpatient team places a HF TCM order within our electronic health record (EHR). The order is received by our Federally Qualified Community Health clinic which functions on a sliding scale fee, making primary care accessible for all patients. The scheduling coordinators then work to ensure a HF TCM appointment is scheduled within 10 days of discharge. When the patient arrives to clinic for their HF TCM visit, the resident leading the visit utilizes a HF TCM note template which ensures that HF-focused care is provided during the visit. Direct goals for the visit include assessing patient’s volume status and adjusting diuretics accordingly, titrating guideline-directed medical therapy (GDMT), confirming the patient was able to pick up all medications from the pharmacy and is taking them as directed, and ensuring the patient is scheduled to see a cardiologist. MEASURES OF SUCCESS: Our primary outcome of interest is 30-day readmission rate. Using data collected via the EHR, we have monitored the 30-day readmission rate of patients who completed a HF TCM visit, compared to those who were referred but did not show for their visit. Other process measures include number of referrals placed and visit show rate. Qualitatively, we are also collecting informal feedback from residents who have led a HF TCM, with plans to formalize feedback in the near future. FINDINGS TO DATE: While we do not yet have enough data for statistical significance, trends strongly suggest that patients who complete a HF TCM visit have a lower 30-day rehospitalization rate compared to those who are referred but do not show for their appointment. With the current limited data, readmission rates is currently at 5.1% for those that have completed a HF TCM visit versus 17.6% for those who were referred but did not show for the visit. KEY LESSONS FOR DISSEMINATION: In an urban community hospital with a large uninsured population, resident-led HF TCM visits can help bridge the gap and lower 30-day readmission rates. BRIDGING THE GAP: HIV PREVENTION IN RESIDENT PRIMARY CARE CLINICS Drake Scott, Jessica Valente. Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC. (Control ID #4241104) STATEMENT OF PROBLEM/QUESTION: Pre-exposure prophylaxis (PrEP) for prevention of HIV is a critical tool to prevent transmission of HIV in high-risk populations. When taken correctly, Descovy (emtricitabine-tenofovir alafenamide) and Truvada (emtricitabine-tenofovir disoproxil fumarate) reduce the risk of HIV transmission from sex by up to 99%. Many more individuals in the population qualify for PrEP than can be seen by infectious disease clinics. There are increased efforts towards educating and empowering primary care providers to prescribe PrEP for their patients. Despite being a Grade A recommendation by the USPSTF, there remains many barriers to prescribing PrEP to eligible individuals. We sought to educate internal medicine residents about PrEP and increase appropriate PrEP prescriptions for high-risk individuals seen in continuity and urgent care residency clinics. DESCRIPTION OF PROGRAM/INTERVENTION: An initial needs assessment survey was sent to all internal medicine residents who participate in one of the Wake Forest resident clinics. An educational email was then sent to all residents detailing the process of identifying a patient who qualifies for PrEP, discussing PrEP with patients, performing initial labwork, prescribing PrEP, and performing continued labwork. An EMR dotphrase and an order panel were also provided to help streamline visits. Additionally, PrEP didactic sessions were arranged as part of the urgent care curriculum. MEASURES OF SUCCESS: A 6-month follow-up survey is being collected for all internal medicine residents to assess the impact of our interventions on knowledge of PrEP, prescribing practices, and uptake of PrEP dotphrase and order panel. FINDINGS TO DATE: Repeat survey results will be available by the time of presentation. We received 27 responses to the initial survey that were well distributed across all PGY years 1-3 with a response rate of 23%. Over 80% (22/27) residents reported never prescribing PrEP. Twenty-five percent of residents (7/27) reported they were not comfortable initiating and managing a patient’s PrEP prescription, while 44.4% (12/27) felt comfortable. The majority of residents (24/27) reported having at least one clinic visit for STI testing and management in the last four months, while only two residents had a clinic visit specifically to discuss PrEP in that time. Thirty-three percent (9/27) of residents reported feeling at least somewhat confident identifying patients eligible for PrEP. Five residents were unaware that PrEP is generally affordable for all high-risk patients, including those without insurance. KEY LESSONS FOR DISSEMINATION: The results of the initial needs-assessment survey uncovered many of the problems our project aims to address. The low response rate is a limitation, but some clear trends emerged. Nearly all residents had a recent visit for STI management, but few had prescribed PrEP and over a quarter were not comfortable with PrEP management. Many patients who presented for STI visits could likely benefit from PrEP and this represents a clear area for improvement that our interventions aim to address. DESIGNING A SUMMARIZATION TOOL TO FACILITATE RESIDENT-PATIENT COMMUNICATION DURING TRANSITIONS OF CARE IN PRIMARY CARE IN THE BRONX Nicole Turturro2; Dolly Patel1; Erin Goss2; Shwetha Iyer3. 1Internal Medicine, Montefiore Medical Center, New York, NY; 2Medicine, Montefiore Medical Center, New York, NY; 3Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4272553) STATEMENT OF PROBLEM/QUESTION: What strategies can support patients’ understanding of next steps after primary care visits and what is the impact of a summarization tool on resident-patient communication? DESCRIPTION OF PROGRAM/INTERVENTION: While communication strategies like teach-back and ask-tell-ask are taught in medical education, physicians are often unaware of patients’ health literacy levels and have difficulty assessing when these methods are needed. Patients’ understanding of next steps is critical during transitions of care, but few have implemented standardized tools to facilitate communication at the end of primary care visits. To address this, we designed a questionnaire to assess patients’ views on the electronic medical record’s (EMR) After Visit Summary (AVS). Questionnaires were administered via convenience sampling at 2 primary care clinics and completed by 28 patients. Most found the AVS helpful, with 46% preferring a written list be added to the AVS to communicate next steps. With this feedback, we created our intervention, a summarization tool. The tool is an EMR quicktext that allows residents to input specific visit-related details (i.e. medication changes, lab orders, follow up appointments, etc) as a brief list into the AVS. To assess for changes in residents’ attitudes toward communicating next steps, we administered pre-intervention pre-surveys and post-surveys 4 months later. Data was analyzed using ANOVA testing. Post-survey collection is ongoing. Patient attitudes will be assessed via post-intervention questionnaires. Chart reviews will be conducted to compare the number of tasks (i.e. labs completed, follow ups attended, etc) addressed pre and post intervention. MEASURES OF SUCCESS: Measures of success include resident uptake of the summarization tool for at least 75% of visits and change in resident perception of patients’ understanding of next steps. Future measures of success are patient acceptability of the tool and an increase in the number of tasks addressed. FINDINGS TO DATE: Fifty residents in 3 specialties (Internal Medicine, Pediatrics, Family Medicine) completed the pre-survey. Thus far, 14 residents completed the post-survey, with half using the tool for a majority of visits. Compared to 11% of pre-survey respondents, 25% of post-survey respondents felt that they had enough time to explain next steps most of the time (p =0.13). Post-intervention, an increased proportion of respondents felt patients knew when to follow up at least 75% of the time (from 34% to 50%; p=0.54) and were aware of medication changes at least 75% of the time (from 34% to 42%; p=0.15). KEY LESSONS FOR DISSEMINATION: Designing a summarization tool to use after primary care visits can be useful in increasing resident efficiency and changing resident perception of patients’ understanding of next steps. As the tool is not EMR specific, it can be reproduced and used by all providers, not only trainees. IMPLEMENTING EVIDENCE-BASED ACTIVITY MANAGEMENT STRATEGIES TO IMPROVE QUALITY OF LIFE IN MYALGIC ENCEPHALOMYELITIS/CHRONIC FATIGUE SYNDROME Stephanie L. Grach1; Jessica Ask1; Nisha Mathews2; Jaime Seltzer3. 1Division of General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Department of Health, Human, and Biomedical Sciences, University of Houston Clear Lake at Pearland, Pearland, TX; 3MEAction, Santa Monica, CA. (Control ID #4228883) STATEMENT OF PROBLEM/QUESTION: Traditional activity management strategies do not help, and may even harm, people with myalgic encephalomyelitis/chronic fatigue syndrome. DESCRIPTION OF PROGRAM/INTERVENTION: Prior to the COVID-19 pandemic, approximately 3 million Americans were living with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). An estimate of 50% of people diagnosed with Long COVID now also meet criteria for ME/CFS. ME/CFS is characterized by disabling multisystem symptom flares that occur with overexertion of any type, called post-exertional malaise. Because symptoms are exacerbated by overactivity, impromper activity management recommendations lead to poor health outcomes and decreased quality of life in ME/CFS. Research has increasingly revealed that old guidelines may be actively harmful for patients. Our outpatient ME/CFS clinic, based in a Midwest academic center, aims to transform our existing education program on ME/CFS management using evidence-based recommendations and data from a survey created and administered by our team. MEASURES OF SUCCESS: Survey assessing patient experience with activity strategies completed. For program outcome measurement, outcomes will be measured through SF-36 and FUNCAP functional questionnaires at baseline and 3 months post-treatment program. FINDINGS TO DATE: A survey was administered to people with ME/CFS to inform program development. Participants were surveyed about their experience with pacing, graded exercise therapy, graded activity management, strength training, and physical therapy. Pacing was rated the most helpful in helping symptoms and maintining/improving completion of tasks, whereas graded exercise therapy was rated the least helpful. 655 individuals with ME/CFS reported trialing pacing. 577 (88.1%) reported pacing to be effective for maintainig or improving their ability to complete tasks, 58 (8.9%) reported no change, and 20 (3.0%) reported pacing to be harmful. 284 respondants reported trialing graded exercise therapy. 17 (6.0%) respondents reported graded exercise therapy was effective for maintaining or improving their ability to complete tasks, 16 (5.6%) reported no change to symptoms, and 251 (88.4%) reported graded exercise therapy to be harmful for their symptoms. In the next phase of our study, we are measuring outcomes of our traditional education program for ME/CFS versus a new program that emphasizes pacing as the recommended activity strategy, designed based on the survey data. KEY LESSONS FOR DISSEMINATION: Our presentation will inform clinicians about the need to shift current practices around activity management in people with ME/CFS, which is increasingly relevant with the prevalence of Long COVID. Our new program will serve as an example of innovative health care delivery for this critical need; however, even practices that may not be able to offer similar programming will benefit from learning about pacing and how to educate patients on this type of activity management. IMPROVING CARE COORDINATION FOR PATIENTS WITH SERIOUS MENTAL ILLNESS IN AN ACADEMIC PRIMARY CARE PRACTICE Victoria H. Chen, Jacqueline Shen, Connor Johnson, Laura Desrochers. Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4228944) STATEMENT OF PROBLEM/QUESTION: How can academic primary care practices improve care coordination for patients with serious mental illness? DESCRIPTION OF PROGRAM/INTERVENTION: Patients with complex medical and psychiatric comorbidities experience care gaps resulting in poor health outcomes and high utilization of emergency services. This is especially true for patients with serious mental illness (SMI), which is any psychiatric condition causing serious functional impairment. We conducted a mixed-methods needs assessment regarding care of patients with SMI at a large academic institution in New England. 18 semi-structured interviews were conducted with stakeholders from primary care, psychiatry, social work, and case management. Key informants were identified from our own and peer institutions through a snowball sampling approach. We analyzed practice-wide data using descriptive statistics stratified by comorbid psychiatric diagnosis. Variables of interest were chronic disease management (diabetes, hypertension), cancer screening (cervical, breast, and colon), and healthcare utilization (clinic visits, emergency visits, admissions). MEASURES OF SUCCESS: We will evaluate this intervention using qualitative and quantitative methods. We will administer pre- and post- surveys to assess changes in provider distress. We will perform practice-wide data analysis to compare changes in patient enrollment in care coordination and appropriate psychiatric care. Key interventions will be streamlined for easy adoption by similar academic institutions. FINDINGS TO DATE: Primary care providers (PCPs) at our institution feel under-resourced to care for patients with SMI. In light of the national shortage for psychiatric providers, PCPs are providing bridging care. While adept at treating mild psychiatric conditions, PCPs are not well equipped to monitor for subtle psychiatric decompensation or titrate antipsychotics/mood stabilizers, leading to provider distress. Challenges caring for this population include lack of robust case management resources, difficulty communicating with community providers, and inadequate post-discharge transitional care. Our subgroup analyses show that patients with SMI fare worse on preventive health metrics. We identified several areas for intervention based on our comprehensive needs assessment: streamlining access to behavioral health resources, realigning existing resources with current practice needs to augment care coordination, formalizing relationships with community providers, and creating a registry of patients for proactive outreach. KEY LESSONS FOR DISSEMINATION: Systematic barriers contribute to unique challenges caring for patients with SMI, leading to poor health outcomes and provider distress. Integration of behavioral health into primary care improves both psychiatric and medical outcomes for patients with SMI. Establishing such a program at academic institutions has proved challenging. However, in an environment caring for medically and psychiatrically complex patients, it is important to innovate in this arena to strengthen integrated care delivery. IMPROVING LUNG CANCER SCREENING IN VETERANS THROUGH ENGAGEMENT IN CENTRALIZED SCREENING MASHKURUL HAQUE1; Ashten Sherman1; Grace Alexander1; Hunter Frederiksen1; Paolo J. DiSano1; Aubriannah T. Larson1; Michael R. Miller1; Matthew D. Soltys2. 1Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; 2Internal Medicine, The University of Iowa Hospitals and Clinics Department of Internal Medicine, Iowa City, IA. (Control ID #4272903) STATEMENT OF PROBLEM/QUESTION: Lung cancer, the leading cause of cancer-related deaths, disproportionately affects Veterans, yet adherence to annual low-dose CT screening at a regional VA resident clinic remains suboptimal due to decentralized workflows. DESCRIPTION OF PROGRAM/INTERVENTION: Lung cancer, the leading cause of cancer deaths in the United States, disproportionately affects Veterans. The USPSTF recommends annual low-dose CT (LDCT) screening for adults aged 50-80 years with a 20 pack-year smoking history who currently smoke or quit within the past 15 years. Despite its mortality benefit, screening practices at the Iowa City VA resident primary care clinic remain suboptimal due to decentralized workflows. A problem analysis identified challenges such as poor scheduling adherence, limited patient awareness of screening eligibility, and inconsistent consult placement and follow-up. Rotating residents, who frequently change clinics and lack familiarity with VA-specific workflows, struggled to navigate screening processes, and communication gaps between the lung cancer screening (LCS) team and primary care providers further hindered adherence to guidelines. To address these barriers, targeted educational sessions clarified USPSTF guidelines, defined roles within the screening program, and improved consult placement and follow-up processes. The intervention aimed to centralize workflows, enhance resident engagement, and increase screening rates in a centralized program from 60% to 80%. MEASURES OF SUCCESS: The operational measure was the percentage of eligible veterans receiving LDCT scans specifically ordered by LCS providers as tracked via a P-chart analysis. A P-chart was selected for its ability to visually track trends and variability in screening rates over time, providing insights post-intervention. The numerator included LDCT scans ordered through the LCS program by dedicated LCS providers, while the denominator encompassed all LDCT scans ordered for the resident clinic. Data was analyzed in monthly intervals starting February 2023 to evaluate quantitative improvements and variability following the intervention. FINDINGS TO DATE: Within a resident cohort, lung cancer screening rates increased from 58% to 83% following QI project involvement and subsequent educational interventions. KEY LESSONS FOR DISSEMINATION: Centralized workflows and educational interventions significantly improved adherence to lung cancer screening guidelines in resident-driven clinics by clarifying roles within the Lung Cancer Screening (LCS) program and addressing challenges faced by rotating providers. With VHA training 45,000 resident physicians annually, integrating resident-specific metrics into quality improvement initiatives and providing feedback and targeted education can enhance care quality nationwide. These strategies align with ACGME CLER Pathways, emphasizing trainee education on quality benchmarks and system processes to optimize clinical learning environments. Providing individualized feedback on screening performance fosters sustainable improvements in resident-driven clinics. INTEGRATED BEHAVIORAL HEALTH IN A RESIDENT PHYSICIAN SAFETY NET INTERNAL MEDICINE CLINIC: AN OPPORTUNITY FOR COLLABORATIVE CARE AND RESIDENT EDUCATION Jared P. Walsh. Medicine, Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4272347) STATEMENT OF PROBLEM/QUESTION: Access to behavioral health services in underserved populations remains a significant challenge, often leading to delayed treatment initiation and suboptimal outcomes. To address this, an integrated behavioral health team was implemented in a safety net internal medicine resident clinic with the charge to also contribute to closing the gap in internal medicine (IM) resident knowledge of the management of behavioral health conditions. DESCRIPTION OF PROGRAM/INTERVENTION: The team consisted of a licensed behavioral health counselor (BHC) and a psychiatric-trained nurse practitioner (NP), embedded within the resident clinic. They collaborated with IM physicians to provide education and support to residents on key psychiatric conditions, including anxiety, depression, ADHD, psychosis, opioid use disorder, suicide risk, and insomnia. This included in the moment education on communication skills, the assessment and diagnosis of the previously mentioned diagnoses. The NP worked closely with resident primary care providers (PCPs) and their supervising physician to develop comprehensive medication plans with the NP performing regular follow-up (in-person and via eHealth) between physician visits. During these NP visits, the NP was able to address medication adherence, health literacy, tolerability, and make medication dose adjustments. MEASURES OF SUCCESS: Both qualitative and quantitative metrics are being used to evaluate the program. Quantitative metrics include the time to initial medication assessment and outcome of that assessment. Qualitative metrics include patient and resident feedback collected via focus groups. These surveys assess satisfaction with access to care, communication with the behavioral health team, and perceived improvement in symptoms. Resident physicians’ feedback evaluates the impact of education provided by the BHC and NP on their confidence and skills in managing psychiatric conditions. FINDINGS TO DATE: During the initial two months, 71 patients were enrolled in the program, with diagnoses including schizophrenia (n=1), ADHD (n=7), opioid use disorder (n=11), anxiety and/or depression (n=51), and insomnia (n=2). All patients underwent medication assessment, with 41 requiring changes. The average time to initial medication assessment or dose adjustment was reduced from 8 weeks pre-implementation to 1 week after the program launched. Patients expressed strong satisfaction with the program for their healthcare. Resident physicians expressed strong satisfaction with the education received and the collaborative care. KEY LESSONS FOR DISSEMINATION: This integration of behavioral health services into a resident internal medicine safety-net clinic demonstrates a successful strategy to improve patient care through a team-based model while also expanding on internal medicine resident education on the management of behavioral health conditions in primary care. This innovation aligns with the theme "From Ideas to Action" by catalyzing change in healthcare delivery through collaboration, education, and timely intervention. INTEGRATING INTERNAL MEDICINE RESIDENTS INTO A COMPREHENSIVE WEIGHT MANAGEMENT PROGRAM IN A FEDERALLY QUALIFIED HEALTH CENTER Rebecca Shafer1; Kimberly Fasciglione2; Lauren I. Shapiro3. 1General Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Mount Sinai Health System, New York, NY; 3General Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4253100) 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 previously developed and launched a comprehensive weight management program at a Federally Qualified Health Center (FQHC) to provide access to obesity medicine care to underserved populations. The program utilizes a comprehensive approach to weight management including dietary, behavioral, physical activity counseling in addition to weight loss medication management. This year, we expanded the program to include an inaugural Obesity Medicine Experience for our Internal Medicine Residents. This experience provides a multi-step training process that includes academic and experiential learning. Residents enrolled in this experience have the opportunity to practice obesity medicine by evaluating and managing patients within the FQHC under the guidance of an obesity medicine trained attending. Residents see patients within the weight management program for 1-2 half-day clinical sessions every ambulatory care block for an entire 1-year cycle. Additionally, residents participate in educational training activities related to obesity medicine. By expanding the program with residents, we are able to increase the number of patients that can be seen in one clinical session, as multiple residents can see patients under the guidance of one preceptor thus providing this much-needed medical service to a larger population. MEASURES OF SUCCESS: We are hoping to evaluate if our primary goal, which 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, is met within the residency weight management panel. The overall assessment of our program will be divided into 2 categories: 1) Physical Exam, as measured by weight and BMI, 2) Biochemical: as measured by blood pressure, lipid profile, hemoglobin A1C, and liver function tests. Our secondary outcome is improvement in access and we will measure both the number of scheduled and completed appointments by the resident physicians. FINDINGS TO DATE: Previously, we demonstrated the effectiveness of the comprehensive weight management program led by a single practitioner. 54 patients were seen during the pilot phase of the program: 81% (44/54) of those patients had either Medicaid or Medicare insurance, 63% (34/54) were prescribed weight loss medications, and during a 5-month period, the average BMI loss was 0.25. 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. By integrating residents into the weight management program, we can provide even more of these services to an at-risk population. Additionally, we hope that through this experience the trainees can feel confident in their ability to manage patients with obesity in their future practice. LOST IN NORTH PHILADELPHIA? ENHANCING RESIDENT CLINIC PANEL CONTINUITY FOR HIGH-RISK PATIENTS Jaime Fineman, Rachel Snyder, Jill Allenbaugh. GIM, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #4236123) STATEMENT OF PROBLEM/QUESTION: Every year patients with complex medical and social needs are “lost” during the PGY-3 to PGY-1 handoff of internal medicine resident continuity clinic. DESCRIPTION OF PROGRAM/INTERVENTION: Every year thousands of patients in resident continuity clinics are “handed off” between a graduating resident and new intern. Handoffs can promote compromised care, specifically for patients with complex medical or social needs. To diminish potential poor outcomes associated with continuity clinic handoffs, the Temple Internal Medicine residency created a curricular innovation for graduating third year residents. With faculty guidance, residents use specific criteria to identify patients that are most “high risk” and participate in an enhanced handoff process. Residents complete easily accessible, standardized documentation, and give verbal sign out to the new intern PCP during orientation week. Residents also provide a list of their high-risk patients to the Ambulatory Chief who works with staff to schedule appointments with incoming intern PCPs. Interns review their list of high-risk patients with their core preceptor during their first two clinic blocks to ensure high-risk patients are scheduled. Interns were surveyed in September 2024 to evaluate the success of the innovation. MEASURES OF SUCCESS: A Redcap survey was distributed to all intern residents (N=39) during their 4th week in clinic. Residents responded with how many of their “high risk” patients had a sign out, if they or another resident had seen those patients, and if they felt the sign out was helpful FINDINGS TO DATE: Of 39 interns who were surveyed, 17 (44%) responded, reporting on 49 high-risk patients they received during handoff. Of the 49 patients, 15 (30%) had been seen by the assigned intern within their first clinic sessions. Another 19 (39%) had been seen by a different resident or intern who had not received the verbal handoff and 15 (30%) had not been seen. Interns opinions surveyed regarding the handoff process noted 41% felt it was a helpful tool for them to utilize when establishing care with high-risk patients, while 30% felt neutral about the process, and 29% had no comment. KEY LESSONS FOR DISSEMINATION: Our goals for this innovation were to ensure follow-up for this high-risk population, prepare interns for unusually complex patient visits, and identify areas for quality improvement in coordination of care. Despite creating an enhanced handoff process that leveraged the time and efforts of interns, faculty, leadership, and dedicated clerical staff, we still fell short of our goal of high patient continuity for this population. This may be a result of the 6+2 schedule, delayed opening of clinic schedules for the new academic year, or inherent social barriers to follow-up. Further research will attempt to identify causes for lack of follow-up in high-risk patients that failed to attend appointments with their assigned PCP. Future intervention ideas include implementing scheduled time for all interns to contact these patients via phone prior to an appointment to increase familiarity. PARTICIPATION IN A CULINARY MEDICINE SHARED MEDICAL SERIES REDUCES BLOOD PRESSURE IN HYPERTENSIVE PATIENTS Richmond S. Doxey1; Benjamin Brown2; Owen Hallett2. 1Internal Medicine, University of Utah, Salt Lake City, UT; 2University of Utah Health Hospitals and Clinics, Salt Lake City, UT. (Control ID #4230734) STATEMENT OF PROBLEM/QUESTION: Hypertension is a prevalent disease and major risk factor for heart disease and stroke, and appropriate blood pressure control leads to improvements in mortality. We aimed to evaluate the impact of a culinary medicine shared medical appointment series on participant's blood pressure. DESCRIPTION OF PROGRAM/INTERVENTION: We developed a three-part culinary medicine shared medical appointment held in a pop-up kitchen in a clinic conference room. Eligible patients were 18 years or older and had any chronic metabolic illness. In each appointment, led by a physician and dietician dyad, participants followed a recipe and cooked complete individual meals from scratch. The physician and dietician led a tailored discussion about the impact of food choices on chronic illness. Each participant set a goal related to lifestyle changes at the end of each visit. Participants were invited to return in two weeks for a second appointment and finally for a third. Retrospective data was collected on 109 patients who participated in at least one shared medical appointment. Initial blood pressure was taken using a automated blood pressure cuff at the shared medical appointment. The initial start-up cost for the pop-up teaching kitchen was ~$3,000, and the ongoing supplies cost, including food, is less than $60 per session. MEASURES OF SUCCESS: Biometrics & medication data were extracted by hand from the chart. Blood pressure & heart rate were recorded at specified time periods 3-6 months from the visit, ("6 months"), 6-12 months from the visit ("12 months"), and 12-18 months from the visit ("18 months"). These data were analyzed using ANOVA to test for statistical significance. Relevant medications were noted on each patient, at each interval. FINDINGS TO DATE: Of the 109 participants in the database, 48 had a systolic blood pressure above 129 mmHg on initial read. At six, twelve and eighteen months, all patients blood pressure decreased except one (n=47, 97.9%). The average blood pressure dropped from 139/82 to 120/76 at 18 months (n=48, p<0.05). Average resting heart rate did not change. Only four patients (8.3%) had medication changes - three reduced medications, and one increased medications. KEY LESSONS FOR DISSEMINATION: Instruction in a culinary medicine shared medical appointment series focused on the Mediterranean diet with hands-on cooking experience and individually tailored nutrition instruction from a physician and dietitian led to a meaningful reduction in blood pressure. This reduction, without medication changes in the majority, persisted for over a year. Culinary Medicine Shared medical appointments, with experiential learning and culinary instruction, can be catalyst for behavior changes and result in improved management of chronic disease, such as hypertension, without changes in medications. These can feasably be done in a variety of spaces with a relatively low start-up and maintenance costs, billed as any shared medical appointment would be, using standard evaluation and management codes for medical appointments to cover ongoing costs. PATIENT OUTCOMES IN WEIGHT MANAGEMENT: A COMPARATIVE STUDY BETWEEN RESIDENT AND ATTENDING CARE MODELS Kimberly Fasciglione2,1; Lauren I. Shapiro2,1; Rebecca Shafer2,1. 1Ryan Health, New York, NY; 2General Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272952) STATEMENT OF PROBLEM/QUESTION: Discussions with patients regarding weight management are time-intensive and require the development of longitudinal patient relationships, however, many primary care clinics can offer only short appointments to their weight management panel. DESCRIPTION OF PROGRAM/INTERVENTION: A Center for Healthy Weight Management (CHWM) was initially established in 2023 at a Federally Qualified Healthcare Center (FQHC) in an urban, underserved area to provide access to comprehensive weight management care in a vulnerable population. The program initially was staffed by attending physicians utilizing 15-minute appointment slots. This was followed by the addition of residents who volunteered to join a weight management experience, which included both academic learning and hands-on training. With the addition of multiple residents per clinic session who were supervised by one obesity medicine certified physician, more patients were able to be scheduled per session. Additionally, this allowed for more time dedicated per patient visit, with an increase to 40-minute appointment slots. We ask the question: Which is more important in improving patient outcomes in obesity management – time-intensive behavioral management counseling, which can be offered by residents, versus less time spent per appointment but more baseline skills and training, which can be offered by attendings? MEASURES OF SUCCESS: We aim to compare patient outcome data between attending physicians (n=2) and the residents (n=18) rotating within our CHWM. Our primary outcomes will be change in weight and BMI over three, six, and twelve months. Our secondary outcomes will compare biochemical data including blood pressure, lipid profile, and hemoglobin a1c over six to twelve months. FINDINGS TO DATE: Previously, a pilot phase of the CHWM program was conducted using clinical data from one attending physician’s patient panel (n=54). These patients demonstrated an average BMI loss of 0.25 over five months. Since the pilot stage we have continued attending-only care and added additional sessions with resident-led care. Between both of these clinics, over 200 additional patients have been seen at the CHWM. KEY LESSONS FOR DISSEMINATION: 1. A successful weight management program requires a comprehensive, personalized approach to each patient, including the development of a longitudinal relationship between patient and provider. 2. Incorporating residents into a weight management center can allow for longer appointment times and thus more time for counseling, potentially improving patient outcomes. SCALING UP WEIGHT MANAGEMENT PROGRAMS: INTEGRATION OF AN INTERDISCIPLINARY WEIGHT MANAGEMENT CLINIC INTO ACADEMIC PRIMARY CARE Sarah Leupold, Sara Li, Jodi M. Grandominico-Bradford, Cory P. Coffey, Allison Rhodes. Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4266296) STATEMENT OF PROBLEM/QUESTION: The importance of addressing obesity through behavior change support and anti-obesity medications is well established but underutilized in primary care due to provider knowledge gaps and clinical time constraints. DESCRIPTION OF PROGRAM/INTERVENTION: Effective management of obesity is essential for improving health outcomes and reducing chronic disease risk. However, there are challenges associated with obesity management in primary care, including provider knowledge gaps and clinical time constraints. To address these challenges, a general internal medicine clinic within a large academic medical center in the Midwest implemented an embedded Weight and Wellness Clinic (WWC). Proof of concept for this clinic was conducted from November 2023 to June 2024 during which patients were referred for weight management and seen by a board-certified obesity medicine physician within the clinic. During this time, workflows for clinic expansion were developed. On July 1, 2024, the WWC was officially established as a unique department within general internal medicine in the EMR. WWC consists of board-certified obesity medicine physicians (0.5 cFTE), a pharmacist (0.2 cFTE), and registered dietitians. Primary care providers refer patients to WWC for integrated, specialized support of lifestyle changes alongside pharmacotherapy management. Patients are followed by the WWC team longitudinally, with an initial 60-minute consultation with a physician (9 available slots/week) followed by monthly 20-minute follow-up visits (25 available slots/week) for six months or until deemed clinically necessary. If a patient is initiated on pharmacotherapy, a referral is made to the pharmacist for medication management through a collaborative practice agreement (14 available slots/week). At each visit, patients receive education on obesity management and complete goal setting on lifestyle changes. Referrals to additional specialties (dietitian, social work, exercise programming, bariatric surgery, etc.) are made as indicated. MEASURES OF SUCCESS: Initial success of the clinic was evaluated by the number of patients referred, visits completed, procedure codes billed, and total charges/payments. FINDINGS TO DATE: There have been 334 patients referred (212 during proof-of-concept and 122 since July 1, 2024), with an average of 24 referrals/month. From 7/1/24 to 11/30/24, there were 457 visits completed with a physician (253 distinct patients referred from 80 providers) and 111 visits completed with a pharmacist. Top procedure codes (n) billed include 99215 (166), 99214 (273), and 99213 (61) with $162,080 and $72,930 in total charges and payments, respectively. KEY LESSONS FOR DISSEMINATION: An interdisciplinary clinic focused on obesity management allows for a specialized team to see a high volume of patients, offload the burden from primary care providers, ensure safe and effective management of obesity, and enhance educational opportunities for learners. Demand for the clinic has outpaced capacity, so next steps include additional expansion to allow for an increase in patient volume. STANDARDIZING PRIMARY CARE DOCUMENTATION PRACTICES AMONG RESIDENTS AT A LARGE URBAN ACADEMIC MEDICAL CENTER Eric Kutscher, Douglas Halket, Alison Koransky, Cary Blum, Fiona Desland, Mary Fishman. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4229611) STATEMENT OF PROBLEM/QUESTION: At a large, urban, hospital-based primary care clinic, how can electronic health record and documentation practices be standardized to improve resident efficiency? DESCRIPTION OF PROGRAM/INTERVENTION: Documentation related burdens in the electronic health record (EHR) are associated with increased levels of burnout, particularly in the outpatient setting. Though major EHR platforms offer guidelines for best practices to increase efficiency, the implementation of these best practices varies widely based on institutional culture and learned practice. At our hospital-based clinic in a large mid-Atlantic urban area, our 160-plus resident physicians each used their own documentation practice style and template. Residents often reported difficulty cross-covering patients who they did not know due to lack of standardization, and many residents reported extensive out-of-clinic documentation that worsened wellness. With the aim of identifying documentation-related best practices to improve efficiency, standardization, and wellness, we conducted focus groups with key stakeholders at our clinic (precepting and non-precepting attending physicians, residents, interns, nurse practitioners, nurses and medical assistants, social workers, and administrative assistants). Using the focus group data, we developed a standardized problem-based note template and order preference list for all physicians. To orient residents to our new standard practices, we conducted training sessions and offered residents financial stipends to update patient charts. Precepting attending physicians were given individualized coaching on the new documentation format and provided with financial stipends for helping support residents transition to these new standardized templates. MEASURES OF SUCCESS: We assessed satisfaction with new documentation practices with repeat focus groups 6 months after launch of the documentation initiative. Additionally, we evaluated length of notes, amount of time required to document in an encounter, and changes in coding complexity that more accurately captured the diagnoses and complications of patients. FINDINGS TO DATE: To date, all residents have adapted the standardized note template and order preference lists with many attending physicians opting to use the same templates as well. Six-month post-intervention focus groups are planned for January 2025. Preliminary review of pre vs. post intervention data shows a decrease in copy-forwarded text, decrease in time spent documenting, and an increase in patient complexity scores. KEY LESSONS FOR DISSEMINATION: We learned a few key lessons in our process. First, focus groups allow for an understanding of provider needs and interests and allow for EHR modifications to be tailored to institutional cultures. Second, transitioning to standardized documentation can be assisted with the use of financial incentives as a means of promoting cultural change. Third, once standardization of documentation has occurred, smaller “real time” updates to further improve and trouble-shoot EHR changes become possible and sustainable. THE IMPACT OF PRIMARY CARE CO-LOCATION ON PATIENTS SEEN AT AN NCI-DESIGNATED CANCER CENTER Cynthia L. Cantu1; Ramon Cancino2. 1Internal Medicine, University of Texas Health San Antonio, San Antonio, TX; 2Family & Community Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX. (Control ID #4254685) STATEMENT OF PROBLEM/QUESTION: Cancer care is often fragmented, with many patients failing to continue care with their primary care physician or lacking one altogether. DESCRIPTION OF PROGRAM/INTERVENTION: Access to primary care is essential for improving health outcomes by facilitating preventive screenings, reducing late-stage cancer diagnoses, and decreasing emergency room visits and hospitalizations.1 Patients who maintain relationships with primary care physicians (PCPs) during cancer treatment and survivorship are more likely to receive preventive care for non-cancer conditions.2,3 Studies demonstrate improved outcomes in breast cancer, a 20% reduction in cervical cancer mortality, and lower colorectal cancer incidence and mortality with increased primary care engagement.4,5,6 Primary care providers (PCPs) are integral to cancer care, contributing to the management of comorbidities, chronic pain, depression, end-of-life care, and social determinants of health. Integrating primary care with oncology addresses key priorities, such as reducing cancer risk, enabling early detection, improving access to specialists, enhancing survivorship care, and mitigating disparities. To address these needs, we developed and evaluated a primary care practice embedded within a National Cancer Institute Cancer Center. This innovative model aims to optimize the continuum of care for patients with cancer while fostering collaboration between primary care and oncology teams. MEASURES OF SUCCESS: Patient Attribution: Number of patients enrolled in the Medical Management Program (MMP) within the first year and thereafter. Timeliness of Care: Time from referral by the oncology team to the first appointment FINDINGS TO DATE: The program has shown measurable success, with a significant increase in patient enrollment and strong support from oncologists. Appointment wait times are on average less than 30 days, streamlining care delivery for patients with newly diagnosed malignancies. KEY LESSONS FOR DISSEMINATION: Training future clinicians to manage this vulnerable population is critical, particularly with advancements in immunotherapies and technology. Comprehensive training equips providers with the skills to deliver holistic and compassionate care. Successful program implementation also requires strong leadership support, clinician buy-in, and adequate visit durations (e.g., 30 minutes for follow-ups, 60 minutes for new patients). Operationally, embedding electronic medical record (EMR) referrals facilitates seamless patient transitions, while maintaining open communication between primary care and oncology teams ensures coordinated, patient-centered care. These lessons provide a roadmap for scaling similar models in other institutions. UNDER PRESSURE: LOW RATES OF COMBINATION PILL ANTIHYPERTENSIVE THERAPY IN RESIDENT PRIMARY CARE Matthew St Jean1; Samantha Marazita1; Jessica Donato2; Penali Noticewala1. 1Internal Medicine, Cleveland Clinic, Cleveland, OH; 2Hospital Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4267553) STATEMENT OF PROBLEM/QUESTION: Polypharmacy is a common problem in primary care with antihypertensive therapy representing a frequent contributor. Over two thirds of patients with hypertension require at least two agents. Combination pills represent an important opportunity to reduce pill burden for patients, which may result in improved adherence and treatment persistence. We sought to characterize the use of combination antihypertensives in the primary care practices of residents at our large academic medical center. DESCRIPTION OF PROGRAM/INTERVENTION: At our large academic medical center, a quality improvement initiative was initiated to increase use of fixed-dose combination (FDC) therapy for patients with hypertension. Current state investigation of antihypertensive prescribing practices were evaluated via retrospective chart review of patients with hypertension in the primary care panels of a subset of internal medicine residents seen in the clinic between July 1, 2024, and November 22, 2024. Chart review delineated those patients prescribed two or more single-agent antihypertensive medications and identified those eligible for transition to FDC therapy within the same therapeutic class. Using the Plan-Do-Study-Act (PDSA) framework, our initiative aims to address barriers faced by residents when initiating or intensifying antihypertensive therapy and to enhance their comfort level with prescribing FDCs. Educational interventions will emphasize the clinical benefits of FDCs, their cost-effectiveness, and adherence advantages as supported by evidence-based guidelines. MEASURES OF SUCCESS: The primary outcome is percentage of patients on FDC antihypertensive therapy for patients with hypertension on two or more agents. We will additionally track patients shifted from multiple single-agent therapies to FDC following interventions. FINDINGS TO DATE: Chart review was completed on 569 patients with hypertension seen in the primary care clinic during the study period. 50.4% (287) of patients were on two or more antihypertensive agents with only 57 patients prescribed an FDC pill, which represents 16.7% of patients on two or more single agent antihypertensives eligible for FDC therapy. Among patients requiring more than two single-agent antihypertensives, 60% could be directly transitioned to FDC therapy within the same therapeutic class. KEY LESSONS FOR DISSEMINATION: A majority of patients on multiple antihypertensives are on exclusively single-agent pills and can be transitioned to fixed-dose combination therapy, thereby reducing pill burden for patients. This represents an important opportunity for quality improvement initiatives and provider education. USING HOME BLOOD PRESSURE MONITORS IN THE OFFICE SETTING TO PROMOTE REPEAT MEASUREMENT Preetha Hebbar, Kelly A. Hennessey, Stephen J. Huot, Benjamin D. Gallagher. Internal Medicine, Yale University School of Medicine, New Haven, CT. (Control ID #4271141) STATEMENT OF PROBLEM/QUESTION: Can using home blood pressure (BP) monitors in the office setting promote repeat BP measurement in primary care visits? DESCRIPTION OF PROGRAM/INTERVENTION: Accurate BP measurement is key to the diagnosis and treatment of hypertension (HTN). The U.S. HTN guideline recommends having patients rest for 5 minutes before measuring BP and obtaining at least two readings 1-2 minutes apart, which is difficult to achieve in a busy primary care practice. Our clinic is a New England Federally Qualified Health Center that hosts 110 internal medicine residents and completes over 35,000 visits per year. We implemented a new protocol for routine BP measurement using home BP monitors as a low-cost approach to promote repeat BP readings. Prior to the intervention, medical assistants (MAs) obtained vital signs (VS) at every visit using a VS cart. After the intervention, MAs measured all VS except BP using the VS cart, then measured BP once using an Omron 5 series home BP monitor and recorded that reading in the chart. MAs left the cuff on the patient’s arm and instructed them to rest quietly for 5 minutes after the MA left the room and take a second BP reading themself while waiting for the provider. The patient took a third reading 1-2 minutes after the second. The provider recorded the second and third readings in the chart. MEASURES OF SUCCESS: We abstracted deidentified BP readings from our electronic health record for all visits to our clinic during two time periods: one month post-intervention (November 2023) and the same month the year prior (pre-intervention, November 2022). Measures included number of BP readings, whether elevated BP was associated with repeat measurement, and whether repeat BP readings differed from initial readings. We used chi-squared tests to compare proportions and independent sample t-tests to compare continuous variables. This study was exempted by our institution’s IRB. FINDINGS TO DATE: In the overall cohort there were 4729 visits (2245 pre-intervention, 2484 post-intervention). Mean (SD) BP was 129.6 (19.9)/79.5 (11.1) mm Hg. 2153 visits (45.5%) had initial SBP ≥130 mm Hg. Only 754 (15.9%) had at least 2 BP readings recorded. BP was more often repeated when initial SBP was ≥130 (548 [25.5%]) vs. <130 mm Hg (206 [8.0%], p <0.001). In visits with at least 2 BP readings, the mean (SD) initial vs. second SBP was 142.6 (24.8) vs. 134.9 (22.2) mm Hg (p <0.001). Second SBP was <130 mm Hg in 130 (17.2%) visits with initial SBP ≥130 mmHg. BP was more often repeated post-intervention (574 [23.1%]) vs. pre-intervention (180 [8.0%], p <0.001). In the subset of visits with initial SBP ≥130 mm Hg, BP was more often repeated post-intervention (380 [34.3%]) vs. pre-intervention (168 [16.1%], p <0.001). KEY LESSONS FOR DISSEMINATION: A new BP measurement protocol using home BP monitors in the primary care office setting led to BP readings being repeated more frequently. The finding that repeat BP readings were on average lower than initial readings highlights the importance of serial measurement to preventing overdiagnosis and overtreatment of HTN. Innovation in Healthcare Delivery (IHD) - Career Development, Professionalism, and Wellness MINDFULNESS WORKSHOPS TO IMPROVE WELL-BEING Sunaina Kaushal. Medicine, Thomas Jefferson University, Philadelphia, PA. (Control ID #4273440) STATEMENT OF PROBLEM/QUESTION: Department-supported mindfulness-practice education to reduce burnout. DESCRIPTION OF PROGRAM/INTERVENTION: Burnout rates for healthcare workers have been staggering in recent years and mindfulness training is one tool proven to help individuals build skills to manage their stress, communicate effectively and show compassion. Mindfulness is defined as “the awareness that emerges through paying attention, on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment.” (defined by Jon Kabat-Zinn, PhD). Mindfulness-Based Stress Reduction (MSBR) programs have been used for decades for stress reduction and various clinical applications. With an existing MSBR program at a large academic institution in the Mid-Atlantic region, outpatient staff and clinicians from several offices were invited to attend one of two 3-hour Mindfulness Workshops. The objectives were to introduce mindfulness techniques, cultivate mindful communication skills, and promote a sense of community. Each workshop included an overview of the history of MSBR programs, followed by several guided mindfulness practices – breath and body awareness, mindful movement, and mindful listening. MEASURES OF SUCCESS: Qualitative pre-surveys and post-surveys were used to assess awareness of and attitudes towards mindfulness practices to reduce burnout, and to gather information for ways in which the institution could further support well-being of healthcare workers. FINDINGS TO DATE: The Mindfulness Workshops brought together clinicians and staff with varied roles and years of employment at the institution. Pre-intervention, 39% of the respondents reported they had varying degrees of burnout symptoms, and 52% felt stressed though not burned out. 82% felt work-related stress negatively impacted their communication, and 43% agreed that mindfulness practices could reduce burnout rates. Post-intervention, 93% of respondents felt that mindfulness practices can reduce stress and burnout, and positively impact their work experience. The overwhelming barrier to participation in institution-organized well-being activities was lack of time, support and flexibility. However, most were excited at the prospect of more events in which they could further learn about mindfulness practices to reduce their stress and better serve in their roles on the healthcare team. KEY LESSONS FOR DISSEMINATION: The well-being of healthcare workers is paramount to having a system that can deliver excellent and consistent care to patients. As physical and emotional exhaustion sets in, depersonalization can be the first outward sign of burnout. This affects communication and professionalism, and ultimately efficacy. Individuals can learn skills for stress-reduction and put them into practice. There is also a responsibility that lies with the overarching system to provide resources, time, and financial support to create an environment that fosters well-being. PROOF OF CONCEPT OF A PEER SUPPORT PROGRAM FOR OUTPATIENT PROVIDERS AT A VA HOSPITAL THROUGH PARTNERSHIP WITH AN AFFILIATED ACADEMIC MEDICAL CENTER Caitlin A. Harrington1; Crystal C. Grimsey1; Christopher Vanderwarker1; Wilkerson Pamela1; Patricia Kritek2; Anne Browning2; Tally Teodosio2; Lauren Beste1. 1General Medicine Service, VA Puget Sound Health Care System Seattle Division, Seattle, WA; 2University of Washington School of Medicine, Seattle, WA. (Control ID #4273321) STATEMENT OF PROBLEM/QUESTION: Primary care team members face a wide range of challenges including leadership dilemmas, complex team dynamics, challenging patient encounters, adverse events, and burn-out. DESCRIPTION OF PROGRAM/INTERVENTION: Peer support is a private conversation between colleagues with similar lived experience which has been proven to reduce clinician distress. The majority of peer support programs have focused on inpatient clinicians. A peer support program has not previously been implemented within an outpatient VA clinic system. The outpatient general medicine service (GMS) at a Northwest VA partnered with our academic affiliate with a well-established peer support program. The VA program launched in April 2024 to support 12 clinics, 2 homeless health teams, and 1 telemedicine group. It is jointly led by provider and nursing representatives. Our academic affiliate provided high quality peer support training as well as electronic infrastructure to collect peer support referrals. GMS tailored the program with a SharePoint site easily accessible from within the VA firewall as well as VA specific educational resources. Ongoing dissemination occurred through leadership meetings, staff meetings, and individual clinic meetings. Participants were surveyed following each peer support intervention. MEASURES OF SUCCESS: Measures include number of peer supporters trained, number of peer support encounters, and participant satisfaction with their peer support encounter. FINDINGS TO DATE: The program has trained a total of 32 peer supporters in 2 virtual trainings (n=14 MDs/ARNPs, 16 nurses, 2 administrative staff). The program has completed 15 peer support encounters for topics including leadership challenges, interpersonal conflicts, moral distress, burnout, patient adverse events, grief and loss, and death of a patient. A voluntary post-peer support survey was completed by 4 supported team members. Of these, 100% stated that they were very satisfied with the peer support encounter and 100% were very likely to refer colleagues for peer support. In one survey, a supported team member wrote “It was so incredibly helpful to talk to someone who completely understood the VA nursing system and culture. I felt really understood and heard.” KEY LESSONS FOR DISSEMINATION: The GMS peer support program has been well received. Staff across multiple professions have trained to be peer supporters and have gained valuable skills that they can use both in formal peer support encounters and in day-to-day clinic relationships. Early data suggests that primary care staff who receive peer support rate the experience positively and recommend the experience to colleagues. Collaboration with our academic affiliate allowed GMS to launch the peer support program without recreating training materials and referral infrastructure. This partnership provides a model that could be replicated by other VA hospitals wishing to provide high quality peer support that leverages existing peer support resources. Innovation in Healthcare Delivery (IHD) - Clinical Informatics, Artificial Intelligence, and Health Information Technology AI FOR BETTER DISCHARGES: SAFETY FIRST Priyanka Solanki1; Jared Silberlust2; Christopher Sonne1; William R. Small3; Nilufar Tursnova5; Lucille Fenelon5; Kellie Owens4; Alyssa Gutjahr4; Jonah Zaretsky1; Jonah Feldman5. 1Internal Medicine, New York University, New York, NY; 2Medicine, New York University, New York, NY; 3Hospital Medicine, New York University Grossman School of Medicine, New York, NY; 4Population Health, NYU Langone Health, New York, NY; 5Clinical Informatics, NYU Langone Health, New York, NY. (Control ID #4273000) STATEMENT OF PROBLEM/QUESTION: Artificial intelligence (AI) can enhance provider workflows and patient outcomes; however, monitoring these tools is crucial to ensure their success and maintenance of patient safety. DESCRIPTION OF PROGRAM/INTERVENTION: Artificial intelligence (AI) can significantly improve provider workflow and efficiency, while improving patient care. AI can be used to generate patient-friendly materials, simplifying complex medical documentation for enhanced patient understanding. At a large urban academic center, we developed a large language model (LLM) to generate patient friendly discharge summaries based on general internal medicine discharge summaries. While AI-generated summaries are more readable and understandable compared to the original input they still remain prone to inaccuracies and hallucinations. We conducted a usability study with 15 patient-provider pairs to assess patient friendly discharge summaries in a control environment. Over 90% of the participants recommended human editing of the AI-generated content before it is provided to patients, highlighting the critical need to ensure that this process is implemented, especially in a live clinical setting. We developed several clinical decision support interventions to promote human editing, including a provider attestation to acknowledge the necessity to review and edit the AI-generated summaries, an EHR-based AI fact card, and a short educational video for providers. During a concurrent live safety review of these AI-generated summaries, we are monitoring the edit distance between the summaries and evaluating them using a rubric to assess the quality of AI-generated, human edited summaries. MEASURES OF SUCCESS: During usability studies, qualitative feedback was obtained from patients and providers regarding the workflow and AI-generated content. Successful implementation of these human-edited summaries involves measuring the Levenstein edit distance, and evaluating their readability, understandability, safety, and overall quality using a custom rubric. FINDINGS TO DATE: During a live clinical phase, only 8 out of 15 (53%) of summaries were edited. Of those edited, the Levenstein edit distance averaged 211 ± 173-character changes. The major categories of edits include the addition of medications changed during the hospital course, additional follow-up information, and the elimination of non-specific words to improve clarity. No overt hallucinations were observed, and all summaries passed a 360-degree concurrent safety review by a physician informaticist, the nurse, the attending, and the patient themselves. KEY LESSONS FOR DISSEMINATION: 1. Integration of AI generated content can be used to enhance patient care and improve provider workflows 2. The implementation of AI generated patient facing materials requires close safety monitoring to ensure overall accuracy and safety AN AI SCRIBE SOLUTION AT HENNEPIN HEALTHCARE Brian Imdieke1; Tyler Winkelman2. 1General Internal Medicine/Clinical Informatics, Hennepin Healthcare System Inc, Minneapolis, MN; 2Medicine, Hennepin Healthcare, Minneapolis, MN. (Control ID #4268779) STATEMENT OF PROBLEM/QUESTION: Provider burnout is a critical issue driven, in part, by administrative burdens of clinical documentation. Cognitive load associated with maintaining clinical documentation leads to decreased job satisfaction. At Hennepin Healthcare (HHS), the largest safety-net health system in Minnesota, annual provider wellness surveys show high levels of stress, symptoms of burnout, limited control over workload, inadequate time for documentation, and large amounts of time spent in the electronic health record (EHR). DESCRIPTION OF PROGRAM/INTERVENTION: To reduce documentation burden and improve provider wellness, HHS has implemented an AI scribe solution for approximately 130 providers across multiple specialties. A large portion deployed in the Department of Medicine. The AI scribe solution captures multi-party conversations during patient encounters and converts them into comprehensive, specialty-specific clinical documentation. These summaries are delivered into the EHR within minutes for clinician review. This intervention aims to streamline documentation processes, allowing clinicians to focus on patient care and less on administrative tasks. We ultimately hope to improve fulfillment in practice and improve patient outcomes. MEASURES OF SUCCESS: We will evaluate our AI Scribe program through several key domains: 1. EHR proficiency metrics: -Time spent in the EHR during off-hours (time not scheduled to be in clinic). -Time spent in clinical documentation activities. -Percentage of encounters closed on same day of service (key factor when measuring clinician burnout) 2. HHS' Provider Wellness Survey. Administered at baseline, 2, 6 and 12-month intervals. Specifically evaluating: -Stress due to job -Symptoms of burnout -Control over workload -Time for documentation -Amount of time spent in the EHR -Feeling valued by the organization -Likelihood to leave the organization in 2 years 3. Impact on Hierarchical Condition Coding. Our hypothesis is that AI scribe use will be associated with increased documentation of complex health conditions, which are important for accurate risk adjustment with payers. FINDINGS TO DATE: HHS' 2024 annual provider wellness survey is used as a baseline: 57% of providers feel great deal of stress due to their job. 39% experience symptoms of burnout. 37% feel poor control over workload. 30% feel poor/marginal time for documentation. 30% feel they spend high or excessive time in the EHR. 51% feel valued by the organization. 32% feel they are likely/definitely to leave the organization in 2 years. At baseline, users have documented 61% of known HCC conditions for patients in an accountable arrangement Baseline EHR proficiency data is pending and will be made available. We will begin collecting and alayzing data at the end of December, 2024 (60 days from implementation). KEY LESSONS FOR DISSEMINATION: Attendees will learn about how the AI scribe solution was strategically implemented at Hennepin Healthcare (HHS) to address the critical issue of provider burnout, how metrics were developed and measured and how learnings can be applied in their own practice. DEVELOPMENT OF AN APP FOR INTERHOSPITAL TRANSFER (IHT) BETWEEN ACUTE CARE HOSPITALS: USER NEEDS AND CONCEPTUAL DESIGN John D'Amore5; Rio Bennin4; Jazzarae K. Kain3; Stephanie L. Singleton3; Pamela Garabedian2; Lipika Samal3,1; Stephanie Mueller3,1. 1Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 2Research & Academics, Mass General Brigham Inc, Boston, MA; 3Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 4Crossroads labs Inc., Boston, MA; 5More Informatics Inc., Wellesley, MA. (Control ID #4271415) STATEMENT OF PROBLEM/QUESTION: Over 100,000 patients with multiple chronic conditions undergo IHTs annually, facing risks of discontinuity of care due to gaps in health information exchange. DESCRIPTION OF PROGRAM/INTERVENTION: Interhospital transfers (IHT, the transfer of patients between acute care hospitals) are common and often undertaken to provide patients with a higher level of care. However, IHT patients are subject to the risks of discontinuity of care given patient illness severity and gaps in information exchange between hospitals. Optimal health information exchange (HIE) includes the appropriate, timely sharing of vital patient information. Prior research has shown that suboptimal HIE during IHT occurs regularly, subjecting patients to therapeutic errors and delays in care. To address these gaps, we utilized user-centered design principles engaging frontline clinicians to design and implement a FHIR-based novel HIE platform for use among patient transfers to inpatient medical services at a large quaternary care hospital. MEASURES OF SUCCESS: We will measure clinician-reported medical errors after transfer via targeted surveys to clinicians caring for IHT patients at time of arrival and compare post- versus pre-implementation. This survey will additionally measure clinician-reported accessibility to patient information and quality of clinical data available at time of IHT patient arrival. We will also evaluate the use and perceived usability of the HIE platform utilizing administrative data for platform use (e.g., unique “clicks” on the HIE platform), and the Health Information Technology Usability Evaluation Scale (Health-ITUES) validated usability survey sent to clinicians who interact with the HIE platform. To complement this, we will conduct interviews and focus groups with a sample of clinicians to explore workflow suggestions for improvement. Together, these results will allow us to detect targets for improvement in future iterations of the platform. FINDINGS TO DATE: User-centered design principals utilizing data collated from frontline clinician focus groups was utilized to develop a novel HIE platform for use during IHT. This HIE platform is currently undergoing integration for use. Data on clinician-reported medical errors, accessibility, and quality of available clinical information has been collected on 500 IHT patients pre-implementation to-date, with post-implementation data planned. KEY LESSONS FOR DISSEMINATION: Patients are increasingly accessing care across diverse clinical settings, with IHT serving as a key example. Our platform enhances health information exchange by improving access to clinical data across these varied settings, offering a model that can be expanded to other types of medical care. Importantly, we incorporated input from key informants to develop and organize the clinical data, ensuring the platform's usability and effectiveness. ECONOMIC IMPACT OF IMPLEMENTING AN ARTIFICIAL-INTELLIGENCE-ENABLED ELECTROCARDIOGRAM (ECG-AI) ALGORITHM FOR EARLY DETECTION OF LOW LEFT VENTRICULAR EJECTION FRACTION AND HEART FAILURE Lars R. Hegstrom, Heather M. Alger, Wui Ip, Nihit Goli, Samir Awasthi. Clinical Science, Anumana, Wilmington, MA. (Control ID #4272855) STATEMENT OF PROBLEM/QUESTION: Background: Heart failure with reduced ejection fraction (HFrEF) poses a significant global health burden, characterized by high morbidity, mortality, and healthcare costs. HFrEF disproportionately impacts patient populations where social determinants of health can be a barrier to access. Early detection of low left ventricular ejection fraction (LEF) and initiation of guideline-directed medical therapy (GDMT) are essential for improving patient outcomes and reducing health disparities.

To evaluate the cost-effectiveness and potential healthcare impact of implementing ECG-AI for detecting LEF compared to the standard of care (SOC), by constructing an economic model based on data from previously published studies. DESCRIPTION OF PROGRAM/INTERVENTION: Methods: An economic model was developed using data extracted from multiple published sources. Key parameters included diagnosis rates of HFrEF using ECG-AI versus SOC (2.1% vs. 1.6%) in the primary care setting from the EAGLE trial between 2019 and 2020. Additionally, costs associated with GDMT (triple therapy at $53 per patient and quadruple therapy at $10,400 per patient), hospitalization costs, readmission rates, and echocardiogram utilization were modeled. The model assessed the impact of ECG-AI implementation on healthcare costs, patient outcomes, and resource utilization. Evaluation metrics consisted of quantitative measures such as cost savings, reduction in readmission rates, and changes in mortality. MEASURES OF SUCCESS: The primary measures of success for implementing an ECG-AI algorithm include clinical, economic, and system-wide outcomes. Key success metrics encompass improved rates of early detection of low LEF compared to the standard of care, increased utilization of guideline-directed medical therapy (GDMT), and reductions in hospitalizations, readmissions, and associated healthcare costs. Additional measures include the quality-adjusted life years (QALYs) gained, mortality reductions, and enhanced equity in access to timely heart failure diagnosis and treatment. FINDINGS TO DATE: Results: For 100,000 ECGs annually, the model projected cost savings of $7.8 million driven by earlier detection and initiation of GDMT, which reduced hospitalizations and readmission rates. The intervention saved 92 lives and achieved a QALY gain valued at $6.9 million. The increase in echocardiogram utilization from 18.2% to 19.2% (p=0.17) was offset by reduced inpatient admissions, demonstrating overall cost-effectiveness. The results highlight the scalability of ECG-AI in clinical and community settings. KEY LESSONS FOR DISSEMINATION: Conclusion: Integrating ECG-AI into clinical practice is cost-effective, with significant potential to improve early detection of HFrEF, optimize GDMT utilization by primary care providers, and achieve meaningful cost savings. These findings support the adoption of ECG-AI to enhance healthcare quality and equity, demonstrating its value across diverse scenarios, including large-scale implementation. IMPLEMENTATION OF A QUICK ENTRY CLINICAL DOCUMENTATION AND CHARTING SYSTEM TO STANDARDIZE AND SCALE A HEALTH SYSTEM-WIDE POSTPARTUM PRIMARY CARE PROGRAM Ruvarashe Rumano2,1; Amythest Gauthier3,1; Kathryn Tobin1; Shadia Jallaq4,1; Rachel D. Gordon1; Vivian P. Beamon1; Rosa G. Negash5; Seuli B. Brill6. 1General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2College of Public Health, The Ohio State University, Columbus, OH; 3Family and Community Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 4Government Resource Center, Ohio Colleges of Medicine, Columbus, OH; 5Division of General Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; 6Internal Medicine, Ohio State University College of Medicine, Columbus, OH. (Control ID #4272955) STATEMENT OF PROBLEM/QUESTION: Is implementation of an electronic health record (EHR) embedded-workflow consolidation tool focused on standardizing delivery of evidence-based postpartum chronic disease prevention and management feasible across a health system wide postpartum primary care program? DESCRIPTION OF PROGRAM/INTERVENTION: Over half of US maternal deaths occur during the postpartum year. Yet, lack of US postpartum care systems and limited primary care provider (PCP) knowledge of postpartum care needs has resulted in less than 20% of individuals accessing primary care within the first 6 months after delivery. This includes individuals with conditions such as hypertensive disorders of pregnancy and gestational diabetes mellitus that increase life-course risk of cardiovascular disease. A Midwestern academic medical center has a postpartum primary care program involving 61 PCPs across 9 clinics. In response to inconsistent delivery of evidence-based services, such as mood disorder screening, during program expansion, an EHR-embedded Express Lane workflow-consolidation tool was implemented. This tool standardizes care, including perinatal mood and anxiety disorder (PMAD) screening and contraception counseling, by providing accessible utilities like documentation, lab orders, clinical referrals, patient education materials, and provider billing, all within a single screen view. Quality improvement coaching (e.g. execution of Plan Do Study Act (PDSA) cycles and real-time data feedback) supported Express Lane implementation. MEASURES OF SUCCESS: Pre and post implementation Express Lane use and provider comfort and satisfaction with the Express Lane were measures of success. FINDINGS TO DATE: There are 61 MOMI PODS providers and over the course of 10 months there were 208 dyad visits. Following completion of training, Express Lane utilization by providers during a dyad visit saw a median shift on the control chart from 33% at baseline to 54%. All providers were sent surveys with 19 completing the pre-survey and 16 completing the post-survey. Provider feedback showed improvements including comfort with documentation (3.94 to 4.33), comfort with placing referrals (3.66 to 4.26), satisfaction with care provided (4.27 to 4.33). Ability to provide high quality care was stable at 4.33. KEY LESSONS FOR DISSEMINATION: Standardizing postpartum primary care through health-system implementation of informatics is feasible. It improves PCP comfort and satisfaction with care delivery. Future evaluation will focus on QI efforts and evaluation focused on clinical service delivery (e. PMAD screening). These tools can also support systems of primary care delivery for other populations with specialized health care needs. IMPLEMENTING AMBIENT DOCUMENTATION FOR AMBULATORY CLINICIANS Katharine Lawrence1,2; Kiran Malhotra2; Conner Polet2; Vasu Kuram2; Sarah Sharif2; Devin Mann1,2. 1Population Health, NYU Langone Health, New York, NY; 2MCIT, NYU Langone Health, New York, NY. (Control ID #4268400) STATEMENT OF PROBLEM/QUESTION: The implementation of AI-assisted "ambient" documentation in healthcare is complex. While many institutions have deployed this technology in ambulatory settings, detailed implementation insights are scarce. Our goal is to offer a comprehensive roadmap covering project planning, EHR integration, clinician engagement, training, and outcome tracking. By sharing best practices, technical insights, and lessons learned, we aim to bridge knowledge gaps and help institutions optimize deployment. DESCRIPTION OF PROGRAM/INTERVENTION: At NYU Langone Health, we evaluated multiple ambient documentation vendors within our EHR (Epic). Our multidisciplinary team, including project managers, analysts, and informaticists, followed a structured process. This included project planning with clear OKRs, provider-level integration, clinician training, and evaluation. We conducted proof of concept (POC) trials with two vendors across specialties, ensuring flexibility and personalized user experience while addressing security constraints. We tracked usage, user experience, and productivity outcomes using surveys, interviews, EHR data, and vendor reports. MEASURES OF SUCCESS: Success was measured through: Clinician Experience: Satisfaction, usability, cognitive load, and wellbeing (via structured interviews and surveys). Usage Metrics: Adoption rates, frequency of tool use, and abadonment over time (via vendor report). Productivity: Key OKRs including: Documentation time, pajama time, note completion rates, and billing levels (via Epic Signal). Patient Experience: Comfort and satisfaction with Ambient AI usage (via patient surveys). Implementation Insights: Perceptions, barriers and facilitators to deploying and supporting the technology FINDINGS TO DATE: Our study included 93 physicians across specialties. Vendor B outperformed Vendor A in user engagement (79% vs. 59%), tool utilization (43.3% vs. 18.2% of encounters), and clinician satisfaction (88% "very satisfied"). Vendor B also reduced note-taking time by 5 minutes per day. Despite these differences, 98% of providers recommended Ambient AI, with 65% expressing comfort using it and 59% believing it improved patient care. These insights underscore the potential of Ambient AI to reduce clinician burden and enhance efficiency. KEY LESSONS FOR DISSEMINATION: Integration Challenges: Varying EHR integration impacts user experience and disrupts workflows. Provider-level integration offers flexibility but may conflict with personalized EHR setups. Improved architecture is needed for smoother deployment. Multidisciplinary Teams: Success relies on collaboration among technical, managerial, and clinical experts, with significant resources needed for rollout and adoption. Clinician Engagement: Early, continuous involvement and clinical champions are key. Individual support promotes adoption but limits scaling. Evaluation Framework: Comprehensive metrics are crucial but reliance on vendor data and EHR metrics may not capture full impact. Vendor Comparison: Side-by-side evaluations reveal differences in usability, satisfaction, and impact. INFORMED CONSENT FOR AMBIENT DOCUMENTATION USING GENERATIVE ARTIFICIAL INTELLIGENCE: AN ANALYSIS FOR OPERATIONAL QUALITY IMPROVEMENT Katharine Lawrence1,2; Vasu Kuram2; Defne L. Levine1; Kiran Malhotra2; Conner Polet3; Kellie Owens1. 1Population Health, NYU Langone Health, New York, NY; 2MCIT, New York University, New York, NY; 3MCIT, NYU Langone Health, New York, NY. (Control ID #4271967) STATEMENT OF PROBLEM/QUESTION: Despite the rapid deployment of AI-assisted “ambient” documentation technologies across hospital systems to optimize clinical note-writing and reduce administrative burdens, little is known about optimal approaches to engage patients in informed consent for these tools. DESCRIPTION OF PROGRAM/INTERVENTION: The ambient documentation program leverages AI-assisted technologies to automatically generate clinical notes from patient-clinician conversations. This program was implemented in pilot phases across various clinical settings within a major academic medical center, involving over 100 clinicians. We conducted an exploratory evaluation that focused on informed consent processes, including 103 patients who participated in encounters where ambient documentation was used. The evaluation identified patient perceptions, comfort levels, and concerns, as well as gaps and opportunities for improving the consent experience. MEASURES OF SUCCESS: Patient Comfort: Percentage of patients reporting comfort with the use of ambient documentation Consent Process Clarity and Optimization: Improvement in patient understanding of data use, storage, and opt-out options, and efficiency of the consent process within clinical workflows Qualitative Patient Feedback: Insights on patient concerns, needs, and suggestions regarding informed consent, focusing on data privacy, trust, and the overall consent experience FINDINGS TO DATE: Most patients (75%) reported being “comfortable” or “very comfortable” with ambient documentation technology, but over half (59%) opposed sharing data with the ambient vendor. Comfort levels varied by encounter type, with greater acceptance for routine visits and documentation support compared to sensitive discussions or diagnostic reasoning. Detailed consent discussions sometimes decreased comfort, though patients valued the potential to reduce clinician note-taking burdens. Many wanted clearer information about data use, storage, and access, along with more time to review risks and benefits. Patients also emphasized the need for a clear opt-out option and clarity on withdrawing consent. KEY LESSONS FOR DISSEMINATION: Integrating ambient AI technologies in healthcare can enhance patient care by reducing clinicians' administrative burdens. However, ethical challenges must be addressed to protect patient trust and prevent disparities. Improved consent requires flexible approaches: clear education, time for risk discussions, digital resources, non-clinical staff support, and opt-out options. Further research is needed to qualitatively explore ambient-enabled care and quantitatively assess its impact on care delivery and outcomes. PILOT STUDY OF ARTIFICIAL INTELLIGENCE (AI) SCRIBES ON HOSPITALISTS' TIME ALLOCATION AND PATIENT-PROVIDER INTERACTIONS Shamila Tilak1,2; Jeffrey L. Schnipper3; Hacho Bohossian4; Bijay Acharya5. 1General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Harvard Medical School, Boston, MA; 3Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 4Mass General Brigham Inc, Boston, MA; 5Mass General Brigham Inc, Boston, MA. (Control ID #4273031) STATEMENT OF PROBLEM/QUESTION: How will the implementation of AI scribes change hospitalists’ documentation time, direct patient care time and the quality of the patient-provider interaction? DESCRIPTION OF PROGRAM/INTERVENTION: Documentation burden has been on the rise since the introduction of electronic health records (EHRs). Artificial Intelligence (AI) scribes use ambient documentation technology and have the potential to mitigate documentation burden. Few studies have investigated the implications of AI scribes on academic hospital medicine providers’ workflow and patient interactions. MEASURES OF SUCCESS: We conducted a stepped-wedge trial at 3 hospitals within a single health care system to investigate the effects of an AI scribe on hospital medicine providers’ time allocation and quality of patient-provider interaction. 9 hospital medicine providers were recruited from a larger operational pilot study and were each observed during up to 5 hospital admission encounters at each study timepoint. At timepoint 0, hospitalists were observed without the use of an AI scribe, and documentation time, direct patient care time and provider eye contact time with the patient were measured. Hospitalists were randomly selected in cohorts for timing of AI scribe onboarding. All measurements were repeated within 1 month of onboarding at timepoint 1 and will be measured again within 4-5 months of onboarding at timepoint 2. Results were stratified by gender given prior literature on potential differences in documentation practices. FINDINGS TO DATE: 45 observations were conducted at timepoint 0, and 32 observations were conducted at timepoint 1. When stratified by provider gender, there was a non-significant reduction in the median documentation time from 27.0 to 22.4 minutes (p = 0.41) for females and a non-significant increase in median documentation time from 14.5 to 17.6 minutes (p = 0.84) for male providers between timepoints 0 and 1. There was no change in direct patient care time. Median provider eye contact time with the patient increased from 7.53 to 12.64 minutes (p = 0.04) for females and from 6.70 to 9.19 minutes (p = 0.30) for males. Timepoint 2 observations are in progress. KEY LESSONS FOR DISSEMINATION: Although these preliminary results demonstrate direct patient care time did not change with AI scribe use, there was a borderline significant increase in provider eye contact time with patients, which may suggest improved quality of patient-provider interactions. Documentation time non-significantly decreased for female providers with the AI scribe but increased for male providers. This difference may be due to documentation practices prior to the introduction of the AI scribe, such as the use of dictation software. There may be a learning curve associated with using new technology and integrating it into clinical workflows, which further observations at timepoint 2 may demonstrate. AI scribes hold potential to change documentation practices and patient-provider interactions for hospital medicine providers, or at least for certain sub-groups of providers. REIMAGINING FMLA - FROM PEN & PAPER TO EHR INTEGRATION Kevin M. Pearlman1; Julie Oyler2; Mim Ari3; Lisa Vinci4; Sachin D. Shah5. 1Internal Medicine, The University of Chicago Medicine, Chicago, IL; 2Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 3Medicine, University of Chicago, Chicago, IL; 4Medicine, University of Chicago, Chicago, IL; 5Medicine & Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4234089) STATEMENT OF PROBLEM/QUESTION: Given that FMLA (Family Medical Leave Act) documentation is a time-consuming element of patient care, can an EHR-embedded FMLA form positively impact clinicians? DESCRIPTION OF PROGRAM/INTERVENTION: Many clinicians at our organization have historically relied upon a “pen-and-paper” approach when filling out FMLA and have anecdotally reported the burden it imposes on their workflows. In order to assess the impact of FMLA on the workflow of ambulatory providers at our organization, we administered a survey to ambulatory providers in July-September of 2024. This was paired with the launch of an EHR-embedded FMLA tool in July 2024 that aimed to reduce the time spent filling out forms, expedite the transmission process to patients and employers, minimize the risk of forms getting lost, and streamline the FMLA renewal process. We also created customized versions of FMLA for caregivers and pregnant patients. In order to familiarize clinicians with the new EHR workflow, educational materials were provided to impacted users. These materials were also made accessible through a hyperlink embedded in the form. To date, there haven’t been any reports of employers denying the EHR-generated form based on formatting or the use of our organization’s letterhead. Of note, our EHR tool was modeled after an Epic build developed by providers at Parkview Health in Fort Wayne, Indiana. MEASURES OF SUCCESS: - Favorable changes in clinician-reported survey metrics (see additional details in findings) - Sustained growth in utilization of EHR-embedded FMLA tool - Uptake of tool across a wide range of departments FINDINGS TO DATE: Survey Findings: We administered a pre-survey to all ambulatory clinicians and received 67 responses. Key results of our survey included the following: - 57% of clinicians disagreed or strongly disagreed that they have an efficient process for filling out FMLA - 86% agreed or strongly agreed that filling out FMLA is a burdensome aspect of their job - 92% agreed or strongly agreed that their workflow would improve if FMLA could be documented on the EHR through a standardized mechanism - 82% indicated they often or always fill out FMLA by hand - 78% reported that FMLA takes greater than 10 minutes to fill out We plan to administer a 6-month post-survey in January 2025 to assess for changes in these metrics. EHR Tool Utilization: Between July and November 2024, our FMLA tool was used 202 times by 87 distinct providers across 31 departments. Uptake of the tool rose steadily between July (17 submissions) and October (67 submissions). Utilization slightly declined in November (53 submissions). 88% of providers who used the form practice in a primary care setting. KEY LESSONS FOR DISSEMINATION: - A clinician informaticist should be directly involved in the development of EHR-based clinical support tools - Collaboration with physician, nursing, and operational leaders in addition to affected clinicians can lead to effective dissemination of an EHR support tool - Provision of concise educational materials at the point of care can facilitate uptake of a new EHR tool SMOKING CESSATION COUNSELING IN THE PRIMARY CARE SETTING: AN OPT-IN VS OPT-OUT APPROACH Kevin Shamash1; Jacalyn Nay2; Jason Hyde4; Isaac Dapkins3; Arielle Elmaleh-Sachs4; David Golombeck1. 1internal Medicine, NYU Langone Health, New York, NY; 2Patient Navigation Center, NYU Langone Health, New York, NY; 3Population Health, NYU Langone Health, New York, NY; 4Family Health Centers, NYU Langone Health, New York, NY. (Control ID #4272505) STATEMENT OF PROBLEM/QUESTION: Counseling for smoking cessation in the primary care setting can vary due to multiple patient and provider factors, leading to inconsistencies in the counseling received and follow-up plan. DESCRIPTION OF PROGRAM/INTERVENTION: Tobacco use continues to be one of the leading causes of preventable disease and death in the United States. Smoking cessation counseling usually falls on the shoulders of primary care providers (PCPs). PCPs manage numerous comorbidities and modifiable factors that affect health, so being able to effectively and comprehensively address all these issues, specifically smoking cessation, can be a challenge during time-limited clinic visits. There are different methods for providing education and counseling for patients using tobacco products, ranging from psychosocial approaches to medical management. Our community health center network previously utilized an opt-in strategy for referrals, where PCPs were prompted by a best practice advisory (BPA) to counsel their current smoker patients on the risks of tobacco use, but only patients agreeable to additional services were linked to referrals such as state-sponsored smoking Quitline’s or started on pharmacotherapy. Our project aims to test whether implementing an opt-out strategy in a BPA improves counseling, follow-up, and smoking cessation rates. Given time limitations in primary care, we created a dedicated virtual clinic for intensive tobacco cessation interventions, consisting of a nurse to perform motivational interviewing, and a nurse practitioner to initiate pharmacotherapy and follow-up. The BPA now prompts PCPs to refer all patients (opt-out) to the virtual clinic for intensive smoking cessation counseling and continues to include an option to refer to the quit-line (opt-in). Patients are informed by the scheduling department that they were referred to this program and offered an appointment. MEASURES OF SUCCESS: Measures of success include rates of referrals by PCPs to the virtual clinic for current smokers, show-rates to the first virtual clinic appointment, retention rate in the clinic, number of visits per patient, and tobacco cessation rates among patients enrolled in the virtual clinic. FINDINGS TO DATE: Between 9/15/2024 and 11/15/2024, providers were alerted through a BPA to counsel and refer 604 current smokers. Among these patients, 17% were referred to the virtual tobacco cessation clinic. Of those referred, 54% of patients agreed to a scheduled appointment, and 21% completed at least one appointment in the clinic. During the same time period, 4% of eligible patients were referred to the smokers’ Quitline, follow-up data among these patients with the Quitline is not yet available. KEY LESSONS FOR DISSEMINATION: Use of an opt-out approach for tobacco cessation counseling interventions increases the referral rates compared to an opt-in approach. Further analysis will be done after 6 months of enrollment to test whether tobacco cessation rates also improve. Opt-out approaches and dedicated clinic visits have the potential to increase tobacco cessation among patients. USING A FHIR-BASED APPLICATION TO ENHANCE INTEROPERABILITY AND ADVERSE EVENT DETECTION IN PATIENTS WITH MULTIPLE CHRONIC CONDITIONS Emma Young1; Patricia Dykes2; Nicole G. Weiskopf1; Li Zhou2; Michelle Bobo1; Matthew Storer1; Lipika Samal3; David Dorr1. 1Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR; 2Brigham and Women's Hospital, Boston, MA; 3Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4272223) STATEMENT OF PROBLEM/QUESTION: Patients with multiple chronic conditions (MCCs) are at higher risk for adverse events (AEs) and require coordinated care across multiple healthcare settings. However, settings often use non-interoperable electronic health record (EHR) systems, leading to data fragmentation that negatively affects clinical outcomes and pragmatic trials by limiting investigator access to comprehensive data. This can adversely impact patient safety and the applicability of trial interventions. DESCRIPTION OF PROGRAM/INTERVENTION: Multiple Chronic COnditions: MultiPle DAta SouRces (MC COMPARE) is a multi-site trial that aims to improve interoperability and AE detection by enrolling 400 patients with MCCs from two extant partner trials focused on hypertension management and reducing AEs during post-discharge care. Participants will use MyCarePlanner, a FHIR-based application (app) that combines primary care and external health data. MyCarePlanner can access over 4,000 EHRs and allows participants to select external healthcare systems, log into patient portals, and import external health data. MyCarePlanner retrieves structured health data through value sets and using standard FHIR resources.The app is implemented at one study site and will soon be implemented at the other. MEASURES OF SUCCESS: We previously conducted interviews for another study to explore patients’ interaction with MyCarePlanner’s user interface. We will interview additional participants to assess the completeness and accuracy of imported data, focusing on data pertinent to our partner studies to identify missed AEs during the partner study period. We will re-analyze partner study outcomes, focused on common AEs missed, by incorporating the external data to evaluate its impact on detecting common AEs. FINDINGS TO DATE: We reviewed external health data for similar patients as those enrolled in our partner studies and found 95% of patient charts include data from outside institutions, with 63-78% from local hospital systems, 28% from community health clinics, and 29-39% from ambulatory clinics. To assess volume of missing data, we randomly reviewed 50 patient charts with known external data, examining the most recent 50 notes. We found that 46.8% of these notes were from outside institutions, highlighting a significant amount of missing data. We are updating the app to enhance the user interface and display additional data relevant to our partner study outcomes, such as expanded blood pressure measurements and detailed encounter information for emergency department visits and unplanned hospitalizations to aid with enhanced adverse event detection. KEY LESSONS FOR DISSEMINATION: This session will introduce general internists to the potential of FHIR-based apps to enhance interoperability and adverse event detection in patients with MCCs, improving care and health outcomes. These apps have potential to address complex, fragmented and high-touch health care, while also supporting patient goals and decision-making regardless of their comfort level or experience with technology. USING THE ELECTRONIC HEALTH RECORD PATIENT PORTAL TO COLLECT ADVANCE DIRECTIVES AND SURROGATE SPECIFICATION Neil Wenger1; Annapoorna R. Chirra1; Anne Walling2,3. 1Medicine, University of California, Los Angeles, Los Angeles, CA; 2Medicine, University of California Los Angeles, Los Angeles, CA; 3VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4272662) STATEMENT OF PROBLEM/QUESTION: Advance care planning (ACP) and completing advance directive (AD) documents is important for health decision making, however integrating the AD into the electronic health record (EHR) is difficult. DESCRIPTION OF PROGRAM/INTERVENTION: In collaboration, Health IT, the Health Information Management System (HIMS) and the Advance Care Planning Program developed a mechanism for ACP documents and surrogate information submitted through the Epic patient portal to be evaluated by HIMS personnel and integrated into the EHR or rejected and a message returned to the patient. The submitted ACP document is reviewed for validity. A valid AD or POLST is uploaded into the appropriate EHR area so it is available to the clinician and viewable for the patient. HIMS staff enters the surrogate into the EHR. If an AD or a POLST is invalid (e.g., unsigned or unwitnessed), the document is rejected and the patient notified. HIMS personnel also process the surrogate information entered by patients. Educational materials were developed for HIMS personnel and training sessions were conducted that included an introduction to ACP and ADs, and HIMS tasks concerning submitted documents and surrogates. A living FAQ was developed and follow up sessions conducted to discuss unusual cases. MEASURES OF SUCCESS: We produced run charts between May 2021 when build went live to September 2024 to evaluate the number of ADs and POLSTs accepted and rejected per month, and the number of rejected documents resubmitted and accepted. We also evaluated the number of submitted surrogates recorded in the EHR, the number rejected and the number removed by the patient. FINDINGS TO DATE: Use of the patient portal for uploading documents was immediate in May 2021 with 180 uploaded during the first month: 120 AD and POLST forms met the quality standard and were accepted and uploaded into the EHR. Seventy documents were rejected and 8 of these were resubmitted and accepted. There was a gradual increase in accepted documents over the studied period. Over the 41-month study, 7274 ACP documents were uploaded via MyChart into the EHR (mean 177 documents per month): 4700 (65%) documents were accepted on first submission and 2574 (43%) documents were rejected. Of rejected documents, 397 (15%) were resubmitted and accepted in the same calendar month. There was no significant time trend in rejected documents accepted after resubmission. Overall, 5097 (70%) of ACP documents were accepted into the EHR during the study period. This included 4852 (95%) ADs, 74 (1.5%) POLST and 171 (3.4%) other documents. Overall, 12,509 surrogates were added (mean 305 per month), 1790 were updated and 911 were removed. KEY LESSONS FOR DISSEMINATION: A collaborative mechanism of engaging HIMS personnel in collection of ACP documents can facilitate document capture through with a common EHR portal. The structure incorporates a check on quality and patient feedback for incomplete or incorrect documents. The number and proportion of accepted documents increased over the three years since initiation. WRITING A NEW CHAPTER ON CLINICIAN WELLBEING WITH AI-ASSISTED SCRIBING Jacqueline G. You1,2; Reema Dbouk4; David Y. Ting3; Amanda J. Centi5; Michelle Frits6; Christine Iannaccone7; Christopher Holland8; Bryan Blanchette8; Lisa Rotenstein9,2; Rebecca G. Mishuris5. 1Pathology, Massachusetts General Hospital, Boston, MA; 2Medicine, Brigham and Women's Hospital, Boston, MA; 3Medicine, Mass General Brigham Inc, Boston, MA; 4Medicine, Emory University, Atlanta, GA; 5Digital, Mass General Brigham Inc, Boston, MA; 6General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 7General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 8User Experience, Digital, Emory Healthcare, Atlanta, GA; 9Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4273333) STATEMENT OF PROBLEM/QUESTION: Does AI-assisted ambient documentation impact clinician wellbeing/burnout? DESCRIPTION OF PROGRAM/INTERVENTION: Burnout represents a national crisis in healthcare, affecting about half of all physicians and resulting in challenges with access, quality of care, and patient experience. Burnout is partially driven by documentation burden. Ambient documentation, also known as AI-assisted scribing, uses large language models (LLMs) to draft visit notes from recorded patient-clinician interactions. Mass General Brigham (MGB) and Emory Healthcare are two quaternary academic medical healthcare systems which piloted ambient documentation across all care settings, including community locations. MGB had a two-vendor pilot with 873 clinicians (attending physicians and advanced practice providers, APPs) and Emory had a one vendor pilot with 628 clinicians (attending physicians, residents/fellows, and APPs). MEASURES OF SUCCESS: Metrics include pre- and post-intervention Provider Fulfillment Index (PFI) burnout (MGB) and wellbeing (Emory) scores and overall likelihood to recommend. FINDINGS TO DATE: MGB used a 32 question presurvey which included PFI burnout related questions, and a 39-question survey administered at the 6-week mark with PFI burnout questions. Emory used a 5-question baseline survey that was administered at the time of pilot enrollment. The post-survey consisted of 9 questions and was administered 60 days following pilot participation. Wellbeing was assessed with a single question on overall perceived impact on wellbeing with answer options using a 5-point Likert scale. MGB had a 30% response rate and Emory had a 15% response rate. 26% and 21% of MGB and Emory survey respondents respectively were primary care clinicians; at both institutions, about 80% of survey respondents were physicians and 20% were advanced practice providers. Our results show a statistically significant decrease in reported burnout (n=134, 50.6% at baseline compared to n=78, 29.4% of survey respondents at the 6-week mark, p < 0.0001) using the PFI survey among MGB clinicians; and a statistically significant increase in positive impact on wellbeing among Emory clinicians (n=1, 1.6% at baseline compared to n=20, 31.3% of survey respondents post-survey at 60 days, p < 0.0001). KEY LESSONS FOR DISSEMINATION: We will focus on impact by user phenotype, and lessons learned for implementation with primary care and hospital medicine. We will discuss implementation and utilization success factors, such as accommodating user documentation styles and recognizing clinical workflows. Pilots at 2 institutions show a decrease in clinician burnout with the use of AI-assisted scribing. Ambient documentation has been most impactful for ambulatory providers, specifically primary care. Further study is needed to assess utility in other settings such as hospital medicine. Innovation in Healthcare Delivery (IHD) - Geriatrics and Palliative Care LEVERAGING POPULATION HEALTH MANAGEMENT TO INCREASE SHARED DECISION MAKING IN CHRONIC KIDNEY DISEASE Michelle Chisdak1; Jordana Yahr2; Jane Schell2,3. 1General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 2Internal Medicine - Renal and Electrolyte Division, University of Pittsburgh, Pittsburgh, PA; 3Internal Medicine - Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA. (Control ID #4272148) STATEMENT OF PROBLEM/QUESTION: Care for non-dialysis patients with chronic kidney disease (CKD) is largely delivered by primary care physicians (PCPs) due to its growing prevalence, and patients with advanced CKD often start on dialysis as the default treatment option without a shared decision-making discussion (SDM) about treatment options including medical management without dialysis (MMWD). DESCRIPTION OF PROGRAM/INTERVENTION: By using EHR-based information and a large-scale Population Health Management (PHM) program, we aim to create a palliative care workflow to identify seriously ill patients with CKD to engage in treatment decision making support. Goals of our intervention include assisting PCPs, improving CKD outcomes, and increasing access to SDM and subspecialist management. As part of an ongoing CKD PHM program, high-risk CKD patients not seeing a nephrologist were identified through EHR and were co-managed with their PCP via E-consult. Our workflow was created to identify older patients within this program who may benefit from MMWD. Enrolled patients with age >80 years and estimated glomerular filtration rate (eGFR) of < 30mL/min were automatically referred for a telemedicine visit with a kidney palliative care advanced practice provider (APP) for advance care planning and treatment decision-making discussion. The workflow was modified as we learned that age and eGFR may not adequately capture the highest degree of serious illness. The criteria were revised to include the surprise question prompt (“would you be surprised if this patient died within the next year?”) for clinicians completing the e-consult. MEASURES OF SUCCESS: Among the patients who received care in an APP-led decision-making session, we assessed (1) the frequency of selecting dialysis vs MMWD and (2) compared demographic and clinical characteristics of those who chose MMWD to those who did not. Furthermore, we assessed the number of unique counties reached via this program. FINDINGS TO DATE: Initial data analysis of the first 150 patients who met with an APP revealed that 74 elected MMWD (49%), while 76 (51%) chose to pursue dialysis as a future treatment option. Patients who chose MMWD did not differ by age (mean 88y vs 86y, p = 0.072), gender (59.5% vs. 61.8% female, p=0.77), or eGFR (mean 29.5 vs 32.2, p=0.085) compared to patients who chose dialysis. Additionally, patients who chose MMWD did not have a significantly higher burden of comorbidities compared to those who chose dialysis. Since then, a total of 295 visits were conducted over a time span of 36 months, spanning patients from 13 counties (including several rural counties). The average age and eGFR of participants were 85.5 years and 33.8 mL/min respectively. KEY LESSONS FOR DISSEMINATION: CKD population health management program with automated referrals to palliative care-led SDM is an innovative method to identify and provide patients with CKD increased access to opportunities to discuss treatment options. Our results demonstrate the need for SDM process to promote patient choice of treatment options in older patients with CKD. Innovation in Healthcare Delivery (IHD) - Healthcare Delivery and Redesign AN ALTERNATIVE TO HOSPITAL AT HOME: INCREASING HOSPITAL CAPACITY BY PARTNERING WITH A HOME HEALTH AGENCY abigail pape2; Stephanie K. Edwards2; Jared Huber1. 1General Internal Medicine, University of Utah Health Hospitals and Clinics, Salt Lake City, UT; 2Internal Medicine, University of Utah Health, University of Utah Health, Salt Lake City, UT, US, academic/health, Salt Lake City, UT. (Control ID #4271499) STATEMENT OF PROBLEM/QUESTION: Hospital at Home offers proven benefits for increasing hospital capacity and reducing readmission, however with uncertainty around the future of the CMS waiver what are sustainable alternatives to Hospital at Home that use existing reimbursement mechanisms? DESCRIPTION OF PROGRAM/INTERVENTION: In early 2020, an academic medical center in the western US acquired a well-established community-based home health agency. Increased demands on hospital capacity caused by the COVID-19 pandemic prompted surgical providers to partner with the home health agency to develop protocols for early-supported discharge for some elective procedures. With provider oversight, the home health agency provided post-surgical care in patients’ homes that otherwise would occur in an inpatient setting. This increased hospital capacity by shortening or eliminating inpatient stays. Reimbursement for these services occurred through the home health benefit included in most insurance plans, not the CMS Hospital at Home waiver. Expanding services to hospital medicine patients had unique challenges. First, most hospital-based providers do not have the resources to manage patients after discharge and the dynamic needs of higher acuity patients cannot be met by many primary care providers. Second, hospital medicine patients are heterogenous; protocol-driven treatment plans need physician-directed adjustments to respond to individual patient needs. Third, many patients who would benefit from additional support do not meet homebound criteria to qualify for home health. To address these issues, in October 2023 we created a transitions of care team for hospital medicine patients consisting of an RN, an MD, and the home health agency. The MD solicited inpatient providers for referrals of patients whose needs could be met by the program. The MD completed telehealth visits during the post discharge period until the patient transitioned back to their outpatient provider. The RN communicated regularly with patients, family members, outpatient providers, and home health agency personnel to implement plans and coordinate care. The home health agency provided in home services for qualifying patients. For sustainability, MD and RN effort can be reimbursed using Transitions of Care Management (TCM) codes. MEASURES OF SUCCESS: We measured total hospital medicine patients enrolled, estimated bed days saved, 30-day Readmissions, 30-day ED visits, and mortality during program enrollment. FINDINGS TO DATE: Between October 2023 and November 2024, 98 hospital medicine patients were enrolled. 54 patients (55%) were enrolled with home health, and 44 patients (45%) were enrolled without home health. We created an estimated 263 bed days. There have been 33 ED visits within 30-days (33%), and 21 30-day readmissions (21%). There were no mortality events during program enrollment. KEY LESSONS FOR DISSEMINATION: A dedicated team who partners with a home health agency can provide many benefits and services of Hospital at Home in a sustainable manner using existing reimbursement mechanisms. A NO-COST STUDENT-LED PROGRAM TO IMPROVE LUNG CANCER SCREENING RATES AND ADDRESS SOCIAL BARRIERS Julia B. Quinn1; Autumn Leavitt1; Erin Cova1; Nivedha Natchiappan1; Henry Siccardi2; Christopher Steele2; Ethan Bernstein3. 1School of Medicine, University of Connecticut School of Medicine, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT; 3Pulmonary and Critical Care Medicine, UConn Health, Farmington, CT. (Control ID #4267215) STATEMENT OF PROBLEM/QUESTION: Despite proven benefits of low-dose computed tomography (LDCT) for lung cancer screening (LCS), LDCT completion rates remain low. Screening rates are especially low in underserved populations due to barriers such as housing insecurity, financial concerns, transportation, and misconceptions regarding screening. While patient navigation programs address these barriers, they are often costly and administratively burdensome. We aimed to determine if a student-led program could improve lung cancer screening rates and address social barriers. DESCRIPTION OF PROGRAM/INTERVENTION: Our project utilized pre-health students to decrease the administrative burden on our health system’s LCS program with the goal of decreasing barriers to screening and increasing patient completion of LCS at no cost. Pre-health student volunteers received training regarding HIPAA, the risks and benefits of LCS, social determinants of health (SDH), and patient engagement. We identified patients at an academic outpatient internal medicine clinic with active, incomplete LDCT orders and our students contacted these patients to assist them with scheduling a LDCT and screen them for SDH. Patients with identified unmet social needs were referred to appropriate resources. A volunteer supervisor tracked suspicious findings and ensured follow-up was coordinated by the primary care and oncology teams. MEASURES OF SUCCESS: We aimed to schedule LDCT appointments for 20% of contacted patients and achieve an overall completion rate of 80%. FINDINGS TO DATE: Baseline LCS completion rate for our clinic was 77.6%. Of 534 patients called since November 2022, 159 spoke with volunteers, leading to 56 scheduled LDCTs (35.2%) and 33 completed LDCTs. Four suspicious findings were identified, including two Stage I adenocarcinomas successfully treated with resection. This project raised the clinic’s overall LCS completion rate to 80.4% and achieved a 20.8% completion rate among patients with incomplete orders. 37% of patients who completed the SDH screening were interested in quitting smoking, and all were provided resources for smoking cessation. Most common barriers to LCS completion were patients forgetting about their appointments or not understanding the purpose of their LDCT. KEY LESSONS FOR DISSEMINATION: Pre-health student volunteers effectively enhanced our centralized LCS program, improving screening rates and addressing social barriers at no cost. Their focused outreach allowed the clinic to address patient concerns and expand program capacity. Importantly, this program also educated future health professionals on SDH, preventative care, and working with underserved populations. A PATHWAY TOWARD CONTROL: HYPERTENSION MANAGEMENT THROUGH A STUDENT-RUN STREET MEDICINE INITIATIVE Dan Bergholz1; Evan M. Shannon2. 1Internal Medicine, University of California Los Angeles, Los Angeles, CA; 2Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA. (Control ID #4271742) STATEMENT OF PROBLEM/QUESTION: Persons experiencing unsheltered homelessness (PEUH) have disproportionately high uncontrolled hypertension (HTN), partly due to limited access to ambulatory care. Can repeated street-based healthcare engagements improve blood pressure (BP) control among PEUH who receive targeted interventions (e.g., screening, medication, counseling, connection to primary care)? DESCRIPTION OF PROGRAM/INTERVENTION: Street medicine delivers care directly in encampments, shelters, and transitional settings, reducing barriers posed by traditional clinics. Miami Street Medicine (MSM), a student-run initiative, provides care directly on the streets. The team of physicians, medical students, and community health workers engages 10-20 patients weekly. MSM provides BP screening, medication, counseling, and longitudinal care coordination to mitigate cardiovascular risk among PEUH. We examined whether these street-based encounters improve BP control. MEASURES OF SUCCESS: All encounters are documented in a custom EMR. We reviewed data from April 2021 to December 2023, including adults (≥18 years) with ≥3 recorded BP readings. We extracted BP readings, medical notes, and case management notes from the MSM EMR. Outcomes of interest included blood pressure control, diagnosis of hypertension, and receipt of anti-hypertensive medication. We applied descriptive statistics (mean, median, SD) and used paired t-tests to compare initial and final BP readings among patients with three or more measurements. FINDINGS TO DATE: Overall, MSM has performed 900 blood pressure checks among 1515 unique patients, whose mean age is 62 years with 65.0% being male. English speakers made up 72.6%, Spanish 24.4%, and Creole 2.4%. Regarding race and ethnicity: White Non-Hispanic (10.0%), White Hispanic (28.1%), Black African American (47.0%), Black Caribbean/Haitian (9.6%), Black Hispanic (2.6%). Among all unique patients, 288 had 3 or more documented BP readings. Among the 288 patients, mean systolic BP was 139.8 mmHg (SD 21.1) and mean diastolic BP was 87.2 mmHg (SD 13.7). A paired t-test between first and last blood pressure readings among patients with 3 or more readings shows modest improvement in systolic BP (t=2.54, p=0.018) and diastolic BP (t=3.68, p=0.001). Overall, street medicine showed potential in building increasing primary care engagement and stabilizing chronic conditions under suboptimal circumstances. KEY LESSONS FOR DISSEMINATION: Community-based engagements foster trust and continuity, bridging toward integrated care for PEUH. Achieving blood pressure control among unsheltered patients with HTN requires multiple flexible encounters, receipt of antihypertensive medication, and follow-up care connection. Standardized documentation and improved data capture are essential. Street medicine alone cannot overcome systemic injustices in healthcare access. Sustainable improvements in chronic disease outcomes for PEUH will require policy reforms, reliable housing options, and stable primary care relationships. BUILDING TRUST THROUGH CONTINUITY: CREATION OF A NOVEL POST-DISCHARGE CLINIC TO ADDRESS HEALTHCARE FRAGMENTATION Shub Agrawal1; Russell E. King2. 1Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2Medicine, Emory University, Atlanta, GA. (Control ID #4273600) STATEMENT OF PROBLEM/QUESTION: Healthcare fragmentation is increasingly common and poses a critical challenge to US healthcare, particularly for patients living with chronic illness and from underserved communities. Fragmented care is associated with increased emergency department visits, higher healthcare costs, and greater utilization of diagnostic tests. Transitions of care clinics (TCC) are often created as a method to address healthcare fragmentation between the inpatient and outpatient setting. However, the literature is mixed regarding the impact on hospital readmissions, ED visits, and healthcare costs. Academic general internists who practice in both inpatient and outpatient settings are uniquely positioned to improve transitions from discharge to primary care. After noting the negative impact of healthcare fragmentation at our public safety-net hospital, we designed a unique post-discharge clinic within our academic primary care practice. DESCRIPTION OF PROGRAM/INTERVENTION: The post-discharge clinic is a clinic for physicians who practice in both the inpatient and outpatient setting. It is currently in an academic setting, meaning teaching attendings will follow up with patients from their teaching service. It is usually 7-14 days after discharge to capture transitional care management billing. Teaching attendings are better able to identify errors and will often close the loop with residents, offering residents a rare opportunity to follow a patient after discharge. MEASURES OF SUCCESS: Initial measurement plan included evaluating show rates, impact on length of stay, impact on readmission rates as well as assessing physician satisfaction. Process measures included number of post-discharge patients seen as well as success of linkage to primary care. FINDINGS TO DATE: The post-discharge clinic has been operating for approximately 11 months. We have analyzed preliminary data from the first 6 months; our show rate was 53%. For similar patients (patients also discharged from medicine teams in the the hospital) the show-rate is 12%. This means that in the pilot phase, patients were 4 times more likely to show up to a visit with a provider that had supervised them inpatient than to a transitions of care appointment. KEY LESSONS FOR DISSEMINATION: Connecting hospitalized patients to primary care is vital to improving the health of the patient. The transition from inpatient to outpatient is rife with errors but also represents a distinct opportunity to leverage patient urgency and concern about their health into high quality primary care. As both inpatient and outpatient care grow increasingly complex, creating opportunities for physician continuity between the inpatient and outpatient setting is a critical avenue to delivering not only patient-centered care, but decreasing cognitive load for physicians, opportunities for practice-based learning and improvement, and improved high-value care. Health systems should consider what opportunities exist to create opportunities for continuity and support physicians who want to work in multiple practice settings. CHANGING THE (CODE) STATUS-QUO: INCREASING OUTPATIENT ADVANCED CARE PLANNING DISCUSSIONS AND DOCUMENTATION Lauren Phinney2; Mike K. Cheng1. 1Medicine, University of California San Francisco, Oakland, CA; 2Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4272650) STATEMENT OF PROBLEM/QUESTION: A minority of patients 65 years and older (older adults) on resident primary care panels at a large academic institution have documentation of advance care planning (ACP) discussions (26% with scanned Advanced Directives (AD) or Physician Orders for Life Sustaining Treatment (POLST) forms, 34% with free-text documentation; 52% with neither); patients of color have lower rates of scanned ACP documentation compared to White patients (30% White, 26% Asian, 24% African American, 22% Latine). DESCRIPTION OF PROGRAM/INTERVENTION: This resident-driven project occurred from 1/2024-5/2024 at our internal medicine resident primary care clinic. We conducted a root cause analysis identifying barriers to ACP discussion/documentation. Barriers included: 1. Provider: discomfort with complexity and cultural variability around ACP discussions, 2. Cultural/Environmental: low prevalence of patient education or reminders around ACP, particularly for patients of color and low English proficiency patients, 3. Process: lack of standardized documentation practices (variable use of the .ACP dot phrase, an institution-wide EPIC dot phrase to free-text document ACP discussions, and suspected errors in labeling of scanned AD/POSLT forms). Interventions included: 1. Mailing language-concordant advanced directives to patients not using MyChart, 2. Creating a dot phrase with tips for culturally-sensitive ACP discussions, 3. Messaging residents with ACP dot phrase information, resources, and reminders to discuss, 4. Reviewing scanned documents containing words possibly related to ACP that were not labeled as ACP documents. MEASURES OF SUCCESS: Process metrics included number of advanced directives mailed, residents messaged, and charts reviewed. Outcome metrics included percent of older adult patients with scanned AD/POLST, percent of patients with ACP dot phrase documentation in the chart, and number of patients with mislabeled but meaningful scanned ACP documentation. FINDINGS TO DATE: Interventions reached 74 residents and 68 patients without MyChart. After interventions, ACP dot phrase usage increased across all patient demographics by 1.91%. The most profound increases were in African American (2.79%), White (2.48%), and Asian patients (1.55%). Efforts to increase scanned AD and POLST forms were not very effective, though scanned AD packets increased by 0.71% for Latine patients. Review of 81 scanned documents revealed that 22% were mislabeled but meaningful ACP documentation. KEY LESSONS FOR DISSEMINATION: In this resident-led effort, ACP discussion documentation via dot phrases increased among resident panel patients through careful analysis of gaps in current ACP efforts in the health system and interventions addressing those gaps. Efforts to mass message residents, provide culturally-sensitive tips, and reminding providers of the ACP dot phrase were successful in increasing documentation. Efforts to mail advanced directives to patients who did not use MyChart were not effective in increasing scanned ADs. A sizable percentage of meaningful ACP documents were incorrectly labeled. DELIVERING AGE-FRIENDLY CARE TO HOSPITALIZED OLDER ADULTS: TEMPLATES, TRAINING, AND TEAMWORK Kelly Cheung, Janice Grandi, Danielle Escueta, Cathy C. Lee. Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4271591) STATEMENT OF PROBLEM/QUESTION: To meet the complex needs of older adults, the Institute of Healthcare Improvement (IHI) has called for health systems to deliver age-friendly care using an evidence-based and cost-effective framework called the 4Ms (Matters Most, Mentation, Mobility, and Medication), however implementation has been slower in hospital settings. DESCRIPTION OF PROGRAM/INTERVENTION: An age-friendly note template was designed for physicians with embedded instructions on how to assess, address, and document the 4Ms of age-friendly care. The note template was implemented on internal medicine wards teaching service and automatically pops up for all patients aged 65 and older. A group of age-friendly resident-physician champions disseminated a concise one-page document on the 4Ms to all residents and demonstrated how to incorporate the age-friendly framework into clinical workflow during educational didactic sessions. Faculty physicians led a collaboration with nursing, pharmacy, and physical therapy to assist in completing assessments. Nurses conducted delirium screenings using the Confusion Assessment Method (CAM), pharmacists assisted in medication reconciliation, and physical therapists assessed mobility using the Johns Hopkins Highest Level of Mobility scale.These interventions were implemented at an inpatient academic VA medical center in the Western region. MEASURES OF SUCCESS: The VA launched an Age-Friendly dashboard in 2023 that tracks the number of age-friendly assessments completed for each of the Ms and number of unique veterans receiving all four Ms. Data is captured through use of Health Factors, which is associated with each assessment. To capture data, the user must indicate whether an assessment was completed in the note template when it pops up, such as clicking "yes" to the question "Was Medication addressed?". Documenting the 4Ms alone without using the pop-up window will not capture data in the dashboard. FINDINGS TO DATE: Compared to 2023, the number of unique veterans receiving all 4Ms of age-friendly care increased from 43 to 192 in 2024. The number of total 4Ms assessments increased from 218 to 3908. The number of assessments increased from 95 to 762 for Matters Most, 86 to 373 for Medication, 111 to 3560 for Mentation, and 100 to 377 for mobility. KEY LESSONS FOR DISSEMINATION: While the template and educational and interdisciplinary interventions were associated with an increase in the number of veterans receiving age-friendly care, the dashboard may be an underestimation, as it relies on users to manually indicate completed assessments instead of extracting data from the EHR. Limitations of the EHR such as inability to copy-forward notes, inaccessibilty to the 4Ms in the patient’s chart, pop-up fatigue, and forced functions pose a barrier to clinician engagement with delivering age-friendly care. Further innovations are needed to accurately monitor the progress of delivering age-friendly care within the constraints of each hospital’s unique health systems. DESIGN AND IMPLEMENTATION OF A WORKPLACE VIOLENCE NAVIGATOR IN THE EHR Sara K. Stowell1; Jennifer Melahn1; Charissa Mueller1; Kyle Hagen1; Margaret E. Reidy2. 1IT, University of Colorado Health, Aurora, CO; 2University of Colorado Health, Aurora, CO. (Control ID #4273446) STATEMENT OF PROBLEM/QUESTION: Recent data reports that American healthcare workers (HCWs) are significantly more likely to suffer nonfatal injuries than workers in any other profession, necessitating innovative solutions to address this problem. DESCRIPTION OF PROGRAM/INTERVENTION: Our goal was to create an objective and reliable method to document any violent patient and/or visitor behaviors towards HCWs as well as any interventions implemented within the electronic health record (EHR). This will allow our 14-hospital system to identify trends and create appropriate solutions. An interdisciplinary team comprised of information technology (IT) specialists, physicians, nurses, and social workers designed and developed a Stop, Assist, Familiarize, Enlist (SAFE) Navigator. This EHR embedded tool is accessible to any frontline HCW. We included Emergency Departments, Acute and Critical Care settings, Ambulatory Care areas, Patient Line (phone triage and scheduling), and all ancillary care areas. We included standard definitions for verbal, physical (which includes sexual) escalations, threatening behavior and impeding care. Most documentation is completed via a click box mechanism, as opposed to free text submission, to minimize emotional data reporting, reduce the risk of bias, and allow for objective assessments of patient behavior. Documentation includes proactive care planning, reactive response teams evaluations, escalation interventions consistent with training provided to frontline staff. MEASURES OF SUCCESS: Upon completion of the navigator, anyone interacting with the patient’s chart will be able to visualize the information, allowing them to understand patient behaviors and plan accordingly for any interaction, ultimately reducing risk to the HCW and better supporting the patient. FINDINGS TO DATE: In the first 16 days since go-live, there have been 315 unique submissions across 15 facilities for an average of 19.5 per day. 29.5% in Inpatient settings, 25.4% of incidences are occurring in Ambulatory settings, 18.9% in Emergency Departments. 39.3% are categorized as verbal escalations, 19.7% as threatening, 14.8% as physical, 10.7% as impeding care and 49.2% were identified as “other” or a combination of multi-select options. KEY LESSONS FOR DISSEMINATION: The primary goal of the SAFE navigator is to streamline documentation to better assess the workplace violence problem across all care areas. Additionally, documentation of violent behaviors increases communication across care areas and admissions/appointments, clearly demonstrates historical care considerations and increase access to relevant mitigation strategies. Identifying behavior trends will allow the health system leadership to create targeted solutions to support frontline HCW and patients. Bringing together IT with clinical disciplines is crucial to developing successful EHR based tools. We will continue to solicit feedback from frontline teams for iterative navigator improvement and partner with various disciplines to create patient centered, trauma-informed solutions to mitigate workplace violence. DESIGN AND PILOT OF A SMARTPHONE APPLICATION UTILIZING REMOTE PATIENT MONITORING (RPM) AND GAMIFICATION TO PROMOTE HEALTHY BEHAVIORS AND CONTROL HYPERTENSION IN MEDICAID MANAGED CARE PATIENTS Laura J. Zimmermann1,9; Kristen Pallok3; Doug Thompson5; Ally Weaver6; Katherine E. Niehaus7; Cynthia Schroeder5; Mihir Mullick6; Michael Gottlieb4; David A. Ansell2,8; Garth Walker5,4. 1Internal Medicine, Rush University, Chicago, IL; 2Internal medicine, Rush University Medical Center, Chicago, IL; 3Internal Medicine, Rush University Medical Center, Chicago, IL; 4Emergency Medicine, Rush University Medical Center, Chicago, IL; 5Rush Health, Rush University Medical Center, Chicago, IL; 6Data Science, Nuna, Inc., Milford, MI; 7Data Science, Nuna, Inc, San Francisco, CA; 8Community Health Equity, Rush University, Chicago, IL; 9Family and Preventive Medicine, Rush University, Chicago, IL. (Control ID #4220128) STATEMENT OF PROBLEM/QUESTION: Despite multiple clinic-based interventions, the hypertension (HTN) control rate amongst our Medicaid managed care patients remained significantly lower (56% year-to-date) than HEDIS top decile (71%) or our health system performance (78% year-to-date). DESCRIPTION OF PROGRAM/INTERVENTION: We partnered with a health tech company to design a mobile app offered to Medicaid managed care patients with uncontrolled HTN receiving primary care at a large, urban academic medical center. A community health worker (CHW) facilitated patient sign up/app set-up via telephonic outreach and home visits. Patients received a blood pressure (BP) monitor for RPM. A nurse reacted to data according to clinic nursing triage protocols. The mobile app used behavioral economics and gamification to promote sustained healthy habits and screen for social determinants of health; patients earned points daily by engaging in BP measurement, medication logging, physical activity (steps), and dynamic, evidenced-based education activities with content developed with community partners during a previous community-based trial. Patients reached successive levels of achievement (Bronze, Silver, Gold, Platinum) as they engaged in these behaviors. Points could be redeemed for sweepstakes entries, which translated to modest gift cards for local/online retailers. MEASURES OF SUCCESS: Proportion of patients enrolled in the program with controlled HTN (<140 systolic, <90 diastolic) by November 1st, 2024. Control was assessed by calculating the 7-day average from the date of the last BP measurement in those with at least two days of BP measurements in this one-week look-back. FINDINGS TO DATE: Of 14,061 attributed adult patients, 2,197 patients had HTN, and 998 (45%) people were uncontrolled as of Nov 1. Of patients with HTN, mean age was 54yrs (18-86, SD 11 years), 61.6% female, 65.5% identified as Black, 11.8% White, and 7.9% Hispanic. Prevalence of obesity/overweight and diabetes were 58.3% and 41.1%. We reached out to 316 Medicaid managed care patients with uncontrolled HTN in 3 clinics. We enrolled 131 individuals between April 1st and November 1st, 2024. The mean in-clinic systolic and diastolic BP measures at time of enrollment were 150.2 (range 106-195, SD 15.7) and 91.0 (range 60-119, SD 11.0), respectively. Mean time spent in the program per participant as of Nov 1 was 86.6 days (range 9 to 165). Mean number of BP measurements per participant was 33.6 (range 0-281, SD 55.6). The proportion of patients with controlled HTN as of November 1st was 72% (43/60 patients with at least two days of BP measurements in the one-week look-back). KEY LESSONS FOR DISSEMINATION: Interventions combining RPM with a mobile app promoting physical activity, healthy diet, and medication adherence through behavioral economics and gamification may be an effective and scalable method to achieve HTN control in patients for whom traditional office-based care is insufficient. Long-term effectiveness must be assessed. We plan to incorporate linkage to community-based resources to help address health related social needs DEVELOPMENT AND EVALUATION OF HEALTH SYSTEM INTERVENTIONS TO IMPROVE MEDICATION ADHERENCE AMONG VALUE-BASED CARE PATIENTS John Hon1; Aaron Curry2; Kimon Stathakos2; Eun Ji Kim1. 1Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; 2Northwell Health, New Hyde Park, NY. (Control ID #4273688) STATEMENT OF PROBLEM/QUESTION: It is estimated that only half of Americans adhere to their medications, leading to $100 billion in preventable healthcare costs. For health systems, medication adherence for conditions like hypertension, diabetes, and hyperlipidemia (HDH) significantly affects value-based care (VBC) reimbursement. DESCRIPTION OF PROGRAM/INTERVENTION: We conducted a prospective observational study was conducted with patients in a large health system’s VBC program. Multiple stakeholders, including VBC management, pharmacy benefits plans, and care management departments, collaborated to develop multimodal interventions. First, eligible VBC beneficiaries were identified and then divided into patient and provider groups, along with additional stratification based on demographics and characteristics. Pharmacists contacted primary care providers through electronic medical record tasks and direct communication about refills for patients with expiring prescriptions, recommending 90-day supplies with three refills, available through mail orders. Care managers called patients with existing refills to remind them about medication pick-ups. MEASURES OF SUCCESS: Success for the CMS medication adherence measure requires patients to fill 80% or more of their prescriptions during the year, thus achieving VBC incentives. FINDINGS TO DATE: The study included about 6,000 beneficiaries. Among patients with pending refills, 39% of those successfully contacted picked up medications within 3 days, while 63% picked up within a week after receiving a voicemail. As of August 2024, medication adherence was 86.7% for hypertension, 86.5% for diabetes, and 87.2% for cholesterol. This is significantly higher than August 2023 measures where medication adherence for hypertension is 81%, diabetes is 80%, and cholesterol is 81%. KEY LESSONS FOR DISSEMINATION: This multidisciplinary approach increased adherence to HDH medications, potentially earning $800,000 in incentives (we will have information about the impact on star rating and financial impact in February 2025). Continued investment from stakeholders could further improve medication adherence across the health system. DEVELOPMENT AND IMPLEMENTATION OF A NOVEL PATIENT PORTAL-DELIVERED HOME BLOOD PRESSURE MONITORING (HBPM) PROGRAM IN A PRIMARY CARE NETWORK Nadia Liyanage-Don1,2; Melinda Chang1; Nadine Dandan3; Joy Gelbman5; Rakhi Kalra4; Erica Phillips5; Jessica R. Singer2; Harry West6; Siqin Ye7; Ian Kronish1,2. 1Center for Behavioral Cardiovascular Health, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY; 2Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY; 3Pharmacy, NewYork-Presbyterian Healthcare System Inc, New York, NY; 4IT, NewYork-Presbyterian Healthcare System Inc, New York, NY; 5Department of Medicine, Weill Cornell Medicine, New York, NY; 6IEME, Columbia University, New York, NY; 7Department of Cardiology, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY. (Control ID #4270100) STATEMENT OF PROBLEM/QUESTION: Determine the feasibility and clinical impact of a patient portal-delivered HBPM program in a primary care network DESCRIPTION OF PROGRAM/INTERVENTION: A multistakeholder team of primary care physicians, cardiologists, nurse practitioners, clinical pharmacists, and design experts partnered with an academic hospital’s digital health team to create MyCare HTN, a patient portal-delivered HBPM program that leverages Epic’s Care Companion infrastructure. Patients use their own BP devices to monitor home BP and receive: 1) weekly prompts to review HTN education materials via the portal; 2) tailored email/text reminders to log home BP readings (or sync data from wireless home BP devices when available); 3) automated triage of extreme BP readings. Clinicians receive: 1) Epic-based ordering of MyCare HTN; 2) weekly in-basket messages listing patients’ home BP readings; 3) graphs of home BP trends; 4) 1-week, 1-month, and 3-month home BP averages. Informational websites were created for patients and clinicians. To increase uptake, patients with uncontrolled HTN were invited to try MyCare HTN via portal messages. Navigator onboarding support was later added. Loaned wireless BP devices were available through a separate high-resource vendor-delivered HBPM program for patients unable to participate in MyCare HTN. MEASURES OF SUCCESS: Program success was measured via RE-AIM. Reach: number/representativeness of patients referred to and engaged in the program. Effectiveness: proportion of patients with controlled BP after 6 months. Adoption: proportion of eligible clinicians who referred patients. Implementation: patient and clinician interviews assessing satisfaction. Maintenance: number of new referrals and BP control over time. FINDINGS TO DATE: In Oct 2023, MyCare HTN was disseminated to 8 primary care practices including ~2400 patients with uncontrolled HTN. From Nov 2023-Dec 2024, the program was ordered for 332 patients (mean age 63±14 years, 60% female, 33% Black, 19% Hispanic, 6% Spanish-speaking). 47% of eligible clinicians referred ≥1 patient and 48% of referred patients logged ≥1 home BP reading. In the first week of monitoring, 28% of patients had mean home BP <130/80 mmHg and 68% had mean home BP <140/90 mmHg. By the last week of monitoring, 35% of patients had mean home BP <130/80 mmHg and 71% had mean home BP <140/90 mmHg. The mean number of patients referred per month rose from 10 to 33 after portal outreach was added. 20% of patients agreed to participate after being sent a single portal message, 48% of whom logged home BP readings. The percentage of patients logging home BP readings rose from 45% to 66% after navigator support was added. KEY LESSONS FOR DISSEMINATION: MyCare HTN leverages Epic Care Companion to scalably increase HBPM. Direct outreach via portal messages can greatly increase clinician and patient participation. Navigator support can increase the number of patients logging home BP readings. HBPM can quickly improve quality metrics by increasing identification of patients with white coat effect (i.e., controlled BP when measured at home). DEVELOPMENT AND IMPLEMENTATION OF A TRANSITIONAL CARE AT HOME TEAM TO FACILITATE DISCHARGES FROM ACUTE AND POST ACUTE CARE FACILITIES TO HOME IN THE SOUTH. Hemali Patel1,2; Snehal Patel1,2; Mustafa Abdul Moheeth1,2. 1Transitions of Care, Travis County Healthcare District, Austin, TX; 2Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4270850) STATEMENT OF PROBLEM/QUESTION: There is a level of uncertainty and risk that exists in the time period between discharge from acute or post acute care facilities to establishment or reconnection with primary care and patient centered medical homes. DESCRIPTION OF PROGRAM/INTERVENTION: This transitional program was developed to mitigate the uncertainty in the time period between acute or post acute discharge to outpatient primary care follow up. The team includes a medical assistant, community health worker, nurse case manager, advanced practice provider and attending physician. The team is deployed to a patient’s home ideally within 72 hours of discharge to complete a visit in the home and complete medication reconciliation, coordination of follow up appointments and transportation to those appointments and connection to home health services if indicated. MEASURES OF SUCCESS: Since implementation of the program in the spring of 2024 100% of patients who entered the program established or re-established care with their primary care provider. A total of 486 encounters were completed within the first year of the program that included face to face home visits and telephonic care coordination visits with team members. On average this is 12 encounters per patient over a two to three week period. The average program length of stay is 21 days. All issues identified during home visits were resolved within 48 hours. These findings included, but are not limited to missing durable medical equipment (DME), medication reconciliation discrepancies, and transportation assistance. FINDINGS TO DATE: -Teams identified gaps in all discharges spanning across various medical and social needs -The value and importance of a high intensity care team in the interim periods of care after discharge is highlighted by the findings. -The information that is gleaned in a patient’s home about their care environment and the impact of it on their medical needs cannot be completely understood outside of the home. For example, many patients live in facilities where maneuvering DME may be difficult or live in areas where broadband access creates digital inequities. KEY LESSONS FOR DISSEMINATION: Most high income countries deploy a provider to patient’s homes to deliver care, and facilitate and optimize care for patients. A unique team specifically developed for this purpose can be leveraged to identify gaps in care during high risk transitions from acute and post acute care settings. This team is also able to intervene on medical needs and prevent hospital readmissions, while bridging gaps by communicating with primary care providers. DRIVING CHANGE FOR PHYSICIAN UTILIZATION MANAGEMENT ADVISERS (PUMAS): ELIMINATING UNNECESSARY SECONDARY UTILIZATION MANAGEMENT (UM) REVIEWS THROUGH SYSTEMS ENGINEERING Heather Hopkins, Chase Houghton. Medicine, Washington DC VA Medical Center, Washington, DC. (Control ID #4272102) STATEMENT OF PROBLEM/QUESTION: The VA system relies on secondary physician reviews to mediate disagreements in evidence-based care management between physicians and UM nurses. Most VA facilities allocate 0.1 FTE for the administrative role of a PUMA, so time is a limited resource. We aim to leverage existing communication pathways to facilitate real-time multidisciplinary discussions and decrease the rate of unnecessary secondary PUMA reviews. DESCRIPTION OF PROGRAM/INTERVENTION: Our facility is an academic VA medical center with 155 inpatient beds and ~25,000 yearly completed UM reviews. The inpatient medicine census is covered by 6 academic multidisciplinary teams, consisting of a hospitalist, pharmacist, social worker (SW), case manager (CM), resident, 2 interns, and medical students from 5 local academic affiliates. UM nurses are assigned to each team and perform reviews on >85% of admitted patients. More than 100 UM reviews per year are sent to the medicine PUMA for secondary review. Multiple interventions were undertaken over a 3-year period. These were created from review of baseline data on number of UM reviews per year, number of secondary PUMA reviews per year, and percentage of patients meeting admission and continued stay criteria. Groups of stakeholders including UM nurses, CMs, and physicians met regularly to design and implement the following processes in a multidisciplinary effort. UM nurses were added to the existing interdisciplinary discharge rounds (IDR) group, Monday-Friday. UM nursing group was expanded to have representation for each of the 6 inpatient medical teams. IDR script was updated to include UM feedback, with ongoing education and updates. UM nurses were added to all 6 inpatient Teams chats. Medicine PUMA was added to existing IDR group in a multipurpose "flow physician" role. MEASURES OF SUCCESS: Several quantitative measures were assessed before, during, and after initiation of the above interventions: Number of secondary reviews sent to PUMA. The percentage of total UM reviews meeting criteria, the percentage of admission reviews meeting criteria, the percentage of OBS reviews meeting criteria, and the percentage of continued stay reviews meeting criteria. These performance metrics were collected through Pyramid Analytics, utilizing the Change Healthcare InterQual criteria. FINDINGS TO DATE: Interventions began in FY22Q1. The number of secondary PUMA reviews decreased from ~30 per quarter to <5 per quarter by FY23Q3, with sustained results through FY24Q4. Throughout this project, the quality of UM reviews remained exemplary, consistently surpassing the numbers of other comparable VA facilities, as indicated by the stable percentage of UM reviews meeting criteria for total, admission, OBS, and continued stay. KEY LESSONS FOR DISSEMINATION: Secondary PUMA reviews become largely obsolete if supplanted by real-time, regular, and effective multidisciplinary communication. Successful interdisciplinary communication can be facilitated utilizing existing communication pathways. Ongoing education of all stakeholders is key to maintaining successful UM discussions. EFFECT OF A VOLUNTEER-STAFFED OUTREACH CALL INITIATIVE ON VIDEO USAGE AND ATTENDANCE FOR TELEHEALTH VISITS IN AN URBAN PRIMARY CARE SAFETY-NET SETTING Kevin Chen1,2; Khera Bailey1; Simon Nemytov3; Mackenzie N. Morrison4; Christine Zhang1; Kenan Katranji1; Hannah Jackson1,2. 1Office of Ambulatory Care and Population Health, NYC Health + Hospitals, New York, NY; 2Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY; 3Department of Biology, Stony Brook University, Stony Brook, NY; 4Department of Biology, Smith College, Northampton, MA. (Control ID #4247818) STATEMENT OF PROBLEM/QUESTION: How does a volunteer-staffed telehealth navigation program impact video visit usage and attendance for telehealth appointments in an urban safety-net primary care clinic? DESCRIPTION OF PROGRAM/INTERVENTION: Two part-time volunteers were recruited and trained to make outreach calls to patients with upcoming telehealth appointments at an adult primary care clinic within a large municipal healthcare system in a major Northeastern city, serving a diverse and high-need community. These calls assessed patients' technical readiness, provided assistance, shared educational resources, and directed patients to helplines as needed. The outreach efforts specifically targeted improving patients' preparedness for technology use, encouraging video visits over audio-only, and reducing no-show rates, addressing barriers common in underserved populations. MEASURES OF SUCCESS: Metrics included the proportion of telehealth visits completed via video compared to audio-only, as well as non-attendance (no-show) rates for telehealth appointments among intervention and comparison groups. Secondary measures examined differences in patient portal activation rates and demographic characteristics among intervention and comparison groups. FINDINGS TO DATE: The program did not produce significant improvements in the primary outcomes. Video usage was nearly identical between groups (14.1% for patients who received outreach compared to 14.0% for those who did not; p=0.91), and no-show rates showed no meaningful difference (22.5% for patients who received outreach compared to 22.0% for those who did not; p=0.76). Patients who could not be contacted during outreach were less likely to have activated their patient portal and more likely to miss their appointments, suggesting they represented a less engaged subgroup. Volunteers successfully contacted 63.7% of the patients they attempted to reach, completing approximately seven outreach calls per hour. KEY LESSONS FOR DISSEMINATION: Volunteer-staffed telehealth outreach programs are a feasible and low-cost way to connect with patients in safety-net settings, enabling significant outreach volume with minimal resources. However, telephone outreach alone was insufficient to increase video visit usage or reduce no-show rates. Patients who responded to outreach appeared to be more engaged than those who did not respond, highlighting the need for tailored interventions. Future initiatives should consider providing day-of-appointment support or combining outreach with other strategies to address broader patient and clinician barriers to telehealth engagement. EMPATHY, COMPASSION, AND THE ART OF HEALING IN THE ERA OF SCIENCE AND TECHNOLOGY Theodore Strange1,2; Joseph Conigliaro2; Luis Quiel1,2; Mario Castellanos1,2. 1Medicine, Staten Island University Hospital, Staten Island, NY; 2Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4271979) STATEMENT OF PROBLEM/QUESTION: How can healthcare systems maintain the physician’s role as a compassionate caregiver while integrating advanced technologies like artificial intelligence and precision medicine? DESCRIPTION OF PROGRAM/INTERVENTION: In an era of artificial intelligence, predictive analytics, and precision medicine, the physician’s role as a compassionate caregiver risks being overshadowed. As technology distances clinicians from patients, it is vital to uphold Compassion, Assistance, Respect, and Empathy (C.A.R.E.). Empathy improves patient outcomes, reduces readmissions, mitigates clinician burnout & supports fulfilling careers. To address these challenges, the Medicine Dept. in a NYC Hospital launched biannual retreats focused on emotional well-being, teamwork, and fostering a culture of care. Led by the Medicine Chair, this initiative began with a JAMA commentary (authors TS, MC) emphasizing C.A.R.E. principles. Anchored by the phrase, "No one cares how much you know until they know how much you care," it highlighted the importance of trust, communication, and empathy in patient healing. This shift was reinforced through monthly departmental meetings and daily Team Chat huddles, emphasizing the critical role of compassion in clinical practice. MEASURES OF SUCCESS: The success of this intervention was assessed using two key tools. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measured patients' perspectives on care, focusing on the "Doctor Communication" composite score, which evaluates communication, listening, and clarity. Additionally, the Physician Engagement Survey assessed workplace culture and physician collaboration, providing insights into team dynamics and leadership engagement. FINDINGS TO DATE: Previously, HCAHPS data highlighted persistent challenges in "Doctor Communication" scores, particularly in the areas of listening and patient comprehension. Following the implementation of the C.A.R.E. principles, the main hospital campus achieved a 5% increase in the "Doctor Communication" composite score for Hospitalist Services, while the secondary hospital facility recorded a 3% improvement. The Physician Engagement Survey showed positive gains across all metrics, including improved comfort discussing concerns with leadership (+11.9%), better work-life balance support (+7.8%), and enhanced team efforts in patient care (+7.2%). KEY LESSONS FOR DISSEMINATION: The integration of C.A.R.E. principles demonstrates that compassionate care is essential and transformative. Leadership fosters this change by cultivating empathy through structured communication, team-building, and reinforcing humanistic values. Studies show positive patient experiences enhance outcomes, satisfaction and reduce readmissions. These strategies also alleviate clinician burnout, promoting a sustainable work environment. By embedding empathy training into workflows and leveraging patient feedback via HCAHPS, institutions can create scalable, impactful models of care that balance technology with the art of healing. ENHANCING OBESITY MANAGEMENT FOR VETERANS: A MULTIDISCIPLINARY MODEL TO INCREASE ANTI-OBESITY MEDICATION ACCESS AND OPTIMIZE CARE DELIVERY Cristina Fischer1; Lisa Thompson2; RAVI GOPAL2; TYLER MILLER2; Karen E. Stenehjem2. 1Internal Medicine, University of Colorado, Denver, CO; 2Department of Medicine, University of Colorado System, Denver, CO. (Control ID #4247668) STATEMENT OF PROBLEM/QUESTION: Obesity is a prevalent and serious condition, yet despite proven efficacy of anti-obesity medication (AOM) only 1.8% of eligible patients are prescribed them and wait times for specialized weight-loss clinics within a Northwest Veteran’s Health Administration (VHA) are prolonged. DESCRIPTION OF PROGRAM/INTERVENTION: Obesity affects over 40% of U.S Adults and disproportionately impacts veterans receiving care through the VHA3. Despite formulary guidelines and patient support, only 1.8% of eligible patients receive anti-obesity medication (AOM). Within a Northwest VHA, 1.1% of eligible non-diabetic patients were prescribed AOM, increasing to 8.3% when patients with diabetes were included, likely due to GLP-1 indications. Barriers to AOM prescribing were identified through PCP surveys and access data, highlighting PCP discomfort with prescribing and an 18-month wait for the endocrinology weight-loss clinic. To address these barriers and improve delivery of AOM, a novel care model with clinical pharmacists as the backbone was developed. PCPs refer patients to a pre-established lifestyle weight management program. After the first session, a group appointment is held with a clinical pharmacist discussing risks, benefits, and availability of AOM. Pharmacists initiate and titrate medications, following up every 4 weeks until a stable, effective dose is reached, at which point management transitions back to PCPs. PCPs also attend educational sessions on obesity management and the new care model. MEASURES OF SUCCESS: Metrics evaluating the intervention include AOM prescriptions, endocrinology weight loss clinic wait times, clinical pharmacist appointments, and PCP attitudes towards obesity management. FINDINGS TO DATE: From February to October 2024, AOM prescriptions for eligible non-diabetic patients increased from 1.1% to 3%. Prescribing of first line AOM (Phentermine-Topiramate, Bupropion-Naltrexone, and Orlistat) rose from 10.7% to 14.2%. Clinical pharmacist appointments related to obesity increased 15-fold, while endocrinology clinic wait times dropped by 12 months. Additionally, PCPs reported improved comfort prescribing AOM. KEY LESSONS FOR DISSEMINATION: Engaging clinical pharmacists in initiating and titrating AOM therapy increases patient accessibility to AOM and reduces the burden on specialty and primary care clinics. This model can be adapted to healthcare settings with low AOM prescribing, limited primary care and specialty availability, and clinical pharmacist engagement. To successfully implement across other institutions, clear eligibility for AOM, streamlined workflows for initiation of AOM and ultimately transitioning patients back to PCPs for long-term management are needed. ENHANCING TEAM-BASED IN-BASKET WORK USING A NOVEL TOOL EMBEDDED IN THE ELECTRONIC MEDICAL RECORD Nicole Hadeed1; Emily Woltmann2; James Henderson2; Yvette Salamey2; Matthew Bucala4; Michael Lanham3; Greta L. Branford1. 1General Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; 2Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; 3Department of Learning Health Sciences, University of Michigan Michigan Medicine, Ann Arbor, MI; 4Biostatistician, The University of Chicago, Chicago, IL. (Control ID #4254083) STATEMENT OF PROBLEM/QUESTION: The clinic in-basket is a highly utilized team-based patient care delivery tool; yet no avenues exist to enhance teamwork or facilitate feedback on these virtual team-based tasks. DESCRIPTION OF PROGRAM/INTERVENTION: Using Epic's native Smart Tools functionality, we developed and embedded a custom feedback interface within the In Basket, enabling staff and providers to provide bidirectional feedback on message routing, prework and communication quality. This tool was piloted at a general medicine outpatient practice in an academic medical center. Prior to release, training and materials were distributed to standardize aspects of in-basket communications and management, targeting improving efficiency of message handling and intra-clinic routing. Following this, the feedback tool was piloted for 3 months. We implemented an analytics dashboard for clinic and nursing managers to track feedback metrics, with generated bi-weekly staff reports and monthly provider-specific performance analytics on routing accuracy and communication quality. At pilot completion, user experience was assessed via qualitative group interviews. MEASURES OF SUCCESS: We employed a multi-methods evaluation approach including: (1) quantitative analysis of tool adoption rates, message routing accuracy, and feedback patterns; and (2) structured qualitative analysis of user interviews (providers n=4, staff n=13). FINDINGS TO DATE: Analysis of 14,019 intra-clinic messages revealed a 5.8% (813) feedback rate. Among participants with > 10 intra-clinic messages received, tool adoption reached 53% (10/19) of physicians and 67% (12/18) of staff. Feedback distribution showed: 76% positive recognition ("Kudos"), 9% routing issues, 4% incomplete information, 2% order-related concerns, and 14% containing specific improvement comments. Provider feedback rates ranged from 0.1-8.1%, while staff rates varied from 0.3-70.6%. Qualitative analysis revealed high usability satisfaction and appreciation for anonymous feedback capability. Implementation gaps identified included: desire for increased feedback frequency, uncertainty about feedback implications, and need for clearer process improvement pathways based on feedback data. KEY LESSONS FOR DISSEMINATION: We describe our experience with a customized tool within Epic and its capability to support implementation of standardized clinic In Basket work. Effective, reproducible strategies can be implemented to help foster better intra-clinic communication, teamwork and standardization of work in the In Basket. ESTABLISHING AN INTER-REGION COLLABORATION TO OPTIMIZE PROVIDER SUPPLY AND DEMAND AND IMPROVE PRIMARY CARE ACCESS WITHIN THE VETERANS ADMINISTRATION. Leonid Frenkel1; meenakshi zaidi3; Esmeralda Young3; Dolores Curbelo1; Matthew R. Augustine2,4. 1Primary Care, James J Peters VA Medical Center, New York, NY; 2Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, New York, NY; 3James J Peters VA Medical Center, New York, NY; 4Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4271718) STATEMENT OF PROBLEM/QUESTION: How can telehealth technology be leveraged to address regional disparities in access to Primary Care within the VA system, where some areas experience provider shortages while others have underutilized capacity? DESCRIPTION OF PROGRAM/INTERVENTION: A collaboration was established between two VA medical centers (one in the Mid-Atlantic and another in the Northeast) to enhance access to care for Veterans in the Mid-Atlantic region experiencing a severe VA primary care physician shortage. Primary care providers (1.5 full-time equivalents) from the Northeast VA were virtually integrated into the Mid-Atlantic VA's local Patient-Aligned Care Team (PACT) consisting of a nurse care manager, health technician, and administrative clerk. Inter-facility team-based care was facilitated by use of technology including two-way synchronous video-audio visits, digital stethoscope, otoscope, and full electronic medical records and Microsoft Teams collaboration access. MEASURES OF SUCCESS: Program success was assessed using clinic utilization rates, patient retention in VA care, provider workload distribution, and cost-efficiency metrics, such as reduced reliance on community care services. Stakeholder feedback on implementation and outcomes provided additional qualitative insights. FINDINGS TO DATE: Within the first 32 weeks, over 1200 veterans were able to remain within VA care due to the new access provided via this initiative. The telehealth primare care program demonstrated high clinic utilization (92%). The Mid-Atlantic facilities reported reduced provider burnout and improved access, while Northeast facilities achieved better workload efficiency with increased panel fullness from 88% to 98%. The initiative also yielded cost savings by minimizing reliance on external VA-purchased primary care services in the community. KEY LESSONS FOR DISSEMINATION: Inter-regional telehealth offers a viable solution to mitigate regional disparities in primary care access. Key factors for success include establishing clear inter-facility agreements, developing robust implementation plans, and maintaining active communication between stakeholders. This model offers a scalable framework for the broader VA system to enhance access, efficiency, and quality of care for Veterans nationwide. EVALUATING ADDICTION CONSULT SERVICE LINKAGE OUTCOMES AT AN URBAN SAFETY NET HOSPITAL Michael Schumeister2; Marco Barber Grossi1; Tiffany Lu3. 1Addiction Medicine, NYU Langone Health, New York, NY; 2Albert Einstein College of Medicine, New York, NY; 3Medicine & Psychiatry, Albert Einstein College of Medicine, Bronx, NY. (Control ID #4270457) STATEMENT OF PROBLEM/QUESTION: How effective is the addiction consult service (ACS) at linking hospitalized patients with a substance use disorder (SUD) to hospital-based outpatient SUD services? DESCRIPTION OF PROGRAM/INTERVENTION: Persistent disparities exist in SUD treatment access, particularly among lower income populations and/or racial/ethnic minorities.To address these disparities, a large, Northeast, urban safety-net hospital with hospital-based outpatient SUD services implemented a pilot ACS in 2021. MEASURES OF SUCCESS: We conducted a retrospective cohort study among hospitalized patients evaluated by the ACS from Jan.-June 2024. We collected EHR data on demographics, clinical information, and referrals/visits within hospital-based outpatient SUD services. Linkage outcomes focused on patients who were eligible for referral to the hospital-based SUD clinic (eg. not referred elsewhere for inpatient SUD services or an opioid treatment program). Treatment referral was defined as the number of patients evaluated by the ACS who were referred to the hospital-based SUD clinic. Treatment linkage was defined as the number and rate of patients who attended a hospital-based SUD clinic visit within 30 days of discharge. Treatment engagement was defined as the number and rate of patients who engaged in 2 or more hospital-based SUD clinic visits within 30 days of discharge. FINDINGS TO DATE: The ACS saw 356 patients over a 6 month period. 73% of patients were male, and the mean age was 50.4. 178 (50%) had AUD, 99 (28%) had OUD, 15 (4%) had co-occurring AUD/OUD, 48 (13%) had other SUD, and 16 (4%) were determined not to have SUD. Referral: 143 (40%) of patients seen by the ACS were referred to the hospital-based SUD clinic. 88 (62%) had AUD, 27 (19%) had OUD, and 6 (4%) had both AUD/OUD. Linkage: 25 patients (17%) were successfully linked to the hospital-based SUD clinic within 30 days of discharge. The linkage rate was higher for patients with OUD (10/27, 37%) compared to those with AUD (13/88, 15%) or AUD/OUD (1/6, 17%). Engagement: 17 patients (12%) were engaged for at least 2 visits within 30 days of discharge. The engagement rate was 100% for patients with OUD who were linked to care (10/10). KEY LESSONS FOR DISSEMINATION: Overall, 40% of patients seen by the ACS in an urban safety-net hospital were eligible for referral to the hospital-based SUD clinic, highlighting the importance of expanding access to low-barrier post-discharge addiction treatment within the hospital system. However, only 17% of those eligible for referral were successfully linked, representing the challenge of treatment linkage for a hospitalized SUD population not already in treatment. Notably, successful linkage and engagement were more common among those with OUD than AUD, potentially reflecting recent efforts to improve OUD treatment access in the midst of the overdose crisis. Opportunities to improve treatment linkage and engagement include expanding walk-in access and same-day scheduling for hospital-based post-discharge SUD care, warm handoffs, and support services to address social determinants of health. FEASIBILITY OF MIXED-REALITY TELECOLLABORATION TO ENHANCE NEUROLOGICAL EXAMINATIONS AND CLINICAL COLLABORATION Hamza T. Ansari1; Vasudha Venkatesh Sosale1; Jasmit Heera2; Syeda Bushra Ahesam1; Edison Jyang1; Tran Tu Huynh3. 1Internal Medicine, Cayuga Medical Center, Ithaca, NY; 2Medicine, Cayuga Medical Center, Ithaca, NY; 3Innovation , OpticSurg Inc, New York , NY. (Control ID #4273385) STATEMENT OF PROBLEM/QUESTION: Are mixed reality glasses acceptable and effective for neurologic exams in stroke care? DESCRIPTION OF PROGRAM/INTERVENTION: Access to specialty care in rural settings, especially for acute stroke, is hindered by communication barriers between frontline clinicians and remote neurologists during telestroke consults. This study, performed in a community medical center, examines the feasibility of using smart glasses with augmented reality to enhance real-time communication and guidance during neurological examinations. MEASURES OF SUCCESS: We conducted a pilot study to evaluate the acceptability of ease of use of smart glasses in a rural community hospital setting using the HIPAA compliant OpticSurg Vision BeyondTM software. Providers received a 10-minute demonstration on operating the smart glasses and associated iPad software. They participated in a simulated neurological examination, alternating roles as the bedside examiner and the remote provider, who interacted virtually. For comparison, they repeated the exam using audio-only and audiovisual communication via a mobile phone. At the end of the session, qualitative data regarding their experience was collected through an interview. Feasibility was assessed through provider feedback on training, usability, advantages, disadvantages, and likelihood of recommendation. FINDINGS TO DATE: Providers appreciated the hands-free functionality and improved communication enabled by smart glasses. Key advantages included performing examinations without holding a device, real-time guidance from remote consultants, and better visualization of findings, particularly for tasks requiring both hands. Challenges noted were limited third-person perspectives, difficulty optimizing camera positioning, and the inability to see bedside providers demonstrate techniques. Participants suggested combining smart glasses with existing tools, such as iPads, to address these issues. Overall, providers recommended the technology for its ease of setup and potential in clinical practice and education, emphasizing the need for further optimization and training. KEY LESSONS FOR DISSEMINATION: Providers found the smart glasses to offer significant advantages, highlighting their potential to streamline telestroke workflows. However, identified challenges underscore the need for thoughtful integration and training. Effective implementation would require addressing these limitations and fostering user familiarity to ensure adoption. These findings can guide healthcare organizations aiming to integrate similar technologies for improving access to timely specialty care in underserved settings. GENERAL INTERNISTS PUTTING IDEAS INTO ACTION: A TEXT MESSAGE-BASED PROGRAM TO TRANSITION PATIENTS WITH WELL-CONTROLLED TYPE 2 DIABETES FROM BASAL INSULIN TO A GLP-1 RA AT A NYC SAFETY-NET CLINIC, FULL RESULTS OF THE MITI-GLP1 PILOT PROGRAM Natalie K. Levy1; Katie Nerlino1; Sherlane B. Bongalos2; Alexis Dasilva2; Chinye N. Uzor2; Ying Jie Liang2; Olubunmi o. Sonubi2. 1New York University Grossman School of Medicine, New York, NY; 2Ambulatory Care Nursing, New York City Health and Hospitals Bellevue, New York, NY. (Control ID #4269142) STATEMENT OF PROBLEM/QUESTION: Insulin lowers blood sugar but brings risks for hypoglycemia and weight gain. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) lower blood sugar, do not cause hypoglycemia, support weight loss and provide multiple cardiorenal and metabolic benefits including decreasing the risk of heart attacks, strokes, and cardiovascular death in people with Type 2 Diabetes (T2D) who either have a history of ASCVD or are at high risk for ASCVD. Thus, many General Internal Medicine physicians would prefer that their patients are maximized on GLP-1 RA medications and have their insulin minimized. MITI-GLP1 helps put that Idea into Action. DESCRIPTION OF PROGRAM/INTERVENTION: Patients with T2D who have well-controlled fasting blood sugars using basal insulin - but who are either not on a GLP-1 RA at all or on a submax dose - are enrolled on a secure web platform that sends them a daily weekday text message asking "What was your fasting blood sugar this morning?". Each weekday (M, T, W, F) the Nursing Team quickly checks for alarm values and once a week, on Thursdays, calls the patients, reviews the fasting sugars, checks in about any side effects from the GLP-1 RA, consults with the preceptor, and advises the patient if/how to lower their basal insulin dose and if/how to raise their GLP-1 RA dose. The goals of the program are to: decrease insulin, increase GLP-1 RA and avoid hypoglycemia during the transition. The Program lasts until the patient is off insulin, or maxed on their GLP-1 RA, or 16 weeks has elapsed. MEASURES OF SUCCESS: Measures of success include % of patients with insulin lowered by >50%, % with insulin stopped completely, % with GLP-1 RA dose increased by > 1 level, % discharged on the maximum GLP-1 RA dose, % of text messages with a value of <80 mg/dL and % of text messages that receive a reply. FINDINGS TO DATE: Seventy-two patients completed the pilot program. At baseline, they had an average age of 54, 71% self-identified as Hispanic or Latinx, 61% opted for texts in Spanish, 61% had no health insurance, the average starting basal insulin dose was 20 units once daily, average BMI was 30 kg/m2, average baseline fasting blood glucose 126 mg/dL and the GLP-1 RA used was 83% Semaglutide, 14% Dulaglutide, 3% Liraglutide. Fifty-five patients (76%) had basal insulin reduced by >50%, 45 patients (63%) had their insulin stopped completely. Sixty-four patients (89%) had their GLP-1 RA increased by >1 level, 45 patients (63%) were discharged on the maximum dose of their GLP-1 RA. Five out of 3,520 text messages (0.14%) had a value <80 mg/dL. Out of 3,671 text messages, 3,520 (96%) received a reply from patients. KEY LESSONS FOR DISSEMINATION: "Well-controlled Diabetes" in 2025 doesn't just refer to good blood glucose values, but rather to well-controlled blood glucose in the context of medications that reduce cardiorenal and metabolic complications. A General Internal Medicine-run MITI-GLP1 program using text messaging and teamwork can effectively and safely transition people with well-controlled Type 2 Diabetes away from basal insulin and towards GLP-1 RA. GROWING AND SUSTAINING A LIFESTYLE MEDICINE PROGRAM IN ACADEMIC PRIMARY CARE: THE IMPLEMENTATION OF VIRTUAL SHARED MEDICAL APPOINTMENTS Jacob Mirsky2; Nancy Haff1; Meekang Sung3; Julie Lauffenburger3; Niteesh K. Choudhry4. 1Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 2Massachusetts General Hospital Department of Medicine, Boston, MA; 3Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; 4Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA. (Control ID #4273331) STATEMENT OF PROBLEM/QUESTION: Interventions to promote healthy behaviors, like a healthy diet, exercise, and sleep, are critical for the prevention and management of chronic disease but are time consuming and therefore difficult to implement in primary care. DESCRIPTION OF PROGRAM/INTERVENTION: Our goal was to provide broad access to Lifestyle Medicine for primary care patients in a financially self-sustaining model using virtual Lifestyle Medicine Shared Medical Appointments (LMSMAs) and individual Health and Wellness Coaching. First, program leadership designed LMSMA session content and established consenting processes, confidentiality standards, and billing practices in collaboration with health system leadership and legal teams. Virtual LMSMAs, conducted by trained primary care physicians and nurse practitioners, were then launched in 2020 for hypertension, diabetes and prediabetes, nutrition, stress reduction, and culinary medicine. Sessions were initially offered within one primary care practice and then expanded across the full academic medical center utilizing an electronic health record referral. As the program grew, sessions on hyperlipidemia, obesity, brain care, gastroesophageal reflux, and insomnia were added and the capacity for Health and Wellness Coaching was expanded. MEASURES OF SUCCESS: Success is being measured through consistent referrals, patient participation in LMSMAs and Health and Wellness Coaching, patient and provider satisfaction, and clinical outcomes. FINDINGS TO DATE: From Spring 2020 through Fall 2024, 3,563 patients were referred to the program and 1,679 patients attended at least one virtual LMSMA. Patients attended a median of 4 LMSMAs resulting in 6,808 virtual patient LMSMA visits. The most attended sessions were hypertension, diabetes and prediabetes, and rotating nutrition topics. A total of 2,733 health and wellness coaching sessions were completed for 409 patients. Sixteen primary care providers and 3 health and wellness coaches currently deliver these interventions, supported by a program coordinator and guided by program leadership. KEY LESSONS FOR DISSEMINATION: Interest among patients and primary care providers for lifestyle medicine programming was high. Program growth and sustainability required increased revenue generation which was accomplished through 1) increasing the number of patients participating in each LMSMA by significantly expanding referrals and 2) increasing the medical complexity of LMSMA programming to drive higher reimbursement. With these changes, the program is financially self-sustaining and is the largest program of its kind in the US. GROWTH AND FINANCIAL OUTCOMES OF A REMOTE PHYSIOLOGIC MONITORING SERVICE FOR HYPERTENSION IN THE PRIMARY CARE SETTING Riley K. Carroll1,2; Neeraj H. Tayal1; Cory P. Coffey1; Jodi M. Grandominico-Bradford1; Natalie S. Lee1; Jennifer A. Sabatino1. 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2The Ohio State University College of Pharmacy, Columbus, OH. (Control ID #4234576) STATEMENT OF PROBLEM/QUESTION: Remote physiologic monitoring (RPM) is increasingly utilized in primary care to improve chronic disease management, but the impact of different models on enrollment and financial outcomes are still unknown. DESCRIPTION OF PROGRAM/INTERVENTION: In the United States (US), nearly half of adults have hypertension (HTN). Lack of routine blood pressure (BP) monitoring and limited access to care are known barriers to HTN management. Traditionally, HTN management has occurred within office visits with primary care providers (PCPs) to monitor BP and adjust medications, but reliance on this model can lead to delays in obtaining BP control. RPM involves patient self-monitoring of physiologic parameters, allowing providers continuous access to data to assess condition status and modify treatment. RPM presents a promising solution to address the challenge of hypertension management by allowing for monitoring of patients’ BP outside of the traditional clinic setting. While RPM is generally considered to have a positive impact on the quality of care provided, barriers to adoption of RPM include concerns for the challenge of managing continuous streams of incoming data, patient capability, and financial sustainability. In an effort to improve BP control and increase access to care, an RPM service for HTN was developed and implemented in a network of primary care clinics at a large academic medical center. The program was implemented in two phases: the first utilizing clinic-owned Bluetooth enabled BP monitors and the second utilizing vendor-supported cellular enabled devices. Within this model, embedded clinical pharmacists played a central role in patient enrollment and management of the BP data under a collaborative practice agreement and PCPs billed for the service using RPM codes. MEASURES OF SUCCESS: Number of patients enrolled each month. Average duration of enrollment for patients in the program. Incidence of RPM CPT codes billed, average charges, and average reimbursement per patient enrolled. FINDINGS TO DATE: During Phase 1, 140 patients were enrolled in 13 months. Patients spent an average of 155 days in the program. PCPs billed an average of $301.46 per patient with an average of $96.30 reimbursement (31.9%). During Phase 2, 172 patients were enrolled in 9 months. Patients spent an average of 72 days in the program. PCPs billed an average of $412.93 per patient with an average of $124.17 reimbursement (30.1%). KEY LESSONS FOR DISSEMINATION: Using clinic-owned Bluetooth enabled BP monitors that were refurbished and reused kept the costs of the program low, but may have limited enrollment. Use of vendor-provided cellular enabled monitors was more costly, but may have facilitated additional billing opportunities and growth of the program, allowing for an increased rate of enrollment and more efficient HTN management. Our findings offer valuable insights for operationalizing and sustaining a pharmacist-led RPM program for HTN management in primary care. HEALTHCARE PROVIDERS (HCP) PERCEPTIONS, OPINIONS AND EXPERIENCES ON THE IMPLEMENTATION OF THE ANAL CANCER SCREENING GUIDELINES AT AN HIV CLINIC IN A LARGE METROPOLITAN CITY. Riya Goel, Mariana Sanchez-Medina, Ghiara Lugo Diaz, Lisa Flowers, Laura Gaydos. Medicine, Emory University, Atlanta, GA. (Control ID #4270458) STATEMENT OF PROBLEM/QUESTION: HPV-related squamous intraepithelial lesions are precursors to anal cancer, disproportionately affecting high-risk populations like people living with HIV, men who have sex with men, and women with vulvar dysplasia. Early detection through screening guidelines is critical, but barriers such as provider engagement and system-wide support hinder implementation. This study evaluated a targeted educational module for providers at the HIV Ponce Clinic, focusing on improving understanding, adherence to screening protocols, and identifying barriers and facilitators to implementation. DESCRIPTION OF PROGRAM/INTERVENTION: This two-phase pilot study involved providers completing an educational module on the guidelines followed by in-depth interviews six months post-training to evaluate compliance. Seven semi-structured interviews with HIV ID Clinic providers explored their understanding, attitudes, and barriers or facilitators related to providing screening. Two independent reviewers conducted thematic analysis of transcripts, comparing themes with the interview guide. Discrepancies were resolved through discussion or a third reviewer. MEASURES OF SUCCESS: Providers shared their comfort performing screenings, interpreting results, and referring patients for high-resolution anoscopy. Success was reflected in increased specificity in understanding guidelines, improved confidence in managing screenings, and adapting practices to include co-testing and broader target patient populations. FINDINGS TO DATE: Before the module, all seven providers were aware of anal cancer screening but lacked detailed knowledge, particularly regarding the appropriate age to start screening, intervals, and protocols for non-MSM individuals. Post-module, all providers reported increased comfort performing screenings, understanding results, and initiating screening at the correct time, with two expanding screening to non-MSM patients. Previously, screening was limited to MSM, with four providers screening individuals under 35 and three omitting hrHPV testing. Post-module, all providers implemented key elements, including co-testing and adjusting practices to focus on those over 35. Facilitators included clinic resources, anoscopy providers, and the module itself. Barriers included long anoscopy wait times (6/7 providers), scheduling inefficiencies (4/7), competing priorities (6/7), laboratory challenges (4/7), and Epic workflow issues, such as screenings not integrated into health maintenance (6/7). KEY LESSONS FOR DISSEMINATION: The educational module improved providers' confidence in performing screenings, discussing anal cancer with patients, and identifying appropriate referrals for anoscopy, demonstrating its success in fostering provider competence. However, providers also reported systemic challenges, including scheduling inefficiencies and EHR integration barriers, highlighting the need for improved logistical support and refinement of guidelines. These qualitative insights offered a nuanced understanding of systemic factors that may not yet be addressed in the educational module. HIGH RISK FOR COLON CANCER—YOU TELL ME! Nicole Napier1; Stephanie Shapiro2; Sheri Giangregorio2; Cecilia W. Stuopis3; Michele David1. 1Clinical Quality and Patient Safety, Massachusetts Institute of Technology, Cambridge, MA; 2Informatics, Massachusetts Institute of Technology, Cambridge, MA; 3MIT Health, Massachusetts Institute of Technology, Cambridge, MA. (Control ID #4270784) STATEMENT OF PROBLEM/QUESTION: Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Despite national screening guidelines, many patients fall behind on CRC screening due to procedural backlogs, scheduling difficulties, or personal reasons. Given the challenges of timely access to colonoscopy, stool-based tests like the Fecal Immunochemical Test (FIT) offer a practical alternative to keep patients on track with CRC screening. While mass mailings promoting FIT can reach large populations, it is vital to identify higher-risk patients and prioritize colonoscopy for more effective screening. DESCRIPTION OF PROGRAM/INTERVENTION: Our program uses electronic health record (EHR) data to stratify patients for CRC screening. Outreach targets average-risk patients identified by EHR data, including family history, prior colonoscopy results, pathology reports, and problem lists. Monthly email and text reminders encourage eligible patients to complete a FIT test. Patients self-identify as high-risk using a detailed checklist of risk factors, selecting specific criteria or providing concerns via an open-response field. A registered nurse (RN) reviews all high-risk responses and contacts the patients to assess the validity of their reported risk status. High-risk patients are advised to undergo a colonoscopy, while average-risk patients are offered FIT. The RN ensures that any validated high-risk factors are documented in the patient’s medical record, either in the problem list or family history, for accurate future care. This intervention increases CRC screening compliance while allowing primary care providers (PCPs) to focus on other health priorities. Initially, the campaign used a binary “yes” or “no” question to assess high-risk status, leading to confusion and unnecessary follow-ups. Implementing a comprehensive checklist improved patient understanding and outreach efficiency. MEASURES OF SUCCESS: Success is defined as achieving 80% FIT completion among average-risk patients and 80% colonoscopy (scheduled or completion) among high-risk patients, facilitated by RN-supported scheduling. FINDINGS TO DATE: Of 302 patients contacted, 40% self-identified as high-risk. Among 89 high-risk responses reviewed, 67% required colonoscopy based on validated risk factors. To date, 46% of these validated high-risk patients have completed or scheduled a colonoscopy, while 18% are actively scheduling. Notably, the EHR algorithm initially classified these patients as average-risk. While the algorithm identified 35% of patients as elevated risk, the campaign revealed additional high-risk individuals through self-reported factors not captured in the EHR. KEY LESSONS FOR DISSEMINATION: Risk stratification in outreach campaigns is critical for effective CRC screening, especially when screening modality depends on patient risk. Providing a detailed checklist enhances patient understanding and reduces unnecessary follow-ups. A dedicated RN is pivotal in patient education, risk assessment, and screening compliance, enabling efficient, patient-centered care. IMPLEMENTATION OF A MULTIDISCIPLINARY POPULATION HEALTH INITIATIVE TO INCREASE PRESCRIBING OF SODIUM-GLUCOSE COTRANSPORTER 2 INHIBITOR THERAPY FOR PATIENTS WITH CHRONIC KIDNEY DISEASE AND TYPE 2 DIABETES IN TWO PRIMARY CARE MEDICAL RESIDENT CLINICS Emily Duncan1; Sydney Robbins2; Katie E. Delille1; Cory P. Coffey3; Neeraj H. Tayal4; Jodi M. Grandominico-Bradford5. 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2General Internal Medicine - Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH; 3Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 4Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 5Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4272273) STATEMENT OF PROBLEM/QUESTION: Despite updated KDIGO guidelines recommending sodium-glucose cotransporter type 2 inhibiters (SGLT2is) as first-line therapy for patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) with an eGFR ≥ 20 mL/min/1.73m2, prescribing of SGLT2is has been poor in the primary care setting. DESCRIPTION OF PROGRAM/INTERVENTION: A third party, Health Insurance Portability and Accountability Act (HIPAA) protected, data analytics tool called Qlik Sense© was used at two Mid-West academic primary care resident clinics to identify patients diagnosed with CKD stage 3a and above and T2DM. This data was then used to identify patients not currently on SGLT2i therapy. A systematic, multidisciplinary outreach approach beginning November 1, 2024 was implemented to contact empaneled patients who met the above criteria and increase prescribing rates. The approach included: 1) adding a SGLT2i discussion prompt to the visit note if an appointment was scheduled within the next 3 months (by the resident lead), 2) sending a secure patient portal message noting SGLT2i eligibility, rationale for therapy, and a prompt to schedule with a pharmacist or resident to discuss initiation if seen in the last 3 months (by the pharmacy lead), and 3) outreach by nursing staff to schedule a primary care visit with their resident provider if >6 months since the last visit. Following the above interventions, the chart was reviewed for initiation of an SGLT2i. If an SGLT2i was not prescribed, the reason why was recorded. Due to low prescribing rates identified through the analytics tool, education by the resident lead was provided to resident trainees regarding indication, side effects, and cost of SGLT2is. Modalities of this education included PowerPoint presentations, tip sheets with prompts and dosing suggestions located in workstations, and emails. A discussion template was also created to guide patient-provider conversations on SGLT2is. MEASURES OF SUCCESS: 1) Total number of patients initiated on SGLT2i following initiative, 2) Number of patients contacted via secure portal, phone, or in-office discussion, 3) Number of patients initiated on SGLT2i by resident or pharmacist. FINDINGS TO DATE: A total of 63 patients were identified who may benefit from SGLT2i initiation. Of these, 11 patients were contacted via secure chat and 18 patients via telephone outreach. A total of thirty-two patients had discussion prompts added to their visit notes. Since beginning the intervention, 5 patients have been initiated on an SGLT2i, 1 by a pharmacist and 4 by a resident. Four patients have declined the therapy (3 for recurrent yeast infections and 1 for rash). KEY LESSONS FOR DISSEMINATION: Data analytics tools are efficient ways to identify a population eligible for treatment of chronic diseases and multidisciplinary interventions are effective ways to increase this treatment. Further data from these interventions described above may inform the method of outreach or education most effective in increasing SGLT2i uptake, as well as assist with reducing barriers to prescribing. IMPLEMENTATION OF A PHARMACY-DRIVEN MEDICATION PRIOR AUTHORIZATION WORKFLOW IN PRIMARY CARE Samantha I. Pitts, Lee Biddison, Kimberly Peairs. Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4270791) STATEMENT OF PROBLEM/QUESTION: Prior authorization (PA) for clinical services, including medications, poses a significant administrative burden to clinicians and contributes to physician burnout. DESCRIPTION OF PROGRAM/INTERVENTION: We implemented a standardized pharmacy-driven workflow for medication PA in three internal medicine practices affiliated with an urban, academic medical center, including two faculty only practices and one combined resident and faculty practice. Among the approximately 14,700 patients at these sites, most had commercial insurance (61.4%), followed by Medicare (28.5%) with small proportions with Medicare Advantage (2.7%), Medicaid (4.6%), uninsured (2.4%), and unknown (5.0%). Prior authorization requests were sent within the electronic health record (EHR) or using RightFax to a pharmacy-based, PA team. A designated pharmacy technician completed the PA request, regardless of the dispensing pharmacy, which was tracked and documented within a referral in the EHR. MEASURES OF SUCCESS: We measured the number and proportion of authorized PA requests using referral data exported from the EHR for 52 weeks from October 23, 2023 to October 20, 2024. We calculated the average rate of PA per 100 provider visits per site. We described the proportion of conditions for which PA were sought by classifying commonly used ICD-10 codes attached to the PA, including weight management (E66, R63, R73, Z68, Z76, Z78, or Z98), type 2 diabetes (E11), pain management (M54,G89, M25, M79), hormone therapy (F64,E29), pulmonary disease (J44, J45, R05), gastroesophageal reflux (K21), ADHD (F90), and grouped medications by pharmaceutic class. We used statistical process control (QI Macros, KnowWare International, Inc, Denver CO) to evaluate the proportion of PA authorized over time. FINDINGS TO DATE: During the 52 weeks, we received a total of 1891 PA requests, with a median of 34 per week [range, 7 – 78, interquartile range, 24 – 43], of which 50.5% were authorized. The average rate of PA per 100 visits by practice ranged from 3.3 to 8.1. Weight management and diabetes together accounted for 45.6% of PA requests (484 and 379 of 1891, respectively), while the top 8 diagnoses accounted for 70.0%. Glucagon-like peptide 1 (GLP1) receptor agonists (including tirzepatide) accounted for 40.7% (769/1891) of PAs, primarily for weight management 464 (60.3%), followed by type 2 diabetes (34.1%). Of GLP1 for weight management, 30.2% were authorized, compared to 74.0% for diabetes. In statistical process control, the proportion of authorized PA increased in weeks 44-46 and week 51. KEY LESSONS FOR DISSEMINATION: A dedicated, pharmacy-driven PA process reduced the burden of medication PA in three academic primary care practices. Variations in the number of PA per week can result in challenges in timely completion with fixed staff capacity. Specific strategies to address PA for GLP-1 receptor agonists are needed. IMPROVING DIABETES CARE THROUGH TEAM-BASED CARE, PRIMARY CARE EMPOWERMENT, AND CONTINUOUS PRACTICE TRANSFORMATION Hee Lee1; Arielle Elmaleh-Sachs1,2; Elan Pelegri1; Emily McVey1; Judd Anderman1; Mila Gonzalez Davila1; Yar Pye1; Doreen Colella1; George Shahin1; Isaac Dapkins1,2. 1Family Health Centers, NYU Langone Health, New York, NY; 2Population Health, NYU Langone Health, New York, NY. (Control ID #4271320) STATEMENT OF PROBLEM/QUESTION: Providing evidence-based diabetes care to underserved and underinsured populations can be challenging due to high medication costs, provider comfort with medication prescribing, and competing priorities in a busy primary care setting. DESCRIPTION OF PROGRAM/INTERVENTION: Evidence-based, patient-centered diabetes care requires a comprehensive approach involving care coordination, population health management, leveraging the electronic health record (EHR) to implement system-wide interventions, and sufficient medical supplies and medications. This project describes a 3-year multi-pronged approach to improving the care for patients with diabetes in a community health center network in the Mid-Atlantic region. Our practice surveyed providers on barriers to insulin prescribing, and they shared concerns about cost and additional burdens on patients, as well as challenges in prescribing insulin in the EHR and lack of primary care and patient education. Following this, primary care providers participated in educational workshops to review best practices for safe insulin initiation and titration. We then leveraged the care team to improve the clinic workflow, distributing pre-visit planning lists to clinical teams daily so that medical assistants could do point-of-care hemoglobin A1c (HbA1c) tests before the visit with the provider. We also utilized recall lists to engage uncontrolled diabetic patients in primary care quarterly visits. Next, we added a clinical decision support tool in the electronic health record for patients with uncontrolled diabetes, including educational components and indications for starting medications. To address barriers to access for medications, we developed a collaboration with a charitable medication distributor program for patients without health insurance to access insulin and glucagon-like peptide-1 receptor agonist medications free of charge. MEASURES OF SUCCESS: 1) a decrease in the overall percent of patients with a HbA1c level>9% across the network of clinics and 2) HbA1c among patients who participated in the charitable medication distributor program. FINDINGS TO DATE: After implementing all the system-wide strategies, the percentage of patients with HbA1c >9% decreased from 21% to 16% over 3 years. Among patients enrolled in the charitable medication program (N = 714), average hbA1c decreased from 9.84 to 8.75 90-days post enrollment (difference = 1.08, P <0.001, Wilcoxon Rank Sum). Most patients who received the medications were Hispanic/Latino and/or spoke Spanish as their preferred language. KEY LESSONS FOR DISSEMINATION: Data shows that health centers implementing a multi-pronged approach to addressing chronic diseases, specifically diabetes, can improve patient health outcomes. By identifying disparities in access to care and medications and by standardizing workflows through system-wide interventions in diabetes care, health centers will be better poised to partner with other organizations or identify resources within their organization for their patients and strive towards health equity. IMPROVING PATIENT IDENTIFICATION OF CARE PROVIDERS THROUGH A VISUAL AID Jaewon Lee1; Xinmiao Yang1; Sophie Wieselquist3; Olivia Raymond3; Jenna Barnes3; Meghna C. Trivedi2; Nneka Onwubueke2. 1Internal Medicine, University of Massachusetts Chan Medical School, Worcester, MA; 2Department of Medicine, UMass Memorial Medical Center, Worcester, MA; 3University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4272491) STATEMENT OF PROBLEM/QUESTION: We designed an infographic that visually represents various healthcare roles in a teaching hospital (including primary care teams, consulting teams, case managers, physical therapists, residents, fellows) with a goal to enhance patients’ clarity about various caregivers in the hospital. We aimed to assess the efficacy of infographic in helping the patients to identify and understand their providers with different roles and interactions. DESCRIPTION OF PROGRAM/INTERVENTION: A patient typically encounters countless new faces during their hospital stay, particularly at a tertiary academic hospital. Often, patients may not know who they’ve interacted with, due to the overwhelming amount of new information and people that they come across daily. This can lead to frustration and poor patient experience during the hospitalization. MEASURES OF SUCCESS: A single center pilot study was conducted with 45 patients admitted to a large urban academic medical center between February 2024 and August 2024. Inclusion criteria required that they read and write English fluently and are able to make their own medical decisions to participate. Patients were first given a pre-survey to identify their baseline knowledge of the various healthcare roles and the infographics were given for them to read. Immediately after, they were given the post-survey. The pre- and post-surveys were identical to each other, but the post-survey had two additional questions which asked the patient to rate the infographic’s effectiveness, as well as provide open-ended feedback. FINDINGS TO DATE: The visual infographic aid improved patients' understanding of healthcare team roles, with survey scores increasing by 15.8% (20.5% relative improvement) to an average post-survey score of 93.1%. Patients showed improvement in comprehension of care team roles, with understanding of the "primary team" rising from 62.2% to 86.7%. Patients also reported an increase in subjective comfort in identifying team members, with scores improving from an average of 6.7 to 7.6 when rated on a scale of 1 to 10. 84.4% of patients found the infographic helpful, reinforcing its value as a communication tool in the hospital setting. Some patients recommended distributing the infographic during admission process. Based on patient feedback, next steps to further improve patient satisfaction and understanding include adding roles like nutritionists and phlebotomists and providing an additional field for patients’ care plans. KEY LESSONS FOR DISSEMINATION: This project emphasized the significant impact on distributing infographics that educate patients about various health care providers that they are likely to encounter during their hospitalization experience. Regardless of their history of hospitalization, patients found the infographics to be helpful in understanding the roles of different providers and in organizing questions and plans to facilitate a collaborative hospitalization experience and care environment. INTEGRATED MENTAL HEALTH CARE IN PRIMARY CARE: RESULTS AT UCONN Shakaib Khan1; Angela Hart2; Luis Velez Figueroa1; Feier Liu1; Mario Caro Sabogal1. 1Psychiatry, UConn Health, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT. (Control ID #4250044) STATEMENT OF PROBLEM/QUESTION: Access to mental health is extremely limited in outpatient medicine DESCRIPTION OF PROGRAM/INTERVENTION: Access to mental health providers and treatment is limited in the outpatient internal medicine setting. A model was created to have a co-located clinic by embedding a psychiatric consultants in the internal medicine outpatient clinic to provide short-term acute stabilization (up to 6 visits). The goal is to provide diagnostic clarity, initiate medication management and then have the primary internal medicine team take over long term care. This gave concise evidenced based psychiatric consultations to primary care teams and enhanced the integration of mental health into primary care. The model additionally allows for collaboration ranging from electronic messages, in-person conversations and re-referrals, depending on the patient's needs. Additionally, these clinics incorporate resident physicians from both psychiatry and medicine. This incorporation includes direct patient care as well as educational modules tailored to the clinical and administrative aspects of the co-located model. Data for the number of referrals and completed appointments was collected through the electronic health record. MEASURES OF SUCCESS: PHQ-9 for depression, GAD-7 scores for anxiety and number of completed new referrals for the access issue FINDINGS TO DATE: This model was initiated at one outpatient clinic in 2021 with it being expanded to 6 other outpatient clinics at an academic medical center in New England over the next year. The program now has a psychiatrist for one half day clinic at 7 outpatient primary care sites across the academic center. The program has been able to address the access issue across the academic center. The total number of referrals for initial consults was 1819 with 902 completed (49.5%) of appointments completed. This led to 1967 follow-ups being scheduled with 1123 completed (57%). Our work has also led to PCPs indicating increased comfort with mental health issues and the psychiatrists feeling more comfortable with medical issues. Data demonstrated decreasing PHQ-9 and GAD-7 scores showing objective improvement in depression and anxiety, respectively. Data from 8/5/21 - 3/7/24 was analyzed. The preliminary analysis including all patients (494) demonstrated improvement in PHQ-9 and GAD-7 scores. Mean PHQ-9 scores decreased by 2 points (p<0.0001) and mean GAD-7 scores decreased by 1.81 (p<0.0001). Secondary analysis removing patients who only had 1 visit (294) showed similar results with mean PHQ-9 scores decreasing by 1.25 and mean GAD-7 score decreasing by 3.72 (p<0.0001). Significance was assessed using a paired sample t-test, explaining that for both the PHQ-9 and GAD-7 data sets, there was a statistically significant decrease in scores (p <0.0001). KEY LESSONS FOR DISSEMINATION: By eliminating the barriers of access, diagnosis, initiation of treatment and follow up in a busy primary care setting through embedding psychiatry into the practice, overall mental health care can be improved. LADDERED PRESCRIBING TO ENSURE CONTINUITY OF CARE AND RELIABLE ACCESS TO MEDICATION FOR PATIENTS ON CHRONIC OPIOIDS Daniel Pastan, Kelly Lavin, Peter Kleinschmidt. Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4270744) STATEMENT OF PROBLEM/QUESTION: Primary care physicians (PCPs) are often tasked with signing opioid prescriptions on behalf of their colleagues for patients whom they may never have met. DESCRIPTION OF PROGRAM/INTERVENTION: The opioid epidemic is responsible for widespread morbidity and mortality. Nevertheless, prescribing opioids maintains medical utility in scenarios ranging from acute pain to cancer-related pain. PCPs regularly encounter patients for whom such prescriptions are indicated, making the continuity of the PCP-patient relationship a cornerstone of safe and appropriate opioid use. To ensure this continuity, clinics could enact policies wherein only the PCP of record is permitted to sign prescriptions for chronic medications. However, this may prove impractical as PCPs are not always available, allowing for gaps in chronic opioid prescription patterns that could negatively impact patients, even contributing to withdrawal symptoms. Accordingly, we sought to reduce the incidence of cross-covering physicians signing opioid prescriptions for their colleagues without disrupting patient experience. MEASURES OF SUCCESS: We conducted a single-clinic intervention involving six physician providers with the aim to increase the proportion of opioid prescriptions signed by a patient’s PCP of record. Medical Assistants were trained to pend up to two sequential opioid prescriptions with fill dates spaced by 28 days. These “laddered” prescriptions were then routed for physician signature. We obtained order reports for all opioid prescriptions for patients on our organization’s Chronic Opioid Registry over 6 month pre-intervention (January - June 2023) and post-intervention (January - June of 2024) periods. FINDINGS TO DATE: In the pre-intervention period, 209 of 244 (85.7%) of prescriptions were signed by the patient’s PCP of record. In the post-intervention period, 261 of 280 (93.2%) prescriptions were signed by the patient’s PCP of record revealing a 7.5% increase in PCPs signing opioid prescriptions for their patients (p=0.004529). KEY LESSONS FOR DISSEMINATION: Our intervention of laddering prescriptions created a modest but statistically significant increase in opioid prescriptions coming from the PCP of record. This was a simple, low-cost, and sustainable intervention. This intervention permits fewer patient interactions with the clinic and the PCP managing their opioid prescription. Although this may improve access and reduce clinic staff workload, it also may lead to chronic opioid patients being assessed less frequently. Future study could include evaluating patient satisfaction with improved continuity and impact on delays of care associated with opioid prescribing. It should also examine the potential implications of less frequent assessment. LEVERAGING ELECTRONIC MEDICAL RECORD TOOLS TO REDUCE HYPERPOLYPHARMACY: A RESIDENT-LED QUALITY IMPROVEMENT INITIATIVE Gwendolyn Lee2; Fletcher Bell2; Stephen Conn2; Noam Margalit2; Colleen A. McGourty3; Sharada Narayan2; Laura Pugh2; Rebecca Varnell2; Alanna Williams2; Mike K. Cheng1. 1Medicine, University of California San Francisco, Oakland, CA; 2Internal Medicine, University of California San Francisco, San Francisco, CA; 3Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4229369) STATEMENT OF PROBLEM/QUESTION: Polypharmacy and hyperpolypharmacy, defined as regular use of at least 5 and 10 medications, respectively, are concerningly prevalent among older adults, and are exacerbated by the use of high-risk medications like benzodiazepines, contributing to adverse outcomes like drug interactions, falls, hospitalizations, and mortality; many resident trainees lack sufficient awareness, knowledge, and experience to appropriate deprescribe medications. DESCRIPTION OF PROGRAM/INTERVENTION: At a large academic primary care practice within a tertiary care health system, which houses 72 Internal Medicine residents, we identified that 8.8% (n=138) of patients aged 65 and older on resident panels were prescribed 10+ medications, or have hyperpolypharmacy. Our intervention aimed to address hyperpolypharmacy through outreach to both patients and resident physicians. Patient outreach strategies included sending individualized messages via EPIC's MyChart inviting patients with hyperpolypharmacy to schedule an appointment with their physician to review mediations. Clinician outreach strategies included sending emails and distributing informational flyers in the resident workrooms to advertise electronic medical record (EMR) smartphrases we created to standardize and facilitate resident and patient education regarding appropriate medication deprescribing. The goal was to promote hyperpolypharmacy awareness and discussions of deprescribing during patient visits to reduce the number of patients experiencing hyperpolypharmacy and reduce the number of unnecessary prescriptions per patient, especially of high-risk medications and among those disproportionately affected, such as older Black adults. MEASURES OF SUCCESS: The outcome metrics we tracked included the total number of medications per patient and the total number of patients with 10+ medications, or a hyperpolypharmacy diagnosis. We stratified patients by race/ethnicity to track disparities. FINDINGS TO DATE: During the initial 4-month intervention period starting summer 2024, among patients with residents as primary care physicians, the median number of medications among 65 yr old or older patients with hyperpolypharmacy was reduced from 12 to 11 medications (mean 12.3 to 11.7). The total number of older adult patients with hyperpolypharmacy prescribed benzodiazepines and anticholinergics decreased by about 3% and 5%, respectively, while the number of patients on opioids and anticoagulants remained stable. The percentage of Black patients with hyperpolypharmacy was 17% compared to 7% for White patients prior to our intervention, and decreased to 11% among Black patients compared to remaining stable at 8% of White patients. KEY LESSONS FOR DISSEMINATION: Our resident-led project successfully decreased the number of medications prescribed to patients, with a focus on deprescribing medications with high risk of adverse effects, and successfully decreased disparities in hyperpolypharmacy between Black and White patients. EMR tools, such as smartphrases, could be an effective approach to standardize quality and delivery of care. NEXT DAY CLINIC TO PREVENT AVOIDABLE HOSPITALIZATIONS: A 13 MONTH TRIAL OF A NOVEL HOSPITAL AVOIDANCE MODEL Richard K. Leuchter1,2; William Turner1; Benjamin Waterman3,4; Jaclyn Spiegel3; Scott Lundberg6; Mandi Occhiuto5; Vinhfield Ta5; Soma Wali5,4. 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; 3UCLA Medical Center Olive View, Sylmar, CA; 4Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 5Medicine, UCLA Medical Center Olive View, Sylmar, CA; 6Emergency Medicine, UCLA Medical Center Olive View, Sylmar, CA. (Control ID #4269401) STATEMENT OF PROBLEM/QUESTION: An estimated 10-20% of hospitalizations could be cared for in alternative settings, but building hospital avoidance models that can be scaled and disseminated has been challenging. DESCRIPTION OF PROGRAM/INTERVENTION: In an academic hospital located in one of the nation’s largest safety net health systems, we implemented the Next Day Clinic (NDC), a hospital-based high-acuity clinic guaranteeing 12-24 hour follow-up for Emergency Department (ED) patients who would otherwise be admitted. Co-located with an Urgent Care, the NDC provides services such as daily IV diuretics, IV antibiotics, daily labs, and diagnostic imaging (e.g., echocardiograms, CT, stress tests) within as little as 12 hours of ED discharge. Patients go home between clinic visits and return to the NDC daily for as long as clinically necessary, thereby avoiding hospitalization. Patients in the ED meeting InterQual criteria for eligible conditions (CHF, COPD, cellulitis, AKI, pyelonephritis, diabetes, syncope, chest pain, pneumonia) triggered our intervention, where the admitting Hospitalist would offer to divert the patient to the NDC instead of admission through the ED. By shifting these patients into a high-acuity outpatient setting, the NDC aimed to conserve inpatient beds, control costs, and maintain high-quality care. MEASURES OF SUCCESS: We tracked the proportion of ED referrals with admission orders meeting InterQual® criteria, which allowed us to establish that the counterfactual to NDC referral was hospital admission and calculate the number of avoided hospitalizations. We also measured days alive and out of hospital (DAOH) at 30 days from the ED visit, and compared this to a control group of similar patients who were hospitalized derived by propensity matching on age, sex, primary diagnosis, and first set of labs and vitals in the ED. Finally, we calculated cost savings using Medicaid reimbursement data in this fully capitated cohort. FINDINGS TO DATE: Between July 2023-July 2024, the NDC received 420 ED referrals with an 88% show rate. After restricting to those referrals that would have been hospitalized in the absence of the NDC, we avoided 336 hospitalizations in 13 months. Patients required an average of 2.4 NDC visits to avoid hospitalization. The NDC group had 29.5 DAOH compared to 26.7 in matched inpatient controls, suggesting an average treatment effect of 2.8 bed-days saved per avoided admission. This imputes 941 hospital bed-days avoided, which translates to $2.07 million saved using hospital-specific Medicaid reimbursement rates. KEY LESSONS FOR DISSEMINATION: The NDC model avoided nearly 1,000 hospital bed-days and over $2 million in a 13-month pilot, and a multi-hospital RCT is underway to establish clinical effectiveness. By co-locating with existing Urgent Cares, the NDC requires very few new resources so is cost-effective to implement, even in resource-constrained safety net settings. This program takes full advantage of economies of scale by centralizing care delivery, thereby supplementing Hospital at Home models that have historically been difficult to scale. NOVEL STRATEGIES TO REDUCE EHR IN BASKET VOLUME IN PRIMARY CARE Reema Dbouk, Pamela Vohra-Khullar, Diego Remolina, Christopher Masi. Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4268978) STATEMENT OF PROBLEM/QUESTION: PCPs spend significant time providing medical care in response to patient queries sent via EHR portal and telephone. High numbers of patient medical advice requests (PMARs), patient calls, and prescription refill requests contribute to PCP burnout. In August 2024, the 217 PCPs at our institution spent an average of 30 minutes each day in the In Basket addressing an average of 44 In Basket messages. These values are in the 90th percentile compared to PCPs nationally. DESCRIPTION OF PROGRAM/INTERVENTION: We formed a Portal Communication Committee comprised of physicians, APPs, nurses, and administrators to identify best practices for message management. The AMA STEPS Forward Portal Message campaign provided key recommendations, including delegating message handling to empowered team members. Based on these recommendations, our Primary Care Telehealth Team increased from 60 to 86 RNs and from 32 to 62 LPNs. In addition, we developed a case-based training curriculum for the Telehealth Team and for the 75 LPNs who staff our 50 practice-based clinical pools. This curriculum is designed to help nurses resolve patient queries, including scheduling requests, referral requests, new and ongoing clinical concerns, DME and home health request, refill requests, and results requests. Finally, we encouraged Telehealth Nursing and the clinical pool nurses to use AI-generated draft responses when replying to portal queries. MEASURES OF SUCCESS: We are tracking the average daily time that PCPs spend in the In Basket, as well as the average daily number and type of In Basket messages. We are also tracking the number of calls to Telehealth Nursing and the percent of these calls forwarded to PCPs. We are monitoring the number of PCPs (physicians and APPs) and nurses (RNs and LPNs) who are using AI-generated draft responses. We are also surveying PCPs and nurses regarding burnout, professional fulfillment, and overall In Basket experience at baseline and 6 months post-intervention. FINDINGS TO DATE: With the recent expansion of staffing in Telehealth Nursing, coverage for incoming portal messages and phone calls increased from 8:00 am to 5:00 pm Monday through Friday to 24/7. This change was associated with significant decreases in most In Basket metrics between August and November 2024. For example, PCP In Basket time decreased from 30 to 26 minutes daily while In Basket messages decreased from 44 to 39 daily. Of the In Basket messages, PMARs decreased from 7.7 to 6.3 daily and patient calls decreased from 5.4 to 4.1 daily while prescription authorizations increased from 6.5 to 7.3 daily. KEY LESSONS FOR DISSEMINATION: An increase in Telehealth Nursing staffing was associated with decreases in PCP In Basket time and volume. We expect further decreases with case-based training of nurses on message management and with increased nurse usage of AI-generated draft responses. Baseline and post-intervention surveys will assess the impact of these strategies on burnout, professional fulfillment, and In Basket experience among PCPs and nurses. OPTIMIZING AMBULATORY CARE THROUGH TEAM-BASED STRATEGIES: EVIDENCE FROM THE IMPACT PILOT PROGRAM Nika M. Harutyunyan1; Cory Hedwall2; Anna Dermenchyan3. 1Internal Medicine , UCLA, Sherman Oaks, CA; 2Department of Medicine- Quality, University of California Los Angeles Health System, Los Angeles, CA; 3Medicine, University of California Los Angeles Health System, Los Angeles, CA. (Control ID #4259059) STATEMENT OF PROBLEM/QUESTION: Team-based care has been shown to deliver better patient outcomes, improve patient satisfaction, and enhance provider and team experience. Part of providing excellent patient care is managing patient messages sent to the InBasket. The majority of the InBasket management workload is being placed on primary care physicians, which contributes to high levels of burnout and stress in healthcare providers. Effective team-based strategies are needed to alleviate the burden of InBasket management and provide high-quality patient care. DESCRIPTION OF PROGRAM/INTERVENTION: The aim of the InBasket Management and Population-health Ambulatory Care Team (IMPACT) pilot program is to enhance team-based care and population health management in the ambulatory setting. The program seeks to improve the quality of patient care, enhance patient access to healthcare services, and decrease physician burnout rates. The IMPACT program was piloted in four primary care clinics within the Department of Medicine, each staffed with an NP and an RN working virtually to support two clinics. This approach focused on three high-yield topics: patient messages and phone calls, care gaps, and opportunities to recapture HCC/RAF diagnoses. These topics are aimed at allowing NPs to conduct telemedicine health appointments and manage InBasket messages, thereby optimizing team-based care. MEASURES OF SUCCESS: The success of the IMPACT program will be assessed by reducing MyChart messages and patient calls routed to physicians, improving patient access through increased telehealth visits by Nurse Practitioners (NPs), and ensuring most messages are managed by NPs and Registered Nurses (RNs) without physician intervention. Additional metrics include closing care gaps, increasing HCC/RAF recaptures, and enhancing provider satisfaction and reducing burnout based on provider feedback, workload reduction, and improved job satisfaction. FINDINGS TO DATE: After the initial message triage by the clinic staff, since February 1, 2024, the IMPACT Team addressed 11,194 messages. With the RNs resolving 4,435 messages and the NPs resolving 3,792 messages. The remaining 2,967 messages routed to the physicians to manage. The NPs were also able to conduct 500 telehealth visits. Preliminary results indicated a promising 69% reduction in MyChart messages and patient calls that were routed to the physician, demonstrating the effectiveness of the program in a team-based approach in managing the InBasket. KEY LESSONS FOR DISSEMINATION: The IMPACT pilot presents a viable solution to healthcare provider burnout through an innovative team-based care approach. By effectively reducing the InBasket burden and improving patient care and access, the program demonstrates the potential for broader implementation and sustainability within UCLA. Future steps include integrating workflows for the RNs to address care gaps as well as integrated workflows for the NPs to address HCC/RAF coding. PRIORITIZING ACCESS BASED ON CLINICAL NEED THROUGH VISUAL REDESIGN OF REFERRAL ORDERS Emilie O'Neill1; Stasha O'Callaghan2; Alomi Malkan2; Christine Zhang1; David Silvestri2; Hannah Jackson1,3; Kevin Chen1,3. 1Office of Ambulatory Care and Population Health, NYC Health + Hospitals, New York, NY; 2Office of Quality and Safety, NYC Health + Hospitals, New York, NY; 3Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY. (Control ID #4232207) STATEMENT OF PROBLEM/QUESTION: Limited availability of specialty appointments prompted an investigation into whether redesigning the referral order choice architecture in the electronic health record (EHR) could encourage referring providers to prioritize orders more effectively for improved scheduling triage. DESCRIPTION OF PROGRAM/INTERVENTION: The intervention focused on improving the outpatient specialty referral process within a large municipal healthcare system in a major Northeastern city by redesigning the ‘Priority’ field in the EHR to include explicit urgency-based options (e.g., "Within 3 days," "Within 7 days") displayed as discrete buttons. The default "Routine" selection was removed, requiring providers to actively choose a priority level. This approach aimed to better align referral urgency with the needs of a diverse, high-need patient population in the outpatient setting. MEASURES OF SUCCESS: The primary measure of success was the volume and distribution of priority selections before and after each step of the intervention. FINDINGS TO DATE: The intervention increased referrals with non-default priorities by 14%. After removing the default selection, urgency levels were more evenly distributed, with significant increases in both urgent and less urgent referrals. "Within 3 days" referrals rose from 3.0% to 7.2%, and "Within 7 days" referrals increased from 7.3% to 14.2%. Additionally, "Within 90 days" referrals also saw an increase from 0.3% to 12.4%, indicating that not all selections shifted toward more urgent categories. KEY LESSONS FOR DISSEMINATION: The redesign demonstrated that changes in the EHR referral order can influence provider behavior and improve referral prioritization, providing a scalable intervention for systems with limited appointment availability. These findings underline the importance of choice architecture for defaults and using specific language to enhance active provider decision-making. PUTTING SCHEDULING IN THE HANDS OF PATIENTS: IMPROVING TEMPLATE UTILIZATION, FILL RATE, AND REVENUE IN AN ACADEMIC SAME DAY TELEHEALTH CLINIC. Dhanu R. Bhat1; Jodi M. Grandominico-Bradford1; Daniel E. Jonas2. 1General Internal Medicine, The Ohio State University, Columbus, OH; 2Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4272023) STATEMENT OF PROBLEM/QUESTION: The primary care acute telehealth clinic was not realizing template utilization rate goal >100 % or fill rate goal >90% leading to missed revenue opportunities. DESCRIPTION OF PROGRAM/INTERVENTION: The primary care same day telehealth clinic (PCSDT) opened in our Midwest academic internal medicine division in 2020. The clinic provides acute telehealth care for low complexity complaints. It is staffed by five different primary care "doc of the day" from 1-5 PM, 5 days a week. Patients are scheduled by triage nurses empowered to make appropriate scheduling decisions. To cover costs of physician salaries in the clinic, revenue goals are estimated to be $10,000 a month in payments. The clinic is busiest from September through January. There is a drop off in utilization from February through August. This has led to an inability to meet revenue targets, placing the clinic’s future stability at risk. A fish bone analysis was conducted to establish areas for intervention to improve template utilization and fill rate. The decision was made to allow patient self-scheduling through the electronic portal in July 2024. A detailed algorithm was developed with the scheduling team to assist with identifying appropriate cases for telehealth visits at the time of rollout. Post intervention, patients had ability to self-schedule into telehealth appt slots opening 72 hours prior to date of service. MEASURES OF SUCCESS: Clinic charges and payments pre and post intervention, template utilization and fill rate pre and post intervention, % of self-scheduled patients. FINDINGS TO DATE: Pre intervention charges per month (avg FY20-24): Jan:$21,542,Feb:$19,046,Mar:$21,591,Apr:$19,441,May:$18,779,June:$20,479, July:$20,620,Aug:$22,697,Sept:$18,448,Oct:$22,263,Nov:$21,773,Dec:$23,601. Pre intervention payments per month (avg FY20-24): Jan:$9,361,Feb:$8,865,Mar:$9,870,Apr:$9,348,May:$9,345,June:$9,726,July: $10,343,Aug:$11,689,Sept:$9,235,Oct:$10,923,Nov:$10,713,Dec:$11,672. Post intervention charges per month FY25: July:$27,709,Aug:$ 36,123,Sept:$26,858,Oct:$31,785,Nov:$28,439,Dec:$18,541. Post intervention payments per month FY 25: July:$12,193,Aug:$16,439,Sept:$11,731,Oct:$13,936,Nov:$11,022,Dec:$2025. Template utilization pre intervention (avg FY20-24): Jan:63%,Feb:45%,Mar:48%, Apr:45%,May:43%,June:46%,July:57%,Aug:63%,Sept: 61%,Oct:70%,Nov:74%,Dec:75%. Template fill rate pre intervention (avg FY20-24): Jan:63%,Feb:44%,Mar:47%,Apr:43%, May:42%,June:45%,July:56%,Aug:57%,Sept: 58%,Oct:68%,Nov:71%,Dec:73%. Post intervention template utilization rate FY25: July:81%,Aug:83%,Sept:81%,Oct:92%,Nov:83%,Dec:92%. Post intervention template fill rate FY25: July:75%,Aug:75%,Sept:78%,Oct:89%, Nov:76%, Dec:77%. % self-scheduled post intervention: 90%. KEY LESSONS FOR DISSEMINATION: Timely access to acute and affordable care can be provided via a same day telehealth model. Relying only on traditional nurse triage scheduling can lead to underutilization of templates and negatively impact revenue. Patient self-scheduling can positively impact template utilization, fill rates, and revenue. QUALITY IMPROVEMENT PROJECT TO IMPROVE PULMONARY REHABILITATION UTILIZATION IN COPD PATIENTS Elizabeth Allen2; Mikyong M. Kang2; Aisha Imam2; Aidan Farrell2; Connor Divens2; David Sypert1. 1Internal Medicine, OhioHealth Physician Group, Columbus, OH; 2Internal Medicine, OhioHealth, Columbus, OH. (Control ID #4272257) STATEMENT OF PROBLEM/QUESTION: There is a lack of pulmonary rehabilitation utilization in COPD patients despite the multitude of research indicating that pulmonary rehabilitation improves quality of life and decreases hospitalizations in this population. DESCRIPTION OF PROGRAM/INTERVENTION: This project studied a resident outpatient clinic serving a low-socioeconomic population. A group of 238 patients with COPD who qualified for pulmonary rehabilitation were reviewed. The goal for the first PDSA cycle was to increase awareness of pulmonary rehabilitation. A presentation on pulmonary rehabilitation was used to educate attending physicians in our residency clinic. The goal for the second PDSA cycle was to create a tool that is educationally sustainable and utilizes frequent physician reminders. PDSA cycle 2 implemented an automized EMR tool and included resident physician education on pulmonary rehabilitation. MEASURES OF SUCCESS: Our quality improvement project objective was to increase the pulmonary rehabilitation referral rate for patients with COPD in our residency clinic. The primary outcome was the number of referrals to pulmonary rehabilitation. The secondary outcomes were the completion of formal pulmonary function tests (PFTs) and the number of annual surveillance visits for COPD. FINDINGS TO DATE: Data analysis included utilization of a two-tailed z score population proportion analysis and a chi square statistical analysis. After PDSA cycle 1, the percentage of COPD patients with pulmonary rehabilitation referrals increased from 17.6% to 18.9% (p=0.71). After PDSA cycle 2, the overall percentage increased to 20.2% (p=0.48). While the number of pulmonary rehabilitation referrals increased after both the first and second PDSA cycles, the difference was not statistically significant. For secondary outcomes, the percentage of PFT completion increased from 82.7% to 86.6% (p=0.25) after PDSA cycle 1 and to 88.2% (p=0.09) after PDSA cycle 2. Overall, the PFT completion rate increased after both PDSA cycles, however the difference was not statistically significant. Finally, the number of annual COPD visits for our study population increased from 86 to122 (p=0.0008) after PDSA cycle 1 and to 132 (p= 0.0002) after PDSA cycle 2. Overall, the increase in the number of annual COPD visits after both PDSA cycles was statistically significant. KEY LESSONS FOR DISSEMINATION: Pulmonary rehabilitation has been demonstrated to not only improve exercise tolerance, symptoms of dyspnea, endurance and quality of life, but decrease healthcare costs. Despite the abundance of studies suggesting benefits for pulmonary rehabilitation there is a lack of outpatient referrals for COPD patients. This effort to increase pulmonary rehabilitation referral at our residency clinic is a long-standing quality improvement measure to improve patient care. Our initiatives are easily reproducible in any ambulatory residency clinic and are cost-effective for low-income or uninsured patients to optimize COPD management. REDUCING BARRIERS TO VACCINATION: RESIDENT-LED EDUCATION SESSIONS AT A COMMUNITY-BASED SUBURBAN SENIOR CENTER Esther S. Kim1; Foysal Daian2; Barbara Keber2; Mariecel Pilapil3; Lauren Block4. 1Internal Medicine, Northwell Health, New Hyde Park, NY; 2Family Medicine, Northwell Health, New Hyde Park, NY; 3Medicine and Pediatrics, Northwell Health, New Hyde Park, NY; 4medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY. (Control ID #4272441) STATEMENT OF PROBLEM/QUESTION: Vaccine hesitancy is a global health concern that is attributed to multiple factors including limited access to accurate information on vaccines. DESCRIPTION OF PROGRAM/INTERVENTION: As part of a community health track, internal and family medicine residents partnered with faculty and a senior center located in a suburban area in the Northeast region. The residents held meetings with the faculty mentors and senior center representatives to plan for informational sessions on vaccines. Feedback from the senior center members who participated in prior vaccine education sessions were utilized to design the session. One session was held in the winter of 2024 on vaccines indicated for adults aged 65 years and older including influenza, COVID-19, pneumococcal, and shingles vaccines. The session consisted of a 15-minute presentation and a Q&A time. Post-session survey was administered and completed by the senior center members on a voluntary basis. Flyers containing information corresponding to the presentation were distributed to the members regardless of their participation in the survey. MEASURES OF SUCCESS: The impact of the session on the senior center members was assessed by collecting feedback surveys after the session. Participants were asked what they had learned from the session and if they had any remaining questions or concerns about the vaccines. FINDINGS TO DATE: Twenty-three participants completed the survey post session. All participants were older than 65 years. About one-third of the participants (n=6, 27%) stated their doctors had not talked to them about vaccines, but most participants (n=19, 83%) indicated that they were likely to receive the vaccines recommended by their doctors or pharmacists. The majority stated that they believed the vaccines were effective in preventing illness (n=17, 74%) and safe to receive (n=14, 61%). Several participants commented that they learned the importance of getting vaccinated after the session. We also received verbal feedback and questions about specific details of the vaccines that were reviewed during the presentation. KEY LESSONS FOR DISSEMINATION: Multiple barriers exist to receiving vaccines especially in vulnerable populations such as older adults whose access to medical visits may be limited. Partnership with local community centers can extend the opportunity to discuss important health-related information such as vaccines. Participant feedback we received from the session will be used to make adjustments for future sessions at the senior center for continued education. SUCCESSES AND CHALLENGES IN IMPLEMENTATION OF A LARGE MAILED FIT PROGRAM Gabriel Monti2,1; Kaleb Keyserling2; K. Paige Gardner3; Jenna Anderson2; Valerie Betancourt2; David Lieberman1. 1Oregon Health & Science University, Portland, OR; 2Department of Hospital and Specialty Medicine, Portland VA Medical Center, Portland, OR; 3Primary Care, Portland VA Medical Center, Portland, OR. (Control ID #4271616) STATEMENT OF PROBLEM/QUESTION: How did implementation of an automated colorectal cancer screening program via mailed fecal immunochemical testing (FIT) affect FIT return and colonoscopy completion rates? DESCRIPTION OF PROGRAM/INTERVENTION: Colorectal cancer screening is universally recommended with either fecal immunochemical testing (FIT) or colonoscopy. FIT offers several advantages including lower barriers to access care, which has led to implementation of automated programs in large health systems. Starting in July 2022, the our Northwestern VA medical center initiated a mailed FIT program (MFP) in which kits are sent to eligible patients annually when they are due for screening without action required from the primary care team (PACT). This is a retrospective analysis of 3 groups of Veterans to assess FIT adherence: Group 1 (baseline) received standard FIT ordered by PACT Aug 2021-July 2022; Group 2 received FIT via MFP from July 2023 to September 2024, and Group 3 received FIT via PACT from July 2023 to September 2024. Many iterative changes occurred throughout the first year of the program and a lab flag was not implemented until July 2023, so data from August 2022 to June 2023 were excluded. MEASURES OF SUCCESS: Relevant measures include the proportion of FIT kits returned and the proportion of patients with a positive FIT who complete a diagnostic colonoscopy within 6 months FINDINGS TO DATE: Group 1 (baseline) had 18,065 FITs ordered and 32% were returned. Group 2 (MFP) had 20,226 FITs ordered as compared to 12,213 for Group 3 (PACT). Group 2 (MFP) FITs were returned more frequently vs. Group 3 (PACT) (37% vs 24%, p value <0.01)) and Group 1 (baseline) (37% vs 32%, p value <0.01). Colonoscopy completion within 6 months for positive FIT was 49% in Group 1 (baseline), 36% in Group 2 (MFP), and 43% in Group 3 (PACT). This difference was statistically significant for Group 1 vs Group 2 (difference 13 percentage points, p value <0.01), but not Group 1 vs Group 3 (p value 0.38) or Group 2 vs Group 3 (p value 0.19). KEY LESSONS FOR DISSEMINATION: Implementation of a large FIT screening program resulted in increased returned FITs in a large integrated health system. Despite concern that that FIT return rates would decrease due to lack of verbal discussion with the Veteran, we observed increased return rates. This may be due to standardized and easy to read educational information and an automated reminder call. However, the proportion of Veterans who received timely diagnostic colonoscopy was lower. We suspect that the increased number of returned FITs and decrease in staff gastroenterologists at our facility overwhelmed the capacity of our system to provide timely colonoscopy. Additionally, due to the process for inclusion in MFP, there is added risk that MFP FITs may be sent to patients who are not appropriate candidates for screening based on life expectancy and comorbidities. Mailed FIT programs should continue to target only individuals who are appropriate for screening and ensure they have adequate support to provide timely colonoscopy for those with positive tests. THE IMPACT OF RESOURCE ALLOCATION AND OBSERVATION EXCLUSION CRITERIA ON PATIENT THROUGHPUT IN A HOSPITAL OBSERVATION UNIT Shaber Seraj, Zaeem S. Chaudary, Samia Nadeem, Mithilesh Kumar Vellaimuthu Kaliyamoorthy, Muhammad Umar. Internal Medicine, Baystate Medical Center, Springfield, MA. (Control ID #4270316) STATEMENT OF PROBLEM/QUESTION: How does implementing exclusion criteria and refining resource allocation influence patient throughput and enhance discharge capacity in an observation unit, addressing the increased healthcare burden post COVID-19 pandemic? DESCRIPTION OF PROGRAM/INTERVENTION: We conducted a quasi-experimental study with a pre and post-test measurement of our intervention in a 38-bed observation unit in an academic medical center in the Northeast. The observation unit provides extended care and monitoring for patients beyond the emergency department, making appropriate exclusion criteria essential. To ensure optimal patient selection and focused resource allocation, we implemented stricter exclusion criteria for observation admissions, supported by refined triage and patient categorization processes. This resource allocation enabled us to transition observation care for these patients from Type IV (discretionary care provided in any hospital bed) to Type I (protocol-driven care specifically within the observation unit). Exclusion Criteria: 1) Patients with active agitation or delirium 2) Patients requiring maximum assistance (i.e. quadriplegic) 3) Patients with difficult disposition (i.e. guardianship cases) 4) Readmission after major surgery 5) Patients with advanced malignancy We then reviewed the discharge data to determine whether the revised resource allocation and stricter exclusion criteria affected patient throughput and discharge numbers. Discharge data were compared for the four-month periods before (January 2024–April 2024) and after (May 2024–August 2024) the intervention. Statistical analysis, including a t-test, was performed to evaluate the significance of changes in discharge volumes. MEASURES OF SUCCESS: The primary outcome was mean discharge volume, compared for the four months before (January–April 2024) and after (May–August 2024) implementing the intervention. A t-test was used to assess statistical significance. FINDINGS TO DATE: Mean discharge volume (per month) increased significantly from 283.75 pre-intervention to 419.75 post-intervention (p = 0.033). A t-statistic of -2.95 confirmed a statistically significant improvement in patient throughput. KEY LESSONS FOR DISSEMINATION: Implementing strict exclusion criteria and refining resource allocation can significantly improve patient throughput and discharge volumes in observation units. Evidence-based strategies to optimize patient flow can enhance hospital efficiency and resource management. THE IMPACT OF TIME-BASED PROTOCOLS AND WORKFLOW OPTIMIZATION ON LENGTH OF STAY: A QUALITY IMPROVEMENT INITIATIVE IN THE OBSERVATION UNIT Shaber Seraj1; Samia Nadeem1; Zaeem S. Chaudary1; Mithilesh Kumar Vellaimuthu Kaliyamoorthy1; Sabeen Chaudry1,2; Muhammad Umar1. 1Internal Medicine, Baystate Medical Center, Springfield, MA; 2Cardiovascular Disease, Baystate Health, Springfield, MA. (Control ID #4271500) STATEMENT OF PROBLEM/QUESTION: How can the implementation of time-based protocols and workflow optimization strategies effectively reduce the length of stay (LOS) in an observation unit, addressing the increased healthcare system burden since the COVID-19 pandemic? DESCRIPTION OF PROGRAM/INTERVENTION: We conducted a quasi-experimental study using a pre- and post-test design in a 38-bed observation unit located in an academic medical center in the Northeast. In November 2023, we implemented five key interventions: 1) Time and evidence-based clinical protocols 2) Structured multidisciplinary rounds 3) Triage coordinator to efficiently manage patient flow, ensure protocol adherence, and facilitate diagnostic workup 4) Dedicated provider team for after-hours coverage 5) Escalation pathways Clinical protocols were developed for chest pain, syncope, and transient ischemic attack (TIA), which accounted for approximately 75% of patients admitted to the observation unit. Additionally, we established a dedicated team of day, swing, and night coverage for enhanced care. We further implemented multidisciplinary rounds at key transition points during the day. Lastly, escalation pathways were introduced to address barriers to care, and a triage coordinator role was created to streamline patient flow and ensure protocol adherence. A dashboard was developed to monitor outcomes, specifically LOS. LOS data were compared for the 10-month periods before (January–October 2023) and after (November 2023–August 2024) intervention implementation. Statistical analyses, including t-tests, were performed to evaluate changes in mean LOS. MEASURES OF SUCCESS: The primary measure of success was the mean LOS in hours, calculated for the 10 months prior to the intervention (January–October 2023) and 10 months post-intervention (November 2023–August 2024). A t-test was used to evaluate statistical significance. FINDINGS TO DATE: A total of 4538 patients were included in the study. The mean LOS significantly decreased from 31.6 hours pre-intervention to 25.1 hours post-intervention (p < 0.005). The reduction was accompanied by a notable t-statistic (8.01), highlighting a statistically significant improvement. KEY LESSONS FOR DISSEMINATION: Implementation of time-based protocols and workflow optimization can significantly reduce LOS in observation units, enhancing hospital efficiency. Multidisciplinary rounds, triage coordination, and expanded after-hours provider coverage are critical to improving patient flow and overcoming system-level barriers. TIME TO BLOOD PRESSURE CONTROL: INSIGHTS FROM A REMOTE MONITORING PROGRAM FOR HYPERTENSION Evan Woo1; Fion Chu1; Chenshu Zhang1; Allison Stark1,2; Sharon Rikin1,3. 1Internal Medicine, Albert Einstein College of Medicine, New York, NY; 2Care Management Organization, Montefiore Health System, Bronx, NY; 3Internal Medicine, Montefiore Medical Center, Brooklyn, NY. (Control ID #4269807) STATEMENT OF PROBLEM/QUESTION: For patients enrolled in remote patient monitoring (RPM) for hypertension (HTN) programs, there is a gap in knowledge for the time to achieve blood pressure (BP) control with RPM in real-world settings with diverse populations, which has important implications for program operations and participant engagement. DESCRIPTION OF PROGRAM/INTERVENTION: We developed a RPM for HTN (RPM-HTN) program at a Mid-Atlantic academic medical center. Patients with uncontrolled BP during a primary care visit could be referred to the program by their physician. Participants received a cellular-enabled BP monitoring device, and at least monthly telephone visits with a team of nurses and clinical pharmacists for BP review and medication management until the BP goal was maintained for 2 months or patients discontinued participation. MEASURES OF SUCCESS: We evaluated time to BP control for patients enrolled in RPM-HTN from 4/13/21 to 6/22/24, participated for at least 3 months, and measured BP on at least 50% of their participation days (consistent with RPM billing requirements). We excluded patients who had BP <140/90 mmHg for the entirety of their participation. The primary outcome measure was number of months to achieve BP control <140/90 mmHg. Covariates included age, gender, preferred language, race/ethnicity, starting BP, and comorbidities (diabetes, chronic kidney disease, cardiovascular disease). Kaplan-Meier survival curves were used to measure the primary outcome, and Cox regression was used to measure association between covariates and the primary outcome. The study received Institutional Review Board approval. FINDINGS TO DATE: Among the 708 patients who met participation criteria, 252 patients were excluded for having BP <140/90 mmHg the entirety of their participation, and 456 patients were included in our final analysis. The mean age was 66.2 years (SD ± 12.6), 34.2% were male, 65.8% were female, 39.9% identified as Hispanic, 43.4% identified as non-Hispanic Black, 16.7% identified as other races/ethnicities. The mean starting BP was 149/88 mmHg (SD ± 10/9). Twenty-five percent of patients achieved BP control by 1 month of participation, 50% by 2 months, and 75% by 4 months. Starting systolic BP was the only covariate associated with time to control and was associated linearly (hazard ratio 0.97, p-value <0.0001). For every 1 mmHg higher in the starting systolic BP, there was a 3% lower chance of achieving BP goal at any time point, thus a longer time to achieve BP control. KEY LESSONS FOR DISSEMINATION: When enrolling patients in RPM-HTN, programs can inform patients to anticipate at least 2 months of participation, with longer duration needed for patients with a higher starting systolic BP. Importantly, race/ethnicity, preferred language, and comorbidities were not associated with time to BP control. While patients’ duration of participation should be individualized to achieve their BP goal, these findings can inform implementation of RPM-HTN programs with regards to staffing capacity for number of participants and setting participant expectations at enrollment. TO CALL OR NOT TO CALL: CAN TEXT MESSAGES SAFELY REPLACE POST-DISCHARGE PHONE CALLS? Olivia Korostoff-larsson1; Holly Krelle1; Jeremy Lu1; Nathan Klapheke2,1; Sarah Tsuruo1; William C. King1; Leora I. Horwitz1,3. 1Population Health, NYU Langone Health, New York, NY; 2MCIT, New York University Grossman School of Medicine, New York, NY; 3Department of Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4270087) STATEMENT OF PROBLEM/QUESTION: Can post-discharge phone calls safely be replaced with text messages, reducing staff workload without compromising quality of care? DESCRIPTION OF PROGRAM/INTERVENTION: Text messages can save significant time and resources compared to phone calls. However, verbal interaction offers benefits, such as addressing follow-up questions and confirming patients’ understanding of their condition. It is therefore crucial to assess any potential adverse effects of replacing verbal communication with asynchronous forms of communication, such as text messaging. In a quality improvement study at a large urban academic medical center, we compared outcomes between patients randomized to receive a phone call or a text message after discharge home from elective outpatient surgery. Only patients without an active MyChart account were included. MEASURES OF SUCCESS: Outcomes were number of incoming calls to nursing staff, 14-day readmissions, and 14-day ED visits. We also tracked patient EHR-based "care plans," created when a caller identifies a patient issue needing resolution. FINDINGS TO DATE: Over two months, 230 patients were randomized to the text group and 240 to the call group. There was no difference in number of incoming calls between the groups (9 vs. 4; p = 0.48) and no difference in 14-day readmissions (13 vs. 11 p = 0.84) or ED visits (4 vs. 1; p = 0.37). Low ED visit volume limited our ability to detect small changes, but bootstrap sampling revealed that the text group had higher ED visit rates in only 12% of 10,000 simulations. More patient concerns were addressed in the call group (20 care plans vs. 4). In the call group, 10 care plans were created for follow-up scheduling, 7 for urgent condition changes, and 3 for medication problems. In the text group, 3 were for urgent condition changes, and 1 for a medication issue. These findings suggest some concerns may be missed with texts, but the absence of increased ED visits or readmissions suggests urgent needs were not overlooked. Overall, we estimate that switching all patients from calls to texts will save 14 hours of nursing work per month. In a follow-up randomized trial, we plan to investigate whether bidirectional texting, by which patients can communicate specific concerns through text, might address the limitations of unidirectional texting and more closely replicate what is achieved through a phone call. KEY LESSONS FOR DISSEMINATION: Replacing calls with text messages for post-discharge communication reduced workload while maintaining patient outcomes. Because of the rarity of our outcome measure (ED visits), we had to use bootstrap modeling rather than traditional analyses. We argue that this is a valuable and valid approach, particularly in a QI context, where we must make timely decisions about the best option for implementation - in this case, calls or text messages. Others may similarly use rapid, randomized tests to assess QI interventions and make quick, practical decisions to improve healthcare delivery. USE OF TEAM-BASED VIRTUAL CARE TO IMPROVE HBA1C CONTROL AMONG PATIENTS WITH UNCONTROLLED DIABETES IN COMMUNITY HEALTH CENTERS Yael Geller1; Jacalyn Nay2; Jason Hyde1; Isaac Dapkins3; Arielle Elmaleh-Sachs4. 1family health centers, NYU Langone Health, New York, NY; 2Patient Navigation Center, NYU Langone Health, New York, NY; 3Population Health, NYU Langone Health, New York, NY; 4Family Health Centers, NYU Langone Health, New York, NY. (Control ID #4272408) STATEMENT OF PROBLEM/QUESTION: Primary care providers (PCP) often have limited availability to provide intensive interventions for patients with uncontrolled DM2. DESCRIPTION OF PROGRAM/INTERVENTION: Patients with uncontrolled DM2 often require multiple pharmacotherapies and medication titration to improve HbA1c control. In addition, identifying patients’ barriers to adherence and providing education on medications and lifestyle modifications that are patient-tailored can improve DM2 control. This project uses a team-based approach to address these components of comprehensive DM2 care in a community health center network in the Mid-Atlantic region. Using a deeply integrated single-step clinical decision support tool, primary care providers (PCPs) are alerted of patients with uncontrolled HbA1c at the time of their visit. PCPs are given the option to refer patients who require intensive interventions for close follow-up in a virtual high-risk clinic with a dedicated registered nurse (RN) and nurse practitioner (NP). The RN and NP are trained in guideline-based diabetes care as well as motivational interviewing techniques. The providers screen for food insecurity, depression, and other barriers the patient may face, and counsel on proper home glucose measurements, review self-management skills, and prescribe medications. Once DM2 is controlled, patients are discharged from the clinic for continued care with the PCP. Implementing this short-term intensified intervention aims to modify illness behavior and achieve DM2 control. MEASURES OF SUCCESS: Measures of success include number of patients enrolled in the high-risk clinic, HbA1c prior to enrollment, at 3-months post-enrollment and at discharge from the clinic. FINDINGS TO DATE: Among patients enrolled in the clinic between 5/2024-12/2024, 17 patients had documented HbA1C measurements before and after our intervention: 10 males, 7 females, median age 48 years, range 26-72. There was a significant decrease in measured HbA1C following the intervention (p-value < 0.001, paired T-test, SPSS). Mean HbA1C decreased from 12.0% (SD=1.7%; range 9.6-14.0%) pre-implementation to 9.1% (SD=2.2%; 6.3-12.3%) post-implementation, and patients were seen for an median of 4 NP visits and 3 RN visits. A decrease in HbA1C was recorded in 14/17 (82%) patients with a mean decrease of 3.6% (SD=1.7%) in these patients. 7 of the patients reached a HbA1C value below 8% following the implementation. KEY LESSONS FOR DISSEMINATION: Through the use of a short-term intensive team-based intervention for DM2 care, addressing both medication titration as well as barriers to adherence and social drivers of health, patients can more promptly achieve control of their HbA1c. VOLUNTEER OUTREACH AND PREDICTIVE MODELING: A RAPID CONTROLLED TRIAL FOR NEW PATIENT ATTENDANCE IN A PRIMARY CARE SAFETY-NET Kevin Chen1,2; Khera Bailey1; Simon Nemytov3; Kenan Katranji1; Michael Bouton4; Andrew Wallach1,2; Hannah Jackson1,2. 1Office of Ambulatory Care and Population Health, NYC Health + Hospitals, New York, NY; 2Department of Medicine, New York University Grossman School of Medicine, New York, NY; 3Department of Biology, Stony Brook University, Stony Brook, NY; 4Enterprise Information Technology Services, NYC Health + Hospitals, New York, NY. (Control ID #4269768) STATEMENT OF PROBLEM/QUESTION: How can a volunteer-staffed outreach program, supported by predictive modeling, improve attendance for new patients in an urban safety-net primary care setting? DESCRIPTION OF PROGRAM/INTERVENTION: Volunteers were trained to make outreach calls to new patients scheduled for their first primary care visits at a hospital-based clinic within a large municipal healthcare system serving a diverse and high-need community in a major Northeastern city. A predictive algorithm was used to prioritize patients based on their likelihood of non-attendance, and every other patient was randomized to the intervention versus control group. Volunteers provided appointment reminders, answered questions, and guided patients on how to attend their visits. Calls were made within three business days prior to the appointment, with interpreters available to assist non-English-speaking patients. In addition to the outreach calls, usual automated reminders, including texts and patient portal messages, were provided to all patients. MEASURES OF SUCCESS: The primary outcome was the attendance rate for scheduled new patient appointments, defined as completed visits recorded in the electronic health record. Secondary metrics included subgroup analyses based on visit modality (in-person vs. telehealth), patients' preferred language, and their predicted no-show probabilities, as determined by the predictive algorithm. FINDINGS TO DATE: The intervention group showed a significantly higher overall attendance rate (68.0%) compared to the control group (54.1%), with an absolute increase of 13.9% (p<0.01). The impact was higher for in-person appointments, with a 19% absolute increase in attendance (p<0.01), while telehealth visits showed no significant difference between the intervention and control groups. The intervention had the greatest effect among patients with moderate predicted no-show probabilities (31%-45%) and those with English as their preferred language. KEY LESSONS FOR DISSEMINATION: Volunteer-staffed outreach calls, guided by predictive modeling, are a feasible and effective strategy for improving attendance in safety-net settings. The approach is most impactful for in-person visits and patients at moderate risk of non-attendance. Tailored interventions are needed for telehealth appointments and non-English-speaking patients to address their unique barriers. “WHAT’S MY ROLE”: RE-EXAMINING VA PRIMARY CARE PROVIDERS ATTITUDES TOWARDS OBESITY MANAGEMENT AFTER IMPLEMENTATION OF NOVEL MODEL FOR DELIVERY OF ANTI-OBESITY MEDICATIONS Cristina Fischer1; Lisa Thompson2; RAVI GOPAL2; TYLER MILLER2; Karen E. Stenehjem2. 1Internal Medicine, University of Colorado, Denver, CO; 2Department of Medicine, University of Colorado System, Denver, CO. (Control ID #4272757) STATEMENT OF PROBLEM/QUESTION: Obesity is a prevalent and serious condition that disproportionately affects veterans receiving care through the Veterans Health Administration (VHA), with prior work revealing that primary care providers (PCPs) often feel inadequately prepared to manage it effectively. DESCRIPTION OF PROGRAM/INTERVENTION: Obesity is a major public health issue affecting over 40% of U.S Adults, disproportionately impacting veterans receiving care through the VHA. Despite formulary guidelines and patient support for use of anti-obesity medication (AOM), only 1.8% of eligible patients receive this treatment. Additionally, while PCPs play a key role in obesity management, a prior survey of 34 PCPs within a Northwest VHA found that while 80% felt prescribing AOM was within their scope of practice, 54% lacked sufficient knowledge, and 77% cited insufficient time within primary care. To address these challenges, a novel care model with clinical pharmacists as the backbone was developed to deliver AOM within a Northwest VHA. Clinical pharmacists partnered with PCPs and a pre-established lifestyle weight management program to improve access to AOM. In this model, PCPs refer patients for AOM, which clinical pharmacists initiate and titrate to a stable dose before transferring management back to PCPs. Educational sessions provided to PCPs covered obesity management and the new care model. MEASURES OF SUCCESS: A post-intervention survey using a modified Anti-Obesity Medications Provider Survey assessed the model and education’s impact among PCPs at the previously surveyed clinic. FINDINGS TO DATE: In October 2024, 24 PCPs completed the follow up survey. Within the new model, 89% agreed they were more likely to address obesity in the primary care setting due to education and pharmacist support. All respondents were comfortable with clinical pharmacists initiating and titrating AOM, with 96% reporting comfort with managing stable-dose prescriptions. Compared to pre-intervention data, 85% of respondents reported sufficient knowledge to prescribe AOM, a 39% increase; while 67% felt they had the necessary resources, a 12% increase. Notably, 96% of respondents reported prescribing or collaborating with pharmacists on AOM prescriptions, reflecting a 25% increase. KEY LESSONS FOR DISSEMINATION: This healthcare delivery model demonstrates that pairing educational sessions with system changes improves PCPs confidence, knowledge, and engagement in obesity management. Team-based care models that leverage clinical pharmacists, result in enhanced provider comfort, and improve patient access to care. This approach is replicable in other settings by combining provider education, multidisciplinary care, and structured AOM pathways, offering a scalable solution to advance obesity treatment. Innovation in Healthcare Delivery (IHD) - Health Care Policy and Health Services Research IMPACT OF CARDIOVASCULAR PREVENTION CONSULT ON CARDIAC REHABILITATION ATTENDANCE Michael Hoffer-Hawlik, Beth Sherry, Patricio Castillo, Cecilia A. Castellano, Jonathan Newman, Saul Blecker, Arthur Schwartzbard, Howard Weintraub, Jeffrey S. Berger, Amrita Mukhopadhyay. Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4272450) STATEMENT OF PROBLEM/QUESTION: Cardiac rehabilitation is a key component of secondary prevention of coronary artery disease. However, cardiac rehabilitation is significantly underutilized, as only approximately 25% of eligible patients in the United States participate in the program. A cardiovascular prevention consultation following percutaneous coronary intervention (PCI) may improve cardiac rehabilitation referral and attendance rates. DESCRIPTION OF PROGRAM/INTERVENTION: The cardiovascular prevention consult service targets modifiable cardiovascular risk factors (e.g., physical inactivity, dyslipidemia, and hypertension) in patients undergoing elective PCI. A cardiovascular prevention attending and fellow meet with patients post-intervention while in the hospital and provide education and recommendations for lifestyle and medical therapy to optimize patient risk factors. One component of this consultation is a discussion regarding cardiac rehabilitation, which includes an overview of the program and logistics of enrollment. This introduction to cardiac rehabilitation during the prevention consult may represent an ideal time point for intervention to increase program participation. MEASURES OF SUCCESS: We are conducting semi-structured telephone interviews with patients who underwent PCI and either received or did not receive a prevention consult following PCI. By applying the Consolidated Framework for Implementation Research (CFIR), we developed interview guides to characterize facilitators and barriers to cardiac rehabilitation attendance, such as patient perceptions of program advantages, constraints to program attendance, and patient experiences at rehabilitation. We incorporated questions related to the impact of the prevention consult on the perceived value of rehabilitation and opportunities to address barriers to attendance. Demographic data are collected from patients during the interview. Interview transcripts are being analyzed using qualitative thematic analysis, with themes identified and codified for comparative assessment and refinement. FINDINGS TO DATE: Between July 2024 and November 2024, a total of 19 eligible patients have been interviewed, of whom 11 had a prevention consult (58%) and 8 did not have a prevention consult (42%). Qualitative feedback regarding patient perceptions of the anticipated benefits and risks of cardiac rehabilitation, barriers and facilitators to attendance, and opportunities to improve attendance were gathered. Coding of themes related to the timing and impact of the preventative consult on cardiac rehabilitation attendance and adherence are being identified and categorized across all interviews. As this project is ongoing, findings from the semi-structured interviews will be presented. KEY LESSONS FOR DISSEMINATION: A cardiovascular prevention consult following elective PCI may improve patient referral rates, attendance, and participation in cardiac rehabilitation. Tailored education immediately following PCI may enhance patient understanding of their own cardiovascular risk and encourage cardiac rehabilitation engagement. Innovation in Healthcare Delivery (IHD) - Health Equity, Diversity, and Inclusion ADDRESSING HEALTH EQUITY IN HYPERTENSION BY CREATING BP MY WAY: A MYCHART CARE COMPANION TOOL Sammy Sayed, Sylvia Lambrechts, Jeffrey Fujimoto, Hannah Kwak, Nika M. Harutyunyan. Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4271103) STATEMENT OF PROBLEM/QUESTION: Can a digital health tool tailored to Black patients improve hypertension management and address racial disparities in blood pressure control? DESCRIPTION OF PROGRAM/INTERVENTION: Hypertension is a significant public health challenge characterized by notable racial disparities. Compared to White adults, Black adults experience a 10% lower rate of blood pressure control, contributing to a four-fold increased risk of mortality from hypertension-related cardiovascular disease. Within our large academic medical center, Black patients demonstrated a 7.7% lower rate of controlled blood pressure in comparison to the overall patient population. To understand this racial disparity gap, we conducted a patient voice survey to explore Black patient perspectives. Key findings revealed a strong preference towards lifestyle interventions over medications and utilizing MyChart, an online health communication platform, for inter-visit interactions. Given consistent literature findings showing improved blood pressure control with enhanced remote monitoring, we developed a patient-facing self-monitoring Mychart Care Companion tool called BP My Way to address this hypertension disparity gap. Care Companion, an extension of the Epic MyChart patient portal, enables patients to interact with their health data remotely. The BP My Way program incorporated tailored educational videos on improving blood pressure control, reminders on medication adherence, a Self-Measured Blood Pressure Monitoring (SMBP) Program with BP escalations to nurse triage as needed, and symptom tracking. Patients identifying as Black, diagnosed with hypertension (blood pressure >140/90), ages 18-85 years old, and with a PCP visit in the last 12 months were invited to joint via a MyChart message. Exclusions included inactive MyChart status, a secondary cause of hypertension, pregnancy, or hospice care. MEASURES OF SUCCESS: Our outcome measure was the rate of hypertension control, as measured by Mean Arterial Pressure (MAP) changes. Our process measures included enrollment and engagement rates. FINDINGS TO DATE: A total of 86 patients met inclusion criteria. 20 patients (23%) enrolled in the program after the initial outreach. Six patients (26%) interacted with the educational content. 4 patients (17%) participated in the SMBP, with one of these participants triggering an alert for very high blood pressure and activating a triage protocol, which prompted an initial ED presentation and subsequent reestablishment with primary care. Over the course of three months, the patient’s Mean Arterial Pressure (MAP) improved by 63 points. Of the three other patients who participated in the SMBP, their MAP was noted to improve by 7 points. KEY LESSONS FOR DISSEMINATION: The BP My Way program shows promising initial outcomes, engaging patients in their own hypertension care management while also identifying individuals who need sooner follow-ups. Increased outreach and reminders may help maintain engagement between patient and the hypertension Care Companion tool for better evaluation of the program’s impact. A MULTI-PRONGED APPROACH TO IMPROVE COLON CANCER SCREENING AND HEALTH EQUITY IN PATIENTS SERVED IN AN ACADEMIC MEDICAL CENTER RESIDENT CLINIC Zeina Bani Hani1; Omar Yaghi1; Tebianne Abubaker1; Ivan Berezowski1; Bobga S. Gang1; Ana Pabalan3; Mrudula Bandaru1; Anna K. Rubin1; Marie Borum2; Chavon Onumah1. 1Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Medicine, Division of Gastroenterology, The George Washington University School of Medicine and Health Sciences, Washington, DC; 3The George Washington University Milken Institute School of Public Health, Washington, DC. (Control ID #4271741) STATEMENT OF PROBLEM/QUESTION: How do we decrease inequities in colon cancer and improve colon cancer screening in resident clinic patients? DESCRIPTION OF PROGRAM/INTERVENTION: Patients from marginalized communities have lower colorectal cancer (CRC) screening rates contributing to increased morbidity and mortality. Data has shown lower CRC screening rates in internal medicine (IM) resident clinics. Cancer prevention strategies such as educational interventions, the use of technology, and initiatives grounded in community engagement and cultural responsiveness can improve CRC screening. Our medicine department, which serves a majority (64%) African-American (AA) population in a major metropolitan area, implemented a multi-pronged approach to decrease inequities in CRC screening. Focus groups with healthcare learners and AA community members facilitated bi-directional learning, trust-building, and informed interventions. Resident-focused interventions included education on CRC inequities, bias mitigation, panel management, structural/social determinants of health (SDOH), and culturally responsive care along with experiential learning through an AA history museum trip and a community exploration workshop. Patient-focused interventions include patient-centered education and materials in clinic and community settings, patient navigation services, general messaging/advertisements, and tailored outreach. Structural barrier-focused interventions include local partnerships for chaperone and transportation services; collaboration with gastroenterology for scheduling and direct access colonoscopies; partnership with IT, administrative, and nursing team members for assessment and documentation of CRC screening status improvements. MEASURES OF SUCCESS: Learner awareness of SDOH’s impact on CRC screening Patient access to patient navigation services Cancer screening rates in patients seen in resident clinic FINDINGS TO DATE: Community member and healthcare learner focus group discussions identified community perspectives regarding barriers to CRC screening. Analysis of discussion transcripts revealed differences in proposed interventions and differences in the perceptions of AA community members and healthcare learners about racial disparities in healthcare, physician respect toward patients, and quality of physician counseling. Over 2 years, CRC screening rates among 2,426 resident clinic patients increased from 57.8% to 72.3%. A total of 519 patients were navigated, with 30% of patients navigated reporting structural, social, and/or psychosocial barriers to completing screening. KEY LESSONS FOR DISSEMINATION: A multipronged approach can improve CRC screening among patients in IM resident clinics. Bi-directional learning between community members and healthcare learners offers valuable insights for shaping cancer screening interventions, ensuring strategies are tailored to meet each group’s unique needs. CARE MANAGERS AND COMMUNITY HEALTH WORKERS IN EQUITABLE HYPERTENSION CARE: IMPLEMENTATION PROCESSES FROM A PRAGMATIC, CLUSTER-RANDOMIZED TRIAL Ali Aahil Noorali1,2; Chidinma A. Ibe1,2; Carmen Alvarez3; Katherine B. Dietz1,2; Shang-En Chung1,2; Deven Brown1,2; Hsin-Chieh Yeh1,2; Kathryn A. Carson2,4; Jill A. Marsteller4; Lisa A. Cooper1,2. 1Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; 2Center for Health Equity, The Johns Hopkins University School of Medicine, Baltimore, MD; 3University of Pennsylvania School of Nursing, Philadelphia, PA; 4Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4272227) STATEMENT OF PROBLEM/QUESTION: Studying the specific interventions of care managers (CMs) and community health workers (CHWs) in providing individualized care is essential for maximizing outcomes for marginalized patients with uncontrolled hypertension (HTN). DESCRIPTION OF PROGRAM/INTERVENTION: We conducted analysis using data from CM and CHW visits in the collaborative care (CC) arm of a 2-arm trial targeting inequities in HTN care. This pragmatic, cluster-randomized, hybrid effectiveness-implementation trial was conducted across several practices within multiple Mid-Atlantic health systems. Patients with uncontrolled HTN and ≥1 cardiovascular risk factor were enrolled. Informed by the Collaborative Care Model, our novel multilevel intervention included a CC team (CMs and CHWs), a specialist consultation, and enhanced standard care interventions: standardized BP measurement, HTN dashboard, and an equity learning network. CMs and CHWs elicited patients’ concerns across several areas: medical (HTN, diabetes, heart disease, hyperlipidemia, depression, tobacco smoking), social determinants of health (SDOH; housing, social support, employment, psychosocial, transportation, environmental, education, economic), lifestyle (medication, exercise and appointment adherence, DASH diet, weight loss) and others. MEASURES OF SUCCESS: We analyzed the frequencies of primary patient issues discussed across completed CM and CHW visits and compared these among those who completed both visit types using a paired t-test analysis. FINDINGS TO DATE: Of 893 CC patients (64.8% Black, 61.2% female, 67.7% with high school education or less), 680 (76.1%) had ≥1 documented visit: CM (n=508), CHW (n=96), or both (n=76). CMs completed 2693 visits with a primary content area, and CHWs completed 311. In CM visits, medical conditions were most discussed (64.7%), followed by lifestyle (26.2%) and SDOH (6.9%). Medical conditions were also discussed most frequently in CHW visits (42.8%); however, SDOH were the second highest (37.3%), followed by lifestyle (9.7%). HTN, including training and monitoring of home BP measurement, was the most common medical subtopic in both CM and CHW visits (74.5% and 56.4%). For CM visits, DASH Diet was the most frequent lifestyle subtopic (34.0%), and psychosocial determinants were the most common SDOH subtopic (38.4%). For CHW visits, economic challenges (e.g., medical insurance, health-related costs) were the most common SDOH subtopic (28.7%). For patients who had both CM and CHW visits (n=76), mean percentages of issue types discussed varied significantly; CM vs CHW: medical (50.7% vs 36.6%, p=0.02), SDOH (20.4% vs 54.2%, p<0.001) and lifestyle (30.8% vs 10.4%, p=0.002). KEY LESSONS FOR DISSEMINATION: Discussions of medical and lifestyle issues with CMs, coupled with discussions of SDOH with CHWs, demonstrate the importance of a CC approach that leverages both roles’ expertise. Future work will evaluate associations between frequency of issues discussed and patients’ outcomes, to distinguish which specific interventions, by which CC team members, are most effective for improving HTN control. INCORPORATING HEALTH EQUITY INTO THE EVIDENCE-BASED QUALITY IMPROVEMENT (EBQI) IMPLEMENTATION STRATEGY – LESSONS FROM THE VA Michelle S. Wong1; Evelyn T. Chang2,1; Bridget Kranke1; Danna Kasom1; Ann-Marie Rosland3; Donna L. Washington4. 1Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA; 2General Internal Medicine, VA- Greater Los Angeles, Los Angeles, CA; 3Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 4UCLA Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4266664) STATEMENT OF PROBLEM/QUESTION: Without explicitly considering equity, implementation of evidence-based practices (EBPs) can inadvertently exacerbate inequities for underserved patient groups if they are less likely to receive or benefit from these practices. DESCRIPTION OF PROGRAM/INTERVENTION: Within a VA initiative that implemented EBPs to manage primary care patients at high risk for hospitalization (“high-risk patients”), we piloted and evaluated an equity-focused adaptation to the Evidence-Based Quality Improvement (EBQI) implementation strategy. This EBQI strategy engages both leadership and front-line providers. Front line clinical champions receive quality improvement (QI) training and practice facilitation. We delivered this equity adaptation to clinical champions who were primary care clinicians. The adaptation comprised: 1) a one-hour didactic session as part of the QI training that provided actionable guidance for incorporating health equity into the implementation process (e.g., develop equity-related implementation goals, include demographic information in data collection plans; and address inequities within implementation plans and workflows); and 2) QI coaching to guide these efforts throughout the implementation process. MEASURES OF SUCCESS: We surveyed primary care clinical champions to quantitatively assess acceptability of the heath equity didactics. We qualitatively interviewed clinical champions after implementation completion to understand their perspectives on the equity EBQI adaptation, including their impressions, areas for improvement, and future plans. Qualitative data are being analyzed with rapid qualitative analysis. FINDINGS TO DATE: Survey responses from eight clinical champions from all six eligible primary care teams indicated neutral to high acceptability of the health equity didactics session, e.g., 80% of respondents planned to incorporate health equity into implementation plans. Examples of equity activities included developing an implementation goal to use EBPs among women veterans and delivering EBPs through both in-person and telehealth modalities to increase access to rural-dwelling patients. In interviews, clinical champions noted increased recognition and awareness of health equity’s relevance to high-risk patients, and in general, to patient care; that facilitators to equity implementation activities included the QI coach’s support, while barriers included a lack of infrastructure to address structural barriers experienced by underserved patient groups e.g., for rural patients, long travel times and limited broadband coverage. KEY LESSONS FOR DISSEMINATION: Health equity is an important consideration for implementation projects. Our EBQI equity adaptation demonstrates a practical and potentially scalable way to incorporate health equity considerations into projects that use the EBQI implementation strategy. The didactic portion of our equity adaptation also offers actionable guidance to front-line clinical champions on how to conduct equity-focused QI. INCORPORATION OF A CLINICIAN- AND PATIENT-FACING SHARED DECISION AID AT THE POINT OF CARE TO IMPROVE COLORECTAL CANCER (CRC) SCREENING RATES AND DECREASE RACIAL DISPARITIES IN URBAN COMMUNITY AND ACADEMIC PRIMARY CARE PRACTICES Ummesalmah Abdulbaseer1; Divya Venkat1; Ana Maria Davila Morales1; Eleanor Belilos1; Laura J. Zimmermann2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Internal Medicine, Rush University, Chicago, IL. (Control ID #4269119) STATEMENT OF PROBLEM/QUESTION: Despite many modalities available for colorectal cancer, screening rates in two primary care clinics (a community clinic and a resident continuity clinic) remained below HEDIS top decile (69%) in 2023 with significant racial/ethnic demographic variation. DESCRIPTION OF PROGRAM/INTERVENTION: This quality improvement project followed a Plan Do Study Act format and focused on two primary care clinics in a large urban area, a community-based clinic with three attending providers and a resident clinic with 21 attending and 90 resident providers. Clinician pre-surveys were used to understand typical clinic CRC screening discussions and were used with American Cancer Society materials to develop a novel, shared decision-making tool. This tool was used by providers in clinical encounters to review the importance of screening and the types of tests. CRC screening rates were measured throughout the calendar year in both clinics. MEASURES OF SUCCESS: We defined success as overall screening rates at HEDIS top decile (69% in 2024) in each clinic and a reduction of 5% in the largest difference in screening rates between racial/ethnic groups. Data presented are as of 11/30/2024 compared to 11/30/2023. FINDINGS TO DATE: Clinician pre-survey data (N=45, 40% response rate) revealed that the majority discussed CRC screening at follow-up and yearly visits for up to 5 minutes. Over 45% said they ordered colonoscopies, while less than 10% ordered stool testing. Nearly 90% did not use educational tools to discuss screening, though 80% were interested in having one. In 2024, the CRC screening rate in the community clinic was 65.4% compared to 52.3% in 2023. The largest difference in screening rates in the community clinic was 6% (70% vs 64%) between patients who identified as White vs. Black. CRC screening completion rate in the resident clinic was 72.3% compared to 68.2% in 2023. The largest difference in screening rates in the resident clinic was 6% (75% vs. 69%) between patients who identified as White vs. Asian/Pacific Islander. Although 2024 screening rates increased in both clinics, White patients were still more likely to complete screening compared to other racial demographics. The post-intervention survey provided limited feedback due to a low completion rate. Those surveyed reported uncertainty regarding the benefits of the tool, but did utilize more varied screening methods compared to the study's start. KEY LESSONS FOR DISSEMINATION: Shared decision making tools can improve CRC screening rates and reduce demographic screening disparities with continued efforts. Future efforts can also address gender and location based screening discrepancies. Interactive community events promote awareness and familiarity with CRC screening while providing valuable opportunities to gather community feedback for future initiatives. PATIENTS AS INNOVATORS: A MODEL FOR CREATING A PATIENT AND FAMILY-LED TASK FORCE TO STRENGTHEN PATIENT EXPERIENCE IN THE HOSPITAL Maham Awan, Jeannie N. Tran, Martha Ockenfels-Martinez, Molly A. Kantor. Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4270221) STATEMENT OF PROBLEM/QUESTION: Despite evidence that patient engagement in hospital improvement projects strengthens healthcare outcomes, hospitals lack a direct pathway for patients to create and shape hospital improvement initiatives. DESCRIPTION OF PROGRAM/INTERVENTION: We designed a Patient Experience Improvement Task Force comprised of patients, families, physicians, and a project manager to create and implement a patient and family-generated patient experience project. This task force emerged from our institution’s inpatient Patient and Family Advisory Council (PFAC), an existing hospital-based patient advocacy group. Internal medicine hospitalists and a project manager acted as co-facilitators, content experts, and liaisons with hospital stakeholders. The task force met bi-monthly for one year (11/2023-12/2024). The task force reviewed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data, a national, standardized patient experience survey given to patients after hospital discharge, to identify priority areas for patient experience improvement efforts. Members voted on improving the process to gather real-time feedback from hospitalized patients rather than only after discharge (e.g. HCAHPS). The task force's patients and families then developed a survey on how hospitalized patients and family members preferred to provide feedback, which student collaborators administered in person at an academic hospital over a 3-month period. MEASURES OF SUCCESS: Our first measure of success in centering patients/families in the process of improving patient experience was establishing the task force. Engagement was qualitatively measured through participation and attendance in meetings and achieving goals such as project selection. Our second aim was to improve the process for obtaining patient experience feedback from hospitalized patients. Success was measured by survey design completion and obtaining and reviewing data gathered from the survey. FINDINGS TO DATE: 99 patients completed the survey. Patients indicated their strongest preference was to provide feedback through in-person surveys (n=46, 47%), email link to surveys (n=23, 24%), or text links to surveys (n=20, 21%). Patients rated 1) staff attitude, courtesy, and attentiveness, 2) rest/sleep quality, and 3) quality of care/safety as their highest priority topics on which to provide feedback. Poor interprofessional communication between physician teams was a commonly cited area for improvement. KEY LESSONS FOR DISSEMINATION: Actively engaging patients and families in patient experience projects redefines their role from passive consultants to central contributors and project co-creators. A patient and family-led task force, supported by providers, addresses the lack of opportunities for patients to shape and lead projects that affect their care. Our patient experience survey results indicate the majority of hospitalized patients prefer providing feedback to in-person survey administrators over other methods. Future efforts to improve inpatient experience should focus on this tactic to solicit patient feedback. SOME OF US DO THIS A LOT: USING EHR DOCUMENTATION ABOUT LANGUAGE ACCESS TO INFORM THE DEVELOPMENT OF A QUALIFIED MULTILINGUAL ASSESSMENT PROGRAM Leonor Fernandez. Medicine, Beth Israel Deaconess Medical Center, Waban, MA. (Control ID #4271900) STATEMENT OF PROBLEM/QUESTION: Patients in the United States whose preferred language is not English (NELP) experience experience less access to meaningful communication during health care encounters broadly, including office visits and hospitalizations. The absence of language access has been shown to result in worse understanding of illnes, worse adherence and chronic disease outcomes, and increased readmissions. Until recently, it has been challenging to track exactly how often patients receive appropriate language access. Health systems often lack limited systematic data about how frequently multi-lingual clinicians use their non-English language skills to communicate with patients. In order to plan a new health system initiative on qualified multilingual assessment, we sought to understand NELP language access in our system, and more specifically, to understand how often clinicians used their self-reported advanced proficiency skills to communicate with outpatients during office visits. DESCRIPTION OF PROGRAM/INTERVENTION: We developed a forced function in EPIC ambulatory visits that requires documentation of how language needs were met for any patient with Non-English Language Preference. We were subsequently able to evaluate how often NELP ambulatory visits communications were interpreted, not interpreted, or occurred with a language-concordant physician (who attested within visit documentation to advanced language proficiency or qualified bilingual status.) MEASURES OF SUCCESS: We will use the data obtained to advocate for and inform our need to develop a program to improve language access, and to initiate and support the policy of offering physicians the opportunity to take a qualifying multilingual assessment. We expect to increase the number of clinicians who have qualified bilingual status, and reduce the rates of non-interpreted visits by having access to these powerful data. We will also survey physicians to understand their attitudes towards and experience of taking a language exam, specifically exploring the experience of being someone who uses their language skills often. FINDINGS TO DATE: Our results in 2 month sample period (23,364 office visits) revealed that 18.5% of NELP patients office visits with physicians were described as language concordant, 42.3% were interpreted, 39% not interpreted, 17.6% were language concordant (per attestation), and 1% reported Qualified Bilingual Staff status. Analysis of the frequency of language concordant office visits by physician revealed that they were highly concentrated among 100 physicians. KEY LESSONS FOR DISSEMINATION: Data about documentation improves the ability to advocate for improved language access, improved access to interpretation, desire to reduce barriers to interpretation, and understanding more about which physicians do the bulk of language-concordant interactions in a health system. It also informs the thoughtful creation of a QBS program. Innovation in Healthcare Delivery (IHD) - Hospital Medicine ADDRESSING UNSAFE INPATIENT BEHAVIOR AND WORKPLACE VIOLENCE: ADMINISTRATIVE DISCHARGE AS A LAST RESORT Kellie Littlefield1; Michael J. Hendricks2. 1Medicine, Oregon Health & Science University, Portland, OR; 2Hospital Medicine, Oregon Health & Science University, Portland, OR. (Control ID #4242296) STATEMENT OF PROBLEM/QUESTION: United States Bureau of Labor statistics demonstrate disproportionately higher rates of violence towards healthcare staff than workers in other industries, with healthcare accounting for 73 percent of all nonfatal workplace injuries and illnesses due to violence in 2018; this leads to significant physical and psychological consequences for healthcare staff including injuries, post-traumatic stress, depression, burnout, increased absenteeism, and higher rates of job turnover. DESCRIPTION OF PROGRAM/INTERVENTION: Our institution's policy to respond to disruptive behavior in hospitalized patients historically has included guidance for treating underlying medical conditions (eg pain, withdrawal, delirium, etc), addressing psychiatric overlay, behavioral code responses, and reiterating behavioral expectations. However, unsafe behavior may persist, compromising the hospital working and healing environment. Our team quickly learned that interventions to mitigate purely maladaptive coping behaviors were often unsuccessful when no repercussions existed, which in turn greatly imperiled staff safety and wellness. We developed a systematic multidisciplinary approach to addressing unsafe inpatient behavior, unifying prior siloed policies into one comprehensive approach, ultimately ending in administrative discharge from the hospital if patient medical stability allows and a pattern of unsafe behavior continues despite attempts to re-engage the patient. Our workflow prioritizes clearly defined multidisciplinary roles, robust documentation, and escalation through nursing leadership for final decision making. MEASURES OF SUCCESS: Patient safety Appropriate patient selection, scheduled follow up, second line treatments prescribed Staff safety and satisfaction FINDINGS TO DATE: Our institution performed 5 administrative discharges from our facility during the 2023 calendar year. All cases qualitatively reviewed. Overwhelmingly, these patients returned for care at our facility with future improved engagement, underscoring this policy’s success at boundary-setting while not deterring patients from seeking subsequent care. Staff surveys also demonstrated significantly improved satisfaction, safety, and sense of workplace support. KEY LESSONS FOR DISSEMINATION: 1) Workplace violence is prevalent in healthcare settings and can lead to negative consequences for both healthcare workers and consumers. 2) While healthcare teams do our best to mitigate the risk of violence, utilize de-escalation tools, and re-engage patients in their care, administrative discharge can be employed as a last resort for patients who continue to behave in disruptive ways. 3) Involving hospital leadership in the escalation pathway for unsafe behavioral scenarios is an essential element to a successful administrative discharge policy; this permits bedside staff to maintain therapeutic relationships with patients. 4) It is possible to enact an administrative discharge policy safely and such that the patient feels comfortable returning for future care and care teams feel supported in unsafe care situations. EXPERIENCE USING TEXT MESSAGES TO INVITE PATIENT REPRESENTATIVES TO JOIN INPATIENT CLINICAL ROUNDS AT A LARGE NEW ENGLAND ACADEMIC CENTER. Praveen N. Meka2,1. 1Medical Oncology, Harvard University, Cambridge, MA; 2Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4270424) STATEMENT OF PROBLEM/QUESTION: Families and patient representatives often wish to be part of care of their loved ones when admitted to the hospital. However, in the inpatient setting, patients are often alone during morning rounds, and this can lead to feelings of isolation and disconnection. We, at a large New England Academic Center, decided to start an initiative to address the problem using automated text messages (SMS). DESCRIPTION OF PROGRAM/INTERVENTION: Patient-centered care has become a cornerstone of modern healthcare. Our idea was born out of the frequent requests from families to be part of the rounding process. We designed a study to evaluate the effectiveness of automated text messaging in facilitating family participation in morning rounds. Pilot included an advance appointment time conveyed via SMS would allow family representative to be available for the rounds via phone or video. We tested the IRB approved program successfully. The workflow involved families signing up using a digital form, followed by backend coordination between the PI and care team to find a suitable time slot for daily rounds. After enrollment, daily reminders were sent - email to care team with a click-to-call link and SMS to families informing of the daily round times. MEASURES OF SUCCESS: The program was well received by patients/ families. In the initial validation study, 17 consented and enrolled leading to 61 encounters (3.6/ patient). * 66% (40/61) of encounters, the enrollees confirmed availability by replying to SMS. * 93% (37/40) of confirmed, conferenced in. Testimonial: I am a mother, daughter and a nurse and get frequent calls throughout the day. Getting calls once a day helps with planning and being available FINDINGS TO DATE: After testing, we piloted in varied settings: 1. Adult Oncology Ward- The pilot enrolled 32 patients over a year, resulting in approximately 130 total encounters. The initiative was well-received, with families expressing ‘gratitude for the support’ and ‘appreciation’ for the daily calls. 2. Pediatric Ward- On the inpatient pediatric service at Boston Children’s Hospital, our team piloted the text message study. We designed a 1-week pilot in May 2023. 7 patients enrolled, leading to 33 total encounters. The pilot was well received. To be scalable and successful, reducing administrative burden for the care team is crucial. 2. Patient Family Relations (PFR): During 2-month pilot program in mid 2023, families who reached out to PFR complaining about the lack of communication were offered this pilot. 4 enrolled leading to 15 clinical encounters. While the pilot had its upsides as being well received by patient/ family, concerns were of not using it as a "one-size-fits-all". KEY LESSONS FOR DISSEMINATION: By bringing patient-centered care to inpatient rounds, healthcare providers can improve communication and enhance the overall perception of care. One issue is its administrative burden on inpatient providers. However, by automating most of the workflow and with only 1-2 patients signing up per week, the added workload is low, making it adoptable for busy hospitalist teams. SUPPORTING THE BACKBONE OF HOSPITAL MEDICINE: THE EFFECT ON MULTIDISCIPLINARY ROUNDS AND GEOLOCATION ON NURSES Joshua Tsai2; Jacob Jernigan2; Chidozie Igbonagwam2; Anas Bizanti1. 1Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL; 2GME Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4273428) STATEMENT OF PROBLEM/QUESTION: To assess the impact geolocating patient and multidisciplinary rounding has on the nursing staff. DESCRIPTION OF PROGRAM/INTERVENTION: A keystone species is an organism essential in maintaining the stability of an ecosystem. Similar to how wolves help maintain the integrity of forests in the continental United States, nurses play a pivotal role in balancing the logistics of inpatient medicine. Healthcare providers from various departments constantly depend on bedside nurses to communicate essential information to patients, their families, and other healthcare providers. Recently, one of the nation's busiest hospitals transitioned from a non-academic institution to a prestigious renowned teaching facility. As part of this transformation, a geolocation-based system was introduced to assign patients within specific hospital units. This system, integrated with multidisciplinary rounds led by a Graduate Medical Education (GME) residency team, aimed to enhance communication, streamline care coordination, and improve hospital metrics. However, the impact of this innovative system on nursing staff, a cornerstone of inpatient care, remained unexplored. MEASURES OF SUCCESS: To evaluate the system's effects on nursing staff, an eight-item questionnaire was administered to day-shift nurses in units where the GME system was most prominent. These nurses managed both GME and non-GME patients, offering a unique perspective on the system's comparative impact. The questionnaire assessed factors such as the responsiveness of GME versus non-GME providers, the effect of multidisciplinary rounds on nurse’s knowledge of patients, comfort with providers, and their understanding of care plans. FINDINGS TO DATE: Preliminary findings revealed a quicker response time to nurse pages when comparing GME providers to non-GME providers. On a scale from one to five, with one being slower and five being quicker, 87.9 percent of nurses noted a quicker response time with GME providers. Collectively, 90.9 percent of nurses sampled agreed they were more comfortable conversing with the GME provider. General medical knowledge and understanding of the treatment plan were also reported to be increased. KEY LESSONS FOR DISSEMINATION: These initial findings suggest that the GME-led multidisciplinary system within geolocated floors not only benefits providers and hospital operations but also positively impacts nursing staff. The observed improvements in responsiveness, communication, and care plan comprehension emphasizes the potential for this system to foster a more cohesive and effective inpatient environment. With the influx of positive feedback from the nursing staff, we anticipate an increase in responses, which will help to further validate our preliminary findings. Just as environmentalists prioritize the preservation of keystone species to sustain ecosystems, healthcare providers and hospital administrators should recognize the impact of quality improvement interventions on nurses—the backbone of hospital medicine. USE OF MULTIDISCIPLINARY HUDDLE TO IMPROVE DISCHARGES FOR LONG STAY INPATIENTS Jennifer B. Cowart, Jamie Johnson, Michael Evans, Ricky Buckshaw. Hospital Internal Medicine, Mayo Foundation for Medical Education and Research, Jacksonville, FL. (Control ID #4247586) STATEMENT OF PROBLEM/QUESTION: Inatients with the longest lengths of stay (LOS) often have complex combinations of clinical, financial, and psychosocial needs that benefit from multidisciplinary, internist-led huddles to facilitate safe, effective discharge. DESCRIPTION OF PROGRAM/INTERVENTION: Inpatient teams are coordinating care for increasingly sicker patient populations with complex psychosocial situations, which creates many barriers to transition of care from hospital to community. At our hospital, we identified a need for multidisciplinary, longitudinal collaboration for the highest LOS patients to improve effective discharge. Currently, the “Long LOS” (LLOS) huddle meets virtually once per week for half an hour and reviews the top 10 longest-stay patients currently in the hospital (excluding active transplant patients). This project began in 2023 at a single-site tertiary academic medical center in the SE US as a collaboration between hospitalists, case management team leaders, nursing and hospital administrators. Over time the team has expanded to include members from registration and billing, utilization reviewers, and PM&R. MEASURES OF SUCCESS: Quantitative measures of success will include improvement in hospital mean LOS as well as long-stay cohort LOS. Additional measures include referrals made including financial applications and ancillary consultations. Qualitative measures of success will include staff satisfaction with huddle process, creation of workflows such as care conference templates and discharge refusal guidelines, and creation of administrative pathways for charitable approvals. FINDINGS TO DATE: Comparing 2023 to 2024YTD, hospital mean LOS decreased from 5.84 to 5.04 despite an increase in case mix index acuity level from 2.05 to 2.18. The team reviewed a sample of 6 representative cases from 2024. The mean LOS for this cohort was 75.8 days (longest stay 309 days). Common barriers to discharge included: lack of insurance or finances, lack of family support, catastrophic change of health, family disagreement with care plan, out of state, and need for legal involvement. Interventions taken by the team included recommendations (care conferences, palliative care and PM&R consultation), insurance referrals (Affordable Care Act Exchange plan, Medicaid application), administrative approval for charity care, community resource referrals, guardianship application, and discharge refusal guideline creation. KEY LESSONS FOR DISSEMINATION: 1. LLOS patients often are pushed to the bottom of discharge planning lists. Having dedicated case managers in charge of overseeing the LLOS patients is crucial to keep moving forward. 2. Internist engagement with case management leadership has allowed for greater interpretation between care teams when communication breaks down. Hospitalists on the team have functioned in a medical director role and add clinical insight into complex cases. 3. In a state that has not expanded Medicaid, referring uninsured patients to ACA Exchange plans has had some success for those who qualify for subsidies. Innovation in Healthcare Delivery (IHD) - Medical Education and Training A STUDENT-DRIVEN VIRTUAL INTERPROFESSIONAL COLLABORATION TO IMPROVE CLIENT HEALTH AND WELL-BEING IN UNDERSERVED POPULATIONS Puja Gandhi1; Tiffany Champagne-Langabeer2; Padmavathy Ramaswamy3; Rachel Jantea4; Elda G. Ramirez3; Erica Brothers1; Jennifer Swails5. 1Internal Medicine, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 2The University of Texas Health Science Center at Houston, Houston, TX; 3The University of Texas Health Science Center at Houston Cizik School of Nursing, Houston, TX; 4Department of Geriatrics, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 5Department of Internal Medicine, Emory University, Atlanta, GA. (Control ID #4270559) STATEMENT OF PROBLEM/QUESTION: Does implementation of a student-led interprofessional (IP) telehealth program in underserved populations result in improved client outcomes? DESCRIPTION OF PROGRAM/INTERVENTION: Health equity is crucial in underserved communities, where language barriers and limited healthcare infrastructure contribute to poorer health outcomes. Telehealth has emerged as an effective solution to provide remote care and increase client engagement and satisfaction. Additionally, Interprofessional (IP) care is a critical collaborative effort needed to promote holistic patient-centered care. To better serve our vulnerable Texas and border population and train health profession students for team-based care, our academic institution created a community-based telehealth IP care experience. The ICARE (Improving Care Access and Realizing Equity) program, launched in 2022, is a recurring 7-week IP telehealth program designed to address health disparities in underserved communities. Health profession students (medical, nursing, dental, public health, social work, nutrition) collaborate through Zoom using medical interpreters to provide individualized client education and resources on chronic disease, nutrition, geriatrics, dental, and mental health. MEASURES OF SUCCESS: Clients completed a 9-question satisfaction survey at program completion. Students completed the Interprofessional Collaborative Competency Attainment Survey (ICCAS) pre-post participation and gave qualitative feedback. FINDINGS TO DATE: 175 clients participated, and 101 clients (58%) completed the survey. Clients were between 20-80 years old, 85% female, 50% spanish-speaking, and lived in parts of Texas including the Rio Grande Valley. Client topics included physical activity (63%), healthy eating (59%), mental health (59%), stress reduction techniques (47%), and dental health (39%). 40% of clients had concerns surrounding specific chronic diseases and weight loss. 98% of clients were satisfied with the services, and 93% would recommend the program to others. 98% of clients agreed that students listened to their concerns and felt they gained skills to improve their health. 82% of clients wanted more sessions. Although 45% of clients encountered technological issues, 95% found the technology easy to use and 86% used the technology without help. Of 398 student post-activity ICCAS responses, 80% agreed that they included the client/family in decision-making, and 85% agreed that they were able to collaborate with IP team members to create effective care plans. KEY LESSONS FOR DISSEMINATION: Telehealth can bridge gaps in healthcare equity and engage underserved communities. Leveraging innovative approaches in health professions training can mutually benefit underserved communities and prepare students for IP collaborative care. Utilizing medical interpreters and multi-language client education resources can improve access and communication for underserved communities and model culturally competent care for students. STUDENTS OFFERING OPTIMISM TO HELP: A MEDICAL STUDENT INITIATIVE TO IMPROVE THE PATIENT EXPERIENCE Lauren Russell, Shreya Sriram, Keon Niknejad, William ElNemer, Christine Gourin, C. Patrick Carroll. The Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #4271696) STATEMENT OF PROBLEM/QUESTION: Can medical student companionship alleviate suffering and support recovery in hospitalized patients experiencing loneliness and distress? DESCRIPTION OF PROGRAM/INTERVENTION: Students Offering Optimism To Help (SOOTHE) was founded by medical students at an academic medical center and partners with inpatient internal medicine, neurology, psychiatry, and surgical units to provide patient companionship from trained medical student volunteers. Medical staff identify inpatients daily who would benefit from interaction and share this information with SOOTHE volunteers. Volunteers visit these patients and ask if they are interested in a session. If patients opt in, volunteers utilize various comforting techniques, including conversation, games, or silent companionship, based on patient interests and needs. MEASURES OF SUCCESS: After each session, volunteers complete an exit evaluation containing free text and Likert scale questions, providing qualitative and quantitative measurements of SOOTHE’s success. Qualitatively, volunteers submit patient quotes and personal reflections. Quantitatively, our exit evaluation tracks the proportion of successful patient visits (vs. patients denying a visit) and students’ comfort, rated 1 to 5 out of 5, with patients over time. Thus, the exit evaluation can be used to track SOOTHE’s growth on both member and organizational levels. We also organize monthly meetings with nursing colleagues and distribute a nurse feedback form. FINDINGS TO DATE: We have recorded 424 shifts from 11/2023-12/2024, with ~75% resulting in successful patient visits, for a total of 305 patients completing a visit with a SOOTHE volunteer. Feedback has been unanimously positive, with 95% of shifts receiving a 4/5 or 5/5 volunteer rating. Patients have reflected on SOOTHE as the “highlight of their week”, a “great opportunity for both patients to have company and students to learn about the patient experience,” and “the human connection they really needed today.” Volunteers learned to demonstrate empathy and selflessness, such as communicating via whiteboard with non-verbal patients and learning to silently sit with a patient with a terminal diagnosis. Nurses have reported immense patient gratification with the majority of patients requesting more visits, asking to write thank you cards, and expressing improved mood after a visit. KEY LESSONS FOR DISSEMINATION: SOOTHE is an invaluable resource for inpatients who are prone to feelings of isolation and loneliness, as well as those admitted for high-morbidity conditions with long hospitalizations. Academic medical centers have a plethora of passionate students, and physicians should encourage the involvement of students in patient care through organizations like SOOTHE. Medical students should feel empowered to utilize their enthusiasm and compassion to fulfill an impactful role in the wellbeing of patients. Innovation in Healthcare Delivery (IHD) - Mental/Behavioral Health and Substance Use Disorders EVALUATION OF AN INTERDISCIPLINARY PAIN TEAM ADDRESSING COMPLEX OPIOID DEPENDENCE WITHIN A PRIMARY CARE CLINIC Stacy T. Charat1,2; Ashley Emami3; Serena Cheng4. 1Medicine, University of California San Diego, Rancho Santa Fe, CA; 2Primary Care, VA San Diego Healthcare System, San Diego, CA; 3VA San Diego Healthcare System, San Diego, CA; 4Pharmacy, VA San Diego Healthcare System, San Diego, CA. (Control ID #4272568) STATEMENT OF PROBLEM/QUESTION: It is challenging to find the appropriate clinical context to provide comprehensive pain management services for patients on prescribed opioids who have opioid use disorder (OUD) or complex persistent opioid dependence (CPOD). DESCRIPTION OF PROGRAM/INTERVENTION: Addiction services at our VA facility frequently received consults for patients taking prescribed opioids for pain who demonstrated aberrant behaviors or were taking escalating doses without functional benefit. Most of these patients did not meet criteria for OUD, and were referred back to primary care. Patients with OUD and chronic pain were also unable to access comprehensive pain management in addiction treatment clinic. We describe an interdisciplinary referral clinic for patients with chronic pain and comorbid OUD or CPOD embedded within a VA primary care clinic. This clinic was established to address the needs of patients with chronic pain on prescribed opioids with OUD or CPOD who would benefit from multi-modal pain management. Patients are evaluated in a joint visit with a primary care internist with expertise in addiction medicine and pain, a pain psychologist, and a pain clinical pharmacist. The clinic optimizes non-opioid medications, facilitates non-pharmacologic treatments, and transitions patients from full agonist opioids to buprenorphine when indicted. The team developed three low-dose initiation protocols for use depending on the starting MEDD of the full agonist opioid (> or ≤ 150 MEDD) and whether the patient has OUD. Patients are transitioned back to primary care providers with a stable pain management treatment plan. MEASURES OF SUCCESS: The metrics collected include the number of patient referrals, the number of accepted referrals who established care, the source of referrals, patients who transitioned from a full agonist-opioid to buprenorphine, patients who tapered off of all opioids, patients who were provided with naloxone when indicated, and patients who were successfully transferred back to primary care with a stable pain management plan. FINDINGS TO DATE: Data was collected between 7/2021 and 11/2024. Full data analysis is ongoing for the above metrics. Preliminary review demonstrates that the clinic received 214 referrals during the period of study, with 201 unique patients. 70% of consults were accepted as appropriate and 81% of accepted consults lead to the patient establishing care. KEY LESSONS FOR DISSEMINATION: Patients with chronic pain and OUD or CPOD can be treated in the primary care setting by an interdisciplinary team transition to safer opioids, provide overdose education and naloxone, and promote engagement in non-pharmacologic therapies. The off-label use of a low dose crossover initiation of buprenorphine-naloxone for pain is a safe and effective tool without the need for a period of abstinence that many patients with chronic pain are unable to tolerate. After a period of treatment with an interdisciplinary team, patients can be safely discharged back to primary care providers for ongoing management. SUBSTANCE USE DISORDER SCREENING WORKFLOW IN AN ACADEMIC PRIMARY CARE CLINIC: QUALITY IMPROVEMENT METHODOLOGY TO ENHANCE ANNUAL SCREENING Mollie Reese1; Nicole Laro1; Madison Dunk2; Kayla D. Feagins1; Christine D. Gladman1; Helen C. West2. 1Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; 2Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC. (Control ID #4272104) STATEMENT OF PROBLEM/QUESTION: Morbidity and mortality from substance use disorder (SUD) remains high. While the removal of the buprenorphine X-waiver and expansion of Medicaid have resulted in increased opportunities for SUD treatment, low screening rates in our academic internal medicine clinic impede patient identification and treatment linkage. DESCRIPTION OF PROGRAM/INTERVENTION: Consequences of SUD include fatal overdose, drug toxicities, infections, and substantial economic costs.1,2. In 2020, over 40 million people had a SUD, with many cases undiagnosed3. The drug overdose epidemic underscores the critical need to identify and treat SUD. Our clinic has developed an embedded medications for opioid use disorder (MOUD) treatment program with strong addiction medicine referral relationships. Our healthcare system is investing in programs to expand access to SUD treatment in the primary care setting and is developing electronic health record (EHR)-based algorithms to standardize treatment protocols. A key early part of this work is to increase screening of our population. This quality improvement initiative aims to increase rates of equitable SUD screening by 10% in an academic internal medicine clinic. Interventions of this study include assessing qualitative data regarding barriers to SUD screening and standardizing workflow processes to increase SUD screening. MEASURES OF SUCCESS: Clinic staff provided qualitative feedback on barriers to screening. Plan-Do-Study-Act (PDSA) cycles were implemented to address barriers, including creating and implementing a workflow for SUD screening in clinic. Following each PDSA, quantitative evaluations analyzed the percentage of SUD screening via manual chart review. We utilized the EHR to track changes in screening rates over time. FINDINGS TO DATE: Among 13,617 patients, the pre-intervention screening rate was 25% in May 2024. After multiple PDSA cycles, the rate of SUD screening increased to 42% by December 2024. Screening rates were comparable between races: White (40%), Black/African American (44%), Asian (39%), American Indian (43%), and Pacific Islander (28%). Additionally, screening rates were similar between male (42.1%) and female (41.6%) patients and between different age groups. KEY LESSONS FOR DISSEMINATION: This study demonstrates that implementation of standardized workflow processes are effective in increasing the rate of SUD screening. With minimal resources, a large patient population can be effectively screened for SUD and ultimately offered the appropriate treatment and resources. Future directions include implementing processes aimed at universal screening in new patients, evaluating the number of individuals with positive SUD screening, assessing the number of patients formally diagnosed with SUD that are connected to treatment with a focus on treatment equity. Innovation in Healthcare Delivery (IHD) - Quality Improvement and Patient Safety #MEDCAREPLAN: A STANDARDIZED DIGITAL SOLUTION TO STRENGTHEN PHYSICIAN-NURSE COMMUNICATION AMONG RESIDENT TEACHING TEAMS Arvind Suresh, Kathryn Benson, Justin Zhang, Karishma Patel, Lillian Peng, Tamara Sanchez-Ortiz, Sangeeta Prabhakar Bhat, Esther Y. Hsiang, Sarah J. Flynn, Maham Awan. Deaprtment of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4273366) STATEMENT OF PROBLEM/QUESTION: Can implementing a standardized electronic paging method for care plan updates improve physician-nurse communication among internal medicine resident teaching teams? DESCRIPTION OF PROGRAM/INTERVENTION: Ineffective physician-nurse communication has been associated with medical errors, prolonged patient hospital stays, and lower job satisfaction. We surveyed resident physicians and medicine unit nurses at our large, urban academic medical center and identified deficits in communicating patient daily care plan updates. In response, we developed and promoted a standardized, resident-led care plan communication strategy for our inpatient general medicine teaching service. Residents were encouraged to send daily care plan messages to bedside nurses using a web-based paging system (CareWeb). Pages included the hashtag (#MedCarePlan) to signal the standardized update and facilitate data extraction. Once paged, nurses replied directly to the page to facilitate bidirectional input to the care plan. We implemented several countermeasures to increase utilization of this communication strategy, including posting flyers in work rooms, providing verbal reminders at educational conferences and signouts, and incentivizing participation with monetary prizes. MEASURES OF SUCCESS: Our primary outcome measure is the number of standardized pages sent (including #MedCarePlan) as a proportion of the daily patient census on medicine teaching teams between October 2024 and May 2025. Secondary outcome measures include resident self-reported frequency of updating nurses, nurse satisfaction with resident communication, and percentage of care plan pages sent before 2PM as a measure of timeliness. FINDINGS TO DATE: Based on a pre-intervention survey of 74 internal medicine residents and 51 nurses, on average, residents reported providing daily care plan updates to nurses 56% of the time and nurses reported receiving care plan updates 43% of the time. However, there was significant variation in these reports; 24% of nurses reported receiving updates only 0-10% of the time. Both residents and nurses most preferred a text-based app as the primary method of communication (35% and 37%, respectively). In the first month following the program launch, nurses received daily care plan pages for 6% of patients. Following implementation of countermeasures such as multimodal reminders and gamification, this increased to 24% of patients in November 2024. To date, 802 care plan pages have been sent with #MedCarePlan. KEY LESSONS FOR DISSEMINATION: Based on our pre-surveys, there is a need for improved communication between nurses and medicine residents particularly around daily care plan updates. Our standardized electronic paging intervention to provide these updates is a feasible and measurable method to improve communication. AORTA GET A TRIPLE A SCREENING: EHR INTEGRATION OF HEALTHCARE MAINTENANCE REMINDERS Nusrat Jahan1; THALIA LITO1; Adam Szerencsy2. 1Internal Medicine, NYU Langone Hospital Brooklyn, New York, NY; 2Ambulatory Informatics, NYU Langone Health, New York, NY. (Control ID #4230700) STATEMENT OF PROBLEM/QUESTION: Lack of systematic integration of health care maintenance (HCM) reminders within the electronic health record (EHR) has led to missed opportunities for abdominal aortic aneurysm (AAA) screening DESCRIPTION OF PROGRAM/INTERVENTION: In an urban community health center network serving a diverse, underserved population, many eligible patients are not receiving recommended abdominal aortic aneurysm (AAA) screening when indicated during their primary care visits. Preventive care, such as AAA screening, is often overlooked due to competing priorities in a busy primary care visit. Other best practice advisories exist within the electronic health record (EHR) to remind providers to order preventative and screening tests when indicated. An intervention using EHR alerts and provider education aims to improve screening rates and align care with evidence-based guidelines. MEASURES OF SUCCESS: Quantitative: Screening Rates: Compare the number of screening orders of eligible patients before and after the health care maintenance reminder went live. Qualitative: Provider Feedback: Gather insights from primary care providers who have encountered the HCM in their clinic sessions on the effectiveness of the reminder. FINDINGS TO DATE: Data from Epic (Jan 2013–Dec 2024) were analyzed for patients meeting AAA screening criteria (male, 65-75, smoker) with an order status of ordered or not ordered. To account for competing priorities, data was limited to patients with at least 2 primary care visits in 18 months. After the October 9, 2024 EHR reminder launch, screening orders increased significantly, from 17 total orders in September 2024 to 163 in October 2024 (959%). This spike, along with a 229% increase in average October orders over 7 years compared to other months, demonstrates that EHR alerts improve screening rates, aligning care with evidence-based guidelines. Among polled residents and attendings who saw the reminder in clinic, 80% thought the reminder helped them remember to address the topic (n=20), further supporting EHR reminders contributing to reducing physician cognitive load. KEY LESSONS FOR DISSEMINATION: EHR Integration Drives Preventive Care: Incorporating health care maintenance (HCM) reminders into the EHR can improve adherence to screening guidelines by providing timely prompts to providers during visits. Efficiency and Workflow Optimization: Automated reminders reduce the burden on providers to manually track preventive care, ensuring critical interventions like AAA screening are not overlooked during busy outpatient visits. Patient Outcomes Improve with Systematic Approaches: Streamlining preventive care through EHR tools helps identify at-risk populations early, leading to timely screenings and better outcomes. Provider Engagement is Critical: Educating providers ensures they understand the value of reminders, increasing their likelihood of acting on them. Scalability and Adaptability: Success with AAA screening shows that similar interventions can apply to other preventive care measures, enhancing quality and outcomes across practices and communities. A PHARMACIST-DRIVEN PROGRAM TO REDUCE CHRONIC OBSTRUCTIVE PULMONARY DISEASE READMISSIONS AT AN URBAN SAFETY NET ACADEMIC MEDICAL CENTER Robert Fain1; Ana Sofia Warner1; Hector A. Marquez3; Soo Jin Koo4; Brian Kopcza4; Chuman Xie4; Jerry Sobieraj5; Lucy Schulson1,2. 1Internal Medicine, Boston Medical Center, Boston, MA; 2Health Care, RAND Corp Boston office, Boston, MA; 3Pulmonology, Boston Medical Center, Boston, MA; 4Pharmacy, Boston Medical Center, Boston, MA; 5Clinical Research Informatics, Boston Medical Center, Boston, MA. (Control ID #4232726) STATEMENT OF PROBLEM/QUESTION: Healthcare organizations (HCOs) have sought to reduce chronic obstructive pulmonary disease (COPD) readmissions, which negatively affect patients’ quality of life and confer high costs to health systems. DESCRIPTION OF PROGRAM/INTERVENTION: This innovation took place at a large, urban academic safety-net hospital. In 2022, the Medicare 30-day COPD readmission rate among patients at the HCO was 25.8% (vs 19.8%, i.e., Medicare national benchmark). To reduce readmissions, we launched a pharmacist-driven COPD program in September 2023, based on an existing evidence-based model. Eligible patients are enrolled through one of three avenues: when hospitalized for COPD with a prior COPD diagnosis, identified as high risk for COPD hospitalization based on prior healthcare utilization and ≤ 60% proportion of days covered (PDC) of COPD medications, or referred by their pulmonologist. For inpatients, the pharmacist meets them in person, provides inhaler teaching, and arranges for follow-up within 14 days of discharge. Patients identified through the other means are contacted via telephone and scheduled for a pharmacy visit. At each visit, the pharmacist administers a validated COPD symptom questionnaire, assesses for medication adherence and appropriate inhaler use, and titrates COPD medications through a prescriber agreement with a pulmonologist. MEASURES OF SUCCESS: The primary measure is 30-day COPD hospital readmissions, with the goal of decreasing COPD readmissions by 15-20%. We also measured how many patients had timely follow-up with pharmacists and pulmonologists. In addition, we are tracking changes in patient-reported symptom scores and changes in PDC. FINDINGS TO DATE: As of December 2024, 176 patients have enrolled in the program. Of those, 109 are actively engaged with a pharmacist, 13 completed the program (i.e., one year of follow-up), 13 died, and 41 disenrolled or were unable to be reached. Of the 100 patients enrolled during an inpatient admission, 25% were seen within 14 days of hospital discharge, and 52% were seen within 30 days of hospital discharge; 89.4% completed a follow-up appointment with a pharmacist. The 30-day COPD readmission rate from September 2023 through October 2024 was 16.7% for patients who were enrolled in the program and engaged with the pharmacist, vs 23.2% for all other patients with a discharge diagnosis of COPD. KEY LESSONS FOR DISSEMINATION: While patients hospitalized for COPD exacerbations have a high risk of readmission, there are evidence-supported health systems interventions that can be adapted to safety-net setting to improve chronic disease management and reduce patients' risk of readmission. Patients in safety-net settings often face increased social challenges and barriers accessing care. Other healthcare systems with high-need patient populations can similarly develop successful interventions to reduce COPD readmissions. A PRE-IMPLEMENTATION STUDY OF OUT-OF-OFFICE BLOOD PRESSURE COLLECTION AND MANAGEMENT IN THE STANFORD INTERNAL MEDICINE RESIDENT CLINIC David Mui1; Alex M. Burgess2; Anuradha Phadke2. 1Medicine, Stanford Medicine, Stanford, CA; 2Medicine, Stanford University School if Medicine, Palo Alto , CA. (Control ID #4272967) STATEMENT OF PROBLEM/QUESTION: Nearly half of adults in the US have hypertension. Out-of-office blood pressure measurements are essential components to both the diagnosis and management of hypertension. Unfortunately, the acquisition and follow-up of out-of-office blood pressure measurements have remained difficult and inconsistent. Specifically, in the Stanford Internal Medicine East (SIME) Resident's Clinic, only 69% of patients were at goal blood pressures. Our objective was to conduct a pre-implementation assessment of barriers/facilitators to home BP reporting and associated patient/provider experience in an internal medicine trainee continuity clinic. The results of our study will be the foundation for subsequent interventions to improve out-of-office blood pressure collection and management. DESCRIPTION OF PROGRAM/INTERVENTION: Semi-structured 20-minute Interviews and 15-question surveys were conducted with residents, patient-care coordinators (PCCs), patients in the SIME clinic (with hypertension or elevated blood pressures in clinic), and attending physicians in primary care, cardiology, and nephrology at Stanford with hypertension expertise. A total of 29 patients, 18 residents, 3 PCCs and 11 attendings were interviewed and surveyed in two rounds. Researchers transcribed and analyzed text segments in patient and provider interviews through a “grounded theory approach” and “constant comparison method” to develop inductive coding labels.4 Each researcher then went through each other’s text segments and coding labels to negotiate consensus. The final consensus labels were verified by the clinician. MEASURES OF SUCCESS: N/A FINDINGS TO DATE: Five patient phenotypes were identified in the SIME clinic, including 1) Engaged adopters (34%), 2) LEP patients (27%)*, 3) Receptive Non-Adherent Trackers (45%), 4) Access-Restricted Trackers (15%) and 5) Non-adopters (7). Receptive Non-adherent trackers made up the largest majority of the patient phenotypes, with a variey of reasons reported for their receptive but non-adherence including 46% mentioning a lack of discipline, 69% not having a systemic way of tracking their blood pressure and 38% not owning a blood pressure cuff. LEP patients also made up over a quarter of the patient seen, with higher portion of LEP patients reported diffculty communicating with their providers than native English speakers. Given the combined prevalence and magnitude of disparities, these two patient phenotypes will be the initial focus for subsequent interventions. KEY LESSONS FOR DISSEMINATION: This pre-implementation needs assessment has given a deepened understanding of the various different patient phenotypes in the SIME clinic and forms a strong foundation for future, more tailored interventions to improve blood pressure collection and management. We will plan on implementing our initial interventions over the next few weeks/months and will continue to report our data accordingly as we move from pre-implementation to implementation. A QUALITY IMPROVEMENT EFFORT TO ADDRESS PROTON PUMP INHIBITOR (PPI) OVERUSE IN OUTPATIENT RESIDENT CLINICS Mandi Abdel Ahad, Samantha Marazita, Joy Yates, Matthew St Jean. Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4246036) STATEMENT OF PROBLEM/QUESTION: We would like to address the issue of PPI overutilization within our patient panels at our outpatient continuity clinics. DESCRIPTION OF PROGRAM/INTERVENTION: Using the electonic medical record chart review, we identified patients seen by internal medicine residents in our outpatient clinics from July 2023 - September 2023 who had an active PPI prescription and evaluated whether the use of the PPI was addressed during that visit. MEASURES OF SUCCESS: We created a dot phrase to be used within our electronic medical record to help us document and address PPI during our continuity clinics from February, March and April 2024. This dot phrase will be used in the encounter note and after-visit summary, which will include a plan for discontinuation/taper of the PPI if deemed appropriate. FINDINGS TO DATE: Initial reported data from our outpatient continuity includes a total of 589 patients seen over 3 prior clinic weeks (July, Aug, Sep 2023), of which 156 were prescribed a PPI, of which 38 discussions were had regarding the medication’s use. Data from our intervention period has been collected during January, February and March clinic weeks. A total of 321 patients were seen, of this number 59 (5.4%) are on PPIs, of those 59 patients, 27 (45.7%) were engaged in a conversation and the intervention dotphrase was used of which 7 (25.9%) patients were tapered from or had their PPI discontinued. KEY LESSONS FOR DISSEMINATION: Proton Pump Inhibitors (PPIs) are often over prescribed or unnecessarily continued by patients. Much of the time their initial prescription was for a medically necessary reason such as: gastroesophageal reflux disease (GERD), peptic ulcer disease or a gastrointestinal bleed but were never re-evaluated to assess the clinical indication to continue treatment with PPI. Our preliminary data shows that of 27 discussions had, 7 of these patients (25.9%) were determined to not need PPI medications and were started on a taper or discontinued. We are encouraged by this data and anticipate helping more patients discontinue PPIs that are no longer needed or not indicated. We hope to continue to engage in meaningful discussions with our patients during medication reconciliation to practice evidence-based medicine and to reduce healthcare costs. ARE YOU MY PATIENT?: IMPROVING ACCURACY OF PRIMARY CARE PANELS FOR BETTER PATIENT CARE Kira C. Watson1; Chanda Sundara3; Bernadette Kiraly3; Anne Cioletti2; Annie Mervis3. 1General Internal Medicine, University of Utah Health, Salt Lake City, UT; 2Internal Medicine, University of Utah Health, Salt Lake City, UT; 3Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT. (Control ID #4271019) STATEMENT OF PROBLEM/QUESTION: Inaccurate primary care provider (PCP) assignments in the electronic health record (EHR) have been a long-standing barrier to care coordination, population health management, provider panel sizes, and allocation of resources. These factors can contribute to lower quality of care and satisfaction for patients, and higher rates of provider burnout. DESCRIPTION OF PROGRAM/INTERVENTION: There is not a clearly identified process for PCP attribution and maintenance within our system. More accurate PCP attribution will lead to more accurate PCP panels, assist in distribution of resources, and address social drivers of health. The team identified barriers within our current processes and created a comprehensive fish bone diagram to track inaccurate empanelment. Industry best practices were identified from a literature search. The team gained outpatient provider consensus for using a utilization-based model to assign and regularly update PCPs. We distributed a provider survey to evaluate PCP perspectives at baseline as a balancing metric. We plan to implement the new process of utilization-based assignment in Spring 2025. MEASURES OF SUCCESS: We plan to evaluate the concordance in panel size for listed patients in our current model to the proposed utilization-based model. The outcome measures include the agreement rate between Epic PCP and Utilization- based PCPs and the percentage of unattributed primary care patients. We also will conduct a second clinician survey post intervention to evaluate knowledge and concerns about the new process. FINDINGS TO DATE: We identified a disconnect between panel size and listed patients in our current model compared to a proposed utilization-based model. The outcome measures are to increase agreement rate between Epic PCP and Utilization- based PCPs from baseline 64.2% to 75% by April 2025; and decrease the unattributed primary care population from baseline 21.6% to 10% by April 2025. We also found several specialists were named in the PCP field, PCPs were frequently not added, and the process and expectations for PCPs assignment were not transparent, causing frustration for providers. KEY LESSONS FOR DISSEMINATION: With this deceptively simple goal of accurate PCP assignment, we have learned the need to define the process clearly, which specialties may be assigned PCP, when and who may assign PCPs, how to include trainees, and how to balance a mixed clinical role (urgent care plus primary care). By having a balanced team with representatives from different clinical sites and operational roles, we noted the need to regularly review our team to ensure all voices were represented. We recognized the need for clear accountability for regular oversight and monitoring of the PCP assignment process. BREAKING BARRIERS: IMPROVING SMOKING CESSATION ACCESS FOR PEOPLE EXPERIENCING HOMELESSNESS Anshul R. Kamatala1; Itzel Favela Perez1; Kirti Malhotra2; Kate Richards4; Savannah Lukkes3; Jeffrey Wang3; Jeetu Sujith1; Claire Lin1. 1UC Davis, University of California Davis, Davis, CA; 2General Internal Medicine, University of California Davis Medical Center, Sacramento, CA; 3UC Davis School of Medicine, Sacramento, CA; 4Family Medicine, UC Davis Health, Sacramento, CA. (Control ID #4272531) STATEMENT OF PROBLEM/QUESTION: How can smoking cessation programs be tailored to meet the unique needs of unhoused individuals to improve patient engagement and retention? DESCRIPTION OF PROGRAM/INTERVENTION: Smoking disproportionately affects people experiencing homelessness, with prevalence rates of 68-80%. Tobacco use exacerbates chronic illnesses, increases healthcare costs, and widens health inequities. To address this challenge, a community-based smoking cessation (SC) program was launched in 2021 at a free clinic in the Northwest region. The program integrates motivational interviewing (MI) and trauma-informed care to support patients in quitting tobacco use. SC sessions focus on open-ended questions, reflective listening, and affirmations to align with patient values and goals. In 2023, the clinic relocated to a community shelter and expanded outreach efforts, implementing same-day SC appointments to enhance accessibility and improve patient retention. The intervention aims to strengthen clinician-patient interactions and patient participation while addressing social determinants of health through targeted innovations in care delivery. The program's reproducibility is supported by its adaptable workflow and community-centered approach, designed to be implemented in similar free clinics. MEASURES OF SUCCESS: Evaluation data include both qualitative and quantitative metrics. Retrospective chart reviews (June 2021–April 2024) identified patient demographics, smoking behaviors, and engagement rates. Among the 689 patients served by our clinic, 48.8% (336) reported active smoking. Program engagement was assessed by tracking screening metrics, survey completion rates, participation levels, and patients’ progression in smoking cessation sessions. FINDINGS TO DATE: Preliminary results highlight progress in the program’s accessibility and impact. Of the smokers screened, 19.6% expressed interest in quitting or reducing tobacco use. Between June 2021 and May 2023, only 5.9% of smokers completed the SC survey. However, after implementing these interventions and relocating to a shelter in June 2023, survey completion rates increased to 8.4%. KEY LESSONS FOR DISSEMINATION: The SC program offers valuable lessons for reproducibility and scalability. Leveraging MI, trauma-informed care, and peer education creates a patient-centered approach that can be adapted to other free clinics. Workflow adjustments, such as same-day hybrid scheduling and inter-clinic referral systems, can expand patient access to care. By addressing structural barriers and fostering trust through patient-centered care, the program demonstrates how delivery models can catalyze equitable change and reduce tobacco-related health disparities. CATALYZING CHANGE WITH INCENTIVE MODELS: INNOVATIONS IN PRIMARY CARE Maryann Elegonye1; Brian Le2; Nika M. Harutyunyan2. 1Department of Medicine, UCLA Health, Los Angeles, CA; 2Medicine, UCLA Health, Los Angeles, CA. (Control ID #4270219) STATEMENT OF PROBLEM/QUESTION: How can a Primary Care Clinical Excellence Incentive Program improve quality metrics, provider engagement, and patient outcomes while aligning with value-based care principles in academic general internal medicine? DESCRIPTION OF PROGRAM/INTERVENTION: The Primary Care Clinical Excellence (PCCE) Incentive Program rewards primary care providers (PCPs) via quarterly incentive payments for delivering high-quality, and patient-centered care. Focused on Centers for Medicare & Medicaid Services (CMS)-based measures, it emphasizes preventive care, chronic disease management, Hierarchical Condition Category (HCC) coding, and patient experience. Key features include data-driven benchmarks, transparent reporting, quarterly incentives, collaborative goal-setting, supportive resources, and a phased rollout for PCP success. MEASURES OF SUCCESS: The PCCEI Program measures effectiveness across Clinical Quality, Patient Experience, Professional Participation, and Risk Coding. Clinical Quality focuses on metrics like Hgb A1c tests, retinal screenings, BP control (<140/90 mmHg), cancer screening adherence (colorectal, breast, cervical), advance directives for patients 65+, statin therapy (ages 40–75), childhood immunizations, HPV vaccines, flu shots, and developmental screenings. Patient Experience uses CGCAHPS surveys to gauge care quality, communication, and recommendations. Professional Participation tracks engagement in teaching, research, and service. Risk Coding assesses chronic condition documentation accuracy (HCC recapture). This framework is meant to drive improvements in care, patient and provider satisfaction, and clinical outcomes. FINDINGS TO DATE: The PCCEI program was rolled out to approximately 300 PCPs a year since its inception in 2021. In Fiscal Year 2023, participating providers attained an average score of 84% across domains all the domains, which further increased to 91% in Fiscal Year 2024. Clinical Quality metrics, including diabetes and hypertension management, cancer screenings, and advance care planning, surpassed benchmarks, while Patient Experience scores improved significantly, with higher patient satisfaction. Providers also demonstrated increased engagement in academic and quality improvement activities. Progress in the Risk Coding domain included exceeding benchmarks for (HCC) recapture rates, supported by tools like self-run reports to track patient health status. Overall, 80% of providers met or exceeded performance goals, with 44% reporting behavior changes linked to program participation. KEY LESSONS FOR DISSEMINATION: The PCCEI program aligns with (PCPs and institutional goals by emphasizing actionable metrics and promoting transparency through dashboards. It supports provider engagement by offering resources such as clinical decision support, educational materials, and workflow optimizations. Transparent reporting is ensured through the use of report cards, while ongoing program refinement is achieved through surveys that gather feedback, fostering both sustainability and scalability. DOES PROVIDER EDUCATION HOLD THE KEY TO INCREASING ABDOMINAL AORTIC ANEURYSM SCREENING? Martin Emmanuel Garcia1; Martin J. Arron1; Ming Yu2; Fernando C. Carnavali1. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4267058) STATEMENT OF PROBLEM/QUESTION: Does provider education hold the key to increasing abdominal aortic aneurysm screening? DESCRIPTION OF PROGRAM/INTERVENTION: This quality improvement program sought to improve AAA screening rates in four academic primary care offices in the Northeastern region, after preliminary data showed a small fraction of eligible individuals had screening orders. Educating PCPs about the importance of screening and providing data of their low utilization rates was the focus. Formal presentations at practice meetings and discussions with providers were conducted by the divisional leadership of two private, non-for-profit hospitals affiliated with a large academic health system. The intervention began in January 2023. Using EMR-based tools, the following data was obtained regarding patients at the four sites: 1. Male patients between 65-75 years old in 2022 to 2024 (January-September) with a history of current or prior tobacco smoking were identified. To be eligible for inclusion, patients must have had one or more visits with a physician or nurse practitioner in that practice during the index year. 2. Eligible patients who had an AAA screening ultrasound ordered during 2022 to September 2024 or the 4 years prior to each of the index years were captured. Credit for a screening order was given once per patient. Manual chart reviews of all patients with ordered ultrasounds in 2022, 2023 and 2024 were conducted. MEASURES OF SUCCESS: The percentages of patients eligible for screening in 2022, 2023 and 2024 who had a screening ultrasound ordered while between ages of 65-75 years were determined. The screening ultrasound completion rate was calculated. The Mantel-Haenszel Chi-Square and Cochran-Armitage Trend Test were used to determine statistical significance. FINDINGS TO DATE: The number of patients eligible for screening in 2022, 2023 and 2024 were 728, 810 and 829 respectively. AAA screening ultrasound orders were present in 33, 197 and 351 of eligible patients. The percentage of eligible patients with an order increased from 4.5% in 2022 to 24.3% in 2023, to 42.3% in 2024, an absolute increase of 19.8% for the first year and 18% increase in the second year of the intervention. The increase in screening was seen across all practices (p<0.0001 and also in aggregate). Manual chart reviews determined that 42%, 55% and 56% of the ultrasounds ordered in 2022, 2023 and 2024 were performed. A total of 8 abdominal aortic aneurysms and 14 iliac artery aneurysms were found among the eligible patients in 2024, with 4.1% of completed ultrasounds detecting an AAA and 11% detecting any type of aneurysm. KEY LESSONS FOR DISSEMINATION: This quality improvement project shows provider education significantly improves AAA screening, addressing low utilization, and detecting undiagnosed aneurysms. While EMR-based decision support and additional staff can enhance screening, practices without these resources can still improve with education. Medical groups should leverage provider education and not wait for EMR support or additional staff. DYNAMIC EXPANSION OF A TAILORED PATIENT NAVIGATION PROGRAM FOR MULTITARGET STOOL DNA TESTING FOR COLORECTAL CANCER SCREENING Kyle Koster1; Kayla Jaeckel2; Edward Cytryn1; Nikita Barai1,3; Mary Fishman1; Rebecca Wool3; Christina Wang1; Lina Jandorf4; Steven Itzkowitz1. 1Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2Ambulatory Care, The Mount Sinai Hospital, New York, NY; 3Mount Sinai Health Partners, Mount Sinai Health System, New York, NY; 4Population Health Sciences, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272299) STATEMENT OF PROBLEM/QUESTION: Multitarget stool DNA (mt-sDNA) is an increasingly utilized home-based colorectal cancer (CRC) screening test with similar sensitivity for CRC as colonoscopy; however, real-world adherence is suboptimal, despite built-in navigation provided by the manufacturer. DESCRIPTION OF PROGRAM/INTERVENTION: Tailored patient navigation (TPN) is an effective intervention for improving adherence to cancer screening tests, but its role for mt-sDNA is unclear. We recently reported improvement in mt-sDNA adherence after implementation of a local TPN program in an academic internal medicine practice serving a primarily minoritized, majority-Medicaid population in East Harlem (EH), New York City. The extent to which these improvements are replicable in other distinct populations is unknown. Therefore, we expanded the program to a multi-site, community-based practice in Staten Island (SI) with low baseline CRC screening rates serving a commercially and Medicare insured population. To achieve this goal, we optimized outreach touchpoints, integrated digital tools, and formed new relationships with gastroenterology practices to improve care coordination. Based on preliminary results, we further expanded TPN to a primarily commercially insured practice with growing mt-sDNA utilization in the Upper East Side (UES) of Manhattan. MEASURES OF SUCCESS: Our primary outcome was mt-sDNA test completion within 90 days. Secondary analyses compared mt-sDNA completion by sociodemographic factors and insurance. Quality assurance included ensuring patients with positive results were contacted for colonoscopy scheduling; colonoscopy completion was beyond scope of the mt-sDNA program due to pre-existing colonoscopy TPN. Fidelity assessment included periodic monitoring of navigator productivity and workflows. FINDINGS TO DATE: The 90d mt-sDNA completion in the pilot study at EH improved from 39% in the 12 months pre-implementation to 51% in the 12 months post-implementation (p<0.001), and this was sustained after expansion to SI. All positive tests at EH received a referral for colonoscopy with at least one contact attempt. At SI, 90d mt-sDNA completion has improved from 47% in the 12 months pre-implementation to 57% 8 months post-implementation (p<0.001). Data collection is ongoing for SI colonoscopy referrals and UES mt-sDNA completion. No differences were observed at EH on the basis of sociodemographic or insurance factors, and further analysis is planned with incorporation of data from all three practices. KEY LESSONS FOR DISSEMINATION: TPN is an effective intervention for improving adherence to mt-sDNA and ensuring positive results are connected to follow-up colonoscopy. The benefits of TPN for mt-sDNA are replicable in at least one other distinct population, and improvements are sustainable despite fewer navigator touchpoints. Future investigation is required to elucidate reasons for persistent test noncompletion after successful patient contact and to evaluate cost-effectiveness of TPN for mt-sDNA from institutional and population health perspectives. ENCHANCING THE EVALUATION FOR SECONDARY HYPERTENSION IN AN OUTPATIENT SETTING Zaraq Khan, Shane Khullar, Marcos A. Alberto, Vyom Patel, Prakhar Anand, Daniel Roque, Mark Georgy, Shawn Curry. Internal Medicine, Indiana University Southwest Indiana Internal Medicine Residency, Evansville, IN. (Control ID #4273569) STATEMENT OF PROBLEM/QUESTION: Effective and consistent evaluation of secondary hypertension does not occur in the outpatient resident setting when indicated. DESCRIPTION OF PROGRAM/INTERVENTION: The ACC/AHA 2017 guidelines state that in a small population, hypertension is secondary to a corrective cause. If such cause is treated, it may lead to a marked improvement in blood pressure (BP) and thus improve mortality. For this reason, effectively and consistently evaluating for secondary hypertension remains important in recommended populations. Unfortunately, this does not occur consistently within the outpatient setting. Through a set of interventions, we looked to improve the rates of appropriate secondary hypertension workup when clinically indicated. Set in an outpatient residency clinic setting, we centered on improving education and access to resources available within the clinic setting. Visually educational material in the form of posters were created and placed in various accessible places within the clinic. These posters contain flowcharts noting exact indications for when to evaluate a patient for secondary hypertension, and specific investigations to complete as per guidelines. Additionally, small-group seminars were held to educate residents on the diagnosis and management of secondary hypertension. These sessions were interactive, incorporating the posters to improve familiarity with them as available resources. MEASURES OF SUCCESS: We measured quantitative success by assessing for an improvement in the rate of screening for secondary hypertension completed when indicated. Qualitative data was obtained through surveys submitted to both residents and attendings. FINDINGS TO DATE: Response from residents and attendings has been equally positive. Individuals have particularly noted that the posters provide an easy-to-follow resource that can be repeatedly and quickly referenced. They serve as an efficient tool improving workflow. We currently await final quantitative data to note the exact change in appropriate rates of screening of secondary hypertension. KEY LESSONS FOR DISSEMINATION: Integrating visual material into more traditional teaching techniques serves as a fantastic tool in improving guideline-directed management for hypertension. This method allows greater engagement and retention of knowledge among learners, and tools to aid better application of learning when managing conditions. ENHANCING CLINIC REVENUE AND STAFF ENGAGEMENT THROUGH A STAFF-LED REINVESTMENT PROGRAM Emmanuel Oundo, Anthony Alchaer, Reuben L. Odai. Internal Medicine, University of Kansas - Wichita, Wichita, KS. (Control ID #4237451) STATEMENT OF PROBLEM/QUESTION: Burnout among healthcare professionals, exacerbated by top-down Quality Improvement (QI) initiatives, highlights the need for inclusive reinvestment programs like Stanford's, which demonstrate potential for organizational improvement but often exclude non-clinician staff, limiting their overall impact. DESCRIPTION OF PROGRAM/INTERVENTION: This proposal introduces a one-year pilot program allocating up to $5,000 annually from G2211 revenues for initiatives led by non-clinician staff. These may include equipment upgrades, educational opportunities, or patient care enhancements, ensuring compliance with Stark Law. Key performance indicators include well-being and engagement metrics from the 2023 Department of Medicine survey and quarterly financial reports. MEASURES OF SUCCESS: Projected quarterly revenue from G2211 claims was estimated at $9.40 per claim, with an adjusted rate of 0.13 across all clinics. Preliminary well-being survey data show varying levels of staff engagement and burnout across departments. Internal Medicine reported high engagement (76%) and low burnout (6%), surpassing benchmarks and demonstrating potential for further improvement through targeted staff-led initiatives. FINDINGS TO DATE: Analysis of financial data for the first quarter of 2024 reveals that the Internal Medicine Clinic (IMC) billed 1,564 Level 4 claims and 198 G2211 claims, generating an average payment of $9.40 per G2211 claim. Across clinics, the rate of G2211 claims per 99214 claims was 0.36 for the IMC, significantly higher than the all-clinic average of 0.13. To provide a consistent comparison, these numbers have been adjusted by a factor of 0.75 to reflect an approximate calendar quarter of billing activity. IMC reported engagement at 76%, exceeding the benchmark of 75%, while maintaining an exceptionally low burnout rate of 6%, compared to the benchmark of 35%. Additionally, 100% of IMC staff surveyed recommended the organization as a good place to work. Proactivity was also reported at 100%, significantly surpassing the benchmark of 91%. In contrast, the Gastroenterology and Midtown clinics demonstrated lower engagement levels, at 38% and 46%, respectively, and higher burnout rates, particularly in Gastroenterology, where burnout reached 50%. Proactivity in these clinics, while slightly below the benchmark, remained high at 88% in Gastroenterology and 79% in Midtown. A sense of responsibility was highest in IMC at 82%, compared to 62% and 71% in Gastroenterology and Midtown, respectively. KEY LESSONS FOR DISSEMINATION: We underline the strong performance of CHC Internal Medicine in key well-being metrics and suggest opportunities for improvement in other clinics. The financial and survey findings further support the proposed pilot initiative to reinvest revenue from G2211 claims into staff-led quality improvement projects. This program has the potential to enhance engagement, reduce burnout, and promote a sense of ownership across clinics, contributing to improved outcomes for both staff and patients. EVALUATING RESIDENT PHYSICIANS’ PERCEPTIONS OF AND IMPROVING UTILIZATION OF ALCOHOL USE DISORDER PHARMACOTHERAPY: A QUALITY IMPROVEMENT INITIATIVE Alan Abboud1,2; Michael Jorgensen1,2; Ann Mary Hanna1,2; Lisa Fisher2. 1Internal Medicine, Stony Brook Medicine, Stony Brook, NY; 2Internal Medicine, Northport Veteran Affairs Medical Center, Northport, NY. (Control ID #4219994) STATEMENT OF PROBLEM/QUESTION: Despite proven efficacy, medications for alcohol use disorder (MAUD) are under-utilized even in the higher-risk veteran population. DESCRIPTION OF PROGRAM/INTERVENTION: This initiative aimed to assess resident physicians' perceptions, comfort and preparedness for prescribing MAUD; and to evaluate the efficacy of a resident-driven outreach team aimed at prescribing MAUD to qualified veterans. An anonymous pre- and post-intervention survey was distributed via e-mail to 49 Stony Brook internal medicine residents completing their primary care block at the Northport Veterans Affairs Medical Center (VAMC) clinic. An Alcohol Use Disorder Fact Sheet highlighting MAUD decision algorithm was distributed as a form of educational intervention. Veterans with AUD diagnosis based on AUDIT-C scores ≥ 8 were identified using the VA Office of Mental Health and Suicide Prevention (OMHSP) Psychoactive Drug Safety Initiative (PDSI) Dashboard. A three-member resident outreach team called veterans to perform brief intervention and/or prescribe MAUD. MEASURES OF SUCCESS: Success was measured through pre- and post-intervention surveys assessing residents’ comfort, knowledge, and preparedness in prescribing MAUD. A chi-squared test of independence was performed to determine statistical differences in pre- and post-intervention responses. MAUD prescription rates and patient response rates were tracked among participating veterans. FINDINGS TO DATE: The pre- and post-intervention response rates were 83.7% and 81.6% respectively. On a five-point survey scale, 36.5% agreed that a primary care physicians’ workload allows for time to discuss and prescribe MAUD. 29.3% of respondents recognized that MAUD can be prescribed along with psychosocial interventions rather than awaiting psychosocial intervention failure. The distribution of AUD Fact Sheet in exam rooms increased residents’ comfort in: deciding when to start MAUD χ2(3) = 17.7, p = <0.0001, prescribing naltrexone χ2(3) = 19.8, p = <0.001, and prescribing acamprosate χ2(3) = 14.56, p = <0.01. With regards to outreach, 50 patients were identified from OMHSP’s PDSI Dashboard with AUDIT-C score ≥ 8. Fourteen patients were excluded due to active MAUD within past year or for active hospitalization. Of the 36 patients identified, all patients were male, with average age of 65.5 ± 15.2, and a FIB-4 score of 1.64 ± 1.0 (n=22) consistent with intermediate risk of advanced fibrosis. The veteran response rate was 64.9%. Of the 23 veterans who answered, 12 decreased their alcohol intake at time of call and no longer qualified for MAUD. Of the veterans who qualified, 25% (n=3) of patients were prescribed MAUD, compared to the national average of 12.5% of all VA patients on MAUD. KEY LESSONS FOR DISSEMINATION: This initiative demonstrates that targeted resident education and patient outreach substantially improve MAUD prescribing practices and reduce alcohol use in veteran populations. Implementing educational interventions with tools like fact sheets and involving residents in direct patient outreach enhance MAUD utilization in high-risk groups. EVALUATING THE IMPACT OF A STANDARD TEXT BUNDLE ON INPATIENT HANDOFF QUALITY AND PROVIDER SATISFACTION Oliver Clark1; Donna Miles1; Subha L. Airan-Javia2. 1Internal Medicine, Pennsylvania Hospital, Philadelphia, PA; 2Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4271512) STATEMENT OF PROBLEM/QUESTION: The transfer of a patient between health providers is a critical moment during patient care that is prone to communication error. To mitigate this risk, handoffs in the I-PASS format, a structured mnemonic that lists the important elements of the handoff, have been shown to reduce incidence of preventable adverse events. While the benefit of I-PASS has been demonstrated across a broad range of clinical settings, the adherence to this structure at our medium-sized academic institution has remained poor for both written and verbal handoffs. DESCRIPTION OF PROGRAM/INTERVENTION: The setting of the study was the Department of Medicine advance practice provider (APP) service at a medium-sized academic hospital. Within our pre-existing online handoff tool, we implemented a handoff text bundle that included pre-set templates for user text entry. Within the bundle, we included sections for day events, primary hospital problems, important physical exam findings (oxygen requirement, access and lines), pertinent medication orders (analgesia, anticoagulation, antibiotics), night tasks, and night anticipatory guidance. Implementing the text bundle was taught to providers and it could be easily applied to their written inpatient handoff tool. MEASURES OF SUCCESS: After 2 months of implementation of the text bundle, we conducted qualitative and quantitative assessment of user uptake and satisfaction with the text bundle. We performed a random spot chart review in December 2024 and visually assessed the proportion of patients where the text bundle had been applied to their written handoff. We also conducted a survey that evaluated subjective handoff quality before and after implementation. Survey questions included assessing clinical assessment matching handoff, receiving anticipatory guidance, being instructed patient care tasks, having an opportunity to ask questions, and overall satisfaction. For each category, users were queried on "never", "rarely" "sometimes", or "always" including the component in handoff, which were equated on a scale of 1-4. We also assessed handoff platform usability and ease of application of the bundle. FINDINGS TO DATE: Random spot chart review revealed 100% adherence to the text bundle (29 of 29 patients). Subjectively, provider experiences pre- and post-intervention revealed broadly similar ratings. On a scale of 1-4 in category frequency, providers (n=10) reported numerically better average ratings, though with no statistical or clinical significance, in components of patient care tasks (3.11 vs 3.00), handoff unintelligibility (2.70 vs. 3.00), and overall satisfaction (3.00 vs. 2.90). Other categories demonstrated similar or poorer ratings. KEY LESSONS FOR DISSEMINATION: Applying a text bundle to a written inpatient handoff tool was successfully adopted by all providers within a medium-sized academic hospital's Medicine APP service. Provider ratings of handoff quality remained subjectively similar before and after the intervention EVALUATION AND IMPROVEMENT OF COLON CANCER SCREENING IN A COMMUNITY CLINIC Olivia Steczko1; Geraldine Nabeta2; Kavita Advani1. 1PCIM, University of Connecticut School of Medicine, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT. (Control ID #4271707) STATEMENT OF PROBLEM/QUESTION: How can we improve colon cancer screening in an underserved resident clinic? DESCRIPTION OF PROGRAM/INTERVENTION: We present a quality improvement study in an outpatient community clinic with colon cancer screening rates below average for the region. Our goal was to assess resident knowledge and confidence with colon cancer screening and improve screening by 10% from baseline within a 2-month period. The study population included patients age 45 to 75 who qualified for colon cancer screening and were scheduled for primary care visits. Baseline data was collected through 3 weeks from September to October 2024. Residents were introduced to the project and its aims in October and prompted to discuss screening with their patients over a course of 2 weeks. They were provided an 8-item pretest with a Likert scale and free-response questions. Residents were later provided an educational presentation and posttest and additional data was collected over 2 weeks. At the end of the study in November 2024, we compared results of pre- and post-tests and compared screening rates to baseline. MEASURES OF SUCCESS: Colon cancer screening rate was the primary outcome. Secondary outcomes included resident confidence and correct definition of screening methods, frequency, and patient eligibility for screening. FINDINGS TO DATE: During the baseline period, 257 patients were scheduled, 179 presented, and 96 were eligible for evaluation. Of these 96, 41.7% were never screened, 43.8% were up to date, 14.6% were previously screened but overdue. Screening was documented for 82.3% of visits. Following resident education, 89 unique patients were eligible. Of these, 27% were never screened, 60.7% were up to date, and 12.4% were previously screened but overdue; screening was documented for 80.9% of visits. 17 of 20 residents completed the pretest. Average confidence with colon cancer screening was 3.6 (1=not at all comfortable, 5=very confident), 53% defined Cologuard and Cologuard screening frequency correctly, and 76.5% and 35.3% correctly identified ages to start and stop colon cancer screening, respectively. 12 of 20 residents completed the posttest. Average confidence was 4.2, 83.3% correctly defined Cologuard and 66.7% Cologuard screening frequency, and 83.3% and 41.7% correctly identified ages to start and stop screening respectively. On followup with 15 residents, 87% correctly identified age to begin screening, difference between Cologuard and FIT, and frequency of Cologuard screening. 73% had ordered Cologuard; those who did not attributed this to patients declining screening or preferring colonoscopy. KEY LESSONS FOR DISSEMINATION: After education, we observed improvement in screening from 43.8% to 60.7% and saw improvements in resident confidence and improved knowledge of USPSTF colon cancer screening guidelines with respect to method and frequency. Additional resident education on USPSTF colon cancer screening guidelines could improve patient care with improvement in colon cancer screening. IMPLEMENTATION OF A STUDENT-LED QUALITY IMPROVEMENT PROJECT ON HIV PRE-EXPOSURE PROPHYLAXIS INCREASED PRESCRIPTION RATES FOR THE BLACK PATIENT POPULATION AT AN ACADEMIC GENERAL INTERNAL MEDICINE CLINIC Nicholas Kelly2; Eva G. Kitlen2; Madelynn Mackenzie2; Rachel M. Mundaden2; Rosemary Lam1; Brent Kobashi1. 1Division of General Internal Medicine, University of California San Francisco School of Medicine, San Francisco, CA; 2School of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4271644) STATEMENT OF PROBLEM/QUESTION: Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method for people at high risk of HIV exposure. However, PrEP is under-prescribed and significant racial disparities in prescribing practices exist. Despite a 2017 study showing that HIV incidence was 10.5 times higher in Black men who have sex with men (MSM) than in White MSM,1 as of 2021, only 11% of eligible Black patients were prescribed PrEP, compared to 78% of eligible white patients.2 At UCSF Division of General Medicine (DGIM), there are inequities in PrEP prescription rates for the Black patient population: in September 2023, only 4.2% (N=5/119) of eligible Black patients were prescribed PrEP compared to 23% (N=242/1049) of eligible non-Black patients. 1. McCree DH, Williams AM, Chesson HW, et al. Changes in Disparities in Estimated HIV Rates Among Black, Hispanic/Latino, and White Men Who Have Sex With Men (MSM) in the United States, 2010–2015. JAIDS J Acquir Immune Defic Syndr. 2019;81(1):57-62. doi:10.1097/QAI.0000000000001977 2. Sundareshan V, Swinkels HM, Nguyen AD, Mangat R, Koirala J. Preexposure Prophylaxis for HIV Prevention. In: StatPearls. StatPearls Publishing; 2024. Accessed December 15, 2024. http://www.ncbi.nlm.nih.gov/books/NBK507789/ DESCRIPTION OF PROGRAM/INTERVENTION: We developed an intervention using quality improvement frameworks to address the under-prescription of PrEP for Black patients in our clinic. We used our institution’s EMR to identify patients at elevated risk for contracting HIV. In May 2024, we conducted targeted direct phone call outreach to Black patients to gauge interest and knowledge surrounding PrEP. We offered video appointments at a new clinic dedicated to initiating PrEP to interested participants. We also posted informational infographics on HIV and PrEP in clinical spaces to raise patient and provider awareness. MEASURES OF SUCCESS: We compiled and analyzed data in R.studio version 2024.04.2+764, using two-sided t-tests to compare rates of PrEP prescriptions in the Black patient population before and after these interventions. FINDINGS TO DATE: Post-intervention (Aug. 2024), 22.6% (N=237/1052) of all high-risk patients and 7.5% (N=9/120) of high-risk Black patients were prescribed PrEP, a 1.7% relative decrease (p=0.77) and 80 % (p=0.28) relative increase, respectively. 4/5 patients who scheduled appointments in our pilot PrEP clinic began PrEP. The overall time-cost of direct patient engagement was approximately 15 contact hours per new prescription. KEY LESSONS FOR DISSEMINATION: Time-intensive direct and indirect outreach efforts increased PrEP prescription rates among Black patients at elevated risk of HIV exposure. This intervention suggests that targeted, personalized communication, increased provider availability, and dedicated appointment time can facilitate discussion and increase awareness around HIV prevention strategies not always addressed in primary care appointments. IMPROVING EFFICIENCY OF MEDICATION RECONCILIATION: MEDS FLAGGED FOR REMOVAL DURING REFILL REVIEW PROCESS BY PHARMACY Unna Albers1; Trevor Luke2; Anthony Biondo2; Robert El-Kareh2. 1Internal Medicine, University of California San Diego, La Jolla, CA; 2University of California San Diego, La Jolla, CA. (Control ID #4270551) STATEMENT OF PROBLEM/QUESTION: Medication Reconciliation poses challenges for any institution at all patients. Our patients can flag meds to be removed from their med list when they are no longer taking, however these flagged meds have been shown to remain active for extended periods. Since patients can add flags to remove meds on a continuous basis, the solution required a continuous process. DESCRIPTION OF PROGRAM/INTERVENTION: The Pharmacy Medication Access Clinic(PMAC) Refill Service implemented an efficient workflow to screen the med list on every refill request received. If a med flagged for removal (MF4R) is identified, the technician alerts the pharmacist to review the encounter. The pharmacist uses clinical discretion to act on these through a decision tree. The pharmacist uses clinical judgement to determine if it is appropriate for the patient to stop the med such as old antibiotic, then the med is discontinued. If not, the pharmacist will determine the level of riskand If it is unsafe for the patient to stop the medication (eg a DOAC), appropriate steps are taken to communicate with the patient and ensure that the patient restarts appropriate therapy. If it is safe for the patient to stop the medication for a short time (eg a statin), the removal flag is left active in the chart, so that the managing provider can review in next office visit. This creates a continuous med list optimization process. MEASURES OF SUCCESS: Reduce total number of MF4R Improve safety Sustain accurate medication list FINDINGS TO DATE: We are not aware of a standardized work to discontinue MF4R in non-face-to-face encounters, prior to implementing this project. Since beginning the process in June ‘22 and up to Feb 1 ‘24, PMAC had removed 15,733 MF4R, and averaged 828 meds removed per month. On average, only 16% of MF4R are left active for review with providers in office visits. A small volume of critical notifications (1% of all MF4R) are sent to providers each month, ensuring that patients do not inappropriately stop critical meds while keeping non-face-to-face workload volume for providers minimized.

have been sustained to present, with slight decreases in average meds removed per month and associated “% of total encounters with meds removed” decreasing over time. The work already impacts all areas of Primary Care and Endocrinology patients. KEY LESSONS FOR DISSEMINATION: Overall, implementation of a standardized process for pharmacists to discontinue meds flagged by patients for removal within existing refill processing workflows has beneficial implications including updated more accurate medication list at all patients, improving patient safety, allowing for higher quality of care, increasing patient satisfaction, and facilitating efficient intake for visits as well as transitions of care by decreasing “noise” in the chart that providers must work through. This process allows for improved efficiency of med rec at all future visits, while providing a safety net for patients who may inappropriately stop their critical meds. IMPROVING FOLLOW UP OF HYPERTENSIVE PATIENTS IN AN OUTPATIENT SETTING Zaraq Khan, Vyom Patel, Marcos A. Alberto, Shane Khullar, Prakhar Anand, Daniel Roque, Mark Georgy, Shawn Curry. Internal Medicine, Indiana University Southwest Indiana Internal Medicine Residency, Evansville, IN. (Control ID #4273558) STATEMENT OF PROBLEM/QUESTION: In an outpatient residency clinic, there is a consistent lack of timely follow-up of patients initiated on new antihypertensives to evaluate if their blood pressure (BP) has met target values. DESCRIPTION OF PROGRAM/INTERVENTION: Evidence-based guidelines note that following the initiation of a pharmacological anti-hypertensive regimen, patients should be reassessed in one months’ time to evaluate if their BP has met the appropriate target. If the BP goal has not been reached the therapy should be adjusted, and the BP should again be re-evaluated in one months’ time. We have noted that at the resident level regular one month follow up is not occurring, impacting the optimization of a patient’s antihypertensive regimen. Focusing on an outpatient resident primary care clinic, we looked to improve the rates of timely follow up of newly diagnosed hypertensive patients initiated on antihypertensive medication. This was completed through a multi-faceted approach targeting education, access to visual resources and remote BP monitoring. Residents were first educated through small-group interactive seminars. Using a case-based format, these teaching sessions were designed to explore the appropriate follow-up of newly diagnosed patients started on antihypertensives. Posters were also created and placed in accessible locations throughout the clinic for easy reference. These posters re-iterated the information initially taught, offering an accessible resource that could be used to revisit guideline-based recommendations. Remote BP monitoring devices were also introduced. These devices were programmed to remotely transmit data to a central office once a patient had measured their BP. These readings were then dispersed to the resident PCPs of such patients for review. Residents were encouraged to utilize remote BP monitoring with all eligible patients, to closely monitor home readings allowing for more reliable titration of antihypertensives. MEASURES OF SUCCESS: We assessed success quantitatively as an adequate increase in the percentage of patients initiated on a pharmacological antihypertensive regimen receiving one month follow ups until goal BP is reached. Qualitative data was measured as survey responses from residents and attendings. FINDINGS TO DATE: Though quantitative data is yet to be reviewed, the interventions have been well received. Qualitative data shows that residents found the posters to be easy to follow, helping to reinforce knowledge. Attendings noted that the content of the seminars was well delivered, commending them as succinct but thorough. KEY LESSONS FOR DISSEMINATION: An initiative that combines education through small-group seminars and reinforcement of knowledge with visual resources may be effective in improving rates of pharmacological antihypertensive regimen follow up. This multipronged approach could be replicated at other institutions, especially at the level of residents. IMPROVING PATIENT SATISFACTION BY COMBINING STRUCTURED BEDSIDE ROUNDS WITH PHYSICAL ELEMENTS IN THE HOSPITAL SETTING Philip Huang, Rupa Baro, Sharon S. Clark. Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4271486) STATEMENT OF PROBLEM/QUESTION: Patient satisfaction can lead to improved adherence to medical advice, better patient safety, and fewer unnecessary services. Structured interdisciplinary bedside rounding (SIBR) can reduce mortality, length of stay, medication errors, and readmissions while improving staff engagement, teamwork, and patient experience. Delivering effective and consistent patient experience may also benefit from consistent physical elements in the hospital setting. DESCRIPTION OF PROGRAM/INTERVENTION: At our academic medical center, joint physician (MD) and nurse (RN) rounding at the bedside is an expectation. However, there remains significant variability in the approach which leads to an inconsistent experience with room for improvement. Combining SIBR with physical elements may also improve outcomes. We then created an institution specific protocol using peer institution protocols as a model. We aimed to highlight key elements while minimizing changes to staff practice patterns. We then shared the protocol at our monthly staff meeting along with strategies to overcome common challenges. We also provided education on best practices regarding the use of physical elements including the patient room whiteboard and updated welcome packets, room signage and physician name cards. Given the large size of our physician group (over 150 faculty covering 5 hospitals), we focused our efforts initially on 3 general med/surg units. MEASURES OF SUCCESS: Our primary outcome was to increase HCAHPS Likelihood to Recommend (LTR) scores. Secondary outcomes included HCAHPS Doctor Communication and Nurse Communication scores in addition to internal surveys regarding staff (RN, MD) perception of interdisciplinary communication. Process metrics included joint rounding completion and understanding of SIBR implementation strategies. FINDINGS TO DATE: Baseline LTR scores for Units “A”, “B”, and “C” were 72%, 65%, 63%, respectively (avg 67%) . Baseline MD communication scores for Units “A”, “B”, and “C” were 77%, 78%, 75% (avg 77%). Baseline RN communication scores for Units “A”, “B”, and “C” were 75%, 75%, 69%(avg 73%). Joint rounding had been recorded as completed 60% of the time. Our initial internal survey revealed 78% of RNs and 83% of MDs agreed/strongly agreed that "physicians and nursing staff communicate well." Only 14% of RNs and 47% of MDs agreed/strongly agreed with being familiar with SIBR implentation strategies. After the initial educational session, 100% of MDs reported familiarity with SIBR strategies. At the time of submission. we are pending survey of nursing staff after their first educational session. We also plan to survey RN/MD staff after two additional follow up sessions and to trend HCAHPS scores. KEY LESSONS FOR DISSEMINATION: Patient satisfaction and improving communication are important drivers of patient outcomes. Joint rounding and physical elements may be successful alone but can be much more impactful when combined in a structured approach to create a consistent, high quality culture. IMPROVING PHYSICIAN-NURSE COMMUNICATION THROUGH NURSE-FACILITATED INVITATIONS FOR BEDSIDE CO-ROUNDING Elaine Kim, Melissa T. Bu, Anuroop Nirula, Michael A. Torres Espinosa, Debbie Adam, Omar Singleton, Shubhra Gupta. School of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4272145) STATEMENT OF PROBLEM/QUESTION: Physician/Bedside Nurse (RN) communication is at the center of care delivery and patient experience for patients admitted to any Hospital Medicine service. While efficient communication within the healthcare team is the hallmark of high quality care, its timing and quality can be highly variable. Inadequate communication, as perceived by patients, negatively impacts patient experience. We aimed to increase visibility of physician nurse communication for patients through bedside co-rounding on our Adult Hospitalist direct care service at University of California, San Francisco (UCSF). During the study period, the average daily patient census was 87 on the UCSF Goldman service, the attending-only direct care service, through which more than 110 hospitalists rotate. Currently, there is no clear national benchmark regarding physician nurse co-rounding. Therefore, we established our own internal benchmarks from data collected on the Goldman Hospitalist service at UCSF. We aimed for a 50% increase in bedside co-rounding from a baseline of 22.9% established in August 2023 to 34.4% by August 2024 for Goldman service patients with behavioral concerns through nurse-initiated invitations. To identify patient populations that would benefit most from physician-nurse co-rounding, we interviewed 11 nurses and nurse managers who highlighted groups for whom bedside co-rounding would be most beneficial. Based on the experiences of frontline staff, we decided to focus on patients with behavioral concerns. DESCRIPTION OF PROGRAM/INTERVENTION: During our gap analysis, we recognized that most co-rounding interventions so far have been physician driven with limited success. We propose that empowering bedside nurses to initiate co-rounding may be a powerful way to bring the physician and the nurse together at the bedside. We began with an implementation period during which nurses messaged providers requesting bedside co-rounding for patients identified to have behavioral concerns. We educated providers through flyers posted in visible areas of medicine wards, announcements at nursing unit meetings, email reminders, and “real time” education on the nursing units. MEASURES OF SUCCESS: We measured progress by calculating the percentage of patients with behavioral concerns who experienced bedside co-rounding as part of their care. FINDINGS TO DATE: Although we did not reach our goal of a 50% increase from baseline in bedside co-rounding for patients with behavioral concerns, we achieved a significant improvement. Pre-intervention data collected one year prior to our intervention demonstrated 22.9% co-rounding, while the data collected after incorporating our intervention displayed 29.4% co-rounding. Our intervention spurred a 28% increase in co-rounding, demonstrating that our intervention reached the intended audience and trended towards reaching our goal. KEY LESSONS FOR DISSEMINATION: Interprofessional approaches to quality improvement projects offer an effective route to implement health systems improvement initiatives for the purpose of enhancing hospital patient care. INCREASING HIV SCREENING RATES AT A FEDERALLY QUALIFIED HEALTH CENTER THROUGH DATA ACCURACY AND PROVIDER DECISION SUPPORT Brian C. Hilgeman1,2. 1General medicine, Medical College of Wisconsin, Milwaukee, WI; 2Sixteenth Street Community Health Centers, Milwaukee, WI. (Control ID #4236405) STATEMENT OF PROBLEM/QUESTION: Increasing HIV screening rates in the United States, particularly in high-risk areas, is important to ending the HIV epidemic in the United States. DESCRIPTION OF PROGRAM/INTERVENTION: The Ending the HIV Epidemic Initiative aims to reduce new HIV infections in the United States by 90% by 2030. HIV testing is a key component of this strategy as Individuals who are aware of their HIV status are 57% less likely to engage in high-risk behaviors and transmit the virus. In 2022, only 36% of people in the United States had been screened for HIV in accordance with the new CDC guidelines for universal, once in a lifetime screening for all people aged 13-65. Among patients in federally qualified health centers (FQHCs), 48.45% had been screened as of 2023. The Sixteenth Street Community Health Centers (SSCHC) is a FQHC based in Southeastern Wisconsin that serves 42,390 patients across 5 clinical sites with 86% being Latino and 83% of patients living at or below the federally poverty level. In 2022, 42.4% of the SSCHC population had been screened for HIV. The clinic set out to improve these numbers through continuous quality improvement methodologies. Leadership engaged in a root cause analysis and discovered two impactful areas of focus: ensuring data accuracy and developing an EHR based best practice alert (BPA) for HIV. Data accuracy was addressed first. In 2021, the health system had changed EHRs and only laboratory data from 2019 forward were abstracted into the new EHR. To ensure accuracy, all historical HIV testing data were abstracted into the new EHR in August of 2023. In December of 2023, provider decision support was deployed through a BPA that would activate at the start of an encounter for a patient missing once-in-a-lifetime testing. The BPA informed providers of a testing need, allowed for a one click order, and provided non-stigmatizing, opt-out language to communicate testing to patients. MEASURES OF SUCCESS: Monthly HIV screening rates were tracked to understand the impact of each tactic. The BPA was also designed to collect reasons providers chose to not test patients for HIV to inform future interventions. FINDINGS TO DATE: Prior to any intervention in July of 2023, testing rates were at 47.9%. By the end of August 2023, after all HIV tests were abstracted, testing rates increased to 62.0%. By October of 2024, testing rates for the clinic increased to 71.2%. Between 12/3/23 and 11/30/24, the BPA was Overridden 3395 times. Top reasons for override were: testing postponed (62.56%), low risk (20.50%), not appropriate at this time 13.40%, and declined 3.53%. KEY LESSONS FOR DISSEMINATION: Provider decision support tools can impactfully increase HIV testing rates within a FQHC but providers often override the HIV BPA prior to patient declination. MANAGING HYPERTENSION: IMPROVING THE EVALUATION OF END ORGAN DAMAGE IN AN OUTPATIENT SETTING Zaraq Khan, Marcos A. Alberto, Shane Khullar, Vyom Patel, Prakhar Anand, Daniel Roque, Mark Georgy, Shawn Curry. Internal Medicine, Indiana University Southwest Indiana Internal Medicine Residency, Evansville, IN. (Control ID #4273506) STATEMENT OF PROBLEM/QUESTION: There exists a deficiency in appropriate workup of organ dysfunction secondary to hypertension in our outpatient residency clinic DESCRIPTION OF PROGRAM/INTERVENTION: New onset hypertension is a common condition diagnosed in the outpatient setting by primary care providers. Evidence-based guidelines state upon diagnosis all patients should undergo a thorough evaluation for evidence of end organ damage. Upon review, it was noted that organ dysfunction secondary to hypertension is not being monitored appropriately at our facility. We first completed a root cause analysis, identifying multiple contributing factors to the lack of end-organ damage work up. Unfamiliarity with most recent guidelines was noted as a significant factor, followed by the scarcity of resources within the clinic environment that physicians could readily reference. A lack of streamlined order sets within the EMR was also noted as an issue. We therefore launched a multifaceted approach to solve the disparity that exists between guidelines and actual practice among residents assigned to our outpatient faculty clinic. Our approach centered on improving the following domains to improve rates of end-organ damage assessment: education among residents, availability of visual resources and EMR automation. We focused on improving education through 30-minute interactive seminars to small groups of residents. Posters detailing algorithms were also created, printed and made readily available in multiple areas of the resident clinic work area. This allowed for easy access to information. Those delivering seminars incorporated these posters into their presentations, improving familiarity with the accessible resource. Finally, an order set was created which included all the workup required to evaluate for end-organ damage per guidelines to improve workflow. MEASURES OF SUCCESS: Quantitative metrics included assessing the change in rate of end-organ damage workup on diagnosis of new onset hypertension after implementation of our initiative. For qualitative data, we completed surveys to assess how the intervention had been received by attendings and residents alike. FINDINGS TO DATE: We await complete quantitative data on rates of change. Per survey, the interventions have been well received by both attendings and residents. Most complimented have been the interactive seminars, with most noting the wealth of useful knowledge gained in an engaging yet efficient format. Posters were deemed easy to interpret and a useful tool to reinforce knowledge. The order sets were found to make workflow more streamlined. KEY LESSONS FOR DISSEMINATION: Educating providers through multiple teaching styles whilst simultaneously boosting workflow by adjusting the EMR can improve rates of hypertensive end-organ damage evaluation. Our approach was intentionally designed to allow other programs in need to easily replicate these steps to improve patient outcomes. MANAGING THE TENSION: IMPROVING THE DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION IN AN OUTPATIENT SETTING Zaraq Khan, Shane Khullar, Vyom Patel, Marcos A. Alberto, Prakhar Anand, Daniel Roque, Mark Georgy, Shawn Curry. Internal Medicine, Indiana University Southwest Indiana Internal Medicine Residency, Evansville, IN. (Control ID #4273544) STATEMENT OF PROBLEM/QUESTION: Appropriate classification and management of stage 2 hypertension has been found to not occur consistently, especially at the resident level in our outpatient clinic. DESCRIPTION OF PROGRAM/INTERVENTION: Stage 2 hypertension is defined as a blood pressure (BP) of ≥140/90 on two separate readings on at least two different occasions (1). Per ACC/AHA 2017 guidelines, it is important to classify hypertension to allow for appropriate management. It is suggested that effective management of stage 2 hypertension requires the use of two separate anti-hypertensives of at least two different classes. Unfortunately, appropriate classification does not occur consistently especially at the resident level. This in turn may negatively impact effective lowering of BP to reach recommended target values. Through a multifaceted approach, we looked to improve the rates of accurate classification and management of stage 2 hypertension in the setting of an ambulatory outpatient residency clinic. Our focus was on improving rates of appropriate prescriptions of two antihypertensive agents of two separate classes for patients diagnosed with new onset stage 2 hypertension, unless contraindications existed. The intervention focused on improving education, coding within the electronic medical record (EMR) and access to visual resources. Initially, through a collection of interactive seminars residents were re-educated on the diagnostic criteria and appropriate medical management of stage 2 hypertension. As part of these seminars, residents were given training into correctly coding for stage 2 hypertension in the EMR. Residents were also taught first-line antihypertensive options as supported by evidence. Posters were created and displayed throughout the clinic environment, serving as accessible resources that could be used for quick reference. These posters contained flowcharts to easily guide readers to the correct classification depending on BP readings, along with suggesting antihypertensives of choice. MEASURES OF SUCCESS: Success was first measured as an adequate increase in the appropriate classification and coding of stage 2 hypertension within the EMR. Followed by this, an increase in the order of two antihypertensives within the EMR when indicated was assessed. Surveys from residents and attendings were also taken. FINDINGS TO DATE: Whilst pending quantitative data, initial survey responses from residents have been overall positive. Many have found the posters as an easily accessible resource that can be used repeatedly to reinforce knowledge learned. Some have noted the EMR training to be particularly useful. KEY LESSONS FOR DISSEMINATION: A combination of education and access to visual resources may be used to improve diagnosis and management of stage 2 hypertension in the outpatient setting among residents. We believe this to be a set of interventions that can be readily applied at other programs. MOVING THE NEEDLE: IMPROVING HPV VACCINATION RATES IN MALE VETERANS Kenton Wong, Holli Sadler, Georgia Williams, Corey Snyder, Thao Le, Abhipsa Das, Madison Terzo, Maria Batchinsky, Nimmy Thomas. Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4267733) STATEMENT OF PROBLEM/QUESTION: The human papillomavirus (HPV) vaccination is effective in preventing HPV infections and related disease in males, including anogenital warts and cancers. [Rosado 2023, Harder 2018] In the general U.S. male population, the National Health and Nutrition Examination Survey (NHANES) 2013-2014 found that the overall prevalence of genital HPV infection was 45.2% with 25.1% having at least one high-risk subtype.[Han 2017] The Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices recommends HPV vaccination for all males through age 26 years. [Workowski 2021]. HPV vaccination rates among male veterans are relatively low. A study of male veterans found that only 1.4% of male veterans aged ≤26 years had received at least one dose of the HPV vaccine prior to initiating care at the VA, with an additional 10.8% receiving their first dose upon initiating care. [Nobel 2019] Additionally, the HPV vaccine series is not required for enlistment or commission as a US Armed Forces member. [Tamar 2019] DESCRIPTION OF PROGRAM/INTERVENTION: Residents will receive instruction in the epidemiology of the human papillomavirus (HPV), benefits and risks of vaccination, and optimal vaccine scheduling for the intended cohort. A panel of male veterans under 26 years old are identified. Those with face-to-face resident appointments scheduled will be offered the HPV vaccine. If agreed, the patient will receive their first dose at that appointment. Those without scheduled appointments will be contacted via phone by residents participating in the study, offering education on the HPV vaccine and an appointment to initiate the vaccine series. If agreed, they will then schedule a nurse visit to receive the vaccine in person. MEASURES OF SUCCESS: The measured outcome of this project will be the response rate of veterans to offers for scheduling vaccination, categorized into agreement, interest, disinterest, and lack of response. FINDINGS TO DATE: A total of 39 male veterans under the age of 26 without prior HPV vaccinations are empaneled in this project, which is currently in its 2nd PDSA cycle. As of this cycle approximately 23% of empaneled veterans have agreed to receive at least one dose of the HPV vaccine. Approximately 13% of empaneled veterans have expressed disinterest in the vaccine, and the majority of remaining patients in the panel have so far been unable to be contacted. KEY LESSONS FOR DISSEMINATION: Preliminary findings are promising; more male veterans under 26 appear willing to receive the HPV vaccination than are disinterested. The project is evolving through iterative PDSA cycles, with future cycles focusing on improving contact with empaneled veterans that have not responded to initial outreach. The end result will be a model of outreach to discuss vaccination with male veterans under 26 that reconciles younger veterans' preference for online communication with the VA's primarily phone- and paper-based system, as integration with text and email is still limited within the practice. NORTHEAST OHIO QUALITY IMPROVEMENT HUB FORMATION AND EARLY RESULTS Shari Bolen1; Rebecca Fischbein2; Aleece Caron1; Mamta K. Singh3; Iyabode Adebambo4; Anne Gaglioti4; Chris Mundorf5; Douglas Einstadter6; Debra R. Hrouda7; Michael Konstan8. 1Medicine, MetroHealth/Case Western Reserve University, Cleveland, OH; 2Family Medicine, Northeast Ohio Medical University, Rootstown, OH; 3Internal Medicine, Case Western Reserve University, Cleveland, OH; 4Family Medicine, The MetroHealth System, Cleveland, OH; 5N/A, Better Health Partnership, University Heights, OH; 6Internal Medicine, MetroHealth Medical Center, Rocky River, OH; 7Psychiatry, Northeast Ohio Medical University, Rootstown, OH; 8School of Medicine, Case Western Reserve University, Cleveland, OH. (Control ID #4266940) STATEMENT OF PROBLEM/QUESTION: Recognizing that different regions may need more local solutions, the Department of Medicaid awarded Colleges of Medicine (CoM) funds from the Medicaid Technical Assistance and Policy Program (MEDTAPP) to establish regional Quality Improvement (QI) Hubs to improve the health of Medicaid enrollees across the state. We describe our Northeast Ohio (NEO) QI Hub formation and early results to assist others working to establish similar structures. DESCRIPTION OF PROGRAM/INTERVENTION: Using a Collective Impact Model, we conducted co-design over a year with partners in our region to establish the NEO QI Hub. The Collective Impact Model includes 5 key elements: 1) common agenda, 2) shared measurement, 3) mutually reinforcing activities, 4) continuous communication, and 5) backbone support. The Model has 4 phases: 1) generate ideas and dialogue; 2) initiate action; 3) organize for impact; and 4) sustain action and impact. MEASURES OF SUCCESS: We will measure success for our initial activities (QI project and QI Hub) using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. FINDINGS TO DATE: Our initial focus is on improving glycemic control and reducing disparities in glycemic control for people with diabetes living in our region, with a goal to reach 60% of Medicaid enrollees in the region over 5 years. In Year 1 (2022), we developed a Charter with a shared purpose, activities, and success metrics. For wave 1 of the project, in 2023, we recruited 26 practices with a high volume of Medicaid patients. Practices submit EHR data every 2 weeks. We recruited 9 people to serve on a patient and family engagement team and conducted a formative evaluation to help establish a community engagement infrastructure for the collaborative. We held an in-person project kick-off with the participating practices followed by monthly QI coaching; ongoing Plan, Do, Study Act cycles; audit and feedback data review; and monthly webinars to promote networking and peer-to-peer learning. During the project, the Government Resource Center coordinated monthly meetings for shared learning from other QI Hubs across the state focused on hypertension or diabetes. Additionally, Medicaid payers, along with a community partner and practice, have begun to codesign a pilot to address food insecurity. At the end of 1-year of implementation, our primary outcome measure (reducing the percent of patients with A1c > 9%) remains relatively unchanged at 16% overall; four practices have realized significant improvements in A1c related to pharmacist collaboration, timely follow-up in primary care, behavioral health integration, and/or addressing social needs as part of care. KEY LESSONS FOR DISSEMINATION: Regional QI Hub formation leveraging CoM, health system leadership, and community and payer partners can establish a strong backbone for continuous QI. We have seen improvement in glycemic control using team-based care strategies. Future work will test how best to integrate community partners into our infrastructure. PRIMARY CARE AUTOMATED OFFICE BLOOD PRESSURE (AOBP) CHECK VISITS: A YEAR 3 PROGRAM EVALUATION Dale D. Kim, Ankita Mishra, Brandon Aflak, Tobenna Nwosu, Joshua Frost, Emily Merlin, Anuradha Phadke. School of Medicine, Stanford University, Stanford, CA. (Control ID #4272323) STATEMENT OF PROBLEM/QUESTION: What is the impact of an AOBP check visit program on blood pressure measurement and patient experience? DESCRIPTION OF PROGRAM/INTERVENTION: Accurate blood pressure measurement is central to hypertension management and diagnosis. Traditional forms of measurement (office visit or home blood pressure measurement) may face challenges of access, accuracy, or patient-engagement. In 2021, we implemented a medical assistant (MA) AOBP check visit program in 5 academic primary care clinics in the Southwest region. The visits protocol combines 1) a series of three unattended blood pressure measurements that are averaged, 2) an accuracy check of the patient’s home BP machine, and 3) protocolized follow-up stratified by BP level. MEASURES OF SUCCESS: Our primary objective was to assess the impact of AOBP visits on blood pressure measurement by comparing the lowest value collected at AOBP visit with the most recent office visit reading in the 6 months prior to the visit. Additionally, we aimed to understand visit utilization by assessing demographics and clinical characteristics of participating patients. Finally, we developed a de-novo patient experience survey that we plan to prospectively distribute to patients starting in January 2025. FINDINGS TO DATE: 1242 patients had AOBP visits during the study period of which 786 were included in the primary analytical cohort. Analytical cohort patients were on average 62.3 years old, 48% female, 88% with English as a preferred language, 42% Asian, 36% white, 5% black, and 10% Hispanic/Latino ethnicity. 76% of cohort patients had documented HTN diagnosis within 1 year of their visit and 83% had comorbidities of diabetes, chronic kidney disease, or heart failure. For our primary objective, we found systolic blood pressure values reduced from 140.1 mm Hg in the preceding office visit to 129.6 mm Hg at the AOBP visit, or a reduction of 10.5 mm Hg (SD 17.5 mm Hg). Diastolic blood pressure reduced from 76.0 mm Hg at the office visit to 74.8 mm Hg at the AOBP visit, or a reduction of 1.2 mm Hg (SD 11.4 mm Hg.) KEY LESSONS FOR DISSEMINATION: AOBP visits demonstrated significantly lower blood pressure measurements as compared to preceding office visits, whether due to improved measurement or hypertension-care interventions. Our next steps involve comparing demographic characteristics of participants to all patients in our hypertension registry to characterize any unintended health disparities associated with our intervention. Patient survey data will also identify valuable patient-level perspective to further optimize this quality improvement initiative. PUTTING THE I IN MORBIDITY, MORTALITY, AND IMPROVEMENT Katherine Allen, Shana Ratner. Division of General Internal Medicine, UNC Chapel Hill, Chapel Hill, NC. (Control ID #4272798) STATEMENT OF PROBLEM/QUESTION: The outpatient Division of General Medicine and Clinical Epidemiology lacked a morbidity and mortality conference. DESCRIPTION OF PROGRAM/INTERVENTION: Morbidity and mortality conferences allow providers to collaborate and review difficult cases, however our outpatient internal medicine faculty lacked such a conference. The division of general medicine already holds a weekly meeting with clinical and research faculty. A biannual Internal Medicine Morbidity, Mortality and Improvement conference (IMMMI) was started in spring 2023 during this preexisting meeting time. Sessions last one hour and take place via secure Zoom conference calls or hybrid in-person and virtual settings. At the beginning of the meeting, emphasis is placed on promotion of a just, reporting culture, reviewing how to formally place a safety report. The meeting template includes 20 minutes of a case presentation, 20 minutes of 3-4 break-out groups for discussion and evaluation using root-cause analysis tools (e.g. Ishikawa diagram), and 20 minutes for full group discussion and brainstorming system improvements. Each conference has resulted in an action item including local and systems-level solutions. MEASURES OF SUCCESS: Measures of success included conference attendance, and ability to create and implement improvement strategies of various types at multiple institutional levels. A measure for the future will be to track improvements in formal safety reporting. FINDINGS TO DATE: The conference was held four times. There were approximately 20 participants for each session. Each conference has resulted in an action item at various levels. Our first conference resulted in the resident-led creation of a simplified standard checklist for outpatient large volume paracentesis. The second conference led to a system wide change in the after-hours nurse triage process, ensuring that patients being treated for opioid use disorder could receive timely refills. The third conference led to a change in our institution’s use of EMR capabilities to enable a pre-existing renal dose warning system. From the most recent conference, one of our dual-trained internal medicine and palliative care faculty plans to give a resident lecture on navigating ethics and moral injury in difficult patient encounters. KEY LESSONS FOR DISSEMINATION: The IMMMI conferences incorporate clear characteristics that have allowed for success. Meetings are well attended since they are integrated into a preexisting weekly conference. Establishing a just, reporting culture allowed for honest conversations amongst faculty and served as a platform to review formal safety reporting. The structured setup of meetings, allowing for interaction and conversation, has let faculty reflect and derive meaning from cases and feel empowered to execute action items. Careful case selection and implementation of QI tools have fostered effective solutions, leading to local changes, educational interventions, and two large scale systems improvements. Future work will investigate whether frequency of safety reporting has increased. RELATIONSHIP FIRST: ENHANCING PATIENT CONTINUITY IN SEVERAL URBAN FEDERALLY QUALIFIED HEALTHCARE CENTERS Ines Varela Knorr1; Kimberly Fasciglione1; Niurka Liranzo Tejera2; Aphrodite Megaris1; Aesha Patel1; Lauren I. Shapiro3. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Mount Sinai Morningside Hospital, New York, NY; 3General Internal Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272556) STATEMENT OF PROBLEM/QUESTION: Continuity in patient care fosters trust, enhances preventive services, improves chronic disease management, reduces healthcare costs, and increases satisfaction for both patients and providers, yet continuity at our Urban Federally Qualified Healthcare Centers (FQHC) averages just 15.3%, far below the national benchmark of 75% and the median of 56% in resident continuity clinics. DESCRIPTION OF PROGRAM/INTERVENTION: To improve continuity, we implemented targeted interventions through PDSA cycles. The first cycle enhanced patient access by offering provider schedules six months in advance and increasing the number of sessions per resident provider. The second introduced a group care model, assigning patients to a rotating team of four residents rather than a single provider. To support this model, patients received handouts with the names and availability of their primary care provider and the other members of their practice group. Additionally, support staff were encouraged to prioritize these practice groups when scheduling appointments to ensure consistency. The third cycle provided educational sessions for new residents, emphasizing the importance of continuity in patient care and offering practical strategies to improve it. Weekly reminders further ensured that continuity remained a central focus in both clinical practice and medical education. These efforts aimed to strengthen patient-provider relationships and improve continuity at our resident-led clinics. MEASURES OF SUCCESS: We will assess the impact of our interventions through various process measures. Our process measures for the first PDSA cycle include the total number of clinic sessions available per resident at each site and the percentage of patients able to schedule follow-up appointments within 2 or 4 months before leaving the clinic. The process measures for the second PDSA cycle focus on the degree of continuity within clinic panels, and the frequency of handout use. The third PDSA cycle builds on the previous two, maintaining an emphasis on these measures. The outcome measure is the continuity rate by clinic site. FINDINGS TO DATE: By increasing the number of clinic sessions per provider, we achieved an average 18.3% rise in visit volume across all clinic sites. Additionally, by implementing this intervention and providing schedules six months in advance, continuity across clinics improved by an average of 5.6% during the first four months. As the PDSA cycles progress, we will continue to evaluate both process and outcome measures to drive sustained improvements. KEY LESSONS FOR DISSEMINATION: Understanding how to effectively implement strategies to enhance continuity of care in resident-led clinics. The use of medical education to improve continuity of care. TACKLING THE CHALLENGES OF OBESITY MANAGEMENT IN AN INNER-CITY PRIMARY CARE CLINIC Alexandra L. Coritsidis1; Shyam Sundaresh2. 1Department of Medicine, Mount Sinai Health System, New York, NY; 2Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4268385) STATEMENT OF PROBLEM/QUESTION: We are evaluating the impact of an internal referral to a Weight Management Clinic (WMC) embedded within our primary care clinic on prescribing antiobesity medications (AOMs) for guideline-eligible patients. DESCRIPTION OF PROGRAM/INTERVENTION: The prevalence of obesity among US adults is over 40% and presents a significant challenge for primary care providers due to time constraints and lack of sufficient provider training in weight management. Obesity treatment guidelines recommend prescribing an AOM as an adjunct to lifestyle interventions, but AOMs are nationally under-prescribed. Our clinic is located in an inner-city academic center in the Northeast region serving a primarily Medicaid-covered population. The current rate of initiation for an AOM at our clinic for Medicaid patients is 1.3%. Our state’s Medicaid does not cover AOMs, but there are recommended yet underutilized strategies for prescribing low-cost AOMs. To increase prescribing, we created an internal weight management clinic within the primary care clinic staffed by three primary care physicians who were offered $1500 each to fund additional training in obesity medicine. The creation of a dedicated WMC within a larger primary care clinic gives providers with expertise the protected time needed to manage this complex chronic condition. To date there are no such internal WMCs that increase AOM prescribing for underserved patients. MEASURES OF SUCCESS: For patients who utilize the WMC, we hope to demonstrate an increase in the proportion of guideline-eligible patients initiated on AOMs from 1.3% to at least 3% as well as increase the proportion of patients who achieve at least 5% weight loss within 6 months. We will also measure the primary care clinic’s internal referral volume to the WMC to assess feasibility. FINDINGS TO DATE: Our team received approval from our institutional Quality Improvement Committee to proceed with the proposed intervention. We built an automated Electronic Health Record report for the WMC that will track the measures of interest, namely the proportion of guideline-eligible patients who are initiated on an AOM and 6-month weight loss achieved. We will compare the proportion of guideline-eligible patients who are prescribed an AOM after enrolling in the WMC to guideline-eligible patients who are scheduled or on the wait list for the WMC but have not yet had an initial visit. This data will be reviewed quarterly using PDSA methodology to improve the proportion of guideline-eligible patients initiated on AOMs. KEY LESSONS FOR DISSEMINATION: This intervention provides a strategy to address the obesity epidemic in the primary care setting, particularly in clinics with historically marginalized and underserved populations. Obesity management is time intensive with multiple close follow ups and provider comfortability necessary in prescribing AOMs. The creation of a dedicated WMC alleviates some of the burden from physicians during busy primary care visits and provides an opportunity for interested physicians to develop greater comfort with managing obesity. TELEMETRY MONITORING, A PROCESS IMPROVEMENT PROJECT TO IMPROVE APPROPRIATE USE Stephanie B. Clauss. General Internal Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4272336) STATEMENT OF PROBLEM/QUESTION: When the Telemetry Policy was due for renewal in late 2022 in our hospital system, we found that the issue was not denial of payment for telemetry but overcharging for telemetry that might not have been provided due to breaks in the continuity of coverage. At its peak, telemetry capacity overutilization was at 45% in our system. On average, we kept patients 32 hours (1.3 days) longer on telemetry relative to the 72-hour AHA Guidelines. DESCRIPTION OF PROGRAM/INTERVENTION: The study focused only on patients who were on telemetry boxes and being remotely monitored. High telemetry utilization was found to cause a increased length of stay (LOS), increased costs, and patient flow concerns necessitating the need for a change. From this we decided to begin the journey of a nurse driven telemetry protocol to help improve LOS, follow AHA guidelines, reduce gaps in coverage, and improve nursing autonomy when it comes to discontinuing telemetry coverage. The first step was improving the selection of the order by providers. Two options are available for the provider, one for 24 hours and one for 48 hours with set diagnosis that the provider has to choose from which are all indications from the AHA. Once an order is placed, the nurse gets an alert that a telemetry order has been entered, so does the Telemetry Technician in the Central Monitoring Unit (CMU). The nurse will then go to the CMU to obtain a telemetry box. A key feature of the Nurse-Driven Telemetry Protocol (NDTP) is that the primary nurse gets an alert three hours before the order is due to expire. Within the three-hour lead time, the nurse will activate the NDTP by clicking on the alert, then answer five questions within the three-hour window. These questions include a change in rhythm or conversion to sinus rhythm, new or unstable chest pain within the last 24 hours, on an antiarrhythmic infusion, an electrolyte abnormality, or pre or post cardiac surgery. If the nurse answers yes to any of the above questions the telemetry order automatically renews for 24 hours but if she answers no to all questions the order will expire, and the nurse is to remove the telemetry box at that time. The Cardiac Telemetry Renewal Assessment quality improvement project was reviewed, edited, and eventually approved by multiple stakeholders in the hospital system. MEASURES OF SUCCESS: We will be reviewing length of stay, ER boarding times due to lack of telemetry boxes avaiable, and cost savings for the hospital system. FINDINGS TO DATE: This protocol is rather new and was implemented in August of 2024 but has led to decreased length of stay as well as more availability of telemetry boxes and cost savings for the hospital system. KEY LESSONS FOR DISSEMINATION: This protocol took over a year to create, get approval from stakeholders, and implement. It is a long term project that requires dedication but has helped with hospital flow, efficiency, lowering costs, and eliminating waste. UTILIZING DIGITAL INTERVENTIONS TO ENHANCE BLOOD PRESSURE MONITORING Zaraq Khan, Marcos A. Alberto, Shane Khullar, Vyom Patel, Prakhar Anand, Daniel Roque, Mark Georgy, Shawn Curry. Internal Medicine, Indiana University Southwest Indiana Internal Medicine Residency, Evansville, IN. (Control ID #4273582) STATEMENT OF PROBLEM/QUESTION: Effective blood pressure (BP) monitoring required to accurately titrate pharmacological antihypertensive therapy does not consistently happen at the outpatient level. DESCRIPTION OF PROGRAM/INTERVENTION: Effective BP monitoring is a crucial step for patients with newly diagnosed hypertension (HTN) as they initiate pharmacological antihypertensive therapy. This approach allows healthcare providers to make precise adjustments to treatment regimens, leading to improved patient outcomes. Many challenges exist that can derail this process. Some patients have limited access to accurate BP monitoring devices, whilst others remain uneducated on monitoring practices leading to inconsistent recorded results. Digital health interventions have expanded significantly over the years, with high-quality evidence supporting their efficacy in combating these limitations. Remote blood pressure monitoring is a promising and innovative approach that offers high-quality, reliable data to assist providers in the clinical decision-making process. Building on these digital advancements, we implemented an intervention aimed to enhance accuracy and frequency of home BP monitoring in this critical period between initiation of antihypertensive medication and achieving adequate BP targets. Set in an outpatient residency clinic, the approach centered on providing patients with remote BP monitoring devices possibly covered by insurance to increase rates of accurate BP readings. Patients newly initiated on antihypertensive therapy were provided with a remote BP monitoring device along with detailed training on how to utilize the machine prior to leaving the office. Upon utilizing the device, patient’s readings were time stamped, sent to the clinic's internal server and uploaded into the electronic medical record (EMR) for provider review. Multiple data points were collected over time allowing for highly accurate BP trends for each patient. Adherence to the program was routinely assessed by our designated clinical team, contacting patients to also see if they had remained compliant with their medication whilst readings had been taken. MEASURES OF SUCCESS: Success was measured as an adequate decrease in the time taken from initiation of antihypertensive medication to reaching goal BP. Qualitative data was obtained in the form of surveys completed by providers. FINDINGS TO DATE: Whilst quantitative data is yet to be finalized, initial feedback from providers has been promising. They have noted an improved ability to accurately and reliably monitor patient’s BP, making more confident decisions when intensifying a patient’s antihypertensive management plan. KEY LESSONS FOR DISSEMINATION: The use of remote BP monitoring may be a successful method to improve the rates of accurate readings following the initiation of antihypertensive regimen. If successfully implemented this process may allow providers to more accurately and confidently titrate antihypertensive regimens based on more reliable data. Innovation in Healthcare Delivery (IHD) - Social Determinants of Health AN INTERPROFESSIONAL TEAM APPROACH TO IMPROVING CARE OF PATIENTS LIVING WITH DIABETES THROUGH ADDRESSING SOCIAL DRIVERS OF HEALTH. Kaleb Keyserling1,2; Jacoba Wentross1; Lisa L. Smith1; Barbara Hettinger1,2; Lisa Winterbottom1,2; Theresa H. Liao1,2. 1Portland VA Medical Center, Portland, OR; 2Oregon Health & Science University, Portland, OR. (Control ID #4266834) STATEMENT OF PROBLEM/QUESTION: To evaluate a team based approach to screening patients with suboptimally controlled diabetes and linking them to social and community resources to improve self-care and wellness. DESCRIPTION OF PROGRAM/INTERVENTION: Targeted Hemoglobin A1C(HbA1c) treatment for patient with diabetes can help reduce complications of disease. Primary care teams are responsible for panel management, and often held accountable for HbA1c control across their panels. Myriad reasons may exist, however, for suboptimal diabetes control, including importantly, the impact of social drivers of health. In order to better address these social factors, we utilized the VA Assessing Circumstances and Offering Resources for Needs (ACORN) screen and created a local resource guide to target the social needs identified by our patients with poorly controlled diabetes. A clinic focus group including multiple primary care providers, a nurse, a social worker, a health and wellness coach, and an endocrinologist developed a clinic-specific resource packet to address social needs identified on the ACORN screen. Patients with an HbA1c >9 or not measured in the past year were called outside the visit by a member of the clinic team and asked if interested in completing the ACORN screen. Patients were given community resources to address identified needs and referred to the appropriate team member for additional support. MEASURES OF SUCCESS: This initiative was designed as a pilot, to investigate the feasibility of using the ACORN screen for diabetes care in the primary care clinic. It was approved as a facility quality improvement project. We tracked the number of patients completing the screen, the areas of need identified, and any follow up tasks required of the primary team. We also asked both patients and screeners for suggestions for future more widespread implementation. FINDINGS TO DATE: Of the 20 patients identified, 14 completed the screen. Fifty percent of patients screened positive for transportation needs and 40% for nutritional support. Twenty-eight percent of participants noted social isolation and challenges affording utilities. Our screeners reported an average of 10-20 minutes to complete the ACORN screen and provide resources. Team members reported that this pilot process was very helpful for learning about additional resources to support patients that they were previously not aware existed. KEY LESSONS FOR DISSEMINATION: The ACORN screen has the potential to help identify social needs of patients struggling with chronic diseases. Patients and screeners noted the resource packet created by our project group included useful information. Food insecurity and transportation assistance were most commonly requested by patients. Further investigation of the associated use of the screen and resource packet at the clinic and healthcare system level is needed to evaluate improvement in diabetes control and outcomes. The resources identified should be made available to patients outside of the specific ACORN screen and patients with other chronic conditions may benefit as well. HARNESSING THE POWER OF AN INTERDISCIPLINARY TEAM TO INCREASE ASSESSMENT AND BILLING FOR SOCIAL DETERMINANTS OF HEALTH (SDOH) IN THE MEDICARE POPULATION Meaghan Costello1; Danielle M. Brunet2; Neeraj H. Tayal2; Jodi M. Grandominico-Bradford1. 1Internal Medicine, The Ohio State University Wexner Medical Center Department of Internal Medicine, Columbus, OH; 2Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4273241) STATEMENT OF PROBLEM/QUESTION: G0136, designed to assess Medicare beneficiaries for the negative consequences of SDOH while providing reimbursement for efforts spent providing assessments and resource linkage, is underutilized in primary care which may prevent patients from being linked with needed services. DESCRIPTION OF PROGRAM/INTERVENTION: The Centers for Medicare & Medicaid Services created G code, G0136, to assess Medicare beneficiaries for the negative consequences of SDOH with no cost sharing when billed during an Annual Medicare Wellness (AMW) visit. We created a multidisciplinary intervention at our multi-site, Mid-West academic general internal medicine division utilizing our social work (SW) team to expand assessments. The goal was to standardize a process to identify vulnerable patients and improve revenue associated with billing code G0136 to increase reimbursement for the work done by the SW team. SWs generated a list of all scheduled AMW visits using the epic reporting workbench. An outreach encounter was created using a smartphrase with a standardized SDOH assessment. Attempts to administer the assessment were made through electronic portal messages and/or phone calls within 3 days of the visit. Positive assessments were routed to PCPs for review through the inbasket. PCPs were provided with a smart phrase that included cues for documentation and billing instructions. Education was provided to PCPs about the proposed workflow and G0136 code just prior to the rollout. Rollout began 6/1/24 as a pilot with dual eligible beneficiaries at clinic location #1 and has now expanded to three clinic locations for all Medicare beneficiaries. Units billed, charges, and payments were tracked using a data analytics tool called Qlik Sense© to track revenue performance. MEASURES OF SUCCESS: Total AMW visits, SDOH outreach encounters, assessments completed, positive SDOH assessments by clinic site. Pre/post: G0136 units billed, charges for G0136, payments for G0136. FINDINGS TO DATE: 603 total AMW visits, 542 SDOH outreach encounters (89.9% of all AMW visits), 345 assessments completed (57.2% of AMW visits), 25 positive SDOH assessments (7.2% of completed assessments), 19 positive SDOH assessments at urban clinic sites (8.3% of completed assessments-- site specific) v 6 patients at the suburban clinic site (5.2% of completed assessments—site specific). Pre/post: 6/12 G0136 units billed, $420/980 charges for G0136, $84.34 /156.1 payments for G0136. KEY LESSONS FOR DISSEMINATION: SDOH assessment at AMW visits can identify unrecognized needs in Medicare patients, providing the opportunity to facilitate connection with various resources. Collaboration between interdisciplinary teams can improve assessment rates by enhancing the role of SW, but the revenue generated does not meaningfully impact the SW budget. Future efforts should prioritize efficient SDOH assessment to allow for reallocation of SW time. We plan to expand SDOH assessment to include AMW visit check in. We are interested in exploring differences between positive assessment rates based on modality used and demographic data. IMPLEMENTATION OF A FREE GROCERY DELIVERY PROGRAM FOR FOOD INSECURE OLDER ADULTS Ines Robles Aponte5; Carolina Cortes-Rivera1; Carey Jernigan2; Stephanie Moshier1; Evianna Cruz Herrera3; Alyson Rosenthal1; Dodi Meyer2,4; Nadia Liyanage-Don5. 1West Side Campaign Against Hunger, New York, NY; 2New York Presbyterian Hospital, New York, NY; 3Pediatric Gastroenterology, Hepatology & Nutrition, Columbia University Irving Medical Center, New York, NY; 4Pediatrics, Columbia University Irving Medical Center, New York, NY; 5Internal Medicine, Columbia University Irving Medical Center, New York, NY. (Control ID #4269443) STATEMENT OF PROBLEM/QUESTION: Despite the growing number of interventions to address food insecurity (FI) in clinical settings, little is known about their implementation in older adult populations. DESCRIPTION OF PROGRAM/INTERVENTION: Food insecurity (FI) affects 1 in 6 people in the U.S., with a disproportionate burden on minorities, low-income individuals, and the elderly. Older adults (≥65 years) are particularly vulnerable to FI due to physical and cognitive limitations, multimorbidity, restricted incomes, and lack of social support, which in turn increases their risk for adverse health outcomes. This has led to the development of various clinical interventions to address FI, which have proven effective for improving food access and diet quality in the short-term. However, the long-term impact on health outcomes is unknown. Furthermore, there is limited evidence on how to tailor FI interventions to adequately meet the needs of food insecure older adults. In response, physicians at a multi-site urban academic health system partnered with a local hunger advocacy organization to create a mobile food pantry that provides high-risk older adult patients with free, healthy, culturally-appropriate groceries. Eligibility: age ≥65 years, positive screen for FI, ≥2 ED visits in the last year, access to a kitchen, able to cook and receive home deliveries. Patients use an online ordering system to select grocery boxes consisting primarily of fresh produce that are delivered directly to their homes every 2 weeks for 6 months. Patients are also connected with government food assistance programs if not already enrolled. MEASURES OF SUCCESS: Feasibility will be based on the proportion of eligible patients who enroll and the proportion of enrolled patients who complete the 6-month program. Reach will be assessed by comparing the sociodemographic and clinical characteristics of eligible patients who did vs did not enroll. Barriers and facilitators to program participation will be identified during semi-structured interviews with eligible patients. Clinical impact will be measured as change in cardiovascular risk factors (blood pressure, cholesterol, glycosylated hemoglobin, body mass index) pre/post program enrollment using EHR data. FINDINGS TO DATE: From Jan 2023 to Aug 2024, 365 patients ages ≥65 years were enrolled in the program. Mean age was 74.8 ± 5.9 years, 62% were female, 64% were Hispanic, 72% were non-White, and 61% were non-English speaking. Over half (57%) of participants were already enrolled in government food assistance programs (e.g., SNAP, WIC). Patient interviews will be conducted over the coming months, and analysis of clinical outcomes data is ongoing. KEY LESSONS FOR DISSEMINATION: FI is prevalent among older adult patients and existing public resources are insufficient to fully address this need. Our grocery delivery program is a novel approach to overcoming food access barriers in this vulnerable population. Additional research is needed to determine the impact on long-term clinical outcomes, as well as how to tailor the program to meet the specific needs of older adults. LEVERAGING A COUNTY HEALTH SYSTEM AND UNIVERSITY PARTNERSHIP TO ADDRESS FOOD INSECURITY BY PROMOTING AND IMPROVING DISTRIBUTION AND USE OF LOCAL FOOD RESOURCES Fatinah Darwish-Elsherbiny3; Julia Caldwell3; Gloria E. Moon1; charmaine dorsey4; Alejandra Casillas2; Arleen F. Brown2; Dipa Shah3; Tony Kuo3. 1Medicine, University of California System, Oakland, CA; 2Medicine, University of California Los Angeles, Los Angeles, CA; 3Los Angeles County Department of Public Health, Los Angeles, CA; 4Los Angeles County Department of Health Services, Los Angeles, CA. (Control ID #4267932) STATEMENT OF PROBLEM/QUESTION: In Los Angeles County, 25% of all households experienced food insecurity in the past year; this rate was 41% for low-income households. To address this public health problem, the Los Angeles County Departments of Public Health (DPH) and Health Services (DHS) formed a learning collaborative in 2021 to promote and improve the distribution and use of local food resources among safety-net patients. Named the “Los Angeles County Food Rx Collaborative”, the group partnered with hospitals, outpatient clinics, and wellness centers to increase food access among these patients. In 2023, the NIH DECIPHeR team at the University of California, Los Angeles (UCLA) joined the Collaborative, bolstering its ability to facilitate higher quality produce events at these healthcare sites. DESCRIPTION OF PROGRAM/INTERVENTION: The public health/health system partnership built upon a 2022 organizational assessment that evaluated the progress of Collaborative stakeholders in implementing a 2-item food insecurity screener, referrals to food resources, and onsite produce events at healthcare sites. It reviewed assessment outcomes (findings), using them to develop a practical framework (i.e., with a focus on feasibility, staff capacity, resource availability) to improve distribution and use of local food resources by safety-net patients. MEASURES OF SUCCESS: Program success was predicated on a better understanding of: (i) the target patient groups’ socio-demographic characteristics and experiences with onsite produce events at healthcare sites; and (ii) identified gaps in staff capacity and patient needs. FINDINGS TO DATE: In 2024, DPH and UCLA led a program evaluation that surveyed 497 patients who attended free produce events held at 16 County safety-net healthcare sites. For the survey, both institutions provided operational support for data collection, including participant incentives and volunteers to run logistics. An organizational assessment was also conducted looking at staff capacity and infrastructure. Among participating healthcare sites, 14 of 16 completed the latter assessment. Results indicate, that for produce events, sites took an average of 3 to 4 hours to prepare, distribute, and clean up afterwards. Six sites reported inadequate staff capacity to run the events. In response to this workload need and shortage in staffing, UCLA released a competitive small grant to help select 3 community-based organizations that could provide experienced personnel (2 for 3-4 hour shifts) to work the produce events at designated healthcare sites. KEY LESSONS FOR DISSEMINATION: The Food Rx Collaborative is a promising practice for addressing food insecurity in a large jurisdiction like Los Angeles County. Program progress to date suggests that the learning effort was able to effectively leverage local government and university (academia) resources to increase healthy food access for low-income patients who rely on safety-net health clinics for usual care. MONEY AS MEDICINE: FREE TAX PREPARATION FOR LOW-INCOME PATIENTS AND STAFF Suhas Gondi1; Rohan Khazanchi2; Adam L. Beckman1; David E. Velasquez1. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Departments of Internal Medicine and Pediatrics, Brigham and Women's Hospital, Boston, MA. (Control ID #4270531) STATEMENT OF PROBLEM/QUESTION: Low-income Americans qualify for tax credits such as the earned income tax credit (EITC) and child tax credit (CTC). These credits are powerful antipoverty tools and studies show they improve health outcomes. Unfortunately, the EITC and CTC are under-utilized. For example, 20% of eligible workers do not receive the EITC, often due to incomplete or inaccurate tax filing. While the government provides free assistance with taxes for low-income people, these services have limited reach. In fact, low-income families lose $2 billion annually to the for-profit tax-filing industry. Simultaneously, many low-income patients struggle to afford medications, adopt healthy lifestyles, and prioritize their well-being due to financial constraints. DESCRIPTION OF PROGRAM/INTERVENTION: Building on existing models of medical-financial partnerships that have returned thousands of dollars to patients and staff through tax credits, we developed Money as Medicine to perform clinic-based screening for tax credit eligibility and referral to community partners for free assistance with tax preparation. Awareness is raised across clinical sites through fliers, posters, staff/clinician education, emails, and patient portal messages. Enrollment is done through forms available online and in paper, available in English and Spanish. Eligible people are referred to ABCD Boston, a community-based nonprofit, for free tax preparation services. We also coordinated for ABCD Boston to hold weekly tax preparation sessions at a local community health center during tax season. These sessions are open to patients, staff, and community members. MEASURES OF SUCCESS: # of people reached through awareness campaigns. # of people who enroll through online or paper enrollment forms. # of eligible people who make appointments. % of appointments that are attended versus no-show. # of people who file taxes through Money as Medicine. Total $ returned to those filers. Cumulative value of tax credits received by those filers. Satisfaction among those filers with the process. Clinic interest in repeating the program in future years. FINDINGS TO DATE: During our first tax season, we received 157 enrollments. Most indicated their doctor is at Brookside Community Health Center, where we offered in-clinic tax preparation. 19 tax returned were filed at Brookside, totaling $29,869 in dollars returned to those filers from state and federal government. Relatively few were EITC (2) or CTC (3) eligible. 7 tax returns were filed elsewhere at community sites. KEY LESSONS FOR DISSEMINATION: Resident-led medical-financial partnerships are both feasible and impactful. We learned starting to raise awareness and enroll people early is key because filing earlier leads to tax returns arriving earlier. In-person tabling and other active forms of engagement are superior to passive forms (e.g., fliers). Trusted community partners are invaluable, and expectations should be set early regarding norms around communication and data sharing. Low-income patients are more likely to engage with interventions offered through trusted messengers. ON-DEMAND PATIENT NAVIGATION: AN AI-SUPPORTED SOLUTION FOR ADDRESSING HEALTH RELATED SOCIAL NEEDS IN OUTPATIENT CARE Leah Taffel2,4; Sheila Phicil4; Krishna Varela Poole4; Kwamane Liddell3; Pablo Buitron de la Vega1,4. 1General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 2Geriatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 3ThriveLink, Saint Louis, MO; 4Boston Medical Center, Boston, MA. (Control ID #4244375) STATEMENT OF PROBLEM/QUESTION: Healthcare institutions struggle to address patients' health-related social needs (HRSN) due to limited resources, with the cost of full-time patient navigators (PNs) often being prohibitive. DESCRIPTION OF PROGRAM/INTERVENTION: From July-November 2024, we implemented a novel HRSN navigation program in an academic safety net hospital's geriatric clinic in the Northeast region. The intervention leveraged existing universal HRSN screening, allowing providers to electronically refer patients who screened positive to an organization providing on-demand, AI-supported PN services. PNs offered three types of support: 1) education about known HRSN services, 2) assistance with applications for city/state/federal programs, or 3) facilitation of community resource referrals. AI capabilities enabled PN to efficiently complete complex applications. The program team met weekly to review outcomes and address barriers. MEASURES OF SUCCESS: We evaluated the feasibility of the program through provider referral completion rates and successful patient contacts. Impact was measured by tracking education provided to patients, resource connections (applications submitted and/or community referral made), and monetary value of secured benefits. We also collected qualitative data. FINDINGS TO DATE: PNs attempted contact with 98% (101/103) of provider referrals and successfully reached 59% (61/103). Among contacted patients, 19 received education about navigating existing HRSN services, while 42 needed direct assistance. These 42 patients had multiple HRSNs, resulting in 59 resource connections: 39 program applications (e.g., housing, insurance, SNAP, transportation) and 20 community resource referrals (e.g., food pantries). Of the 39 program applications, 20.5% were approved, generating $19,000 in benefits, 71.8% are pending, and 7.7% were denied. Of the 20 community resource referrals, 25% confirmed receipt of support (including services such as emergency housing placement, hygiene supplies, clothing banks, and caregiver support services) and for 75% of referrals, primarily to food pantries, confirmation of service utilization could not be obtained despite successful referral completion. The cost of the on-demand PN service was $4,250 for five months versus an estimated $23,000 for a full-time PN. Qualitative data revealed meaningful impact: patients reported feeling "alive again" after receiving support, successfully obtained affordable housing through lottery applications, secured health insurance coverage after navigation support with documentation requirements, and accessed affordable medications through insurance plan optimization. KEY LESSONS FOR DISSEMINATION: On-demand, AI-supported PN services offer a feasible, cost-effective model even for older adults. Weekly program oversight enables effective troubleshooting while preserving frontline staff time. Though upstream determinants require systematic attention, this model provides impactful interim patient support with substantial return on investment. YEAR TWO, WE FOLLOW THROUGH: LONGITUDINAL SOCIAL DETERMINANTS OF HEALTH SCREENING IN A LARGE ACADEMIC RESIDENT PRACTICE Daniel J. Coletti1,2; Anna Andrews3; Elise Rooney4; Anne Chen1; Jason Alvarenga3; Jennifer Verbsky5. 1Medicine, Northwell Health, Great Neck, NY; 2Psychiatry and Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; 3General internal Medicine, Northwell Health, New Hyde Park, NY; 4General Internal Medicine, Northwell Health, New Hyde Park, NY; 5Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4272310) STATEMENT OF PROBLEM/QUESTION: Identifying social determinants of health (SDH) is a new universal healthcare mandate, requiring ambulatory practices to develop protocols to screen for and support patients with social needs. In order for primary care practices to recognize the impact of their protocols on addressing patient needs, it is important to assess response to assistance and to detect changes in patient needs over time. Passive referral for social work services or community-based resources is unlikely to serve as a sufficient intervention for most patients with complex needs. Therefore, triaging acuity and tailoring care management support is critical to help those in most need, particularly in the presence of limited primary care and social work resources. DESCRIPTION OF PROGRAM/INTERVENTION: This report examines social need identification patterns within our ongoing “DGIM Connections” SDH program. This initiative facilitates regular assessment of SDH and stepped support for patients with self-reported needs. Step 1: Positive screens are reviewed by the medical provider and patients are provided with written materials about local resources in the examining room. Step 2: Patients with more complex needs are connected to our social work team for further assessment and referrals that are curated to patient needs and preferences. MEASURES OF SUCCESS: Since April of 2023 we have compiled a secured database of 3,369 SDH surveys on 3,236 unique patients. Social needs are assessed using a validated self-report survey completed during all new patient visits and comprehensive physical exams. We are now screening patients returning for their subsequent annual exam and are comparing follow-up assessment to patterns of identified need at their first encounter, with the hope that fewer needs are identified after receiving our support. FINDINGS TO DATE: Since program inception we have assessed 129 patients two or more times. Among these repeat patients 31 (24%) endorsed a social need at initial assessment, and a total of 40 patients (31%) reported ≥1 need at either baseline or at follow-up. The majority of patients screening positive at baseline (21/31 or 68%) reported no needs (n=12) or fewer needs (n=9) at follow-up. Patients with needs at any time were more likely to be uninsured (P<.001) and non-English speaking (p<.001). KEY LESSONS FOR DISSEMINATION: As we continue our comprehensive SDH screening program utilizing existing resources, initial data suggest some “wins” in ameliorating social needs by implementing what now will be an annual assessment. Longitudinal screening has helped us identify a population of patients who have persistent needs for targeted and more comprehensive intervention. The emergence of new needs at a second screening underscores the importance of repeated assessment, either because of the evolving nature of social needs and/or increased comfort asking for help as assistance is offered routinely and repeatedly. These preliminary datapoints support the effectiveness of our model of graduated patient support that could be replicated in other primary care settings. Innovation in Healthcare Delivery (IHD) - Vulnerable Populations CHRONIC DISEASE SELF-MANAGEMENT PROGRAM IMPLEMENTATION WITH COMMUNITY HEALTH WORKERS Thao-Vi Dao1; Sarah Reinhold2; Alex Rennick4; Amy Shideler2; Elizabeth R. Pfoh3. 1Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; 2Community Health Equity, Cleveland Clinic, Cleveland, OH; 3Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; 4Community Health and Equity, Cleveland Clinic, Cleveland, OH. (Control ID #4237142) STATEMENT OF PROBLEM/QUESTION: Self-management skills are important for managing chronic disease without which patients’ health can decline. Marginalized populations may not have learned these skills due to historic disinvestment in education and health care access. For those with both chronic health and complex social needs, this lack of knowledge exacerbates disparities in health outcomes. DESCRIPTION OF PROGRAM/INTERVENTION: In January 2024, we launched the Chronic Disease Self-Management Program (CDSMP) through a license with the Self-Management Resource Center. It was led by 2 community health workers (CHWs), who have lived experience to understand the context within which participants are managing their health. The program was hosted at a community health center located in a neighborhood deeply impacted by disinvestment due to historic redlining. We held 5 sessions, each lasting 6 weeks for 2.5 hours each class with 10-16 participants per session. Participants are empowered to learn self-management skills, including managing symptoms, communicating with providers, and implementing behavior change. An internal grant funded the program, which ensured funding for transportation and in-session food for participants. Our local IRB deemed this a quality improvement project. MEASURES OF SUCCESS: The program’s goal was to have participants complete 4 of 6 classes. Participants completed pre- and post-session validated surveys measuring self-efficacy (Self-Efficacy for Managing Chronic Disease 6-Item Scale), medication adherence (Single-Item Self-Rating Adherence Scale), health behaviors (Exercise Behaviors Survey), and satisfaction with the program (Long Form Participant Satisfaction Survey). FINDINGS TO DATE: In 2024, 67 participants began the program. Sixty participants (90%) attended ≥4 classes, with 5 out of 6 classes completed on average. Thirty-six of 67 (54%) participants used our transportation resource. Self-efficacy score improved by an average of 5.1 points, out of a total score of 33 points. All participants who initially reported fair medication adherence and/or no exercise weekly reported improvement after program completion. Participants were highly satisfied with the program, with 94% responding that they agreed or strongly agreed to “this workshop has helped me take responsibility of my health” and 100% responding agreed or strongly agreed to “I would recommend this workshop to someone with a chronic health condition”. KEY LESSONS FOR DISSEMINATION: Using CHWs to lead the program ensured culturally relevant content and a trusting environment, resulting in a very high completion rate. Offering transportation was critical to participant retention. Collecting information from participants about self-efficacy, satisfaction with the program, and health behaviors is key to refining and sustaining the program, because evidence of success is required for institutional support and funding beyond the grant period. DEVELOPING AN INTEGRATED WEIGHT MANAGEMENT PROGRAM AT A COMMUNITY HEALTH CENTER: AN INTERVENTION TO ADDRESS OBESITY IN UNDERSERVED POPULATIONS. Girija Phadke1; Celia Bora2. 1General Internal Medicine, Lahey Hospital & Medical Center, Burlington, MA; 2NeighborHealth, East Boston, MA. (Control ID #4270443) STATEMENT OF PROBLEM/QUESTION: Obesity is associated with serious comorbidities and disproportionately affects underserved populations who often have limited access to evidence-based weight management programs. DESCRIPTION OF PROGRAM/INTERVENTION: Obesity has been associated with chronic diseases such as diabetes mellitus, hypertension, and heart disease, which are all leading causes of mortality and morbidity in the U.S. A modest weight loss of 5-10% can improve these conditions, making weight management a critical intervention to reduce chronic disease. Obesity has a disproportionately high prevalence among the non-Hispanic Black and Hispanic populations. These populations also experience language and cultural barriers, bias among healthcare workers, and financial barriers – particularly the lack of weight management services covered by Medicare and Medicaid, which limits their access to care. We developed an adult weight management program in a large, federally qualified health center (FQHC) with the goal of providing multi-modality, culturally competent, accessible weight management care. The program was informed by key personnel within the FQHC and through consultation with leadership of a hospital-based weight management program. We determined that co-location of this program within the primary care Internal Medicine Department would allow for utilization of existing space and staffing, while reducing patient barriers to access. The IT department created a referral and visit workflow within our electronic medical record. Two continuing medical education sessions were offered to our clinicians to educate them on obesity management, and the appropriate use of the new program. At the time the program was launched, the state Medicaid program did not cover any weight loss pharmacotherapy. However, we were able to make weight loss pharmacotherapy affordable for patients due to the health center’s participation in the 340B drug pricing program. At the launch in May 2022, the program was staffed by three part time employees, a physician, a nurse practitioner and a nutritionist. Later, a social worker was added to provide behavioral health support. MEASURES OF SUCCESS: Increased access to weight management care for historically underserved communities as measured by the volume of referrals to the program and the number of visits conducted. FINDINGS TO DATE: From July, 2022 through June, 2023, 982 internal referrals were placed to the program. 263 visits were completed during year 1, demonstrating the need for program growth to accommodate referral volume. KEY LESSONS FOR DISSEMINATION: Implementing community-based integrated weight management programs increases access to weight management services for underserved communities. Specific resources may vary at different health centers; however, utilizing existing clinical infrastructure reduces costs for personnel and space. Placing the program within the patient’s primary care office reduces barriers to care and builds on the trusting relationships patients may already have with their care team. EXPLORING A HOSPITAL’S ROLE IN ADDRESSING HOMELESSNESS: A QUALITATIVE EVALUATION OF A HOSPITAL-HOUSING PARTNERSHIP FOR SENIORS AND DISABLED PATIENTS Rebekah A. Davis1; Adnan Syed2; Sara Shemali5; Taylor Sun4; Sarah A. Stella3. 1n/a, University of Colorado School of Medicine, Denver, CO; 2Research, VA Eastern Colorado Health Care System, Aurora, CO; 3Department of Medicine, Denver Health, Denver, CO; 4Denver Health, Denver, CO; 5University of California Berkeley, Berkeley, CA. (Control ID #4267073) STATEMENT OF PROBLEM/QUESTION: Homelessness is prevalent in hospitalized patients and associated with adverse outcomes, but hospitalization is frequently a missed opportunity for meaningful connection to housing and support that could mitigate these outcomes. DESCRIPTION OF PROGRAM/INTERVENTION: In December 2023, a safety-net hospital located in the mountain west partnered with a local housing authority to launch a transitional housing program for at-risk hospitalized patients experiencing homelessness. Located on the main hospital campus, the housing program provides 14 housing units for elderly or disabled patients, who are identified during hospitalization and discharged directly into the program where they receive support from a social worker and a housing navigator through a shared staffing model. The program aims to stabilize health conditions, reduce avoidable acute care utilization by increasing engagement in primary and preventative healthcare, foster community connections to address health related-social needs, and facilitate entry into permanent housing. MEASURES OF SUCCESS: We conducted semi-structured interviews with16 participants who had been enrolled in the program for at least 45 days. Interviews explored participants’ perceptions of the program’s acceptability, benefits, barriers, and impact on health and resource access. Thematic analysis was conducted with themes identified a priori and inductively through content analysis. FINDINGS TO DATE: Three main themes emerged from data analysis: 1) Perceived Benefits: Participants valued having a dedicated case manager to assist with obtaining vital identity documentation and applying for public assistance, and appreciated the proximity of housing to healthcare services; 2) Health Improvements and Enhanced Access to Care: Participants reported improved medication adherence and more consistent attendance at medical appointments; 3) Impact on Well-being: Participants expressed deep gratitude for the housing opportunity, describing it as a pivotal step toward securing permanent housing. For some, it was their first time off the streets in over a decade. They shared stories of past homelessness with program staff to assess implementation challenges and identify opportunities for improvement, and contrasted those experiences with their new environment. Additional program evaluation will examine staff perspectives and assess the program’s longer-term impact on housing and health outcomes. KEY LESSONS FOR DISSEMINATION: Our evaluation suggests that this transitional housing program is highly regarded by participants, providing meaningful improvements to physical and mental well-being, and improved access to critical supports. Our findings underscore the importance of housing-health partnerships in addressing the complex needs of individuals experiencing homelessness, including those utilizing hospital systems. HEALTHCARE IN THE COURT!: A NOVEL TRANSITIONS OF CARE CLINIC WITHIN A COMMUNITY COURT Eugene Keener1; Anupama M. Kapadia1; DeLawnia Comer-HaGans2. 1Internal Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX; 2Office of Health Equity, The University of Texas at Austin Dell Medical School, Austin, TX. (Control ID #4271763) STATEMENT OF PROBLEM/QUESTION: There is no healthcare program that is dedicated to caring for patients released from incarceration in Austin, Texas. DESCRIPTION OF PROGRAM/INTERVENTION: We developed and implemented a low-barrier primary care mobile clinic within the Downtown Austin Community Court (DACC) in Austin, Texas. The goal is two-fold: 1) to facilitate connection to healthcare for a marginalized population of patients living at the intersection of housing instability and criminal justice involvement and 2) to support transitions of care for patients recently released from incarceration. The care team includes a primary care and addiction medicine provider, behavioral health counselor, nurse, medical assistants, and a care coordinator. Patients are seen the same day and linked to medical and mental health care within a local federally qualified health center. The clinic currently sees patients twice per month. MEASURES OF SUCCESS: Metrics include number of patient visits and continued linkage to care FINDINGS TO DATE: The clinic served 43 patients in the first 4 months of implementation. Patients had high rates of mental illness, including depression, anxiety, PTSD, bipolar disorder, and schizophrenia. They also had high rates of substance use disorders, particularly stimulant use and tobacco use. Hypertension was the most common medical condition. Of all patients seen , 37% were linked to further healthcare. Additional patients may have been linked to mental health care within the county mental health authority, though this was unable to be measured due to limitations with data-sharing. Limitations to data collection include that information was based on chart review prior to standardization of information gathered during history-taking. KEY LESSONS FOR DISSEMINATION: The creation of a low-barrier primary care clinic within a community court is a novel approach to support diversion efforts and to provide transitions of care for recently incarcerated individuals who are at high-risk of significant morbidity and mortality at the time of release. DACC is presided over by a local judge who works to divert individuals away from incarceration and into supportive services. DACC is located in downtown Austin, a short distance from a Travis County jail. By situating a pop-up primary care clinic within this facility, we can reach patients that otherwise would have difficulty accessing primary care and mental health services. We learned that patients seen in this clinic had high rates of mental illness, substance use, cardiovascular disease including hypertension, and chronic musculoskeletal pain. One barrier to linking these patients to further care is lack of access to a reliable phone and transportation. By integrating our healthcare services within the case management services already being provided at the community court, we can help patients address these barriers. Future directions include creating a transitions of care clinic system in consultation with Transitions Clinic Network, incorporating more mental health services within the clinic, and growing to a once weekly clinic. INNOVATIVE CLINICAL COMMUNITY HEART HEALTH PROGRAM ACHIEVES LASTING BLOOD PRESSURE CONTROL AFTER SIX MONTHS Priya Sarin Gupta1,2; Cesar Guerra Castillo3; Seyda Kilic3; Kaileen Kirkwood4; Sara Keen4; Elsie Taveras5,2. 1Medicine, Massachusetts General Hospital, Newton, MA; 2Harvard Medical School, Boston, MA; 3Mass General Brigham Inc, Boston, MA; 4Network Development, Mass General Brigham Inc, Boston, MA; 5Community Health, Mass General Brigham Inc, Boston, MA. (Control ID #4272794) STATEMENT OF PROBLEM/QUESTION: Data shows a critical need for improved hypertension management in our urban community especially among minoritized patients where limited healthcare access, inflexible appointment times, and lack of culturally competent care contribute to exacerbating health disparities and preventable complications like heart disease and stroke. DESCRIPTION OF PROGRAM/INTERVENTION: This clinical community program in an urban setting in the northeast offers convenient heart health services in partnership with a non-traditional community based organization, a retail pharmacy, to improve health outcomes and narrow equity gaps for targeted chronic conditions. By collaborating with clinical, pharmacy, and community health workers, the program addresses social needs, improves medication adherence, and utilizes pharmacists as vital community resources. Patients are self recruited into care through messaging or referred by their physicians or at discharge from area emergency rooms. Visits are conducted by an on-site physician or nurse practitioner and during visit, patients were also seen by a community health worker. Follow-ups are conducted via phone or in-store by a nurse practitioner at 1 week, 3 months, and 6 months post-visit to ensure ongoing care and support. MEASURES OF SUCCESS: Measures: -demographics of patients -monitor improvements in patients’ readings over three blood pressure checks within 12 months. -identification and addressing social risk FINDINGS TO DATE: Since February 2024, the program has served over 200 unique patients across three locations. Among these patients, 29.3% were Black or African American, 29.3% were Hispanic. At initial visits, 38% had uncontrolled blood pressure. Social Determinants of Health screenings identified 40.2% with positive indicators, leading to connections with community health workers for care coordination. Emergency department referrals for some patients helped prevent potential complications, highlighting the program's effectiveness in improving cardiovascular care access and addressing health disparities in underserved areas. Clinical care provided consisted of initiation of pharmacotherapy, titration of pharmacotherapy, provision and education of home blood pressure monitor as well as health education focused on American Heart Association's, Life’s Essential 8 (exercise, diet, sleep, tobacco cessation, control cholesterol, manage blood sugar). Follow up of patients (450 encounters) resulted in sustained blood pressure control at a rate of 78.6% for those individuals (N=76) who initially presented at point of care with increased blood pressure (greater than 140/90). KEY LESSONS FOR DISSEMINATION: The program aims to improve access to care through convenient times and locations and empower patients to take care of their heart health. Early findings which show sustained improvement in blood pressure which suggests that this care management model with an embedded partnership between an academic medical center and a retail pharmacy, has potential to improve blood pressure health outcomes in majority of engaged individuals. VITALS CLINIC: A NOVEL COMMUNITY PROGRAM TO MITIGATE DIABETES AND HYPERTENSION AMONG THE UNHOUSED COMMUNITY Sonam Kumari1; Sanjana Neeli2,1; Kirti Malhotra3,1; Nathaniel M. Lime1; Abhignya Uppalapati1. 1School of Medicine, University of California Davis, Davis, CA; 2University of California Davis, Davis, CA; 3General Internal Medicine, University of California Davis Medical Center, Sacramento, CA. (Control ID #4271242) STATEMENT OF PROBLEM/QUESTION: Structural inequities drive housing instability, high uninsurance rates, and financial adversity, often preventing individuals from accessing medical interventions needed to mitigate chronic conditions. DESCRIPTION OF PROGRAM/INTERVENTION: A novel vitals monitoring service named “Vitals Clinic” (VC) was implemented at an outpatient community clinic located at a transitional housing center. VC allows patients to get their vitals measured in a streamlined clinic visit with reduced wait times. MEASURES OF SUCCESS: This project aims to assess service impact, utilization rates, and the burden of diabetes and hypertension among our patient population. Long wait-times and appointments are notable barriers to care in our general medical clinic, preventing patients from addressing pressing needs. At VC, check-in/out times are recorded to measure efficiency. Vitals recorded include blood pressure, blood glucose, heart rate, oxygen saturation, and respiratory rate. Information regarding pre-existing conditions and medication management is collected. Visit outcomes are assessed as (1) within normal range, (2) elevated readings, seen in general clinic (3) elevated readings, refused general clinic, and (4) emergency services called. Patients with abnormal readings are encouraged to consult with the on-site physician to ensure adequate management of the underlying condition. Finally, patients receive a physical summary of their measured vitals to bring to future visits. Vitals are also recorded on Practice Fusion, an EMR shared between VC and the medical clinic, for internal records. For data assessment, unique identifiers are assigned to patients to assess longitudinal trends in a password protected database. FINDINGS TO DATE: According to clinic data, 60% of patients have a pre-existing hypertension diagnosis, and over 30% of clinic encounters include a blood pressure reading aligned with uncontrolled hypertension (≥140/90). Prevalence of comorbid diseases include diabetes (8%) and depression (46%). Since the start of VC in March 2024, 31% of patients have returned for follow-up. 100% of VC patients have requested for a blood pressure check, and over 50% have requested a blood-glucose check. 23% of patients have had an abnormal reading, and received a referral to the medical clinic. KEY LESSONS FOR DISSEMINATION: The success of healthcare delivery programs for underserved patients is contingent on their ability to address underlying barriers. VC was a response to challenges surrounding access and health maintenance for chronic conditions. While assessing vitals as a proxy to measure overall health is crucial in the management and prevention of disease complications, providing options is important to facilitate patient engagement, trust, and agency. The Vitals Clinic is a versatile and flexible community-health model, and a promising approach to address gaps in care. Findings from this project are continuing to inform further quality improvement initiatives that address health disparities affecting unhoused patients. Innovation in Healthcare Delivery (IHD) - Women’s Health, Sex, and Gender-Informed Medicine IMPLEMENTATION OF A REPRODUCTIVE GOALS SMARTFORM TO IMPROVE CONTRACEPTION AND PRECONCEPTION COUNSELING IN AN INTERNAL MEDICINE RESIDENT CLINIC WITHIN A SAFETY-NET HEALTH SYSTEM Rondalyn R. Dickens1; Emily Decicco1; Heather Wainstein2. 1Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 2General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4266381) STATEMENT OF PROBLEM/QUESTION: This project aims to implement a standardized tool (SmartForm) in the electronic medical record to facilitate reproductive goals counseling. DESCRIPTION OF PROGRAM/INTERVENTION: The QI project is being conducted from April to December 2024 in an internal medicine resident clinic within a Southern safety-net health system. The target patient population is females ages 18-49 who have not yet undergone menopause or permanent sterilization. The SmartForm is based on “One Key Question”: Would you like to become pregnant in the next year? Based on the patient’s answer of yes, no, or unsure, additional prompts guide counseling on preconception, contraception (including emergency contraception), or a combination of both. A best practice alert (BPA) reminds residents to complete the SmartForm during clinic visits. The SmartForm directs residents to an order set (SmartSet) to simplify prescribing contraception and referring to gynecology for long-acting reversible contraception (LARC) placement. MEASURES OF SUCCESS: We aim to increase completion of the SmartForm from 0 to 50% for eligible patients seen in clinic during the study period. We will collect interim feedback on the SmartForm and SmartSets’ usability. Secondary outcomes will include (1) resident reproductive counseling practices and barriers to counseling based on pre-and post-survey responses and (2) rates of residents ordering contraception, emergency contraception, and gynecology referrals for LARC placement pre-and post-intervention. FINDINGS TO DATE: The pre-survey was completed by 54 residents. Only 17% of the residents reported asking their female clinic patients of reproductive age about their reproductive goals or desire to get pregnant often or routinely. The leading barriers to reproductive goal counseling were not enough time during clinic visits and uncertainty about contraceptive options available. A survey to assess usability of the smart tools was completed by 20 residents. 12 had never completed the SmartForm, citing barriers of limited time, more pressing issues, few eligible patients, and not realizing it existed. Of the 8 residents who had used the SmartForm, 87% were satisfied with the ease of completing it and 75% were satisfied with completion time. Only 2 of these 8 residents had utilized the Contraception SmartSet, with the others stating they didn't need it or forgot it existed. KEY LESSONS FOR DISSEMINATION: The initial data suggests the SmartForm has been well received in terms of ease of use and time to complete; however, both smart tools appear to be underutilized. Since starting this initiative, we have implemented several improvements, including addressing technical issues with the tools, posting reminders in clinic, and adding links to contraception counseling tools to the SmartForm. The current BPA is noninterruptive, and thus, a future consideration is to trial an active alert to improve SmartForm completion rates. Implementing these smart tools in other primary care settings, as well as creating modified tools for subspecialty clinics, is currently being explored. INTEGRATING WOMEN’S HEALTH TRAINING TO BOOST PAP SMEAR RATES: BRIDGING GAPS IN PREVENTIVE CARE AND RESIDENT EDUCATION Madison Panell1; Sumbal Wajid1; Josephine Lee1; Alice Varughese2; Ann-Marie Wilhelm2; Megan R. Gerber2. 1Medicine, Albany Medical Center, Albany, NY; 2Medicine, Albany Medical College, Albany, NY. (Control ID #4270487) STATEMENT OF PROBLEM/QUESTION: Cervical cancer is the most commonly diagnosed gynecologic malignancy worldwide. Early detection offers excellent outcomes, with a 5-year survival rate exceeding 90%. Internal medicine physicians play a pivotal role in cervical cancer screening, particularly for patients without direct access to specialized gynecologic care. Despite their importance, internal medicine residency programs often provide inconsistent training in women’s health topics, including cervical cancer screening. This gap underscores the need for structured, hands-on training to ensure competency and confidence in these critical skills. This quality improvement project aimed to increase the number of Pap smears performed at the Internal Medicine Group (IMG) clinic by 50% over 6 months while identifying and addressing knowledge gaps in cervical cancer screening among internal medicine residents. DESCRIPTION OF PROGRAM/INTERVENTION: A baseline review of electronic health records identified the number of Pap smears performed at the clinic over a six-month pre-intervention period. A survey of 39 internal medicine residents (PGY-1 through PGY-3) assessed their baseline knowledge of cervical cancer screening guidelines, comfort levels, and interest in performing Pap smears during continuity clinic. To address gaps, the IMG women’s health clinic, established in 2022 by a chief resident and an attending physician with an interest in women’s health, was resumed with a focus on hands-on training. Residents with interest were scheduled for rotations on Wednesday mornings during primary care clinic blocks. Additionally, informational posters were displayed in exam rooms to encourage eligible patients to inquire about cervical cancer screening. MEASURES OF SUCCESS: Number of Pap smears performed at IMG clinic over the six-month post-intervention period FINDINGS TO DATE: Over the 6-month pre-intervention period, 16 Pap smears were performed at the IMG clinic. This increased to 37 Pap smears during the six-month post-intervention period, representing a 2.3-fold (131%) increase, exceeding the project’s goal. Surveys revealed that 62% (24/39) of residents had never performed a Pap smear or pelvic exam, and 69% (27/39) lacked confidence in these procedures. Despite this, 87% (34/39) of residents recognized the importance of proficiency in cervical cancer screening, and 30% (12/39) expressed interest in participating in the women’s health rotation. Ultimately, 9 residents completed the rotation during the intervention period. KEY LESSONS FOR DISSEMINATION: A structured women’s health rotation combined with patient-centered educational initiatives improved the number of Pap smears performed at the IMG clinic, highlighting the effectiveness of targeted interventions in addressing gaps in resident training. By integrating women’s health education into internal medicine residency programs, internal medicine physicians can enhance preventive care, particularly for underserved populations. Expanding these initiatives is essential for promoting equity in cervical cancer prevention and ensuring early detection. Innovation in Medical Education (IME) - Assessment of Learners ASSESSING EVIDENCE-BASED MEDICINE PROFICIENCY WITH AN INNOVATIVE OSCE Matthew J. Flanigan2,1; Eric J. Nolan2,1; Cynthia Leung3,1. 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Internal Medicine, The Ohio State University College of Medicine, Columbus, OH; 3Emergency Medicine, The Ohio State University, Columbus, OH. (Control ID #4272473) SETTING AND PARTICIPANTS: One hundred eighty-eight clerkship-year medical students at an academic medical center DESCRIPTION: An Objective Structured Clinical Examination (OSCE) was designed to assess evidence-based medicine (EBM) skills. Students interviewed a standardized patient with constipation and a family history of colon cancer to assess the need for colon cancer screening. They formulated clinical questions using the PICO (Population, Intervention, Comparison, Outcome) framework, conducted literature searches, identified relevant evidence, and developed patient-centered recommendations. Ten faculty raters assessed student performance using a structured rubric that incorporated case-specific background information, ensuring consistency and actionable feedback. The rubric was designed to facilitate fair and reliable evaluations without requiring faculty raters to have expertise in EBM. Students were allotted ten minutes for the interview and ten more minutes to complete the exercise. EVALUATION: Among 188 participants, the mean score was 84% (SD 10%), with 20 students (11%) scoring below 70%. Three students failed to complete the exercise within the allotted time. Although the exercise aimed to focus on family history as a screening indication, 32% of students focused their clinical questions on constipation, causing confusion and inconsistent evaluations among raters. To address these issues, the case was changed to a patient with gallstone pancreatitis and a query about cholecystectomy. Revisions included extending the post-interview time and refining the rubric to separately assess problem identification and the application of EBM. 185 students completed the revised exercise, with a mean score of 87% (SD 9%) and 8 (4%) students scoring below 70%. These students received targeted feedback to guide improvement. Faculty raters indicated that the modified rubric enhanced clarity and consistency in evaluations. On review, the targeted feedback provided to students was recognized as high quality in guiding their improvement. The revised exam demonstrated strong internal consistency (Cronbach’s alpha 0.71) and excellent inter-rater reliability (Cohen’s kappa 0.90).

/ REFLECTION / LESSONS LEARNED: EBM skills are essential for clinical decision-making, professional development, and improved patient outcomes. OSCEs provide a structured method to evaluate the application of EBM in realistic, simulated clinical scenarios. Our findings demonstrate that a well-designed EBM OSCE can reliably assess student proficiency, provide meaningful feedback, and produce consistent evaluations, even with non-expert raters. This is particularly significant, as surveys of deans and EBM educators highlight the shortage of EBM-proficient faculty as a key barrier to effective EBM education. Future directions include assessing the communication of EBM-based recommendations to patients, or integrating advanced decision-support tools, such as large language models, for real-time evidence retrieval and synthesis. ONLINE RESOURCE URL: n/a COMPARISON BETWEEN HUMAN AND GENERATIVE AI GRADING OF NARRATIVE RESPONSES AND PERSONALIZED FEEDBACK FOR LEARNERS Kristie Kim1; Zachary Peterson3; Robert Treat2; Sarkis Dagley1; Spenser Kaplan1; Dario Torre1. 1College of Medicine, University of Central Florida College of Medicine, Orlando, FL; 2Medical College of Wisconsin, Milwaukee, WI; 3No Affiliation, Orlando, FL. (Control ID #4270333) SETTING AND PARTICIPANTS: In the context of medical education, artificial intelligence (AI) has the exciting potential to automate grading and personalize learning experiences with immediate meaningful feedback. However, limited research exists as to how well AI tools can perform these functions. The purpose of this study was to compare scoring of clinical reasoning illness scripts of human raters vs. OpenAI’s GPT-4o. DESCRIPTION: 116 third-year medical students from an academic medical center were tasked to write the clinical features, including risk factors, history, physical exam, and diagnostic data (illness scripts) for two common diseases (acute pericarditis and acute pancreatitis) during a clinical reasoning intersession. Three senior students and one faculty member reviewed the students’ written scripts and extracted a score for each illness script based on a predetermined rubric. Scores were divided by illness script components: enabling condition, fault and consequence. Rater training was conducted by a faculty member using 10 cases. OpenAI’s GPT-4o Application Programming Interface (API) was provided with initial context on how to report scores, a one-paged rubric, the prompt, and 10 examples of graded scripts. Inter-rater reliability of human and GPT-4o ratings was calculated using intra-class correlation coefficients (ICC(2,1)) using SPSS 28.0. Dependent and independent t-tests were used to compare human and AI scoring. EVALUATION: 116 illness scripts for each disease were obtained, for a total of 232 scripts. Intra-class correlations (ICC) for acute pericarditis and acute pancreatitis between human and AI raters were 0.72 and 0.81, respectively, indicating moderate to good correlation. There were statistically significant (p<0.001, Cohen's d=0.5) mean differences in the enabling condition scores for acute pericarditis between human (1.6(1.0)) and AI (2.2(1.2)). There were statistically significant (p<0.001, Cohen's d=0.3) mean differences in the consequence scores for acute pancreatitis between human (7.1(2.6)) and AI (7.8(2.6)). There was a statistically significant difference (p=0.041, d=0.2)) in consequences scores for acute pericarditis (6.3(2.0)) and in enabling conditions for acute pancreatitis (6.0(2.1)) between human and AI ratings. AI scored 232 student responses in less than 10 minutes, providing justification/feedback for each of 232 ratings. See URL for an interactive website providing AI-generated scores, score breakdown, and personalized constructive feedback.

/ REFLECTION / LESSONS LEARNED: Our results highlight and support the effectiveness and efficiency of generative AI as an assessment aid for clinical reasoning. Despite differences in ratings between AI and human raters with small to medium effect sizes that may not be clinically relevant, immediate scoring and feedback makes AI a very useful tool to support the development, assessment and learning of clinical reasoning. ONLINE RESOURCE URL: https://med-edu-ai-grading.vercel.app/ ENHANCING 360 DEGREE EVALUATION THROUGH STANDARDIZED ONE-WORD DESCRIPTORS Vivek I. Patel1; Christina Chen-Milhone1; Melissa A. Rusli2; Mrhaf Alsamman2. 1GME, Lakeland Regional Medical Center Inc, Lakeland, FL; 2Internal Medicine, Lakeland Regional Medical Center Inc, Lakeland, FL. (Control ID #4273588) SETTING AND PARTICIPANTS: 3rd and 4th year medical students at a 900+ bed tertiary care hospital with 7 ACGME accredited programs DESCRIPTION: The evaluation process is key to shaping healthcare professionals in medical education. Traditional methods often combine quantitative and subjective feedback but face ambiguity and inconsistency, impacting learning and assessment. Variability in feedback causes confusion, hindering clarity on strengths and weaknesses. To address this, standardized directions and one-word descriptors were explored to improve fairness and clarity. Semi-annual evaluations revealed a need for concise, objective feedback, prompting the use of standardized descriptors to enhance reliability and effectiveness in assessments. EVALUATION: The innovation introduces a standardized one-word descriptor system in medical education evaluations, offering a lexicon of 30 traits beyond "excellent" or "satisfactory." Evaluators select up to four traits to complement traditional feedback methods. This aims to streamline evaluations by bridging quantitative and qualitative approaches, improving clarity and efficiency. Tools like New Innovations can integrate descriptors to standardize data collection and analysis, fostering a more objective and effective feedback process. The pilot will implement descriptors in post-rotation evaluations over 12 weeks. Analysis methods include pre- and post-intervention surveys on feedback clarity, performance trend tracking, and qualitative focus group insights via MaxQDA. Success metrics include increased evaluation reliability, improved self-assessment accuracy, and enhanced learning experiences. Results are expected to show that standardized descriptors improve evaluations and medical education outcomes.

/ REFLECTION / LESSONS LEARNED: The adoption of standardized single-word descriptors in medical evaluations has the potential to revolutionize assessment methods. This approach aims to enhance communication between educators and students, surpassing traditional feedback systems. Implementing these descriptors in core and elective rotations could enable more individualized learning through educational archetypes. However, challenges include achieving evaluator consensus on traits and adapting existing frameworks. Faculty discussions highlight the need for training to fully utilize this system. Investigations will assess descriptor adaptability across formative and summative evaluations. This pilot project seeks to improve medical education assessments by generating data to refine student evaluations and support future learning. By tailoring educational pathways to individual learners, it promises better educator-student communication. The initiative’s success relies on evaluator support and adaptable assessment models. As it progresses, it is expected to offer valuable insights into "360-degree" assessments for students, faculty, and staff, improving evaluations at all levels, including Medical Student Performance Evaluation letters and graduate medical assessments. FEEDBACK ON FEEDBACK: A PILOT PROGRAM OF OBSERVED VERBAL FEEDBACK WITH RECIPROCAL PEER COACHING Jeffrey Redinger1; Andrew V. Raikhel2; Helene Starks3; Gabrielle Berger1. 1Department of Medicine, University of Washington School of Medicine, Seattle, WA; 2Hospital Medicine, VA Puget Sound Health Care System Seattle Division, Seattle, WA; 3Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA. (Control ID #4272580) SETTING AND PARTICIPANTS: We developed the Direct Observation of Feedback Scale (DOFS) for assessing verbal feedback quality and piloted it in a longitudinal, reciprocal peer coaching program in which hospitalists observed and coached each other on feedback delivery to residents. Our innovation was conducted at a VA affiliated with a large Internal Medicine residency program in the Northwest region. Participants included VA hospitalists and Internal Medicine residents (IMRs), all of whom were consented for participation. The pilot study was deemed exempt by our local VA and academic affiliate IRBs. DESCRIPTION: Effective verbal feedback from attending physicians plays a critical role in resident education, yet curricula to improve feedback delivery often overlook a vital aspect of skill development: direct observation by an external observer. A survey at our institution revealed considerable differences in the perception of feedback quality between IMRs and hospitalists. This data was consistent with national trends of faculty having a higher estimation of feedback quality than what learners perceive. To address this gap, we developed the 9-item DOFS for assessing verbal feedback quality by gathering validity evidence in content, response process, relation to other variables, consequences, and internal consistency domains. We then piloted this tool in a program where 4 hospitalists were paired in dyads and alternated roles of coach and coachee over three months. The dyads first participated in a training session about the DOFS and then observed each other delivering feedback to IMRs and provided coaching to one another on how to improve feedback. Survey data on the observation was collected from the hospitalist delivering feedback to the IMR, the hospitalist observing feedback, and the IMR receiving feedback after each observation. Our objectives were to: 1) improve the quality of feedback delivered by hospitalists to IMRs via a program of direct observation with longitudinal peer coaching; and 2) to maintain the psychological safety of both IMR and observed faculty during and after feedback delivery observation. EVALUATION: Hospitalists participating in the coaching program (n=4) reported self-perceived positive impacts in both the coach and coachee roles related to improving their own feedback delivery skills. Both hospitalists and IMRs reported that psychological safety was maintained or improved during their involvement with the observed feedback peer coaching program. Feedback quality captured by the feedback assessment tool was congruent between the perception of the faculty delivering feedback, faculty observing feedback, and the IMR.

/ REFLECTION / LESSONS LEARNED: Results point to a potential bidirectional benefit between the hospitalists involved in the intervention. The program required coordinating times for feedback delivery to be observed among busy hospitalists which is a limitation for implementation. Next steps include expansion of the program to a larger cohort of hospitalists or multiple hospital sites. IMPROVING OUTPATIENT EVALUATIONS: LEVERAGING NEW INNOVATIONS FOR IN-THE-MOMENT FEEDBACK IN RESIDENT CLINIC Alex Galloway, Eva Rimler, Dylan M. Baker, Shub Agrawal, Marshall Fleurant, Pamela Vohra-Khullar, Britt Marshall, Shelly-Ann Fluker, Mackenzie L. Garcia, Dheepa Sekar. Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4269285) SETTING AND PARTICIPANTS: This initiative was implemented in a large academic internal medicine residency program with three resident primary care clinics. DESCRIPTION: Formative feedback is a cornerstone of competency-based medical education, yet delivering and documenting feedback in the fast-paced ambulatory setting is challenging. Our large academic internal medicine program noted a lack of quality outpatient evaluations, exacerbated by the X+Y schedule design, which limited consistent resident-faculty pairings. With updated ACGME guidelines requiring four or more recorded evaluations per year, we aimed to improve the quantity and quality of outpatient feedback. We set three primary objectives: (1) develop an accessible, user-friendly feedback tool integrated with residency program tracking; (2) train faculty on this tool and best practices for feedback; and (3) create a campaign to ensure feedback for all residents and consider long-term sustainability. We identified key feedback domains through literature review and expert consultation, focusing on high-yield skills essential for outpatient care. Selected domains included agenda setting, shared decision making, teach-back, presentation skills, and an “other” category, each with a skill-specific entrustment scale. We then designed a concise form on the New Innovations platform, which is widely used in our residency program. A "feedback campaign" was launched to raise awareness across clinics. In two clinics, residents were assigned to specific preceptors, while in the third clinic with more preceptor variability, a physical spreadsheet tracked evaluations. Scheduled emails and physical signs in clinics reminded faculty and residents of the campaign. EVALUATION: After one five-week block, evaluations were completed for 109 unique residents (63%) by 28 different faculty preceptors. In the subsequent block, we targeted the remaining residents and identified specific preceptors for their evaluations. Initial feedback was overwhelmingly positive, with program leadership incorporating it into semi-annual meetings. Residents found the feedback helpful and requested additional evaluations and more tailored feedback. Next steps include reviewing the quality of faculty narratives using a validated qualitative tool.

/ REFLECTION / LESSONS LEARNED: Providing effective feedback in ambulatory settings remains challenging, but an accessible online tool can facilitate efficient “in-the-moment” feedback. Direct observation, though difficult in busy outpatient settings, is critical for resident education. This initiative demonstrated that a simple, streamlined feedback tool integrated with existing systems can be effective. New Innovations helped overcome logistical challenges associated with real-time feedback. We plan to continue this initiative, refining the feedback form to better align with ACGME milestone data and ensuring quality feedback remains a regular, ongoing process throughout the clinical year. LONGITUDINAL EVALUATION OF CLINICAL REASONING AND DIAGNOSTIC ERRORS IN MEDICAL STUDENTS USING CLINICAL REASONING MAPPING EXERCISE (CRESME) Justin Cho1; Youngbin Yoon1; Analia Castiglioni2; Dario Torre2. 1n/a, University of Central Florida College of Medicine, Orlando, FL; 2Internal Medicine, University of Central Florida, Orlando, FL. (Control ID #4215828) SETTING AND PARTICIPANTS: Sixty students of an academic medical institute in the Southern Region were randomly selected to complete two CResMEs (Chest (CP) and Abdominal Pain (ABD)) at two clerkship time points: May 2023 (pre-clerkship) and January 2024 (mid-clerkship). Learners completed each assessment in an electronic format independently. DESCRIPTION: CResME is a knowledge-based assessment requiring students to connect informational nodes (history, physical exam, lab data) to arrive at a final diagnosis. Brief description of the chief complaint was provided, and learners were instructed to accurately match each node to form a connected illness script while writing a final diagnosis in an empty node for 4-5 cases. CRESMEs were scored by experienced clinician educators using a validated rubric based on successful connections between HPI, PE, and data (sequence score) and final diagnostic specificity and accuracy (diagnostic score). EVALUATION: Mean CP score was 78.6% ± 18.07% and 80.35% ± 23.43% in 2023 and 2024, respectively. In both years, Pericarditis scored highest (95.79%± 18.8%, 93.68% ± 22.73%), and Pulmonary Embolism lowest (47.02% ± 48.62%, 58.60% ± 48.82%). Mean ABD score was 65.6% ± 26.6% and 55.92% ± 28.15% in 2023 and 2024, respectively. Acute Pancreatitis scored highest in both years (88.07% ± 22.95%, 84.56% ± 32.74%), Acute Cholecystitis lowest in 2023 (42.81% ± 47.73%), and Diverticulitis lowest in 2024 (42.81% ± 47.58%). There was decline in overall score (sequence + diagnostic) for Peptic Ulcer Disease (PUD) from 2023 to 2024 (p < 0.05), with less connections between HPI and lab data in 2024 compared to 2023 (p < 0.001). Sequence and diagnostic scores were positively correlated for both exercises at all periods (p < 0.001). No significant differences were detected in sequence, diagnostic, overall score, and total scores between timepoints.

/ REFLECTION / LESSONS LEARNED: CResME is a tool that can evaluate and facilitate clinical reasoning and illness script development in medical students over time. For most cases, students’ clinical reasoning skills did not decline across clerkship time. This suggests that medical students retained their previously constructed illness scripts over time. CResME revealed a significant relationship between appropriate illness scripts and accurate and specific diagnoses. CResME highlights the critical relationship between appropriate illness scripts and accurate diagnoses and identifies potential gaps in reasoning that may lead to diagnostic errors. ONLINE RESOURCE URL: https://edtech.med.ucf.edu/files/2024-25/UCF_CRESME_Demo/story.html PATTERNS OF CLINICAL REASONING ERRORS AND BEHAVIORS IN CLERKSHIP STUDENTS: THE CLINICAL REASONING MAPPING EXERCISE (CRESME) Youngbin Yoon1; Justin Cho1; Analia Castiglioni2; Dario Torre2. 1n/a, University of Central Florida College of Medicine, Orlando, FL; 2Internal Medicine, University of Central Florida, Orlando, FL. (Control ID #4270203) SETTING AND PARTICIPANTS: 118 medical students at a Southern academic institution completed 3 CResMEs (chest pain, abdominal pain, anemia) mid-clerkship in January 2024. DESCRIPTION: The CResME is a validated tool designed to assess learners’ development and instantiation of illness scripts. Each CResME included 4-5 diseases commonly encountered in differential diagnoses of chest pain, anemia, and abdominal pain. Exercises were scored using a validated rubric assessing connections between “nodes” containing history, physical exam (PE) findings, and diagnostic workup/data (sequence score) and specificity and accuracy of final diagnosis (diagnosis score). EVALUATION: Descriptive and inferential statistics were performed, and sequence, diagnosis, and total (sequence+diagnostic) scores for each exercise were compared using independent T-tests. Mean total scores (out of 100%) were 80%±22% (chest pain), 57%±28% (abdominal pain), and 63%±29% (anemia). Mean diagnostic scores were highest for pericarditis, iron deficiency anemia, and acute cholecystitis; lowest for pulmonary embolism, G6PD deficiency, and diverticulitis. Mean sequence scores were highest for pericarditis, B12 deficiency, and acute pancreatitis; lowest for pulmonary embolism, anemia of chronic disease, and diverticulitis. For each connection (History-PE, PE-Data, History-Data), students who successfully paired the two nodes showed significantly higher diagnostic, sequence, and total scores compared to students who did not for most diagnoses (P<0.05), except for a few cases. These exceptions included diagnostic scores for aortic dissection (History-PE, P=0.111; PE-Data, P=0.111), ascending cholangitis (PE-Data, P=0.083), and pericarditis (History-Data, P=0.107), where no significant difference was found between students who did and did not form these connections.

/ REFLECTION / LESSONS LEARNED: For most diseases, sequentially connecting individual nodes may be crucial for accurate and specific diagnoses, suggesting the importance of connecting components of previously-formed illness scripts to generate a diagnosis. Emphasizing the thinking process (“sequence”) while teaching CR could be beneficial. The exceptions observed in this study reveal interesting patterns for further investigation. This highlights the potential value of focusing instruction on how to promote the development of illness scripts early on in the curriculum, fostering connections among key clinical components of clinical reasoning. Analyzing clinical reasoning skills over time and across different contexts could provide a more comprehensive understanding of the clinical reasoning patterns identified in this study. ONLINE RESOURCE URL: https://edtech.med.ucf.edu/files/2024-25/UCF_CRESME_Demo/story.html TRANSFORMING TRANSITIONS THROUGH TELEMEDICINE: A WORKPLACE-BASED SIMULATION TO TEACH AND ASSESS VIRTUAL CLINICAL SKILLS Daniel Sartori, Renee Heller, Sondra Zabar, Rachael Hayes. Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4254254) SETTING AND PARTICIPANTS: Thirty-seven internal medicine residents (20 PGY1, 17 PGY2) participated in two visits with standardized patients (SPs) at a community-based clinic in the Mid-Atlantic. DESCRIPTION: The transition from hospital to home is a vulnerable time for patients, with the potential for medication errors, fragmented follow-up and adverse patient outcomes. Telemedicine provides an avenue for accessible post-discharge care to facilitate safer transitions, yet few dedicated initiatives exist that teach and assess the unique skills necessary to provide virtual transitional care. Objective structured clinical encounters fall short of capturing the challenges of real clinical environments. Therefore, we developed two workplace-based, virtual encounters with SPs as a high-fidelity initiative to teach and assess virtual transitions of care. We created assessment checklists, trained SPs, generated mock electronic health record entries and scheduled encounters in resident clinics. Both cases featured patients recently discharged after hospitalization, with either COPD (case 1) or CHF (case 2). Case 1 was conducted in the first half of the 2023-2024 AY, while case 2 was completed in the second half. After each visit, SPs assessed skills with a behaviorally anchored checklist on a scale of not, partly, or well done (WD) and provided verbal feedback. A faculty member also gave feedback on clinical decision-making. Paired t-tests analyzed differences in the percentage of items rated WD from case 1 to case 2; unpaired t-tests evaluated PGY differences. EVALUATION: Overall, residents performed well in communication domains (84 % WD), and less well in telemedicine (65% WD) and care transitions (74% WD). In case 1, PGY2s performed better in each domain compared to PGY1s, notably in telemedicine (74% vs. 47% WD, p< 0.001) and education/counseling (80% vs 47% WD, p< 0.001). PGY1s improved from case 1 to case 2 in all domains, particularly in telemedicine (47% vs 68% WD, p< 0.05), education/counseling (47% vs. 67% WD, p< 0.05), and care transitions (63% vs. 79% WD, p< 0.05). Resident perception was positive: 97% of respondents (42% response rate) somewhat or strongly agreed that this format provided effective feedback and facilitated awareness of telemedicine skills.

/ REFLECTION / LESSONS LEARNED: Implementation of a workplace-based post-discharge simulation is feasible and had perceived benefit among residents. Findings suggest that early residents have gaps in specific skills necessary for high quality virtual patient care following hospital discharge, likely due to inconsistent exposure early in residency. Clinical experience is important in filling these gaps; senior residents showed stronger skills at baseline, and junior residents improved in all domains with time. However, both groups still have opportunities for growth. Future studies will identify the specific experiential factors that contribute to skill development for virtual care transitions to inform educational programs and prepare residents for future practice. Innovation in Medical Education (IME) - Career Development, Professionalism, and Wellness AN ESSENTIAL TOOLKIT: SUPPORTING THE TRANSITION FROM RESIDENT TO INDEPENDENT PRACTICE Sajal Akhtar, Nicole M. Frerichs, Nitu Kataria. Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4272897) SETTING AND PARTICIPANTS: This toolkit is designed for use in academic medical settings, targeting residents preparing to transition to independent practice. Participants include residents and educators who mentor residents during this pivotal career phase. DESCRIPTION: This comprehensive toolkit is designed to help physicians smoothly transition from residency to independent practice, supporting them in navigating the complexities of their evolving roles. It provides a structured framework for understanding and balancing the three key professional identities: Learner, Clinician, and Leader. The toolkit includes worksheets for self-reflection, mentorship identification, and actionable plans, along with scenarios that address common challenges faced by early-career physicians. With practical strategies, best practices, and curated resources, this toolkit equips physicians with the tools they need to thrive in their independent practice. The Toolkit includes the following worksheets: Professional Role Identification: Helps define roles as Learner, Clinician, and Leader and guidance to identify role models for each. Discussion Prompts: Questions to guide conversations with mentors and colleagues. Practice Scenarios: Real-world challenges with strategies for success. Best Practice Advice: Actionable tips for overcoming common challenges. Further Reading: Curated resources for continued professional development. EVALUATION: Evaluation will include pre and post surveys along with 3 month follow-up surveys to measure the toolkit’s effectiveness via assessment of perceived value, relevance, and usability. These will be given to PGY-3 residents or attendings who are newly in practice (0-3 years since residency). A small group discussion with residents approaching the transition to independent practice after utilizing the toolkit may be performed as well to gain insights into the toolkit's usefulness and any potential improvements.

/ REFLECTION / LESSONS LEARNED: For doctors stepping into independent practice, this toolkit is an invaluable resource that addresses the multifaceted nature of the transition to independent practice. It guides physicians in defining their roles as learners, clinicians, and leaders, offering concrete steps to develop each identity. Through mentorship identification, structured reflection, and scenario-based problem solving, doctors can gain clarity on how to manage clinical responsibilities, enhance patient care, and lead effectively. The toolkit’s emphasis on continuing education, feedback, and work-life balance ensures that new physicians have the support they need to succeed and grow in their independent practice while maintaining their professional and personal well-being. ONLINE RESOURCE URL: https://docs.google.com/document/d/1KIfkHDb79w482UyX-hHcFMB8GfmHkAJUNwajfdNKUSA/edit?usp=sharing BRIDGING DIVISIONS: ASSESSING COHORT-BASED PEER MENTORSHIP FOR EARLY-CAREER FACULTY IN ACADEMIC MEDICINE Gloria Ye1; Shuchi Anand1; Maja Artandi1; William Collins1; Minjoung Go1; Linda Anh Nguyen1; Paul Wang1; Wen-Kai Weng1; Kavitha Ramchandran1; Upinder Singh1,2. 1Medicine, Stanford University School of Medicine, Stanford, CA; 2Internal Medicine, The University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, IA. (Control ID #4271191) SETTING AND PARTICIPANTS: 88 participants at a West Coast academic medical center were included: 7 leads (mid-late career) and 81 mentees (early career). Mentees were grouped in 7 cohorts based on their speciality divisions. DESCRIPTION: Mentorship is vital for growing professionally, reducing burnout, and increasing job satisfaction. Access to mentorship can be limited by divisional silos and overstretched faculty. Our research evaluates the efficacy and feasibility of a 12-month group-based cross-divisional peer mentorship model designed to address these challenges. Mentor-leads received 17 hours of training on 13 topics to prepare for a 12-month mentorship program consisting of 1:1 meetings, social gatherings, and monthly workshops. We used surveys, independent development plans, and validated scales to assess our model in four domains: 1) professional and career advancement; 2) community and belonging; 3) personal wellness and work-life balance; 4) skill and knowledge building. EVALUATION: Interim analysis of pre and mid-point surveys from mentees (n=70) and mentor-leads (n=6) showed small or negligible effect sizes across wellness outcomes: burnout from work (Cohen's d = -0.165), callousness toward people (Cohen's d = -0.011), worthwhile work (Cohen's d = 0.031), professional value (Cohen's d = 0.031), and difficulty in developing meaningful relationships (Cohen's d = -0.087). However, those experiencing the highest burnout (n = 4) saw a substantial reduction (t(3) = 5.00, p = 0.015, Cohen's d = -3.54), and those who felt least professionally valued (n = 11) showed significant improvements (t(10) = -2.76, p = 0.020, Cohen's d = 1.18). In feasibility analysis, all mentor-leads reported being "Very Satisfied" (n = 3) or "Satisfied” (n= 3). Training effectiveness rated similarly. 66.7% of respondents (n=4) rated Division Chief support as "Excellent”. Qualitative analysis highlighted structured career development sessions, milestone setting, and opportunities for publications and grants as the most beneficial activities. Challenges included time management, scheduling, session standardization, and fewer cross-divisional interactions.

/ REFLECTION / LESSONS LEARNED: Interim findings suggest individuals most affected by burnout and feelings of low professional value may benefit most from this program. Targeting at-risk individuals could produce more meaningful outcomes. Future analysis will include stratifying results and comparisons with broader data sets to better assess our intervention’s effectiveness. CULTIVATING SELF-COMPASSION TO FOSTER INTERNAL MEDICINE RESIDENT WELL-BEING Sarah L. Floden, Amy Zelenski, Mariah Quinn. Division of General Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4269501) SETTING AND PARTICIPANTS: A workshop was developed and delivered to 42 first-year internal medicine residents at an academic medical center in the Mid-West. The workshop was repeated four times for groups of 10-12 residents, and all sessions took place on the main hospital campus during regularly scheduled education time. DESCRIPTION: The rigors of residency training amidst our complex healthcare system can push even the most compassionate trainees to their limits. This can create compassion fatigue, burnout, and breakdowns in communication. Compassion cultivation and self-compassion can be an antidote, as self-compassion increases connectedness, curiosity, and optimism and decreases depression, anxiety, and shame (Neff 2009, Weng et al 2023). We sought to harness self-compassion as a novel approach to support resident well-being throughout their training and professional identity development. Our session was led by academic faculty members with expertise in resident well-being and communication skills. We began each session by engaging residents in a discussion about empathy, compassion, and compassion fatigue. We then introduced two interactive writing and reflection activities to practice self-compassion and explore the relationship between self-compassion and the inner self-critic. Concepts were reinforced through pair-and-share conversations and large-group discussion. EVALUATION: At the conclusion of the workshop, residents completed a de-identified five-question survey assessing their 1) perceived efficacy at practicing self-compassion before and after the workshop and 2) understanding of the inner self-critic. Each of these parameters was rated on a 1-5 scale. Residents were also invited to provide free-text responses regarding insights gained and suggestions for improving future sessions.

/ REFLECTION / LESSONS LEARNED: Residents found the writing exercise meaningful to explore the nuanced relationship between practicing self-compassion and acknowledging their inner self-critic. Many residents expressed how they were not aware how frequently they were guided by their self-critic, often out of fear of making a mistake or becoming complacent. The writing exercise demonstrated how balancing this perspective with self-compassion can relieve stress and create more space for growth, learning, and professional satisfaction. Residents left the session with more confidence in their ability to practice self-compassion. This is a feasible session, adaptable to multiple environments (in person, virtually), and applicable to a variety of participants (resident physicians, faculty, and other members of the healthcare team). Not only can learners utilize self-compassion during their early career development, but they can build on this foundation as they grow into mentors and leaders themselves. FROM DOCTORS TO LEADERS: STRENGTHENING THE LEADERSHIP SKILLS OF PRIMARY CARE PHYSICIANS Jennifer Nahrgang3,1; Bradley Mecham3; Daniel Newton3,1; Jacqueline K. Spencer2; Lisa Altman4; Melissa J. Steffen3; Matison Howard3,1; Brinn Jones6; angela denietolis5; Greg L. Stewart3,1. 1University of Iowa, Iowa City, IA; 2VA New England Healthcare System, Bedford, MA; 3Iowa City VA Medical Center, Iowa City, IA; 4VA Greater Los Angeles Healthcare System, Los Angeles, CA; 5VA Office of Primary Care, District of Columbia, DC; 6VA Puget Sound Health Care System Seattle Division, Seattle, WA. (Control ID #4272807) SETTING AND PARTICIPANTS: Primary Care Leaders from VA medical centers across the USA participating in a 40-week leadership development program DESCRIPTION: Primary Care is the cornerstone of the Veterans Health Administration, which addresses the complex medical and behavioral health needs of nine million veterans. The Office of Primary Care recognized an opportunity to strengthen leadership skills among current primary care leaders and created the Primary Care Physician Leadership Development Program. This evidence-based leadership program includes curricula on leadership types and styles, meaningful conversations, leading during challenging times, continuous process improvement, change management, and negotiation skills, with a component of mentoring and coaching. A formal application and selection process prioritizes broad geographic representation and diversity. Participants commit to four hours weekly over approximately 40 weeks with an initial three day in-person meeting. To date, 88 Primary Care Leaders have graduated from this competitive and successful program, with another 26 new participants currently embarking on their leadership journey. EVALUATION: A sample of participants who had completed the program (N=57) were compared to a sample of participants beginning the program (N=22). Participants who completed the program rated themselves higher for leadership identity (e.g., Being a leader is very important to me) and confidence as a leader (e.g., I am confident in my ability to lead workgroups effectively). Although peer ratings of leadership behavior did not differ between the two groups, those that completed the program rated themselves higher on engaging in important leadership behaviors (e.g., providing task support, providing social support, and challenging the team). In response to an opened-ended question on how the program helped develop leadership competence, participants reported the program helped develop general and specific leadership skills, personal skills, and provided access to key benefits. Key benefits of the program included networking with peers, mentorship, opportunities for self-development and reflection, and increased knowledge of the VA.

/ REFLECTION / LESSONS LEARNED: Participants who completed the program rated the value of the program as very high and agreed their participation improved their ability to act with courage. Overall, the evidence-based leadership program increased participants’ leadership identity, confidence as a leader, and engagement in desirable leadership behaviors. GRIEF, GROWTH AND GRATITUDE: A RESIDENT-LED WELLBEING NOON CONFERENCE INTERVENTION FOR INTERNAL MEDICINE TRAINEES Lauren Phinney1; Cattle Chloe1; Alyssa Perez1,2. 1Internal Medicine, University of California San Francisco, San Francisco, CA; 2Pulmonary and Critical Care, University of California San Francisco, San Francisco, CA. (Control ID #4272978) SETTING AND PARTICIPANTS: The intervention took place at a large internal medicine residency program across three university-affiliated sites: a federal hospital, a county hospital, and an academic medical center, from January to June 2024. Participants included internal medicine residents and medical students rotating through their clerkships or acting internships. DESCRIPTION: Based on the results of a needs assessment highlighting burnout and identifying grief as a frequent but inadequately processed issue among residents, a Wellbeing Noon Conference intervention was developed to dedicate time and space for emotional reflection. Although a wellbeing curriculum existed as part of intern orientation and annual protected didactic days, residents expressed a need for longitudinal opportunities to process challenging situations, including grief. Resident feedback from the needs assessment shaped the intervention, which utilized existing conference times at the three primary residency hospital sites. The enhanced wellbeing curriculum incorporated four key domains identified by residents to foster emotional resilience: 1. End-of-life care education (didactics with chaplains and palliative care specialists), 2. Remembrance and gratitude (annual patient memorial art creation), 3. Grief processing (narrative medicine and debriefing with chaplains), 4. Diastole (fun communal wellbeing activities, such as massages, painting, and pet therapy). Seventeen noon conference sessions were held over six months across the three sites, supported by a grant from the institution's Graduate Medical Education wellbeing fund. EVALUATION: An anonymous post-intervention survey was distributed to participants via QR code and email. In a pre-intervention needs assessment (n=66), 39% of respondents reported minimal or no support for grief processing during residency. In the post-intervention survey (n=70), only 8.5% of respondents reported minimal or no support. Residents indicated that the small, interactive, optional sessions—particularly those discussing death, dying, and learning from palliative and spiritual care specialists—were instrumental in providing emotional support in the clinical environment. Participants also valued the variety of topics and activities, which catered to diverse emotional needs while allowing for voluntary sharing without the pressure to debrief. Furthermore, residents appreciated community-building activities, especially collaborative art projects, pet therapy, and massages, which provided relaxation during the workday.

/ REFLECTION / LESSONS LEARNED: This three-site monthly intervention was effective in changing residents’ perceptions of support for emotional processing. Resident-driven design and leadership likely contributed to peer buy-in and engagement. While funded activities like massage therapy were appreciated, residents increasingly valued informal, relaxed spaces for connection and reflection. Future steps include integrating Wellbeing Noon Conference as a regular component of the residency curriculum. INTEGRATING A COMPASSIONATE CARE CURRICULUM INTO INTERNAL MEDICINE RESIDENCY Jeanie Gribben, Nekee Pandya, Bradley Hayward, Kirana Gudi. Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4272736) SETTING AND PARTICIPANTS: The Compassionate Care Curriculum (CCC) was implemented for all internal medicine (IM) residents at an academic medical center in the Northeast. The curriculum was developed by a clinical ethics-trained hospitalist, a palliative care-trained intensivist, and the IM residency program director. DESCRIPTION: PGY1s participated in two small group sessions. The first was a facilitated discussion regarding common ethical dilemmas, surrogate decision makers, and advanced directives. The second explored burnout, compassion fatigue, and moral distress through individual and group debriefing. Interns brainstormed “best practices” to promote compassion satisfaction and foster positive inpatient team dynamics, which were distributed to senior residents and hospitalists. PGY2s participated in a full day Communication Retreat. CCC faculty conducted sessions on team dynamics and communication adapted from the VitalTalk curriculum. A narrative medicine session included group reflection on poetry and sharing resources for providers facing harassment or abuse. Case-based sessions on feedback and the learning climate were also conducted. PGY3s participated in academic conferences conducted by CCC faculty and invited guests, including: Hospice 101, Trauma Informed Care, Combating Misinformation, Medical Humanities Journal Club, Narrative Medicine, and Promoting Wellness for Hospitalized Patients. All residents participated in “Death and Donuts,” a debrief during residents' MICU and CCU rotations. The session began with a moment of silence for the patients who had passed during the clinical rotation. Residents were invited to share their reflections on their experiences with critical illness and death in this confidential space. EVALUATION: Feedback was solicited both formally and informally for each aspect of the curriculum, and incorporated into subsequent sessions by the CCC faculty.

/ REFLECTION / LESSONS LEARNED: Compassionate care was traditionally taught as a part of the "hidden curriculum." In formalizing this curriculum, we prioritized fitting the sessions into the residents' existing workflows and incorporating their own experiences and challenges into the sessions for increased engagement. The CCC successfully integrated didactic teaching, case-based learning, and facilitated discussion on medical ethics, communication skills, and well-being into IM residents’ clinical training. The longitudinal nature of the curriculum and diverse session formats allowed for all residents to complement their clinical work with professional growth in communication skills and a better understanding of ethical dilemmas, moral distress, burnout, and compassion fatigue. LAUNCH TEAMS: A NOVEL APPROACH TO EARLY CAREER FACULTY DEVELOPMENT AND MENTORSHIP Christine D. Jones2,1; Emma Faye Sylvester2; Kara Price2; Vineet Chopra3; Sunita Sharma2. 1Center of Innovation, Research Service, VA Eastern Colorado Health Care System, Aurora, CO; 2Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; 3Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4272796) SETTING AND PARTICIPANTS: Early career faculty physicians, advanced practice providers, and PhD researchers in their first 3-4 years on faculty within the Department of Medicine (DOM) are eligible for the program. Potential participants are identified by division leadership and then approached for program participation. DESCRIPTION: Launch teams include one early career faculty member or launchee and four faculty. Faculty roles include: (1) a facilitator ideally serving in a leadership role outside the launchee’s home division, (2) the division chief (or designee), (3) a senior faculty member of the same division, and (4) a faculty member outside the division with complementary expertise. The DOM launch team project coordinator and faculty lead email prospective team faculty members no more than three times to request participation. Launch Teams meet for one hour quarterly over one year. Meetings are led by the team facilitator and launchee, covering a progressive curriculum. The first meeting centers on “What is your why?” Subsequent meetings are customized to support launchee researchers in one track and clinicians/educators in another. The 4th meeting helps the launchee determine additional mentorship needs and how team members can support them post-program. In 2024, 32 Launch Teams were convened for early career faculty across the DOM. The first pilot cohort of 13 teams started in January 2024, followed by a second cohort of 19 teams in July 2024. A total of 65 launch team meetings have occurred to date for these 32 teams. A third cohort of 19 teams will start in January 2025. EVALUATION: Launchees complete pre-program surveys before their first meeting to assess satisfaction with mentorship and comfort with career goal-setting; 31 of 32 (97%) launchees in the first two cohorts completed surveys. Launchees were 61% Female, 75% White, 19% Asian, and 6% Other race/ethnicity. 68% identified as clinicians or educators, and 32% as researchers; 68% were satisfied with mentorship received to date. Notably, 90% of researchers versus 29% of clinicians/educators were comfortable setting long-term career goals. Launchee described goals to gain mentorship, sponsorship, and guidance for academic promotion. Post-program surveys are currently being collected from the 13 launchees in the first cohort following completion of their fourth and final launch team meeting. Of the 4 responses so far, 100% have been satisfied with mentorship to date, and 100% of clinicians/educators now feel comfortable with setting long-term career goals, showing growth in this domain.

/ REFLECTION / LESSONS LEARNED: Administrative support from the DOM is essential for building launch teams and scheduling meetings. Involving launchees in building their launch teams, including suggesting potential team members, boosts their engagement. Future plans include more in-person launch team meetings and more in-person events for launchees to connect and engage in peer mentorship. SCRUBS TO SWADDLES: DEVELOPMENT OF A RESIDENCY PROGRAM POLICY SUPPORTING TRAINEE PARENTS Jessica Zimo1; Sarah Khorasani1; Bruce L. Henschen2; Maria Theodorou1. 1Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4272893) SETTING AND PARTICIPANTS: Our Internal Medicine residency program at a large, urban academic medical center in the Mid-West region developed a policy to address challenges resident parents face. We incorporated feedback from residents who had a child during training and from residents assigned additional clinical responsibilities to accommodate parents. Key stakeholders including residents, program leadership, and our institution’s Graduate Medical Education (GME) leadership participated in policy development. The policy applies to birthing and non-birthing resident parents. DESCRIPTION: Our policy establishes mechanisms of support related to pregnancy, family leave, returning to work, and lactation. In addition to outlining the family leave available, novel interventions for our program were checklists for planning family leave, rescheduling night shifts in the third trimester of pregnancy, the creation of a resident lactation space, the implementation of program-mandated rotation swaps (instead of volunteer-only) to minimize use of backup coverage, and access to parenting resources. EVALUATION: Narrative feedback was solicited from impacted residents. Resident parents were satisfied with their plans for parental leave (range 7-10 weeks) and felt supported during the planning process. One parent shared that the “program’s support for my parental leave has made an incredible difference during this important time for my family.” Residents whose clinical rotations had been adjusted to accommodate expecting parents reported a neutral impact on their schedules. Unplanned backup coverage related to parental leave was reduced from the prior year’s average of 9 days per resident (range 0-12) to 0 days.

/ REFLECTION / LESSONS LEARNED: Becoming a parent during medical training poses unique challenges. Beyond family leave, the needs of birthing and non-birthing parents may include medical accommodations and postpartum support. Clinical assignments during pregnancy are also a concern, as a growing body of evidence suggests an increased risk of adverse pregnancy outcomes for medical trainees. Supporting a trainee’s health and wellness is paramount and must be balanced with individual career goals and training requirements. Establishing clear and transparent policies helped our program maximize resident health and wellness, navigate accommodations for trainee parents, reduce the impact of family leave on co-residents, and minimize the logistical burden on individual trainees. ONLINE RESOURCE URL: Policy and Policy Development Frameworks: https://drive.google.com/file/d/1wFbvHI9l_mcm0RZqcdeJ68s1t5VLwAkV/view?usp=sharing UNEQUAL ACADEMIC ADVANCEMENT – CROWDSOURCING IDEAS FOR INTERVENTIONS Brittany Chatterton2; Melody Tran-Reina1; Alicia Gonzalez-Flores1; Jason Heath1; Ashley H. Riggs3; Jacqueline Stocking1; Elora M. Negose4; Sara Teasdale5; Tonya Fancher1. 1Internal Medicine, University of California Davis, Sacramento, CA; 2General Internal Medicine, Geriatrics, and Bioethics, University of California Davis Department of Internal Medicine, Sacramento, CA; 3General Internal Medicine, UC Davis Health, Sacramento, CA; 4Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA; 5Internal medicine, University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #4232256) SETTING AND PARTICIPANTS: Setting: Department of Internal Medicine at one academic center Participants: 100 faculty who were eligible for advancement in a single academic year DESCRIPTION: Each year, the University publishes aggregate advancement statistics for all faculty in the Schools of Health (medicine and nursing). These data consistently demonstrate unequal advancement by faculty academic series - clinician-researchers are advanced more quickly than clinician-educators. We sought to better understand, on a granular level, the advancement process and statistics within the Department of Internal Medicine. EVALUATION: At our institution, faculty are promoted from the rank of assistant to associate to full professor and are advanced within each rank at a prescribed cadence to help ensure readiness for promotion. Each faculty member who undergoes review for advancement submits a dossier that includes their scholarly, teaching, service, and clinical accomplishments during the review period. Most department faculty are in the clinician-educator series and are also under-represented in medicine. A smaller number of under-represented faculty are in the clinician-researcher series. In their dossier, faculty undergoing advancement can request regular or accelerated advancement, guided by university expectations. The completed dossier is reviewed by all faculty in the department who comment and vote on the requested regular or accelerated advancement. The majority vote is forwarded to a university-appointed panel of peers or a university senior administrator who reviews the dossier and can agree or disagree with the faculty request and departmental vote. For the first time in 2023-24, the Department collected data on this process.

/ REFLECTION / LESSONS LEARNED: Consistent with University and national findings, we found differences in rates of advancement by academic series. The requested acceleration by clinician-educators was more frequently denied by the department and the University, compared with clinician-researchers. No clinician-educator received the highest accelerated advancement option, whereas several clinician- researchers did. No clinician-educators were denied advancement, but a few clinician-researchers were denied their regular advancement A detailed process map of the path of the academic dossier from faculty to department to university identified several areas for improvement. We now seek to crowdsource input from SGIM attendees on mitigation strategies to counter unequal advancement. UPSTANDER TRAINING AT RESIDENT RETREATS: EMPOWERING OUR PHYSICIANS TO FIND THEIR PROFESSIONAL VOICE AGAINST BIAS Jody Sharninghausen1; Korynne DeCloux1; Jacqueline Savage1; Cynthia F. McNamara1,2; Shaili Gupta1,2. 1Internal Medicine, Yale University, New Haven, CT; 2Internal Medicine, VA Connecticut Healthcare System West Haven VA Medical Center, West Haven, CT. (Control ID #4239719) SETTING AND PARTICIPANTS: Chief residents (CR) and associate program directors (APD) facilitated an Upstander Training for 138 Internal Medicine residents (PGY1-3) in fall of 2024. This was the educational cornerstone of a mandatory wellness retreat during ambulatory rotation, held on 4 dates for 4 unique cohorts. Self-reported identity of residents was 48% women, 18% non-US citizens, 39% White, 38% Asian, 11% Hispanic/Latinx, and 6% Black. DESCRIPTION: Despite diversity and inclusion efforts, institution-wide surveys showed that resident physicians remain vulnerable to bias and harassment in work and learning settings. We created an upstander training to equip residents to identify and respond to mistreatment. We collected firsthand accounts of mistreatment from residents via an anonymous survey. Themes included gender, race/ethnicity, accent/country of origin, religious, and hierarchy based scenarios. From these lived experiences, we created role plays for residents to act out in small groups. Prior to the retreat, residents were shown a video from a faculty upstander training (DIVERSE), introducing the "4D" framework (directly intervene, defend and support, delegate and report, distract and de-escalate) with examples of each strategy. At the retreat, a CR and APD reviewed strategies and context for the training, and residents shared and reflected on situations of bias or mistreatment in clinical settings and how they or others responded. Residents then split into groups of 5-6 each and interacted in 3-4 role-play scenarios. Each resident practiced being an upstander in situations presented in the scenario by improvising and using learned strategies. CR and APD assisted with the debriefs, which occurred in small then large group settings after each scenario. An anonymous survey was administered immediately following the training. EVALUATION: Of the 60 residents who completed the post-survey, 97% reported that the workshop helped them find their voice against bias and harassment in work and learning settings. On a scale of 1-100, the impact on their ability to respond was highest for xenophobia/racism (81), sex/gender based bias (79), and verbal harassment (78). Residents felt least prepared to respond to hierarchy/faculty bias (62%), physical threat/harassment (42%), and religion-based bias (37%). Residents voiced specific quotes of how they would respond if they see a colleague being mistreated in the future. 72% showed interest in another session of upstander training this academic year.

/ REFLECTION / LESSONS LEARNED: An upstander training with small-group role plays based on real-life scenarios was effective and well-received. Hierarchy-based bias was the most challenging offense for residents to feel equipped to respond to and will require ongoing support from academic leadership to address. Future directions include incorporating identity-based bias into our clinical simulation curriculum to provide ongoing upstander training and collaborating with interprofessional teams to identify upstanders among hospital staff. Innovation in Medical Education (IME) - Chronic Disease Management ENHANCING INTERNAL MEDICINE RESIDENTS' COMPETENCE IN INFLAMMATORY BOWEL DISEASE MANAGEMENT THROUGH AN EXACERBATION TRIAGE ALGORITHM AND THINK-PAIR-SHARE EDUCATIONAL APPROACH Ki Jung Lee1; Lilani Perera3; Sonia Friedman3; Laura K. Snydman2. 1Internal Medicine, Tufts Medical Center, Boston, MA; 2Internal Medicine, Tufts Medical Center, Boston, MA; 3Gastroenterology and Hepatology, Tufts Medical Center, Boston, MA. (Control ID #4267966) SETTING AND PARTICIPANTS: Twenty Internal Medicine (IM) residents (PGY-1 to PGY-3) attended a 45-minute educational lecture about Inflammatory Bowel Disease (IBD). Residents were randomly paired in groups of 2-3 to complete questions using a printed IBD Exacerbation Triage Algorithm. Out of twenty, nineteen residents completed pre- and post-survey. DESCRIPTION: The American Board of Internal Medicine blueprint includes Crohn’s disease and ulcerative colitis as essential knowledge areas. In all, 55 of 83 IM residents (66%) participated in a needs assessment survey. Despite 94% of the participants answering that IBD management is at least moderately important, 72% of the residents were uncomfortable triaging and initiating management for this patient population. Therefore, we designed an IBD exacerbation triage algorithm with renowned IBD experts based on gastroenterology guidelines and published studies to address the knowledge and confidence discrepancies. During a 45-minute didactic session, residents spent 20 minutes reviewing the algorithm and 25 minutes applying it to clinical cases in small groups. The cases focused on severity grading, appropriate workup, urgency recognition, and management decisions. A presenter reviewed cases and emphasized key points of the algorithm. EVALUATION: On retrospective paired pre- and post-surveys, residents self-reported their comfort and likelihood of using the algorithm for IBD exacerbation on a 5-point Likert scale. Data analysis to date reveals a trend towards significantly higher improvement in likelihood and knowledge compared to having not learned about the algorithm. Knowledge-based multiple-choice quizzes on algorithm concepts showed significant improvement in residents correctly employing the Truelove and Witts criteria to assess severity of IBD (52.9% pre- vs. 80.4% post-session, p=0.006). In addition, fewer residents selected the incorrect response of corticosteroids before ruling out infection to treat an acute flair of ulcerative colitis after the session (33.6% pre- vs. 11.8% post-session, p=0.041). Overall, quiz scores showed statistically significant improvement (p<0.001). Most residents rated the session as organized (95%, n=19/20), effective (85%, n=17/20), and meeting objectives (85%, n=18/20). Notably, 90% (n=18/20) of participants were extremely likely to use the algorithm in practice.

/ REFLECTION / LESSONS LEARNED: The IBD exacerbation triage algorithm helped to simplify the process of caring for complicated IBD patients. Using think-pair-share encouraged communication despite differences in training level, fostered engagement with the cases, and led to relevant patient-care related inquiry. We have completed this workshop once and are planning another session. Based on feedback after the first session, we plan on simplifying the dense content further and highlighting key aspects to maintain resident engagement without overwhelming them. OBESITY MEDICINE UTILIZATION IN A COUNTY HOSPITAL: INTERVENTIONS TO IMPROVE PROVIDER EDUCATION AND PRACTICE Kelly Cheung1; Natalie Bouri2; Nathaniel M. Pedley2. 1Internal Medicine, University of California Los Angeles, Los Angeles, CA; 2UCLA Medical Center Olive View, Sylmar, CA. (Control ID #4271074) SETTING AND PARTICIPANTS: We collected data on the percentage of patients with obesity in our primary care clinic at a county hospital who received weight loss medication, nutrition consult, and/or referral to bariatric surgery. DESCRIPTION: We created a concise and educational one-page handout for resident physicians and attending physicians on motivational interviewing, multidisciplinary resources such as nutrition consults, pharmacologic therapy, and bariatric surgery. It was placed in clinic spaces and disseminated electronically. We surveyed sixty-six Internal Medicine residents and attendings to assess their confidence in utilization of obesity medicine and available interventions within our county system prior to providing education materials. This assessment was completed on a Likert scale of 1 to 5, with 1 being most confident and 5 being least confident. EVALUATION: Of approximately 4600 patients at our primary care clinic, 48% of them were classified as obese (BMI>30) in our EHR (electronic health record). Of this population, only 9.3% had received a prescription for weight loss medication and 12.3% had been referred to see a nutritionist. Out of 66 providers surveyed, over 60% percent did not feel that they received sufficient training to help patients achieve sustainable weight loss. Of this cohort, only 26.2% responded with either 1 or 2 when asked about their confidence in using motivational interviewing, and only 27.7% responded with either 1 or 2 when asked about their confidence in using medications. Of the twenty-six attending physicians surveyed, 42% responded with either 1, 2 or 3 in regards to their confidence in prescribing medications for weight loss in their practice. Results from our post-intervention survey and are still being collected. Post-intervention data on use of weight loss medication and number of referrals to nutritionist are in the process of being collected.

/ REFLECTION / LESSONS LEARNED: Obesity treatment options and interdisciplinary referrals are underutilized. There is a need for increased educational emphasis on obesity medicine for medical trainees and physicians to employ a multipronged approach to treating obesity. Obesity medicine continues to evolve and as the area of pharmacologic weight loss interventions develops further, established education for medical trainees is becoming increasingly important. Equally important is discussing obesity in a patient-centered manner that improves patient engagement with physicians. Future goals of this project involve assessing our cohort of providers for retention of educational materials, analyzing its translation to clinical practice, and assessing its impact on patient outcomes. ONLINE RESOURCE URL: https://drive.google.com/file/d/1H_pzjn8DGuTt744xN3qZVZ2NYTuAIf9E/view?usp=drive_link Innovation in Medical Education (IME) - Clinical Informatics, Artificial Intelligence, and Health Information Technology CHART YOUR PROGRESS: USING SIMULATED ELECTRONIC HEALTH RECORD CASES TO ASSESS RESIDENT CLINICAL SKILLS Rebecca A. Griffith2,4; Rajiv Bhagat2; Craig Muckle1; Ahmed Ezzelden2; Namita Joshi3,1; Jeremy C. Cuevas1; Cilian J. White2. 1Information Services & Support, Atlantic Health System Inc, Morristown, NJ; 2Internal Medicine, Morristown Medical Center, Morristown, NJ; 3Family Medicine, Morristown Medical Center, Morristown, NJ; 4Academic Affairs, Atlantic Health System Inc, Morristown, NJ. (Control ID #4236060) SETTING AND PARTICIPANTS: A core expectation of learners in medicine is the ability to efficiently review the electronic health record (EHR). This is a challenging concept not only to teach but also to assess. We describe an innovation in medical education at a community teaching hospital in the mid-Atlantic region. Faculty members from our IM residency along with members of our EHR training team developed structured chart review exercises in a simulated (non-production) EHR environment. The simulated environment is available at no cost to our hospital system as part of the training package included with our EHR and allows a real-world feel to the exercises. DESCRIPTION: The group developed cases focused on inpatient admission and discharge scenarios designed with common or high-stakes situations built-in and were delivered in an OSCE-type format to interns as part of an assessment week prior to their transition to PGY2. The group met with EHR training team members to discuss case development and functionality of chart- review exercises to ensure the cases functioned as close to real-world scenarios as possible. All cases were de-identified and not linked to real patient data. Learners were observed by trained faculty members and scored via rubric. The learners were also surveyed about the exercise. We developed guidelines for writing the cases during the process to allow easier translation into the training environment and a timeline map with process steps as an aid to others developing cases. EVALUATION: For the admission EHR Simulation Case: ● Completion rate for PGY1 of 82% ● 43% of interns did not meet critical actions and performed below expected level ● 92% found the cases realistic, 84% felt the cases helped them practice clinical decision making; 84% learned methods to improve their chart review process. For the discharge EHR Simulation Case: ● Completion rate of 100% ● 24% missed patient unsafe-for-discharge indicators and 76% failed to identify proper follow-up plans ● 95% found the cases realistic, 88% felt the cases helped improve med reconciliation skills and 100% recommended the exercises for others.

/ REFLECTION / LESSONS LEARNED: The success of the initial exercises encouraged expansion of the EHR Simulation Program to include faculty from other residency programs and work is underway on outpatient-focused exercises including transition of care management, outpatient call encounters and incidental or abnormal findings on testing. Our intention is to continue to expand to other areas within our institution and develop multi-institutional collaboration guidelines to foster dissemination as we have had interest in sharing our cases from other residency programs in our region. We feel that the program has been well accepted by our residents and provided both residency and EHR training team leadership with valuable information that will help improve EHR training and assessment going forward. We feel that the EHR Simulation approach would be useful not only as assessment tool but also in teaching and remediation situations. GENERATIVE AI PROMPT-A-THON FOR MEDICAL STUDENTS Verity Schaye, Magdalena R. Scheer, Shani Smilovich, Marc Triola. New York University Grossman School of Medicine, New York, NY. (Control ID #4235204) SETTING AND PARTICIPANTS: The rapid advances of generative artificial intelligence (GAI) have the potential to be a disruptive innovation for medical education. Several articles have been published on the importance of developing curriculum to ensure we are teaching our learners best practices and limitations of GAI but little has been published about implementation. Here, we describe the implementation of an innovative GAI prompt-a-thon for clerkship students. DESCRIPTION: This two-hour curriculum comprised of a 45-minute didactic and an hour and 15-minute interactive component. It was embedded within a 3-day clinical skills curriculum for clerkship students inbetween clerkship blocks. First, two faculty with expertise in AI gave a brief overview and limitations of GAI technology, highlights of the literature, prompting best practices, and the school’s guidelines for usage. Students then broke up into groups of 8 to practice prompting with GAI use cases moderated by the two faculty and additional staff with expertise in AI. One of the session leads created an online platform which is publicly available (https://navigator.med.nyu.edu/pat/) for the small group breakouts to facilitate practice with prompting. This platform includes links to both public and the private institutional instance of ChatGPT as well as several use cases with which the students could practice prompting. An example use case includes creation of a virtual interactive Objective Standardized Clinical Exercise case to practice interviewing a patient. Each use case provided sample text, synthetic clinical notes, and prompts to get the students started. Students then had the opportunity to iterate on the prompts in groups. Finally, each group reported out on lessons learned on prompting best practices and on how they might integrate GAI into future practice. EVALUATION: One hundred and thirteen medical students participated. 81 % viewed the workshop as somewhat or very effective. Qualitative feedback included that it was useful to practice different AI use cases using individualized prompts and to learn how to utilize this resource for their learning. Students reported wanting more structure to the interactive component and more focus on what aspects of GAI are ready to be implemented now in clinical care and limitations of these technologies.

/ REFLECTION / LESSONS LEARNED: Although student input was solicited in developing the content, there was a range in skills with these technologies in the session, suggesting an opportunity to conduct our needs assessment with a wider group of students as we iterate on the curriculum. The online platform that was developed makes any iterations on content easy to conduct. The fact that this online platform is publicly available also facilitates implementation at schools without the same extent of resources. Based on further study of how and when students are utilizing GAI in medical school, it will be important to adjust when this workshop is delivered and what content is covered to best meet their needs. WIN-WIN: TEACHING RESIDENTS TO USE EHR POPULATION HEALTH TOOLS TO IMPROVE PATIENT CARE AND BUILD CONFIDENCE IN MANAGING A PANEL Sumitha Raman, Anna K. Rubin. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4273374) SETTING AND PARTICIPANTS: The ACGME requires Internal Medicine residents to utilize the EHR to achieve quality targets for patient panels, yet there is limited data on teaching residents to apply EHR data tools for panel management. In our pre-curriculum survey, 72% of residents found panel management relevant to their future practice, but reported low confidence in applying EHR tools to analyze their panels and quality metrics. 75% of residents reported never or rarely using existing EHR dashboards to identify patients with care gaps. To address these needs, in AY 2024-25 we launched a longitudinal ambulatory panel management curriculum, delivered to 68 PGY1s and PGY2s in Internal Medicine. DESCRIPTION: We delivered interactive, 60-minute sessions every 10 weeks during protected QI time in ambulatory weeks. Teaching modalities included PPT lectures, EHR tool demonstrations, and structured independent activities. In Session 1, we defined panel management and empanelment and reviewed clinic guidelines for empanelment. We demonstrated how to run patient panel reports in Epic, and residents then ran their own panel reports and corrected empanelment errors. In Session 2, we demonstrated how to analyze panel demographics and metrics using Slicer Dicer, an interactive data tool in Epic. Residents formulated questions about their panels and answered them using Slicer Dicer. In Session 3, we introduced our EHR quality dashboard that displays provider-level performance on key quality metrics. Residents reviewed their own performance, ran a report of their lowest metric, and performed targeted outreach to 3-5 patients to close a care gap. In upcoming sessions, residents will meet our institution’s population health staff, PGY1s will present their individual panel data, and PGY2s will choose metrics to target for panel management in their PGY3 year. EVALUATION: Pre- and post- curriculum surveys evaluate residents’ confidence in performing EHR panel management activities, frequency of using EHR tools for panel management, and relevance of the curriculum to their future practice. 57 PGY1s and PGY2s completed the pre-survey prior to Session 1, and the post survey will be conducted after Session 5. Additionally, we will track empanelment, continuity of care, and patient outcomes in key quality metrics for patients with resident PCPs.

/ REFLECTION / LESSONS LEARNED: Incorporating panel management into our existing QI curriculum was optimal, as it protected time for these activities and helped residents generate data for their longitudinal QI projects. It was helpful to have a faculty co-leader with organizational involvement in population health, highlighting the importance of close connections between academic educational and population health leadership. Our goals to improve this curriculum include incorporating additional resident feedback, tailoring the panel management activities to each PGY class, expanding faculty development for preceptors to increase familiarity with EHR tools, and including interdisciplinary team-based care activities. Innovation in Medical Education (IME) - Curriculum Development – CME CATALYZING MENTAL HEALTH AND ADDICTION EDUCATION FOR PRIMARY CARE CLINICIANS Zoe Kopp1; Irina (Era) Kryzhanovskaya2; Emma Samelson-Jones3. 1Department of General Internal Medicine, University of California San Francisco, San Francisco, CA; 2Medicine, University of California San Francisco, San Francisco, CA; 3Psychiatry, University of California San Francisco, San Francisco, CA. (Control ID #4272806) SETTING AND PARTICIPANTS: PsychSnaps is an electronic curriculum that aims to improve the management of behavioral health problems by generalists. The authors are 3 clinician-educators in a large, academic primary care medicine setting – 1 embedded psychiatrist, 1 addiction specialist and internist, and 1 internist. PsychSnaps launched in 12/2022 and now has 525 active subscribers. In a 9/2024 survey, 73% of subscribers identified as MD/DO, 24% as APPs (NP/PA), and the majority practice internal medicine, in the state of California, in academic-affiliated medical settings for more than 10 years. DESCRIPTION: PsychSnaps is a curriculum of concise, clinically focused email-newsletters, delivered to subscribers every 2 weeks and accessible via the website. The curriculum focuses on common psychiatry and addiction e-consult questions from primary care and specific topics requested by subscribers in surveys. Each lesson is grounded in a relevant case and combines up-to-date literature with best practice recommendations, distilling emotionally charged mental health care into actionable steps (i.e. how to talk about self-harming behavior, how to treat agitation in older patients with dementia). EVALUATION: 50 PsychSnaps have been delivered via 15,946 email newsletters, with an open rate of 64%. In our 9/2024 evaluation survey, 100% of respondents found PsychSnaps to be clinically useful and trustworthy. 73% noted that PsychSnaps had changed clinical practice, specifically in expanding medication options, empowering communication on difficult topics, and increasing confidence in clinical reasoning. 90% found PsychSnaps unique or very unique compared to continuing medication education offered at their institution.

/ REFLECTION / LESSONS LEARNED: Given the limited availability of psychiatric care, it is imperative that clinicians are prepared to care for (and continually learn about how to help) people with psychiatric illness. We anticipate the questions primary care clinicians have, provide guidance in an extremely accessible and low-barrier format, and invite subscribers to use this information as a teaching tool for trainees. Over the past 2 years, PsychSnaps has exposed learners to new content every other week via the newsletter and offered easy access to a repository of prior lessons and original, curated resources. We are currently applying for CME accreditation, partnering with a non-profit funding source, and launching a social media campaign. Moving forward, we will expand the topics covered with subspecialty guest authors and strive to obtain sustainable support for our mission. Our aim is to become the go-to choice for primary care mental healthcare questions and serve as the easiest to use resource and teaching tool for trainees and practitioners. ONLINE RESOURCE URL: www.psychsnaps.com ENHANCING EVIDENCE-BASED PRACTICE THROUGH A NOVEL, REVITALIZED QUARTERLY JOURNAL CLUB Wanna Zhang1; Michelle Sweet2. 1Internal Medicine, Rush University Medical Center, Chicago, IL; 2Internal medicine, Rush University Medical Center, Chicago, IL. (Control ID #4272037) SETTING AND PARTICIPANTS: Large, academic-based Internal Medicine hospitalist group in the midwestern United States DESCRIPTION: To address the need for continuous learning and up-to-date medical knowledge, our large academic-based hospitalist group implemented an "Updates in Hospital Medicine" journal club series. This reimagined initiative condenses our previously monthly journal clubs into quarterly sessions. Each session reviews 2-4 high-yield articles published within the last two years, with a focus on practices directly applicable to hospital medicine. Articles with relevance to hospital medicine are chosen from NEJM Journal Watch and carefully reviewed to ensure relevance to the clinical challenges faced by hospitalists. Due to the condensed format, we emphasize how the findings may (or may not) influence our current practices, instead of focusing on dissecting study methodologies and analyses. EVALUATION: The implementation of this novel journal club has led to higher attendance from hospitalists, allowing for more meaningful engagement with the material. A survey was sent out to the hospitalists to evaluate the group’s preferences. 29 responses were collected, response rate . Overall 96.6% of the group agreed or strongly agreed that the Updates in Hospital Medicine series has improved their clinical knowledge. Moreover, 71.4% agreed and 7.1% strongly agreed that this series has changed their clinical practice. Participation in didactic conferences is often challenging due to the demands of patient care. With this restructuring of journal club, we have seen a marked increase in both journal club presenters and session participants. 85% surveyed prefer this format of journal club, citing this is more engaging, high-yield, and efficient. 83% stated they were more likely to present an article in the Updates in Hospital Medicine format as opposed to the traditional journal club format. The increased attendance and focused discussions have sparked group conversations about individual and collective clinical practices, promoting the application of new knowledge in daily patient care.

/ REFLECTION / LESSONS LEARNED: Transitioning to a dynamic, high-yield format has increased participation and fostered an environment of reflective practice, enhancing our group’s commitment to evidence-based medicine. This innovation can serve as a model for other hospitalist groups aiming to balance high clinical demands with continued professional development and commitment to academic progress. Several other groups, including the Physician Assitant program and Primary care group have reached out and plan to change their journal club to this model. We plan to implement an evidence-based medicine curriculum based on this format in which we cycle through the subpecialties every two years and highlight the most notable, practice-changing articles to remain current with our care. INTERNIST'S SALON: FOUR YEARS OF COMMUNITY AND KNOWLEDGE BUILDING FOR GIM PHYSICIANS Milna Rufin, Gaby Mayer, Heather B. Levitt, Pamela Boodram, Julia Adamian, Sondra Zabar. Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4270171) SETTING AND PARTICIPANTS: General internal medicine (GIM) faculty at an urban academic medical center. DESCRIPTION: The Internist’s Salon, now in its fourth year, is a monthly virtual continuing medical education (CME) conference series for the GIM community at our institution. This includes faculty & advanced practice providers at multiple practice settings: the nation's largest safety net clinic, multi-site faculty practices, Veterans Affairs clinics, & federally qualified health centers. The hour-long session occurs before the clinic day to optimize attendance. The Salon team curates topics highly relevant to GIM practice, offering three formats: 1. Case Conference: an internist presents on a specialized topic (e.g., advanced hypertension management). 2. Ask the Expert: cased-based series where internists interview a thought leader in a GIM-relevant subspecialty relevant (e.g., erectile dysfunction). 3. Journal Club: two internists discuss articles that may alter practice patterns (e.g. new hepatic steatosis guidelines) EVALUATION: Over three years, mean Salon attendance was 57 per session; the highest attendance was at Asthma for the Internist (70 attendees) and Advanced Depression (68 attendees). At the end of the Salon's second and third years (2022-2023 and 2023-2024), faculty seeking CME credit completed surveys with quantitative and qualitative data. n = 38 repondents expressed high satisfaction with the quality of the speakers, rating clarity and engagement at 4.6 and 4.7, respectively (1–5 Likert scale, 5 being most favorable). They felt the conference both reinforced previous medical knowledge (4.6, 1-5 Likert scale) and challenged their understanding of medical topics (4.7, 1-5 Likert scale). When asked what changes they will incorporate into their practice as a result of the Salon, respondents mentioned three themes: 1. Honing their practice of chronic disease management using new techniques or information. 2. Renewed commitment to stay up-to-date with medical content. 3. Recognition that peer consultation is a powerful form of learning. Respondents enjoyed the following aspects of the conference: 1. The practicality of the content for daily clinical practice. 2. The sense of community fostered by the meetings. Future Salon proposals included medical topics (e.g. CKD, pulmonology) but also multidisciplinary themes (bioethics, end-of-life care)

/ REFLECTION / LESSONS LEARNED: Our findings suggest that a monthly, hour-long virtual conference is effective & enjoyable for medical learning among academic GIM physicians. Participants valued the Salon not just for medical content, but also the community it fostered, which allowed physicians to exchange metacognitive strategies for learning (e.g., clinical reasoning, ways to stay current with literature). These findings align with medical education literature emphasizing the importance social interactions in enhancing workplace learning. Future directions include gathering more participant data (both demographic and qualitative) to tailor content to maximize engagement. Innovation in Medical Education (IME) - Curriculum Development – GME "SO HOW DID THAT GO?": A RESIDENT PEER-TO-PEER DIRECT CLINICAL OBSERVATION AND FEEDBACK PROGRAM Hannah M. Borowsky1,2; Mary Thorndike1,2; Beret Amundson1,2; Andrew Lawton3; Sonja R. Solomon1,2. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Harvard Medical School, Boston, MA; 3Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4272319) SETTING AND PARTICIPANTS: We implemented this program within a primary care internal medicine residency. We piloted the program from January-May 2024 with PGY2 and PGY3 residents (n=12). We have started year two of implementation, which will occur from December 2024-March 2025 with PGY1 and PGY2 residents (n=17). DESCRIPTION: Direct observation with feedback is a key component of medical education and required by the ACGME for residencies. Residents commonly report lack of preparedness for difficult conversations and desire more real-time feedback to improve. However, research shows that direct observation of clinical encounters with high-quality, formative feedback is uncommon during residency training and beyond. We developed and implemented a novel peer-to-peer observation and feedback program for internal medicine primary care residents. Drawing on tools for bedside teaching and feedback from palliative care education, we developed a structured method for observing and debriefing a clinical encounter, which we taught to residents during an interactive workshop. Following the workshop, residents were paired with a peer and assigned dates to reciprocally join each other in clinic for a half day session where they applied the method to observe each other. During debrief time, residents gave each other feedback specifically focused on clinical communication by highlighting strengths and troubleshooting “stuck points”. EVALUATION: We conducted a survey of participants in the first year of this program and will complete data collection on year two by March 2025. The survey includes rankings on a 4-point Likert scale and free-response questions. Survey data from year one showed that residents would choose to participate in a peer observation experience again (M=3.65, SD=0.55), rating both aspects of the observation experience to be highly worthwhile – including being observed in their own clinic (M=3.3, SD=0.52) and observing a peer in clinic (M=3.4, SD=0.55). Additional survey data from year 2 will allow us to gain more insights on residents' perceptions and experiences.

/ REFLECTION / LESSONS LEARNED: Our educational innovation provided residents with an opportunity for direct observation of communication skills, using a novel peer-to-peer feedback approach in the primary care setting. Our results illustrate resident willingness to participate in peer-to-peer clinical direct observations, and a strong interest in receiving and giving feedback on clinical communication. By designing the experience to be entirely non-evaluative and framing constructive feedback around identification of "stuck points" in the conversation, we found that this activity promoted trust, connection and a growth mindset. Expanding the program to involve multiple observations and opportunities to receive feedback, may elevate the impact of this type of experience. Finally, structuring observations and feedback around defined clinical competencies, could further elevate the quality and impact of this program. ACCELERATED AUTONOMY: A NOVEL PGY1-PGY2 TRANSITION MODEL FOR INTERNAL MEDICINE RESIDENCY Priyank Jain1; Stephanie M. Hastings2; Adam Tapley3; Rebecca Rogers1. 1Medicine, Cambridge Health Alliance, Arlington, MA; 2Graduate Medical Education, Cambridge Health Alliance, Cambridge, MA; 3Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4239485) SETTING AND PARTICIPANTS: A university affiliated community hospital in the Northeastern US that has two IM ward teams consisting of two interns, one resident, and one attending each. Each team has 10-14 patients on most days. DESCRIPTION: In 2023, we piloted a novel team structure called the, "Spring ward team," where interns worked directly with attendings without a resident. Clear guidelines were provided to facilitate the division of responsibilities typically handled by the resident. The objective of this pilot was to prepare interns for more autonomy in patient care before they transition into supervisory roles in PGY2 (1). EVALUATION: Five of eight interns in PGY1 class participated in the pilot. All interns were surveyed before and immediately after the pilot ward rotation. One hundred percent of the post-test respondents strongly agreed that being on a wards team without a resident improved their “readiness to take on the resident role on wards as a PGY2”. In the following year, several PGY2 residents who participated in the pilot as interns reported in their program director meetings that the pilot increased their confidence when they started in the role of team leaders.

/ REFLECTION / LESSONS LEARNED: The transition from IM intern to supervising resident has historically been challenging. It demands greater independence in patient assessment, interdisciplinary coordination, and the ability to supervise and teach interns and medical students. However, traditional intern year structures often limit opportunities to develop these essential skills. In our program, previous attempts to encourage more autonomy and relevant skills acquisition toward the end of intern year, such as through more "hands-off" supervision or brief "resident-for-a-day" experiences, were inconsistent and often felt contrived. The Spring wards pilot aimed to overcome these limitations by fundamentally redesigning the team structure. Removing the resident from the team forced interns to assume greater responsibility for medical decision-making and systems-level thinking, such as participating in multidisciplinary rounds. This "learning by doing" approach fostered greater autonomy and confidence. A key lesson was that modifying the team (environmental restructuring) proved more effective than relying on reminders (persuasion) to change resident behavior (2). This intervention required buy-in from attendings, who initially expressed skepticism. They were tasked with increased coaching responsibilities, including direct supervision of interns and cross-checking orders. However, attendings anecdotally ultimately appreciated the opportunity for more individualized assessment and coaching, and witnessed significant growth in the interns. Due to the successful implementation and positive feedback from all stakeholders, the Spring wards model has been permanently integrated into our intern year curriculum. This simple yet effective change can be readily adopted by other residency programs. ONLINE RESOURCE URL: (1) https://shorturl.at/hXb2V (2) https://shorturl.at/pjHDJ AN INTEGRATED CURRICULUM FOR PATIENT SAFETY AND QUALITY IMPROVEMENT: TEACHING INTERNAL MEDICINE RESIDENTS TO LEAD CHANGE David Ozimek1; Jennifer D. Baldwin3; Snehal Naik2. 1Internal Medicine, UConn Health, Farmington, CT; 2Internal Medicine, UConn Health, Farmington, CT; 3Medicine, UConn Health, Farmington, CT. (Control ID #4272391) SETTING AND PARTICIPANTS: A multi-site university residency program in the northeast from 2021-2024. DESCRIPTION: The second revision of the ACGME Internal Medicine Milestones set a graduation goal for residents to conduct analysis of patient safety (PS) events, disclose PS events to patients and families, and demonstrate the skills required to identify, develop, implement, and analyze a quality improvement (QI) project as outlined in Systems Based Practice 1: Patient Safety and Quality Improvement (SBP1). We developed a longitudinal, integrated PS and QI curriculum to meet these goals. Our curriculum uses an array of teaching activities throughout the intern year including both a simulated and real apparent cause analysis, online learning, small group interactive workshops, and simulated patient encounters to ensure residents meet the recommended graduation competencies and milestones. EVALUATION: Our curriculum was implemented in 2021 and has increased resident engagement in QI, as measured by a QI project presentation or completion of a Plan-Do-Study-Act (PDSA) cycle prior to graduation. Graduating resident QI engagement increased from a pre-curriculum average of 23% to 77% in 2024, the first class to receive the full curriculum. During this time, the total number of unique QI projects presented annually increased from 6 in 2022 to 11 in 2024. The safety event analysis experiential has allowed our residents to meet the PS graduation goal of SBP1 during their intern year. Event reporting by residents increased from 4 events in the last 6 months of 2021 to an average of 10 events per half year in 2023. In addition, our residents reported higher than national average ratings for knowing how to report safety events (98% vs 93% respectively) and participating in safety event investigation and analysis (93% vs. 79%) on the 2022-2023 ACGME IM survey.

/ REFLECTION / LESSONS LEARNED: Our curriculum has successfully enhanced residents’ participation in PS and QI, as evidenced by our strong survey results and increased QI engagement. Early PS and QI skill development facilitates the culture of safety needed to increase event reporting, and provides the time needed to observe systematic change and allow for QI project completion. Capturing reported events across our multi-site program remains challenging. While residents’ preference for anonymity encourages reporting, it has made tracking submission difficult, which despite increases in the number of reported events, likely contributes to our low numbers. To address this, we plan to implement a system requiring residents to indicate their training program when submitting events. This will allow us to identify trends and provide tailored feedback to administration. Increased reporting and tracking will also provide potential QI projects for learners. These efforts aim to sustain and further improve the culture of PS and QI within our program. ASSESSING THE STATE OF NUTRITION EDUCATION IN U.S. MEDICAL SCHOOLS Sarah Bdeir, Kareem Tayeb. School of Medicine, Wayne State University School of Medicine, Detroit, MI. (Control ID #4271468) SETTING AND PARTICIPANTS: This study involved an online survey sent to medical students across the United States. DESCRIPTION: Despite the National Academy of Science recommending a minimum of 25 hours of nutrition education, U.S. medical schools dedicate an average of only 19 hours, and 75% lack mandatory clinical nutrition classes. Alarmingly, only 14% of current healthcare providers feel confident discussing nutrition with patients, despite its critical role in disease prevention and management. To address this gap, we surveyed medical students about their schools' approaches to culinary medicine, self-perceived competence, and recommendations for improving nutrition education curricula. EVALUATION: Quantitatively, a single survey administered after the completion of the culinary medicine program captures students’ self-assessments of their knowledge and readiness. The survey includes retrospective pre-program questions, asking students to evaluate how knowledgeable and prepared they felt before starting the program, alongside current post-program assessments of their knowledge and preparedness. These self-ratings are collected using a 1-10 Likert scale, allowing for comparative analysis of perceived growth and the effectiveness of the education program. Qualitatively, students will describe specific areas of improvement and perceived gaps in culinary education at their respective programs.

/ REFLECTION / LESSONS LEARNED: Preliminary findings reveal a significant gap in nutrition education across medical schools, with only 20% incorporating the recommended 25 hours of instruction into their curricula, while 80% offer no formal nutrition training. Some schools relegated to an optional fourth-year elective. Students acknowledged the critical need for robust nutrition education, expressing concerns about their own and their peers' ability to effectively counsel patients on dietary health. This highlights both future physicians' personal desires for better training and the urgent need to address the growing demand from patients for both culturally competent and socioeconomically aware nutritional guidance. Bridging this educational gap is essential to enhancing the competence of future healthcare providers and equipping them with the tools to prevent chronic diseases to better empower their patients. ONLINE RESOURCE URL: https://www.uofmhealth.org/conditions-treatments/culinary-medicine https://culinarymedicine.org/ ASSESSMENT OF AN EDUCATIONAL INTERVENTION REGARDING LIPOPROTEIN (A) TESTING TARGETED AT INTERNAL MEDICINE RESIDENT PHYSICIANS Yehuda Eidensohn1; Paul O'Rourke2. 1Internal Medicine, Johns Hopkins University, Baltimore, MD; 2Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4262159) SETTING AND PARTICIPANTS: Internal medicine residents of an academic medical center in the Mid-Atlantic. DESCRIPTION: Lipoprotein(a) [(Lp(a)] is an independent genetic risk factor for the development of atherosclerotic cardiovascular disease (ASCVD). Lp(a) levels greater than 125 nmol/L or 50 mg/dL are associated with a 20% increase in risk of ASCVD. The AHA/ACC 2018 Guidelines on the Management of Blood Cholesterol identified elevated Lp(a) as a risk-enhancing factor favoring more aggressive management of lipids. Despite the increasing recognition of Lp(a) as an important biomarker in assessing risk for cardiovascular disease, clinical utilization of Lp(a) testing has been low. Prior studies have shown especially low rates of Lp(a) measurement among internal medicine providers. Therefore, there is a need for educational interventions targeting internal medicine providers around the topic of Lp(a). Our hypothesis was that a brief presentation on the topic of Lp(a) testing will increase resident confidence in ordering and interpreting the test and will be associated with increased frequency of testing. We designed a 30-minute presentation that included a general overview of ASCVD risk assessment, differences between Lp(a) and regular low-density lipoprotein (LDL-C) cholesterol, and examples of how elevated Lp(a) can change clinical management. The presentation was administered to a total of 22 interns in the fall of the 2024-25 academic year. EVALUATION: A five-question survey assessing participant confidence in ordering and interpreting Lp(a) tests was administered before and after the presentation. Each question was scored between 1 (lowest confidence) and 5 (highest confidence), with a maximum total score of 25. Results demonstrated an increase in participant confidence, with mean scores increasing from 10 to 24. The survey demonstrated good internal validity with a Cronbach's alpha of 0.83. To assess how this intervention impacted behavior, data on participants’ Lp(a) ordering practices was extracted from the electronic medical record for the 3 months before the presentation. To provide context, we evaluated four groups of residents: Interns who participated in the presentation, interns who did not participate, PGY-2s, and PGY-3s. Over the preceding 3 months, all combined PGY groups ordered a total of 48 Lp(a) tests, of which 7 (15%) were ordered by participants in the presentation. After 3 months have elapsed from the presentation, we will extract data for those 3 months and compare it to the 3 months prior to the presentation.

/ REFLECTION / LESSONS LEARNED: Lp(a) testing is an underutilized adjunct to ASCVD risk stratification, and internal medicine trainees may receive little to no education in this area. We developed a brief presentation that was well received by residents and was associated with increased confidence regarding the topic of Lp(a) testing. This curriculum could be easily incorporated into current ambulatory curricula and may enhance internal medicine residents’ management of cardiovascular risk in their career. BASKET CASE NO MORE: IMPROVING RESIDENT CLINICAL DECISION-MAKING IN ADDRESSING AMBULATORY IN-BASKET RESULTS Mary Solis1; Pamela Vohra-Khullar2; Reema Dbouk3; Kajal Patel1; Miranda A. Moore1. 1Medicine, Emory University School of Medicine, Atlanta, GA; 2Internal Medicine, Emory University School of Medicine, Atlanta, GA; 3Medicine, Emory University, Atlanta, GA. (Control ID #4273138) SETTING AND PARTICIPANTS: This quality improvement project took place in a resident ambulatory clinic within a southern academic institution. 30 categorical residents each rotate for 1 week at a time on an X+Y system. 7 primary care residents each rotate for 4 weeks at a time. There is a coverage system in which residents currently in clinic complete tasks for peers who are on inpatient rotations. DESCRIPTION: There are several barriers to addressing patient messages and in-basket results. We have found that many barriers – allocated time, expectations, comfort with the medical record system – are being actively addressed. Unfortunately, there is little formal training in the medical knowledge and clinical decision-making needed for appropriate in-basket management. We developed a case-based curriculum centered around common in-basket scenarios to discuss the nuance of outpatient management, provide insight on systems-based practice, and to offer guidance in uncertain areas. The toolkit included a resident-facing outline and attending-facing answer key. The sessions were completed in 20 minutes to allow completion before or after clinic sessions. The topics were acute kidney injury, hypokalemia, hyperglycemia, and hypothyroidism. These topics were chosen based off informal feedback from residents and attendings. These sessions occurred twice a week and the same topic was repeated over the course of the ambulatory block (5 weeks), to capture all residents. EVALUATION: We administered electronic pre- and post- intervention Likert scale surveys to compare the residents’ confidence with interpreting specific results scenarios and to assess perception of the training. The surveys were tested for content validity by non-participants. 20 residents (54%) completed the post-survey. 16 residents (80%) agreed that the discussions improved clinical reasoning skills. An unpaired chi-squared test of the pre and post surveys showed that satisfaction with in-basket training increased (25% to 75%, p=0.007). There was an increase in confidence with assessing hypokalemia (79%, p=0.045), hyperglycemia (17, p=0.066), and acute kidney injury (19, p=0.139). Upon analysis of Epic Signal data, the average time spent addressing in-basket results and messages was small (6.59 minutes per clinical session) and slightly increased following the intervention (7.8 minutes per clinical session, change not statistically significant).

/ REFLECTION / LESSONS LEARNED: In-clinic case-based discussions hold promise as an effective way to teach needed clinical decision-making skills as part of the resident ambulatory curriculum. Though this intervention did not decrease the time spent in the resident in-basket, it improved confidence in addressing these results. We plan to offer this curriculum to new residents, providing lunch to increase participation, and adding more participants for data collection. BINGO! GAMIFIED LEARNING FOR NIGHT FLOAT Ryan Salemme1; Matthew Taglieri1; Caitlin Mingey1; Chavon Onumah2; Shazia Samanani2. 1Hospital Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Medicine, The George Washington University, Washington, DC. (Control ID #4270894) SETTING AND PARTICIPANTS: At our institution, two senior residents admit patients at night to our busy Internal Medicine service, supervised by an in-house nocturnist. Admitting during night float is regarded as a great learning opportunity for medicine residents in that it affords them a sense of autonomy while learning through the various patient admissions they see. However, adding structured educational opportunities to this rotation can pose a challenge due to time constraints, the volume of admissions, and limited face-to-face time with the attending nocturnist. Our residents have expressed these constraints have led to a lack of formalized teaching and feedback. Specifically, they have asked for the opportunity to debrief on the unfolding events of patients whom they admitted in the prior nights. To address this and add more structured education to this rotation, we have incorporated gamified learning to our night float in the form of “night float bingo.” When surveyed about their preferred method of learning, more than 50% of our residents said that they learn best from gamification. DESCRIPTION: At the start of their night float rotation, residents receive blank bingo boards to personalize with topics from various categories drawn from a curated list. These categories include common medical issues, disposition-oriented admissions, "bite-sized" teaching mini-talks with the nocturnist, overnight wellness activities, debriefing opportunities, and feedback on patient admissions from previous nights. When the residents achieve one of these areas, they discuss it with the nocturnist and jointly complete that bingo square. This promotes more face-to-face encounters between the resident and nocturnist fostering more “bite-sized” teaching and in-person discussions. EVALUATION: Residents are expected to complete two mini-clinic evaluation exercises (mini-CEX) based on patients they admit and discuss with the attending. We have also designed a specific milestone-based night float rotation evaluation which will be completed by the attending nocturnist which includes questions on engagement with learning overnight. Our new gamified night float initiative will be evaluated with a survey containing a Likert-based questionnaire and open-ended questions aimed at assessing resident perception of education over nights pre-implementation and again 6-months post-implementation.

/ REFLECTION / LESSONS LEARNED: Gamification has proven to be an effective strategy for engaging learners in an otherwise busy schedule, improving learning outcomes, fostering clinical decision-making skills, and delivering effective and engaging educational experiences. In implementing our night float curriculum, we anticipate that game-based learning will help overcome resident-identified barriers to overnight learning. Our goal is to use this innovative approach to mitigate time constraints as a barrier to education while maximizing face-to-face interactions with the nocturnist, thereby enriching the learning process through education and real-time feedback. BRIEF DIRECT OBSERVATION (BDO) TO TEACH PATIENT EDUCATION COMMUNICATION SKILLS IN MENTAL HEALTH Shyam Sundaresh1; Eric Woods2; Lauren Peccoralo2. 1Department of Medicine, Mount Sinai Health System, New York, NY; 2Medicine, Icahn School of Medicine at Mount Sinai, Briarcliff Manor, NY. (Control ID #4272232) SETTING AND PARTICIPANTS: This curriculum takes place in an urban academic resident clinic that primarily serves a Medicaid-insured community affected by a high burden of social determinants of health, with a HRSA-designated critical deficiency in mental health care. The participants are > 50 PGY-2 Internal Medicine (IM) residents. DESCRIPTION: Primary care physicians provide the majority of mental health care in the US, yet many do not receive adequate training. Our needs assessment identified five communication skills gaps in patient education for managing depression and anxiety: 1) determining patient understanding of symptoms 2) explaining the diagnosis in a patient-centered way 3) discussing treatment alternatives 4) exploring patient preferences 5) ensuring patient understanding of the treatment plan From 7/1 through 12/11/2024, we implemented a new method, Brief Direct Observation (BDO), to teach these communication skills which at present is not taught successfully by any published curricula. BDO focuses traditional direct observation on the final 5-10 minutes of a clinic visit for depression or anxiety, when the four communication skills listed above occur. After residents see a patient and talk to their preceptor, residents are asked to discuss their assessment and plan with patients under observation for 5-10 minutes and then receive feedback. Faculty were trained to use a published 5-item skills checklist, demonstrated adequate inter-rater reliability, and trained to use the R2C2 model (relationship building, exploring reactions to the feedback, exploring understanding of feedback content, and coaching for performance change) to provide residents feedback. Our goal was to improve self-perceived confidence and observed competence in the above communication skills. EVALUATION: During the study period, a total of 45 BDO were performed – an average of 1 per resident – based on collected skills checklists. There were 20 residents who completed post-BDO surveys, rating the quality of feedback they received to be 4.6/5. Anonymous comments included “Autonomy with appropriate support, very helpful feedback.” Of those respondents, 60% felt more confident in the above communication skills after 1 BDO experience compared to before. Faculty scored observations in the first half of the study period as having competently performed 2.3 skills on average compared to 2.8 in the second half which was not significantly different by an unpaired Student t-test.

/ REFLECTION / LESSONS LEARNED: BDO was an acceptable teaching method with high resident satisfaction that felt useful for most learners. However it failed to increase observed competence. We will increase the number of BDO per resident by modifying appointment slots and reassess. If successful, the IM residency program has agreed to continue this program, and we anticipate other programs will want to use BDO to teach other communication skills. BUILDING SKILLS THROUGH ACTION: A COLLABORATIVE NUTRITION CURRICULUM FOR INTERNAL MEDICINE RESIDENTS Francesca Garofalo1; Lucas Fass1; Victor Y. Chen1; Megan Gjertsen1; Veronica Skaradzinski2; Sarah L. Floden1. 1Medicine, University of Wisconsin-Madison, Madison, WI; 2University of Wisconsin-Madison, Madison, WI. (Control ID #4267472) SETTING AND PARTICIPANTS: A nutrition workshop was developed and delivered to thirty-five first-year internal medicine residents at an academic medical center in the Mid-West. The workshop was repeated four times for groups of 8-10 residents. DESCRIPTION: Nearly every professional society recommends counseling patients on nutrition and lifestyle interventions to reduce cardiovascular mortality (Jain et al 2020, Krishnan et al 2024). However, few internal medicine residency programs have formal nutrition curricula. Internal medicine residents who receive nutrition education in medical school are more likely to counsel patients on nutrition (Khandelwal et al 2018). Different modalities for teaching nutrition have been utilized, but rarely has an intervention combined both traditional lectures with a hands-on cooking experience to reinforce concepts (Bassin et al 2020). During regularly scheduled intern didactics, a Registered Dietician Nutritionist and senior resident led an hourlong session focused on weight management approaches and dietary interventions (e.g. Mediterranean diet). This was immediately followed by a hands-on, chef-led cooking class of katsu chicken and chana masala focused on knife skills and frying techniques. All classes took place in a learning kitchen on the university campus. EVALUATION: Just prior to the workshop, interns completed a de-identified eleven-question survey assessing level of agreement with statements regarding: 1) comfort and knowledge of nutrition and weight loss counseling, and 2) perceived importance and desire for nutrition classes. Participants rated their ability to cook healthy meals while on busy rotations on a 1-10 scale. Lastly, residents answered three case-based questions on the effects of dietary strategies on health outcomes and the amount of expected weight loss from anti-obesity medications. A follow-up survey after the workshop re-assessed the same questions.

/ REFLECTION / LESSONS LEARNED: Our hands-on, multidisciplinary nutrition curriculum for internal medicine interns increased perceived and tested knowledge on nutritional counseling. Interns felt more comfortable with nutritional counseling after the workshop. They also had increased confidence in cooking healthy meals for themselves. This may translate to increased patient counseling, as residents’ personal intake of fruits and vegetables is a predictor of nutrition counseling (Khandelwal et al 2018). Our curriculum was valued, as nearly every intern (97%) desired additional nutrition training after the workshop, compared with 76% prior. This workshop underscores the importance of partnering with nutrition and culinary experts for nutrition education in residency programs and in primary care clinics to improve patient care. Limitations include lack of a control or comparison group to evaluate the efficacy of the intervention compared with traditional teaching methods. We plan to continue and to expand this curriculum to include advanced lectures for senior residents and create a three-year longitudinal curriculum. CAN A SUMMATIVE OSCE BE FORMATIVE? ASSESSING IN-TIME COACHING FEEDBACK IN AN IM RESIDENCY SUMMATIVE OSCE Gabrielle J. Gundermann1; Emily Pinto Taylor2; Danielle Jones2,1; Reena Hemrajani1; Mackenzie L. Garcia3; Daniel C. Brown4; Dheepa Sekar4. 1Internal Medicine, Emory University, Atlanta, GA; 2General Internal Medicine, Emory University School of Medicine, Atlanta, GA; 3Internal Medicine, Emory University School of Medicine, Atlanta, GA; 4Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4270430) SETTING AND PARTICIPANTS: Objective structured clinical examinations (OSCEs) often serve as summative assessments. Traditionally, our residency program assessed intern skills using summative OSCEs focused on serious illness communication and agenda setting. OSCE results also helped determine interns’ readiness for graded autonomy and use of the primary care exception in continuity clinic. In this “standard” model (SM), interns received feedback after the encounter. Given the financial and time resources required to conduct OSCEs, our program aimed to enhance the value of the OSCE by incorporating formative in-time coaching. DESCRIPTION: We implemented a formative in-time coaching model (ITCM) during the established summative OSCE. We trained core faculty through a case-based workshop on the ITCM which was anchored in Burch’s conscious competence model. In this model, faculty were taught to identify if and when a simulated encounter should be paused based on perceived learner challenges. Interns were also able to pause to ask for skills coaching from faculty. Of the 53 interns, 50 interns participated in one OSCE case with the ITCM and another using the SM. EVALUATION: Faculty and interns completed post-participation surveys for each OSCE model which underwent qualitative analysis through the lens of social learning theory. Additionally, the summative scores of the ITCM OSCE will be quantitatively compared to the SM to assess non-inferiority of the ITCM. Thirty-nine residents and 51 faculty completed the SM survey. In the SM, 21 (41%) faculty and 10 (26%) interns indicated they would have elected to pause the encounter to address communication skills and/or clinical knowledge gaps if given the chance. Twenty-one residents and 41 faculty completed the ITCM survey. In these encounters, 12 (29%) faculty and 5 (12%) interns elected to pause, primarily when interns appeared or felt stuck and/or to address communication skills and/or clinical skills. All but one observer reported evident improvements in the intern’s approach and encounter trajectory following the ITCM. Among interns in the ITCM, 74% found it helpful.

/ REFLECTION / LESSONS LEARNED: The evaluation of the ITCM versus the SM during OSCEs suggests faculty and interns perceive value in formative feedback during a summative assessment. The ITCM allowed for immediate skill correction, to build confidence, and observational learning from a faculty member. However, more than half of faculty and interns who were given the opportunity to pause the encounter did not do so because they felt the encounter was running smoothly, they had concerns about disrupting the authenticity of the simulated encounter, or they struggled to identify the right moment to intervene. These concerns suggest the need for additional faculty training to recognize optimal pause points and manage the balance between intervention and simulation flow, such as through performance dimension training. Overall, the findings support the potential of an ITCM to enhance skill acquisition during OSCEs. CLIMATE HEALTH EDUCATION IMPROVES RESIDENT CONFIDENCE IN ENVIRONMENTAL COUNSELING & ADVOCACY ENGAGEMENT Rahee M. Nerurkar1; Emily Fishbein1; Ananna N. Kazi1; Charles E. Moon2; Darlene LeFrancois1. 1Medicine, Montefiore Medical Center, Bronx, NY; 2Environmental Medicine and Climate Science, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4255037) SETTING AND PARTICIPANTS: The study was conducted at a large urban academic medical center that serves a majority marginalized patient population. Three lectures were delivered within the academic calendar for different multidisciplinary sets of residents. 41 total participants represented the fields of pediatrics (15), family medicine (5), internal medicine (15), child neurology (1), anesthesiology (1), ophthalmology (1), and unspecified (3). DESCRIPTION: Climate change (CC) is the greatest evolving threat to human health that disproportionately affects marginalized communities and worsens the health disparities linked to social determinants of health (SDOH). The healthcare sector is responsible for nearly 10% of US carbon emissions. Physicians must understand the dangers of adverse CC health impacts and advocate for mitigation both in and out of the hospital. We developed 3 distinct peer-led climate health lectures focusing on CC health impacts and environmental justice. The session objectives were to: (1) Recognize CC’s health impacts through extreme heat, air pollution, and extreme weather exposures, and (2) Review actions and guide residents in advocating for environmental health and justice in the hospital and community. Content was developed from published education materials and current CC health impact research. Sessions were tailored to address local as well as specialty-specific health outcomes to improve relevance. All sessions included patient counseling guidance and specific strategies for resident advocacy engagement. EVALUATION: The sessions were evaluated with pre- and post-surveys using a 12-question, 5-point Likert scale. Residents reported increased CC health impact knowledge, greater likelihood of counseling patients on adaptation strategies, and improved readiness for environmental advocacy in clinical settings (p<0.001). There was no significant change in understanding the connection between CC and SDOH disparities, or in the reported likelihood of engaging in community advocacy or adopting more sustainable personal habits.

/ REFLECTION / LESSONS LEARNED: Teaching residents about climate health improves residents' knowledge of CC, their likelihood to counsel patients, and their readiness for environmental advocacy in clinical settings. While residents reported increased likelihood to engage in institutional sustainability advocacy initiatives, their likelihood to engage in community advocacy did not improve. This may reflect the time constraints of resident schedules and the lack of formal advocacy skills training. The lack of improvement in resident understanding of the connection between CC and SDOH disparities may reflect the institution's strong existing focus on linking health outcomes to SDOH. Next steps include delivering additional sessions across ACGME residency programs at our institution, and disseminating our climate health education materials to other local institutions. DEVELOPMENT AND EVALUATION OF AN OUTPATIENT “BETWEEN VISIT CARE” CURRICULUM FOR INTERNAL MEDICINE RESIDENTS Gena Lenti. General Internal Medicine, University of Washington, Seattle, WA. (Control ID #4240827) SETTING AND PARTICIPANTS: Surveys were administered to internal medicine interns at the University of Washington from July-September, 2024. While interns at four primary care sites completed surveys, only interns at one site received the “between visit care” intervention curriculum, while all other sites received their clinics’ previously established outpatient curricula. DESCRIPTION: Surveys were administered to participants at the beginning and end of their “outpatient immersion” block, a month-long rotation during which interns spend time learning primary care skills and seeing patients in their primary care clinics. Survey questions sought to assess intern experience, confidence, and concerns in managing different aspects of between-visit care, including responding to test results, triaging patient calls and messages, coordinating care between members of the care team, addressing medication refills, scheduling follow up, and completing outpatient paperwork. A between-visit care curriculum was developed and administered to the intervention group (IG) with sessions focusing on the above skills. EVALUATION: Of the interns asked to complete the survey, 29/35 (83%, 14 IG) responded to the pre-immersion survey and 30/35 (86%, 13 IG) responded to the post-immersion survey. In the pre-immersion survey, a majority (55%) of respondents said they did not participate in any aspect of between-visit care as a medical student, and less than half felt confident responding to results (45%), triaging messages (28%), coordinating care (28%), managing medication refills (31%), scheduling follow up (35%), or completing paperwork (8%). At the end of the outpatient immersion block, there were significant differences between the intervention group (IG) and comparison group (CG), with a higher proportion of the IG reporting confidence in their ability to manage test results (IG 92%, CG 53%, p=0.042) and triage calls and messages (IG 92%, CG 47%, p=0.017). A higher proportion of the IG reported confidence in other categories of between visit care, including coordinating care (IG 77%, CG 53%, p=0.26), managing medication refills (IG 85%, CG 53%, p=0.12), scheduling follow up (IG 92%, CG 71%, p=0.20), and completing paperwork (IG 62%, CG 41%, p=0.46), though these results were not statistically significant.

/ REFLECTION / LESSONS LEARNED: Interns feel unprepared to manage outpatient between-visit care at the start of residency given the majority do not get experience with these responsibilities during medical school. A curriculum dedicated to outpatient between-visit care can increase intern confidence in inbox management skills. While certain aspects of between-visit care may be taught in traditional introductory outpatient curricula (ex. coordinating with the clinic care team or scheduling follow up), didactics focusing on triaging patient calls and messages and responding to test results are particularly important, as these tasks account for the highest amount of inbox work time in prior studies and may require more intentional training. DEVELOPMENT OF A GLOBAL HEALTH SCHOLARS PROGRAM FOR INTERDISCIPLINARY LEARNERS Poorvi Hardman1; Tasha Posid2; Mark Troyer3; Vignesh Doraiswamy4; Megan Quimper5; Maju Brunette6; Nadia Khan3; Kerry J. Rubadue7; Kevin Douglas7; Sharon S. Clark8. 1General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Urology, The Ohio State University Wexner Medical Center, Columbus, OH; 3Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH; 4Internal Medicine, The Ohio State University, Columbus, OH; 5Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH; 6Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus, OH; 7College of Medicine, The Ohio State University, Columbus, OH; 8Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4240009) SETTING AND PARTICIPANTS: The Global Health Scholars Program (GHSP) offers didactic and experiential learning for GME trainees at an academic institution. GME trainees applying to the program must be PGY2 and above to successfully complete the program requirements. The steering committee are faculty with an interest and expertise in Global Health (GH). DESCRIPTION: GME trainees are increasingly seeking international electives and experiences in cultural competency. Our pre-program needs assessment demonstrated that formal GH training remains a gap in graduate medical education (Figure 1). A committee of experts and leaders in medical education created an innovative, pan-specialty, asynchronous curriculum, modeled after CUGH competencies, to develop skills and gain experiential learning in GH. This curriculum includes didactic learning through modules and lectures, experiential learning via an elective with underserved populations, and formal GH mentorship in the following areas: Globalization and GH Systems; Sociocultural and Environmental Determinants of Health; Ethics and Vulnerable Groups; Global Burden of Disease; GH Intervention and Capacity Strengthening. We piloted the curriculum in 2023 with 11 GME participants. We have since added two cohorts (10 participants/year) annually to the program. EVALUATION: The curriculum was assessed via pre-post evaluations of knowledge, skills, and attitudes in the competency framework. We find significant gains in content knowledge across metrics of cultural competency (all p<0.001, Figure 2), with the greatest gains for GH capacity strengthening and interventions to improve GH equity (p<0.001). None of the trainees reached “expert level” (i.e. rated themselves as 5/5 across competencies), indicating this training was a single step in the process, and that there are still gains to be made over time and experience. Learners do acquire some cultural competency skills through “on the fly” through their residency training (Figure 3). Following participation in our curriculum, learners across specialties felt more ready to care for diverse patient populations across key metrics (p<0.05; Figure 4).

/ REFLECTION / LESSONS LEARNED: This pilot cohort of our novel pan-specialty GH curriculum already demonstrates meaningful gains in knowledge, skills, and attitudes related to GH and cultural competency. Our pre-post evaluations demonstrate that this type of curriculum provides a model of improved perceived proficiency in GME learners and allows for multi-faceted exposure to GH practice. This program is concurrent with the trainees’ residency/fellowship program, both limiting additional time or depth to the GH training experience but presumably giving learners “on the fly” training with patients. Based on learner feedback, post-Cohort 1 curriculum changes have included the addition of a “Decolonizing Global Health” module, and we continue to evolve the curriculum based on learner feedback. DISASTER MANAGEMENT IN INTERNAL MEDICINE RESIDENCY: A TWO INSTITUTION EXPERIENCE Jacqueline Savage1; Patrick LaBuff2; Jordan Swenson3. 1Yale University Department of Internal Medicine, New Haven, CT; 2City of New Haven, New Haven, CT; 3Emergency Management, Yale New Haven Health, New Haven, CT. (Control ID #4221714) SETTING AND PARTICIPANTS: Two large academic internal medicine residency programs in Connecticut associated with tertiary care hospitals with established emergency management departments. Data was collected from one institution from 2021-2023 encompassing 32 PGY-2 residents and 64 PGY-3 resident participants. Additional data was collected from 2024 at the other instiution with 16 PGY-3 residents participants. DESCRIPTION: We expanded our emergency managment for the internist curriculum and delivered to our PGY-2 residents a basic incident command education followed by a table top exercise on building collapse. This was followed by PGY-3s putting the skills learned from the previous module into practice in an active shooter and incident command activation drill. Half of the PGY-3s would be in the clinical scenario and the other half would function as the incident command team. They would then switch halfway through the morning in order to get experience in both settings. After transitioning to another institution, we then built a similar introductory didactic session with the emergency management department in order to try and replicate the educational didactic session and determine if a completely different cohort of residents would be equally receptive to the material. EVALUATION: Pre and Post survey data was collected with each educational session performed. Topics included basic emergency management concepts as well as interest in future educational didactics and simulations. Residents were also asked about the need for an emergency response resident team and if they would be willing to be part of this team. 80% of PGY-3 residents at our current academic institution have never received education on emergency managment principles which was consistent with our previous cohort of PGY-2/3 residents (84%). A majority of residents confirmed they would consider being part of an emergency response team in their residency program with a positive response rate of 69%. Almost all residents responded that they would like more education on this topic to include simulation with fire, police, emergency medicine, surgery, etc. The highest ranked simulation topics included mass casualty drill, medical evacuation of an ICU and active shooter drill.

/ REFLECTION / LESSONS LEARNED: With increasing disasters, both natural and man-made, internists need to evolve to be ready to meet the needs of their patients in the community. There is currently no ACGME or ABIM expectation to teach disaster readiness or emergency management to internal medicine residents. As a result, each generation of internists have had to learn, in the midst of a crisis, how to support and engage with emergency response teams to be able to contribute to large volume patient care. Our current data aligns with previous data we collected and further reinforces that internal medicine residents have a medical knowledge gap as it relates to disaster medicine and that there is a large desire to learn from our community leaders and physician colleagues who work in this space daily. ENHANCING BOARD REVIEW WITH GAMIFICATION: IMPROVING RESIDENT PERFORMANCE ON HIGH-STAKES EXAMINATIONS Alicia M. Latta2; Christopher Yard2; Kelsey Wilson2; Aamir Akram2; Kamil B. Salam1; Isaac A. Pearce1; Kathryn Burtson2. 1Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH; 2Internal Medicine, Wright State University, Dayton, OH. (Control ID #4272454) SETTING AND PARTICIPANTS: This study, conducted from June to October 2024, was based in a mid-sized, university-affiliated Internal Medicine residency program comprising 79 residents across all postgraduate years. The intervention utilized the Internal Medicine In-Training Examination (IM-ITE) as a predetermined endpoint and primary outcome measure. Residents participated in a gamified board review series during protected educational didactic sessions. DESCRIPTION: Residents participated in a 26-question multiple-choice question (MCQ) review game hosted on the Kahoot platform. The game focused on high-yield pulmonary and critical care topics identified by the American Board of Internal Medicine. This gamified session aimed to enhance knowledge retention and promote active learning. Following the intervention, residents completed the 300-question IM-ITE. Performance in pulmonary and critical care topics was compared between 2023 and 2024, analyzing changes in percent correct and percentile scores on the IM-ITE. Cohorts who participated in the gamified board review were compared to those who did not. A 1-to-7 Likert scale attitudinal survey was developed to assess perceptions of the MCQ board review. Outcomes were analyzed using a controlled pre-test and post-test design. Statistical analysis was conducted with a two-tailed paired t-test. EVALUATION: Of the 79 residents, 51 PGY1 and PGY2 residents with complete IM-ITE data from 2023 and 2024 were included in the analysis. Among these, 28 residents (54%) participated in the board review curriculum session on pulmonary and critical care topics. Residents who attended the session achieved higher percentile scores compared to those who did not attend (attended: 35.57 vs. not attended: 32.37; p=0.024) and demonstrated greater percent correct (attended: 12.76% vs. not attended: 11.58%; p=0.023). The gamified board review curriculum showed a moderate positive effect (ES= 0.66, ES= 0.65) on both outcomes. Pre- and post-surveys assessing attitudes toward the MCQ board review were distributed in June 2024 (pre-intervention: 56/79, 71% response rate) and October 2024 (post-intervention: 52/79, 66% response rate). 36 resident responses (46%) were successfully paired for analysis. The surveys demonstrated no significant changes in attitudes among residents participating in the MCQ board review before and after the intervention.

/ REFLECTION / LESSONS LEARNED: The gamified board review curriculum significantly enhanced resident performance on the IM-ITE, with participants achieving higher percentiles and greater accuracy on high-yield pulmonary and critical care topics. While resident perceptions of MCQs did not change, gamification demonstrated a clear positive impact on exam performance, highlighting the effectiveness of interactive, game-based learning in preparing residents for high-stakes assessments. Integrating gamified review strategies into resident training programs can foster greater engagement and improve knowledge retention, optimizing preparation for critical exams like the IM-ITE. ENHANCING SUPPORTED SPACES: ITERATIVE DEVELOPMENT AND EVALUATION OF A RESIDENT REFLECTIVE PRACTICE CURRICULUM Sharada Narayan1; Gail Wright2; Ryan Laponis1; Irina Kryzhanovskaya1. 1Department of Medicine, University of California San Francisco, San Francisco, CA; 2Santa Clara Valley Medical Center, San Jose, CA. (Control ID #4268427) SETTING AND PARTICIPANTS: 20 residents total: 10 residents per class (2nd and 3rd year residents (R2, R3s)) in a primary care internal medicine (IM PC) residency program in a large, urban, academic medical center. DESCRIPTION: Interventions to develop reflective capacity in trainees may improve well-being, professionalism, and patient care skills1-5. However, current approaches to reflection in graduate medical education (GME) fall short, even as the skills of effective reflective practice are ACGME competencies2, 6-7. A local needs assessment of R2s revealed lack of medical community, doubts about the sustainability of a primary care career, and desire to build skills in reflective practice. In response, we created and implemented an 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 model5,8. We piloted the program in 2023 with 10 R2s, and expanded to rising R2s and the original residents (now R3s) in October 2024. The program consists of three 2-hour sessions a year with reflective exercises and facilitated discussion. Sessions had developmentally appropriate themes such as ‘breathing room’ (cultivating presence in a busy practice) and ‘the shadow’ (acknowledging fallibility and imperfection as human physicians). EVALUATION: Curricular evaluation includes focus groups, informal feedback, and assessment of impact and overall experience via pre- and post-course surveys at the end of R2 and R3 year. Surveys ask trainees to self-report impact on engaging with reflection, finding meaning in everyday practice, and feeling part of a community in medicine. Focus groups are planned for 1 year post-intervention to obtain information about impact and further iterations in process.

/ REFLECTION / LESSONS LEARNED: Elements of the program that trainees found effective included the open-endedness of the exercises, facilitation that emphasized conversations among participants to build connection, and having a trained facilitator who was unaffiliated with the residency. Residents also expressed a preference for opportunities to discuss in pairs as well as in the larger group. Constructive feedback focused on improving the sessions’ logistical convenience. In response, we integrated Supported Spaces sessions into the pre-existing resident didactic schedule on campus, rather than after clinic at a resident’s home. Overall, this resident-driven curriculum has created new spaces for trainees to reflect on key aspects of physicianship, forge community, grapple with difficult experiences that often go unacknowledged in training, and practice the reflective skills needed for compassionate doctoring. ONLINE RESOURCE URL: https://docs.google.com/document/d/1pk6pPNJX0yt3vhRNvLNVE_Zcw65WFXst8PNR1S3pwkA/edit?usp=sharing EVALUATING A LEARNER-DRIVEN NEAR-PEER ANATOMY TEACHING MODEL FOR FIRST-YEAR STUDENTS AT CASE WESTERN RESERVE UNIVERSITY SCHOOL OF MEDICINE Nathan Cowan1; Nicholas G. Beattie1; Ever Mkonyi2; Kelli Qua2; Susanne Wish-Baratz3. 1Case Western Reserve University School of Medicine, Cleveland, OH; 2Office of Medical Education Research and Evaluation, Case Western Reserve University School of Medicine, Cleveland, OH; 3Anatomy, Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #4269145) SETTING AND PARTICIPANTS: This innovation was implemented in 2023 at a Midwest medical school for an introductory anatomy/radiology curriculum for first-year medical students. Participants included 181 first-year learners and 41 second-year near-peer teachers. The curriculum consisted of four two-hour sessions, with small groups of eight learners and two near-peer teachers. DESCRIPTION: The redesigned curriculum transitioned from a passive near-peer teaching format to an active, learner-driven approach emphasizing preparation, discussion, and collaboration. Gross Anatomy and Radiology learning objectives (LOs) were provided to learners one week prior to class, and learners researched them independently in preparation for small group discussion. Learners researched the LOs using faculty-created Modules—concise readings with foundational content—and Practicums— activities to contextualize anatomy and radiology concepts. Near-peer teachers facilitated discussions with facilitator guides, which provided standardized answers and timing suggestions. Collaborative tools such as whiteboard walls and shared digital resources enhanced group interaction. Practical activities included anatomical models, palpation techniques, and radiology image interpretation to reinforce LOs. Sessions concluded with structured "check-out" discussions for feedback on group dynamics and learning outcomes. EVALUATION: Evaluation metrics included anonymous surveys and focus groups for learners and near-peer teachers. The 12-item surveys measured perceptions of engagement, preparation, and efficacy using a four-point Likert scale. Focus groups offered qualitative insights into strengths and challenges. Learners reported increased engagement (92.8%), deepened understanding through independent research of LOs (89.5%), and improved confidence (69.6%). Near-peer teachers noted greater learner preparedness (93.2%) and enhanced discussions with equally balanced contributions and reduced distractions (90.9%). However, learners highlighted challenges with unclear preparatory materials and limited faculty support, while teachers emphasized the need for improved alignment between facilitator guides and learner resources.

/ REFLECTION / LESSONS LEARNED: The innovation demonstrated the value of active, self-directed learning combined with structured guidance in fostering engagement and understanding. Learners appreciated the collaborative environment and accountability fostered by peer interactions. Near-peer teachers found the facilitator guides helpful but called for clearer differentiation of essential content. Challenges with material alignment and limited resources highlighted areas for improvement, including better integration of practical exercises and enhanced preparatory materials. This study underscores the importance of balancing learner autonomy with structured support, offering insights for refining medical curricula to promote teamwork, adaptability, and lifelong learning. GETTING TO THE HEART OF CONTINUITY CLINIC WITH PCI (PRIMARY CARE IMMERSION): AN ORIENTATION TO AMBULATORY MEDICINE FOR INTERNAL MEDICINE (IM) RESIDENTS Jordan Cahn2; Stephanie M. Hastings1; Preston Williams4; Karla Chamorro Garcia2; Nora Lenhard2; Elsa Teixeira Semedo2; Rebecca Rogers3. 1Graduate Medical Education, Cambridge Health Alliance, Cambridge, MA; 2Internal Medicine, Cambridge Health Alliance, Cambridge, MA; 3Medicine, Cambridge Health Alliance, Arlington, MA; 4Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4255530) SETTING AND PARTICIPANTS: Interns entering residency at a primary care (PC) IM program at an academic community hospital in the Northeast. Our institution is a public safety net community hospital that aims to support trainees to feel confident pursuing rewarding, sustainable careers in PC. DESCRIPTION: We designed and implemented a PCI block for incoming interns, goals included improving efficacy and integration into PC clinic, and building community within their clinics and among the intern class. PCI block occurred during 1 week, following orientation. Content included didactic sessions on common ambulatory conditions, a panel handoff and time in the PC clinic. See link for complete schedule details. EVALUATION: Interns were surveyed before PCI week, at the end of the week and at 5 months. They were asked about their comfort with PC workflows, precharting, managing results, contraception, disease management, screening, using the EMR, conducting a visit, working with a care team, precepting, caring for immigrant patients and understanding their role as PC physicians (PCP). They were asked to comment on what they were most excited/ nervous about, challenges they faced, and their early experiences as PCPs at each time point. Interns were most excited to form longitudinal relationships with their patients. They were most nervous about understanding workflows, time management and medical knowledge. Immediately after PCI week, interns’ scores increased in 10 of the 12 domains surveyed. At 5 months post PCI-week, scores increased in 11 of the 12 domains. Scores that increased the most were understanding their roles as PCPs, contraception, chronic disease management and using the EMR. Qualitative feedback was universally positive, both at 1-week post-PCI and at 5-month follow-up; all interns stated that PCI week should continue in future years.

/ REFLECTION / LESSONS LEARNED: Medical students may spend limited time in PC settings and often feel unprepared to start PC practice as IM residents. The learning curve in PC is steep, and it often takes longer for residents to gain confidence and competence in ambulatory settings when compared to inpatient settings. This project aimed to address that learning curve. Post-PCI week surveys showed higher scores in all domains except conducting a visit (no change) and precepting. One downside was that PCI week prolonged the orientation period. This year interns will begin seeing patients directly during PCI week to give them more experience conducting visits and precepting. PCI-week faculty and residents also observed that it would be helpful to have more instruction of results management and intervisit care; we plan to add this to our longitudinal PCI week curriculum. We expect additional benefits to occur as we improve the residents’ orientation and integration into their clinics via PCI week, supporting their learning and growth in the clinic throughout their intern year and beyond. ONLINE RESOURCE URL: Block schedule diagram https://docs.google.com/document/d/1LhfCMlr_8cQKmDm90iNfoyAwCBN7UwuozzwsDCdxmRI/edit?usp=sharing HOW TO TRAIN AN ADVOCATE: ADVOCACY SKILL BUILDING FOR INTERNAL MEDICINE RESIDENTS Constance R. Morrison, Karen Kimel-Scott. General Medicine, UNC Chapel Hill, Durham, NC. (Control ID #4272143) SETTING AND PARTICIPANTS: We created a week-long elective for Internal Medicine residents at an academic medical center. In an X+Y (4+2) system, this was offered to each cohort, totaling three one-week electives. All participants were 2nd or 3rd year IM residents. Each elective had 3 resident participants for a total of 9. DESCRIPTION: Our curriculum focused on the importance of advocacy in physician practice and developing tangible skills to advocate for patients. It was adapted from a peer advocacy curriculum developed at the Warren Alpert School of Medicine. In our curriculum, we taught residents about persuasive writing by critiquing published OpEd and Letters to the Editor and writing their own opinion pieces. We provided expert information about the local political landscape accompanied by concrete skills of how to plan and conduct a legislative meeting with an elected official. We also met with a local representative to discuss a health-related issue of the participants’ choosing. The three topics chosen were prior authorization reforms, gun safety research funding, and making tianeptine, an addictive substance sold in gas stations, a controlled substance in our state. We met with two state house representatives and a staffer for a state Senator (from both major parties). We also discussed system advocacy within our healthcare organization. Finally, we featured a local physician who shared her experience leading an advocacy non-profit designed to engage healthcare organizations in addressing climate change. EVALUATION: We informally solicited feedback from participants but did not conduct any formal evaluation. We plan to survey our participants this year and will measure success by participants’ self-assessment of comfort with advocacy skills, the number of published OpEd articles, and legislative movement on the issues our participants lobbied for. For example, we were able to celebrate that tianeptine became a controlled substance in our state this December.

/ REFLECTION / LESSONS LEARNED: While 94% of residents surveyed in 2019 agreed “as a physician I have a duty to advocate,” only 12% reported adequate training in residency.(1) We set out to change this by adapting a previously existing advocacy curriculum to our program’s needs. Our experience mirrors that of other successful GME advocacy curricula outlined in a recent systematic review by Nupur Agrawal et al.(2) We were successful in implementing our curriculum because we adapted it to a 1-week elective opportunity, had protected time for residents and educators, and focused on hands-on learning. This review also suggests the importance of project-based work completed longitudinally over time, which is lacking in our current elective-based format.(2) We have encouraged residents to submit their OpEds, but could support ongoing advocacy by developing a longitudinal advocacy project, creating a community for residents to support each other, and connecting with community organizations, including local chapters of organizations such as SGIM and ACP. IMPLEMENTATION OF AN OBESITY MEDICINE CURRICULUM FOR RESIDENT PHYSICIANS TO ADDRESS THE INFLUENCE OF WEIGHT STIGMA AND BIAS Gaia Linfield1; Aditi Rao1; Anita Ganti2; Erica Phillips2. 1Internal Medicine, Weill Cornell Medicine Joan and Sanford I Weill Department of Medicine, New York, NY; 2Department of Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4272804) SETTING AND PARTICIPANTS: All PGY-1 internal medicine residents at a large urban mid-Atlantic academic medical center participated in this curriculum during their ambulatory medicine blocks from August 2024 - November 2024. DESCRIPTION: Obesity is an epidemic projected to affect over half of the United States population by 2030. Despite its prevalence, many patients with obesity report feeling uncomfortable discussing weight-related concerns with their physicians. A commonly cited reason is encountering weight stigma by healthcare providers, which has been shown to result in suboptimal care and poorer health outcomes. Nevertheless, medical trainees are seldom taught how to discuss weight management with their patients. To fill this gap, we developed and implemented an obesity medicine curriculum and assessed its impact on provider attitudes toward weight management. The curriculum consisted of three interactive sessions. In the first session, trainees learned about the evaluation of obesity, history gathering skills emphasizing people-first language, and the impact of obesity on overall health. During the second session, residents were taught a multifaceted treatment approach, including evidence-based nutrition and physical activity recommendations, FDA-approved pharmacotherapy, and indications for bariatric surgery. This was followed by a final session in which trainees spent dedicated time reflecting on their experiences with weight stigma and weight bias and discussing strategies for addressing this within their practice. EVALUATION: Between August and November 2024, 44 PGY-1 residents participated in this obesity medicine curriculum during their mandatory ambulatory rotation. Before the first session, trainees completed a 16-item survey adapted from a validated questionnaire entitled “Belief About Obese Persons Scale” (Allison, Basile, & Yuker, 1991). Psychometric properties were adapted for our study population. Following curricular completion, trainees filled out the same survey. Analysis of pre and post-survey results will be completed before the conference date. We hypothesize that the implementation of an obesity medicine curriculum will reduce internal medicine residents’ attitudes of weight stigma and bias towards patients with obesity.

/ REFLECTION / LESSONS LEARNED: This curriculum was developed to fill a significant gap in resident training regarding the management and treatment of obesity. We also hope to positively impact providers' attitudes toward people with obesity, with the larger goal of reducing weight stigma and improving health outcomes. We plan to expand on this study by evaluating the language trainees use when documenting visits with patients who have obesity. We plan to employ machine learning techniques to compare phrases from progress notes written before and after curriculum implementation. ONLINE RESOURCE URL: Link to aforementioned survey, which was tansferred from Qualtics to a Google Doc copy for de-identification during peer review. https://docs.google.com/document/d/187lNsd9W743FDLaoZyItm0e9c6z_MnhXdOEmhi99LHQ/copy INTERVISIT CARE ADVANCES PATIENT CARE: A MULTIPRONGED CURRICULUM FOR RESIDENTS IN AMBULATORY Anna K. Rubin1; April Barbour2. 1Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC; 2Internal Medicine, The George Washington University, Washington, DC. (Control ID #4271391) SETTING AND PARTICIPANTS: Many residents are not formally trained to provide "intervisit care", the amalgam of care conducted between office visits, which is foundational to modern ambulatory care and reflected in ACGME milestones. Internal Medicine residents often take longer to feel confident in the outpatient setting compared to inpatient, and the intervisit care workload may contribute to the delay, as well as to burnout. Our program identified a need to purposefully educate residents on EHR In Basket management and intervisit care skills to improve their efficacy, efficiency and comfort for future practice. In our program's X+Y model, ambulatory block occurs every 5 weeks, and the ambulatory residents cover the In Baskets of their colleagues. We delivered a multipronged Intervisit Care curriculum to ~100 residents in ambulatory in AY 2023-2024. DESCRIPTION: The Intervisit Care curriculum included: 1. a didactic presentation in the first ambulatory block, 2. peer coaching sessions with a Primary Care track resident champion mid-year, 3. one-on-one feedback and evaluation session with faculty preceptor late in the year, 4. faculty development for preceptors on completing the assessment. The didactic session included case-based intervisit scenarios with a focus on utilizing the care team, timely task completion, and effective communication to covering colleagues. Two Primary Care track residents with advanced and efficient intervisit care skills provided peer coaching with opt-in office hour sessions to residents seeking In Basket guidance. The feedback session with the firm preceptor used a customized Inbox Management evaluation form specific to intervisit care skills. EVALUATION: Pre- (N=24) and post-curriculum (N=30) surveys assessed residents' confidence in specific intervisit care skills for their own patients and in covering their colleagues. Residents' mean confidence in managing results, responding to patient messages and refilling meds improved after the curriculum. The percentage of residents who reported that they received faculty feedback on their In Basket management half the time or more also increased. The most helpful form of intervisit care teaching was the peer coaching by a primary care resident champion.

/ REFLECTION / LESSONS LEARNED: Resident survey data post-curriculum showed improved confidence in key intervisit care skills, such as managing results, responding to messages and prescribing. Our curriculum was unique in incorporating peer coaching by residents with advanced skills, as well as a resident evaluation specific to Inbox Management to help guide faculty feedback and track progress. We learned that residents crave opportunities to learn from their peers in ambulatory. Goals to improve our curriculum are to push one-on-one feedback with faculty earlier in the year and expand availability of primary care peer coaches. Optimizing how we educate about intervisit care has a significant potential impact on our trainees' future practice, their career choices, and ultimately, the healthcare workforce. LAYING THE FOUNDATION: ENHANCING THE UME TO GME TRANSITION IN PRIMARY CARE USING A MASTER ADAPTIVE LEARNER FRAMEWORK David S. Edelman, Sejal Shah, Kristen Welch, Shwetha Iyer. Primary Care and Social Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4271636) SETTING AND PARTICIPANTS: Ten first-year residents in a primary care internal medicine residency at a large, urban academic center in the Mid-Atlantic, during the first 4-week ambulatory curriculum. DESCRIPTION: The master adaptive learner (MAL) framework teaches self-regulated and self-directed learning skills necessary for independent practice and applicable to all experience levels. Our program has developed a longitudinal MAL curriculum that integrates coaching to guide learners to iteratively create goals, assess growth, and incorporate feedback (i.e., MAL cycle). Given inconsistent experiences in UME, we used a focused application of the MAL framework to redesign the introductory ambulatory curriculum in our residency program with the goal of improving the UME to GME transition. We anchored the beginning, middle, and end of the 4 weeks with sessions on goals, learning strategies, and feedback. Tools used to implement the MAL cycle included facilitated group and individual coaching sessions by faculty with coaching training; feedback reflection; observed clinical encounters (OCEs) with faculty feedback; and precepting encounters. Residents reflected on their learning goals and incorporation of feedback at the end of week 4. EVALUATION: All 10 residents participated in the 4-week curriculum; one had partial absence due to illness. In week 1, residents engaged in group reflection on learning styles, learning experiences, and feedback in UME. All residents then created “SMART” learning goals in group coaching sessions. In week 3, residents reflected on feedback experiences in GME and practiced eliciting feedback for learning goals. 9 residents completed a written reflection on implementation of and progress on their goal at the end of week 4. Learning goals varied in domains of medical knowledge (synthesizing information, clinical reasoning, differential diagnoses), patient care (social needs screening, incorporating shared-decision making, leveraging patient strengths), professional development (career plans), and systems-based practice (using templates). By the end of week 4, 4 residents met their goals, 2 partially met goals, and 3 adjusted goals. 8 residents noted at least one curricular session helped them achieve their goals, with 4 listing MAL-specific sessions as most useful. Residents solicited feedback from preceptors and faculty during OCEs and incorporated information from didactic sessions into their goals.

/ REFLECTION / LESSONS LEARNED: We redesigned our introductory ambulatory medicine curriculum using a MAL framework to foster skills, regardless of prior primary care experience, that independently strengthen the ACGME core competency of Practice-Based Learning and Improvement. Residents engaged in goal setting and reflective practice that demonstrated growth in self-directed learning and goal refinement. Future work will build iteratively on MAL practice and involve further qualitative analyses. This redesign can serve as a model to implement the MAL cycle during the UME to GME transition in primary care. MORTALITY REVIEW FOR INTERNAL MEDICINE RESIDENTS: A CURRICULAR APPROACH TO IMPROVE PSYCHOLOGICAL SAFETY SURROUNDING MORTALITIES Alison Koransky, Aveena Kochar, Vinh Nguyen. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4241530) SETTING AND PARTICIPANTS: PGY-2 Internal Medicine (IM) residents at a large, quaternary, academic hospital participated in this curriculum. Survey data is from 12/2023-10/2024. DESCRIPTION: ACGME milestones 2.0 assessed learners on system-based practices within patient safety and quality improvement.1 Understanding and completing mortality reviews is one method of advancing learners in this category. When re-instituting a mortality review curriculum, it was important to acknowledge and address burnout related to patient deaths and medical errors. It has been shown that self-perceived medical errors are associated with substantial subsequent personal distress in IM residents, which in turn has been associated with increased odds of future self-perceived errors.2 This curriculum begins with a small group didactic session introducing the concept of a mortality review, explaining its importance in the safety review process, and instructing learners on how to complete a review. Just culture and self-reflection are emphasized throughout the didactic. Each resident is then assigned a real patient case and asked to complete a mortality review. The resident then meets with a faculty advisor, who has also reviewed the mortality, to discuss the events of the case, any system factors which contributed to the mortality and standard of care. To evaluate psychological safety and resident wellbeing in respect to patient mortalities, voluntary pre- and post-surveys were collected. EVALUATION: The pre- and post- surveys were completed by 44/64 and 25/64 residents respectively. Based on the Edmonson Psychological Safety Survey, residents considered various statements in the context of a patient mortality utilizing a 5 point likert scale (1= not true - 5= completely true). Resident perceptions of the following showed improvement: 1. I feel my ideas are valued and I feel safe in suggesting them (pre: 2.91, post: 3.68, p:0.019) 2. If I make a mistake on this team, it is never held against me (pre: 3.02, post:3.68, p:0.013) 3. When something goes wrong, we work together to find the systemic causes (pre: 3.18, post: 4.08, p<0.001) 4. It is safe for me to take an intelligent risk on this team (pre: 3.07, post: 3.88, p<0.001) 5. Working with members of this team, my unique skills and talents are valued and utilized (pre: 3.14, post: 3.88, p: 0.007) 6. I feel in control when dealing with difficult problems at work (pre: 2.95, post: 3.60, p: 0.008) When asked “I feel more comfortable reporting errors” on the post survey, 64% of residents answered either completely true or very true. 76% of residents answered either completely true or very true to “I have a deeper understanding of the importance of reporting errors.”

/ REFLECTION / LESSONS LEARNED: Understanding patient safety concepts is a critical skill for IM residents. This mortality review curriculum teaches those skills while embedding just culture concepts. While there is a limited sample size, this combination of content shows improvement residents' psychological safety around inpatient mortalities. NAVIGATING TRANSITIONS: EMPOWERING RESIDENTS THROUGH A HEALTH SYSTEMS SCIENCE ROTATION Lauren Heery1; Jeremy Lin2; Arielle Elmaleh-Sachs3; Daniel Sartori1,2; Rachael Hayes1,3. 1Medicine, New York University Grossman School of Medicine, New York, NY; 2Internal Medicine, NYU Langone Health, New York, NY; 3Family Health Centers, NYU Langone Health, New York, NY. (Control ID #4273065) SETTING AND PARTICIPANTS: Thirty-seven senior internal medicine residents in an urban academic community-based program in the Mid-Atlantic participated in a transitions of care rotation at one hospital and two Federally Qualified Health Center (FQHC) clinics. DESCRIPTION: Patients’ care transitions from hospital admissions to home represent vulnerable periods in the care continuum. While residency training equips learners with extensive inpatient and outpatient clinical experiences, these experiences are often siloed. Few curricula are designed for safe and effective transitions in care. We designed Transitions of Care Rotation (TOC) to address this unmet need by immersing residents at important care transition points. In this hybrid inpatient-outpatient role, the TOC resident collaborated with inpatient teams to identify medically or psychosocially complex patients. The TOC resident facilitated discharge planning for these complicated patients, providing patient education, medication reconciliation and ensuring appropriate follow-up. In addition, they saw recently discharged patients in Transitional Care Management (TCM) visits where they ensured patients received new medications, specialty referrals, home care services and safely transition back to their primary care physician (PCP). Patients who did not have a PCP could establish care. Didactics included literature reviews, participation in root cause analyses, assessment of other residents’ discharges, and guided self-reflection on readmissions using a Resident Provider Dashboard. EVALUATION: Participants completed a survey as part of the self-guided reflection of their readmissions data. This reflective activity prompted residents to review their practice data and describe areas for practice improvement. Participants in the rotation also completed peer evaluations of resident teams’ discharges to provide additional feedback to trainees on how to improve upon the discharge process. Early analysis of these responses shows resident satisfaction in the educational intervention and demonstrated insights into how residents plan to improve their discharge practices.

/ REFLECTION / LESSONS LEARNED: The TOC Rotation is a novel educational innovation which facilitates the development of transition of care skills and provides a practice-based learning opportunity in health systems science. Reflections from resident participants highlight the importance of dedicated training for transitions of care skills. Secondarily, this evaluation data demonstrates how reflective practices can serve as teaching tools for the competency domains of systems-based practice and practice-based learning and improvement. Preliminary data suggests that patients who participate in TCM visits may have lower rates of readmission compared with other patients in the FQHC clinics. PARTNERS IN CARE: A MULTI-DISCIPLINARY SOCIAL CARE WORKSHOP FOR RESIDENTS Beret Amundson, Kristene Tadese, MaryCatherine Arbour, Sonja R. Solomon. Department of Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4243311) SETTING AND PARTICIPANTS: Our work aimed to integrate multidisciplinary social care training into internal medicine intern (R1) ambulatory education. Primary care physicians partnered with a multidisciplinary social care team including social workers, community resource specialists, community health workers (CHWs), and nurse case managers to teach skills in social care delivery through a case-based workshop. The workshop occurred four times yearly over two years as part of the ambulatory curriculum. Approximately 50 R1s participated each year. DESCRIPTION: We developed a Social Care Workshop using case-based pedagogy to teach principles of team-based social care including screening, triage, and referral to resources in the social domains of housing, transportation, food, income assistance, and behavioral health. In small groups, multidisciplinary social care professionals facilitated interactive case discussions with residents. Each case involved a patient experiencing one or more social care needs, with pause points for discussion about how to understand and address the specific need. Following case discussions, facilitators summarized their individual roles and responsibilities. Then, a specialized housing CHW presented action steps for physicians caring for patients at risk of eviction. EVALUATION: Residents completed pre- and post-workshop surveys including Likert-scale questions that queried confidence assessing social domains in which patients may need support and addressing specific needs in the domains of housing, transportation, food, income assistance, and behavioral health. Prior to the workshop, 7% of residents felt extremely confident assessing social needs and 44% felt somewhat confident. After the workshop, 33% of residents felt extremely confident and 57% felt somewhat confident. Overall, residents reported higher confidence assessing social needs after the workshop (X2p=0.001). Residents also reported higher confidence addressing needs in the domains of housing, transportation, food, and income assistance after the workshop (X2p<0.05 in all domains). Residents reported high baseline confidence addressing behavioral health needs and the pre- and post-workshop level of confidence was not statistically significant (X2p=0.2).

/ REFLECTION / LESSONS LEARNED: We learned that this workshop filled an unmet need in resident education by teaching skills in assessing and addressing social needs. The workshop also enabled residents and social care professionals to develop mutual understanding of each other’s roles and deepen relationships as collaborators in patient care. Workshop cases often evolved into discussions of cases residents encountered in clinic, which led to spontaneous information-sharing by social care experts and novel opportunities for team-based problem solving. Professionals in social care also demonstrated enthusiasm for the educator role, expressing their desire for continued collaboration in residency social care training. ONLINE RESOURCE URL: https://drive.google.com/drive/folders/1QzlV4AnQ372x6LZUCeV2Y9hKEl2QLJ98?usp=sharing PLACING THE FOCUS ON OUTPATIENT POCUS RESIDENT EDUCATION Michael Houghan1,2. 1Department of Medicine, University of Wisconsin-Madison, Madison, WI; 2UW Health, Madison, WI. (Control ID #4270778) SETTING AND PARTICIPANTS: This curriculum was developed for Internal Medicine Primary Care Track Residents at a single midwest academic hospital system DESCRIPTION: Point-of-care-ultrasound (POCUS) is an emerging technology for internists to improve their diagnostic precision. POCUS is popular among residents but training opportunities remain limited. There is growing evidence that POCUS can be useful for decision making in the outpatient setting. We opted to create an outpatient-focused POCUS curriculum for our primary care track residents with a goal to train our learners to use POCUS to improve their diagnostic accuracy. We focused on topics that had both strong evidence to support its use for clinical decision making, as well as would be useful in the outpatient setting and split them up into 4 workshops: cardiopulmonary, abdominal, vascular, and skin/soft tissue. Each workshop was preceded by an online module that introduced the topic to the resident, then they would participate in a 1 hour lecture on the topic which was followed by 2 hours of hands-on learning with the ultrasound and standardized patients. EVALUATION: To develop our evaluation tool for this project, we utilized Kirkpatrick’s Four Level Evaluation model to develop questions that would best evaluate our curriculum and impact educational research. We used this tool to consider questions at all 4 levels of Kirkpatrick’s Model and then opted to narrow our focus on questions that fit into the first 2 levels of the model: Reaction and Learning. We evaluated the success of our curriculum by asking residents to fill out surveys before and after each workshop. These surveys asked each resident their interest in learning POCUS and their confidence in performing exams. In addition, residents also answered multiple choice questions regarding the covered topic which evaluated their general knowledge of ultrasound, anatomy in ultrasound windows, and interpretation of images.

/ REFLECTION / LESSONS LEARNED: 13 primary care track residents completed our course this year. By the end of our curriculum, survey results showed that residents felt significantly more confident in their ability to use POCUS as a decision making tool and felt more confident in their understanding of how POCUS works. Additionally, after each session and after a year-end exam, residents displayed knowledge and skills acquisition for each POCUS exam. We believe that our survey results show that by creating an outpatient POCUS curriculum, we can teach residents to learn and obtain POCUS skills. We can also increase confidence in their ability to use POCUS independently and their belief that POCUS can be used by internists nationwide. We know that this data is overall limited in scope, as it is a single center study, with a small sample. Therefore, we will continue developing research questions utilizing Kirkpatrick’s Model, and next focusing on Level 3 and 4 questions. This is a multiyear project, so we will continue to teach our residents and encourage their use of ultrasound in the clinic. PREPARING FOR THE ROAD AHEAD: A HEALTH POLICY, EQUITY, AND ADVOCACY CURRICULUM FOR GERIATRICS AND PALLIATIVE MEDICINE FELLOWS Natalie Sohn, Alina Kung, Diane Meier. Icahn School of Medicine at Mount Sinai Brookdale Department of Geriatrics and Palliative Medicine, New York, NY. (Control ID #4273109) SETTING AND PARTICIPANTS: The curriculum was developed and implemented in a Geriatrics and Palliative Medicine fellowship at an urban, academic medical center. Thirty fellows received the curriculum. DESCRIPTION: The curriculum consisted of ten sessions. Session content was guided by surveys from the previous year’s fellows (n=11), who identified interest in learning about the basics of health insurance [9 (82%)], safety net programs [9 (82%)], financing and payment models [7 (64%)], drug pricing [9 (82%)], and options for universal healthcare access [8 (73%)]. Topics covered included health economics, payment models, the financialization of healthcare and its impacts, advocacy, and health inequities related to geriatrics and palliative care. Session formats varied and included: large group sessions with faculty and policy experts, facilitated small group sessions, expert Q&A, and multidisciplinary case reviews. This format was based directly on feedback from incoming, rising, and outgoing fellows regarding their preferred teaching modalities. EVALUATION: A pre-curricular survey was completed by 13 out of 30 fellows. Most received either some [5 (39%)] or a moderate amount [5 (39%)] of education on health policy in residency or medical school. Some [4 (31%)] had never received education on advocacy, while others [6 (46%)] had received a moderate amount. On average, respondents rated their understanding of the U.S. healthcare system as “fair” (3.1 out of 5 on a Likert scale) and of health policy as “fair” (2.8 out of 5 on a Likert scale). Respondents felt less familiar with payment models, recent healthcare legislation, current health policy issues, and the role of corporatization in healthcare. At baseline, 53% rated themselves as “somewhat likely” [5 (38%)] or “very likely” [2 (15%)] to pursue health policy in their future careers. 72% rated themselves as “somewhat likely” [5 (45%)] or “very likely” [3 (27%)] to pursue advocacy in their future careers. A post-curricular survey will be administered at the end of the year to assess changes in self-rated knowledge of health policy issues, likelihood of incorporating policy and advocacy in future careers, and overall curriculum usefulness.

/ REFLECTION / LESSONS LEARNED: This year-long curriculum aims to improve geriatrics and palliative medicine fellows’ understanding of key topics in health policy, equity, and advocacy. Trainees will evaluate the impact of the curriculum on their understanding of these topics as well as their likelihood to integrate this knowledge into their future career path. Lessons learned from this curriculum can be applied to other audiences, including general internal medicine fellows and residents. RESIDENT FELLOWSHIP TRACK: ADVANCING ULTRASOUND EDUCATION IN INTERNAL MEDICINE Ahmad A. Rathor1; Fakhra Sultan2; Robert Broughton2. 1Center for Ultrasound Education, Augusta University, Augusta, GA; 2Department of Medicine, Augusta University, Augusta, GA. (Control ID #4270749) SETTING AND PARTICIPANTS: A Southern academic medical center initiated a two-year ultrasound fellowship track in 2022-2023 with one internal medicine resident, and expanded to four residents in 2023-2024, comprising one third-year and three second-year resident fellows. DESCRIPTION: The curriculum, modeled after an accredited EUFAC Ultrasound staff fellowship, includes: - Weekly didactic training in core and advanced ultrasound applications - Personal tablet and Lumify cardiac probe for continuous learning - Supervised research projects with an ultrasound focus - Peer teaching to medical students, residents, and fellows - Annual knowledge and skill assessments through hands-on practicums, written exams, and simulation-based image interpretation EVALUATION: Program outcomes were assessed by tracking the number of scans performed by internal medicine residents before and after program implementation. Additionally, ongoing data collection includes knowledge and skill assessments through annual hands-on practicums, written exams, and incorporation of image interpretation into our simulation curriculum. The fellowship track demonstrated remarkable growth in POCUS engagement: - Logged POCUS scans by internal medicine residents increased from 56 (2021- 2022) to 614 (2022-2023) and 2,319 (2023-2024) - From 2021-2022 to 2022-2023: +558 scans (an increase of 996%) - From 2022-2023 to 2023-2024: +1,705 scans (an increase of 278%) - The total increase represents a 4,041% growth in logged scan volume over two years - Fellowship logs expanded from 553 to 2,543 scans as the number of fellows increased from one to four

/ REFLECTION / LESSONS LEARNED: The resident fellowship track successfully addresses ultrasound education barriers by creating a sustainable, scalable model for training POCUS educators. By providing residents with portable equipment, structured training, and teaching opportunities, the program significantly enhanced ultrasound accessibility and residents' clinical competencies. This innovative approach offers a replicable framework for residency programs seeking to integrate advanced ultrasound education. Future research will focus on longitudinal skill assessment, clinical outcome impacts, and curriculum refinement to meet evolving educational needs. RESIDENT PERSPECTIVES ON A LONGITUDINAL, DYNAMIC COMMUNITY ENGAGEMENT AND ADVOCACY CURRICULUM UTILIZING DESIGN-THINKING PRINCIPLES Rahee M. Nerurkar1; Mary Gover1; Nilka Martell3; Miya Osaki2; Marc Shi1; Erin Goss1. 1Division of General Internal Medicine, Montefiore Medical Center, New York, NY; 2School of Visual Arts, New York, NY; 3Loving The Bronx, Bronx, NY. (Control ID #4254617) SETTING AND PARTICIPANTS: Ten primary care internal medicine residents at an urban academic medical center participated in the curriculum, in collaboration with five graduate-level design students from a local design school and a community-based organization (CBO) focused on environmental justice. DESCRIPTION: We developed a 9-month curriculum to enhance residents' skills in community engagement (CE) and systems-level advocacy. The curriculum began with an initial “community conversation” to explore common goals and individual assets, and an immersive walking tour in the community. Residents then chose an advocacy project relevant to the CBO, focusing on environmental justice through the lens of health. They created visual resources advocating for structural changes to a highway bisecting the community and leading to several negative health consequences. Design students taught residents design thinking (DT) principles, which emphasize collaboration and experimentation to creatively solve problems. Using this approach, residents and design students refined the visual materials through iterative feedback from the CBO and community members. Throughout, we tracked additional advocacy activities residents engaged in outside the curriculum. EVALUATION: Nine of ten resident participants submitted written reflections on the curriculum via a 22-item survey on Qualtrics. The research team reviewed the responses to identify emerging themes. Participants reported gaining tangible CE skills, strengthening their connection to the city, and feeling more prepared for advocacy after learning about environmental health effects. They saw DT as an effective CE tool and viewed their role as expanding from physician to physician-advocate. Time constraints and competing residency priorities limited participation. Residents engaged in advocacy outside of the formal curriculum: one wrote an op-ed on air pollution and asthma, three gave a talk on environmental justice, and two started an environmental advocacy committee at the institution. Representative quotes from the survey responses include: -“Showing myself that I’m able to partner with communities […] deepen[ed] my confidence in my ability to advocate for environmental justice” -“My role is not just about treating patients but also improv[ing] community awareness of health” -“So much of the time in medicine we are trained to think in linear ways. Design thinking […] helped me practice thinking outside of a linear pathway."

/ REFLECTION / LESSONS LEARNED: Few residency programs offer formal training in advocacy and CE. Our innovative curriculum taught residents to use DT for CE, preparing them for future advocacy. Themes in the survey, such as an increased connection to the city, align with studies linking advocacy to reduced physician burnout. We hope our curriculum serves as a model for other institutions, helping residents develop essential advocacy skills for their medical careers. RETHINKING THE DRINKING: USING THE JIGSAW TEACHING METHOD TO IMPROVE KNOWLEDGE, CONFIDENCE, AND ATTITUDES OF INTERNAL MEDICINE RESIDENTS IN ADDRESSING UNHEALTHY ALCOHOL USE IN THE OUTPATIENT SETTING. Ahmar Alam, Brandon Ng, Shabnam Parsa, Janey James, Patricia Ng. Internal Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY. (Control ID #4270759) SETTING AND PARTICIPANTS: Thirty-two PGY3 and 33 PGY2 IM residents from a university program in Stony Brook, NY were invited to participate in the study. Twenty-four residents (12 PGY2,12 PGY3) were assigned to the control group and 41 residents (21 PGY2 and 20 PGY3) were in the Jigsaw intervention group. DESCRIPTION: This was a quasi-randomized control trial where residents participated in either a traditional case-based lecture (control/CON) or a jigsaw teaching session (intervention/INT). The control didactic was a 2-hour PowerPoint lecture given by 2-3 study investigators. The intervention didactic was a 2-hour jigsaw workshop with 2 study facilitators. Intervention residents were in teams of 3 (home group), and each were assigned to be an “expert” in 1 topic (e.g. Expert 1- Definitions and SBIRT; Expert 2- Alcohol use disorder treatment; Expert 3- Alcohol withdrawal management). To become “experts,” residents join peers from teams with the same topic assignment, and together they reviewed tailored readings. Later residents returned to home groups to peer teach and apply their collective expertise to solve patient cases. To reinforce teaching points, case answers were reviewed with home groups via the online platform- Kahoot! EVALUATION: Residents completed pre, post, and year-end surveys assessing knowledge and confidence in diagnosing, managing, and counseling patients on UAU. Surveys also assesses residents’ satisfaction in the curriculum they experienced. Response rates were: Pre 83.1% (54/65), Post 73.8% (48/65), Year-end 52.3% (34/65). There were no statistically significant differences between CON and INT when comparing median knowledge scores, confidence, or curriculum satisfaction. Both groups had trends for improved study outcomes post curriculum, but only INT learners did not report dissatisfaction in the curriculum at year-end. Qualitative feedback showed that INT participants liked the interactive group work, SBIRT role-play, and gamified debrief via Kahoot!. Controls stated that they liked the succinct presentation with questions, but suggested a more interactive format.

/ REFLECTION / LESSONS LEARNED: The jigsaw teaching method is feasible to implement when teaching UAU and has similar efficacy to traditional case-based lectures. Similar to other studies, jigsaw teaching may be more effective in increasing learner satisfaction given the structure for interactive group activity. Study limitations include small sample size and exclusion of PGY1 residents. SAFE & EVIDENCE-BASED HOSPITAL DISCHARGE APPOINTMENTS: A CURRICULAR APPROACH Alison Koransky, Allison Samuel, Cary Blum, Mayce Mansour. Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4270985) SETTING AND PARTICIPANTS: All (N=60) PGY1 internal medicine (IM) residents at a large, urban academic ambulatory practice participated in the three-part hospital discharge curriculum, during ambulatory rotations from 12/2023 - 03/2024 DESCRIPTION: Transitioning from the hospital to the community exposes patients to high rates of medical errors. However, in a needs assessment survey including 63 PGY-2 and PGY-3 IM residents, only 54% reported using a standardized approach for hospital discharge appointments and 30% of PGY-1s reported no prior transitions of care training. To address this deficit, we developed a multi-modal curriculum starting with a didactic on how to approach safe, evidence-based hospital discharge appointments. This didactic emphasizes medication reconciliation, review of inpatient data, and introduces an electronic medical record (EMR) dotphrase that provides guidance and standardization for a post hospital discharge visit. This is followed by an OSCE simulating a discharge follow up visit, including medication reconciliation and patient counseling on abnormal laboratory results. The curriculum concludes with a session in which residents perform a hospital discharge follow up phone call for two of their recently discharged patients. We studied the impact of the new curriculum on residents’ attitudes, knowledge, and documentation. Voluntary, IRB-approved pre- and post-surveys were collected. Utilization of the EMR dotphrase was compared before and after the curriculum. EVALUATION: The pre- and post surveys were completed by 39 (71%) and 37 (67%) of PGY1 IM residents, respectively. Residents considered various statements utilizing a five-point likert scale (1=strongly disagree- 5=strongly agree). After participating in the curriculum, residents reported a statistically significant increase in agreement with the following statements: - I have a standardized approach to completing a hospital discharge appointment (Pre average: 2.49, post average: 3.97, P <0.0001) - I feel comfortable setting an agenda for a hospital discharge appointment (pre average: 3.05, post average: 4.08, pm P <0.0001) - I can complete a hospital discharge follow up visit within the allotted visit time (pre average: 3.03, post average: 3.78, P P <0.0001) - I enjoy seeing patients for hospital discharge appointments (pre average: 3.46, post average 3.92, P 0.041) The standardized EMR dot phrase was utilized for 4% of hospital discharge appointments prior to the curriculum and more than 8% after.

/ REFLECTION / LESSONS LEARNED: This novel, multimodal curriculum was associated with substantial increases in satisfaction and standardization of hospital discharge visits conducted by IM residents. Not only did the residents subjectively feel that their approach was more standardized, but this was also demonstrated by the increased utilization of the dot phrase. However, improving utilization above 8% remains an ongoing goal. ONLINE RESOURCE URL: https://drive.google.com/drive/folders/1qus-pnM6rBXOKCKSNhANXXwyOJBLTgdg?usp=sharing SOLO TOGETHER: HOW SLOWING-DOWN CASE-BASED SESSIONS MAY HELP ENHANCE TEACHING OF COMPLEX CONCEPTS IN MEDICAL EDUCATION Liza Raffi. Internal Medicine, Cedars-Sinai Health System, Los Angeles, CA. (Control ID #4267795) SETTING AND PARTICIPANTS: This 90 minute session was conducted with a mixed group of first, second, and third year internal medicine residents in the primary care track (n=10). DESCRIPTION: Residents often cite EBM as a topic that is both daunting yet important to learn. The format of this lecture was crafted to neutralize daunting aspects of learning EBM and other complex concepts. The session started with a 5 minute retrieval exercise in which residents were invited to “mind dump” onto a brief worksheet what they already remembered about the learning objectives. Instruction then consisted of repeating cycles of brief periods of lecture, solo time to independently solve 1-2 questions, and group discussion of solutions. We intentionally avoided break-out groups for this session to encourage residents to engage actively with the material without worrying about how their knowledge may compare to their peers’. EVALUATION: Residents were anonymously surveyed 12 days after the session. All 10 residents filled out a survey. 80% marked that there was a good amount of time allocated per problem. 20% marked that while they were glad we did the problems together, the time allocated per problem was too much. No one selected that they would have preferred to do the problems at home and used the lecture time for something else statistics-related, or used the lecture for something besides statistics altogether. While 40% found the retrieval exercise useful, 50% indicated they thought the time could have been used better. One resident wrote in a recommendation to limit the time for retrieval to 2-3 minutes as they didn’t remember enough for concept recall. When asked whether they would recommend this session to other Internal Medicine residents, 90% said either agree or strongly agree.

/ REFLECTION / LESSONS LEARNED: The data from this survey provided useful feedback. Residents judged overwhelmingly in favor of doing the cases together over doing them alone and were mostly in favor of the slow pace. Given we had learners in different years, we were concerned that time needed to complete each block of questions would be disparate between the first and third year residents. However, we were reassured to see that 80% felt the session was well-timed. We also learned that the retrieval exercise was not uniformly found to be a good use of time, though this may have been due to the duration.

of this study are numerous. The small group size limits generalizability to larger groups, and requires more teacher time to capture an entire residency. While the survey captured 100% of participants, there was a small sample size and surveys were conducted almost two weeks after the session. Though surveys were anonymous it’s possible residents judged the session more favorably given they knew the instructor. ONLINE RESOURCE URL: https://docs.google.com/document/d/1AvKMKRMYluoPrevg849Ki_z0nu4Y_YWXu9cteIF9NVU/edit?tab=t.0 TEACHING COUNSELING SKILLS FOR OBESITY THROUGH DIRECT OBSERVATION Shyam Sundaresh, Christine Schindler. Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4272241) SETTING AND PARTICIPANTS: Our urban academic internal medicine (IM) resident primary care clinic treats underserved patients without access to specialty obesity care. DESCRIPTION: Amidst the obesity epidemic, patients prefer to address obesity with their primary care physician, but our needs assessment showed our residents do not feel comfortable with counseling for behavior change. We implemented the Direct Observation model published by the ACGME to teach residents the 5A framework for behavior change. We developed a 6-item skills checklist adapted from published ACGME material and proved inter-rater reliability amongst 2 faculty who received training in the R2C2 model (relationship building, exploring reactions to the feedback, exploring understanding of feedback content, and coaching for performance change) and $1500 to support board certification in Obesity Medicine and Lifestyle Medicine. EVALUATION: A total of 10 PGY-2 residents participated in the curriculum 7/1 - 10/15/2025, and a convenience group of 10 PGY-2 residents who participated in the curriculum beginning 10/22/2024 served as the comparison group. For the study group, a total of 18 direct observation experiences were performed, which were rated by residents on average 4.8/5 (5 = Excellent) by 12 survey responses of which 75% found the experience useful in learning how to suggest SMART goals. Anonymous comments included, “I really liked the one on one education and live feedback, I felt it was very helpful to help build effective communication skills.” A total of 5 respondents rated the curriculum on average 4.4/5 (5 = Excellent). The study group’s post-confidence in suggesting SMART goals was on average ‘Very Confident’ (4.2/5, 5 respondents) compared with the comparison group’s pre-confidence of ‘Moderately Confident’ (3.1/5, 7 respondents) which was a statistically significant difference (p = 0.03) by the Mann-Whitney U Test. At the end of their rotation, the study group competently completed 4.5 skills on average per observation (18 observations) compared with 3.2 skills by the comparison group (23 observations) at the beginning of their rotation which was a statistically significant difference (p = 0.002) by the Mann-Whitney U Test.

/ REFLECTION / LESSONS LEARNED: The direct observation curriculum was an acceptable teaching method with high satisfaction and was successfully implemented for 10 PGY-2 residents. The curriculum improved resident self-confidence in suggesting SMART goals and observed competence. Importantly the evaluation plan eliminated the possibility of a maturity bias. However, faculty were not blinded to the study design and could have been biased in their assessments. No other published IM residency curriculum successfully improves communication skills for obesity on a closely matched comparison group. We anticipate other IM residency programs will emulate our curricular model. TEACHING FUTURE PHYSICIANS ADVOCACY: A COMPASSIONATE RELEASE ELECTIVE FOR MEDICAL RESIDENTS Nicole Mushero. Department of Medicine, Boston University School of Medicine, Boston, MA. (Control ID #4235901) SETTING AND PARTICIPANTS: Internal Medicine Residents at a large academic hospital in New England taking a one week elective DESCRIPTION: The incarcerated population is aging and, on average, sicker than their community counterparts. Care of older, sicker people is costly and challenging and, as a result, most states and the federal correctional system have implemented a method of release based on degree of medical illness alone, a process known as compassionate release. The compassionate release process requires a physician affidavit which is typically not done by correctionally affiliated physicians, and many community physicians are unaware of this avenue of advocacy. Few resident physicians learn about the incarcerated population formally at all and what education does exist rarely confronts biases or injustices of the legal system. The goal of this elective is to increase knowledge of resident physicians on the health needs of incarcerated people and equip them to become advocates for a medically vulnerable and neglected population. This one-week elective provides residents with background information on the health needs of incarcerated people and the compassionate release pathway. Working with the Medical Justice Alliance, a national volunteer physician advocacy organization, residents are paired with a case, review medical records and draft an affidavit certifying to the severity of the health issues. EVALUATION: Residents fill out a survey at the end of the week discussing their elective experience which contains both quantitative and qualitative responses. Additionally, the course director attempts to track the results of medical parole process for cases which are submitted. In the first year of the elective, 6 residents participated in the elective, 5 completed survey results and 7 affidavits were submitted. Of the 7 cases advocated on behalf of, 2 people were approved for release, 1 person was denied, 1 person died while awaiting the results and 3 case results are pending. Although this is a small sample size, 80% of residents report caring for incarcerated patients but only 40% had received any formal education on that care and all reported that education had been self-selected elective experience. Residents report uniformly positive experiences with the elective especially noting their appreciation of working on a project with a concrete output (the affidavit) and a sense of “making a difference” in peoples’ lives. Twelve residents are scheduled to take the elective in year 2.

/ REFLECTION / LESSONS LEARNED: A compassionate release elective for medical residents is a novel method of education for physicians in training. It allows education on an oft-neglected population, as well as directly confronting bias and injustice. In addition to education, it serves as a direct avenue for advocacy for incarcerated patients. THE CLINICIAN EDUCATOR TRACK: A MULTIMODAL, INTERDEPARTMENTAL APPROACH FOR RESIDENTS AND FELLOWS Rachel S. Casas, Nabeel Akhtar, Sue A. Glod. Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA. (Control ID #4271326) SETTING AND PARTICIPANTS: All residents and fellows at an academic institution were invited to apply annually to the Clinician Educator Track (CET) from 2020-2025. DESCRIPTION: Residents and fellows as educators (RFAE) programs have been widely implemented to develop advanced teaching skills but can be time and resource intensive. While interdepartmental RFAE tracks allow for pooled resources, implementation can be logistically challenging. We developed a flexible, multimodal CET with synchronous and asynchronous pathways. The CET featured a synchronous or asynchronous pathway to meet participants’ interests and schedules. The synchronous pathway included a 2-week rotation that promoted application of teaching, curricular design, and professional development skills through peer-teaching, simulation, and workshops. The asynchronous pathway mirrored elective content through online modules, guided readings, and reflection. Both pathways additionally offered individual mentorship, learner feedback, observed teaching, reflection, and 20 hours of professional development. EVALUATION: All participants were invited to complete anonymous electronic surveys of teaching attitudes, skills, and professional identity at baseline and immediate-post track. All track graduates will be surveyed in July 2025 about job satisfaction, current and planned educator activities, scholarship, and perceived impact of the CET on their career choice. We will complete comparative analyses of survey responses by pathway, and narrative analyses of open-ended questions. Program evaluation comprised a survey of course satisfaction with suggestions for improvement at track completion. The CET grew from 7 to 38 participants from 2020 to 2025 with representation from 16 departments (total 67 participants). Participants were mostly female (N=39, 58%), residents (N=61, 91%), and from pediatrics and/or medicine departments (N=31, 46%). Fifty participants (75%) pursued the elective pathway, and 17 participants (25%) pursued the alternate pathway.

/ REFLECTION / LESSONS LEARNED: The CET has been sustainable and positively received. To preserve education quality with increased participants, we expanded our asynchronous options for professional development and mentorship pool. With the COVID-19 pandemic and participant feedback, we adapted (and maintained) course materials on an online shared platform. Despite the CET flexibility, it has been challenging to recruit RFAE in the surgical specialties due to time constraints. Over time, we shifted from focusing on education scholarship to a scholarly approach to teaching to best meet RFAE where they are in their academic journey. THE INCORPORATION OF A TRANSGENDER CARE CURRICULUM INTO INTERNAL MEDICINE TRAINING Brent Arcayan1; Lenisse Reyes Reyes1; Tamara Goldberg1; Helene F. Hedian2; Lou Xie3; Sharel Sadud4. 1Internal Medicine Residency at Mount Sinai Morningside and West, Mount Sinai Morningside Hospital, New York, NY; 2Medicine, Johns Hopkins University, Baltimore, MD; 3Internal Medicine, UCSF Medical Center, San Francisco, CA; 4Infectious Disease, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX. (Control ID #4272939) SETTING AND PARTICIPANTS: A one-hour classrom-based session for ~40 PGY2/PGY3 internal medicine residents at a large urban academic center. The session will be held twice with two different cohorts. DESCRIPTION: Internal medicine (IM) residents play a key role in caring for LGBTQ+ patients, making it crucial to assess their preparedness to deliver culturally competent care. In Phase 1 of our curriculum (Sept-Nov 2023), we conducted a needs assessment among IM residents at our program to evaluate their comfort with LGBTQ+ specific topics. Results indicated that learners largely felt unprepared to address the needs of LGBTQ+ patients, particularly regarding knowledge of gender-affirming hormone therapy; 82.5%; (n=52) and fear of seeming intrusive; 61.9%; (n=39). In Phase 2, to address these gaps, we developed a one-hour panel session focused on trans-inclusive care. Through use of an expert moderator and two transgender panelists, we aim to use narrative commentary and discussion to promote learner reflection on optimizing care for transgender patients. This curriculum has been selected for Spring 2025 rollout and will be evaluated via pre- and post-session surveys and a post-session reflection. EVALUATION: Pre and post curriculum surveys will assess attitudinal and cognitive objectives. Learner reflection will be used during the sesion to encourage self-awareness.

/ REFLECTION / LESSONS LEARNED: For LGBTQ+ patients, the physician-patient interaction offers opportunities to affirm identities and provide compassionate care. In Phase 1 we identified specific gaps in IM residents' comfort with LGBTQ+ care. In Phase 2 we will use transgender patients' narratives to teach inclusive care strategies. An open dialogue with panelists offers an alternative to lectures, suited to addressing barriers like fear of intrusiveness and lack of training. Pre/post surveys and reflections will evaluate the curricula's impact on residents' perceived ability to deliver compassionate care. ONLINE RESOURCE URL: N/A THE POWER OF STORYTELLING: A NARRATIVE MEDICINE CURRICULUM TO PROMOTE RESIDENT WELLNESS AND HEALTHY IDENTITY FORMATION Michelle H. Silver1,2. 1Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2Harvard Medical School, Boston, MA. (Control ID #4270632) SETTING AND PARTICIPANTS: A Narrative Medicine (NM) curriculum for IM residents at a New England academic hospital. This includes 90-minute sessions during required ambulatory didactics, 5-15 residents per session, with residents averaging 4 sessions per year. Sessions follow a typical format: 1) reflective engagement with narrative, literary, or art sources 2) personal reflection and 3) shared discussion. Sessions cover topics universal to training, ranging from moral injury to difficult patients. DESCRIPTION: Narrative Medicine (NM) uses literature and art to foster reflection and group discussion. NM targets two key pedagogical functions for medical Arts and Humanities (AH) curricula, per the Prism Model: personal insight and perspective taking. This promotes “reflective practice and commitment to growth,” and “knowledge of factors of well-being,” ACGME milestones. Only 17% of AH curricula target GME despite this being a vulnerable time with worsening self-esteem, declining empathy, and increased burnout. NM can combat this by providing intentional space to process challenging, emotionally intense, unfamiliar stories. This, in turn, promotes wellness and healthy identify development. My curriculum is one of few existing GME interventions and uniquely offers a standardized approach. EVALUATION: Residents complete a voluntary survey after each session including Likert-scales (levels of agreement) and open-ended questions. Open responses address perceived purpose and impression of sessions. Likert-scale questions range from sense of wellness and enjoyment to impact on job satisfaction, peer connectivity, and patient care. As next steps, I will conduct semi-structured interviews to elaborate on survey themes and explore ways the program impacts clinical behavior.

/ REFLECTION / LESSONS LEARNED: Survey data from a pilot intervention with primary care residents demonstrates measurable improvements in wellness, job satisfaction and patient care, while promoting camaraderie and emotion processing; results and curricular tools are published in MedEdPortal (see URL). Given limitations in sample size and with survey data, I am expanding my intervention by 1) implementing department-wide and 2) adding qualitative interviews. Qualitative data can measure beyond reaction and self-reported learning by eliciting examples of how this learning impacts clinical practice. Along the way, I realized learning environment is just as important as session materials for promoting session engagement. It can be challenging to encourage equal participation, and I find think-pair-share effective for lowering the threshold of engagement. Further, faculty facilitators should have comfort in the medical humanities, communication skills, empathy, and understanding of psychological safety. Lastly, I continue to adapt sessions in response to environmental and learner needs: The curriculum is widely adaptable given the breadth of topics and sources to be explored. ONLINE RESOURCE URL: https://www.mededportal.org/doi/10.15766/mep_2374-8265.11446 THINKING FAST AND ACTING SLOW: DEVELOPMENT OF A PEER LED RAPID RESPONSE CURRICULUM FOR INTERNAL MEDICINE RESIDENTS Kyle Santerian, Deepika Potarazu, Rachel Strock, Jillian Hall, Brianna Graham, Dharmini Shah Pandya. Internal Medicine, Temple University Hospital, Philadelphia, PA. (Control ID #4271715) SETTING AND PARTICIPANTS: Rapid Response Teams (RRT) are utilized to respond to medical emergencies in hospitalized patients. Internal medicine residents are frequently the first to respond to situations involving decompensating patients and are integral members of the rapid response team. Often, life-saving interventions must be implemented swiftly with limited clinical information. To effectively deliver care in these situations, residents must have a solid foundation in the management of acute illness with an emphasis on effective clinical reasoning. Despite the clear need for trainees to be proficient in these skills, formal curricula to teach best practices in resuscitation are lacking. To address this, we designed a peer-led RRT curriculum at a quaternary care academic medical center tailored to internal medicine residents. DESCRIPTION: For the upper year didactic series, we conducted a needs assessment survey of junior residents to identify attitudes and knowledge gaps in managing common emergencies that occur on the medical floor. A comprehensive lecture series was designed and administered by senior residents, with guidance from critical care and hospitalist faculty. The educational model utilized a multi-modal approach inclusive of didactics, hands-on simulations and targeted education focusing on diagnostic reasoning in rapid response scenarios. Participants were surveyed before and after each educational session to assess confidence in management of RRT scenarios. Surveys utilized a 5-point Likert sale and results were analyzed using two sample t-tests. EVALUATION: Resident comfort with rapid response situations increased after participation in the curriculum (p<0.0001, mean pre-intervention 2.25 ± 1.30, mean post-intervention 4.57 ± 0.29). Participants better understood indications for peripheral vasopressor administration (p<0.0001, mean pre-intervention 2.06 ± 1.06, mean post-intervention 4.57 ± 0.62), and approach to tracheostomy emergencies (p<0.0001, mean pre-intervention 1.33 ± 0.25, mean post-intervention 4.71 ± 0.24). Respondents reported improved comfort with bag-valve mask ventilation (p=0.0001, mean pre-intervention 3.22 ± 0.44, mean post-intervention 4.71 ± 0.24), as well as management of acute ischemic stroke (p=0.017, mean pre-intervention 2.66 ± 1.00, mean post-intervention 3.73 ± 0.66).

/ REFLECTION / LESSONS LEARNED: A resident led RRT curriculum with emphasis on clinical reasoning and evidence-based decision making improved participants’ confidence in managing acutely ill patients. Our model represents a unique, peer-driven approach to development of a RRT curriculum that is generalizable across institutions and specialties. “HIGH ALERT!” A HIGH-RISK END-OF-YEAR HANDOFF INTERVENTION FOR RESIDENT CONTINUITY CLINIC Rachel Snyder, Jaime Fineman, Jill Allenbaugh. Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #4235622) SETTING AND PARTICIPANTS: The innovation included PGY3 residents at a large, urban academic medical center in Philadelphia. DESCRIPTION: Every year thousands of patients in resident continuity clinics are “handed off” between a graduating resident and new intern resident. This can lead to compromised care, specifically for those patients who are most vulnerable, including those with complex medical or social needs. To diminish potential poor outcomes associated with continuity care handoffs, the Temple Internal Medicine residency created a curricular innovation for graduating third year residents. With faculty guidance, residents use specific criteria to identify patients that are most “high-risk” and then participate in an enhanced handoff process. Residents complete standardized documentation that is easily accessible for any future providers and give verbal sign out to the assigned intern PCP during intern orientation week. This innovation began in the spring of 2021 with three-year outcomes evaluated in 2024. EVALUATION: A Redcap survey was sent to all graduating PGY-3 residents in June 2024 assessing the follow up of the high-risk patients they were given as PGY1s. The survey evaluated the number of patients they had been signed out, and 6 potential outcomes: “Still high-risk,” “No longer high-risk,” “Patient died”, “Patient transferred care to another resident,” “Patient transferred care to an attending,” or “Patient was lost to follow up or followed up outside of our practice.” Of 32 residents who were surveyed, 25 (78%) responded, reporting on a total of 99 high-risk patients they received during handoff in 2021. Forty patients (40%) remained under their care, while another 33% (34/99) remained in our resident clinic and 6% (6/99) transferred to attending clinic. Only 20/99 (20%) had been lost to follow up or transferred practices. Of the 40 patients that remained with the original resident, 14 (35%) are still considered high-risk, while 11 (27.5%) had died. The remaining 15 patients were no longer considered to be high-risk patients.

/ REFLECTION / LESSONS LEARNED: This simple innovation was successful at identifying patients at high-risk for poor outcomes, as evidenced by the high mortality of the identified patients (27.5% over three years) and continued recognition of 48% of the remaining patients as high-risk three years later. In 2014, a national survey of Internal Medicine program Directors demonstrated only 34% of IM programs have an end-of-year ambulatory handoff. This is an easily implementable innovation for any program looking to improve their end-of-year handoffs. Further research can investigate which medical and social factors lead residents to consider patients as “high-risk” and whether patient outcomes are improved with the use of a high-risk ambulatory patient handoff. Innovation in Medical Education (IME) - Curriculum Development – UME ADDING A LONGITUDINAL OUTPATIENT MEDICAL STUDENT ROTATION ENHANCES STUDENT LEARNING AND IMPROVES FACULTY SATISFACTION Gwendolen Buhr1; Saumil Chudgar2; Bruce Peyser3; Tracey Reynolds2; Anivarya Kumar4; Madhura Pande2; Poonam Sharma2. 1Medicine, Duke Medicine, Durham, NC; 2Medicine, Duke University School of Medicine, Durham, NC; 3Internal Medicine, Duke University, Durham, NC; 4School of Medicine, Duke University School of Medicine, Durham, NC. (Control ID #4272072) SETTING AND PARTICIPANTS: Academic medical center in the Southeast. DESCRIPTION: Traditionally, the preponderance of medical education in internal medicine has taken place in the hospital setting, but increasingly patients are hospitalized for briefer periods and most of their care is now delivered in the outpatient setting. To address this mismatch, we expanded upon a successful small innovative program for medical students interested in primary care in which students were paired with outpatient clinical educators. Starting with the 2023-2024 academic year, a new 16-week longitudinal outpatient clerkship for all students in internal medicine (IM), pediatrics, obstetrics and gynecology, neurology, and emergency medicine was designed to enable deeper learning and relationship building among students, patients, and attendings. Students were assigned to the same half-day IM clinic for 16 weeks. Half were paired with general IM preceptors and half with subspecialists in IM. This ambulatory clerkship was paired with a 6-week inpatient IM clerkship, which together replaced an 8-week inpatient only clerkship. EVALUATION: The impact of the new ambulatory clerkship was assessed with a student survey with qualitative and quantitative questions and an optional faculty survey, as well as from an existing instrument, the Observed Structured Clinical Exam (OSCE).

There was no statistical difference in the OSCE scores before and after the clerkship change. Student survey comments were positive reporting improved consolidation of their IM knowledge, better relationships with preceptors, ability to track patients longitudinally, and exposure to different specialties. Some students advocated for improved coordination of site assignments to reduce driving time between clinics. Students rated faculty teaching abilities highly in the end of course evaluation. For the question, “How would you rate the preceptor’s overall teaching abilities, the GIM and specialist mean ratings were 4.3 and 4.7 respectively (P = 0.02) on a scale of 1 (poor) to 5 (excellent). 34 faculty responded to the optional end of session survey. Of those responding 38% had not worked with second year medical students in the past. Of those who had worked with students in prior years, 63% felt that the new model was better and the remaining felt it was about the same.

/ REFLECTION / LESSONS LEARNED: The novel longitudinal ambulatory clerkship broadened IM training for students and improved faculty experience of teaching. Students rated both generalist and subspecialty faculty highly as educators, suggesting this model is feasible across all IM practitioners. Early results suggest benefits for the institution, including increased opportunity for faculty teaching. While shorter than a traditional longitudinal integrated clerkship, our experience suggests some of the same benefits can still be captured. We will continue to track longer-term student outcomes and residency specialty selection in the years to come. APRENDáMOS JUNTOS: LEVERAGING STUDENT FACILITATORS IN A MEDICAL SPANISH EDUCATIONAL INITIATIVE Doris A. Cubas1; Susana Garcia2; Claudia Gomez Vega2; Sofia Leyva2; Lizzeth N. Alarcon1. 1Medial Education, Florida International University, Miami, FL; 2Florida International University Herbert Wertheim College of Medicine, Miami, FL. (Control ID #4271576) SETTING AND PARTICIPANTS: Our institution serves a large Latinx population that primarily speaks Spanish. Medical students in our institution have long expressed interest in opportunities to learn Spanish. This longitudinal co-curricular focus in Medical Spanish was created to address this educational gap. Participants included faculty directors, student facilitators, and medical students enrolled in this focus in their preclinical years. DESCRIPTION: The longitudinal focus was launched over the summer 2024 with fifteen rising second-year medical students who elected to enroll in the focus. Students selected their level of Spanish proficiency based on a validated self-assessment scale. A third-party online medical Spanish resource specific to healthcare professionals was used for asynchronous learning. Specific lessons were assigned to students to be completed before small group practice sessions. Students were grouped by their level of proficiency and paired with a student facilitator. Student facilitators role played as a Spanish speaking patient and provided immediate feedback to students after completing the scenario. Patient case scenarios were aligned with the content of the third-party platform and concurrent organ system course. EVALUATION: During the small groups, pre- and post-surveys were completed by each student. Students rated their confidence using a 4-point Likert scale assessing various history taking skills. Students provided qualitative feedback on the use of peer facilitators. General feedback about the third-party platform was also provided.

/ REFLECTION / LESSONS LEARNED: There is growing evidence that language concordant care can help improve health outcomes and we provide an educational opportunity that allows students to better serve members of the Latinx community. Preliminary results show students found it beneficial to use student facilitators during practice sessions. Confidence levels in their medical Spanish increased after small group sessions. This is an example of a novel education initiative using a multi-faceted approach that integrates student and faculty expertise, which can be implemented at other institutions. Previous barriers to implementing a curriculum like this included limited faculty allocation. Partnering with student facilitators who are fluent in Spanish and interested in teaching, engages their expertise while developing their skills as educators. ASYNCHRONOUSLY ALIGNED: IM RESIDENT-DEVELOPED CLERKSHIP CONTENT TO ENHANCE IM CLERKSHIP STUDENT LEARNING AND FOSTER RESIDENT PROFESSIONAL IDENTITY FORMATION Parth K. Patel2; Cindy Li2; Elizabeth Reznik2; Katherine Penziner1. 1Internal Medicine, Weill Cornell Medicine, New York, NY; 2Internal Medicine, NewYork-Presbyterian Weill Cornell Medical Center, New York, NY. (Control ID #4247062) SETTING AND PARTICIPANTS: The initiative is based at a large academic medical center in the Northeast. Internal medicine (IM) residents developed asynchronous content based on the Alliance for Academic Internal Medicine (AAIM) Clerkship Directors in Internal Medicine (CDIM) Core Medicine Clerkship Curriculum Guide. Residents were paired with IM and subspecialty faculty who provided subject expertise and initial feedback. A second round of review was conducted by peer IM residents. Residents will record their content into videos, which will be offered to IM clerkship students to supplement their learning. DESCRIPTION: Clerkship students have a large breadth of content to learn with limited time for both clinical application and shelf exam. It is impractical and antithetical to the clerkship experience to pull students off the wards for lectures. In parallel, residents passionate about teaching seek opportunities to develop as educators. Our innovation addresses both needs by involving residents in creating case-based video content aligned with the AAIM CDIM Clerkship Curriculum Guide, which also serves as the source of the NBME shelf exam learning objectives. Residents collaborate with faculty mentors for content review, followed by peer review to ensure both clinical relevance and pedagogical effectiveness. The final video content will be produced and made available to third-year medical students to supplement their learning and prepare for the NBME shelf exam. EVALUATION: For medical students, the primary endpoint is their preparedness before and after the initiative. We hypothesize that it will increase the level of preparedness for the IM clerkship. A pre- and post-implementation survey will assess comfort with the topics using a Likert scale as a proxy for preparedness. NBME shelf exam scores will also be compared before and after implementation, controlling for content utilization, to measure the impact on exam performance. For residents, the primary endpoint is its effect on their professional identity as educators, assessed through a brief qualitative survey on their experience.

/ REFLECTION / LESSONS LEARNED: This initiative seeks to bridge the gap between didactic learning and clinical application, and to create a sustainable education framework by integrating UME, GME and faculty education. It provides students with resources aligned to clerkship objectives and helps resident editors develop and apply teaching skills to enhance educational materials. We will assess whether asynchronous, CDIM-aligned content enhances student preparedness and shelf exam performance, and if creating content influences residents’ professional identity as educators. A TRANSITIONS-OF-CARE CURRICULUM FOR INTERNAL MEDICINE CLERKSHIP STUDENTS Bingyan Shi1; Stacy Han2; Tianyu Chen3; Michi Yukawa2; Nancy Choi1; Cindy Lai1. 1Medicine, Division of Hospital Medicine, University of California San Francisco, San Francisco, CA; 2Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA; 3Medicine, Division of Hospital Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4269994) SETTING AND PARTICIPANTS: Two 50-minute small-group sessions delivered to internal medicine clerkship students at an urban academic quaternary hospital between July and December 2024. DESCRIPTION: Following Kern’s 6-steps, a needs assessment of the existing medicine clerkship curriculum revealed a lack of formal teaching on transitions-of-care (TOC) and interprofessional collaboration in discharge planning. Students expressed a desire to learn practical strategies for determining appropriate post-acute care settings. We developed an interactive curriculum with input from hospitalists, geriatricians, case managers (CMs), and social workers (SWs). In session one, students learned a framework for reviewing patient factors that determine discharge location, including medical, social, rehabilitation, and financial needs, and patient preference. They also learned post-acute care settings and roles of CMs and SWs. In session two, students debriefed their own complex discharge cases with an internist, CM and SW. These discussions built upon the framework and concepts taught during session one. EVALUATION: This pilot curriculum was delivered to three blocks of students (n=25). Students completed pre-curriculum and post-curriculum surveys to evaluate comfort level in three domains: identifying patient factors that determine care setting, describing post-acute care settings, and roles of CMs and SWs (0=not comfortable at all; 5=very comfortable). Pre-curriculum surveys showed an average comfort level of 2 in all three domains; this increased to a post-curriculum average of 3.7 (3.5 for describing patient factors and care settings, and 3.8 for describing roles of CMs and SWs). Surveys also assessed knowledge retention. Prior to session one, students correctly selected the appropriate discharge location for case-based patients 71% of the time and identified CM and SW roles 64% of the time. After session one, scores improved to 89% and 94%, respectively. Assessment questions given at the start of session two demonstrated retention of knowledge, with scores of 86% and 81%, respectively. Students rated the course at a 9 (out of 10) for relevance, applicability, and engagement in session one, and 8 in session two. Students specifically reported utility and efficacy of case discussions during session two.

/ REFLECTION / LESSONS LEARNED: TOC are a vulnerable time for patients. Our pilot curriculum successfully introduced TOC concepts to internal medicine clerkship students with preliminary data showing increased comfort level in the content area and sustained retention of knowledge. Feedback highlighted the positive impact of our unique multidisciplinary approach. The two-session delivery during students’ internal medicine clerkship allowed for spiral learning and direct application of concepts to cases encountered on rotation. We hope to prepare all students for competency in discharge planning with this ongoing curriculum. CREATING A REQUISITE MEDICAL STUDENT SERVICE-LEARNING CURRICULUM IN COLLABORATION WITH A COMMUNITY ADVISORY BOARD: LESSONS LEARNED Micaela Roy1; Rita Lee2; Kristin Furfari3. 1internal medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 2Medicine, University of Colorado, Aurora, CO; 3Medicine, University of Colorado, Denver, CO. (Control ID #4245616) SETTING AND PARTICIPANTS: This curriculum was co-created by faculty and a community advisory board for an urban academic medical institution and implemented for first- and second-year medical students over a two-year period. DESCRIPTION: Effective community service addresses community-defined needs. Thus, designing an impactful service-learning program requires community involvement at all levels. While past UME curricula have involved communities in individual projects, no program to our knowledge has collaborated with the community in designing the service-learning program in its entirety. We describe a longitudinal, requisite service-learning curriculum that was uniquely co-created with a community engagement curriculum advisory board (CECAB). CECAB was composed of 10 community members and/or leaders of community-based organizations (CBO’s) representing diverse sectors and met monthly over the course of 2 years. CECAB identified key content needed in preparation for the community service experience, including cultural responsiveness, structural racism and oppression, implicit bias, and conflict resolution. CECAB also set core tenets for the program including bi-directional collaboration and longitudinal relationships with community. Ultimately, the team developed a service-learning curriculum that involved 16+ hours of coursework, 60 hours of community engagement completed longitudinally in collaboration with a community partner, and self-reflection activities. Students were matched with a community organization and tasked with collaboratively designing, implementing, and evaluating a community engagement experience. EVALUATION: The program was evaluated through reflection and feedback from students and community organizations.

/ REFLECTION / LESSONS LEARNED: The service-learning curriculum was successfully launched in 2021, matching 184 students into 70+ local CBO’s. Developing and implementing the service-learning program highlighted the importance of flexibility when balancing community, student, and school needs. In co-creating the curriculum, we learned that CECAB’s preferred design did not always align with what was feasible within the structure of a medical school curriculum. While integration of core coursework into the curriculum was seamless, the burden of the concomitant medical course load led to disjointed student engagement with community partners despite the goal of longitudinal contact with community organizations. Though CECAB’s input was central to our design, this process emphasized the multiple factors necessary in forming a program which benefits all interested parties. DEVELOPMENT OF A PRECLINICAL CAPSTONE PROJECT TO ADDRESS BARRIERS TO PATIENT AND CAREGIVER RESOURCES IN THE COMMUNITY Gretel Sanchez-Hoehing2; Marni K. Gleiber2; Stacy Rubin1. 1Internal Medicine, Florida Atlantic University, Boca Raton, FL; 2Neuroscience, Florida Atlantic University Charles E Schmidt College of Medicine, Boca Raton, FL. (Control ID #4273202) SETTING AND PARTICIPANTS: At a community-based, patient-centered medical school in the Southern region, we created a group capstone project in a preclinical course allowing students to identify and educate patients on accessing community resources, through which students applied Systems-based and Interprofessional Collaborative Practice Competency concepts into clinical coursework. The assessment can be adapted to individual students, clinical clerkship students, or for learners in graduate medical education. DESCRIPTION: Medical students must demonstrate the ability to anticipate patient needs, educate patients, coordinate care, and understand healthcare systems. We created a case-based assessment requiring learners to identify patient care needs and provide interprofessional community resources. Then, students were tasked with creating a management plan that included detailed instructions on how to educate the patient on navigating the healthcare system to access the resources. Additionally, learners addressed service gaps and found resources available in other geographic regions that would bridge the void(s). Each group received a different patient case to avoid overlap of themes and identified resources. Finally, all students compiled their list of resources, creating a dynamic, pooled reference of resources for their use during clinical curriculum, post graduate training, and eventual medical practice. This assignment's inherent strength is in empowering early trainees to collaborate in pooling local community resources into a shared living document to continue to reference and build throughout their training. Additionally, it serves as a model for developing a similar reference in their future practice community. EVALUATION: Success of this intervention will be measured via student rating on a five-point Likert scale and narrative feedback via anonymous course evaluation. We are in the process of collecting these data but will include the analysis in our presentation.

/ REFLECTION / LESSONS LEARNED: The need for resourceful and dynamic healthcare providers to care for increasingly complex medical and psychosocial concerns in the community led to the creation of assessment in which students identify and educate patients in accessing community resources, applying Systems-Based and Interprofessional Collaborative Practice Competency concepts into clinical coursework. There is feasibility and transferability of this project to most if not all levels of medical curricula. DRIVING TRANSFORMATION IN MEDICAL EDUCATION: EMPOWERING CHANGE THROUGH A QUALITY IMPROVEMENT CURRICULUM FOR MEDICAL STUDENTS Chloe Krugel1; Patrick J. Tempera3; Issam Halasa2; T. Charles Martin2; Sarah Pogge1; Olga Khazen1; Mustafa Mahmood1; Rachel Hathaway2. 1Medicine, Albany Medical Center, Albany, NY; 2Internal Medicine, Albany Medical Center, Albany, NY; 3Saint Joseph's Healthcare System, Paterson, NJ. (Control ID #4234534) SETTING AND PARTICIPANTS: Our institution is an academic medical center in the Mid-Atlantic region with approximately 600 medical students. This initiative currently includes 145 medical students and 62 Internal Medicine Residents. DESCRIPTION: Quality Improvement (QI) is a robust field focused on improving the safety, effectiveness, and overall experience of medical care. Following ACGME requirements, residency programs incorporate QI as part of their curriculum; however, there is a noticeable gap of QI curriculum in undergraduate medical education which is also evident in medical education literature. Within our institution, there is no existing QI curriculum for medical students. Furthermore, the resident-medical student relationship represents a valuable near-peer relationship in the clinical and educational setting. It is vital for students and residents to have opportunities to collaborate. To address this gap, we developed a novel QI curriculum that bridges undergraduate and graduate medical education through a QI Interest Group for medical students. Using the existing curricular framework within our Internal Medicine Residency program, we are creating opportunities for students to work with residents on QI projects, present and publish their work, and participate in educational initiatives including training through the Institute for Healthcare Improvement. The group hosts monthly educational lectures and shares QI opportunities via email. It serves as a link to the Internal Medicine Residency QI Chief and receives faculty support from the Associate Director of the Internal Medicine Clerkship. EVALUATION: In October 2023, we disseminated a pre-intervention needs assessment to first through third year medical students and received responses from 40 students indicating interest in this program. We established the program in April 2024 and currently have 145 medical students involved. In our most recent recruitment effort targeted toward first-year medical students, we recruited 54 new students. Since the implementation of this initiative, we have been able to help many medical students bring their ideas to life by connecting them with residents and faculty members involved in QI work.

/ REFLECTION / LESSONS LEARNED: Helping medical students turn their ideas into actionable projects is a key goal of this initiative and part of the larger mission of improving patient safety and quality of care. Through this framework, we have developed a method for medical institutions to take advantage of interprofessional models of teamwork as well as diversifying care teams through the inclusion of medical students. Our curriculum is in the expansion phase, and we are in the process of creating a database of QI projects by working with QI leadership throughout the hospital. Bridging the gap between medical students and the broader hospital environment in the setting of QI has allowed students to contribute and learn from QI while advancing patient care and developing skills that will help them succeed in their future careers as physicians. ENHANCING MEDICAL STUDENT COMPETENCY IN BEDSIDE DEVICES: A STRUCTURED CURRICULUM FOR LINES, TUBES, TELEMETRY, AND VENTILATORS Pouya Arefi1; Benjamin Finard1; Rita Malley2; Megan R. D'Andrea1; Sabrina Khan1; Rex Hermansen3; Eve Merrill1. 1Internal Medicine, Mount Sinai Health System, New York, NY; 2Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 3Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4271702) SETTING AND PARTICIPANTS: This medical education curriculum was implemented at an academic medical center in the northeastern United States and involved Internal Medicine residents as session leaders with third year medical students as participants. It is delivered every 6 weeks to students who are beginning their inpatient medicine clerkship. DESCRIPTION: The curriculum was designed to cover four major bedside skills/devices, including intravenous lines, enteral feeding devices (nasogastric tubes and percutaneous endoscopic gastrostomy tubes), telemetry, and ventilators. Discussion of each bedside device involves an overview of its purpose, methods to interpret and assess functionality at the bedside, actionable steps for medical students at the bedside, and strategies for incorporating these tools into care plans during rounds. The initial phase involves classroom-based instruction on intravenous lines and enteral feeding devices. This includes hands-on access to supplies, visual aids, brief handouts and clinical scenarios. Students learn the specific applications of various lines and tubes, methods to assess proper placement and function, and strategies to integrate this knowledge into patient care plans. The next phase focuses on bedside teaching with consented patients, emphasizing telemetry and ventilators. This supervised hands-on approach will help students identify and interpret essential data commonly reported during medical rounds. EVALUATION: We are using the Kirkpatrick model to evaluate student satisfaction, learning, and behavioral impact of the curriculum. We initially evaluated student satisfaction with an anonymous feedback form sent to 60 participants. Among 20 respondents, 75% rated the session as very or highly relevant, and 80% planned to apply the skills during rotations. Additionally, over 70% found the session to be very or highly educational. Students also provided constructive feedback, including the use of PowerPoint slides and pocket guides for quick reference. Over half of respondents also suggested transitioning to a hybrid classroom-bedside teaching model. The next step in evaluation will implement a pre and post session survey to evaluate knowledge acquisition and the practical impact of the curriculum on clinical performance.

/ REFLECTION / LESSONS LEARNED: The clinical years of medical school are pivotal for bridging classroom knowledge with direct patient care. However, undergraduate medical education may lack sufficient practical training on bedside devices such as lines, tubes, ventilators and telemetry. This can result in knowledge gaps and reduced confidence in utilizing these tools effectively. This curriculum helps address this gap by providing students with practical skills to enhance their clinical competency and quality of care delivered. ENHANCING VALUE-BASED CARE EDUCATION: EVALUATING THE IMPACT OF A CLERKSHIP CURRICULUM ON MEDICAL STUDENTS' UNDERSTANDING AND APPLICATION Tasmia Promi, Shirley Eisner, Isabel McFarlane. College of Medicine, SUNY Downstate Health Sciences University, New York, NY. (Control ID #4272163) SETTING AND PARTICIPANTS: This study was conducted at a Brooklyn medical school and involved 152 third-year medical students rotating through their internal medicine (IM) clerkship over four academic rotations. Participants engaged with a newly implemented Value-Based Care (VBC) curriculum designed to introduce them to core principles such as evidence-based practice, cost-conscious care, and patient-centered decision-making. Faculty preceptors facilitated case-based discussions and supervised the application of VBC concepts during clinical encounters. Plans are underway to survey fourth-year sub-interns to evaluate the retention and application of VBC principles, assessing the curriculum’s long-term impact. DESCRIPTION: The innovation of this curriculum is the integration of VBC principles into the clinical clerkship, addressing a gap in traditional medical education where these topics are often restricted to pre-clinical years. The curriculum included ACP and IHI modules on cost-conscious care, risk-benefit analysis, and patient-centered decision-making. Students applied these concepts during clinical case presentations, focusing on diagnostic appropriateness, cost considerations, and socio-economic factors. Additionally, students completed assignments evaluating cases using VBC principles and reflecting on their decision-making processes. Unlike traditional approaches, this curriculum combined theoretical learning with practical application and preceptor-guided discussions, emphasizing real-world relevance. EVALUATION: Post-rotation surveys collected quantitative and qualitative data. Among third-year students, 93% reported increased discussions of costs and risks with attendings, and 95% considered patient costs in clinical decisions. Qualitative reflections highlighted challenges, such as balancing cost-effectiveness with quality care, particularly in complex cases, and ethical concerns about prioritizing cost over patient needs. Many students found preceptor discussions more effective than online modules but noted these alone were insufficient for mastering VBC principles. These findings informed plans to evaluate fourth-year sub-interns to determine whether earlier VBC training supports advanced clinical decision-making.

/ REFLECTION / LESSONS LEARNED: Integrating VBC into clerkships increased awareness of cost-conscious decision-making but exposed gaps in applying these principles to complex cases. Feedback highlighted the need for a sequential curriculum, starting with role-playing and team-based problem-solving exercises in pre-clinical years, followed by case-based discussions during clerkships. Emphasizing case presentations evaluating diagnostic appropriateness and socio-economic factors proved effective and should be expanded. For schools lacking a Health Systems Sciences thread, this model offers a practical framework for embedding VBC education. Future surveys of sub-interns will evaluate the curriculum’s long-term impact, assessing its role in preparing students for independent clinical decision-making and beyond. IMPLEMENTATION OF A NOVEL INTERINSTITUTIONAL & INTERNATIONAL CURRICULUM INNOVATION FOCUSED ON TRANSITIONS IN TRAINING FOR MEDICAL STUDENTS James T. Boothe1; Bernard A. Landry-Wegener2; Mesut Yilmaz3; Resham Rahat1; Zishan Siddiqui1. 1Department of Medicine, Johns Hopkins Medicine, Baltimore, MD; 2Medicine, Johns Hopkins Medicine, Baltimore, MD; 3Istanbul Medipol Universitesi Uluslararasi Tip Fakultesi, Beykoz, İstanbul, Turkey. (Control ID #4270556) SETTING AND PARTICIPANTS: We collaborated internationally to design and implement a novel undergraduate medical education (UME) curriculum at an urban, internationally focused medical school in Türkiye. The innovation targeted students in the clinically focused years (years 3-6) of the 6-year UME program, though the innovation was also open to preclinical students. DESCRIPTION: The UME curriculum in the US & Canada emphasizes graduated, competency-based independence and integration of students as patient care team members during the clinically focused years of training. International variations in UME curricula can pose challenges for students of foreign medical schools who are aiming to train in the US & Canada. With increasing numbers of trainees applying to US & Canadian residency programs, preparation of foreign medical students to meet expectations for audition rotations and “Day 1” PGY-1 readiness is critical for successful placement into graduate medical education (GME) programs in the US & Canada. Review of the local curriculum revealed a high reliance on lecture-based learning during clerkships, very low student involvement in direct patient care, frequent absence from the patient care team, and significant differences in cultural expectations regarding professionalism and communication for learners. This pilot program consisted of a seminar series delivered over one week, featuring interactive didactic sessions, case discussions, writing exercise, mock interviews, and an interview with a successful Turkish applicant. The curriculum addressed transitions from preclinical to clinical training, preparation for standardized licensure exams, and US & Canadian residency application processes, alongside topics of professionalism and communication skills. Extensive open discussions engaged students, faculty, and medical school leadership at this Turkish medical school. Sessions were informed by the experiences of a faculty member with experience mentoring Turkish students pursuing US residency programs and extensive UME and GME teaching experience. Junior faculty with leadership roles in medical education contributed curricular frameworks, expertise in medical education theory and practice, and guidance on aligning with US & Canadian standards. Turkish medical students also contributed their experiences as part of needs assessment. EVALUATION: Formal evaluation for further development of this curriculum is processing through an IRB-approved survey of the medical students involved in the pilot offering of the innovation.

/ REFLECTION / LESSONS LEARNED: This innovation serves as a novel foundational framework for US academic hospitalists to develop international medical education curricula. It addresses multiple areas of need, enhancing the preparedness of international medical graduates (IMGs) to deliver safe, high-quality care from Day 1 of residency training in the US & Canada. By bridging gaps in UME training systems, such efforts can both support the training of IMGs and the career goals of US academic hospitalists. INCORPORATING A LONGITUDINAL MODULAR POPULATION HEALTH MANAGEMENT CURRICULUM INTO CORE CLINICAL CLERKSHIPS Catherine Varnum1; Jillian S. Catalanotti2. 1DGIM, The George Washington University, Washington, DC; 2Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4272801) SETTING AND PARTICIPANTS: Sessions were conducted with 3rd year medical students during the didactic day of the core clerkship rotation. Sessions were a mix of in-person, virtual and hybrid and lasted about 1 hour long. The group size ranged from 15-25, depending on the rotation. DESCRIPTION: We created 4 modules of our longitudinal modular population health (PopH) management curriculum for 4 core clerkships (Internal Medicine, Primary Care, Surgery and Obstetrics/Gynecology). Next year, we will create the final 2 modules and implement them in the remaining 2 core clerkships (Psychiatry and Pediatrics). The topics for the created modules include: “Mind the Gap,” (identifying a population, health outcome of interest, data limitations and target setting), “Why Oh Why?,” (performing root cause analysis), “There’s No I in Team,” (stakeholder analysis) and “The Best Laid Plans,” (intervention design). The two additional modules will discuss implementation and sustainability. Each module consists of a 10-minute video with PopH management content and a 30-minute faculty-facilitated small-group application activity with clerkship-relevant data. Regardless of specialty, the first time the student was on a clerkship, they received Module #1, and modules proceeded in order whenever a student was on a participating clerkship. After discussion with each clerkship director (CD), we pulled PopH data relevant to their field from our EHR (examples include: diabetes control, inpatient opioid use disorder treatment, surgical site infections, and gestational diabetes screening.) This illustrates the universal relevance of PopH management across clinical fields. EVALUATION: Students took optional, anonymous pre- and post-tests to assess knowledge gains. Post-tests included optional feedback on usefulness, clarity of modular components and free-text suggestions. We delivered modules 1 time spanning IM, PC, Surgery and Ob/Gyn Clerkships. We received 183 post-test responses. Students overwhelmingly believed facilitated discussion with field-specific data had a positive impact on learning (80.3%, 147/183). Videos were believed to have a positive impact (53.6%, 98/183) or neutral impact (39.9%, 73/183) on learning by most.

/ REFLECTION / LESSONS LEARNED: Students found the application activity using field-specific data particularly helpful. Responses suggest the modular format was effective and it was straightforward to implement, resulting in all students receiving the content in the same order despite different timing of core clerkships. Because PopH is new to students, even limited data was adequate to drive rich discussion. Seeking field-specific expertise from CDs made application activities highly relevant. We delivered content in videos to facilitate a potential need to have inexperienced faculty lead sessions. Students felt positive or neutral about the videos; we will incorporate feedback to improve them. Next year, we will recruit 2 additional educators with PopH management experience to help implement all 6 modules in all core clerkships. INTEGRATING CLIMATE CHANGE INTO UNDERGRADUATE INTERNAL MEDICINE CURRICULUM Elizabeth Whidden, Phoebe Cunningham, Jessica Campanile, Farah Hussain. Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4268240) SETTING AND PARTICIPANTS: This initiative was conducted at a medical school in the Mid-Atlantic region, engaging medical students during an elective course, their preclinical courses, and their internal medicine clinical rotations. Participants included students completing pre- and post-evaluations following the elective course and a broader cohort assessed through a Community Strengths and Needs Assessment (CSNA). DESCRIPTION: Integrating climate change into medical school curricula is essential to equip future physicians with the skills to recognize and address climate-related health impacts. Internal medicine is deeply affected by climate change, as it exacerbates a range of chronic conditions, increases the burden of infectious diseases, and contributes to health disparities. With rising awareness of the climate crisis, there is a need to shift focus from solely demonstrating climate health impacts to inspiring action. This includes developing effective patient communication techniques, addressing healthcare sustainability, and promoting advocacy. To meet these needs, we are developing PlanetaryRx, an interactive, online, climate curriculum focusing on health impacts, sustainability, policy, and patient communication. The curriculum will be integrated into preclinical content and internal medicine clinical rotations. Early-phase development of PlanetaryRx included a one-day elective course, which provided feedback that informed the creation of three pilot modules focusing on infectious disease, cardiology, and pulmonology. Evaluative tools, including Likert-scale surveys assessing climate-related attitudes, practices, and knowledge, alongside qualitative feedback, are being used to refine the curriculum and ensure its relevance and effectiveness in both preclinical and clinical education. EVALUATION: Pre- and post-elective surveys demonstrated significant improvements in 12 out of 19 statements related to attitudes and practices surrounding climate change, such as increased belief in personal and professional agency to address climate change (mean Likert scale change: 4.00 to 4.86, p < 0.001). Knowledge assessments revealed significant growth in understanding of the effects of climate change across 6 out of 7 health domains. Qualitative feedback highlighted strong interest in sustainability and equity topics, though time constraints during patient encounters persisted as a noted communication barrier.

/ REFLECTION / LESSONS LEARNED: This project highlights the effectiveness of combining advocacy, sustainability, and communication training to enhance student agency and knowledge surrounding climate change. Healthcare’s role as a greenhouse gas emitter resonated with students, and emphasized the need to prioritize sustainability within the curriculum. Innovative strategies to address communication barriers, particularly during time-limited patient encounters, remain essential. Future iterations of the Planetary Rx curriculum will incorporate broader feedback, and aim for for scalable deployment across medical institutions. LEVERAGING THE ROLE OF VERBAL PROCEDURES TO TEACH FIRST YEAR MEDICAL STUDENTS TANGIBLE SKILLS TO RESTORE PATIENT RAPPORT AND MITIGATE BIAS Jessica Dennehy1; Ryan Wilkerson5; Richard E. Greene3,5; Renee Williams2,1; Joseph Ravenell1,4; Cristina M. Gonzalez4,1. 1Institute for Excellence in Health Equity, NYU Langone Health, New York, NY; 2Medicine, NYU Langone Health, New York, NY; 3Medicine, NYU Grossman School of Medicine, New York, NY; 4Medicine and Population Health, New York University Grossman School of Medicine, New York, NY; 5Office of Diversity Affairs, New York University Grossman School of Medicine, New York, NY. (Control ID #4273104) SETTING AND PARTICIPANTS: First year medical students at a large urban academic medical center received an in-person skills-based course. DESCRIPTION: Medical students received instruction on implicit bias recognition and management during introduction to clinical skills course. Students were asked to submit “verbal procedures” which are verbatim statements the would-be physicians would say to a patient. Students were presented with three hypothetical patient scenarios. The first scenario, patient A, was presented to the students prior to a 40-minute-long didactic session and discussion. Patient A perceives race-based bias in response to a routine clinical question regarding presentation for a miscarriage. Students electronically submitted verbal procedures via anonymous platform. Post-intervention students were presented with two additional patient scenarios, B and C, to submit verbal procedures to share how they would restore rapport with the patient once implicit bias impacted the clinical encounter. In scenario B the physician asks the patient, a Black male, who presents for an elbow injury, about their smoking history, which the patient perceives as racial bias. Patient C perceives physician bias when presenting to the physician requesting a refill on birth control. The physician makes an incorrect assumption rooted in implicit bias incorrectly assumes the patient's sexual orientation. EVALUATION: The three sets of verbal procedures were blinded and randomized for qualitative analysis. Two coders independently used inductive coding to assign codes and subsequently score the verbal procedures after reconciling codes. Scores were based on the number of codes applied, and if the codes were deemed “helpful” or “unhelpful” for restoring rapport with the patient. Scores were on an interval scale and ranged from –1 (low) to +4 (high). Post-intervention verbal procedure scores were higher than the verbal procedures that were submitted pre-intervention: Patient A mean =1.67 (n=45); Patient B mean =2.02 (n=47); Patient C mean =1.91 (n=50).

/ REFLECTION / LESSONS LEARNED: The sample size was relatively small, and the effect size was calculated using Cohens d. The intervention had an effect size 0f 0.30 when the cases were both related to perceived bias on a routine question, patients A and B. The effect size was smaller, 0.23, when the intervention was compared to patient C, where bias was made by a physician assumption. The change in effect size suggests learners may need additional education surrounding restoring rapport when the physician makes an assumption rooted in bias. We were underpowered to achieve statistical significance (80% power requires n=90 responses for comparison between patients A and B and an n=151 for patients A and C). Findings suggest skills-based verbal procedures can be one tool to teach students' skills to restore rapport and mitigate bias with patients. NIGHT MEDICINE: EQUIPPING FOURTH YEAR MEDICAL STUDENTS FOR INTERN YEAR SUCCESS Paula E. Marfia. Hospital Medicine, Loyola University Chicago Stritch School of Medicine, Chicago, IL. (Control ID #4228831) SETTING AND PARTICIPANTS: Fourth year medical students at an academic medical center who sign up voluntarily for the night medicine elective. Elective occurs in the main hospital, observation unit, medical floors, and the emergency department. DESCRIPTION: The night medicine elective is geared toward students who desire additional experience in admitting and caring for patients during the night as well as an introduction to cross coverage care in preparation for sub-internship and or intern year. During the elective, students will work directly with nocturnists who run the observation unit overnight. Clinical time will be comprised of 6 twelve-hour shifts from 7pm-7am over a two-week time block. Flexibility in hours is available if discussed prior to the start of the elective. Students will be responsible for admitting anywhere from 2-4 observation unit appropriate patients under supervision of a nocturnist. Students will also be responsible for interacting with and answering questions on patients from the observation unit nurses. Each student will also practice answering pages from the cross-coverage pager. A prepared curriculum about the principles and practice of observation medicine, answering cross coverage questions on medicine patients, and basic management of common observation unit diagnoses is covered. EVALUATION: The research employs a cross-sectional design with pre- and post-tests. Participants complete surveys before and after an elective, assessing perceptions of cross-cover care. They also undergo knowledge assessments and write reflective reports analyzed for themes like confidence and preparedness. Quantitative metrics include pre- and post-elective surveys to evaluate attitude changes and a knowledge test measuring understanding of cross-cover responsibilities, with statistical comparisons for improvement

/ REFLECTION / LESSONS LEARNED: At this stage, I am evaluating the quantitative and quantitative metrics of the cross-cover elective. Although results are pending, we are optimistic about gaining insights into its effectiveness and impact on participants' preparedness. Challenges: 1. Voluntary Participation: Recruiting enough participants has been difficult. Strategies to Enhance Participation: 2. Increased Awareness: Promote the elective through informational sessions, emails, and social media. 3. Incentives: Consider offering certificates, recognition, or academic credits to encourage enrollment. 4. Feedback from Past Participants: Share testimonials about the elective's positive impact on training. 5. Collaboration with Faculty: Work with faculty to highlight the elective's value. By implementing these strategies, the aim is to boost enrollment and gather sufficient data for a robust analysis of the elective's effectiveness. ONLINE RESOURCE URL: Night Medicine M4 Elective Syllabus.docx C. Survey & Quiz (Pre & Post).docx POCUS-FOCUSED LEARNING: INTEGRATION OF POINT OF CARE ULTRASOUND INTO PHYSICAL EXAM COURSE Georgia M. Vasilakis1; Andrew J. Klein1; Desiree Neville3; Bryce X. Bredell2; EMILY LOVALLO2. 1Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 3Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4235769) SETTING AND PARTICIPANTS: First-year medical students were invited to participate in our novel point-of-care ultrasound (POCUS) session, taught by POCUS-trained facilitators (faculty, residents, and fourth-year students), to enhance cardiovascular and abdominal physical exam learning in their required introductory physical examination course. DESCRIPTION: Early physical exam instruction can feel abstract prior to learning the relevant normal and abnormal physiology. We hypothesized POCUS would be a powerful tool to help make the physical exam easier to conceptualize at this stage. Prior to attending, students reviewed custom-made videos explaining the basics of cardiac and abdominal ultrasound as they pertain to the physical exam. During the session, student groups spent one hour with POCUS-trained facilitators obtaining cardiac and abdominal views on their peers that correlate with core physical exam maneuvers. The goal of the session was to help students visualize and conceptualize their exam, rather than develop proficiency with POCUS. Students consented and volunteered to be the POCUS subjects within each group. EVALUATION: Students were invited to complete a pretest at the start of class time and posttest and survey after class. A total of 44 (28% of all students) students completed both the pre and posttest. Scores were analyzed with a paired t-test. There was significant improvement in knowledge test scores when comparing pretest (3.14 +/- 1.2) to posttest (4.48 +/- 0.76, p <0.01). A total of 79 (51%) students completed the post-survey. 92% of students reported <4 hours of POCUS experience prior to this session, 94% of students reported the session helped improve their cardiovascular physical exam skills, and 97% of students reported that it improved their abdominal physical exam skills. More specifically, the majority of students felt the session helped with identifying S1/S2 as well as evaluating the liver, spleen and abdominal aorta. In addition, 99% of students would keep a POCUS session in the physical exam course and 94% of students felt POCUS would benefit their career.

/ REFLECTION / LESSONS LEARNED: Our study demonstrates the feasibility and potential power of integrating POCUS early in physical exam instruction for first year medical students. Students demonstrated significant improvement in knowledge after only 1 hour of instruction and overwhelmingly rated the experience positively, appreciating the benefit in both their immediate exam skills and future career. Our future aim is to assess the impact of early POCUS exposure on these students’ clinical performance during their internal medicine clerkship. Limitations include a small sample size of completed pretest and posttest completion and lack of historical control. PRACTICING CURIOSITY: AN ART MUSEUM-BASED COURSE FOR MEDICAL STUDENTS. Sam Woodworth1,2. 1Medicine, Maine Medical Center, Portland, ME; 2Tufts University School of Medicine, Boston, MA. (Control ID #4271024) SETTING AND PARTICIPANTS: The course is offered to second, third, and fourth-year medical students twice yearly. Four 90-minute sessions occur weekly or biweekly at a local art museum, which is within walking distance of the associated academic medical center. DESCRIPTION: This curriculum was designed using a multidimensional model of curiosity developed by Todd Kashdan, a psychologist at George Mason University. Kashdan has defined curiosity as a human quality consisting of five dimensions: joyous exploration, deprivation sensitivity, stress tolerance, social curiosity, and thrill-seeking. The course director selects artworks at the local art museum that speak to one or more of Kashdan’s five curiosity dimensions. Course participants are challenged to identify, focus, and practice curiosity skills. They benefit from observing peers doing the same in a safe learning environment. At the end of each discussion of a particular artwork, the course director makes direct connections to the practice of medicine, modeling for the students how enhanced curiosity skills can transfer from the art museum and into the hospital or clinic. Examples include 1) exploring the rough edges of clinical medicine through an unfinished Mary Cassatt painting 2) recreating the experience of calling a consult using Grace Hartigan’s Don Quixote and Madame Butterfly and 3) finding the person behind the pathology via a deep look at Chaïm Soutine’s Landscape. EVALUATION: Pre/post-course curiosity assessments are conducted using The Five-Dimensional Curiosity Scale, which was developed by Kashdan and colleagues.

/ REFLECTION / LESSONS LEARNED: Multiple studies have reported that the incorporation of visual art training into medical education is associated with improvements in observational skills. Additional studies have suggested that experiences with visual art can help medical students become more empathic, provide a unique context to explore the uncertainty often encountered in medicine, and even help them renew a sense of purpose in their work. These findings do not come as a surprise. Artists devote their lives to explicating different aspects of human experience, giving both joy and fresh perspectives to observers. Above all, artists and their artworks stimulate curiosity, pushing viewers to find new questions equally fulfilling as arriving at expected answers. Practicing Curiosity is an innovative and exciting pedagogical approach that encourages participants to conceptualize curiosity as a multidimensional quality as they explore problem representation in medicine, enrich their diagnostic abilities, and learn more about their patients as humans. One course participant wrote about an especially formative experience at the art museum in their application for residency. Other students have lauded how the course calls explicit attention to curiosity as a mutable human behavior, one that can readily be practiced at the art museum while they are (in parallel) learning the practice of medicine via their traditional studies. ONLINE RESOURCE URL: N/A PUBLIC HEALTH AND MEDICINE CURRICULUM (PHAM-C): A PILOT FOR FIRST YEAR MEDICAL STUDENTS Anjali S. Vora2,3; Stephanie A. Grilo1; Devshri Lala1; Melissa Pence-Moore1; Rosa Lee2; Monica Lypson2; Marina Catallozzi3. 1Columbia University Mailman School of Public Health, New York, NY; 2Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 3Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY. (Control ID #4243226) SETTING AND PARTICIPANTS: There is increasing interest in ensuring that public and population health (PHH) training occurs during the pre-clinical years of medical education. Accrediting bodies require schools to teach the medical consequences of societal issues, health care delivery, health inequities, health systems science, and skills to serve a diverse society. A Northeast urban medical school lacks a standardized, expert-based PHH curriculum for pre-clinical students. DESCRIPTION: Students and faculty from the academic medical center’s public health and medical schools developed an interactive, online, and learner-paced curriculum with 4 units: Foundations of Public Health, Methods in Public Health, Determinants of Public Health, and Trends and Actions in Public Health. The committee partnered with an emergency medicine physician and climate health expert to develop an innovative climate health module. A summer 2023 pilot included 19 students; curricular iterations were based on student feedback and then offered to all 140 incoming first year medical students and 53 volunteered for the fall 2024 pilot. EVALUATION: 2024 pilot assessment included unit-specific surveys, a summative survey, a written final reflection, discussion board posts and in-person gatherings. Feedback solicited focused on course content and modality, interactions with peers, faculty, teaching assistants (TAs), and course logistics.

/ REFLECTION / LESSONS LEARNED: Students reported that they had enough or more than enough time to complete the materials, content matched the discussion board posts, and enjoyed the opportunities to interact with their peers, faculty and TAs. Students found all learning modalities (readings, interactive modules, videos), and learning checks engaging; they expressed a desire for fewer didactic videos and more case-based learning. Highly rated topics included USPHS Tuskegee Study, mixed methods, climate health, dissemination strategies, and systems thinking. In final reflections, students considered how they plan to incorporate public health principles into their future practice. Lunch-and-Learns provided an in-person opportunity for students to dig deeply into specific public health topics and share their experiences with their peers. Following these sessions, students expressed the desire for more in-person collaboration. The 2024 pilot study supports that PHAM-C can be implemented at a larger scale with both asynchronous and in-person components. Next steps include curricular refinement based on student feedback, alignment with existing courses, expansion of interdisciplinary curricula to first year dental students. In the future, the students’ educational plans and public health scholarly work will also be tracked. PHAM-C's formal inclusion in the curriculum will incorporate the 12 principles of public health into medical education and map to accrediting bodies’ competencies. ONLINE RESOURCE URL: https://360.articulate.com/review/content/47cf6bca-3b09-4da5-8e1b-8df3b96bfb68/review REAL-TIME, BRIEF REFLECTIONS AS A TOOL TO FOSTER CHARACTER AND PROFESSIONAL IDENTITY DEVELOPMENT IN MEDICAL STUDENTS Noah Miller1; Brian C. Hilgeman1; Mary Hoeschen1; Zachary Hovis2; Rachele Harrison2. 1Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; 2School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4272735) SETTING AND PARTICIPANTS: From August–December 2023, more than 300 first-year and 80 fourth-year medical students at a Midwest academic medical center voluntarily reflected on their clinical experiences. First-year medical students partnered with a physician preceptor for 8 clinic days and were instructed to complete a reflection following each clinic. Fourth-year medical students participating in a 4-week medicine acting internship were encouraged to reflect twice per week. DESCRIPTION: Real-time, brief reflections (RTBR) 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 via cellphone or laptop. EVALUATION: Students completed a post-rotation survey designed to evaluate components of professional identity formation and self-reported character development. The survey also assessed familiarity, efficiency, ease-of-use, and contextual significance of the Qualtrics reflection interface. Reflections were qualitatively analyzed using Dr. Wald’s themes of clinical reflections (1) and Dr. Holden’s framework of Professional Identity Formation (2).

/ 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 (3, 4, 5). 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 (6). Our tool aims to eliminate these barriers and provide students a more accessible space to digest their patient encounters. M1 and M4 students agreed that RTBR were valuable (59%, N=37 and 60%, N=5) and easy-to-use (89%, N=37 and 100%, N=5). Post-survey results and deductive coding indicate that RBTR had a positive impact on Professional Identity Formation. Despite the brevity of the reflections, students wrote with a high level of emotion and cognitive processing which showed metacognition for their clinical experiences. Student usage was low in the context of a research study, but integrating these reflections into the curriculum will likely increase usage and impact. ONLINE RESOURCE URL: https://mcwisc.co1.qualtrics.com/jfe/form/SV_3QPUmnF6NtpNqtM RESIDENT-LED SMALL GROUP SESSIONS TO ENHANCE MEDICAL STUDENTS’ CLINICAL REASONING SKILLS Sara Wallam, William Fuller. Department of Medicine, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY. (Control ID #4266818) SETTING AND PARTICIPANTS: This innovation took place at an urban, academic medical center in the Mid-Atlantic region. Learners were third-year medical students during their Internal Medicine clerkship. Facilitators were second- and third-year Internal Medicine Residents. DESCRIPTION: The AAMC’s third core Entrustable Professional Activity (EPA #3) requires that all medical students be able to recommend and interpret common diagnostic and screening tests. While competency in this activity is frequently assessed as part of student performance evaluations, instruction on data interpretation is generally provided ad hoc rather than in a standardized manner, and associated clinical team assessments are frequently non-specific. To address this gap in formal instruction and targeted feedback, we created a resident-led, case-based, small group exercise in interpreting diagnostic tests and utilizing this data to inform problem representations and patient assessments. During these hour-long sessions, three to four medical students met with one resident and received real-time feedback on their ability to perform this skill. Sample cases were provided, but students were encouraged to bring their own patient cases from the wards. A workplace-based assessment (WBA) was completed for each student after the session. EVALUATION: Students completed a post-session survey to assess their confidence in interpreting diagnostic tests afterwards and to evaluate the utility and effectiveness of the session. Out of 36 learners, 30 (83.3%) completed the survey. While 93.3% of students had previously gone over diagnostic tests with residents or attendings on the wards, only 43.3% of them received feedback on their ability to perform this skill, and only 46.7% felt confident in this skill before the session. All responders (100%) felt that the session was useful, increased their understanding of the rationale for ordering common diagnostic tests, and enhanced their ability to apply clinical reasoning when interpreting diagnostic tests. Ninety-six percent of students reported that the session increased their confidence in this skill, 93.3% reported receiving useful feedback, and 96.7% found the session engaging and interactive. Twenty-seven students (90%) were interested in additional sessions on practicing other clinical skills.

/ REFLECTION / LESSONS LEARNED: A focused, resident-led exercise in interpreting diagnostic tests within clinical cases was effective in increasing students’ confidence in their ability to perform this skill. While students had reviewed results with their resident teams during the clerkship, they had not previously received structured feedback about their performance. Students appreciated the engaging and interactive nature of the session, the time dedicated towards improving this skill and applying it to their patients, and the opportunity to receive real-time feedback. TEACHING SOFT SKILLS: BINATIONAL DEVELOPMENT, IMPLEMENTATION, AND EVALUATION OF A CURRICULUM FOR GRADUATING MEXICAN MEDICAL STUDENTS ON SOCIOEMOTIONAL COMPETENCIES Brandon S. Altillo1; Yolanda Martinez Barragan2; Timothy Ruttan3; Marisol Velasco Villa2; Victor Blanco Alvarez2; Erika Barrios Gonzalez4; David Gonzalez Campillo4. 1Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; 2Benemerita Universidad Autonoma de Puebla, Puebla, Pue., Mexico; 3Pediatrics, The University of Texas at Austin Dell Medical School, Austin, TX; 4Psychology, Universidad Autonoma del Estado de Morelos, Cuernavaca, Mor., Mexico. (Control ID #4269848) SETTING AND PARTICIPANTS: 26 graduating medical students at a central Mexico medical school DESCRIPTION: Graduating physicians in Mexico must complete a social service year. Many young physicians are placed in unfamiliar, isolated rural communities to serve as the primary care provider for that community, often with little preparation or supervision. Because medical school is focused on biomedical concepts, they have limited background in communication skills, trust building, community engagement, and self-care in these new settings. The purpose of this project was to implement a curriculum that would prepare graduating students with these “soft skills”. Through an established global health consortium, a team of medical educators in central Mexico collaborated with counterparts at a medical school in the Southwest US. Socioemotional competencies are integrated into US medical education to a greater extent than in Mexico, so the US team was able to offer important insights and support, while the Mexico team contributed their wealth of knowledge on the communities of interest and the gaps in medical education that could be best addressed with this project. We also contracted with 2 academic content experts at a second Mexican university to deliver the curriculum. We based our curriculum on Bisquerra’s model of socioemotional competencies. The 3-day workshop took place after the end of their medical school coursework but prior to graduating and starting their social services year. For this pilot run, students self-selected to participate. The first day was a virtual didactic session on socioemotional skills in community engagement, while the second and third days were in-person and included communication role play and personal reflection. EVALUATION: On pre-/post-tests, analysis using Wilcoxon signed-rank test showed statistically significant increases in students’ confidence in their ability to recognize the needs of the community, identify social norms in their new contexts, adapt their professional practice to the local sociocultural context, engage in community work responsibly, establish and maintain appropriate boundaries, stay motivated to fulfill their responsibilities, maintain their personal well-being, and seek help when needed. We plan to administer the evaluation instrument again at 6 and 12 months to assess durability of these impacts through the social service year.

/ REFLECTION / LESSONS LEARNED: Though this was a small, self-selected pilot project, the evaluation results are promising in demonstrating potential effectiveness of the curriculum. If the 6-month survey shows durable impacts, we will approach the administration to make this a required experience. Ultimately, we hope that this results in higher quality, more patient-centered care for patients in rural Mexican communities, and improved experiences for social service physicians. The process of curriculum development across 2 countries and 3 institutions was a unique and valuable exercise in academic collaboration and mutual learning for the involved faculty. THE POWER OF A COLLECTIVE VOICE: LESSONS FROM THE CONSORTIUM OF ACCELERATED MEDICAL SCHOOL PATHWAY PROGRAMS (CAMPP) Alicia Gonzalez-Flores4; Lisa Strano-Paul2; Zachary Holt5; Mark C. Henderson5; Tonya Fancher3; Judith Brenner1. 1Medicine, New York University Long Island School of Medicine, Mineola, NY; 2Internal Medicine, Stony Brook Medicine, Stony Brook, NY; 3University of California Davis, Davis, CA; 4Internal Medicine, UC Davis Health, Sacramento, CA; 5Internal Medicine, University of California Davis, Davis, CA. (Control ID #4232177) SETTING AND PARTICIPANTS: Setting: The consortium of Accelerated Medical Pathway Programs (CAMPP) includes program directors from 34 medical schools. Participants: 34 Program directors, faculty, and other stakeholders involved in developing and managing accelerated 3-year MD pathways. DESCRIPTION: The purpose is to describe the goals and outcomes of the Consortium of Accelerated Medical Pathway Programs (CAMPP), which provides guidance to medical schools interested in developing accelerated 3-year MD programs. The initiative addresses critical challenges in medical education, including rising student debt, physician shortages, and the shift toward competency-based education. By shortening the time to practice, these programs aim to reduce the financial burden on students and help mitigate workforce shortages in the healthcare sector. EVALUATION: The evaluation plan for CAMPP focuses on outcomes derived from group discussions and data collection within the consortium. Key measured outcomes include the organization of annual meetings, the development and maintenance of a national database, and contributions to publications and scholarly activities. Notably, the consortium has facilitated significant growth in the number of accelerated medical programs, increasing from 8 to 34, and has produced a total of 18 publications related to its work. Nearly all CAMPP programs include Internal Medicine and most emphasize primary care.

/ REFLECTION / LESSONS LEARNED: The discussion of CAMPP highlights several strengths and limitations of the innovation. A key strength is the creation of a national database, which allows for the analysis of educational impacts and outcomes, and the sharing of best practices to guide the development of new accelerated MD programs. However, variability in program missions poses challenges for the uniform application of this guidance. In terms of feasibility and transferability, accelerated medical pathways have proven to be highly feasible, as demonstrated by the significant increase in participating programs. The consortium’s guidance has been instrumental in supporting the expansion and transferability of these pathways across a diverse range of institutions, from resource-rich universities to state-sponsored schools. ONLINE RESOURCE URL: Consortium of Accelerated Medical Pathway Programs TRAINING COLLEGE STUDENTS TO ADDRESS HEALTHCARE WORKFORCE SHORTAGES IN A U.S. TERRITORY Sonjia Kenya1; Tai Hunte-Ceasar2; BreAnne Young3; Lashonette M. Schjang2; Deborah L. Jones4; Justa E. Encarnacion2; Ana Riccio1; Olveen Carrasquillo1. 1General Medicine and Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL; 2General Medicine and Public Health Sciences, University of the Virgin Islands, St. Thomas, St Thomas, Virgin Islands (U.S.); 3psychology, University of Miami, Coral Gables, FL; 4Psychiatry, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4273058) SETTING AND PARTICIPANTS: United States territories suffer from severe health inequities and persistent health professional shortages. In 2024, the Cardiovascular Research Empowerment Workforce (CREW) program was established in an English-Speaking U.S. territory in the Caribbean to facilitate culturally-tailored research training that inspires undergraduate students to pursue healthcare careers in the Territory. In year one, 10 trainees (9 Black, 1 Latin) were selected from 22 undergraduate applicants. DESCRIPTION: A medical school in southeastern U.S. partnered with a U.S. territory department of health to establish CREW as an 8-week, summer training program for undergraduates to hone cardiovascular research skills, work within the local healthcare infrastructure, and complete a mentored, cardiovascular disease (CVD) research project. In the first two weeks, trainees completed a research boot camp at a medical school in southeastern U.S. which included instruction on: 1) health disparities; 2) social determinants of health on CVD; 3) local health system barriers linked to increased CVD risk; and 4) developing a feasible research project. After research boot camp, trainees resided in their U.S. territory homeland where they were mentored by a local health expert in completing a CVD-focused research training project. They also formulated a professional development plan outlining education and training that would lead to a local healthcare career. The experience culminated with a research symposium, where trainees presented a research poster to local leaders, including the Governor. Ongoing virtual workshops provide support for professional development and preparing competitive graduate school applications. EVALUATION: At the end of the experience, participants completed a 16 item survey. Seventy percent of participants were satisfied or very satisfied and none were dissatisfied. Open-ended items provided additional suggestions to strengthen CREW in future years. The Commissioner of Health expressed, “Programs like this are so valuable to the Territory because they keep the brightest minds engaged in applying their expertise to improving health in their homeland. By preparing them to recognize the problems, they have already started to find solutions.”

/ REFLECTION / LESSONS LEARNED: Partnerships between U.S. territories and mainland medical training institutions are a promising strategy to address persistent health workforce shortages. Optimal outcomes require mainland institutions to be attuned and responsive to the substantial cultural nuances that can impact implementation feasibility when working in a U.S. territory. Despite numerous challenges establishing CREW between two large and complex entities, participants and local healthcare leaders consistently and enthusiastically supported CREW and expressed overwhelming interest in expanding these types of training opportunities and partnerships. ONLINE RESOURCE URL: https://med.miami.edu/departments/medicine/divisions/general-internal-medicine/research/cardiovascular-research-empowerment-workforce TRANSFORMING UNDERGRADUATE MEDICAL EDUCATION DELIRIUM CURRICULUM TO IMPROVE CARE FOR PATIENTS EXPERIENCING DELIRIUM: A PRECLINICAL PRELUDE Arushi Saini1; Andrea W. Schwartz2; Brooke Lubinski3. 1Medical Education, Harvard Medical School, Boston, MA; 2VA Boston - GRECC, Harvard Medical School, Boston, MA; 3Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4273539) SETTING AND PARTICIPANTS: The workshop was conducted with second year medical students in a preclinical geriatrics curriculum at a New England medical school. Nearly 160 students participated over seven weeks. DESCRIPTION: Delirium is an underrecognized medical emergency with significant morbidity and mortality. Its prevalence ranges from 9-35% across inpatient settings, with incidences as high as 83% in intensive care units. To address gaps in preclinical education and prepare students for clinical rotations, we designed a one-hour interactive workshop to teach foundational skills for recognizing, diagnosing and preventing delirium. The session included case-based discussions, gamification, and small group exercises on delirium features, instruction on validated screening tools such as the Confusion Assessment Method (CAM) and non-pharmacological interventions for prevention and management. EVALUATION: Anonymous pre-and post-session surveys assessed learner confidence in the management of delirium. Of the 36 students selected, response rates were 72% (pre) and 53% (post). Forty-two percent of respondents reported prior exposure to delirium through clinical or personal experiences. Pre-survey results revealed gaps in understanding: 81% defined delirium as a change in mentation, but only 46% defined it as an acute process and 35% attributed it to an underlying cause. Post-session, 100% of respondents identified delirium as an acute process, and 68% equated it to brain failure. Confidence significantly increased in diagnosing delirium (12% v. 98%; p<0.001), distinguishing it from other etiologies (15% v. 68%; p<0.001), identifying precipitants (7% v. 84%; p<0.001), and enacting non-pharmacological strategies (8% v 95%; p<0.001). Uncertainty in naming effective interventions to prevent delirium resolved, with all respondents able to list at least two strategies post-session (pre-58% v. post-100%).

/ REFLECTION / LESSONS LEARNED: This curriculum equips students with the essential skills to manage delirium before their clinical rotations, where it is a frequently encountered clinical challenge. Early training in identifying delirium, diagnosing it effectively, and enacting non-pharmacological interventions has the potential to improve outcomes for vulnerable patients. Future iterations of the curriculum will include longitudinal reinforcement of these concepts and assess whether participation in the curricula enhances confidence in managing delirium during clinical rotations. UPDATING A MEDICAL INTERVIEWING CURRICULUM TO ALIGN WITH EVIDENCE-BASED PERSON-CENTERED INTERVIEW MODELS Elizabeth S. Ferzacca-Allaire1; Susan Hogan2; Christine MacGinnis3. 1General Internal Medicine, University of Massachusetts Chan Medical School TH Chan School of Medicine, Worcester, MA; 2Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA; 3medicine, University of Massachusetts Chan Medical School TH Chan School of Medicine, Worcester, MA. (Control ID #4270949) SETTING AND PARTICIPANTS: In fall of 2022, a Northeast medical school launched a comprehensive curricular redesign. One objective of the renovation was alignment of its longitudinal small-group doctor-patient communication curriculum with evidence-based models for a person-centered medical interview. After a literature review and comparison of the schools' existing curriculum with the available medical interviewing evidence-base, the syllabus was revised to focus heavily on three communication skills shown to be easily learned and associated with improved outcomes: agenda setting, open-ended questioning, and emotion-seeking[1-7]. The student pre-readings and faculty facilitation guides for the 32 class sessions, along with the grading checklists for the 5 objective structured clinical examinations (OSCEs) occurring across the MS1 and MS2 years were updated to incorporate the added skills. During academic years 2022-2023 and 2023-2024 more than 28 faculty members were trained in the revised interview model. 175 students in the class of 2026 and 200 students in the class of 2027 were taught and tested in the revised interview model. DESCRIPTION: Agenda-setting is a multi-step communication skill developed in response to evidence showing most patients have more than one concern they wish to share with their clinician[8], that the last concern mentioned is often the most important[9-10], and that frequently they never get to share their most pressing concern with their clinician[11]. Open-ended inquiry, a second evidence-based communication skill, acknowledges that eliciting the story of the patient's chief concern in narrative form is diagnostically useful, efficient, and therapeutic. Finally, emotion-seeking and response skills recognize that eliciting and responding directly to emotion during the clinical encounter is shown to improve patient satisfaction and adherence to treatment[12], improve retention of information and informational recall[13], and shorten the length of the clinical encounter[14-15]. The revised curriculum trained students in behavioral frameworks for setting a visit agenda, using open-ended inquiry to elicit the story of the chief concern, and directly eliciting and responding to emotion. The frameworks were introduced during early class sessions and practiced at all subsequent sessions. Sessions included pre-work, discussion, and interview practice with standardized patients. Students received facilitator feedback on their communication skills after all practice interviews. EVALUATION: A passing grade for all OSCEs was a 70%. All students passed the communication section of OSCEs 1-5 during the 2022-2024 academic period.

/ REFLECTION / LESSONS LEARNED: Updating a medical interviewing curriculum to align with evidence-based models for person-centered communication is feasible and may add curricular credibility. Challenges include obtaining faculty buy-in and training faculty to the model. ONLINE RESOURCE URL: https://docs.google.com/document/d/1eBnfBfr_IYyN3NHLWCnYxnAWD5Nh8kBf1cWH8xIkB88/edit?usp=sharing UTILITY OF POETRY AS A REFLECTIVE LEARNING TOOL IN RURAL COMMUNITY-BASED EDUCATION FOR MEDICAL STUDENTS Michito Sadohara, Taito Kitamura, Kunihiko Matsui. General Medicine and Primary Care, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto Prefecture, Japan. (Control ID #4269976) SETTING AND PARTICIPANTS: Medical students participated in a two-day rural logging trip as a part of a extracurricular community-based learning program This program aimed to motivate students and enhance their engagement with the community. DESCRIPTION: Although poetry has been used in art therapy, speech and language therapy, and entertainment during medical training, the role in community-based medical education remains underexplored. In the 2024 program, we implemented poetry session to encourage deeper reflection on scenes encountered during the fieldwork. We selected higo-kyoku as the poetic form - a type of haiku consisting of three-line, using colloquial local dialect and often emphasizing sire and humor. The utility and effectiveness were assessed through a questionnaire, which included items rated on five-point Likert scale items and free-text responses. The analysis focused on educational impact, feasibility, enjoyability, novel realization, deeper insights, and regional perspectives. The poems were categorized based on the of Community as Partner model’s eight subsystems to identify key themes. EVALUATION: Of 27 medical students, 32 poetries were collected. The top three scenes were safety and transformation (8 poems), health and social services (7 poems), and physical environment (6 poems). From the questionnaire, mean scores (1=Never to 5=Very much) rated by students were feasibility of 2.2 ± 0.7; enjoyability of 4.1 ± 0.8; novel realizations of 3.8 ± 1.0; deeper insight of 3.8 ± 0.9; regional perspectives of 4.1 ± 1.0. The scores of overall effectiveness on community-based medicine were rated 3.8 ± 0.8 by students and 4.1 ± 0.7 by faculty and staffs. Free-text responses highlighted the poetry’s value in enhancing reflection and understanding local culture. By condensing their thoughts in concise phrases, students organized their experiences and gained insights. Using of local dialect fostered engagement more deeply with the community (e.g., local language, culture), increasing familiarity and interest. Some student noted technical difficulty composing poetry (e.g., mastering dialect, constraints of brief poetic format). Nevertheless, they acknowledged its role in promoting mutual understanding between healthcare providers and community residents.

/ REFLECTION / LESSONS LEARNED: Incorporating a poetry session alongside fieldwork promote deeper reflection on students’ experiences and fosters engagement with rural community thought the creative process of composing poetry. Despite technical challenges in composing, the poetry encouraged students to explore perspectives beyond healthcare and connect with local culture. This approach provides valuable insights into the realities and familiarization with the local community, particularly for future healthcare professionals. With appropriate guidance, poetry session is an easy and enjoyable tool for community-based medical education. Innovation in Medical Education (IME) - DEI, Health Equity, and Social Determinants of Health ADVOCATING FOR CHANGE: IMPLEMENTING A SOCIAL JUSTICE AND ADVOCACY CURRICULUM IN THE UCSD INTERNAL MEDICINE RESIDENCY PROGRAM Natalie M. Colaneri, Sean C. Kenmore, David Timmer, Dirk Gaines, Simerjot K. Jassal, Megha Shankar. Internal Medicine, University of California San Diego, La Jolla, CA. (Control ID #4272334) SETTING AND PARTICIPANTS: The UCSD Internal Medicine residency program (UCSDIM) has developed a new, supplemental Social Justice and Advocacy Curriculum (SJAC) for interns and residents during the 2024-2025 academic year. The SJAC consists of interactive evening sessions focused on important social justice topics as well as various community engagement opportunities. DESCRIPTION: Physician advocacy and promotion of health equity are integral to improving health and well-being of communities. The Accreditation Council for Graduate Medical Education, as well as numerous professional organizations, recognize advocacy as a core physician responsibility. Advocacy curricula within medical education has been shown to increase trainees’ knowledge and engagement in social justice efforts. The SJAC involves interactive sessions to build skills in legislative advocacy, community engagement, health disparities research, and patient advocacy. Sessions include panel discussions on intersectional social justice topics including refugee health, LGBTQ+ health, environmental justice, healthcare for the homeless, and addiction. The SJAC builds on existing curricula with added breadth and depth through these sessions, community engagement, and legislative advocacy opportunities. EVALUATION: UCSDIM residents (n=17) agree that advocacy is a professional responsibility of physicians (94%) and that learning about social justice and advocacy during residency is important (100%). 27 residents have signed up for SJAC during this academic year and identified border health and LGBTQ+ health as specific topics of interest. 100% (n=7) of residents found the introductory SJAC session to be valuable and informative. Future sessions will undergo comprehensive evaluation using both quantitative and qualitative methods to continue to inform program development and measure impact.

/ REFLECTION / LESSONS LEARNED: The SJAC provides a structured, experiential health equity curriculum for trainees. Varied approaches to health equity are critical for residents to develop a diverse skill set. Strong community-academic partnerships are paramount to understanding unique needs of marginalized communities. Residents are engaged in SJAC, but scheduling and funding remain challenges. The SJAC seeks to inspire personal and professional growth for trainees and better equip them to serve their patients and communities. A SYSTEMATIC AND PRACTICAL FRAMEWORK ON GENDER AND SEXUAL DIVERSE (GSD) HEALTH FOR INTERNAL MEDICINE RESIDENTS Sebastian Suarez1; Emily L. Lupez5; Katherine L. Modzelewski2; Chad Hinkle4; Carl Streed5; Jennifer Siegel3. 1Medicine, University of Miami Miller School of Medicine, Miami, FL; 2Endocrinology, Boston Medical Center, Boston, MA; 3Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; 4Infectious Diseases, The University of Chicago Medicine, Chicago, IL; 5Medicine, Boston Medical Center, Boston, MA. (Control ID #4244859) SETTING AND PARTICIPANTS: Internal medicine (IM) residents often lack knowledge, comfort, and competency to care for gender and sexual diverse (GSD) patients, contributing to health disparities. There are few standardized curricula that target IM residents. Therefore, we developed a practical, evidence-based framework that provides residents with a systematic and stepwise approach to address GSD health needs. The curriculum was implemented for 46 IM residents at an urban hospital in New England during a mandatory educational block. DESCRIPTION: We designed objectives aligned with the AAMC competencies, focusing on practical skills that general internists need to care for GSD patients. Based on a needs assessment, the curriculum featured two 2-hour case-based, small group, interactive sessions. These sessions covered screening and treatment of sexually transmitted illnesses (STIs), pre-exposure prophylaxis (PrEP) prescription, and gender affirming hormone therapy (GAHT) initiation for a transgender woman, dedicating over 50% of the time to active learning activities. Residents received “one-pager” handouts with step-by-step instructions on how to approach GSD health. EVALUATION: Pre- and post-session surveys evaluated knowledge, attitudes towards the importance of GSD care, and perceptions of confidence in performing specific skills related to GSD care. Wilcoxon signed rank tests compared pre- and post-session answers. Responses to open-ended questions were analyzed using content and theme analysis.

/ REFLECTION / LESSONS LEARNED: There was an increase in perceived confidence in providing sexual healthcare, prescribing PrEP, and initiating GAHT (p<0.001), as well as recognizing the importance of comprehensive sexual histories, discussing gender identity, assessing gender dysphoria, and offering GAHT for GSD patients (p<0.001). The median score for knowledge-based questions rose from one to four out of five (p<0.001). Before the curriculum, most IM residents felt uncomfortable discussing GSD health, often favoring conversations with cisgender, heterosexual patients, potentially limiting care and reinforcing disparities. All residents agreed the sessions improved communication with GSD patients, and 97.5% agreed they enhanced their ability to prescribe GAHT. This reflects the curriculum’s practical focus on communication and medical management. Residents reported using the framework and handout in clinics for PrEP and GAHT, demonstrating its immediate utility and durability. However, long-term impacts and behavioral changes were not measured. Our curriculum is one of the first to develop a systematic and practical framework to address GSD health using evidence-based, practical skills tailored for busy IM residents, some of whom will be PCPs. In conclusion, this systematic framework increased IM residents’ perception of importance and competency, and knowledge in STI screening and treatment, PrEP prescription, and GAHT initiation, offering a practical and evidence-based tool with immediately useable materials to enhance GSD healthcare. BRIDGING THE GAPS: UNVEILING NEEDS FOR A TRANSFORMATIVE HEALTH EQUITY CURRICULUM Tamara F. Godfrey. Internal Medicine, University of North Carolina System, Chapel Hill, NC. (Control ID #4215966) SETTING AND PARTICIPANTS: The link to an anonymous survey, using Qualtrics software, was provided via email to residents in the Internal Medicine and Internal Medicine-Pediatrics residency programs at an academic medical center in June 2024. There were 34 respondents, representing a 29% response rate. There was near equal representation of PGY-1, PGY-2, and PGY-3 residents. DESCRIPTION: A needs assessment survey with 15 questions was administered to evaluate residents' interest in learning about health equity, current knowledge about health equity-related topics, satisfaction with the residency programs' current education on health inequities, and comfort level with discussing racism and health inequities with different groups (co-trainees, patients, and leadership). Two questions provided space for respondents to share what topics they were interested in learning about and suggestions for methods of effective curriculum delivery. EVALUATION: All respondents had some (26%) or strong interest (74%) in understanding how to promote health equity. Most respondents rated their current level of knowledge on health inequities and different factors that influence the health of underserved populations as moderate (68%), while the remainder rated themselves as slightly knowledgeable (18%) or very knowledgeable (15%). Most perceived their co-residents to be at least moderately knowledgeable about these issues (56%) however 32% perceived their co-residents to be only slightly knowledgeable. Most respondents rated the quality of the Internal Medicine residency program's education on health inequities as fair (47%) or good (38%). 53% somewhat agreed that they were confident in their ability to effectively care for the medically underserved, while 32% neither agreed nor disagreed. While 79% either somewhat or strongly agreed that they felt comfortable discussing racism and inequities with other trainees, only 62% somewhat or strongly agreed that they were comfortable discussing this with patients or families.

/ REFLECTION / LESSONS LEARNED: Internal Medicine and Medicine-Pediatrics residents take care of patients of varying backgrounds, socioeconomic status, and experiences therefore need to be well-versed in health care inequities, how it affects their patients, and solutions focused on improving outcomes. Results from this survey confirmed that there is a strong interest in learning about these issues, and that the knowledge of these topics and comfort level discussing these topics can be improved. We are incorporating the feedback from this survey in the design and content of the new Internal Medicine longitudinal curriculum. Since July 2024 there has been one monthly noon conference dedicated to this curriculum. Topics have included: an introduction to health equity and racism in medicine, microaggressions, health literacy, disparities in opioid use disorder treatment, kidney health disparities, and primary care of the LGBTQ patient. We have also added health equity pearls to the weekly ambulatory pre-clinic conference curriculum. BUILDING A LONGITUDINAL PATHWAYS PROGRAM TO PROMOTE DIVERSITY IN MEDICINE Kyla Dewar2; Luckson Omoaregba1; Joseph Diaz1. 1The Warren Alpert Medical School of Brown University, Providence, RI; 2Division of General Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, RI. (Control ID #4269856) SETTING AND PARTICIPANTS: Undergraduates students from underrepresented backgrounds and medically underserved areas participating in a medical schools pathways program. DESCRIPTION: Early exposure to healthcare careers promotes early interest in healthcare careers and has the potential to improve diversity in the healthcare workforce. Our institution has developed a continuum of pathways programs from middle school through college. The “Road to Medicine” program provides undergraduate pre-health students from medically underserved areas, or with demonstrated commitment to serving those communities, exposure to medical school curriculum and clinical shadowing opportunities. The program includes a 3-week summer experience where participants are exposed to the medical school first year curriculum and are introduced to clinical reasoning through case based learning and standardized patients. After the initial summer program, participants are matched with hospital based faculty for clinical shadowing experiences. The program then provides ongoing mentorship/advising as well as MCAT preparation resources for participants. EVALUATION: Utilizing the Social Cognitive Career Theory framework, we conducted post-program evaluations and qualitative interviews to assess program impact on student self-efficacy. Here we present a summary of the qualitative analysis. In written comments participants (n=21) noted increased confidence in applying to medical school and in becoming a healthcare professional. This is attributed to several factors including guidance and support, practical advice, and dispelling misconceptions. Interview data highlighted the value of clinical shadowing in dispelling misconceptions and fostering a sense of belonging within the medical community. Participants emphasized the importance of ongoing mentorship in providing support, guidance, and a strong sense of community.

/ REFLECTION / LESSONS LEARNED: Pathways programs play an important role in diversifying the physician workforce. This shadowing and longitudinal mentorship program demonstrated a positive impact on participants’ confidence, motivation, and sense of belonging in the medical field. “[This Program] finally made me feel like this is where I belong and like I can actually do it.” Road to Medicine serves as a model for others seeking to implement effective and impactful diversity initiatives in medical education. By providing a comprehensive and supportive pathway, we can cultivate a more diverse and inclusive physician workforce that better reflects the communities it serves. DEVELOPMENT AND CONTENT VALIDATION OF A STRUCTURAL COMPETENCY ASSESSMENT INSTRUMENT Iman Hassan1; Rebecca Leeds2; Sharon Connor10; Shwetha Iyer3; Sarah S. Mills4; Joe Grochowalski5; Gareth Gingell6; Ijeoma N. Opara7; Hetty Cunningham9; Thuy Bui8. 1Internal Medicine, Montefiore Health System, Bronx, NY; 2Center for Family and Community Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 3Internal Medicine, Montefiore Medical Center, Bronx, NY; 4Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX; 5Psychology, New York University, New York, NY; 6Medical Education, The University of Texas at Austin Dell Medical School, Austin, TX; 7Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 8Medicine, University of Pittsburgh, Pittsburgh, PA; 9Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 10Pharmacology and Therapeutics, UPMC, Pittsburgh, PA. (Control ID #4272287) SETTING AND PARTICIPANTS: A national working group of health equity medical educators developed a five-domain Structural Competency Assessment Instrument (SCAI), a behavioral assessment rubric for evaluating trainees’ structural analyses of clinical cases. Using Delphi methodology, we solicited feedback on SCAI from nine content experts nationally to refine the rubric and establish content validity. We piloted SCAI with 20 graduate medical education learners across multiple institutions. DESCRIPTION: Structural competency, or the ability to recognize and respond to social, economic and political factors in patient and community health, is now a mandated accreditation requirement for medical student training. However, there is a lack of validated assessment tools for measuring structural competency among medical trainees. To address this gap, we developed and evaluated the content validity of a structural competency assessment instrument. SCAI measures behaviors across four proficiency levels ranging from “pre-recognition” to “applying” in five domains: (1) Recognizing structures that shape clinical interactions, (2) Developing an extra-clinical language of structure, (3) Re-articulating “cultural” presentations in structural terms, (4) Observing and imaging structural intervention, and (5) Developing structural humility. EVALUATION: Nine national experts participated in two rounds of a Delphi survey. Experts made suggestions to improve the clarity, consistency, and specificity of behavioral items. All experts agreed that the revised SCAI was a useful tool for assessing levels of structural competency in medical trainees, and that the most relevant and important domains of structural competency were measured. Eight out of nine experts agreed that the competency levels (Pre-Recognition, Recognition, Understanding, Applying) were clear, and the revised SCAI was clear and accessible for both medical trainees and educators. Initial pilot of SCAI with graduate medical trainees revealed several considerations for applying this rubric. These included the learning contexts that are optimal for applying SCAI, strategies for its application in time-limited settings, and the need for faculty development.

/ REFLECTION / LESSONS LEARNED: We developed a behavioral assessment tool for structural competency in medical trainees. SCAI exhibited content validity for structural competency assessment among national experts surveyed. Our work demonstrates that structural competency, despite its complexity, is a measurable and demonstrable skill for which validated assessment tools can be developed. Next steps will involve continued piloting of SCAI to assess reliability and construct validity in medical trainees. HEALTH EQUITY TRAINING: DEVELOPMENT OF A LONGITUDINAL CURRICULUM FOR INTERNAL MEDICINE RESIDENTS Adam Panzer1; Kathryn Buckman1; Riley Irish2; Elizabeth J. Westling1. 1Internal Medicine Residency Program, Washington State University, Everett, WA; 2Office of Community, Health Equity, and Belonging, Washington State University Elson S Floyd College of Medicine, Spokane, WA. (Control ID #4231779) SETTING AND PARTICIPANTS: This program includes didactics, clinical experiences, and hands-on projects across all three training years of a community internal medicine residency program in the Northwest Region. DESCRIPTION: A formal needs assessment showed that residents felt comfortable identifying health inequities affecting their patients, but wanted practical skills for addressing them. In response, we designed a pilot curriculum with the goal of empowering residents to include health equity in their roles as physicians. Through discussion-based, reflection, and experiential sessions, PGY-1 and PGY-2 residents learn structural competency and analyze the effects of structural oppression on their patients. Residents review strategies for advancing change at interpersonal, institutional, and societal levels (e.g., patient-centered communication, equity-focused QI, and community organizing) and practice these skills in clinic and community outreach. For practical experience applying the skills learned in the prior two years, PGY3s receive protected time to engage in resident-driven capstone projects on a topic/population of their choosing (e.g., housing instability). EVALUATION: We will conduct pre- and post-surveys to assess attitudes towards health equity in medicine and medical education. Participants will rate their comfort with various health equity topics and skills on a scale from 1 to 5 as well as their intention and perceived preparedness to promote equity in their future careers. Secondary outcomes will include the long-term benefits, or lack thereof, of capstone projects for our community partners. Throughout the curriculum, we will also assess the effectiveness of individual modules and the extent to which residents feel they contribute to their understanding of equity skills.

/ REFLECTION / LESSONS LEARNED: Residents believe that it is part of the role of a physician to be aware of health inequity and to address them in their work. However, awareness without the ability to affect change promotes despair rather than empowerment. Similarly, merely discussing analytical frameworks or skills for advancing change is perceived as too abstract without guided opportunities for practical application. Our curriculum strives to provide this while also recognizing challenges inherent to the context of IM residency, including maintaining relevance to a spectrum of subspecialties and practice settings, limited extra-clinical time and healthful work-life balance. As a result, the curriculum is delivered within protected educational time and provides ample opportunity for residents to drive the focus and form of the advocacy in which they engage. More data is needed to assess whether this curriculum meets its long-term goals of increasing graduated physician engagement in promoting health equity at interpersonal, institutional, or community levels. HONORING THE PAST, INSPIRING THE FUTURE: UNC'S EARLIEST BLACK MEDICAL STUDENTS AND THE FIGHT FOR HEALTH EQUITY Portia Nleya1; Brian Wood1; Alexandria Card2. 1Internal Medicine, UNC Health, Chapel Hill, NC; 2UNC Children's Hospital, Chapel Hill, NC. (Control ID #4272500) SETTING AND PARTICIPANTS: This panel discussion will be held in one of UNC Internal Medicine's lecture halls during the noon conference hours. The session will be optional, but residents from Internal Medicine, Pediatrics, and Medicine-Pediatrics will be invited, along with medical students from the Student National Medical Association (SNMA) and Latino Medical Student Association (LMSA). The session will be tailored to engage both early-career and seasoned trainees in discussions about race, history, and medical education. DESCRIPTION: The EMBRACE (Ending Medical Bias and Racism by Advocating for Change and Equity) series, launched in 2020 by the UNC Internal Medicine (IM) and Pediatrics (Peds) departments, has been a key initiative aimed at addressing health disparities in medicine. Traditionally, the series featured didactic lectures on critical diversity, equity, and inclusion (DEI) issues in healthcare. However, in response to feedback from trainees, we shifted to a more interactive format. This new approach includes a panel discussion with physicians from diverse backgrounds, particularly those representing the earliest Black medical students at UNC. These individuals share personal stories of the challenges and successes they faced, offering historical context for racial barriers to integration and the ongoing fight for equity in medicine. A central component of this effort is the Black Alumni Experience Project, led by UNC’s Student National Medical Association (SNMA), which has gathered powerful first-person accounts of Black alumni navigating racial integration. These stories form the foundation of the panel, allowing attendees to gain a deeper understanding of how history, racial identity, and health equity intersect. EVALUATION: To assess the impact of this innovation, we will administer a pre-session survey to gauge participants' baseline understanding of the history of racial integration in medical schools and their perceptions of systemic racism within the healthcare system. A post-session survey will be distributed to measure changes in understanding, engagement with the historical context of Black medical students' experiences, and the impact of these lessons on participants’ commitment to dismantling systemic racism. This feedback will inform future iterations of the EMBRACE series and provide valuable data for evaluating the effectiveness of this educational approach.

/ REFLECTION / LESSONS LEARNED: This project represents a significant shift from traditional lecture-based DEI education toward a more dynamic and personal form of learning. By integrating the lived experiences of Black medical students, we create a deeper connection between history and current efforts to combat racism. Early feedback from participants indicates that the interactive, story-driven approach fosters a greater sense of empathy and understanding. Future iterations will build on this feedback to enhance the format and ensure continued engagement with these critical issues. IMPLEMENTING AN ACCESSIBILITY ACTIVITY TO IMPROVE EDUCATION ON ABLEISM FOR INTERNAL MEDICINE RESIDENTS Kunali Gurditta1; Mahala Schlagman2; Any Blatt2; Adriana Verwey3; Abigail K. Kroening4. 1Internal Medicine-Pediatrics, University of Rochester Medical Center, Rochester, NY; 2Internal Medicine, University of Rochester Medical Center, Rochester, NY; 3Pediatrics, University of Rochester, Rochester, NY; 4Pediatrics, University of Rochester Medical Center, Rochester, NY. (Control ID #4238414) SETTING AND PARTICIPANTS: This activity was a part of the ambulatory health equity curriculum for first-year Internal Medicine residents (n = 27) at an Academic Medical Center during the 2024-2025 academic year. DESCRIPTION: Pre-survey was completed prior to first-year residents’ lecture on social determinants of health equity within their community during orientation. During their first ambulatory block rotation (1 to 7 weeks after orientation), first-year residents went to the library in groups of 3 or 4 with one of the authors as a guide. Residents used a worksheet to independently assess how the library space addressed physical, hearing, vision, neuro-divergence (autism), and communication differences (non-verbal, assistive technology). They took photographs and/or notes to reflect on during a debrief session within the next week. The one-hour debrief sessions were facilitated by one or more of the authors during ambulatory education half-days in groups with 7 to 8 residents. Post-survey was completed immediately following the debrief session. EVALUATION: First-year residents (n = 27, 100% response rate) completed a pre- and post-survey regarding their understanding of the Americans with Disabilities Act, how often they think about accessibility, their awareness of accommodations in various categories, and their confidence in identifying and advocating for accommodations for their patients. Two-tailed t-tests revealed a statistically significant increase in the number of residents who felt they had a strong understanding of the ADA (p = 0.017); awareness of physical (p = 0.021), sensory (p < 0.001), and neurodivergence (p < 0.001) accommodations; and confidence advocating for accommodations (p = 0.0058). Residents self-reported during the debrief session that experiential learning at the library positively impacted their resource awareness regarding disability access. Additionally, residents’ suggestions for improving accessibility at the community library were shared with library leadership, at their request.

/ REFLECTION / LESSONS LEARNED: The first iteration of this accessibility activity revealed that it is an effective and efficient way to improve first year residents’ awareness of and confidence in advocating for accessibility resources for patients within their community, ultimately creating a culture of inclusivity. Future directions may also include ongoing assessments regarding whether these attitudes are durable throughout residency training. Current evaluation focused on knowledge and attitudes; future iterations may consider measuring integration of skills into clinical practice. IMPLEMENTING ANTIRACIST PEDAGOGY IN MEDICAL EDUCATION: CREATING CURRICULUM ACCOUNTABILITY GROUPS FOR TEACHING FACULTY Manasa S. Ayyala2; Michelle DallaPiazza1; Tatiana D. Berrios-Chango2; Maria Soto-Greene2. 1Howard Brown Health Center, Chicago, IL; 2Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4273099) SETTING AND PARTICIPANTS: Teaching faculty at a medical school in the northeast DESCRIPTION: Faculty development lags undergraduate medical education in content around anti-racism in medical education. Awareness and ability to implement key principles of anti-racist medical education pedagogy and apply these principles to develop and modify existing curricula across the learning continuum is paramount to achieving anti-racism in medical education. We created a faculty development workshop for teaching faculty starting with an interactive didactic component using evidence-informed strategies for anti-racist medical education with sharing of existing curriculum & barriers for incorporating these principles. Then, we piloted a ‘curriculum accountability group’ (CAG) modeled after the well-known writing accountability group (WAG) model. Interested teaching faculty then participated in a longitudinal CAG with the goal to further develop and implement anti-racist med ed curricula into their curriculum. Each CAG started with 10-15 minutes of intention-setting, followed by 30-45 minutes of real-time work, and ended with 15-20 minutes of sharing, brainstorming, and setting next intentions using the WAG model. EVALUATION: Pre- and post-survey data were collected from 14 workshop participants focused on feasibility, acceptability, and satisfaction with the didactic and CAG portions of the session. Most (86%) were satisfied with the overall content of the session and 79% with the CAG portion of the session. All (100%) shared they would either implement a change or seek additional information on the topic and 93% shared they would be likely to attend another CAG in the future. Action items shared post-session included “implement new program for students and residents” and “working to support a dedicated session on this topic in the clerkship.” Five teaching faculty joined the AY 2023-2024 CAG focused on hands-on, practical discussions resulting in real-time changes.

/ REFLECTION / LESSONS LEARNED: The CAG model for curriculum development for anti-racist medical education pedagogy was feasible and acceptable to participants in our pilot cohort and may serve as a novel model for other institutions. Institutional support from educational leaders is instrumental to development and continued implementation of this type of faculty development. PREVALENCE, SOURCE, AND REPORTING OF MICROAGGRESSIONS DURING THE CLERKSHIP YEAR Anima Shrestha1; Rachael Tan2; Shanta M. Zimmer3; Tai Lockspeiser4; Heather Cassidy1. 1School of Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 2Office of Medical Education, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 3Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO; 4Pediatrics, University of Colorado, Denver, CO. (Control ID #4270913) SETTING AND PARTICIPANTS: Clerkship students at an academic medical center in the Northwest region. DESCRIPTION: Microaggressions are brief, subtle exchanges, verbal or nonverbal, intentional or unintentional, that communicate hostile or derogatory messages toward an individual based on an aspect of their identity. The frequency and impact of microaggressions on medical students have been explored, but the sources of microaggressions are less understood. Microaggressions from patients may be especially damaging to students. Our study aims to understand the prevalence and source of microaggressions in the clerkship year at a single institution, and to explore students’ reporting behaviors. Questions about microaggressions were integrated into a required End of Phase (EOP) survey distributed to students at the end of the clerkship year. The EOP survey is designed to gather feedback about the curriculum and medical school. All questions are optional, and reporting is anonymous. The survey queried the frequency of microaggressions, targeted aspect of identity, source, reporting, and mitigation strategies. EVALUATION: All clerkship students received the survey, and 172 students responded (94% response rate). Of these students, 71 (41.3%) reported experiencing microaggressions during their clerkship year, with incidents characterized as happening once (14.3%), occasionally (74.3%), or frequently (11.4%). Among students who experienced microaggressions, 80.3% reported experiencing them from patients, 46.5% from faculty, and 36.6% from staff. From all sources, the top three identity aspects targeted were gender (62.2%), race or ethnicity (47.3%), and age (32.3%). Most students (90.1%) did not report these incidents to school administration; common reasons were perceived unimportance (84.4%), the student resolved the issue independently (28.1%), the student did not think anything would be done in response (25%), and fear of reprisal (15.6%). Students suggested anonymous reporting methods (49.3%), small group debrief sessions (19.7%), and bystander training (11.3%) as methods to increase support for students experiencing microaggressions.

/ REFLECTION / LESSONS LEARNED: Microaggressions are a common experience for students during their clerkship year. In our study, a majority of microaggressions experienced by students came from patients. Most students chose not to report, with the most common reason being the perceived insignificance of the incident. However, microaggressions can cause long-lasting harm, and mitigation strategies should be explored. Recognizing that the preponderance of microaggressions are committed by patients can guide intervention and mitigation strategies at medical schools. Limitations of this study include administration of the survey by school leadership, which may impact student responsiveness. STANFORD HOMELESSNESS OUTREACH INITIATIVE: A STUDENT-LED MEDICAL EDUCATION PROJECT Michael D. Mayer1; Meg Quint1; David Chang2,1. 1Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA; 2Medicine, Stanford University School of Medicine, Stanford, CA. (Control ID #4271030) SETTING AND PARTICIPANTS: This initiative was developed by two second-year Stanford medical students through a funded community health fellowship. Both students brought relevant experience in community health research and experience with homelessness services. To ensure our work added value to the community, we partnered with organizations embedded in homelessness services, including the Santa Clara and San Mateo Departments of Public Health, a local food pantry, a community case management provider, and a major homelessness healthcare provider. We integrated three existing Stanford outreach programs—Stanford Flu Crew (outreach-based vaccination events), Cardinal Free Clinics (free care for uninsured patients), and the Stanford Housing Equity Project (student group focused on case management)—to create a cohesive outreach model for people experiencing homelessness (PEH). DESCRIPTION: We created pop-up "clinics" in collaboration with community partners. Clinics were held twice weekly, lasting approximately three hours, at locations such as food pantry parking lots, shelters, and RV encampments. Services included: flu vaccinations, blood pressure screenings, resource distribution (drug use harm reduction kits, safer sex kits, toiletry kits), and voter registration. Future areas include blood sugar checks and basic wound care. Events were supervised by medical school faculty. Volunteers included Stanford undergraduates, PA students, and MD students, who gained hands-on experience engaging with PEH. EVALUATION: Quantitatively, we track services provided and collect demographic data to monitor population trends (e.g., drug use patterns and geographic distribution). Qualitatively, we aim to formalize feedback mechanisms through surveys of student volunteers, community partners, and unhoused clients. Preliminary informal feedback has been overwhelmingly positive: community partners are eager for program expansion, and students express strong enthusiasm for continued participation. Organizations note continued need for additional services. Faculty and stakeholders have also praised the program's alignment with academic and community needs.

/ REFLECTION / LESSONS LEARNED: By prioritizing community partnerships and integrating existing school programs, we built a med-ed program that creates opportunities for service-learning and cohesion with community partners. Our project recently secured an additional $15,000 in grant funding, ensuring its continuation next year. Key lessons include: 1) The importance of collaboration with community experts to design effective, non-redundant services 2) The value of integrating existing programs to maximize impact and sustainability 3) The ability of service-learning projects to stimulate student interest, allowing participants to apply classroom knowledge in real-world settings This initiative represents a critical step toward addressing homelessness within the Bay Area while enriching medical education. With continued collaboration, we aim to become a long-standing component of Stanford's medical curriculum. THE AMAZING RACE AROUND THE CITY YOU SERVE: A CULTURAL HUMILITY AND TEAMWORK SKILLS ACTIVITY Danielle V. Lefebvre, Ashley Yoo, Tebianne Abubaker, Ashley Wong, Lisa Horvath, Chavon Onumah. Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC. (Control ID #4271708) SETTING AND PARTICIPANTS: PGY1 residents in an academic medical center in Mid-atlantic DESCRIPTION: To achieve health equity and help residents achieve ACGME competencies in collaborative communication skills, patient-centered care, and responsiveness to patient needs and social determinants of health (SDOH), graduate medical education (GME) programs must design curricula to prepare trainees to deliver equitable care to diverse populations in complex health systems. The “Amazing Race Around the City You Serve” is a team-based scavenger hunt to promote reflection, team-work, and cultural humility among early year interns. Pre-race, interns identify their B.A.N.K. code. The B.A.N.K. coding system, a tool originally designed to quickly identify personal values to enhance communication and accelerate negotiations, helps people self-categorize into personality categories of Blueprint (B), Action (A), Nurturing (N), or Knowledge (K) based on overarching values. Randomly assigned teams are given “clues” of various sites of historical, environmental, and/or cultural significance across the city. Each team must take a photo or video at the site described in the clue. The first team to successfully visit all sites wins. Post-race, interns responded anonymously to questions: 1) What did you observe about yourself? 2) What is something you might consider as you work with others? and 3) What is something you might consider while delivering patient care in this city? Following the self-reflection, the larger group debriefs. EVALUATION: 114 interns have participated in the activity to date. The composition of interns that self-identified with Nurturing (48%), Blueprint (20%), Action (16%), and Knowledge (15%) pre-race is similar in composition to reflections about what interns learned about themselves post-race. However, when reflecting on working with others and when delivering care to patients, 80% and 69% of responses, respectively, aligned with nurturing qualities. Themes that emerged from intern responses include appreciation of the natural and cultural diversity of the area, communities, and teams; Socioeconomic/SDOH awareness and responsiveness; community and inclusivity; leadership, teamwork and relationship building behaviors. Participant feedback included appreciating the opportunity to explore the city, learn new things, and connect with co-interns; issues with distance between sites, commuting, and weather.

/ REFLECTION / LESSONS LEARNED: More literature about curricula at the intersection of teamwork, health equity, and DEI is needed. Experiential learning has been proposed as one way to improve health equity related education. The emerging themes indicate that this experiential learning activity at the intersection of teamwork, healthy equity, and DEI may be an effective way to build cultural humility and teamwork skills in residents. A back-up plan for inclement weather is advised. Next steps include additional followup with prior participants to see if/how the activity influenced team interactions and clinical encounters. THE LOCAL GLOBAL HEALTH ELECTIVE: SUPPORTING GLOBAL HEALTH LEARNING BY ENGAGING COMMUNITIES AT HOME Tracy Rabin, Sheela Shenoi. Internal Medicine, Yale University School of Medicine, New Haven, CT. (Control ID #4272532) SETTING AND PARTICIPANTS: Global health clinical rotations (GHCR) provide vital opportunities for immersive, experiential learning outside of trainees’ standard learning environment. Due to Covid-19-related travel restrictions early in the pandemic, innovative approaches were required to facilitate learning for internal medicine residents who had planned GHCR. To meet these needs at an urban New England academic center, a one-month ‘local global health elective’ (LGHE) was developed, facilitating engagement with community partners in front-line, comprehensive care for marginalized populations in the city. Over 4 years, 12 residents undertook LGHEs in place of GHCR; five of these rotations occurred after international COVID-19 travel restrictions had ended. DESCRIPTION: In 2015, the Consortium of Universities for Global Health, published 11 interprofessional global health education competencies (GHEC) domains to guide the development of global health programs, including Global Burden of Disease; Globalization of Health and Health Care; Social and Environmental Determinants of Health; Capacity Strengthening; Collaboration, Partnering, and Communication; Ethics; Professional Practice; Health Equity and Social Justice; Program Management; Sociocultural and Political Awareness; and Strategic Analysis. Each LGHE, tailored to individual resident interests, met these domains through outpatient, street medicine, and mobile clinic experiences; engagement with social service agencies; online instruction via specialty topic lectures and a self-paced clinical tropical medicine and global health curriculum; and reflection sessions with global health faculty. EVALUATION: We conducted thematic analyses of resident debriefs, presentations to peers, written reflections, and feedback from community partners. Residents identified five benefits linked to the GHEC which addressed gaps in their clinical education: 1) enhanced knowledge of community support services; 2) deeper understanding of marginalized patient population needs; 3) understanding the role of contextual immersion in broadening their concept of ‘doctoring’; 4) increased comprehension of social determinants’ impact on health access and outcomes; and 5) enhanced appreciation of diversity (e.g. gender, race, socioeconomic status) as socially constructive. Community partners identified that LGHE residents, as a real-time clinical resource, enhanced service delivery to their clients.

/ REFLECTION / LESSONS LEARNED: LGHE are an acceptable means to explore GHEC, and provide benefit to both trainees and community partners. Trainees gained appreciation of community contexts, assets, and structural disparities, and changed their perceptions about patients' view of the health care system and how trainees view their own roles. Although COVID-19-related limitations were the impetus, broader implementation of LGHEs can support global health learning and career development, while addressing gaps in postgraduate clinical training that are relevant both locally and outside of one's home community. USING LITERATURE TO BUILD EMPATHY: A READING ASSIGNMENT AND DISCUSSION TO IMPROVE INTERNS' UNDERSTANDING OF THE HAITIAN IMMIGRANT EXPERIENCE Erin N. Marcus1; Mashli Fleurestil3; Shana Zucker2; Jennifer Denike2; Shanice S. Spence3; Manuela Araque3; Stefanie R. Brown4. 1General Internal Medicine, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL; 2Internal Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, PA; 3Jackson Memorial Hospital, Miami, FL; 4Departments of Internal Medicine and Pediatrics, University of Miami Miller SOM, Miami, FL. (Control ID #4243348) SETTING AND PARTICIPANTS: Miami-Dade County, Florida, is home to the largest Haitian immigrant community in the U.S. Many of these patients seek care at the University of Miami/Jackson Memorial Hospital (UM/JMH), the county's safety net. Haitian immigrants have been the subject of negative stereotyping; many health providers are unaware of Haitian history and culture and of the barriers Haitian patients face obtaining health care and achieving personal and economic stability in the U.S. This educational intervention occurred on the first day of orientation for UM/JMH internal medicine residents. Sixty first year residents participated. DESCRIPTION: After the Match, the residency program instructed all incoming interns to read the memoir Brother, I’m Dying, by author Edwidge Danticat. The book recounts her childhood in Haiti, her immigration to New York, and her relatives’ interactions with the healthcare system. She details the death of her uncle at UM/JMH, shackled to a hospital bed and in the custody of the U.S. Immigration and Naturalization Service (INS). On the first day of orientation, a faculty member spoke about the demographics of Miami’s Haitian population. A resident raised in the local Haitian community spoke about ways in which Danticat’s experiences resonated with her own. Residents and faculty led guided small group discussions. The discussion guide included prompts encouraging participants to discuss their thoughts on the book and what they had learned about immigration. The activity was conducted in June 2024. It built on a previous activity in which author Danticat spoke to the incoming interns with no guided breakout and no demographic talk. EVALUATION: 38/60 participants (63%) completed an anonymous postsession online survey. 16 (42%) of respondents indicated they were “not at all” familiar with the Haitian community prior to the activity; 20 (53%) were "slightly" familiar. A majority (71%, n=27) indicated the activity had improved their understanding of the Haitian community “a great deal”; a quarter (26%, n=10) indicated the activity had improved their understanding “moderately.” Two-thirds (n=25) indicated the activity had significantly improved their understanding of immigration issues patients face; 29% (n=11) indicated it had improved their understanding moderately. All respondents (n=38) indicated that the activity should be repeated in future years. Free text comments on the activity were overwhelmingly positive; respondents wrote that they would “exercise more empathy” and “consider the breadth of experiences patients have had.”

/ REFLECTION / LESSONS LEARNED: Literature and the humanities have been used to foster empathy. This activity was well-received. Residency programs serving immigrant populations and/or patients from marginalized groups may want to consider instituting a similar activity that asks incoming interns to read a memoir or book—particularly related to the residency milieu—prior to arrival, along with organized discussions at orientation to build empathy and dispel negative stereotyping. Innovation in Medical Education (IME) - Geriatrics and Palliative Care AMBULATORY PALLIATIVE CARE FOR THE INTERNAL MEDICINE RESIDENT: A PILOT CURRICULUM Prasanti Ravipati1; Mary K. Buss2,3; Laura K. Snydman1. 1Internal Medicine, Tufts Medical Center, Boston, MA; 2Palliative Care, UConn Health, Farmington, CT; 3Division of Palliative Care, Tufts Medical Center, Boston, MA. (Control ID #4230504) SETTING AND PARTICIPANTS: Interns at an academic center in New England participated in 2 one-hour protected educational conferences. 20 interns completed the 1st session which occurred in a classroom. Two facilitators, a palliative care (PC) attending and a senior Internal Medicine (IM) resident, led a large group didactic followed by breakout groups of 4-5 interns. The 2nd session occurred 1 month later in a simulation center with 20 interns. After a brief large group didactic, learners split into groups of 5- each with a PC facilitator (MD or RN/SW). DESCRIPTION: We designed 2 conferences to enhance interns’ understanding of PC in ambulatory management of chronic illness and apply Ask Tell Ask (ATA) as a primary PC communication skill. We wrote 4 cases (renal, pulmonary, geriatric, cardiac) of patients with chronic diseases. During the 1st session, the PC facilitator delivered content and led a large group discussion re-framing PC. Then in small groups, interns debated the appropriateness of PC in the cases. The 2nd session began with a brief review of the 1st session and introduction of ATA by a PC attending. We expanded upon cases from the 1st session, creating provider and patient scripts. Each intern role-played a provider discussing their case with a patient and their family (the remaining interns in the group) using ATA. Facilitators were instructed to provide real time feedback and debrief with learners. EVALUATION: Anonymous surveys (control, pre, and post curriculum) were used to evaluate interns’ PC knowledge and skills. During AY 2022-2023, 20/27 interns completed a survey at the end of the year, serving as a control group. The interns in AY 2023-2024 completed pre (9/2023, n=18) and post/four-month retention surveys (2/2024, n = 19). Data analysis revealed improvement in knowledge about the domains and appropriateness of PC post-curriculum (p < 0.01). Compared to the control and pre-groups, more interns in the post group felt well-prepared introducing PC to a patient (58% vs. 20% control; 6% pre; p < 0.05) and leading a goals of care discussion (95% vs. 65% control; 65% pre; p < 0.05). 52% of the post curriculum group used ATA at least once every week. After each session, learners scanned a QR code to complete a feedback survey. 95% (n=19/20) and 90% (n=9/10) somewhat or strongly agreed that sessions 1 and 2 respectively should be included in the intern curriculum.

/ REFLECTION / LESSONS LEARNED: Participation in large and small group sessions with PC and IM facilitators improved PC knowledge. Through role-play, interns learned ATA and increased their comfort with difficult conversations. The significant difference between the AY 2022-2023 (control) and AY 2023-2024 (post) groups suggests that improvement in preparedness introducing PC to a patient could be attributed to the intervention, independent from experience gained by participants being 2/3 through their intern year. Utilization of the simulation center for session 2 along with heavy participation from our PC department may have increased learner interest in PC. CAREGIVERS AS PARTNERS IN CARE TEAMS (CAP-CT): TRAINING HEALTHCARE TEAMS TO ENGAGE CAREGIVERS Clara Park1; Julie Rousseau2; Sarah Hooper3; Sonia Sehgal2; Denise Watt3; Elizabeth Peters3; Gina Lima1; Dustin Le1; Josette Rivera1; Anna H. Chodos1. 1Medicine, University of California, San Fransisco, San Francisco, CA; 2Internal Medicine, University of California Irvine, Irvine, CA; 3UC College of the Law San Francisco, San Francisco, CA. (Control ID #4273054) SETTING AND PARTICIPANTS: A national program focused on reaching healthcare teams in a variety of clinical practice settings DESCRIPTION: About 53 million family caregivers provide essential, yet often unrecognized, care. And caring for caregivers helps care recipients' well-being and health, too. In 2022, the Administration for Community Living (ACL) released the National Strategy to Support Family Caregivers, the first national effort to recognize and assist family caregivers. Funded by the ACL to fulfill Goal 2 of the Strategy, Caregivers As Partners in Care Teams (CAP-CT) is a 4-year program to build a nation-wide training and resource hub that provides health care teams with the skills to include family caregivers in a patient's care journey. It is a multi-instituion and organizational partnership including academic institutions, institutes, and a foundation. Here we describe the development of the first course, titled “Foundational Skills for Engaging Caregivers in Health Care”, that was launched in November 2024. This course was developed by a core team of expert educators (from medical, nursing, legal, and interprofessional fields) and advised by a National Steering Committee made up of key subject matter experts in healthcare, caregiver inclusion, community-based organizations, as well as family caregivers with lived experience. Over the course of a year, these groups determined the knowledge gap that exists for healthcare teams through a landscape analysis, developed a content outline, wrote a storyboard with images and interactive elements, and partnered with an instructional designer to create the final course. The foundational training is offered as a self-paced, online course with the option to claim free continuing education credits. We are disseminating the trainings among clinical and health systems partners currently in California and the Gulf Coast states. EVALUATION: We will evaluate the impact of this training through two main methods. First, through post-training feedback via brief structured and open-ended surveys that assess the quality of the training and relevance to their work. These surveys will determine if there was increased trainee knowledge and confidence about including caregivers in care teams. Second, we will conduct qualitative interviews and focus groups with trainees to determine if there was improved inclusion of family caregivers in health care processes.

/ REFLECTION / LESSONS LEARNED: Working with a multidisciplinary team that includes family caregivers with lived experience has been instrumental in ensuring that CAP-CT’s training and other resources meet the goal of equipping healthcare teams with the skills to include family caregivers in care processes and connect them to resources. The next phase of the program will focus on the dissemination of this training, evaluation of its quality and impact, and improving resources for healthcare teams to learn and meaningfully support caregivers in practice. ONLINE RESOURCE URL: https://carepartners.ucsf.edu/ UNTAPPED POTENTIAL: USING SOCIAL MEDIA FOR GERIATRICS EDUCATION AND RECRUITMENT Kelly Cheung. Internal Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4271117) SETTING AND PARTICIPANTS: An internal medicine resident at an academic medical center in the West created @GeriMatters and @KellyTakesMedicine on a primarily video-based social media platform, Instagram. @GeriMatters focuses on clinical pearls in geriatric medicine such as the Age-Friendly 5Ms. @KellyTakesMedicine incorporates more personal experiences of the creator, who is a resident pursuing geriatrics, that may be more inspiring and relatable to users. Content includes the creator's journey to becoming a geriatrician, rewarding patient encounters that are de-identified, and reflections from caring for older adults. Both accounts are publically available and tailored to early trianees. Primary formats of content include video and infographics. DESCRIPTION: Education, mentorship and exposure are often citied in the literature as potential ways to improve the shortage of geriatricians. The innovation in this project lies in the strategic use of social media as an educational and recruitment tool. Creating engaging content involves blending education with creativity, storytelling, and humor. Platforms like Instagram can be an engaging and easily accessible method to reach a wider and younger audience who may not have been exposed to geriatrics otherwise. Social media can create a sense of mentorship and community, inspiring early-career trainees to consider geriatric medicine as a specialty or learn core principles of caring for older adults. EVALUATION: Individual metrics for video content are available with the application, including views per video, total watch time, number of accounts reached, and average watch time. Metrics for best performing video on @GeriMatters included 180,301 views per video, about 8 days of watch time, 95,022 accounts reached, and 7 seconds of averge watch time. The best performing infographic reached 3654 accounts. Between November 16, 2024 and December 15, 2024, @GeriMatters reached 3,666 accounts. @KellyTakesMedicine reached 2.4 million accounts. Numbers for @KellyTakesMedicine are higher due to the age of the account as well as covering other topics outside of geriatrics.

/ REFLECTION / LESSONS LEARNED: Running a social media platform for geriatrics education is both rewarding and challenging. Sharing experiences with patients or personal reflections seems to resonate deeply with followers. These platforms also allow knowledge to be shared that improves care for older adults and fills gaps in geriatrics education. Connecting with an online community has been especially fulfilling, as their feedback highlights its real-world impact. Ensuring content that is both engaging and ethical adds another layer. Additionally, managing a public platform means dealing with the pressure of visibility. Misinterpretations of content or criticism can arise, and addressing these constructively is essential. Overall, this project has been an exercise in growth, reflection, and responsibility. ONLINE RESOURCE URL: https://www.instagram.com/gerimatters https://www.instagram.com/kellytakesmedicine Innovation in Medical Education (IME) - Health Policy THE IMPACT OF A HEALTH POLICY COURSE ON PRECLINICAL MEDICAL STUDENTS' ATTITUDES TOWARDS INCREMENTAL REFORM VS. COMPREHENISVE OVERHAUL OF THE U.S. HEALTHCARE SYSTEM Venkatesan R. Krishnamoorthi1,2; Frazer Tessema2. 1Medicine, University of Chicago, Chicago, IL; 2The University of Chicago Pritzker School of Medicine, Chicago, IL. (Control ID #4273485) SETTING AND PARTICIPANTS: Required health policy course at a Midwestern medical school, with 90 students per entering class. DESCRIPTION: Many medical students enter training with a strong interest in health advocacy but report inadequate knowledge about the health care system, affecting their opinions on reform. We evaluated the impact of changes to our health policy course for preclinical students regarding their attitudes about reform, focusing on the debate between incremental reform (e.g., the Affordable Care Act) and comprehensive overhaul (e.g., Medicare-for-All). In 2021, we incorporated targeted readings, guest lectures, and small group learning to compare these approaches. We discussed the private-public hybrid approach and the ACA's results and the pros and cons of single-payer, including political and financial feasibility. These topics were assessed on the final exam, and improvements to this part of the course were made each year. EVALUATION: We administered pre- and post-course surveys about prior education in health policy, advocacy experience, interest in advocacy for their career, and confidence in their knowledge of the US healthcare system. We also included a 5-question knowledge assessment. Finally, we asked what healthcare reform approach they supported: status quo, incremental reform, system overhaul, or “I do not know enough to express an informed opinion.” We compared changes in opinions from pre- to post-surveys in 2020 (before focusing on the topic) and 2023 (third year of this course addition). At baseline, 65(76%) in 2020 and 61(69%) in 2023 reported having no prior education in health policy. However, 59(69%) and 63(71%) had participated in advocacy, and 67(78%) in 2020 and 74(84%) in 2023 planned to make advocacy a part of their career. From pre- to post-course, almost all respondents improved on the knowledge assessment (change in median of 3/5 to 5/ 5 correct in 2020 and 2/6 to 5/6 correct in 2023). Knowledge confidence on a scale of 1 to 5 increased from 7 (8.3%) rating 4 or 5 to 71 (80%) in 2020 and 8 (9.5%) to 65 (73%) in 2023. The percentages who chose incremental reform, system overhaul, and “I don’t know enough” changed from 29 (34%), 37(44%) , and 20(23%) pre-course, to 52(62%), 32 (37%), and 1(1%) post-course in 2020 and from 52(61%), 26 (31%), and 7 (8%) to 68 (80%), 7(8, and 1(1%) post-course in 2023.) 73 students in 2020 and 64 in 2023 completed both pre- and post-surveys. Of these, 12 (16.4%) switched their opinions from supporting overhaul to supporting incremental reform; in 2023, this number increased to 13 (20.3%). Those who responded "I do not know enough" decreased from 20(23%) to 1(1%) in 2020 and 7(8%) to 1(1%) in 2023; most of them switched to incremental reform.

/ REFLECTION / LESSONS LEARNED: A health policy course can significantly shift opinions on health care reform. The increase in support for incremental reform may stem from understanding the complexities of the health system, which hinder comprehensive change from a pragmatic perspective. Innovation in Medical Education (IME) - Inter-Professional Education A MULTIDISCIPLINARY ADDICTION TRAINING PROGRAM (MAT): FEASIBILITY AND INITIAL OUTCOMES James Grigg1,2; Katherine P. Mullins1; Talia Rosen1. 1Medicine, NYU Langone Health, New York, NY; 2Medicine, New York City Health and Hospitals Bellevue, New York, NY. (Control ID #4271005) SETTING AND PARTICIPANTS: MAT recruited two groups of learners in an urban academic medical center to distinct 1-year programs: a) n=35 'Scholars,' current allied health students enrolling in part-time hybrid curriculum, and, b) n=6 'Fellows,' licensed non-physician health professionals hired into a full-time clinical fellowship. Faculty are from the academic medical center’s schools of Medicine, Nursing, Social Work, and Occupational Therapy programs, and include three addiction medicine physician fellows and five GIM faculty. DESCRIPTION: A hybrid, year-long addiction medicine curriculum includes webinars, journal clubs, simulated interprofessional case-based modules (SIM), career development in-person meet-ups, and clinical rotations. Scholars engage in part-time volunteering, while Fellows rotate full-time through academic, public hospital, and community-based treatment programs. Scholars receive individual financial stipends ($10,000); Fellows are hired by the academic medical center as full-time trainees. EVALUATION: Pre- and post-program assessments track changes in interprofessional and addiction medicine knowledge, attitudes, and clinical confidence. Monthly journaling queries free-text program feedback. Mid- and post-program SIM assessments chart changes in participants' self-reported interprofessional competencies and applied skills. Individual learner assessment and feedback show pre-program confidence in substance use screening and treatment as 63.52% ‘low confidence’ or ‘neutral.’ Mid-program journaling indicated increased understanding of interprofessional care models and the importance of collaboration. Pre- and post-SIM assessments show improvement in interprofessional skills during case-based, group interactive exercises. Agreement on using an interprofessional team approach rose from 54.6% to 100%, and strong agreement in understanding team members’ contributions increased from 18.2% to 63.6%. ‘High confidence’ in providing feedback, care planning, and team communication increased to 70% post-SIM. Career development in-person networking events are monthly and have introduced participants to a wide constellation of NYC-area treatment providers. Pending post-project outcomes include career goals and job placements.

/ REFLECTION / LESSONS LEARNED: MAT demonstrates the feasibility of a medical school-based multidisciplinary addiction training model for non-physicians. Initial data and feedback underscores a demand for multidisciplinary training, high interest in addiction medicine content, and pre-program deficits in clinical confidence and interprofessional competencies that can be addressed by this type of multidisciplinary curriculum. Programs like MAT may help close gaps among health professionals in addiction education, clinical confidence, and addiction workforce development and retention with support from GIM faculty and addiction physician fellows. ONLINE RESOURCE URL: https://med.nyu.edu/departments-institutes/medicine/divisions/general-internal-medicine-clinical-innovation/education/multidisciplinary-addiction-training-program AVENUE M: A COMMUNITY COLLEGE TO 4-YEAR UNIVERSITY TO MEDICAL SCHOOL PATHWAY PROGRAM Brittany Chatterton1; Charlene K. Green2; Tonya Fancher1. 1General Internal Medicine and Bioethics, University of California Davis Department of Internal Medicine, Sacramento, CA; 2University of California Davis School of Medicine, Sacramento, CA. (Control ID #4273043) SETTING AND PARTICIPANTS: We recruited undergraduate students from 8 Northern California community college (CC) districts to participate in a multi-year long pathway to medical school program. DESCRIPTION: To help close the diversity gap among physicians in Northern California, we created a pathway program starting from CC through medical school. The CC student population was select due to the high number of students who are historically underrepresented in medicine both in race/ethnicity and socio-economically. Our pathway program collaborates with 8 Northern California CC districts, three 4-year university partners, and 1 medical school. Once enrolled in the program, students are provided with holistic support tailored for each step in their pathway to applying to medical school. During the CC years, attention is spent to ensuring appropriate progression in pre-transfer courses, exposure to the diversity of medical specialties, and internships to explore medical research/gain clinical experiences. This is particularly important for the CC students who rarely have access to such experiences during their CC years. After transfer to 4-year universities, emphasis on planning for standardized exams, creating personal statements, and compiling activities for the medical school application becomes the emphasis. Students are paired with individual career mentors and program coordinators longitudinally through the program. In addition to the academic components, the development of professionalism is highlighted, and students are exposured to the PREview exam early in their enrollment in the program. Our college and university partners are engaged in our program through involvement in our professional learning communities (PLCs). We have three main PLCs: learner analytics, student support, and program leadership. EVALUATION: We currently have two cohorts totally 100 students. Our students include 68% female, 28% male, and 4% gender minorities. Race/ethnicity includes 31% Asian, 24% Hispanic, 15% Caucasian,10% Middle Eastern/Northern African, 8% African American, and 12% Other. A third of our students’ primary language at home is non-English and half are first generation college students. To date we have successfully had our first cohort transfer from CC to 4-year universities. Of our transfer cohort, 86% completed a summer internship ranging from exposure to basic science medical research to clinical experiences at local hospitals. Five students will be applying to medical school in this upcoming cycle.

/ REFLECTION / LESSONS LEARNED: Through building this program, we have found that importance of leveraging partnerships with our colleges and universities using their collective knowledge to help guide our programming and student support. We have found for student recruitment and retention the value in having program coordinators geographically positioned to ensure students in our more remote school locations are engaged in the program and have face to face support. CREATING INCLUSIVE AND NON-JUDGMENTAL OPPORTUNITIES TO IMPROVE CLINICAL KNOWLEDGE AND COMPETENCIES FOR INTERNAL MEDICINE RESIDENTS REFERRED FOR REMEDIATION Hyun Jung. Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4273548) SETTING AND PARTICIPANTS: Internal Medicine residency trainees who completed their elective rotations at an academic medical center in the Mid-Atlantic region DESCRIPTION: Remediation provides timely and proactive intervention to support struggling learners achieve appropriate knowledge and competence during their medical training. These trainees are often enrolled in intensive individualized longitudinal mentorship to formulate guided study plans and receive frequent feedback. This intervention focused on creating an inclusive and non-judgemental learning environment to motivate self-directed and collaborative learning, especially for those referred to remediation. All Internal Medicine residents who were on elective rotations were offered an optional opportunity to engage in this intervention. As a part of the intervention, each participant received individualized guidance and mentorship at the beginning of the participation period to formulate study plans. A protected study time of 12 hours were provided over the course of their 2-week rotations to complete 70 to 120 questions in a subspecialty area of their choice using Medical Knowledge Self-Assessment Program (MKSAP). Each participant also prepared educational slides detailing 3 to 5 topics they struggled, and presented them to their peers at the end of the intervention period for peer-based learning. EVALUATION: Participants completed a voluntary questionnaire at the beginning and end of their clinical rotations. The survey consisted of quantiative questions evaluating participant experiences and perceived educational benefits of the intervention. The collected data were evaluated using descriptive statistical analyses.

/ REFLECTION / LESSONS LEARNED: Amongst 109 trainees eligible to participate, eighteen (16.5%) enrolled in the intervention, six (33.3%) were either previously referred to remediation or currently on remediation. Each participant completed 70 to 120 questions using MKSAP over the course of intervention, which were significant higher than those reported their peers who did not participate in the intervention. All participants--regardless of their remediation status--reported overall positive experiences, educational benefits, peer-to-peer learning, and desire to participate again in the intervention. ENHANCING PRE-MEDICAL STUDENTS' UNDERSTANDING OF INTERDISCIPLINARY HEALTHCARE TEAMS THROUGH A HOSPITALIST SHADOWING PROGRAM Divya Singh, Dylan Yang, Shannon Martin, Kavita Renduchintala. Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4268964) SETTING AND PARTICIPANTS: Setting: An Academic Hospital in the Mid-West region Participants: Pre-Med Undegraduate Students and Hospitalists DESCRIPTION: Pre-medical physician shadowing is an important part of medical school applications that students are encouraged to pursue. For many prospective medical school applicants, it is difficult to obtain formal shadowing opportunities. The Section of Hospital Medicine in partnership with our university's undergraduate Pre-Health team, aims to improve access to pre-medical shadowing opportunities. In addition, the goals of the program include enhancing students’ exposure to hospital medicine, understand differences in inpatient and outpatient care, and improve familiarity with various roles within a interdisciplinary medical team. EVALUATION: 34 students have participated in the shadowing program to date. Of these, 24 completed pre-program surveys and 14 completed post-program surveys. The majority of students were in their first or second year of college and 88% have never shadowed a physician before. While 63% of students stated that they are moderately or very familiar with the role of a physician, only 32% were familiar with the role of a nurse. Students were least familiar with the roles of nursing assistants, case managers, and patient care navigators. 67% of students were very or extremely interested in pursuing a healthcare career and 88% of students were interested in becoming a physician prior to the experience. Post-program results show that 92% of students expressed an increased interest in pursuing a healthcare career after the experience. All students shadowed one physician for at least 3 hours on one day, saw between 2 to 15 patients, and had exposure to inpatient care. In addition to physicians, students had the most exposure to social workers and case managers. The students' overall familiarity with the roles of physicians and other healthcare professionals, including nurses, physical therapists, occupational therapists, patient care navigators, case managers, and social workers, increased. 100% of students would participate again and recommend the program to their peers.

/ REFLECTION / LESSONS LEARNED: The shadowing program increases students’ familiarity with the roles of physicians and other members of the interdisciplinary care team. By involving faculty on both direct care and teaching services, the program expands access to student shadowing opportunities without competing for time with other learners. Students report high satisfaction and express interest in additional shadowing hours and opportunities to learn more about physician careers and interdisciplinary care. The Section of Hospital Medicine aims to expand these opportunities and will continue to evaluate the program to improve the experience in the future. ONLINE RESOURCE URL: N/A INTERPROFESSIONAL EDUCATION FOR IM PGY1S WITH PRIMARY CARE CLINICAL PHARMACISTS Anna Bondar, Nitu Kataria. Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4269840) SETTING AND PARTICIPANTS: All Internal Medicine (IM) PGY1s at a large academic medical center in Ohio with primary care clinical pharmacists who are part of the continuity clinic sites medical home DESCRIPTION: Managing chronic diseases in an outpatient clinic can be challenging for interns at the start of residency as much of medical education experiences occur in an acute hospital care setting. The purpose of this interprofessional experience is to guide interns to the role a clinical pharmacist plays in the outpatient setting through didactic content and a half-day shadowing experience. During the didactic session, the pharmacist covers core topics such as medication procurement, medication device teaching, and continuous glucose monitor overview. During the observational session, the pharmacist answers any other medication related questions. Interns observe the pharmacist-led patient visits to gain valuable insights into medication reconciliation, instruction on use of medications, and chronic disease management that is done during a clinical pharmacy visit. To date approximately 32 interns have completed the half-day experience with one of seven clinical pharmacist educators at a clinical site during the 2024-25 academic year. This interprofessional experience is placed at the second quarter of the academic year when interns have had at least one or two weeks of their continuity clinic and after the ambulatory intern curriculum presentation given by the clinical pharmacists EVALUATION: Pre-and post-intervention surveys were sent to interns to voluntarily complete. The surveys assessed their planned career choice, their clinical site, and their perceived knowledge of the role of the clinical pharmacist at their site. Post-intervention surveys gauged satisfaction with the curriculum and suggestions for improvement. To date, a total of 28 participants completed both surveys. The residents’ perceived comfort in consulting the pharmacy team increased from 61% to 94% (n=28) after their half-day session and the percentage of residents strongly agreeing that pharmacists are helpful in co-managing patients in clinic increased from 89% to 97% (n=28).

/ REFLECTION / LESSONS LEARNED: This initiative has grown into a yearly interprofessional educational experience for interns. We are fortunate to have two ambulatory chiefs and a large outpatient clinical pharmacy team that also has their own pharmacy residency as this experience requires dedicated time and bandwidth. And while all parts of the program may not be generalizable, having residents learn about medications and chronic disease management from a pharmacist's perspective is feasible for many programs and important for professional development and understanding of system-based practice in the form of an outpatient medical home for interns. The educational interprofessional experience is ongoing in this academic year. MULTIDISCIPLINARY APPROACH TO HEALTHCARE IN INTERNATIONAL, RESOURCE-LIMITED SETTINGS: EMPOWERING PATIENTS THROUGH EDUCATION, PREVENTATIVE CARE, AND SPECIALTY CARE IN COLOMBIA. Elimarys Perez-Colon1,2; Shreya Chapyala2; Bryan L. Ortega3; Britannia Noel2; Keiver D. Cardona4; Marcela Valencia-Franco4; Sandra Moreno Realphe4. 1Internal Medicine-Pediatrics, University of South Florida, Tampa, FL; 2College of Medicine, University of South Florida, Tampa, FL; 3College of Medicine, Florida State University College of Medicine, Tallahassee, FL; 4Facultad Medicina , Universidad ces, Medellín, Antioquia, Colombia. (Control ID #4272383) SETTING AND PARTICIPANTS: The International Health Service Collaborative (IHSC) is an initiative based in the U.S. that brings together 17 students—eight from Medicine, six from Pharmacy, and three from Public Health—along with three faculty members for a cross-cultural exchange with an academic medical center in Colombia. This interdisciplinary team worked collaboratively to deliver essential clinical care, pharmacy services, and public health education. Over a four-day period, the team provided care to nearly 450 community members. IHSC serves as a platform for students to develop clinical and interpersonal skills while actively promoting global health awareness and sustainable solutions. DESCRIPTION: While students traditionally focus on a single area of expertise during training, IHSC’s model enables each participant to contribute their unique skills and perspectives in a truly collaborative setting. The team engaged in diverse areas such as internal medicine, pediatrics, gynecology, and community health fairs, working together to enhance patient care and safety. Medical students partnered with internal medicine doctors to provide guidance on formulary selection and alternative therapy options. Pharmacy students counseled patients on the risks and benefits of local medicinal herbs, incorporating knowledge shared by Colombian pharmacists. Teams—comprising medical, pharmacy, and public health students—conducted home visits to perform comprehensive medical evaluations, medication reconciliations, health education, and assessments of socioeconomic barriers to care. During cardiovascular risk screenings, medical students took histories and vital signs, while pharmacy students reviewed medication lists and measured blood sugars. Together, they developed cohesive care plans for patients. EVALUATION: Students’ appreciation for interdisciplinary collaboration in healthcare was evaluated through longitudinal reflections conducted in the form of debriefs before, during, and after trip participation. Ongoing surveys of students’ evolving perspectives enabled the team to assess their understanding of global healthcare challenges and their ability to identify and implement solutions in diverse cultural contexts, particularly as they built deeper connections with peers and the local community.

/ REFLECTION / LESSONS LEARNED: The IHSC emphasizes the importance of interdisciplinary collaboration, preparing future healthcare professionals with the multifaceted skills necessary for 21st-century healthcare. By partnering with a local university and government health clinics, IHSC established a sustainable care model tailored to meet the community's needs. Through active participation across the health spectrum, students improved their ability to engage patients in care planning, bridge health literacy gaps, and address social determinants of health. This initiative not only enhanced clinical competencies but also fostered cultural humility and a global perspective on healthcare delivery. Innovation in Medical Education (IME) - Medical Education and Scholarship "SEE AND BE SEEN": AN OBSERVATION-BASED, PEER FEEDBACK INNOVATION FOR AMBULATORY FACULTY Jaime Fineman, Rachel Snyder, Jill Allenbaugh. General Internal Medicine, Temple University, Philadelphia, PA. (Control ID #4245738) SETTING AND PARTICIPANTS: Sixteen general internal medicine (GIM) faculty preceptors at an internal medicine resident ambulatory clinic at a large urban medical center participated in the intervention. DESCRIPTION: Effective precepting in the GIM clinic is imperative to resident education, yet training on this teaching skill is often lacking. Peer observation has been shown to support educator professional development; however, there are few studies of faculty peer observation of outpatient precepting. Previous published studies focused on the inpatient setting or validating a precepting evaluation tool but without directed faculty feedback. We created a faculty peer observation innovation in the ambulatory setting with the goals to (1) identify areas for group and individual faculty development and (2) promulgate successful precepting strategies. Faculty first completed an anonymous pre-survey to identify their perceived strengths and weaknesses, utilizing precepting domains established in prior studies. Participants then discussed themes from the pre-survey, prompting group discussion about common precepting situations. Over three weeks, each faculty member did one four-hour observation of 3-4 colleagues, observing several resident encounters per colleague. Each preceptor was observed during at least two separate sessions by different faculty observers. Prior to observation, the faculty pairs had a “pre-brief” where each observed preceptor noted 1-2 skills they were hoping to improve upon. After the session, the observer filled out an anonymous survey, noting at least one opportunity for improvement and one strategy they plan to incorporate into their own precepting. The observer then shared their feedback with their colleague. After all observations were completed, post-survey themes were presented at a group meeting, leading to discussion about next steps for faculty development. EVALUATION: On the presurvey, faculty identified their highest areas of strength: offers positive reinforcement (93% agreed), admits uncertainty (86%), identifies pertinent problems (71%), identifies relevant clinical pearls (71%). The most common areas identified for improvement included: motivates learners for self-study (64%), probes for understanding (50%), teaches organization of presentation and plan (43%). Similar themes were noted in the post-observation surveys. During the post innovation debriefing session, faculty deemed the innovation to be a valuable experience and expressed interest in participating again.

/ REFLECTION / LESSONS LEARNED: This intervention reinforced a culture of lifelong learning and commitment to growth with a shared goal of improving ambulatory GIM precepting skills. In addition to fruitful conversations at planned section meetings, it led to impromptu discussions about best precepting practices during clinic downtime. Next steps include developing a faculty curriculum focusing on 3-4 identified themes to improve precepting best practices. ADVANCING DIGITAL HEALTH EDUCATION: A NEEDS ASSESSMENT AND INTERACTIVE WORKSHOP FOR AN EMERGING PARADIGM AMONG MEDICAL RESIDENTS Saimanoj Guntaka1; Rubina Boparai1; Syed E. Ahmad1; Karen Friedman1; Lauren Block3; Sneha Shrivastava2. 1Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; 2General Internal Medicine, Northwell Health, Great Neck, NY; 3medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY. (Control ID #4272128) SETTING AND PARTICIPANTS: Our study was conducted at an academic internal medicine residency program involving 33 categorical and preliminary internal medicine residents. DESCRIPTION: Digital health is an emerging paradigm with innovations such as mobile medical applications, digital therapeutics, and wearable devices aimed at improving healthcare. Despite its potential, medical education lacks structured training on digital health competencies. To address this gap, a survey was developed to assess internal medicine residents’ exposure, comfort, and practice behaviors regarding mobile health software applications in an ambulatory setting. Based on the survey, an interactive workshop was implemented to address identified gaps and enhance digital health knowledge, skills, and confidence. EVALUATION: Our survey highlighted that while 84% of residents recognize the value of digital therapeutics, there were significant gaps in knowledge. Specifically, 82% of residents reported no formal digital health education during medical school, and 62% had no exposure during residency training. Although most residents used mobile applications for personal health, over half did not recommend them to patients with the majority expressing discomfort in using these tools alongside standard of care. Following our workshop, residents demonstrated an increased appreciation for the usefulness of digital health tools. Comfort levels in utilizing mobile health software applications for patient care also improved. Moreover, confidence in using platforms such as Apple Health, Google Fit, and Samsung Health increased markedly, suggesting that the workshop effectively addressed key barriers to digital health adoption and skill development.

/ REFLECTION / LESSONS LEARNED: The findings of our study underscore a significant gap in digital health competency among internal medicine residents, which has contributed to discomfort and limited proficiency in integrating these tools into clinical practice. Despite the potential for digital health to improve patient outcomes, many residents reported insufficient formal education in using digital health tools, specifically mobile health applications. However, the implementation of an interactive workshop successfully addressed these gaps. Residents showed significant improvements in their attitudes, comfort, and confidence, particularly with platforms such as Apple Health, Google Fit, and Samsung Health, demonstrating the effectiveness of the educational intervention. As the field of digital health continues to evolve, incorporating comprehensive education into medical training is essential for equipping future healthcare providers with the skills needed to harness these innovations and transform patient care. A LONGITUDINAL INTEGRATED CLERKSHIP CLINIC PILOT: ADDRESSING THE PRIMARY CARE PRECEPTOR SHORTAGE IN UNDERGRADUATE MEDICAL EDUCATION. Matthew Mulligan, Kira C. Watson, Anne Cioletti. General Medicine, The University of Utah School of Medicine, Salt Lake City, UT. (Control ID #4242102) SETTING AND PARTICIPANTS: The school of medicine employed a new clerkship curriculum in academic year 24-25, assigning an entire medical class to longitudinal integrated clerkships (LIC). This significantly increased demand for general internal medicine (GIM) preceptors compared to the previous traditional 1:1 assignment. We aimed to meet this demand by developing an LIC clinic pilot in an academic faculty primary care clinic that would increase the number of students in GIM. DESCRIPTION: In our novel LIC clinic model, we assigned 15 students to 5 primary care faculty. Each preceptor oversaw 3 LIC students, with the goal of having 2 students in clinic one half day a week, while the third rotated on an immersion block. We created two teamlets by pairing two preceptors and their students in clinic to build a shared sense of community and allow flexibility in clinic flow. There was one preceptor who was not paired due to the odd number of preceptors and space constraints. The pilot utilized the same staffing and room resources of the faculty practice. Additionally, patients paneled to the faculty were scheduled into these templates as all faculty had closed practices. We created schedules to allow students to see up to three patients per half day of clinic, which we increased to four patients after two months. All visits were scheduled for 40-minute visits (instead of a 20- minute return visit), and we staggered start times to balance education and staffing/room constraints. We received funding from the school of medicine to help support faculty productivity losses. EVALUATION: The aim of our project is to implement a LIC primary care model that will increase the number of students in GIM, maintain comparable productivity, and provide a comparable educational experience to LIC experiences at similar clinical sites. Our primary outcomes are work related revenue units (wRVUs) and the number of student half days per attending. We plan to compare educational experiences by surveying both students and attendings about their experience. We will evaluate the frequency and types of conditions seen by students by evaluating ICD-10 codes of patients seen in the student clinic as well as patient-student continuity. We will compare data from the pilot clinic to two other GIM clinics that implemented a traditional 1:1 student to preceptor LIC model.

/ REFLECTION / LESSONS LEARNED: This novel LIC pilot clinic aims to address a shortage in ambulatory GIM preceptors by incorporating more students than a traditional LIC model while maintaining physician productivity. Since traditional primary care schedules are not optimized to include time for student teaching, which impacts the ability to provide an adequate number of preceptors for students, we used a schedule that built in more time for teaching and would allow one preceptor to work with multiple students. Informal feedback so far has been positive. If successful, this pilot would allow increased student capacity in GIM and potentially a better educational experience for faculty and students. A NEW CLINICALLY FOCUSED GIM FELLOWSHIP: A WORKFORCE PIPELINE TO PRIMARY CARE Samuel C. Fountain1; Tyra Fainstad2; Brandon Combs1. 1Internal Medicine, University of Colorado System, Denver, CO; 2Internal Medicine, University of Colorado, Denver, CO. (Control ID #4270873) SETTING AND PARTICIPANTS: This fellowship, formally called the “GIM Clinician Educator Fellowship”, began in 2024 at a large academic medical center in the Mountain West. The fellow is embedded in a primary care clinic associated with the General Internal Medicine Division at the University, as well as a large non-profit health system. There is one fellow per year, under the mentorship of experienced faculty members who are primarily clinician educators. DESCRIPTION: This fellowship has two general aims. One is to offer an transitional opportunity for recent graduates of internal medicine residency who are considering a career in outpatient internal medicine but want more exposure to the field before committing. This is aimed at residents who perhaps focused more on inpatient or subspecialty medicine in residency and are now changing paths. There are structured clinical experiences in dermatology, sports medicine, wound care, and addiction medicine, all geared toward applicable skills for primary care. The fellow also spends time staffing resident clinic, as well as teaching lectures throughout the year to the residents. The other aim is to create a workforce pipeline into primary care. This is achieved through mentorship and coaching in professional identity formation, as well as longitudinal patient care which ideally fosters a passion for primary care medicine. Fellows have individual mentorship in the clinic with experienced primary care doctors who help with clinical care, teaching skills, and career planning. Additionally, fellows have their own panel of patients and see patients three half days per week, creating an opportunity for them to experience a closer approximation to primary care than they received in residency, where outpatient care is often disjointed and interrupted by inpatient responsibilities. While many GIM fellowships exist, ours is innovative in that it is primarily clinically focused, and it is aimed at a pipeline into primary care generally, rather than focusing on teaching and promoting academic scholarship. EVALUATION: The evaluation of the fellowship, which is mid-way through it’s first year, will include multiple facets. One will be a cost-analysis considering the amount of patient the care the fellow contributes to the clinic, and whether this is a feasible model to be implemented at other clinics at other Internal Medicine Programs. The other facets, which are more limited given there has only been one fellow, will include evaluations from residents and clinic staff members on the impact of the fellow on clinic operations and resident educations.

/ REFLECTION / LESSONS LEARNED: While originally envisioned as an internal workforce pipeline, the feasibility of hiring a graduating fellow each year as a new faculty member for primary care may not be realistically possible. Similarly, physical clinic space can be limited and fellows in the future are going to be splitting time at two different primary clinics associated with the University. A NOVEL MULTIMODAL SIMULATION-BASED PROGRAMME FOR TEACHING FAMILIAL COMMUNICATIONS IN MEDICAL EDUCATION Isaac K. Ng1; Wilson G. Goh2; Li Feng Tan3; Desmond B. Teo4; Ann Toh5; Nicola Ngiam6. 1Medicine, National University Hospital, Singapore, Singapore, Singapore; 2Infectious Diseases, National University Hospital, Singapore, Singapore, Singapore; 3Geriatric Medicine, National University Health System, Singapore, Singapore, Singapore; 4Fast & Chronic Programme, National University Health System, Singapore, Singapore, Singapore; 5HCA Hospice Care, Singapore, Singapore; 6Paediatrics, Khoo Teck Puat - National University Children's Medical Institute, Singapore, Singapore, Singapore. (Control ID #4244227) SETTING AND PARTICIPANTS: Familial involvement has been increasingly recognised as important in the care of hospitalised patients, associated with better healthcare communications, clinical outcomes and discharge planning. In Asian and collectivistic cultures, medical practitioners routinely provide updates to the family members of admitted patients due to significant familial involvement in caregiving roles and decision-making. However, most current communications teaching in medical school are focused on direct patient encounters, leading medical trainees to be less equipped in dealing with familial communications that have different contextual (e.g. intra-familial dynamics), and ethical (e.g. collusion, confidentiality) nuances. Hence, we developed a novel, multimodal, simulation-based familial communications workshop for final year undergraduate medical students to address this gap in clinical training. DESCRIPTION: In this 3-hour programme, the students were first given a didactic lecture on principles of familial communication including a novel “UPDATE-R” (understanding clinical context, gathering perspectives, deliver medical information, address questions/concerns/expectations, tentative plans, demonstrate empathy, post-communication reflection) communication framework, followed by small-group simulated practice with standardised patients (SPs) acting as the family members of an elderly female patient with advanced dementia and chronic kidney disease who was admitted for pneumonia with incidental metastatic lung nodules on chest X-ray. In an evolving three-part case scenario, candidates in the “hot seat” had to tackle different aspects of familial communications from a routine medical update, to navigating physician-familial conflicts and intra-familial conflicts in treatment decision-making and patient care. At the end of the simulation practice, structured feedback was provided, which started with candidates’ self-reflection, followed by peer, SP and clinical tutor feedback. EVALUATION: For the post-course online feedback, a 94% response rate was attained, with average scores in six assessed educational domains exceeding 90% on a Likert rating scale. We intend to study our programme further in the subsequent academic year, with conduction of pre- and post-intervention surveys/tests to obtain more holistic metrics of its utility in improving participant knowledge and confidence in familial communications.

/ REFLECTION / LESSONS LEARNED: Lessons learnt included: 1. A multimodal pedagogy involving didactic front loading and subsequent simulation teaching using scripted real-life scenarios with standardised actors enable medical students to engage in practice-based learning in a psychologically safe environment 2. Multi-source feedback post-communications task which incorporates self-reflection/appraisal, sequential peer/standardised patient/tutor feedback, and tutor facilitation of sieving out key learning points from the task facilitates a social constructivist approach to learning communications skills A NOVEL SELF-DIRECTED LEARNING ‘RESIDENT AS A TEACHER’ ELECTIVE Shazia Samanani, Ryan Salemme, Chavon Onumah. Medicine, The George Washington University, Washington, DC. (Control ID #4267460) SETTING AND PARTICIPANTS: ACGME requires medicine residents to develop proficiency as educators during residency, however, structured opportunities for developing teaching skills are often lacking. Recognizing this, our Internal Medicine residents requested an elective that allows them to grow as educators. This led to the development of a self-directed learning (SDL) elective named the “Resident as a Teacher” elective. The SDL design was chosen so residents can participate in an elective not based on a clinical service line while allowing them to develop lifelong SDL skills. The goal of the elective is to allow the residents to grow as educators while inculcating in them what a career in teaching can entail. The elective was designed for senior residents, to ensure solid foundational knowledge prior to teaching peers. DESCRIPTION: An elective guide is provided taking them through creating personal learning goals (PLGs) and foundational principles needed. The elective requires development of a lesson plan, 2 teaching sessions, and participating in 2 additional teaching and learning activities selected from a list or creating their own to best achieve their PLGs. Faculty provide direct feedback on at least 1 teaching session. The evaluation of the residents is formative, and the elective evaluation includes Likert and short responses. The innovation and timeliness of this elective comes in its SDL form. To date there are no SDL electives described in the literature. It presents a novel way for approaching non-clinical based learning for residents. EVALUATION: 30 residents completed the elective. Evaluations show strong agreement in achieved learning objectives and educational goals. 95% of residents strongly agreed or agreed the elective had a positive impact on their abilities as a teacher. Many noted the immediate direct-observed feedback on teaching was invaluable. One resident stated they “got feedback that will affect how I teach in the future and my career overall,” and another said they “want to emphasize that the feedback after teaching was a hallmark”. They appreciated the SDL nature, and the balance between autonomy and support. One resident said “the SDL curriculum is a good way to do this elective and it gives you the freedom to pick optional teaching and learning objectives,” and another “enjoyed the autonomy, the opportunity for self-guided learning.”

/ REFLECTION / LESSONS LEARNED: The SDL Resident as a Teacher elective successfully enhanced residents' teaching skills, introduced them to SDL and provided insights to their abilities as future educators. The elective's design proved effective in fostering resident engagement and skill development. Limitations include its single-institution implementation and reliance on self-motivation. Future directions involve longitudinal assessments and moving the elective guide to a centralized platform for dissemination and reproducibility with the the goal is that it can serve as a model for other institutions wishing to incorporate a SDL elective in non-clinical areas. A POCKET OF UNTAPPED POTENTIAL: SHIFTING PARADIGMS IN PROCEDURAL COMPETENCY Joseph Abraham, Vasundhara Singh, Lance Maresky. Internal Medicine, Mount Sinai West Medical Center, New York, NY. (Control ID #4267884) SETTING AND PARTICIPANTS: The Hospitalist Teaching Service (including both attending physicians and resident house staff) for the Internal Medicine Residency Program at Mount Sinai Morningside and Mount Sinai West. DESCRIPTION: The aim of our curriculum is to leverage secure chat technology to connect paracentesis-certified faculty and residents with new learners eager to gain certification by performing 5 procedures under direct supervision. The initiative aims to enhance procedural safety, increase the number of procedurally competent providers within the hospital medicine service, and ensure compliance with best-practice guidelines while improving patient care by expediting important procedures. EVALUATION: We are tracking a number of metrics, including number of secure chats using our electronic medical record initiated over the study period, length of time it took to connect performing and supervising physicians, number of procedures completed successfully, number of supervised procedures logged, and number of residents who have achieved procedural competency.

/ REFLECTION / LESSONS LEARNED: With increasing subspecialization in the field of Internal Medicine, the role of the hospitalist has metamorphosed, and the expectation for certification in specialized procedures, such as paracentesis, previously well within their scope of practice, is diminishing. This gap in certification poses challenges for procedural safety and operational efficiency. Our program has endeavored, and shown promise, in shoring up these shortcomings. Some potential limitations to our method include availability of supervising physicians, awareness of the project within the hospital, and continuity of the program from year to year. However, the success of this program is designed to directly mitigate these and other issues that may arise by creating more available supervisors, increase systemwide investment in the program, and endowing it with longevity. Our initiative was met with great enthusiasm with 70+ residents signing up to participate in the first month. It has also provided house staff and attendings with a unique opportunity in medical education for collegiality and collaboration, where newly certified residents are supervising uncertified attendings. ONLINE RESOURCE URL: https://sites.google.com/view/proceduremsmw/paracentesis A RESIDENT-AS-ATTENDING ROTATION TO FOSTER A GROWTH MINDSET AND DELIBERATE PRACTICE THROUGH COACHING Alice J. Tang1; Shira Sachs1; Stephanie J. Tang1; Neil R. Lim1; Ozan Unlu3; Deepa R. Nandiwada2; Art Evans1. 1Medicine, Weill Cornell Medicine, New York, NY; 2General Internal Medicine, University of Pennsylvania, Philadelphia, PA; 3Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA. (Control ID #4273146) SETTING AND PARTICIPANTS: Hospital Medicine Faculty and Internal Medicine senior residents at a large urban Mid-Atlantic academic medical center. DESCRIPTION: Feedback is essential for skills improvement and mastery. Yet the clinical training environment often poses barriers for attending physicians to provide trainees with effective feedback. We created a novel rotation called Mastering the Art and Nuance of Team Leadership and Education (MANTLE), designed to create a structure and environment to foster growth mindset and deliberate practice through coaching. Residents served as acting-attendings and attendings physicians served as coaches on this “Resident as Attending” rotation. Attendings also received peer-coaching. EVALUATION: We conducted design-based research with a convergent mixed methods design. Residents and attendings compared the frequency with which they experienced components of deliberate practice on this rotation with other general medicine rotations. Retrospective pre-/post- confidence in coached skills (leadership and teaching for residents, coaching for attendings) was also assessed. A thematic analysis was conducted after semi-structured interviews exploring resident and faculty experiences on the rotation. Ten faculty and twenty residents participated in the MANTLE rotation from July 2019 to June 2021. Residents reported engaging in deliberate practice more on the MANTLE rotation (aggregate median 14.0 (CI 13.0-15.0), relative to other rotations 8.5 (CI 7.0-9.0) (p < 0.001). Residents reported increased confidence in leadership and teaching skills post-rotation aggregate median 21.0 (CI 18.0-25.0) to 28.0 (CI 27.0-34.0), (p < 0.001). Faculty reported increased confidence in coaching skills, with aggregate median 18.0 (CI 16.3-19.0) to 20.5 (CI 20.0-21.8) after MANTLE (p=0.009). Themes were grouped by phase of the coaching experience. During the setup, explicitly placing residents in the attending role was motivating, goal setting promoted accountability, and setting expectations for frequent coaching destigmatized feedback and fostered a growth mindset. During the observation phase, attendings strategically used role modeling and priming teaching points when needed for patient care and teaching. During coaching, frequent coaching fostered a closer attending-resident relationships and tailoring feedback to the residents’ agenda improved feedback acceptance. Peer observation was motivating and promoted accountability for attendings.

/ REFLECTION / LESSONS LEARNED: This study shows ways in which the clinical training environment can support a growth mindset and deliberate practice in both attending and trainee. Crucial aspects for success include clear expectations around individual roles, goals, and intention behind and frequency of feedback. These findings can be used to inform development of other rotations aiming to harness coaching to foster deliberate practice and growth mindset. It can also be a model for developing a rotation aimed at improving resident leadership and teaching skills. A SURVEY OF GRADUATES OF A LONGITUDINAL MEDICAL SPANISH TRAINING PROGRAM IN A MEDICAL SCHOOL IN THE US Connor Randolph2; Marco A. Alemán1; Daniel S. Reuland1; Ana L. Bermudez3; Alison T. Brenner4. 1Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; 2The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; 3Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; 4Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC. (Control ID #4272098) SETTING AND PARTICIPANTS: Some US medical schools have implemented medical Spanish programs. However, little is known about long-term outcomes of such programs, such as the extent to which program graduates are using Spanish in clinical practice. We conducted a survey of graduates of a medical Spanish program at one US medical school. DESCRIPTION: The program, started in 2004, enrolled medical students entering with formally assessed intermediate to advanced fluency level of Spanish and offered multi-year curricular enhancements that included integrated in-classroom interactive and didactic sessions on medical Spanish, practice sessions with Spanish-speaking patients, supervised clinical encounters with Latine patients, targeted clinical rotations, and community service experiences with local Latine organizations. We used the Dillman method and invited program graduates via email to participate in an online survey. The survey included multiple-choice and open-ended questions designed to assess participant satisfaction with the program and to understand where they are currently practicing medicine and how they use their Spanish when practicing. The 30-item survey took approximately 10–15 minutes to complete. No incentive was provided to take the survey. EVALUATION: The survey had a response rate of 49.4% (118/239), with 239 program graduates receiving recruitment emails, 132 started the survey, and 118 completed it. Most participants are still practicing medicine (94%), with the majority working in ambulatory settings (59%), as opposed to inpatient or hospital settings (41%). A large proportion of graduates have continued to practice in the program’s home state (48%). Among all program graduates, 26% practice in medically underserved areas, 21% at a federally qualified health center, and 15% in a rural area (not mutually exclusive). The graduates frequently use their Spanish in practice, with 91% of participants using Spanish to complete important clinical tasks with patients without the use of an interpreter and 68% of participants saying they speak more than 1 hour a week in Spanish. Participants also felt confident in their use of Spanish, with 72% self-rating their fluency as advanced or native/native level. When assessing their knowledge gained via the program, a large majority said the program increased their understanding of Spanish medical terms (82%), practical Spanish skills (81%), confidence in speaking Spanish (77%), and ability to provide culturally competent care (71%) “very much”.

/ REFLECTION / LESSONS LEARNED: The majority of graduates of this program reported benefitting from its instruction and frequently use their Spanish in their clinical practice. This multifaceted longitudinal program may serve as a model for training future bilingual providers who wish to work with Spanish-speaking communities and help reduce language-based health disparities. BRIDGING LANGUAGE BARRIERS: ENHANCING INTERPRETER TRAINING IN MEDICAL EDUCATION TO IMPROVE PATIENT CARE Patricia Otero Valdes1,2; Brian Tuohy2. 1Internal Medicine, Tulane University, New Orleans, LA; 2Temple University, Philadelphia, PA. (Control ID #4272599) SETTING AND PARTICIPANTS: Temple LKSOM students from class of 2024-2027 (M1-M4s), were recruited through flyers and educator announcements to participate in three virtual focus groups with a total of 27 participants. These focus groups took place on zoom on 11/27/2023, 12/19/2023, and 1/30/2024. DESCRIPTION: Interpreter services play an integral role in ensuring equity in healthcare for patients with limited English proficiency (LEP), whose language barrier places them at increased risk for healthcare disparities. Even with the growing number of non-English-speaking patients, and although such training leads to more culturally competent care with better patient outcomes, there is little curricular time during medical school devoted to effectively using interpreters. Prior literature described physicians who received training on cultural competence and the appropriate use of medical interpreters were likelier to utilize LEP services in the hospital. This study aimed to evaluate the preparedness of medical students to use interpreter services and to identify gaps in the current medical education curriculum regarding training on interpreter use. The study sought to assess the perceptions of medical students about their readiness to provide culturally competent care to patients with limited English proficiency (LEP). EVALUATION: A qualitative study was conducted with medical students from Temple LKSOM, who participated in three virtual focus groups. A total of 26 students from various years of study (2024-2027) were included. The focus groups were semi-structured, with questions designed to elicit students' experiences and perceptions regarding the use of interpreter services in their education and clinical practice. Thematic analysis was performed on the transcribed data to identify key themes. Five themes were found in the responses of students from all three focus groups.

/ REFLECTION / LESSONS LEARNED: The analysis reveals several key themes, including the critical role of interpreters in providing culturally competent care, the burden placed on bilingual students to serve as untrained interpreters, the lack of formal training on interpreter usage, and the value of simulations with non-English-speaking standardized patients. Mixed feelings were expressed regarding the inclusion of interpreter use in Objective Structured Clinical Examinations (OSCEs). The findings indicate a significant gap in the current curriculum regarding the effective use of interpreters. This study highlights the need for comprehensive training on using interpreter services within medical school curricula to ensure future physicians are prepared to provide equitable care to LEP patients. Medical education can significantly change how future physicians interact with LEP patients thus by addressing these educational gaps, physicians can be better equipped to manage language barriers in clinical practice, ultimately improving patient outcomes and reducing health disparities. CAREGIVER CONVERSATIONS: A CASE-BASED WORKSHOP FOR MEDICAL STUDENTS Noam Margalit1; Susannah Cornes2. 1Medicine, University of California San Francisco, San Francisco, CA; 2Neurology, University of California San Francisco, San Francisco, CA. (Control ID #4267488) SETTING AND PARTICIPANTS: Focus interviews were conducted with our academic institution’s UME course directors to evaluate gaps in caregiver communication education in the pre-clinical curriculum. We designed the workshop for all second-year medical students to allow for incorporation of acquired skills into clinical rotations, where conversations with patient caregivers are vital. DESCRIPTION: Caregivers are essential to the care of older adults, particularly those with cognitive impairment. However, trainees receive minimal education on communication skills with caregivers, which can compromise patient care. We developed a workshop to bridge this gap early in undergraduate medical training. We designed a pilot workshop featuring 2 student-led cases in academic year 1 (Y1), with a transition to 3 student-led cases session in academic year 2 (Y2) based on student feedback. Students were surveyed using a five-point Likert scale that focused on assessment of Kirkpatrick levels 1 and 2, “Reaction” and “Learning,” determined primarily through self-rated changes in student knowledge and confidence. EVALUATION: 187 MS2’s participated in the workshop Y1. Of these, 139 (74%) completed the pre-session survey and 81 (43%) the post-session survey. 146 MS2’s participated in the workshop in Y2. Of these, 110 (75%) completed the pre-session survey and 54 (37%) the post-session survey. In sum, approximately two-thirds (63%) of students reported no prior experience interviewing caregivers of older adults. Following the session, a higher percentage expressed comfort interviewing caregivers (48% v 82%) as well as confidence in their knowledge of barriers (56% v 82%) and best practices (49% v 85%) for effective communication with older adults and their caregivers.

/ REFLECTION / LESSONS LEARNED: This workshop improves students’ confidence and self-rated understanding of caregiver communication skills. Student narrative feedback highlights the value of perspective-taking and practice-based learning. In the future, this session could be expanded to other levels of clinical training, where gaps in caregiver communication skills also persist. CBLC-CAMPOS CONFERENCE, A CASE-BASED INTERACTIVE MEDICAL SPANISH CURRICULUM FOR THIRD YEAR MEDICAL STUDENTS ENROLLED IN THE COMPREHENSIVE ADVANCED PROGRAM OF SPANISH (CAMPOS) AT UNC SCHOOL OF MEDICINE Ana L. Bermudez, Marco A. Alemán, Daniel S. Reuland. Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC. (Control ID #4224085) SETTING AND PARTICIPANTS: To pilot the addition of an interactive, case-based course to an existing longitudinal medical Spanish program for intermediate-advanced Spanish speakers during a required 16-week ambulatory rotation for third-year medical students DESCRIPTION: The course was administered in Spanish to CAMPOS third-year students during their required ambulatory medicine rotation called Community-Based Longitudinal Course (CBLC). Four monthly sessions were held in person with students at two of the four clinical campuses. Common ambulatory medical conditions were identified and fourth-year, MD-PhD students, or students on leave of absence for their graduate studies but who have previously participated in at least one required clinical rotation, were identified as case-presenters and performed role-play as patients. A bilingual attending mentor was assigned to the presenter and guided the conference. The case was revealed in segments as third-year students asked relevant culturally sensitive questions about the history, exam, including social determinants of health (SDOH). Learners discussed choices of diagnostic tests, differential diagnoses, and treatment plans with the patient. The presenters then provided a clinical summary, addressed, and taught about the clinical topic and any SDOH and cultural issues that are identified as learning objectives for the case. EVALUATION: A seven question anonymous survey was administered to the students after the first and fourth session (n=31). Survey response rate was 94% during the first academic year of the conference and 73% during the current academic year. Data showed 86% of students found the sessions helped with practicing medical Spanish after the 4th session, 93% of students felt better prepared to identify common health disparities affecting the Latine population, and 57% of students felt they did not need assistance performing case-specific, culturally respectful history in Spanish after the 4th session compared to 40% after the 1st session.

/ REFLECTION / LESSONS LEARNED: The CBLC-CAMPOS Conference is a case-based interactive medical Spanish curriculum for third year students during their third-year ambulatory rotation, currently undergoing its second rendition. The pilot study has showed that students enjoyed and learned from the sessions. Adding a series of case-based, interactive medical Spanish teaching during a required clinical rotation to medical students with intermediate-advanced Spanish fluency was feasible. CO-PRODUCING CULTURALLY RELEVANT SIMULATION CASES ACROSS CONTINENTS: A COLLABORATIVE APPROACH TO ENHANCING COMMUNICATION SKILLS IN NORTHERN GHANA Christine P. Beltran1; Abdul-Jalilu M. Muntaka2,3; Sondra Zabar1; Sheila A. Owusu4,5; Fathea Bani4,5; Alhassan Abdul-Mumin4,5; Kathleen Hanley6. 1Medicine, New York University Grossman School of Medicine, New York, NY; 2Surgery, Tamale Teaching Hospital, Tamale, Ghana; 3Surgery, University for Development Studies, Tamale, Northern Region, Ghana; 4Pediatrics and Child Health, Tamale Teaching Hospital, Tamale, Northern Region, Ghana; 5Pediatrics and Child Health, University for Development Studies, Tamale, Northern Region, Ghana; 6Internal Medicine, NYU Langone Health, New York, NY. (Control ID #4271427) SETTING AND PARTICIPANTS: Faculty from an academic center in the United States and faculty from a teaching hospital and medical school in northern Ghana engaged in a co-production process following the ADAPT-ITT model to develop simulation cases that were later implemented in Ghana. DESCRIPTION: Since February 2024, faculty from both institutions participated in bi-weekly Zoom meetings to co-produce standardized patient (SP) exercises aimed at assessing communication skills. Ghana faculty prioritized skills of ‘breaking bad news ‘and ‘conducting an informed consent’, leading to the development of two Objective Structured Clinical Examination (OSCE) cases: 1) delivering bad news to a mother about her newborn’s jaundice and 2) conducting an informed consent discussion for an appendectomy. United States cases were adapted, with input from Ghanaian faculty and further refined during the training of eight SPs who were midwives and nurse interns to ensure cases were authentic and culturally relevant. Changes made included modifying the SPs’ personality to reflect their more reserved/stoic communication style and including family dynamics, Ghanaian cultural norms, and considerations specific to the local hospital setting. In October 2024, US team members visited Ghana to assist with piloting these cases with house officers who have completed six years of medical school and currently in their required two-year house officer training. SP encounters were held in offices and classrooms, SPs completed the checklist via an online REDCap survey on their phones, and learners filled out paper post-OSCE evaluations. Cost of implementation was ~$750. EVALUATION: Participants (n=62) completed a post-OSCE evaluation and more than 95% of learners reported that both the case and the educational activity were educationally valuable. 97% of house officers recommended this educational activity to future learners. Ghanian faculty described the co-production process as ‘enlightening’, as developing the cases bridged the gap between theory and real-life situations. They appreciated seeing how learners would handle these cases without fear of making mistakes or causing harm and to see learners’ satisfaction with the experience. Faculty also gained skills in designing and implementing OSCEs, making them more confident and comfortable to deliver future OSCEs.

/ REFLECTION / LESSONS LEARNED: This low-cost, high-impact OSCE pilot demonstrates how the OSCE approach, commonly used in US medical education, can be successfully adapted to new settings with minimal resources. Despite challenges in cross-cultural collaboration navigating time differences, technology issues, differing communication styles and expectations, and team fluidity, we built trust through a shared goal of enhancing communication skills among new doctors. This shared vision drove our co-production process and underscored the value of active faculty engagement and shared responsibility, making learning engaging, relevant, and effective for all. CROWDSOURCING FOR LGBTQ+ MEDICAL EDUCATION: ANALYSIS OF AN LGBTQ+ HEALTHCARE GRADUATE CERTIFICATE PROGRAM Christopher P. Terndrup. General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4220012) SETTING AND PARTICIPANTS: Participants were recuited via Graduate Medical Education at Vanderbilt University Medical Center (VUMC). Residents and fellows were invited via distribution lists and during orientation. They were connnected virtually for teaching sessions and supported virtually with connections for clinical exposure and research interests. Teaching sessions were held over Microsoft Teams and other work was completed at VUMC and with local community resources. DESCRIPTION: The certificate in Lesbian, Gay, Bisexual, Transgender, and Queer + (LGBTQ+) Health provides advanced training and experience to better equip residents and fellows to meet the unique needs of LGBTQ+ individuals, address disparities these marginalized groups may face, and improve the experience of LGBTQ+ individuals interfacing with the health care system. The certificate is granted by Vanderbilt University Medical Center (VUMC) and the Office of Graduate Medical Education (GME) after successful completion of a curriculum coordinated by VIVID Health and the Vanderbilt Program for LGBTQ+ Health. The goal of the program is to improve provider knowledge and enhance physician leadership regarding education, cultural competence, and compassionate care for LGBTQ+ populations. The certificate program is comprised of three components: - Didactic elements composed of group discussion seminars and journal clubs - Experiential activities - Capstone project Monthly seminars with topics covering key topics related to LGBTQ+ health are coordinated with VIVID Health and the Vanderbilt Program for LGBTQ+ Health, as well as with faculty and invited subject matter experts. EVALUATION: Program participants were evaluated via a RedCap survey at completion of the Certificate Program. They were quesionted regarding: satisfaction with program components, effectiveness of instructional approaches, selfreported behavioral change towards LGBTQ+ patients, and qualitative review of the program. Participants reported rates on a 100-point scale: enjoyment at 92.4% with teaching sessions, 94.4% with journal clubs, and 99.6% with clinical experiences; effective learning at 98.6% with teaching sessions, 91.1% with journal clubs, and 98.2% with clinical experiences. 80% expected changes in their behavior towards LGBTQ+ healthcare based on the certificate program.

/ REFLECTION / LESSONS LEARNED: Our Certificate Program in LGBTQ+ Health supported GME trainees in enjoyment, instruction and behavior change regarding care for sexual and gender minority patients. The residents benefited from the program and "loved meeting other trainees from different departments" and recognizged needs to "be more inclusive in setting up clinical spaces". Institutional knowledge across disciplines supported broad-ranging education for more mpactful teaching. Trainees enjoyed virtual flexibility but wished they "could have met in person sooner." Other institutions can likely create similar programs to benefit trainees locally and contrbute to larger cultural change to improve healthcare outcomes for LGBTQ+ patients. DESIGNING A RIGOROUS PROGRAM EVALUATION FOR LEADERSHIP DEVELOPMENT PROGRAM FOR WOMEN TRAINEES IN MEDICINE Gayathri Krishnan1; Namrata Patel1; Kylie Cleavanger1; 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 #4269127) SETTING AND PARTICIPANTS: The Forum for Women in Medicine (FWIM) Trainee Leadership Development Program (TLDP) is an 8-month long certificate program for women trainees in medicine. The curriculum covers topics such as effective communication skills, negotiation strategies, creating individual career development plans, curating your professional network etc., delivered as 7 sessions. FWIM TLDP was piloted in 2022, and data collected from the two graduated trainee cohorts through pre-course surveys, post course surveys, and post session surveys show significant increase in self reported confidence in targeted leadership competencies. While self reflections, satisfaction, feasibility and interest were assessed in the first two years, program outcomes of knowledge or skill development were not analyzed. A model for rigorous program evaluation was created for the third iteration of FWIM TLDP that commenced in September 2024 and will complete in April 2025. DESCRIPTION: Since this is an innovative program which is novel and not evaluated previously, the primary program evaluation model is of Program Outcomes- oriented approach. The short-term program outcomes to be assessed are skills, knowledge, and attitude changes of trainees through 7 sessions of FWIM TLDP. Data collection is done in-person during sessions as well as through a web-based data collection instrument, Qualtrics. Kirkpatrick model for program evaluation is the framework for assessing outcomes. EVALUATION: The first step was to create curriculum mapping for the program. Individual sessions had SMART objectives and in-session data was collected for assessment that would map to the objectives. Kirpatrick level 1 will be assessed through pre and post course surveys and post session surveys on satisfaction, effectiveness of speaker and content delivery. Kirkpatrick level 2 evaluation will be through iRAT (Individual Readiness Assurance Test), listing/identifying of core content covered during Team Based Learning (TBL), and in-session recording of trainee responses. Team and individual application exercises help assess application of knowledge. Kirkpatrick level 3 evaluation of change in practice will be assessed through role plays. Check lists containing the demonstrable techniques and influence tactics taught in sessions, for implementation of skills. The long-term program outcome is impact assessment. For this, graduated trainees from the first and second cohort will be followed up at 1 year and 5 years and surveyed on the application of these skills and how the change in behavior has impacted their careers.

/ REFLECTION / LESSONS LEARNED: Leadership development courses provide vital leadership skills to support the future women leaders in medicine. A robust evaluation will help an innovative curriculum such as this with scholarship, scalability, leadership buy-in for sustainability, future impact evaluation and broader dissemination and replicability. ONLINE RESOURCE URL: https://internalmedicine.wustl.edu/diversity/forum-for-women-in-medicine/fwim-trainee-leadership-development-program/ DEVELOPING INTEGRATIVE MEDICINE/WHOLE HEALTH CLINICAL ROTATIONS AND CURRICULUMS FOR RESIDENT PHYSICIANS: BRINGING THE PATIENT BACK TO THE CENTER OF MEDICINE Ronovan Ottenbacher. Internal Medicine, Fargo VA Health Care System, Fargo, ND. (Control ID #4228768) SETTING AND PARTICIPANTS: These rotations took place at our local VA medical center. It involved our Internal Medicine and Transitional Year residents. DESCRIPTION: We developed embedded and stand-alone rotations for residents focused on integrative medicine and Whole Health at the VA. Initially 25-30% of the time on our PC rotation was used for this process then the same concepts/structures were used to start a stand-alone rotation (Integrative Medicine in Internal Medicine). The defining feature of the curriculum and rotation was how to implement integrative medicine and Whole Health into clinical and hospital medical practices including changing the conversation with patients from “What’s wrong with you?” to “What matters to you?” as a core tenant of VA Whole Health. There was a strong and intentional focus on operationalizing concepts so they would be practical and functional in clinic/hospital practice settings. Additionally, there was a significant focus on thought-provoking, interactive discussions with residents. Along with critical thinking and challenging of practices, there was training in the intentional application of common sense and communication techniques. The saying for the rotation was: “STOP and consider- apply the 4 C’s- did you apply Critical thinking and Common sense? Did you Challenge the status quo? How are you Communicating?” These skills were tied into the larger goals of developing a medical practice emphasizing integrative medicine ideals and a strong patient focus. EVALUATION: Qualitative information and tracking was central to our continuous rotation improvement. This included structured weekly feedback (with real time rotation adjustments for the current resident) and structured end of rotation feedback including resident input for how feedback would be integrated into the next rotation.

/ REFLECTION / LESSONS LEARNED: The rotations received outstanding feedback. Residents found them to be highly engaging and noted they teach skills not learned with traditional education. The rotations were also a lot of fun (which was intentional) and multifaceted. There has been a clear consensus from the residents that this will have a major impact on their future medical practice. To this point (noting it was only a few residents), 50% of the residents in the first quarter requested to make time for a second integrative medicine rotation. There were challenges and barriers. One was working with whole health staff and providing high level education when the teaching staff are not physicians. The second challenge has been to make the rotation interactive and appropriate for resident physicians and not just a shadowing experience. To mitigate this, we worked closely with the whole health team. We outlined clear goals breaking down to granular details the daily schedules including leveraging experience and ideas from our PC attending physicians with signficant backgrounds resident education (to assist Whole Health staff). ONLINE RESOURCE URL: https://drive.google.com/drive/folders/1pBBrw7EUckrp0ma6-nbzcPRCKWGnmPKX DEVELOPING OUTPATIENT PRECEPTORS’ SKILLS THROUGH AN EMBEDDED PEER OBSERVATION PROGRAM Kendra Moore, Miranda Dunlop. Department of Medicine, UCSF, San Francisco, CA. (Control ID #4250369) SETTING AND PARTICIPANTS: Participants included 22 GIM faculty and fellows precepting residents in the ambulatory environment at an academic medical center. DESCRIPTION: Medical educators who precept in the outpatient setting often teach alone and are limited in opportunities to obtain feedback from peers. Our institution offers teaching observations but few participate due to clinical demands. Educators desire time efficient development opportunities that simultaneously facilitate supportive peer relationships. We developed a preceptor observation program (POP) embedded into preceptors’ existing scheduled sessions. We created educator dyads with similar levels of experience to observe one another while precepting. A brief recorded training and tips for peer observations1 were sent to participants. Pairs met just prior to a half-day observation so the observed preceptor could share their goals. The observing partner used an observation form to guide feedback, delivered at a debrief following the session. Afterwards, both educators chose a teaching experiment they would try moving forward. In a subsequent session, roles were reversed and the process repeated. EVALUATION: The program was evaluated through informal conversations and a satisfaction survey (n=7). Overall satisfaction with the program was 4.67 (5 point scale). Notably, participants rated their confidence in delivering feedback to peers at 3.42 (5 point scale). Participants highlighted the strengths of the program to be connecting with another educator and having protected time to focus on educator development. The main challenge that was highlighted was variable quality of feedback.

/ REFLECTION / LESSONS LEARNED: Several lessons were identified: Protect time for faculty development in context: It was essential that observations took place during participants’ regularly scheduled precepting time, and that faculty received their normal work credit for this time even when observing. Cultivate psychological safety: Participants valued setting their own learning priorities and focusing on skills and behaviors. Both partners choosing takeaways to integrate into their teaching enhanced a feeling of equality. Paired educators should be peers with similar levels of experience and the two observations should be scheduled close together to increase trust within the dyad. Train faculty to deliver feedback. We provided limited training for educators. Participants highlighted that the quality of the experience depended on the pairing. Training is needed around feedback delivery and likely requires experiential skills practice. To build on these lessons, we made incremental changes to POP in its second year: shifting from opt-in to opt-out, encouraging participants to attend feedback skills workshops, and simplifying the observation form to facilitate psychological safety. DEVELOPMENT AND EVALUATION OF A PATIENT DISCHARGE SKILLS CURRICULUM FOR SENIOR RESIDENTS Gena Lenti, Anna F. Hagan, Maralyssa Bann. General Internal Medicine, University of Washington, Seattle, WA. (Control ID #4220162) SETTING AND PARTICIPANTS: The curriculum was administered to and assessed by senior residents rotating at Harborview Medical Center (HMC), Seattle’s county hospital, between August 2023-October 2024. DESCRIPTION: The curriculum was developed using Kern’s six step framework. Prior to creating the educational content, needs assessment focus groups were conducted with social workers and case manager nurses who work closely with resident teams to support patient discharges. Via these focus groups, themes for resident improvement in discharge planning were identified. Using these themes, an educational module and discharge practice cases were created and delivered via optional just-in-time trainings for residents prior to rotating on inpatient service at HMC. Elective surveys were administered after participants viewed the module and at the end of the rotation. EVALUATION: Interdisciplinary focus groups identified six main themes for resident improvement in discharge planning: understanding discharge locations, communicating earlier with consultants regarding discharge, discharge medication reconciliation, identifying need for outpatient appointments, placing orders for home support (i.e. equipment, home health), and completing discharge summaries in a timely fashion. CCNs also suggested education include teaching on harm reduction around discharge to combat moral injury they perceive residents to experience with non-ideal discharges of vulnerable patients. Evaluations of the curriculum were collected monthly, with 38 residents responding to the post-module survey and 27 to the end of rotation survey. Of participants who completed the end of rotation survey, 93% (25/27) agreed or strongly agreed that it is important to learn the above discharge planning skills and felt that learning those skills helped them more effectively move patients toward discharge. 96% (26/27) of participants agreed or strongly agreed that the educational module helped them employ strategies for harm reduction around discharge. Fewer residents participated in the discharge cases, though 88% (7/8) felt that the simulated cases helped them better prioritize discharge tasks for their actual patients.

/ REFLECTION / LESSONS LEARNED: Residents found the discharge curriculum helpful for effectively managing patient discharges and felt that learning discharge skills is important. Given the perceived importance, dedicated time for a discharge curriculum should be considered. Future study should seek to better understand the moral injury incurred by learners around non-ideal discharges, though teaching harm reduction strategies could improve discharges for vulnerable populations and mitigate distress. ONLINE RESOURCE URL: Link to online video module: https://drive.google.com/file/d/10y4QfIz5dZfo-LdoH-ZVECFFo1qdDFJp/view?usp=drive_link Link to cases (learner): https://drive.google.com/file/d/1SMvusS4s2kySAsMIdB2G1KMf43yyixbb/view?usp=sharing Link to cases (facilitator): https://drive.google.com/file/d/1cEkQdsLpozM1ArBSViAyZHrA8yqrRE5j/view?usp=sharing ENHANCING EVIDENCE BASED MEDICINE EDUCATION THROUGH WEB BASED VISUALIZATIONS WITH PYTHON Venkata S. Patchigolla1; Amolak S. Jhand1; Hyeok Jun Lee1; Laura J. Benjamins2. 1School of Medicine, Wayne State University School of Medicine, Detroit, MI; 2Pediatrics, Wayne State University School of Medicine, Detroit, MI. (Control ID #4271453) SETTING AND PARTICIPANTS: We piloted interactive online visualizations in EBM small group sessions during the 2024-2025 academic curriculum for first year medical students in a Midwest medical school. Students were anonymously surveyed regarding the utility of the tool for understanding challenging statistical topics. DESCRIPTION: Developing an understanding of statistical concepts is a core component of evidence based medicine (EBM), which is a vital discipline for interpreting and applying scientific evidence into clinical practice. However, learning these concepts remains a challenge for many medical students. Traditional teaching methods rely on didactic lectures, which can limit student engagement. To address this limitation, we developed interactive web-based modules which were incorporated into small group learning sessions for first year medical students in a Midwest medical school to enhance their comprehension of the pre-existing EBM curriculum. Python-Streamlit was used to develop interactive online applications for visualizing EBM concepts that are part of the standard medical school curriculum. Concepts included power, type 1 and type 2 errors, confidence intervals, biases and other EBM concepts. Visualizations were focused on encouraging students to be interactive and allowed them to experiment with the demos. For example, in a demo aimed to teach students about confidence intervals, students were given the ability to dynamically adjust sample size to observe how this changed the confidence interval on a separate plot in real time. EVALUATION: This tool was built iteratively throughout the year as first year medical students were going through the curriculum. A Qualtrics Survey was used to anonymously survey students on their satisfaction with the tool so that future demos could be better tailored to suit their needs. Volunteer responses (N = 6) to our preliminary survey were overwhelmingly positive. All respondents reported an improvement in their understanding of EBM concepts after using the tool. Written feedback expressed appreciation for providing visual representations of the curriculum content. As this tool was a new addition to the 2024-2025 curriculum, students will be surveyed at the end of the academic year on their feelings regarding the utility of the tool. This future survey will increase sample size, improving our ability to draw conclusions regarding the tool’s utility.

/ REFLECTION / LESSONS LEARNED: Integrating interactive web-based tools into medical education can significantly enhance student understanding of complex concepts. By allowing students to interact with data, it encourages active learning and provides an intuitive and engaging way to learn EBM. Our Streamlit-based platform was free to build and is free to use, allowing easy and accessible integration into the medical curriculum. Future directions could include expanding the tool to interactively teach physiological and other medical concepts that classically challenge students. ONLINE RESOURCE URL: EBM Visualizations: https://dsimctool.streamlit.app/EBM ENHANCING FOOD INSECURITY SCREENING AND INTERVENTION PRACTICES: A RESIDENT-LED EDUCATION APPROACH Edward Corty1; Rohin A. Aggarwal2; Katherine Shaw3,1. 1Internal Medicine-Pediatrics, Johns Hopkins University, Baltimore, MD; 2Geriatrics, Mount Sinai Health System, New York, NY; 3Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4241513) SETTING AND PARTICIPANTS: The project took place in an internal medicine resident continuity clinic situated in a federally qualified health center in the Mid-Atlantic region. The initiative targeted adult patients and engaged residents to enhance food insecurity (FI) screening and intervention practices. DESCRIPTION: Food insecurity is associated with an increased risk of numerous negative health outcomes including type 2 diabetes, cognitive impairment, and falls. While approximately 13.5% of households were food insecure in 2023, a recent universal screen of 300 patients at our clinic revealed a rate close to 50%. We developed a short educational program with the following aims: 1) increase resident knowledge of FI and its health impacts, 2) improve the rate of FI screening and use of the Hunger Vital Signs, and 3) facilitate referrals to social work and known FI community resources. Teaching residents presented the prepared curriculum during a ten minute education session once weekly over a four month period. Presentation topics included FI epidemiology, clinical relevance, screening recommendations, and intervention options. For efficient workflow, we developed smart phrases for residents to document an assessment and plan for FI and to provide a list of community food resources in the patient’s discharge instructions. EVALUATION: We used pre- and post-education surveys to assess resident knowledge about FI, comfort screening for FI, knowledge about next steps after a positive FI screen, and use of the intervention. Twenty three of 47 (49%) residents completed both pre- and post-education surveys. Residents demonstrated improvement in their knowledge of FI prevalence (91% vs 96%), FI terminology (17% vs 52%), associations with chronic disease and geriatric syndromes (84% vs 96%), and validated screening tools for FI (70% vs 100%). On a 10-point Likert scale, residents on average had increased comfort screening for FI (6.4 vs 7.7), knowledge on counseling patients with FI on next steps (5.2 vs 7.2), and found the educational sessions useful for their clinical practice (7.9). Results also showed that 87% of residents screened at least 1 patient for FI and 30% screened greater than 5 patients over the four month period.

/ REFLECTION / LESSONS LEARNED: This brief education intervention improved resident knowledge, comfort, and engagement with FI screening and interventions. Residents were also exposed to the pervasiveness of FI among our community and appreciated the importance of addressing FI in primary care settings. Leveraging residents as teachers during pre-clinic education sessions proved an effective educational strategy by fostering peer learning and participation. Future efforts should focus on tracking referrals and further integrating social determinants of health into clinical practice to ensure comprehensive patient care. EVALUATING INTERNAL MEDICINE RESIDENTS’ ATTITUDES TOWARDS THEIR HEALTH EQUITY CURRICULUM Alyssar Habib2; Juan Cerezo2; Yanbing Chen2; Lena Jorde2; Margaret Horlick3; Elie S. Al Kazzi1; Christian Torres4. 1Internal Medicine, NYU Langone Health, New York, NY; 2Internal Medicine, New York University Grossman School of Medicine, New York, NY; 3Medicine, New York University, New York, NY; 4Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4272355) SETTING AND PARTICIPANTS: Categorical Internal Medicine (IM) residents in a large academic medical center. DESCRIPTION: Advancing health equity has increasingly been prioritized in healthcare delivery and as a pillar of medical education. The Accreditation Council for Graduate Medical Education (ACGME) and Association of American Colleges (AAMC) have encouraged residency programs to expand educational opportunities in health equity. Despite this, in a 2020 survey of 227 program directors, only 40% of IM programs were noted to have a formal health disparities curriculum, with the majority focusing on lecture and discussion-based learning. However, little is known about learners’ satisfaction with these curricula. We therefore aim to assess resident satisfaction with our local health equity education and identify additional learner needs in preparation for a potential restructuring of our curriculum. EVALUATION: We first measured learner satisfaction and performed a needs assessment using an anonymous program-wide survey. The survey utilized yes/no and 4-point Likert scale questions to assess overall satisfaction with the current health equity curriculum. Multiple-choice and short-answer questions were also included for a needs assessment. Statistical analysis was performed using regression and qualitative analysis. Preliminary results from a 25% overall response rate showed that residents with a prior interest in health equity were 90% less likely to report satisfaction with the current health equity curriculum (OR = 0.09, p =0.03). Most respondents expressed interest in opportunities to get involved with health equity activities, such as research (53%), medical education (66%), and community service (59%). Respondents also reported interest in a health equity elective (81%) or a health equity concentration/track (55%).

/ REFLECTION / LESSONS LEARNED: Our results suggest a discrepancy between residents’ expectations and their degree of involvement in health equity-related activities during residency training. The results also suggest an interesting gap in learner satisfaction, highlighted by respondents’ desire to engage in active learning opportunities like research or community service, as opposed to additional didactics. This stresses the need to better connect house staff to mentors and institutional resources, particularly at institutions like ours that possess many opportunities in health equity, both within and outside the residency program. Incorporating health equity scholarly activities and designing strategies to leverage institutional resources to improve educational experiences require further investigation. Next steps include increasing our survey’s response rate and performing focus groups to further characterize learning gaps. We hope to use this information to pursue a collaborative, learner-driven restructuring of our health equity curriculum. EVALUATING PATIENT CARE THROUGH A UNIQUE CONTINUITY OF CARE PROGRAM AT A STUDENT RUN FREE CLINIC Juan A. Briano1; Elizabeth K. Benitez1; Tiffany Merlinsky1; Isaac A. Nathoo1; Ashita S. Batavia2; Cecilia E. Nicol2; Pamela Charney3. 1Medical School, Weill Cornell Medicine, New York, NY; 2Medicine, Weill Cornell Medicine, New York, NY; 3Internal Medicine, Weill Cornell Medical College, New York City, NY. (Control ID #4272190) SETTING AND PARTICIPANTS: A student-run free clinic (SRFC) provides primary care services for uninsured patients living in a large mid-Atlantic city. Medical students at a mid-Atlantic medical school support this mission by facilitating care under the supervision of board-certified attending physicians. Patients who participate in a longitudinal patient program within the SRFC were assessed for care process metrics. DESCRIPTION: At the start of the preclinical curriculum, all medical students have the opportunity to enroll in a unique continuity of care (COC) program in which they are assigned an SRFC patient for whom they act as the primary point of contact throughout their preclinical education. Students are expected to have monthly contact with their patients, and assist with their care at all SRFC appointments. They are also encouraged to attend outside appointments, and assist their patient in navigating the healthcare system. The internal records of patients who participated in this program between the years 2021-2024 were assessed and compared to age and gender-matched non-participant controls. The data were analyzed using Microsoft Excel. EVALUATION: Between the years 2021 and 2024, forty-six patients participated in COC program. Thirty-three age and gender matched controls were identified among the general SRFC patient population. We found that a significantly greater proportion of program participants were successfully referred to and received subspecialty care (OR=3.1, p=0.02). These referrals spanned diverse medical and surgical specialties. We also found that a significantly lower proportion of program participants were English speaking compared to the general SRFC patient population (OR=0.29, p=0.02). We found no significant difference between program participants and controls in loss to follow up, rates of transition to insurance, or use of SRFC services such as mental health counseling and gynecology.

/ REFLECTION / LESSONS LEARNED: Our results indicate that while this SRFC is able to ensure that patients are able to access SRFC resources, additional support from medical students is beneficial to patients seeking outside specialty care and those who are not proficient in English. Patients who may need additional SRFC support are often identified as candidates for COC enrollment, which may explain the greater proportion of non-English speakers. That these patients then go on to have significantly more successful referrals than the general SRFC patient population indicates that this intervention is effective at addressing these concerns. One possible limitation to this study is selection bias, as patients seeking subspecialty care may also be more likely to enroll in the program. Future work may include assessing patient satisfaction with this program. EVALUATING THE INCORPORATION OF THE UNINCORPORATED: MEDICAL STUDENT PERCEPTIONS AND KNOWLEDGE OF US TERRITORIES AFTER INTEGRATION IN THE PRE-CLERKSHIP MEDICAL CURRICULUM Marinna Okawa1; Sarita Warrier1,2. 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 #4271595) SETTING AND PARTICIPANTS: This innovation was a curriculum review and enhancement of US territory health pre-clinical content for first-year medical students in a Northeast region academic medical institution. To evaluate short and longer-term impacts, first-year medical students took a Likert-scale survey in the first month of classes (early-year MS1) and at the end of the academic year (end-year MS1) about US territory knowledge and perceptions. The same survey was administered to fourth-year medical students (MS4) and faculty. DESCRIPTION: A curriculum review was conducted via a Canvas website iSeek keyword search to identify first-year lectures on epidemiology, patient education, Indigenous health, and health policy, infrastructure, and disparities. These were manually reviewed to identify additional content opportunities. Results were presented to course leaders to coordinate curriculum development plans. Developments included tailored slide or guide submissions to lecturers and addition of a mini-lecture series on US territory and Indigenous health. Of 499 lectures, 203 had at least one positive iSeek result. 155 were manually reviewed, 35 were appropriate and had sufficient information to add, 30 had edits submitted, and 20 were ultimately incorporated. EVALUATION: Responses were compared among early-year MS1s, end-year MS1s, MS4s, and faculty (Kruskal-Wallis) and early- vs end-year MS1s (unpaired t-test). Preliminary results showed that early-year MS1s already differed from MS4s and faculty responses: they disagreed that US territories receive similar healthcare access and quality as the states (P=0.005) and felt more confident discussing territory health disparities (P=0.02). End-year MS1s, as compared to all other groups, also disagreed about equality of US territories’ health care access and quality (P=0.0002) and felt more confident discussing health disparities (P=0.0001). In addition, they better understood how residents of the US territories experience different rights from the continental US (P=0.01) and differences in their government and healthcare infrastructure (P=0.003). End- vs early-year MS1s had similar results and felt more comfortable working with patients from the US territories (P=0.01).

/ REFLECTION / LESSONS LEARNED: These results suggest that early incorporation of US territory health across multiple lectures can significantly impact knowledge and perceptions of health care inequalities and comfort in working with underrepresented populations. These additions are more feasible in lectures that discuss epidemiology and social determinants of health vs pathophysiology and anatomy. The former themes provide a framework for discussions of US territory health and avoid conflating outcome discrepancies with race-based medicine. Providing information on US territories to course leaders and designing pre-made slides tailored to lecturers’ styles assisted with content integration. As lectures change, this project will focus on creating broadly available and adaptable slides for continuous incorporation. EVALUATION OF A CLIMATE CHANGE AND PULMONARY HEALTH CURRICULUM FOR FIRST YEAR MEDICAL STUDENTS Riya Goel, Anne Emanuels, Rebecca Philipsborn, Ashish Mehta. Medicine, Emory University, Atlanta, GA. (Control ID #4270314) SETTING AND PARTICIPANTS: 148 first year medical students taking a pre-clinical pulmonology module exam. DESCRIPTION: The profound and growing impacts of the climate crisis impinge upon pulmonary health. Air pollution, a major contributor to climate change, plays a critical role in asthma pathogenesis, impaired lung development, and heightened respiratory morbidity and mortality. Historically marginalized populations are disproportionately exposed to higher levels of air pollution, with social vulnerability amplifying the burden of respiratory illnesses. While around 70% of US medical schools cover climate change in their curriculum, strategies for assessing students and evaluating curricula are lacking. Our institution was an early adopter of a disseminated climate change and health curriculum integrated in the pre-clinical phase, including in the first year Pulmonary Course. The curriculum includes content integrated into core pulmonology topics (asthma, chronic obstructive pulmonary disease, pulmonary function tests, pathology) delivered via large class lectures as well as small group problem-based learning. Students were assessed on their understanding of the pulmonary curriculum via multiple-choice and essay questions; these results inform our evaluation of the climate change and environmental health content woven into the first-year medical school pulmonary curriculum. EVALUATION: Two of the multiple-choice items and one essay question in the course exam focused on climate and respiratory health. Course directors developed a rubric to score the essay question and assess student performance across key domains—pathophysiology, epidemiology, PFTs, exposure, susceptibility, and adaptive capacity. Two independent reviewers evaluated essay responses using this rubric. Discrepancies were resolved by a third reviewer. Descriptive statistics were used to demonstrate the frequency of student application of content across these domains towards evaluating performance of the curriculum and student understanding of critical topics related to air pollution and asthma.

/ REFLECTION / LESSONS LEARNED: 103 (72%) students chose to answer the essay question on climate and health. The average score was 3.92/4 (range 3–4), compared to 3.29/4 (range 1.5–4) for the emphysema question. Among six climate and health domains, student essays overwhelmingly demonstrated understanding of epidemiology (99%) and the significance of exposure (98%) in pollution-asthma relationships. Fewer responses reflected understanding of pathophysiology (62%), physiologic susceptibility (60%), and adaptive capacity relevance (61%). Only 4% described the effects of air pollution on pulmonary function tests and asthma. These findings highlight successes and opportunities for improving the climate change and environmental health curriculum in the pulmonary course. Results will inform targeted revisions to course content, questions, and scoring rubrics, specifically to enhance understanding of pulmonary function tests in clinical care for patients exposed to air pollution. HOUSE CUP: LONGITUDINAL GAMIFICATION TO IMPROVE ENGAGEMENT OF INTERNAL MEDICINE RESIDENTS Sunny Han, Jordan Cahn, Stephanie M. Hastings, Priyank Jain, Lakshmana Swamy, Rebecca Rogers. Medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #4270762) SETTING AND PARTICIPANTS: Participants were internal medicine interns, residents, and volunteer faculty members within the department of medicine of a small community-academic hospital in the Northeastern United States. DESCRIPTION: Resident participation in didactics and submission of feedback surveys have been a challenge, and in-person conference attendance has not returned to pre-pandemic levels. We hypothesized that gamification of participation would increase engagement and improve a sense of community among residents. The game format is a “House Cup” where 39 residents are divided into 3 teams across years of training based on their ambulatory block groups to build upon established relationships and friendly rivalries. The teams devised names and logos for their “houses.” They competed against each other for points and the team with the highest points at each round won a prize. Categories for which residents can earn points are diverse and include rewarding busy shifts with multiple discharges or admissions, in-person attendances to conferences, completion of feedback surveys after didactics, and presenting patient cases. Prizes are events hosted by faculty members in their homes. EVALUATION: After each didactic session, we collected attendance and feedback from residents. Of the 15 didactic sessions held in July-October of 2024 vs 15 sessions in July-October of 2023, 136 surveys were collected compared to 46 in 2023 before gamification was implemented. Attendance rate during the same time period was 89.2%, of which 76.1% were in-person attendance. 79.5% of residents participated in earning points in categories other than attendance and feedback survey submission such as submitting extreme lab values and patient cases for presentations in the same time period. 6 out of 8 residents in the winning group of the first round attended the faculty sponsored prize event.

/ REFLECTION / LESSONS LEARNED: Gamification of medical education was well-received in the first several months of implementation with the majority of residents actively participating. It was a helpful tool to increase resident engagement as marked by the significant increase in feedback survey completion. Through faculty sponsored events, it also helped to increase a sense of community and collegiality among residents and faculty. The first two rounds were won by two different teams. Because points reset after every round, it motivated teams who did not win the prior round to rejuvenate their participation for a chance to win at the next round. However, it can be labor-intensive from the hosts (chief residents) of this “House Cup” to keep track of all the points and keep the competition engaging. Through several PDSA cycles, it has been important to terminate opportunities for points that gather low participation and introduce fresh categories to maintain resident enthusiasm. ONLINE RESOURCE URL: https://docs.google.com/document/d/1UBXY-rw_Dvmzrtm_rYB1DpvgYmzF_S8JWwcGLC1Z6FU/edit?usp=sharing INBOX MANAGEMENT CURRICULUM: ASSESSING FOURTH-YEAR MEDICAL STUDENT RESPONSES TO SIMULATED OUTPATIENT PATIENT MESSAGES Tristan Lemon, Lauren Heidemann, Amanda Huey, Amanda Cox, Eric Walford. Internal Medicine, University of Michigan, Brighton, MI. (Control ID #4259736) SETTING AND PARTICIPANTS: Medical students receive limited training on how to respond to outpatient electronic patient messages (i.e. “inbox messages”). However, this is an essential skill for residents who serve as primary care providers (PCP) during residency. The aim of this study is to determine if a curricular intervention can increase ability to effectively respond to patient messages. Participants were senior medical students at a Midwest academic medical school enrolled in an internal medicine (IM) residency preparation course. DESCRIPTION: Students received two simulated patient messages via email and submitted responses (role-playing as the PCP) to these cases via Qualtrics (Provo UT) platform. Case 1 was a patient requesting financial assistance for apixaban as well as exercise guidance while on a blood thinner. Case 2 was a refill request for levothyroxine in the setting of an elevated thyroid stimulating hormone (TSH). The quality of responses was assessed using a rubric organized by Accreditation Council for Graduate Medical Education (ACGME) competencies (Patient Care, PC; Interprofessional Communication, ICS; Professionalism, Prof; and Systems-Based Practice, SBP). The rubric was created with input from 3 PCPs, with students receiving points for items they should do (e.g. adjusting levothyroxine dosage appropriately) and losing points for potentially harmful actions (e.g. declining to refill levothyroxine until patient makes an appointment). Students then participated in a 30-minute interactive didactic on inbox management strategies (also developed with input from 3 PCPs) and re-wrote their responses to the cases. Members of the research team graded pre- and post-session de-identified responses. Scores were calculated as a percentage of total possible points, and data was analyzed using t-tests. EVALUATION: Forty-two students consented to have their data used. Mean (SD) scores increased pre- vs. post-intervention for Case 1 (72.2% +11.7 vs. 83.0% + 13.1, p=0.002) and Case 2 (26.5 % + 15.5 vs. 37.3% +19.7, p=0.03). When broken down by ACGME competency, the difference was attributed to PC for Case 1 (59.4% +17.3 vs. 74.5% +19.2, p=0.003); whereas there was no single ACGME competency that was significantly different pre- vs. post-intervention for Case 2. Many students received negative points for Case 2 in the areas of PC and SBP both pre- and post-intervention, such as for declining to prescribe levothyroxine without repeat bloodwork (n=2 vs. n=6) or without an appointment (n=19 vs. n=10).

/ REFLECTION / LESSONS LEARNED: Responding to inbox messages is a complex skill that integrates baseline medical knowledge, effective use of patient-friendly written language, and appropriate utilization of clinic support staff and resources. In this small, single-center study, we demonstrated that a brief didactic intervention improved students’ inbox message communication, although many students still struggled with clinical decision making and resource utilization. Future curricula will incorporate increased emphasis on SBP. LEVERAGING CHATGPT FOR QUESTION WRITING: A FACULTY DEVELOPMENT INNOVATION Jill Allenbaugh2,1; Judith Litvin1; Kathleen M. Keefe1; Karen Lin2,1. 1Biomedical Education & Data Science, Temple University Lewis Katz School of Medicine, Philadelphia, PA; 2GIM, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. (Control ID #4264171) SETTING AND PARTICIPANTS: This innovation was implemented at a large, urban medical school in Philadelphia, PA. Participants included four faculty members in educational leadership. DESCRIPTION: Creating high-quality multiple-choice questions is challenging in both undergraduate (UME) and graduate medical education (GME). The role of teaching faculty is multifaceted, with question writing as one of the least developed skills. This skill takes training, and deliberate practice, both of which are difficult as a busy educator. For reference, the National Board of Medical Examiners (NBME) item writing guide consists of a checklist of 18 criteria. The use of Generative Artificial Intelligence (AI) in medical education is emerging with little data on its use in question writing for formative or summative assessments. We conducted a pilot study to explore ChatGPT's potential for generating USMLE-style questions from didactic material and its role as a faculty development tool. Piloted in UME, thirteen hematology lectures were obtained from course faculty and uploaded to ChatGPT with a standardized prompt to generate 5 USMLE-style questions per lecture. The questions, copied unedited from ChatGPT, were reviewed by a team of four medical educators (two clinicians, two basic scientists) using a rubric to assess the criteria of: (1) appropriate clinical vignette structure, (2) appropriate learner level, and (3) alignment with session learning objectives. EVALUATION: The scored rubrics were reviewed for agreement among the faculty. The questions met the criteria of (1) appropriate clinical vignette structure 100% of the time (65/65), (2) appropriate learner level 95% (62/65), and (3) alignment with session learning objectives 97% (63/65). For a question to not meet criteria, it had to be scored as such by at least 3 of the 4 reviewers. Only one question (1.5%) failed to meet at least two criteria.

/ REFLECTION / LESSONS LEARNED: This pilot study showed that 95% of ChatGPT-generated questions were high-quality. AI-generated scaffolding of USMLE-style questions provides a model for faculty to develop question-writing skills. Additionally, faculty can incorporate more USMLE-style questions into any teaching modality without the additional time burden often attributed to this skill. Faculty expertise can instead be focused on editing content for accuracy and evidence-based practice. We envision expanding its use across both UME and GME curricula to assist faculty in creating USMLE-style questions for both preclinical formative and course assessments, interactive lectures, and board preparation. MINDS – MENTORING IN-CLINIC NEW AND DEVELOPING STRENGTHS: REAL-TIME FEEDBACK FROM SENIOR PRECEPTORS TO NEW PRECEPTORS IN RESIDENT CONTINUITY CLINIC Harrison Jackson1; Matthew Schirtzinger1; Richard Thompson2; Sonya Wegman1. 1Internal Medicine, The Ohio State University, Columbus, OH; 2The Ohio State University, Columbus, OH. (Control ID #4271514) SETTING AND PARTICIPANTS: Setting: resident continuity clinic at an academic medical center Participants: preceptors for ambulatory clinic: six senior preceptors, six first year preceptors DESCRIPTION: Timeliness is critical for effective feedback in resident graduate medical education (Ann Allergy Asthma Immunol 2022, 128:256-262). Similarly, faculty-to-faculty teaching feedback has demonstrated effectiveness when given immediately after a teaching event (Sullivan et al BMC Medical education 2012, 12:26). However, real-time educator to educator feedback during clinical teaching is unstudied and a potential opportunity for educator development. This pilot study assessed real-time feedback between faculty educators while precepting outpatient continuity clinic. Senior precepting faculty (three or more years of precepting) were paired with new preceptors (less than one year precepting). The senior preceptor attended the new preceptor’s continuity clinic and provided developmental feedback in a non-evaluative, conversational manner in real-time during clinic. EVALUATION: Evaluation: This pilot study used qualitative responses as the primary measure. Both new preceptors and senior preceptors completed surveys before and immediately after the real-time observation and feedback session. Qualitative evidence assessed the ways in which session time was spent, lessons learned, and ways to improve future coaching sessions. Secondarily, the study compared the new preceptors’ self-assessed numerical scores of teaching confidence before and after the clinic session.

Eight faculty members and four chief residents participated in real-time feedback sessions. In post-survey feedback, new preceptors reported that senior preceptors provided excellent support, that these sessions were a valuable use of time, and that the feedback included helpful techniques. These techniques included improvements prioritizing resident autonomy, improving workflow management, and effective presentation approaches. Suggestions included earlier introduction of real-time feedback and more frequent sessions. The secondary measure of pre and post self-assessed confidence scores was limited by small sample size and high pre-survey values and did not demonstrate a statistical difference.

/ REFLECTION / LESSONS LEARNED: The pilot program’s qualitative data indicates that real-time peer to peer feedback for new preceptors provides valuable insight and educator development. Real-time feedback allows for best practice sharing during specific clinical teaching moments, which works well in resident clinic with varied, unpredictable teaching opportunities. The teaching technique improvements cited by the new preceptors appear to advance the ACGME core competencies of communications skills, professionalism, and practice-based learning. Future directions include further study of how real-time feedback advances ACGME core competencies, a longitudinal feedback program with multiple sessions, and introduction of real-time feedback for faculty preceptors of all experience levels. NURSING, PHARMACY AND NUTRITION: OH MY! TEACHING TO IMPROVE UTILIZATION OF OUR INTERDISCIPLINARY TEAM FOR DIABETES EDUCATION DURING AMBULATORY EDUCATION SESSIONS. Sara Gianfagna1; Catherine Gracey2. 1Internal Medicine, University of Rochester Medical Center, Rochester, NY; 2Medicine, University of Rochester Medical Center, Rochester, NY. (Control ID #4231907) SETTING AND PARTICIPANTS: 81 Internal Medicine residents at a mid-Atlantic, academic program participated. Our interdisciplinary team included a registered nurse, registered dietician and clinical pharmacist, who are embedded in our practice. DESCRIPTION: The activity was designed as a 1-hour session within an educational half-day. Groups of 7-9 residents rotated between 3 stations where they met with a pharmacist, dietitian or a nurse. They spent 20 minutes at each station: 15 minutes for teaching and 5 minutes for questions. Each station was given learning objectives. The goal was to improve knowledge about diabetes and team-based care. We focused on utilization of team members and enhancing patient care during and between resident visits. EVALUATION: Residents received a pre- and post-survey, which had questions about content and processes, confidence and satisfaction. We had a 75% pre-survey response rate and a 64% post-survey response rate. Content questions included questions on roles of the team. For some questions, there was more than one answer. For example, when asked who can help with teaching and placement of a continuous glucose meter, on the pre-survey, 63% of residents correctly answered nursing and pharmacy, with 9% incorrectly selecting “nobody” (n=61). In the post-survey, 84% correctly identified nursing and pharmacy, and 0% selected “nobody” (n=52). Survey questions on logistics included questions on how to refer to and involve team members. Residents identified how to utilize the electronic record to set up appointments with the team. When asked how to schedule a nursing visit on the pre-survey, 49% answered incorrectly, with 37% responding “I do not know, and hope to learn.” In the post-survey, 100% answered correctly.

/ REFLECTION / LESSONS LEARNED: Evaluation showed the session was a useful educational tool that was well received. Residents were better able to identify team member roles and know how to involve them after the intervention. Residents found the small, interactive groups useful for learning (91%). Many replied that they were “much more aware of the resources.” Almost all were “fairly” or “extremely confident” that they understood team roles (96%). The format allowed engagement and discussion of “more specific questions.” Responses highlighted a gain in knowledge about services our pharmacist and dietician could provide, emphasizing a blind spot in residents’ education. Feedback from participants was that providing 5 more minutes at each station may give more time for questions. Residents enjoyed the discussion between the disciplines and questions from their peers. Additionally, participants requested a handout summary for reference. We could also consider adding a clinical case to provide more structure at the stations. We would like to see if utilization of our interdisciplinary team increased after the intervention though we found it difficult to get quantitative data. ONLINE RESOURCE URL: https://docs.google.com/document/d/1J5l2AhheCVNclr8IO7XgHvCraByWtgyQ/edit?usp=sharing&ouid=108192720813434612546&rtpof=true&sd=true OUTCOMES OF NEAR PEER MENTORSHIP FOR MEDICAL STUDENTS INTERESTED IN MED-PEDS Emma Granberry1; Ellen L. Gorman1; Li'an Williams1; Carlie Stein2. 1The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; 2Medicine, UAB, BIrmingham, AL. (Control ID #4268241) SETTING AND PARTICIPANTS: UAB medical student mentees, ranging from first to third years, were partnered with UAB Medicine-Pediatrics (Med-Peds) resident mentors to have scheduled check-ins and shadowing experiences in Internal Medicine and Pediatrics. In evaluating six years (2016-2022) of the program, we collected match data from 50 of the 77 enrolled medical students. Match data excluded students that did not complete the program (n= 6), students that have not yet matched (n= 9), and students in the year 2020-2021 (n= 12) due to COVID restrictions impacting the program structure. A total of 33 different residents participated in the program during this timeframe. DESCRIPTION: Through collaboration of the UAB Med-Peds Residency Program and the School of Medicine Med-Peds Interest Group (MPIG), an educational innovation program was established in 2016 to pair interested medical students with resident mentors. EVALUATION: Of the match data, 18% (n= 9) of students matched Med-Peds, 32% (n=16) Pediatrics, 10% (n=5) Internal Medicine, and 2% (n= 1) into Family Medicine. When reviewing national match data over the same time frame (excluding the 2021 match year), 1.2% of total applicants matched into Med-Peds, 26.0% into Internal Medicine, 8.7% into Categorical Pediatrics, and 12.38% into Family Medicine programs. In that seven-year span, 47.12% of all national applicants matched into primary care programs. Additionally, qualitative survey data from our program revealed themes of improved professional development, exposure to Med-Peds, and understanding of healthcare team dynamics.

/ REFLECTION / LESSONS LEARNED: Of the students that matched from our program, 62% (n= 31) matched into a primary care specialty. While there is a level of self-selection, we aim to promote primary care through early exposure and mentorship. As we continue tracking reported satisfaction and match data among participants, we plan to add targeted questions to our post-program survey to elucidate specific program experiences that pushed students toward their chosen specialty. Based on survey results, we will make needed changes for future years to improve satisfaction and further promote primary care specialties with hopes to address the growing need for primary care physicians. PEER-TO-PEER POCUS PROGRAM: A MENTORING PROGRAM FOR FIRST-YEAR INTERNAL MEDICINE RESIDENTS LEARNING POINT OF CARE ULTRASOUND Julia A. Bast, Ellen Brinza, Cristina Fischer, Carolina Ortiz-Lopez, Michelle Fleshner. Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4270498) SETTING AND PARTICIPANTS: First year IM residents enrolled in a pre-existing POCUS curriculum and senior internal medicine residents interested in advancing POCUS competency at an academic medical center located in the Northwest. DESCRIPTION: Point of care ultrasonography (POCUS) is an important diagnostic tool that is increasingly being utilized in clinical care to aid in diagnosing and managing various disease states. Several internal medicine residency programs have created longitudinal curricula to enhance residents’ basic POCUS knowledge and application of fundamental POCUS principles in daily practice. While expert faculty members are available during dedicated POCUS didactic sessions, this is often not the case when residents first begin to utilize POCUS in clinical settings. This curriculum was created in response to the challenge of finding mentored, hands-on scanning in the inpatient setting. The POCUS ambassador program connects interns with senior residents who have passed an introductory POCUS class and have self-identified themselves as being interested in providing mentorship. A schedule was created to pair first-year and senior residents rotating at the same site. Interns message senior residents and set up a dedicated time to assist with image acquisition and troubleshooting. EVALUATION: First-year residents are prompted to fill out a “worksheet” that describes the point-of-care ultrasound image after acquiring an ultrasound image. Each worksheet contains a question asking if a POCUS ambassador was used to track program utilization. An analysis was also performed to determine whether the use of a POCUS ambassador increases “passing images” acquired by novice users.

/ REFLECTION / LESSONS LEARNED: Program implementation began in July 2023 and has been ongoing, with final results available in January 2025. Preliminary data shows that of the 106 residents who have participated in the program, 33% have utilized a POCUS ambassador for image acquisition. Based on feedback, modifications have been made throughout the curriculum to increase program utilization. These include attaching a QR code with a list of available POCUS ambassadors to all ultrasound machines and encouraging senior residents to connect with interns at the start of each inpatient block to facilitate mentored connections. The leadership team continues to develop strategies to mitigate barriers to implementation. PILOT IMPLEMENTATION OF AN ELECTRONIC HEALTH RECORD (EHR) PERFORMANCE REPORT TO EVALUATE RESIDENT PROFESSIONALISM IN INTERVISIT CARE Shyam Sundaresh, Rachel Engelberg. Department of Medicine, Mount Sinai Health System, New York, NY. (Control ID #4270478) SETTING AND PARTICIPANTS: Our intervention takes place in an urban academic resident clinic that serves a publicly insured patient population and is the sole ambulatory training site for the Internal Medicine (IM) Residency Program. Participants include > 15 faculty who supervise intervisit care and > 160 residents, who rotate in a 6 + 2 model. DESCRIPTION: The primary care physician has been increasingly tasked with managing the EHR inbox, i.e. intervisit care. Though completion of intervisit tasks is listed among the Professionalism competency domain of ACGME Milestones 2.0, there exist no published curricula that assess the professionalism of intervisit care. Our needs assessment showed that a large proportion of residents do not meet professionalism expectations for intervisit care and that faculty struggle to address this need. To address this gap in competency, we built a novel assessment tool: an automated EHR report to deliver weekly intervisit performance data using the QI methodology of feedback-and-audit. We wrote an implementation guide to train faculty on how to use the report to deliver brief, effective feedback to residents on their intervisit performance using the R2C2 (relationship building, exploring reactions to the feedback, exploring understanding of feedback content, and coaching for performance change) model. Our goals for 2/1-4/30/2025 for a convenience group of pilot residents: 1) Implement an EHR report for feedback-and-audit of intervisit performance. 2) Increase frequency of direct preceptor-to-resident feedback for intervisit care to once per week. 3) Improve proportion of residents who meet intervisit professionalism expectations from 58% to 90%. 4) Assess the usefulness of the report for faculty. EVALUATION: We will use three key metrics to evaluate success. The first will be perceived frequency of faculty feedback assessed by a post-survey to residents and faculty. The second will be the proportion of pilot residents who meet intervisit professionalism expectations, collected by the EHR report which will also collect comparison data from both historical data and non-pilot residents. Finally, faculty will be surveyed on their satisfaction and perceived usefulness of the report.

/ REFLECTION / LESSONS LEARNED: If successful, our IM Residency Program wants to implement this for all residents in Academic Year 2025-2026. Several other IM residency programs are interested in implementing our method, and we will disseminate our EHR (Epic) report code and implementation guides. Because IM resident clinics commonly care for underserved populations, this method may improve intervisit care for marginalized communities. PRIMARY CARE INTEREST GROUPS: APPROACHABLE TEACHING AND CAREER DEVELOPMENT FOR MED/PEDS RESIDENTS Philip Chang1; Jenna Hatab1,2. 1General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Nationwide Children's Hospital, Columbus, OH. (Control ID #4269913) SETTING AND PARTICIPANTS: Academic Medical Center, Midwest Region. Combined Internal Medicine-Pediatrics residents from PGY1-PGY4. DESCRIPTION: Many combined trainees in Internal Medicine-Pediatrics often find primary care daunting. This is due to a combination of factors, including the inpatient focus of combined training, lack of formalized opportunities for teaching such as inpatient rounds, and the volume of outpatient clinic being less conducive to adult learning. Thus, many only find themselves comfortable in primary care late in residency, with delayed knowledge building, scholarly activity, and career development opportunities as a result. In hopes of improving timely resident education, an interest group quarterly newsletter was created to improve access to and knowledge of evidence-based care of common outpatient illnesses. Newsletters were sent in an opt-out fashion to all trainees. They included primary literature and embedded podcast learning, as well as faculty-created highlights and clinical takeaways for each topic. In addition, local faculty updates and nationally relevant discussion points in primary care were provided to boost exposure to outpatient careers and prompt discussion. Semiannual in-person career development panels were created in conjunction to provide opportunities for networking, wellness, and increase interest in the field. EVALUATION: Survey data was collected from resident participants after introduction of the innovation for 1 academic year. Out of 19 anonymous respondents, 90% reported improved confidence in caring for common primary care illnesses. 95% reported increased confidence in accessing literature in primary care. 95% reported increased knowledge of evidence-based medicine in primary care. 63% reported increased interest in primary care as a career.

/ REFLECTION / LESSONS LEARNED: Time constraints, patient care volume, and resident training schedules are common obstacles in the education of combined Internal Medicine-Pediatrics trainees. The described primary care interest group and newsletter was helpful in providing a remote, asynchronous learning and networking opportunity to overcome those obstacles. Providing this resource improved resident confidence and knowledge in evidence-based medicine in the primary care setting. Concurrently, improved comfort in the ambulatory space and increased touch points for career development increased resident interest in careers in primary care. A limiting factor was the faculty time needed to review literature, create the newsletter, and organize in-person events. Increasing support for resources such as this will improve knowledge in ambulatory care and resident interest in generalist careers. The obstacles to primary care learning and career development are also mirrored in categorical internal medicine training and other combined training programs. Future directions for this resource should include sharing with all trainees types to increase the exposure to what primary care learning and careers have to offer. RAISING THE ROOF: BUILDING A HOUSE SYSTEM TO IMPROVE RESIDENT COMMUNITY AND WELLBEING Anne A. Richardson1; Alyssa Kelder1; Kate L. Amodei1; Benjamin E. Zuchelkowski2; Amar Patel1; Andrea Carter2. 1Internal Medicine, UPMC, Pittsburgh, PA; 2Medicine, UPMC, Pittsburgh, PA. (Control ID #4270930) SETTING AND PARTICIPANTS: Internal medicine residency; Residents, chief residents, and faculty DESCRIPTION: Learning communities, often referred to as colleges or houses, enhance learning, support professional development, and foster connectedness. While prevalent in undergraduate medical education, they remain underutilized in residency programs despite their potential benefit. Our large Mid-Atlantic academic internal medicine residency program is facing post-pandemic challenges mirroring national trends of increased resident burnout. To address this, we implemented a House system, targeting three domains of Maslach and Leiter’s burnout framework: breakdown of community, value conflict, and lack of reward. Residents, faculty, and chief residents were grouped into five Houses, each named after a famous humanitarian from our city, each with its own motto, values, and mascot. To promote identity and belonging, residents and faculty were given a pin to wear identifying their House affiliation. The Houses are focused on building community, aligning values through service, and rewarding engagement in didactics. Houses are competing in the House Cup by earning points for didactic attendance and scholarly work, organizing program-wide community service events, and hosting various social activities. EVALUATION: We hypothesize the House system will decrease resident and faculty burnout while improving community well-being, engagement in community service, and attendance at didactics. Burnout and community well-being are being measured using validated tools. A pre-survey was administered in fall 2024 prior to our House kick-off event, and a post-survey will be conducted in summer 2025 after the awarding of our first annual House Cup. Didactic, social, and service event attendance data are also being tracked for year-long comparison.

/ REFLECTION / LESSONS LEARNED: Resident well-being is a critical area for improvement amidst increasing demands, particularly in the post-COVID-19 era. Learning communities are a feasible and effective strategy to improve resident connectedness and foster meaningful engagement. While learning communities are common in undergraduate medical education, residency programs have limited guidance for their implementation. Early successes in our program highlight the importance of leadership support, thoughtful faculty selection, and prioritizing wellness when establishing learning communities. Our survey evaluation data will further refine our approach and recommendations. RESIDENT EMPOWERMENT: DEVELOPMENT OF A RESIDENT COUNCIL COMMITTEE AT A NEW COMMUNITY HOSPITAL PROGRAM Estefania montanez, Giulia Leggett, Mengyu Zhou. Internal Medicine, Oregon Health & Science University, Portland, OR. (Control ID #4273410) SETTING AND PARTICIPANTS: OHSU Hillsboro Internal Medicine- Department of Medicine: Faculty leads and Trainees DESCRIPTION: Burnout is becoming synonymous with the resident training experience. Whether new or old, programs have ongoing changes throughout the year and require constant and transparent communication between leadership and residents. Lower odds of burnout have been shown to be associated with residents’ perceptions of residency program leadership. At a new community hospital program, a Resident Council Committee (RCC) was developed to engage and facilitate communication between residents and lead faculty. To assess both resident and lead faculty perceptions of the RCC’s influence on the training experience, a 12-question Likert survey with some free response, was conducted, engaging active members and nonmembers of the RCC. 24 residents and 3 lead faculty members were invited to voluntarily participate. 14 trainees were surveyed, PGY2s had the highest representation (25%) and only 1 lead faculty participated. EVALUATION: The results demonstrated that overall, residents viewed the RCC positively with over 50% of respondents selecting Strongly Agree for questions related to the RCC’s role in promoting leadership skills and identifying areas of improvement within the program, as well as allowing a safe space to discuss concerns. >50% of responses stated Somewhat Agree to claims that the RCC effectively made changes within the program and implemented change in the wellness of resident house staff. There was a 50/50 split among respondents who Somewhat Agree/Somewhat disagree that the RCC was supportive in promoting resident house staff voices. PGY2s were more likely to favor the RCC positively in their residency training than PGY1s and PGY3s. Using these responses, in the 2nd year of the RCC, the program developed 2 chief positions which were selected from the PGY3 class as leaders for the new year and positioned them as the communication path between the RCC and program leadership. The RCC also opened to include any residents who wanted to participate instead of limiting the number to 2 people from each cohort. In the third year the RCC changed to include leadership positions such as president, vice president, and secretary in an effort to optimize organization.

/ REFLECTION / LESSONS LEARNED: Concerns identified were largely centered around the RCC structure, which stated need for a clearer path of communication between residents and program leadership, as well as additional work on the RCC leadership structure. While it is clear that the RCC was a useful tool in amplifying resident voices to address concerns, there is a need to further evaluate the most effective structure for these leadership groups and clear guidelines to facilitate communication to program leadership. Therefore, a second survey was introduced to better compare perceptions of the RCC as it changed over the years. We share our experience to provide a systematic approach to standing up these efforts in an academic department. RHEUM4GAMES: A GAME-BASED BOARD REVIEW TO ENHANCE CONFIDENCE AND KNOWLEDGE IN RHEUMATOLOGY FOR INTERNAL MEDICINE RESIDENTS Megan Schermerhorn1; Sonam Kiwalkar2; Sarah Drummond3; Sarah Donohue4; Christine D. Sharkey4. 1Internal Medicine, Providence Health and Services Oregon and Southwest Washington, Portland, OR; 2Internal Medicine, Legacy Health System, Vancouver, WA; 3Physician Assistant Education, Oregon Health & Science University, Portland, OR; 4Internal Medicine, University of Wisconsin-Madison, Madison, WI. (Control ID #4248954) ETTING AND PARTICIPANTS: This study aimed to evaluate the impact of incorporating a gamified rheumatology board review session into existing didactic curricula to improve In-Training Examination (ITE) scores and enhance resident satisfaction with the teaching format. We partnered with five internal medicine residency programs, including four community-based programs and one academic program. DESCRIPTION: We developed Rheum4Games, a board game based off of Snakes and Ladders where residents were split up into teams and answered questions from our PowerPoint question decks in order to advance across the board. Throughout the game, the game master provided explanations and key learning points after each question. The winning team was either the first to reach the end of the board or the team that advanced the furthest within the allotted time. In order to develop our PowerPoint question slide decks, we utilized the American Internal Medicine blueprint to ensure that our game questions were based on high-yield board material. Our question decks were extensively reviewed by two general medicine educators, one rheumatology fellow in-training, and three rheumatologists in academic/community practice. EVALUATION: All residents completed a pre-session survey as well as a post-session survey. Using Likert scales, the survey assessed residents' levels of motivation, engagement, satisfaction, and confidence with gamification compared to traditional didactics. We also evaluated the effectiveness of the intervention by comparing aggregate In-Training Examination (ITE) rheumatology scores from the pre-intervention year (2023) to the post-intervention year (2024).

/ REFLECTION / LESSONS LEARNED: While various card and board games have been developed for pre- and postgraduate medical education, none, to our knowledge, have been specifically designed to prepare residents for the rheumatology sections of the Internal Medicine In-Training Examination (ITE) and the American Board of Internal Medicine Certification Exam (ABIM-CE). We found no significant difference in rheumatology percent correct scores on the ITE between Rheum4Games participants and non-participants from 2023 to 2024. However, our study highlights the challenges of uncontrollable variables in evaluating educational interventions. Additional analyses are planned to explore ITE performance variations between community and academic programs and assess the impact of intervention timing on outcomes. Rheum4Games received positive feedback amongst residents. In a post-session survey, 98% of residents agreed or strongly agreed that the activity was enjoyable and increased their rheumatology knowledge. These findings highlight gamification’s potential to boost learner satisfaction and engagement, demonstrating its value as an innovative educational tool in graduate medical education. SERVICE HONOR SOCIETIES AS CATALYSTS FOR LEADERSHIP, MENTORSHIP, AND COMMUNITY IMPACT Hunter Cohn3; Hussien Bazzi4; Lauren Fleckenstein1; Chayton Fivecoat3; Jenna L. Carter3; Diane L. Levine2. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2Internal Medicine, Wayne State University, Detroit, MI; 3Medical Education, Wayne State University School of Medicine, Detroit, MI; 4Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI. (Control ID #4270596) SETTING AND PARTICIPANTS: Undergraduate medical education; medical students DESCRIPTION: Honor societies in medical education recognize excellence and promote values like service, leadership, and ethical practice. For over 50 years, a midwestern medical school's Service Honor Society (SHS) has sustainably advanced service, outreach, and social justice in an urban setting. Peer-nominated medical students are selected by an inductee committee for their excellence in service and leadership. Members commit to active volunteering and mentorship throughout medical school. Annually, SHS partners with a local Community Partner of the Year (CPOTY) to support grassroots efforts. Members engage through volunteering and fundraising, gaining insights into community needs, deepening their understanding of social determinants of health, and fostering compassionate care. SHS prioritizes community engagement over academic and clinical achievements, though good academic standing is required. Members contribute through direct service and sustained outreach, creating a culture of action and reflection. Members remain committed to serving the broader community year-round, extending their impact beyond the CPOTY partnership. SHS’s 50+ years of sustainability reflect its impact and sought-after membership. Internally, SHS strengthens its community through mentorship pods and subcommittees managing service, research, and fundraising. Externally, it engages the entire medical school through events that foster collaboration and creativity, such as an annual comedy show that both acts as a fundraiser for the CPOTY as well as a way to honor students and faculty members. In addition, extensive mentorship is provided for junior students which includes Q&A panels, study sessions, and individual mentor pairings for the first year medical students. EVALUATION: Medical student demographics, specialty of interest, and value of SHS participation assessed via self-reported surveys. Community impact assessed via retrospective analysis of community service hours, fundraising outcomes, and engagement in mentorship.

/ REFLECTION / LESSONS LEARNED: By integrating service, professional development, and mentorship, SHS provides a replicable model for honor societies, emphasizing collective impact and growth. Rooted in self-determination theory, SHS fosters autonomy in community engagement, competence in addressing social determinants of health, and relatedness through purposeful community activation. This model supports holistic medical education and a deep appreciation for service and community health. SHAPING THE FUTURE: INTEGRATING DEBRIEF TRAINING INTO MEDICAL EDUCATION Chana Bushee1; Heather Burton1; Jared W. Squires1; Glenn Bushee2. 1Internal Medicine-Pediatrics, Medical College of Wisconsin Department of Medicine, Milwaukee, WI; 2Children's Hospital and Health System Inc, Milwaukee, WI. (Control ID #4272619) SETTING AND PARTICIPANTS: We designed a one-hour debrief education and training session for third year medical students (MS3s) at an academic medical center in the mid-west region. The session was integrated into the internal medicine (IM) clerkship curriculum. MS3s were divided into cohorts (each approximately 30 students) based on their clinical rotation schedules and sessions were held scheduled mid-way through their IM clerkship. DESCRIPTION: Adverse and distressing events are experienced by nearly all physicians, however, despite the desire for support, there have been several identified barriers. Debriefing following adverse events has been identified as a means for development of healthy coping strategies, improve team functioning, and reduce physician burnout. However, rarely is formal debrief training integrated within medical education and is under-utilized clinically. Our resident-lead, one-hour debrief training session was designed to address this gap in medical training. The session is comprised of an educational presentation, debriefing examples, small group debrief practice, and wrap up discussion. EVALUATION: Pre- and post-session survey results were obtained and analyzed using a Chi-Square test across Likert Scale categories. Over an academic year, greater than 80% of MS3s experienced one or more adverse events, yet less than 25% of these were followed by a debrief discussion. Prior to the training sessions, 89% of MS3s agreed that debriefs were important; however, less than 30% of MS3s knew the components, or were comfortable requesting or leading a debrief. Following the training sessions, students felt even stronger about the importance of debriefing (p = 0.0019) and were empowered to request a debrief and participate (p = <0.0001). Furthermore, there was a significant increase in MS3s ability to identify when a debrief was needed (54% to 87%, p = <0.0001), knowledge of the components (11% to 75%, p = <0.0001), comfortability requesting (27% to 67%, p = <0.0001), and comfortability leading debriefs (14% to 52%, p = <0.0001).

/ REFLECTION / LESSONS LEARNED: The implementation of debrief training sessions successfully met all of our objectives. Most students reported positive experiences with the session; some of the identified strengths included: resident lead training, vulnerability of the resident leaders in the small groups, and the opportunity for MS3s to share their experiences and learn how to utilize debriefing in patient care. This medical education initiative exemplified the importance of integrating formal debrief training into medical education across academic medical centers. As well as potentially expand to include fourth-year students and residents, transforming the culture of how we approach distressing / adverse events in medicine. STANDARDIZED CURRICULUM IN CARDIAC CRITICAL CARE: A PILOT SIMULATION TO IMPROVE CONFIDENCE IN CENTRAL AND ARTERIAL LINE PLACEMENT Adam Koraym2; Anas Abed2; Aria Kenarsary2; Thomas Schrauth1; Clayton Skogman1; Umbish Dino1; Parag Tipnis1. 1Medicine, University of Wisconsin System, Madison, WI; 2Medicine, University of Wisconsin System, Madison, WI. (Control ID #4273149) SETTING AND PARTICIPANTS: Introduction: Internal Medicine (IM) residents require proficiency in invasive procedures like central venous catheter (CVC) and arterial line placement. Point-of-care ultrasound (POCUS)-guided line insertion has become a crucial skill in critical care settings and improves outcomes for patients. Many IM learners report low confidence in performing these procedures. Studies show that simulation-based training can significantly improve procedural performance and reduce complications such as catheter-related bloodstream infections. This pilot program evaluates the effectiveness of a simulation-based POCUS training in improving senior resident confidence in central and arterial line placement. DESCRIPTION: Methods: An email was sent to IM residents at the University of Wisconsin asking for voluntary participation in a pilot POCUS-guided line training session. Training included a didactic presentation followed by hands-on practice with manikins in the simulation center. Participants completed pre- and post- surveys assessing their baseline experience, confidence, and troubleshooting complications with CVC and arterial line placement. EVALUATION: Statistical Analysis: Pre- and post-survey results were compared using paired t-tests to determine if there were statistically significant improvements in confidence across key domains: central line insertion, arterial line insertion, troubleshooting complications, and using POCUS for guidance. Descriptive statistics were used to summarize the survey results, with means and standard deviations reported for each variable.

Of 11 emails sent, 8 residents completed both the pre- and post-surveys. A student t-test was used to assess confidence pre and post simulation. On a scale of 1-5 (1 being least and 5 being most confident). Post-survey results showed an improvement in average confidence in central line and arterial insertion from 1.5 to 3.5 (p < 0.01) and 1.75 to 3.75 (p < 0.01) respectively. There was also an improvement in average confidence in troubleshooting central and arterial lines from 1.75 to 3.2 (p < 0.05) and from 2.75 to 3.0 (p < 0.05) respectively.

/ REFLECTION / LESSONS LEARNED: Discussion: This pilot demonstrates simulation-based curriculum can significantly improve the confidence of IM residents in performing POCUS-guided line placements. Future iterations of this program should consider integrating more advanced procedures, such as transvenous pacemaker placement and Swan-Ganz catheterization, especially for fellow-level trainees.

This pilot study highlights the potential for simulation-based training to strengthen procedural skills among IM trainees. The results indicate that focused simulation sessions, improves confidence and competence for residents and can likely be applied to early fellows. Continued efforts to expand this training are warranted to ensure that learners are fully prepared to perform these critical procedures confidently to continue to advance their careers and provide better, safer care for patients. TEACHING SERVICE UTILIZATION OF ELECTRONIC HEALTH RECORD (EHR)-EMBEDDED CLINICAL PATHWAYS Christopher Sankey1; Necia Hunter1; Nancy Kim2. 1Internal Medicine, Yale School of Medicine, New Haven, CT; 2Yale New Haven Hospital, New Haven, CT. (Control ID #4241813) SETTING AND PARTICIPANTS: Electronic health record (EHR)-embedded clinical pathways are increasingly prevalent as means of reducing variation and promoting quality of inpatient care by providing evidence-based clinical decision and order entry support for a wide array of medical conditions at the point of care. Implementation gaps are common, and clinical pathway utilization is a key metric. Published literature suggests clinical pathways are seen as both resources and threats to medical learners. Little is known about clinical pathway use patterns among inpatient teaching teams, nor the extent to which utilization can be augmented. We sought to track and describe inpatient teaching team use of EHR-embedded pathways. Participants were attending physicians and PGY-1 through PGY-4 learners. DESCRIPTION: Clinical pathways are fully embedded in the EHR at our institution, with 300-500 available during the time of data collection. For one academic year, we tracked pathway use on a single inpatient medical unit shared by two teaching teams. The daytime teams had separate structures and workflows: Hospitalist team (Team A) had two hospitalist attendings and two residents in an apprenticeship model without interns; Traditional team (Team B) had two general medicine attendings, two residents, and two interns. The overnight team (Team C) had one resident, one intern, no in-person attending coverage, and covered both Team A and Team B patients. Pathway use patterns were measured and compared between individuals and teams, including total pathway use, average pathway uses per 2-week rotation block, and use rate per block. EVALUATION: The hospitalist team (Team A) demonstrated the highest total number (1355), average number (51.3), and individual rate (12.8) of EHR pathway use. Attending role-modeling and education via pathways were likely drivers, as the attending pathway use rate (15.3) surpassed resident (10.4) on Team A. The traditional model (Team B) demonstrated the lowest rate of EHR pathway use (4.5), potentially due to low pathway incorporation (attending use rate 1.5). The overnight team (Team C) demonstrated a pathway use rate of 10.5, higher than Team B but lower than Team A. We hypothesize that the absence of overnight in-person attending presence makes learners more likely to seek point-of-care guidance in the EHR.

/ REFLECTION / LESSONS LEARNED: EHR-embedded pathways are an important means by which we can continue to translate ideas into action and catalyze change. While EHR-pathways are not new, our innovation is in considering how they can be meaningfully integrated into current-era medical training. Overall, our data suggest that EHR-based pathway use is likely influenced by team structure, attending role modeling, and time of day, which can be leveraged if training programs/health systems wish to improve utilization. We propose using the pathway use rate per block as an effective characterization of teaching team utilization and basis for comparison between teams of different sizes. THE IMPACT OF NEAR-PEER RESIDENT/MEDICAL STUDENT MENTORSHIP PROGRAM FOR PRECLINICAL MEDICAL STUDENTS Stanley Yuan1; Laurence Katznelson1; Rachel Brook2. 1Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 2University of California Los Angeles, Los Angeles, CA. (Control ID #4271538) SETTING AND PARTICIPANTS: Our near-peer mentorship program recruited residents and fellows from multiple hospital systems (UCLA, West-LA VA, Olive-View, Cedars Sinai) as mentors and 1st and 2nd year medical students from UCLA David Geffen School of Medicine as mentees. DESCRIPTION: Many preclinical medical students lack sufficient clinical exposure and thus, could significantly benefit from mentorship and shadowing opportunities. To address this gap, we developed a mentorship program linking preclinical (MS1/MS2) medical students with residents and fellows, fostering connections and promoting clinical exploration. We sent emails to program directors, residency coordinators and chief residents to recruit residents and fellows across various medical disciplines to mentor preclinical medical students. Both mentors and mentees completed recruitment surveys detailing personal demographics, identity/affinity affiliations, and hobbies. The medical student survey asked for their top 3 fields of interest and their rating of their interest in each field on a scale from 1-10. Matches were made based on shared interests and demographics. Subsequent match emails facilitated initial connections, and quarterly email reminders encouraged regular check-ins. At the end of the academic year, we assessed the program’s impact through Likert surveys targeting both mentors and mentees. EVALUATION: Since its inception in 2020, the program has operated successfully each academic year, with an average recruitment of approximately 250 resident and fellow mentors and 180 preclinical medical students. We facilitated approximately 350 mentor/mentee matches annually. On average, pairs met informally 3-5 times per year. Students rated the near-peer mentorship program highly (4.1/5) in terms of perceived value compared to faculty mentorship, citing greater approachability and relatability regarding their experiences in medical school and residency. The program has positively influenced students' specialty decision-making (4/5), providing opportunities for shadowing and research and offering insights from their mentors’ residency experiences. Resident and fellow mentors reported that their mentorship roles were both rewarding (4.1/5) and manageable alongside their residency responsibilities (4.3/5). Notably, medical student interest in their selected subspecialties shifted after participating in the mentorship, suggesting that these mentorship relationships may help to clarify their career paths.

/ REFLECTION / LESSONS LEARNED: This near-peer mentorship program was developed to provide timely and accessible mentorship for preclinical medical students, facilitating exploration of various medical subspecialties. The program has successfully created avenues for clinical shadowing and research, equipping students with essential advice for navigating their medical careers. Resident and fellow mentors found the experience enriching and sustainable. Our findings suggest that near-peer mentorship can play a crucial role in guiding medical students' career decisions. THE IMPACT OF TRANSITIONING TO AN INTEGRATED RESIDENT PROGRAM WEBSITE AND EDUCATIONAL CENTER Oliver Clark. Internal Medicine, Pennsylvania Hospital, Philadelphia, PA. (Control ID #4273075) SETTING AND PARTICIPANTS: We conducted our intervention in a moderately-sized, academic internal medicine program. DESCRIPTION: Internal Medicine residency websites often rely on rudimentary, plain-text platforms that fall short of meeting the needs of residents and program leaders. In a brief survey of Internal Medicine programs in our urban area, programs use websites based on Canvas by Instructure, Microsoft Teams, among others. These basic websites frequently suffer from storage limitations, poor performance, and leave residents at a disadvantage. To address these challenges, transitioning to a comprehensive and professional platform can significantly improve the storage, presentation, and accessibility of program content. We transitioned our team website from a basic platform (Canvas) to a robust, dynamic, and integrated platform (Microsoft Sharepoint). Microsoft Sharepoint offers several key advantages for residency programs, such as large storage capacity, intuitive page creation, multimedia integration, and overall visually appealing design. This platform also allows system-based ownership and editable user permissions, which can be leveraged to give administrators the birds-eye view of the entire platform. EVALUATION: To gain an understanding of webpage traffic, we evaluated weekly page views from our residents on each platform pre- and post-intervention. To standardize time-frame, we evaluated a 16-week period in fall 2023 and 2024 for Canvas and SharePoint viewership, respectively. Page views were obtained from each platform's website usage analytic tool. Among residents who had experienced both websites, we conducted a survey to evaluate subjective experiences of navigability, accessibility, design, function, speed, searchability, content quality, and overall experience. We also queried the users most accessed pages and their preferred and disliked characteristics of the new platform. During the pre-specified time frames, there was not a statistically significant difference in average weekly page viewership on Canvas vs. Sharepoint (683 vs 687 page views, p=0.94). Subjectively, resident survey (n=15) revealed improved user experiences across categories of content quality, navigation on desktop, design and visuals, function, and overall experience. The mean user ratings in all these categories were between moderately improved to significantly improved on SharePoint compared to the Canvas website. The lowest user rated category was accessibility on phone, which scored an average rating as similar experience and mildly improved experience on SharePoint compared to Canvas. The most commonly accessed page category was "Rotation Operations".

/ REFLECTION / LESSONS LEARNED: Residents routinely check on program information through a central education hub. Our program experience transitioning to a dynamic and integrated website platform led to broadly improved subjective user experiences while maintaining the approximate same level of page viewership. THE “MICRO-INNOVATION”: IMPROVING OUTPATIENT TEACHING THROUGH INDIVIDUALIZED FACULTY DEVELOPMENT Dana G. Callahan1,2; Mary W. Montgomery1,2; Nora Osman1,2; Stephen Pelletier2; Emily Piper-Vallillo2; Helen M. Shields2. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Harvard Medical School, Boston, MA. (Control ID #4273081) SETTING AND PARTICIPANTS: This program was conducted at an academic medical center in New England. Eligible faculty were identified by department leadership as faculty who were actively engaged as outpatient clinical teachers for clerkship medical students. Twenty-four (24) outpatient teaching faculty from six clinical departments (medicine, neurology, obstetrics-gynecology, pediatrics, psychiatry, and surgery) completed the program between September 2021 and May 2022. DESCRIPTION: Outpatient medical education is essential for preparing trainees for clinical practice, but workplace factors such as high patient volume present challenges to outpatient faculty. This pilot program sought to empower faculty to enhance their outpatient teaching through an individualized faculty development program. The authors developed an individualized outpatient faculty development program that encouraged faculty to take an active role in improving their teaching. Faculty participated in a 60-minute faculty development session with two trained medical educators. Using coaching methods, faculty were invited to reflect on challenges teaching students in clinic and encouraged to design and implement one change in their clinics – termed a “micro-innovation” – to address a salient challenge. EVALUATION: The program was assessed through surveys and a focus group. The survey response rate was 75% (18 of 24 faculty). All respondents (18/18, 100%) reported implementing their micro-innovations and felt that their micro-innovations improved their student clinics. Most faculty reported that designing their micro-innovation was professionally satisfying (17/18, 94%). Faculty valued receiving individualized support and exchanging ideas with fellow medical educators.

/ REFLECTION / LESSONS LEARNED: An individualized approach to outpatient faculty development that encouraged faculty to take an active role in improving outpatient education by designing a “micro-innovation” to address a salient teaching challenge was feasible, useful, and valued by outpatient clinicians. Most faculty successfully implemented their micro-innovations in their clinics, suggesting that an individualized approach that considered workplace-specific factors enabled faculty to overcome common teaching challenges. Faculty valued how individualized faculty development and the creation of a “micro-innovation” helped address their teaching needs in real-world clinical settings. Our “micro-innovation” faculty development model offers an opportunity to enhance student teaching in outpatient settings while empowering and supporting outpatient medical educators. ONLINE RESOURCE URL: N/A TRAINING GENERAL INTERNISTS: BALANCING INPATIENT, OUTPATIENT, AND INDIVIDUALIZED LEARNING EXPERIENCES WITH A 2+2+2 BLOCK SCHEDULE Jillian Senner, Judy Griffin, William Supplee, Michael Berlin. Internal Medicine, Cayuga Medical Associates, Ithaca, NY. (Control ID #4267672) SETTING AND PARTICIPANTS: This residency program has 30 residents and serves 250,000 individuals in a physician shortage area in the Northeast. Our community hospital has 280 beds and our 16-exam room continuity clinic serves over 3,500 patients. DESCRIPTION: To address one of the program’s missions of “training and retaining” general internists who choose primary care as a career, we aim to instill confidence and competence in primary care skills and knowledge in trainees.Since AAIM called for the improvement of ambulatory training for internal medicine residents in 2007 (Myers et al.), most programs have adopted an x+y system. It was recognized then that ambulatory training was a “lesser” component of residency training than inpatient care, “both in time and perception.” We developed a block schedule in which residents rotate through two weeks of inpatient (wards, ICU, night float), two weeks of continuity clinic (7 half-day sessions each week), and two weeks of Individualized Learning Experience (electives, selectives; vacations and required rotations of EM, neuro, addiction, palliative care, and geriatrics also go here). EVALUATION: To date nine of the twenty-three program graduates have entered primary care in our health system. We are currently collecting evaluation data from residents about their perception of the block schedule change. The 24-25 academic year is the first implementation year for this schedule, so we do not have quantitative data yet regarding board pass rates or graduation data. As of December 2024’s Clinical Competency Committee meetings, residents are meeting their milestones as expected.

/ REFLECTION / LESSONS LEARNED: The x+y block schedule has historically been weighed heavily towards inpatient time. We challenge the current system by suggesting that becoming a competent internist requires as much time in the outpatient setting it does in the inpatient setting, with allowance for extra time spent in either setting based on resident goals and preferences. A 2+2+2 block schedules allows for the most individualized learning experiences while still adequately covering all service lines needed in our system and exposing residents to diverse opportunities in medicine. ONLINE RESOURCE URL: Meyers FJ, Weinberger SE, Fitzgibbons JP, Glassroth J, Duffy FD, Clayton CP, et al. Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med. 2007;82(12):1211–1219. doi: 10.1097/ACM.0b013e318159d010. UNDERSTANDING MEDICAL STUDENT SPECIALTY CHOICE Polly D. Fraga1,2; Colton Thompson3; Sophia Fraga3. 1General Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA; 2University of Massachusetts Chan Medical School, Worcester, MA; 3University of Michigan Medical School, Ann Arbor, MI. (Control ID #4267080) SETTING AND PARTICIPANTS: A google survey was created to assess factors that impact medical student specialty choice. The form consists of demographic information (school, year, gender), followed by 7 multiple choice questions regarding specialty choice or debt information. The survey was distributed via email and GroupMe to University of Michigan Medical School (UMMS) students. DESCRIPTION: Primary outcomes of this survey examine popular specialty choices, the most important factor in specialty choice and whether debt impacts specialty choice. Secondary outcomes include differences by gender, year in medical school and if students with significant debt (over $100,000) have different specialty preferences. Descriptive statistics were used to evaluate all outcomes. A statistician (YK) performed Fisher's exact test to evaluate the significance of the association between specialty choices and the factors that impact specialty choice EVALUATION: The survey received 99 responses at UMMS. When examining students’ top specialty choice, Surgery accounted for 29% of respondents' first choice. Other popular specialties were Pediatrics (14%), Internal Medicine (IM; 11%) and Emergency Medicine (EM; 8%). Work/life balance was the most frequently referenced factor in choosing a specialty– 31% of students listed this their first priority and 23% listed it as their second. Compensation after residency was not a common first priority (2%), however many students did list this as the second largest factor (17%). Only 28% of respondents found student debt to factor into specialty choice. There were significant differences in specialty choice for first year students, who had not yet completed their clinical year rotations, compared with later years (p = 0.02). M2+ students chose primary care specialties, FM (9.7%), IM (14.5%) and Pediatrics (19.4%) at an increased frequency compared to first year medical students (2.6% FM; 5.3% IM; 5.3% Pediatrics). First year students were significantly more likely to choose Surgery (42.1%) than M2+ students (21%). Additional analyses on gender and indebtedness to be presented.

/ REFLECTION / LESSONS LEARNED: To our knowledge, this study is one of few to examine factors impacting medical students’ specialty choice since the COVID-19 pandemic. Our study found that surgical specialties are the most popular among medical students, and surgery is a significantly more popular choice among first year students and among men. Work-life balance is the most important factor to students when choosing a specialty. The vast majority of students (68%) state that debt does not impact their specialty choice, though 46% of respondents estimated their educational debt as less than $49,000, which limits the generalizability of these results. As physician shortages in certain fields become increasingly pronounced, it is important to understand how medical students are choosing their specialties.The current landscape of physician work may need to adapt to entice medical students to join these fields. USING SIMULATION TO TEACH ARRHYTHMIA MANAGEMENT TO CLERKSHIP STUDENTS—A PILOT STUDY Bryan Leppert1; Stephen A. McCullough1; Kevin Ching1; Ying Liu2; Aram Kim1; Katherine Penziner1; June M. Chan1; Joseph Safdieh1. 1Weill Cornell Medicine, New York, NY; 2Memorial Sloan Kettering Cancer Center, New York, NY. (Control ID #4271737) SETTING AND PARTICIPANTS: Accurate interpretation of ECGs is critical for medical learning. Weill Cornell Medical students in their clinical clerkship year, which takes place following 1.5 years of pre-clinical learning, may receive didactic or problem-based learning sessions on ECG interpretation and management, but their effectiveness is unclear. We hypothesized that students taking part in an experiential, team-based simulation education session would show greater command of managing cardiac arrhythmias than students who received the same education through traditional lecture. DESCRIPTION: In 2023, we designed and implemented a two-phase study in which consecutive groups of students received a traditional, didactic, case-based learning session (phase I) or a novel team-based simulation education session (phase II) over the course of the clinical clerkship period. Students completed pre- and post-test questions on related knowledge and clinical reasoning; post-tests also asked students to rate their agreement with statements regarding their understanding, engagement, session design, confidence, and usefulness of the session. EVALUATION: Among the 77 students who completed the clerkship during this study, pre- and post-survey data was available for 10 students from phase I and 12 students from phase II. Pre- and post-test knowledge scores between classroom-based and simulation-based participants were not significantly different (Pre-Test p = 0.18; Post-Test p = 0.42). Engagement scores were significantly higher in the simulation-based education group compared to the usual classroom-set case-based learning group (p = 0.03). Usefulness scores showed a trend toward increasing usefulness in the simulation-based education session (p = 0.055). All other surveyed measures had similar scores.

/ REFLECTION / LESSONS LEARNED: Our study suggests medical simulation is an effective format in which to deliver medical knowledge while improving engagement and potentially improving usefulness. This adds to the growing movement to incorporate simulation into undergraduate medical education to better prepare students for real-world practice. Limitations of our study include its small sample size, incomplete survey data, and bias towards motivated students as surveys were not a clerkship requirement. Students who took part in the simulation-based education session, which occurred in the latter half of the clerkship year, had higher baseline pre-survey knowledge scores than their classroom-based session counterparts who completed the sessions during the initial part of the clerkship year, which may reflect clinical growth during the year. However, both groups showed similar improvement on their post-survey knowledge scores. The use of medical simulation requires a greater time and resource commitment from faculty, which can limit its adoption in other areas of the medical school curriculum. UTILITY OF PHOTOVOICE AS A TOOL FOR REFLECTIVE LEARNING IN RURAL COMMUNITY-BASED LEANING FOR MEDICAL STUDENTS Taito Kitamura, Michito Sadohara, Kunihiko Matsui. General Medicine and Primary Care, Kumamoto Daigaku Byoin, Kumamoto, Kumamoto, Japan. (Control ID #4269979) SETTING AND PARTICIPANTS: The participants were medical students who joined a two-day extracurricular logging trip to a rural area as a part of a community-based learning initiative. This program aimed to motivate students who have scholarships with rural obligation in the future and enhance their engagement with the community. DESCRIPTION: In the 2024 program, we implemented photovoice, a visual participatory research method, which enables participants to express their lived experiences thought photographs and accompanying written narratives. To encourage deeper reflection on scenes encountered during the fieldwork, a photovoice session was conducted. The utility and effectiveness were assessed through a questionnaire including items rated on five-point Likert scale items and free-text responses addressing the overall educational impact, feasibility, enjoyability, novel realization, and deeper insights. The student works were categorized based on the Community as Partner model’s eight subsystems to identify significant community-focused themes. EVALUATION: Of 27 medical students participated, 33 works were collected. Categorization by the eight subsystems revealed the top three scenes were health and social services, safety and transformation, and economics (11 works each). From the questionnaire, mean scores (1=Never to 5=Very much) rated by students were feasibility of 2.9 ± 0.5; enjoyability of 4.0 ± 0.9; novel realizations of 4.0 ± 1.0; deeper insight of 4.0 ± 1.0. The scores of overall effectiveness on community-based medicine were rated 4.3 ± 0.8 by students and 4.0 ± 0.8 by faculty and staffs. Free-text responses, they highlighted the advantages as enhanced observation and perspectives (e.g., attention to fine details and distinctive features to the community), deeper reflection and review (e.g., an opportunity to organize and reflect on experience), and communication and sharing, though the process of selecting the photos, verbalization the thought, and sharing experiences. However, some student noted the areas for improvement, such as limited time to elaborate their works.

/ REFLECTION / LESSONS LEARNED: Incorporating photovoice session alongside fieldwork suggests that the tool promote deeper reflection and engagement through the process to select photos, verbalize thoughts, and share their lived experiences. Unlike traditional fieldwork, photovoice fosters broader exploration of perspectives extended beyond healthcare. Given that these students may be assigned to rural area in the future, this approach provides valuable insights into the realities and current conditions of rural communities. When implemented with appropriate guidance, photovoice is easy and enjoyable tool and has the potential to serve as a powerful tool in community-based education. UTILIZING POINT-OF-CARE ULTRASOUND (POCUS) IN AN INTERNAL MEDICINE RESIDENT URGENT AND PRIMARY CARE CLINIC Ahmed K. Saleh1; Kathryn Vickers1; Lauren Anderson1; Meghan Black1,2. 1General Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; 2Medicine, Birmingham Veterans Affairs Hospital, Birmingham, AL. (Control ID #4271759) SETTING AND PARTICIPANTS: Internal medicine residents participating in primary and urgent care clinic with access to point of care ultrasound. DESCRIPTION: Point of Care Ultrasonography (POCUS) is an increasingly popular and available tool to aid in the assessment of patients; however, uptake and education in the ambulatory setting is significantly lagging behind the inpatient setting. This study is aimed at defining how internal medicine residents translate POCUS to the outpatient setting and the subjective impact of this use. A cart-based ultrasound machine was made available to Internal Medicine residents participating in a Veteran’s Affairs primary and urgent care clinic. A survey after each use of the ultrasound machine was conducted between July 2022 and October 2024 to assess resident use of POCUS in an ambulatory setting. Survey questions were designed to document reason for use and perceived utility as a diagnostic and procedural aid. EVALUATION: A total of 122 surveys were completed after exams with 54.1% exams performed in the primary care clinic versus 45.9% exams in urgent care clinic. Exam types included 59 (48.4%) musculoskeletal, 27 (22.1%) skin and soft tissue, 17 (13.9%) cardiac, 13 (10.7%) abdominal, 4 (3.3%) pulmonary, and 2 (1.6%) other. Overall 95.1% of residents reported that utilizing POCUS changed or aided their management. 69.7% of residents felt their exam helped them establish a diagnosis and 31.1% of residents felt that their ultrasound exam eliminated the need for further diagnostic testing, including labs and imaging. Of those residents who felt additional testing was indicated, 28.7% felt that POCUS helped guide which follow-up labs or imaging to obtain. 53.2% of exams were supervised by an attending.

/ REFLECTION / LESSONS LEARNED: Many studies have shown the diagnostic utility of POCUS, but due to numerous factors the uptake is slow in the ambulatory setting. Our survey revealed the subjective impact of POCUS exams in resident-run clinics, with a majority of trainees agreeing that the use of POCUS in a primary and urgent care clinic can help establish a diagnosis. In many cases, the implementation of POCUS was thought to reduce the need for additional testing or guide appropriate next steps. Residents are excited about POCUS in the clinic and these findings support the implementation, education and expansion of ambulatory POCUS within internal medicine residency programs. We recognize the limitations of ambulatory POCUS education– including trained providers, ultrasound equipment, and funding for training. Despite limited ambulatory training, it is important to note that roughly 47% of residents obtained exams without attending supervision - suggesting translational skills to the ambulatory setting. Overall, our innovation and data suggest that there is a strong utility for ambulatory POCUS. While inpatient POCUS skills are tranferable, further resources for faculty and resident training are needed especially in musculoskeletal and skin and soft tissue scans where inpatient education is limited. WHAT NOTE TO DO? Ekenedilichukwu Nnadi1,2; Hazel-Ann Prince-Wannah3,2; Anwesha Chaudhuri1,2; Ryan Gheevarghese1,2; Dina Jaber1,2; Nadia A. Williams4; Melissa S. Lee5,1. 1Primary Care Internal Medicine, NYC Health + Hospitals, New York, NY; 2Internal Medicine, SUNY Downstate Health Sciences University, New York, NY; 3Primary Care Internal medicine, NYC Health + Hospitals, New York, NY; 4Ambulatory Care - Primary Care, New York City Health and Hospitals Corporation, New York, NY; 5Ambulatory Medicine, Kings County Hospital, Brooklyn, NY. (Control ID #4273561) SETTING AND PARTICIPANTS: 43 resident physicians (PGY-1,2,3) in a safety-net resident primary care practice serving primarily Afro-Caribbean patients in Central Brooklyn. DESCRIPTION: We surveyed residents to assess baseline measures of confidence and satisfaction with note writing, burden of time writing, and work after-hours using a Likert Scale. Residents engaged in a 1-hour note writing workshop, focused on efficient and effective communication. Residents were trained using a standardized curriculum including slides and review of actual patient notes, to promote critical analysis and behavior change. We surveyed the residents afterwards and analyzed results using a Wilcoxen signed-rank test. 43 clinical notes, completed before the intervention, were randomly assigned to 1 of 4 resident evaluators for review using the QNOTE1 tool. 43 clinical notes completed after the intervention were similarly reviewed and scored. Reviewers rated 12 elements (CC, HPI, Problem List, Meds, Plan, etc) per note as fully, partially, or un-acceptable. We compared ratings for elements using a paired samples t-test. EVALUATION: QNOTE scores for many elements improved significantly after the intervention: CC (t(42)=-2.203, p=0.033); HPI (t(42)=-2.723, p=0.009); PMHx (t(42)=-2.709, p=0.010); Soc/Fam Hx (t(42)=-2.703, p=0.010), Problem List (t(42)=-2.572, p=0.014); Physical Findings (t(42)=-2.300, p=0.026) and Plan of Care (t(42)=-3.046, p=0.004). Documentation of the Medication list (t(42)=-0.122, p=0.903); Allergies (t(42)=-0.860, p=0.395); ROS (t(42)=-1.019, p=0.314); Assessment (t(42)=-1.798, p=0.079) and Follow Up Information (t(42)=0.210, p=0.834) were not statistically different after the intervention. Surveys of Resident self-perceptions and behaviors demonstrated increased satisfaction (z=-3.946, p=0.000) and confidence (z=-3.640, p=0.000) with note writing after the workshop. More residents felt note writing matters (z=-3.207, p=0.001). Note writing felt faster (z=-2.437, p=0.015) and was more often completed within an hour of the last patient visit (z=-1.993, p=0.046). Residents continued to complete notes at home (z=-1.190, p=0.234); motivation to change lagged (z=-1.830, p=0.067).

/ REFLECTION / LESSONS LEARNED: Our curriculum improved note quality, increased resident physicians’ satisfaction, and reduced the time spent on documentation. Reducing the burden offers a strategy to potentially mitigate burnout. Structured documentation and effective use of EMR tools, enhanced resident ability to organize and prioritize clinical information, improved resident confidence in writing, and may be a surrogate for developing clinical reasoning skills. Improving quality of care while reducing burden may have profound benefits on resident well-being. ONLINE RESOURCE URL: 1Burke, Harry B et al. “QNOTE: an instrument for measuring the quality of EHR clinical notes.” Journal of the American Medical Informatics Association: JAMIA vol. 21,5 (2014): 910-6. doi:10.1136/amiajnl-2013-002321 “SEA OF PEARLS”: PROMOTING SELF-DIRECTED AND COLLABORATIVE LEARNING DURING INPATIENT INTERNAL MEDICINE ROTATIONS FOR GRADUATE AND UNDERGRADUATE HEALTH PROFESSIONAL TRAINEES Hyun Jung. Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4273017) SETTING AND PARTICIPANTS: Graduate and undergraduate health professional trainees who completed their inpatient Internal Medicine rotations at an academic medical center in the Mid-Atlantic region DESCRIPTION: Adult learning principles have a unique implication in medical education. Some widely recognized strategies focus on externally motivating learners to initiate internal motivation to learn. This intervention utilizes a visual display of self-directed learning progress, fosters peer-to-peer learning, and incorporates gamification strategies to engage learners. During inpatient Internal Medicine rotations--spanning 2 to 4 weeks--all new patient cases were reviewed by chief residents during patient turnover at the time of shift change each morning. Case-relevant clinical questions were asked to every medical residents and students who were involved in patient turnover. Trainees were then encouraged to independently delve into their assigned topics, which were followed up 24-48 hours later. At the time of follow up, trainees provided verbal teaching of the topic to their peers and filled a post-it note to be added to a large foam board titled the "Sea of Pearls"--which was installed in an area easily accessible to all involved trainees. The board then served as an avenue for all inpatient and outpatient trainees to conveniently learn from the knowledge their peers contributed at any given times of the day. A reward point system was separately implemented to further incentivize learners to engage. At the end of the clinical rotation, interactive lectures using gamification strategies, such as jeopardy game, was created based on the contribution to the board in order to further engage learners and motivate the retention of knowledge. EVALUATION: Participants completed a voluntary, anonymous questionnaire at the end of their clinical rotations. The survey consisted of quantiative and qualitive questions evaluating participant experiences and perceived educational benefits of the intervention--including learner engagement, promotion of independent and collaborative learning, appropriateness of study contents in terms of level of difficulty and time requirement, and retention of knowledge. The collected data were evaluated using descriptive statistical and qualitative analyses.

/ REFLECTION / LESSONS LEARNED: Among eighty-four trainees who directly participated in the intervention, twenty (24%) completed evaluations. Participants rated educational values, promotion of independent learning and collaborative learning, convenience, low time commitment, and knowledge retention to be the strengths of the intervention with the median of 5 in the 5-point likert scale. Qualitative analyses revealed peer-to-peer learning as the most valued aspect of the intervention, followed by gamification and visual learning strategies. Innovation in Medical Education (IME) - Medical Ethics and Humanities CREATING A REFLECTIVE ART GALLERY EXPERIENCE IN A MEDICAL SCHOOL TO EXPLORE HUMANISM IN MEDICINE Rebecca Ho, Esha Shah, Manasa S. Ayyala. Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4271050) SETTING AND PARTICIPANTS: Medical students, dental students, and faculty at a medical school in the northeast DESCRIPTION: Per the Arnold P. Gold Foundation, humanism in medicine “reflects attitudes and behaviors that are sensitive to the values and the cultural and ethnic backgrounds of others.” Creating and viewing art is intricately tied to developing these skills through introspection and reflection. We created the Art for Healing Collective (AHC) at our medical school to connect art with medicine. After a call for submissions, we selected ten pieces for display in our medical school. We created a curated art gallery viewing experience to foster reflection. This included attaching each piece with its own specific reflection question. Participants were split into small groups rotating with each piece and reflecting on the individual piece’s associated prompt question. EVALUATION: A total of 15 students attended the curated art gallery viewing. All participants completed the anonymous post-surveys to evaluate the acceptability and feasibility of the experience. Using an online survey system, questions focused on the connection of art and medicine using a 5-point Likert scale (5 = yes, very much, 1= not at all). Open-ended included questions focused on empathy and reflective questions like, “What was most surprising to you about this gallery event?” Descriptive statistics were applied using Microsoft Excel. Of the survey responses, 87% (n=13) of participants identified as medical students and 87% (n=13) considered themselves “casual museum-goers.” One participant said it was their first art experience ever. When asked about what surprised them the most about the gallery, most participants commented that they were surprised about the diversity of content of the artwork, and that the work was created by their peers. One participant wrote, “It was interesting seeing how different people interpret their experiences in medicine and express them through physical mediums.” Participants mostly agreed that they valued the connection between the arts and medicine (mean 3.67) and that the gallery experience and prompts had led to reflection on empathy (mean 3.73). The individual prompts were viewed positively with one participant sharing, “I think having prompts for people to reflect on the paintings was a great idea to get people to be more interactive.”

/ REFLECTION / LESSONS LEARNED: This pilot AHC art gallery featured art created by students, staff, and faculty at an academic medical center, with the goal to create a reflective viewing experience focused on humanism in medicine. Participating in the event fostered self-reflection and group reflection on themes related to empathy, collaboration, and humanism in medicine. Many participants were surprised that their peers created the artwork, and many wanted to see more artwork and collaborations with AHC in the future. This gallery is unique in that it was curated to be healthcare-inspired and is certainly feasible for replication at other medical schools. CULTIVATING VIRTUOUS PHYSICIANS THROUGH AN INNOVATIVE PROGRAM IN RESIDENCY ETHICS EDUCATION Beatriz Desanti de Oliveira1; Ashley Moyse2; Lydia S. Dugdale1. 1Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 2Columbia University Vagelos College of Physicians and Surgeons, New York, NY. (Control ID #4272249) SETTING AND PARTICIPANTS: Two-year program for Internal Medicine residents in a large academic medical center in New England DESCRIPTION: We designed a specialized training pathway for residents interested in ethics. After a rigorous application process, five residents were selected as the first cohort of the pathway and embarked on it this fall. The pathway rests on 4 pillars: 1. Clinical Ethics Education: Through seminars, case discussions, reflections on personal experiences, and tutorial learning, residents engage in an in-depth exploration of ethical theory. These sessions, led by experts in the field, provide a platform for critical analysis, self-reflection, and collaborative learning, supporting residents to become well-versed in ethical frameworks, justificatory analyses, and decision-making processes. The education also focuses on strengthening and sharpening the literacy of residents in virtue ethics. 2. Clinical Ethics Consultation Services: residents have the opportunity to engage in clinical ethics consultation services, gaining practical experience in resolving ethical conflicts. Residents contribute to real-world ethical deliberations, honing their skills in ethical analysis and conflict resolution. They can also join in the hospital’s monthly Ethics Committee meetings. 3. Mentorship: residents receive mentorship as well as serve as mentors for medical students interested in ethics. This mentorship role not only fosters the development of leadership skills but also reinforces residents' commitment to professional excellence and responsible practice. 4. Research and Scholarly Writing: Residents collaborate with faculty to undertake research projects and prepare articles for presentation or publication. From conceptualization to dissemination, residents receive mentorship and support to refine their research skills, mature their writing competencies, and contribute to the scholarly discourse in clinical ethics. EVALUATION: We plan on interviewing pathway residents at the end of each academic year. We will collect qualitative data pertaining to each of the 4 pillars of the pathway (quality of educational sessions, topics learned through participation in clinical consultations or Ethics Committee meetings, experience of having and being a mentor, experiences learned through research projects).

/ REFLECTION / LESSONS LEARNED: The complexity and intensity of resident schedules pose significant challenges to incorporating in-depth, specialized training into their curriculum. By utilizing a tailored, innovative approach to medical education, we are able to integrate clinical ethics, mentoring, and research to cultivate intellectual and moral virtues essential for physicianship. The excitement and enthusiasm with which the residents engaged in this pathway speak to the gap this program has filled in their medical training. LIFE WORTH LIVING: A MIXED METHODS STUDY ON A SUMMER SEMINAR'S IMPACT ON MEDICAL STUDENTS Daniel L. Ibraheem, Jake Villanova, Benjamin R. Doolittle. Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4270972) SETTING AND PARTICIPANTS: This summer elective accommodates busy student schedules, meeting for weekly 1.5-hour sessions for 5 – 7 weeks (year dependent). The curriculum approached the question of meaning from the perspective of various religious and philosophical traditions. Students are assigned weekly readings, videos, and discussion questions and write final essays on what makes a life worth living. Course attendees were invited to participate in a mixed-methods study to assess the impact of the course. Quantitative methods included the 2-Question Maslach Burnout Index, evaluation of course impact, and questions regarding meaning and life satisfaction. Qualitative interviews were conducted to elicit in-depth thoughts on similar questions. Ten students participated in the study, composed primarily of second-year medical students from diverse backgrounds with an even male female split. DESCRIPTION: Vocational formation in medicine is the process of self-reflection by which physicians discern their calling as a healer. By helping physicians find meaning in their roles, vocational formation could increase career satisfaction and reduce burnout. Leaders in medical education should consider methods prioritizing vocational formation to improve physician well-being – a benefit also known to positively impact patient care. Here, the implementation of a summer seminar, Life Worth Living, is proposed for medical students that facilitates discussion of what is a meaningful life, and how that applies to physicians. By offering a chance to reflect on what is of importance, students may learn to integrate these beliefs into their careers, improving their well-being. EVALUATION: On a scale from 1-5, the average course impact rating was 4. Burnout prevalence was 30%. Based on interviews, students chose to pursue medicine for various reasons: directly serving others, intellectual curiosity, and prior experiences. In terms of life’s meaning, some saw it as self-determined, while others saw it as grounded in a particular faith tradition. Students endorsed benefitting from exposure to diverse perspectives through classmates and provided resources, and reflecting on their own reasons for choosing medicine through group discussions and the final essay. Consequently, all participants felt strongly about the course’s benefit and desired more and/or longer sessions. Three participants suggested integrating the course into medical school curricula, while others felt making it mandatory might make discussions feel forced.

/ REFLECTION / LESSONS LEARNED: Life Worth Living successfully engaged medical students in vocational formation by facilitating small group discussion of a diversity of perspectives on the meaning of life. Student satisfaction with the seminar was high, emphasizing a desire for more class-time – with some suggesting more formal curricular integration. Future directions include expanding the course to include practicing physicians and evaluating the impact of the course on metrics such as life satisfaction, mental health, and stability. PROSE-ITIVE OUTCOMES: IMPLEMENTING A RESIDENCY-WIDE NARRATIVE MEDICINE CURRICULUM Nicholas B. Safian, Jennifer P. Weintraub, Lauren Peccoralo. Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272973) SETTING AND PARTICIPANTS: This curriculum is currently implemented at an internal medicine residency program at a major urban academic medical center. The program consists of 56 PGY1’s, 54 PGY2’s, and 53 PGY3’s (n=163). DESCRIPTION: Residents participate in six Narrative Medicine (NM) sessions, offered every eight weeks during outpatient clinic didactics. Sessions are one hour. The first session is mandatory, and delivered to a PGY1 group (~15 residents) and a PGY2/3 group (~30 residents). This session consists of a brief introduction to NM followed by an interactive writing activity. Subsequent NM sessions are optional and held during the lunch hour, open to all years. These sessions consist of three parts: 1) reading of a short piece of writing/art (poem, prose, painting, etc.); 2) group discussion about the piece; 3) reflective writing exercise. All sessions are facilitated by NM faculty from Columbia University. EVALUATION: Both the objectives and evaluation of this curriculum have been designed to correspond to relevant ACGME Internal Medicine milestones. Participants completed pre-curriculum surveys at the beginning of the academic year. Following the completion of all six NM sessions, participants will complete a post-curriculum survey. Surveys assess participants’ familiarity with NM; participant self-efficacy in reflective practice and connection/communication with patients; the Stanford Professional Fulfillment Index (SPFI); and the MiniZ One Question Burnout Score. The SPFI and MiniZ are validated measures for assessing professional fulfillment and burnout, respectively. We plan to compare pre- and post-curriculum survey data via paired t-test. De-identified attendance is taken at each session as well; we will further analyze data based on the number of sessions respondents have attended.

/ REFLECTION / LESSONS LEARNED: In a needs assessment of 121 internal medicine residents, 85.9% of residents agreed/strongly agreed it is important for residents to have time to reflect on their experiences with patient care; however, only 13.3% of residents agreed/strongly agreed they are already provided with enough opportunities to do so. Consequently, only 10.7% of residents strongly agreed that they feel a sense of connection with their patients. Furthermore, the majority of residents experience at least one symptom of burnout. This curriculum addresses these needs by providing residents a space for reflection, connection, and communication. The curriculum maps to ACGME Internal Medicine milestones such as Reflective Practice and Commitment to Personal Growth; Patient- and Family-Centered Communication; Knowledge of Systemic and Individual Factors of Well-Being. There are instances in the literature of smaller-scale and pilot medical humanities curricula that have been implemented at the residency level. Our curriculum represents the first of its kind in an internal medicine residency program: a longitudinal NM curriculum offered to an entire IM residency program of such scale (n=163), with sessions facilitated by trained NM faculty. UTILIZING LIVE MUSICAL PERFORMANCE AND THE VISUAL ARTS TO TEACH FUNDAMENTALS OF HUMANISM IN MEDICINE TO PRECLERKSHIP MEDICAL STUDENTS Arman Sawhney2; Michelle DallaPiazza1; Ronald Bangiyev2; Manasa S. Ayyala2. 1Howard Brown Health Center, Chicago, IL; 2Rutgers New Jersey Medical School, Newark, NJ. (Control ID #4272144) SETTING AND PARTICIPANTS: All first-year medical students at a medical school in the Northeast DESCRIPTION: As highlighted in the American Association of Medical Colleges (AAMC) Fundamental Role of Arts and Humanities in Medical Education (FRAHME) 2022 monograph, integrating arts into medical school curricula can improve outcomes in learning and wellbeing. Starting in AY22-23, we created a 1-hour mandatory workshop utilizing live musical performance and the visual arts to explore humanism and empathy in a required first-year medical school course. The session incorporated a brief didactic overview of the role of close listening and observation skills to enhance presence and communication. This was followed by an interactive live musical performance from the medical school’s jazz band and the viewing of select visual art pieces. Throughout the session, students were prompted to take part in self-reflection and group reflection. EVALUATION: In AY24-25, 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 and interactive components were measured using a 5-point Likert scale. Variables were descriptively summarized using frequencies and proportions, and pre- and post-surveys were compared using paired signed rank tests (ordinal variables) and chi-square or Fisher’s exact tests (categorical variables). All analyses were performed using R Statistical Software (v4.1.2; R Core team 2021).

/ REFLECTION / LESSONS LEARNED: 171 students participated in the workshop and anonymous identifier-matched pre- and post-surveys were submitted by 144/171 (84.2%) of students. There were significant increases (p<0.05) in students’ confidence in their abilities to define humanism, explain clinical empathy, distinguish between affective and cognitive empathy, and explain how presence, close listening, and close observation can cultivate connection and promote humanism in medicine. Additionally, students were significantly more confident in their ability to describe the use of visual art and live music as educational tools to practice the skills of close observation and close listening. Most students reported a high satisfaction (4 or 5 on Likert scale) with the content (115/144, 79.9%) and delivery (122/144, 84.7%). As a requirement for all first-year medical students, this brief, highly interactive arts experience was effective in achieving its learning objectives. Future directions include applying these exercises into small group or flipped classroom formats, as well as investigating its value in other levels of medical training. Innovation in Medical Education (IME) - Mental/Behavioral Health and Substance Use Disorders AN INTERDISCIPLINARY RESIDENT LED TRAINING INNOVATION: IMPROVING HEALTH OUTCOMES FOR PATIENTS WITH SERIOUS MENTAL ILLNESS Kyle Hunter, Cristina Calderon, Lisa Ochoa-Frongia, Anne Rosenthal. Department of Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4270358) SETTING AND PARTICIPANTS: Setting: Academic-community partnership with behavioral health clinics in an urban public health system Participants: Behavioral health staff (clinicians, case managers, health workers), resident physician, and faculty mentor DESCRIPTION: Patients with serious mental illness (SMI) face a 15–20 year reduction in life expectancy, driven by low cancer screening rates and a high prevalence of metabolic syndrome and cardiovascular disease. Behavioral health care teams often have greater contact with patients with SMI than primary care clinicians but may lack training to support preventative healthcare. Through a residency curriculum on mental and behavioral health in primary care, we developed a training program to equip behavioral health clinic staff with preventive care strategies for SMI populations. Residents rotated at the clinics and the trainings were designed to reciprocally support clinic needs. Workshops focused on improving cancer screening and metabolic syndrome through culturally tailored education, case-based discussions, and workflow interventions. A primary care resident helped lead design and delivery. Resident-facilitated activities were: 1. Educational sessions: Interactive workshops for behavioral health teams, emphasizing practical strategies for cancer screening and metabolic health management tailored to the unique challenges of SMI populations in an urban safety-net setting. 2. Quality improvement: Collaboration with clinic staff to identify barriers and brainstorm workflow changes, such as improving primary care-behavioral health coordination to enhance preventive care delivery. EVALUATION: A total of 55 participants completed evaluations; 79% Agreed or Strongly Agreed that 'I feel better prepared to support my clients in completing recommended cancer screening tests than I was before the session,' 94% Agreed or Strongly Agreed 'I have learned things about metabolic conditions associated with SMI that will help me counsel my patients' and 93% desired additional sessions. Qualitative feedback emphasized the importance of culturally sensitive education, improved care workflows, and clear referral pathways. An example participant response was, 'I loved the portions that allowed for collaboration of how to talk with/educate patients.’

/ REFLECTION / LESSONS LEARNED: This program bridges critical gaps in preventive care by empowering behavioral health staff with targeted training and offers a replicable strategy to improve interdisciplinary education. Post-session evaluations demonstrated improvements in participants’ knowledge, confidence, and motivation to implement preventive health strategies. This project exemplifies a dual-layered educational innovation: it delivers a targeted curriculum to address disparities in cancer screening and chronic disease management and equips residents with skills to design and implement systems-level changes within interdisciplinary teams. A NOVEL RESIDENT CLINICAL ROTATION AT A DROP-IN MEDICAL CLINIC WITHIN A COMMUNITY-BASED HARM REDUCTION AGENCY WITH OVERDOSE PREVENTION CENTER David S. Edelman1,2; Sejal Shah1,2; L Synn Stern2; Susan Spratt2; Shwetha Iyer1; Benjamin Hayes2,3. 1Primary Care and Social Internal Medicine, Montefiore Medical Center, Bronx, NY; 2OnPoint NYC, New York, NY; 3Internal Medicine, Montefiore Medical Center, Bronx, NY. (Control ID #4272854) SETTING AND PARTICIPANTS: 12 PGY-2 and PGY-3 residents in a primary care internal medicine program at the drop-in medical clinic of a community-based harm reduction agency in a diverse urban area in the Mid-Atlantic, with one of the region’s highest rates of opioid overdose. DESCRIPTION: Harm reduction (HR) acknowledges autonomy of people who use drugs (PWUD), realigning clinical practice to respond to the spectrum of goals driven by individuals. Using collaborative, non-stigmatizing approaches, HR engages patients who otherwise may be excluded from traditional healthcare settings. There is a paucity of HR education in residency, presenting an opportunity to expand to trainees. We designed a clinical rotation for residents to develop and apply skills in HR and addiction medicine at a drop-in medical clinic co-located within a community-based HR agency. The site also provides risk reduction, including syringe exchange and an overdose prevention center (OPC) where people can consume drugs in a supervised setting, and health and supportive services including case management. We created learning objectives with input from participants at the agency; HR and clinic staff; and trainees and faculty. Learning objectives included providing holistic, low-threshold, patient-centered clinical care in a community setting; constructing clinically appropriate plans that acknowledge patient needs and preferences; prescribing medication for opioid use disorder (mOUD); and recognizing and treating xylazine-associated skin and soft tissue infections (SSTI). Residents received pre-reading on the HR agency and HR approaches. One resident per day worked with a preceptor seeing patients in the drop-in medical clinic and engaged in a 10-minute “chalk talk” on treatment of SSTI among PWUD. EVALUATION: Residents saw an average of 5.8 patients per day. Cases involved evaluation and management of various substance use disorders, including mOUD; xylazine-associated SSTI; sexual health, including PrEP, DoxyPEP, and STI treatment; and primary care and acute medical needs. Residents reflected on the unique clinical setting, approach and impact on care: “You get to take care of [patients] in a more community setting and really get to meet them where they are” “It is truly providing easily accessible, comprehensive primary care to people who have been excluded, neglected, stigmatized from traditional health settings” “Having the clinic and the safe injection site… together at one place is really helpful when trying to keep people engaged in care” “One patient with complex medical concerns… said she would never have felt comfortable walking into a traditional clinic to receive care but trusted the staff”

/ REFLECTION / LESSONS LEARNED: To our knowledge, this is among the first integrated residency clinical experiences in a community-based HR agency. Co-location of an OPC is an additionally unique practice setting. Residents applied HR principles and gained valuable insight from working in a community space; future work will continue to qualitatively assess impact. ENHANCING BEHAVIORAL HEALTH EDUCATION THROUGH INTERDISCIPLINARY LEARNING AND CLINICAL DECISION TOOLS IN INTERNAL MEDICINE RESIDENT CONTINUITY CLINICS Gina N. Mo1; Liza Raffi1; Romana P. Dymkoski2; Itai Danovitch2; Neda Laiteerapong4; Stephen D. Sisson3; Rita Rossi-Foulkes1. 1Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 2Psychiatry, Cedars-Sinai Medical Center, Los Angeles, CA; 3Internal Medicine, Johns Hopkins University, Baltimore, MD; 4Medicine, The University of Chicago, Chicago, IL. (Control ID #4264162) SETTING AND PARTICIPANTS: Internal medicine residents in primary care continuity clinics DESCRIPTION: Over 25% of the population in the United States is affected by one or more mental health conditions and up to 70% of patients with the most common conditions are treated in the primary care setting. A recent study of internal medicine primary care physicians and residents reported significant barriers treating patients with behavioral health conditions. Feedback from our residents reflected similar concerns. With permission, we adapted resources from a collaborative care program at an academic medical center to create a toolkit for diagnosing and treating common behavioral health conditions and identifying and referring patients needing a higher level of care. The toolkit consists of patient education materials and diagnostic and treatment algorithms for 13 conditions. At one resident continuity clinic, we added a psychiatrist to staff patients along with internal medicine preceptors one half-day per week, serving as an immediate consultative and educational resource. EVALUATION: We conducted a baseline resident survey to determine their knowledge and comfort managing 13 different behavioral health conditions. With permission, knowledge questions were selected from the Physician Education and Assessment Center (PEAC). Baseline results revealed that lack of access to behavioral health professionals, knowledge, and time were the biggest perceived barriers to care. On average residents rated they were neither comfortable nor uncomfortable treating behavioral health conditions. Of the nine knowledge-based questions, residents scored the lowest on questions regarding anxiety treatment with benzodiazepines and depression treatment with antipsychotic medications. We will conduct a follow up survey in one year and will compare results between clinic sites to determine if there are differences based on the presence of the psychiatrist. We will also obtain baseline and follow up data from the EMR regarding frequency of behavioral health diagnoses and medication prescriptions.

/ REFLECTION / LESSONS LEARNED: The toolkit provides residents with succinct, evidence-based resources to diagnose and treat behavioral health conditions. Real-time collaboration with a psychiatrist provides residents with additional education and support. Anecdotally, residents report that they have utilized screening tools, algorithms, and patient education materials while caring for their patients. Those working alongside the psychiatrist have regularly cited improved confidence managing their patients. Examples include excluding a diagnosis of bipolar disorder as chart lore in a patient, allowing the resident to provide the patient treatment for unipolar depression, approaching a patient with somatic symptom disorder more effectively, de-escalating and assessing safety in an acutely psychotic patient, selecting specific medications to treat depression and anxiety, treating insomnia, and diagnosing and treating adult ADHD. MEDICATION-ASSISTED TREATMENT CLINIC REFERRAL PROCESS: A RESIDENT EDUCATIONAL INTERVENTION PROJECT Frances Norlock1; Reshma Mohiuddin1; Bryan Acevedo1; Diego Mateo Cornejo Gonzalez1; Natalia Rodriguez1; Maria Cuartas1; Seba Qaddorah1; Ilelaboye Ayodeji1; Noelle Krueger1; Ena Mahapatra2. 1Medicine, John H Stroger Jr Hospital of Cook County, Chicago, IL; 2Internal Medicine, Stroger J Hosp of Cook County, Chicago, IL. (Control ID #4271769) SETTING AND PARTICIPANTS: Internal medicine (IM) residents frequently referred patients to the medication-assisted treatment (MAT) clinic for substance use disorders (SUDs) by messaging the clinic’s physicians directly. This resulted in delays in care, when physicians were out of the office, and access to resources - bypassing the clinic’s pre-visit support services. An educational intervention was conducted to improve residents’ confidence in how to correctly refer patients into MAT clinic and where to find SUD information and resources on the health system’s intranet. DESCRIPTION: Residents on the Addiction Medicine rotation created 3 educational slides and trained the Chief Medical Residents (CMRs) and continuity clinic preceptors on the 4 ways to correctly refer patients into the MAT clinics, including: 1) sending a page text to the MAT Bridge Coach; 2) messaging the MAT Bridge Clinic Pool in the electronic medical record (EMR); 3) submitting a MAT order in the EMR; or 4) directly calling the MAT Bridge Pool extension. CMRs reviewed slide content with residents at ward orientations, while attending preceptors reviewed information at clinic huddles during the same 3 consecutive rotations. Residents completed pre- and post-intervention surveys using 5-point Likert scales (0=not confident at all, 1=somewhat not confident, 2=neutral, 3=somewhat confident, 4=mostly confident, 5=very confident) to assess their confidence in how to refer patients into MAT clinic and where to find SUD information and resources on the health system’s intranet. EVALUATION: Among 135 IM residents, 36 (27%) and 39 (29%) completed the pre- and post-intervention surveys, respectively. Using a cut-off score of 4 or greater, pre-intervention, 28% of residents were mostly or very confident about making referrals to MAT clinic from the inpatient setting vs. 30% post-intervention. A more dramatic increase in confidence post-intervention was seen when referring patients from the outpatient setting (19% vs. 35%, respectively). Fourteen percent vs. 23%, pre-and post-intervention respectively, were mostly or very confident about where to access available information and resources on the health system’s intranet. The largest gains in residents’ understanding of the methods for referral were seen in learning that one could send a page text to the MAT Bridge Coach (50% vs. 77%), call a direct number (19% vs. 46%), or send a message to the MAT Bridge Clinic Pool in the EMR (58% vs. 67%).

/ REFLECTION / LESSONS LEARNED: An effective educational intervention focused on practice-based learning and improvement (PBLI) and systems-based practice (SBP) can be obtained over a brief period, using different methods of delivering the same information. The largest gains in learning new information were seen when referring patients in the outpatient setting, underscoring residents’ original lack of confidence in ambulatory systems-based practices. Residents also had gains in learning simplified referral methods (sending a page text and calling a direct number). Innovation in Medical Education (IME) - Quality Improvement and Patient Safety A QUALITY IMPROVEMENT INITIATIVE TO ENHANCE CONFIDENCE IN LEADING RAPID DECOMPENSATION AND CPR EVENTS IN RESIDENT TEAMS AT A TERTIARY ACADEMIC CENTER amira dalmazio1; Som Singh1; Sabiha Armin1; William Harding2. 1Internal Medicine, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 2Pulmonary, Critical Care, and Sleep Medicine, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX. (Control ID #4250341) SETTING AND PARTICIPANTS: In the 2024-2025 academic year, 21 one-hour-long simulation sessions were conducted bi-monthly for internal medicine residents rotating through cardiology and medical intermediate and critical care units. These sessions, led by a pulmonary critical care faculty member, were divided into two groups: one for PGY-1 residents and one for PGY-2 and PGY-3 residents. DESCRIPTION: Residents participated in simulation scenarios using the full capabilities of the simulation lab (use of an interactive mannequin, intubation equipment, crash cart with a functional defibrillator, and containing ACLS dose of medications) where they alternated roles as code leaders. Scenarios were tailored to assess real-time decision-making, clinical management, CPR quality, and rhythm analysis. Following each simulation, a debrief focused on clinical decision-making, CPR quality, and rhythm interpretation. Residents completed pre- and post-simulation surveys, which included a 5-point Likert scale to assess their confidence and six competency-based knowledge questions. EVALUATION: This quality improvement initiative involved 41 participants, with 32 completing the post-survey, resulting in a 78% response rate. Survey results pre- and post-simulation indicated significant improvements in resident confidence and knowledge. Initially, most residents (n=32) reported low confidence in leading a code blue. Following the simulation-based intervention, residents demonstrated a significant increase in confidence, with the average confidence score rising by +0.85 points (p=0.0011). Confidence in providing and assessing chest compression quality improved by +0.72 points, while confidence in in ACLS protocol knowledge increased by +0.48 points. Confidence in recognizing and responding to abnormal cardiac rhythms improved by +0.72 points (p=0.0050). Furthermore, prior experience in leading a code blue was associated with higher baseline confidence levels (p=0.0076). An alpha level of 0.05 was used to indicate statistical significance. The cumulative knowledge score pre-intervention was 74.4%. This score increased to 81.8% following the intervention (p= 0.115). Analyses were completed using Stata 14.

/ REFLECTION / LESSONS LEARNED: In reviewing the residents’ performance during the simulations, areas for improvement were identified which included addressing reversible causes of cardiac arrest, role clarity, and cardiac rhythm recognition. Group training may enhance team performance and outcomes. Given the substantial increase in resident confidence following the simulation and the association between prior experience and higher confidence, this study concludes that simulation-based training is an effective, low-cost intervention for enhancing ACLS competency and confidence. This approach has the potential for widespread application in resident training curricula. ONLINE RESOURCE URL: https://tinyurl.com/CodeBlueSimGuide BLOCK SWITCH TEAM TRANSITION OF CARE NOTE FEASIBILITY, UTILIZATION, AND IMPACT ON DISCHARGE COORDINATION AND HANDOFF SATISFACTION ON INPATIENT MEDICINE RESIDENT SERVICES Necia Hunter, Sharon Ostfeld-Johns. Internal Medicine, Yale University Department of Internal Medicine, New Haven, CT. (Control ID #4273361) SETTING AND PARTICIPANTS: The study was conducted on inpatient medicine teaching services at a New England academic medical center. Participants included senior residents on internal medicine rotations, as well as social workers and care coordinators involved in discharge planning. DESCRIPTION: Inpatient changes in care teams are known to lead to communication breakdowns and patient safety concerns. Currently, at one New England academic medical center, senior residents communicate patient handoff at the end of each rotation via informal email, leading to variability in discharge planning and non-standardized handoff information. This study aims to implement a standardized transitions of care note to improve both the quality of handoff information between residents as well as coordination of discharge plans. The standardized note is designed to be visible to all members of the care team and integrated into the patient record. The study focuses on evaluating the feasibility, utilization, and satisfaction with this standardized communication method. EVALUATION: Surveys were distributed to senior residents, social workers, and care coordinators at the end of each block. Residents were asked about the feasibility of completing the transitions of care note and its effect on their discharge coordination, as well as their satisfaction with the information provided in the handoff. Care team members assessed how the note affected discharge planning when rotations changed. A review of patient charts was conducted at the beginning of each block to assess whether the transitions of care note was completed according to the standardized template.

/ REFLECTION / LESSONS LEARNED: The implementation of a standardized transitions of care note on inpatient medicine resident services is ongoing. Preliminary feedback indicates that both residents and care team members felt the note improved discharge coordination. ENHANCING INTERNAL MEDICINE RESIDENTS' UNDERSTANDING OF THROMBOPHILIA TESTING AND ANTIPHOSPHOLIPID SYNDROME DIAGNOSIS THROUGH FOCUSED EDUCATIONAL INTERVENTIONS Hannah Hugo1; Harleen Sidhu1; Youssef Samaha1; Matthew Wend1; Angelica Singh2; Mohamed Abdelghffar1. 1Internal Medicine, NYC Health and Hospitals Elmhurst, Elmhurst, NY; 2Hematology - Oncology, NYC Health and Hospitals Elmhurst, Elmhurst, NY. (Control ID #4273329) SETTING AND PARTICIPANTS: This study was conducted at a safety-net urban hospital, with 54 internal medicine residents participating in the educational intervention. DESCRIPTION: The American Society of Hematology (ASH) advises against routine thrombophilia testing in hospitalized patients with new VTE due to potential inaccuracies during the acute phase of the disease. Testing is generally reserved for outpatient follow-up, except in specific clinical scenarios such as suspected antiphospholipid syndrome (APS). Thrombophilia panels cost between $1,100 and $2,400, depending on the laboratory. Retrospective data from May 2023 to June 2024 revealed that 395 thrombophilia workup tests were ordered by internal medicine residents. To address this, a pre-test questionnaire assessed residents' baseline knowledge regarding thrombophilia testing and APS. A hematologist delivered a 60-minute lecture, followed by 20-minute small group discussions facilitated by the study team. Post-test questionnaires were administered immediately after the intervention, and results were compared using a paired t-test, with statistical significance defined as a p-value of <0.05. EVALUATION: A total of 54 residents participated in the educational intervention and completed the pre- and post-tests. Key areas of knowledge improvement included correct timing for thrombophilia workup and the identification of patient scenarios that would warrant inpatient testing. We noted 96.3% of residents correctly answered questions regarding appropriate inpatient thrombophilia testing and most residents could correctly answer clinical (88.9%) and laboratory criteria (83.3%) of APS. The average test scores increased significantly from 53.0% to 81.9% following the educational intervention with a p-value of <0.001.

/ REFLECTION / LESSONS LEARNED: Analysis of pre- and post-test data revealed a statistically significant improvement in residents' understanding of appropriate thrombophilia testing and APS management. While the study demonstrated significant improvements in knowledge immediately following the intervention, maintaining and reinforcing this knowledge over time is essential for long-term retention. We plan to implement quarterly educational sessions focused on appropriate thrombophilia testing, complemented by additional coverage of these topics during night float shifts. During these shifts, a study team member will facilitate case-based discussions to reinforce key concepts and encourage practical application in real-world scenarios. Our next planned intervention is a best-practice advisory in EMR that will alert an ordering provider of ASH recommendation against inpatient thrombophilia testing for VTE patients. Our hope is that these interventions will keep clinicians aligned with current guidelines and best practices, ultimately enhancing patient care by reducing unnecessary testing and associated healthcare costs. PARTNERSHIP TO ADVANCE INNOVATION IN RESEARCH (PAIR): INCREASING TRAINEE SCHOLARLY OUTPUT THROUGH PAIRED RESEARCH MENTORSHIP MIRIAM ROBIN2,3; Timothy Kuzel1; Alvin G. Wong2,3. 1Internal Medicine, The University of Arizona College of Medicine Phoenix, Phoenix, AZ; 2Department of Medicine, University of Arizona College of Medicine Phoenix, Phoenix, AZ; 3Phoenix VA Health Care System, Phoenix, AZ. (Control ID #4254736) SETTING AND PARTICIPANTS: Scholarly output is a crucial component of medical education and successful residency and fellowship matches. Difficulty identifying research projects or mentors often impede medical students’ ability to fulfill this expectation. For residents, the most common barrier is lack of time. Competitive matches, such as surgical subspecialties, have the most stringent expectation in the scholarly output of their applicants yet rank among the least diverse of the medical specialties by race and gender. We initiated our project at one Southwestern medical school and its affiliated sites including an academic medical center, an academic pediatric hospital, and VA medical center, where historically there was no system to connect Graduate Medical Education (GME) trainees with Undergraduate Medical Education (UME) trainees or track scholarly output. The paucity of structure led to significant communication gaps between residents who require assistance with their scholarly work and students interested in scholarly activity. We developed an open-source, centralized system to pair GME trainees with UME students. We aim to increase the number of abstract submissions by paired trainees and underrepresented in medicine (URiM) students from July 2024 to July 2025. DESCRIPTION: An open-source database compliant with institution data security policies and accessible from all sites via personal devices was created to track scholarly projects by specialty and output. Projects requiring medical students’ support were solicited through GME emails, didactics, and personal outreach. Medical students were recruited through listservs and direct outreach by fourth-year student liaisons. A management team, which includes a med/peds resident, IM resident, and UME student liaisons, paired GME trainees with UME trainees and prioritized URiM students to promote equity. EVALUATION: URiM participants were defined as current or former pipeline program students. Each trainee and resident pairing was counted as one pair. Scholarly output was measured by abstract submissions. If multiple students or residents worked on a project, the number of pairings was derived from the number of students. Over six months, 46 projects were added to the database. 35 residents across three institutions formed 47 unique research pairs with 33 students. 12 URiM pipeline students participated. 44 abstracts were submitted. 33 abstracts were accepted with 10 co-authored by URiM UME students.

/ REFLECTION / LESSONS LEARNED: Prior to our intervention, communication barriers from institution-specific data security practices prevented collaboration amongst affiliated sites. Centralized open-source tools and a dedicated program management team addressed both barriers without breaching data security policies. This successfully increased scholarly output and cross-institutional collaboration, benefiting both UME students and GME trainees. Prioritizing pairings for URiM trainees may potentially address the systemic underrepresentation of URiM physicians and researchers. REDUCING INAPPROPRIATE USE OF TELEMETRY ON MEDICAL-SURGICAL UNITS AT TUFTS MEDICAL CENTER THROUGH A RESIDENT EDUCATIONAL INTERVENTION Kathleen Oakes1; Jenna J. Port1; Lauren Ehrhardt-Humbert1; Diane Sun2; Alexander Sugerman1. 1Internal Medicine, Tufts Medical Center, Boston, MA; 2internal medicine, Tufts Medical Center, Boston, MA. (Control ID #4271903) SETTING AND PARTICIPANTS: This intervention took place at Tufts Medical Center and was focused on internal medicine residents. DESCRIPTION: Residents initially completed a survey querying their awareness of telemetry guidelines. They were provided with patient cases and asked whether they would order telemetry for that patient. Additional questions were asked about their current practices with telemetry – how often they reviewed who was on telemetry, how often they discontinued telemetry, and how often they reviewed telemetry data on their patients. We held a resident noon conference as our intervention. This presentation included a pre-test and post-test. The conference was primarily a review of the guidelines for appropriate telemetry use and was conducted in a case-based practice format. After the conference, all residents were sent a review of the guidelines. EVALUATION: We audited telemetry use on two medical-surgical inpatient floors consisting of patients admitted under internal medicine resident services. Our team reviewed which patients were ordered for telemetry daily over a two-week period before and after our resident noon conference. We completed a chart review for each patient with an active telemetry order to determine if they had an appropriate indication for telemetry. In addition, we compared pre- and post-test scores of residents who attended the noon conference.

/ REFLECTION / LESSONS LEARNED: After a resident noon conference and distribution of information on telemetry guidelines, inappropriate telemetry usage on two inpatient medical units decreased by 29%. Prior to the intervention, residents scored an average of 72% on a test assessing their knowledge of telemetry usage. Post-intervention the average score was 94%. Overall, we received positive feedback from residents. Many expressed that they had often not known when to order telemetry. This intervention was brief and demonstrated a measurable change in telemetry ordering behavior, but it is not clear how long this change will last. We plan to host this noon conference annually and to create a pocket reference guide. We hope to expand data collection to more inpatient units including primary non-medicine floors and expand this teaching to nursing staff and surgical services as well. ONLINE RESOURCE URL: https://wellforceinc-my.sharepoint.com/:p:/g/personal/kathleen_oakes_tuftsmedicalcenter_org/ERoABmNWt7pOvruKHgBQePMBu4M0-KLSVu2bbGOAfT3W6Q?e=f5tnTM Innovation in Medical Education (IME) - Women’s Health, Sex, and Gender-Informed Medicine ASSESSMENT OF A NOVEL LACTATION MEDICINE CURRICULUM FOR INTERNAL MEDICINE RESIDENTS Molly Perri2,3; Rebeca Ortiz Worthington1. 1General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 2Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 3Yale University School of Medicine, New Haven, CT. (Control ID #4268124) SETTING AND PARTICIPANTS: In Spring 2024, residents in the Internal Medicine (IM) and Med-Peds (MP) programs at one institution participated in a lactation medicine curriculum targeted at knowledge necessary for Internists to address common issues specific to lactating patients. This was delivered through 1 in-person session with Women’s Health Track residents (PGY1-4) and 3 virtual sessions during senior resident (PGY-2-3) teaching conferences. DESCRIPTION: Authors developed a 60-minute didactic curriculum on lactation medicine. Learning objectives (LO) included: 1) breast and lactation anatomy and physiology, 2) recommendations, 3) impact on parent and infant, 4) history and exam, 5) latch, 6) nipple and breast pain, 7) diagnosis and management of complications, 8) maintaining supply, 9) medication and substance use safety, 10) return to work, and 11) disparities. Complications were taught interactively, with hands-on practice using infant “models” and breast pumps during the in-person session. Pre- and post-surveys were analyzed using Wilcoxon Signed Ranks tests for 5-point Likert scales and knowledge scores. EVALUATION: Twenty-four residents participated in a lactation medicine course, with 17 completing pre- and post-assessments (70.8% completion rate). Most were PGY2 (58.3%) and PGY3 (33.3%) from IM (54.2%) and MP (16.7%) programs. Four had prior lactation training. Perceived importance of lactation medicine improved (pre=2.08, post=2.65; p=0.046). Knowledge scores (range 0-38) significantly increased (pre=25.21, post=34.76; p<0.001). Greatest gains were seen in topics like contraindications for breastfeeding (LO2: pre=4.96, post=6.76; p<0.001), health benefits (LO3: pre=8.21, post=11.65; p<0.001), managing complications (LO7: pre=1.57, post=1.94; p=0.020), medication safety (LO9: pre=0.67, post=1.0; p=0.046), ordering breast pumps and workplace protections (LO10: pre=3.75, post=4.65; p=0.016) and disparities (LO11: pre=1.54, post=2.35; p=0.005).

/ REFLECTION / LESSONS LEARNED: This 60-minute course aimed at teaching residents about complications, safety, and protections for lactating patients successfully improved lactation-related knowledge. While curricula on lactation medicine exist in OB/GYN, Pediatrics, and Family Medicine, there are none specifically for general internists. Although 83% of parents initiate lactation, only 25% maintain exclusive breastfeeding through six months. Many patients struggle to maintain lactation due to limited access to evidence-based medical advice and a lack of PCP knowledge. Created by an internist and Certified Lactation Consultant, the curriculum connected lactation medicine with concepts familiar to internists, including disease pathophysiology (e.g., edema, hormone feedback, infection source control), preventive health, DME orders, and medical conditions in the workplace. This curriculum demonstrates that lactation medicine is both learnable and relevant to internists, with potential for adaptation to other institutions, faculty, and clinical outcomes evaluations. IMPLEMENTING WOMEN’S HEALTH EDUCATION AND TRAINING INTO A RESIDENCY PROGRAM; A PRACTICAL EXAMPLE Sanjna Vinze4; Elise Kahn4; Brittany M. Denzer4; Michelle Cleeves2; Sai Anandi Ramaswami1; Nicole Soiseth3. 1General Internal Medicine, Denver Health, Denver, CO; 2General Internal Medicine, University of Colorado System, Denver, CO; 3Internal Medicine, Denver Health Main Campus, Denver, CO; 4Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4268290) SETTING AND PARTICIPANTS: Primary care track residents within a large Internal Medicine residency program located in the western United States. Implemented across 3 hospital settings including academic, community, and VA. DESCRIPTION: Women's health (WH), defined as sex and gender-based care of people with a uterus and ovaries, has seen significant advancements over the past decade. Given the existing health disparities faced by women and the potential threats to their healthcare access, it is crucial for general internists to possess competencies in this care. To address this need, a large academic residency program developed a comprehensive curriculum integrating WH into primary care track education. The multifaceted approach of this curriculum includes: 1) FDA Nexplanon insertion training for first year residents 2) A required WH month with rotations through family planning, gynecology, urogynecology, bone health, breast health, pelvic pain, and menopause clinics 3) WH topics integrated into ambulatory didactics including but not limited to contraception counseling, OB care, menopause, pelvic pain 4) The option to choose family planning as a subspeciality clinic; this offers training in IUD and Nexplanon procedures and management with a longitudinal approach, allowing for sufficient training to perform these procedures independently upon graduation Gaps in the curriculum and plan for improvement (based on “Practical steps to facilitate the integration of sex- and gender-based WH competencies into resident education and training” from SGIM position paper) include: 1) Mentors/Core faculty members from other disciplines 2) Developing standards to accurately assess competency in IUD and Nexplanon procedures EVALUATION: This curriculum is already evaluated through standard evaluation by residents. A survey that recently received IRB approval will further evaluate this curriculum using data pre and post rotation.

/ REFLECTION / LESSONS LEARNED: Developing a long-lasting curriculum requires program leadership and GIM faculty who have the clinical knowledge and passion to implement high yield teaching. Tailoring training to those pursuing primary care where an extensive knowledge of WH topics and procedures is required is the focus of this curriculum. The additional clinical opportunities in family planning clinics allow residents to shape their careers early and facilitates further procedural competency. Including leaders from other disciplines to be a part of curriculum and didactic development is an area for improvement. Additionally, the forthcoming survey will identify deficiencies from a resident perspective and implement solutions accordingly. LABORING OVER PERI-PREGNANCY CARE: DELIVERY OF A NOVEL CHRONIC DISEASE MANAGEMENT CURRICULUM FOR INTERNAL MEDICINE RESIDENTS Ashley N. Youngs1; Deborah DiNardo1; Scott D. Rothenberger3; Rachel S. Casas2; Sara Spinella1. 1Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2General Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA; 3Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4242785) SETTING AND PARTICIPANTS: Peri-pregnancy care includes pre-conception counseling, chronic disease optimization, postpartum follow-up, and long-term risk assessment based on pregnancy outcomes. Sex specific aspects of common chronic disease management have been delineated as part of the core competencies for general internists. Despite its importance, internal medicine (IM) residents report low confidence in this area. IM residents from two Mid-Atlantic academic institutions participated in a novel ambulatory curriculum addressing these gaps. DESCRIPTION: This curriculum focuses on peri-pregnancy management nuances of hypertension, diabetes, and obesity and was developed utilizing national guidelines and was peer-reviewed with local content experts. The curriculum was delivered during protected didactic time in two 30-minute sessions held one week apart over a two week period to promote spaced learning. The first session featured synchronous viewing of a pre-recorded interactive didactic video paired with a worksheet to ensure engagement and content uniformity. The second session involved a facilitator-led small-group discussion that applied concepts from the video to patient cases. Residents completed pre- and post-surveys to measure changes in knowledge, confidence, and attitudes. A $10 gift card incentivized survey completion. Knowledge was assessed using 12 multiple-choice questions piloted by IM fellows and faculty, while confidence and attitudes were measured on a 5-point Likert scale. EVALUATION: Of 228 eligible residents, 78 completed both pre- and post-tests and are included in this analysis. The total percent correct of knowledge scores increased from 50.5% (±15.8%) pre-curriculum to 76.9% (±14.0%) post-curriculum (p < 0.0001). Knowledge gains were observed in all tested areas of hypertension, diabetes, and obesity. Confidence also improved in all domains, particularly with postpartum chronic disease management and long-term risk stratification with score increases of 1.80 (±0.84) to 3.48(±0.65) (p < 0.0001), and 2.42 (±0.79) to 3.63 (±0.61) (p < 0.0001), respectively. Resident recognition of the importance of peri-pregnancy care in primary care also increased slightly from 3.54 (±0.94) to 3.95 (±0.76) (p = 0.0001).

/ REFLECTION / LESSONS LEARNED: This curriculum leverages adult learning principles including spaced learning and delayed recall to address gaps in peri-pregnancy care education among IM residents. While residents recognized the importance of peri-pregnancy care in primary care, they initially lacked knowledge and confidence in this area of patient care. Our curriculum significantly enhanced residents' knowledge and confidence across multiple institutions, demonstrating its scalability and impact. ONLINE RESOURCE URL: https://edpuzzle.com/media/676338941d82ba1c290755d2 LINKING PANEL MANAGEMENT TO THE OUTPATIENT AMBULATORY CURRICULUM 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 #4273074) SETTING AND PARTICIPANTS: The 120 residents whose primary care clinic was at an urban FQHC were included in this study. Residents were part of either the traditional or primary care residency programs affliated with a New England academic medical center. DESCRIPTION: All internal medicine residents received a half-day didactic on outpatient women's health topics including teratogenic medications. A week prior to the didactic session, the residents were instructed how to use SlicerDicer to determine which of their reproductive-aged primary care patients were on teratogenic medications. SlicerDicer is an Epic-based tool which quickly extracts and visualizes patient data. One week later, they were emailed an optional 15 question survey including questions on how many patients were prescribed each of the teratogenic medications; if residents had determined what, if any, family planning method affected patients were using; plans or completed actions to reach out to affected patients; and interest in incorporating panel management with future outpatient didactic sessions. Faculty also held a 10-minute debriefing session to discuss possible interventions and next steps for identified patients on teratogenic medications. EVALUATION: A total of 40 responses (33%) were collected, although 60% (29/48) primary care residents responded compared to 23% (17/72) of the traditional residents. 35 (87.5%) residents completed the SlicerDicer exercise either before or after the didactic session. Of these 35, 34 identified at least 1 patient on 1 of the 3 classes of medications queried. 27 (67.5%) residents had already reached out to or discussed these medications with affected patients by the time of the survey. A large majority (80%) of residents either "Agreed" or "Strongly Agreed" that SlicerDicer should be integrated into more didactics. Residents' written comments were generally reflective of this enthusiasm with quotes such as "This was great! I feel more empowered and also it is helpful to see the data and have measurable variables that we can change” and "Really underscored the importance of correlating our didactics to panel management.”

/ REFLECTION / LESSONS LEARNED: Overall, residents were receptive to incorporating panel management into didactic sessions. The varying program survey response rates likely reflect that the debriefing session during which survey participation was encouraged was mandatory for the primary care residents but optional for the traditional residents. In the future, incorporating the survey into the didactic session could lead to a higher response rate (although this would not allow time to see what actions residents may have taken in the interim). We plan to train additional faculty in SlicerDicer and other EMR-based panel management tools to allow for more routine incorporation of panel management to resident didactics. We are also in the process of obtaining prescribing data for resident patients to see if their was an affect on teratogenic medication prescription among reproductive-aged patients. MICROLEARNING INNOVATION TO IMPROVE MENOPAUSE EDUCATION IN INTERNAL MEDICINE RESIDENTS Sneha Shrivastava1,2; Brooke Juhel2; Mahima Mangla3; Katherine Killian3; Rosemarie L. Conigliaro2. 1General Internal Medicine, Northwell Health, Great Neck, NY; 2Internal Medicine, Northwell Health/Zucker SOM, New Hyde Park, NY; 3Internal Medicine, Lenox Hill Hospital, Bronx, NY. (Control ID #4272767) SETTING AND PARTICIPANTS: Menopause affects all women with nearly 80% reporting distressing symptoms. Despite the known challenging physical and mental manifestations of menopause, general internists are often underprepared on how to address them. The American Board of Internal Medicine has stated the need for formalized women's health education to fill these knowledge gaps. With the rapid advancement of digital learning, the creation of concise and medically accurate content for resident self-learning is imperative. Microlearning (presenting small learning units in an incremental approach to reinforce key concepts) is a powerful strategy for teaching adult learners. Our goal was to create a menopause curriculum based on the use of asynchronous microlearning videos for IM residents. We hypothesize that residents will have a greater improvement in medical knowledge of menopause after this curriculum and would prefer asynchronous short video content over assigned pre-readings. DESCRIPTION: The curriculum was implemented at two large IM programs (186 residents) during ambulatory didactics. A two-part menopause curriculum was created, focusing on (1) diagnosis and risk management and (2) hormonal and non-hormonal treatment of menopause. Brief engaging videos and educational handouts were created to complement these topics as pre-work. Residents were randomized to the intervention group (short video) or the control group (topic handout). All residents received the same interactive case-based lecture on both topics to apply the concepts from the pre-work. The curriculum was evaluated using pre- and post-surveys that consisted of Likert scale questions on resident satisfaction and multiple-choice style questions to assess knowledge. Results were analyzed using unpaired T tests. EVALUATION: The pre and post-response rates for the menopause diagnosis lecture were 52% (96/186) and 75/96 (78%) respectively, and those for the menopause treatment lecture were 47 (87/186) and 79% (69/87) respectively. The pre-lecture knowledge scores for menopause diagnosis did not differ significantly between the two groups (handout: 75% vs. Video: 87%, p=0.247). However, pre-lecture knowledge scores were significantly higher for the video group on menopause treatment (handout: 64% vs. video: 80%, p=0.049). There was not a significant difference in aggregate post-lecture knowledge scores between handout versus video (handout: 82% vs. video: 84%, p=0.652).

/ REFLECTION / LESSONS LEARNED: There is a clear need for menopause education for IM residents. In this intervention, there was a significant difference between the pre-test knowledge in the group who watched the video on menopause treatments. This finding showcases how creating short-form content using microlearning can be beneficial when addressing more challenging topics. Moving forward, our goal is to further expand and disseminate this curriculum across our health system. The videos can used for educating medical students, interdisciplinary learnrs and faculty on menopause. THE ABCS OF WOMEN’S HEALTH—ABNORMAL BLEEDING, CONTRACEPTION, & CERVICAL CANCER SCREENING: ENHANCING WOMEN’S HEALTH IN AN INTERNAL MEDICINE RESIDENCY USING SGIM SEX- AND GENDER-BASED WOMEN’S HEALTH CORE COMPETENCIES Ashley Gordon-Phillips1; Christina D'Agostino2; Michelle York3; Christiana Zhang4. 1Internal Medicine, The Johns Hopkins Hospital, Baltimore, MD; 2General Internal Medicine, Johns Hopkins University, Baltimore, MD; 3Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; 4Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #4271381) SETTING AND PARTICIPANTS: This curriculum was delivered Fall 2024 to all Internal Medicine (IM) interns at a mid-Atlantic academic medical center across four ambulatory block academic half days (AHD). DESCRIPTION: As internists, it is our responsibility to be well-versed in sex- and gender-based medicine to provide the high-quality care our patients deserve. Residency is the ideal time to develop foundational knowledge and skills, yet there is a lack of consistent, comprehensive women’s health (WH) education across IM residency programs, a gap this curriculum seeks to address. Zhang et al found that there have been multiple efforts to bridge this gap, but there has been a lack of consensus on what topics should be taught and a wide variety of teaching methods (Zhang 2019). In 2023, the SGIM Women and Medicine Commission published seminal core competencies in sex- and gender-based medicine for internists (Henrich 2023). These competencies served as the foundation for a new WH curriculum at our institution. This three-hour AHD covering contraception, abnormal uterine bleeding, vaginitis and cervical cancer screening was administered to all interns during their ambulatory rotation using didactics, gamification and pelvic model simulations. Prior to this initiative, there was no longitudinal, fully-integrated WH content in our institution's IM residency curriculum. EVALUATION: Learners completed a pretest and posttest assessing knowledge, confidence and behavior before and after the AHD. Each item was mapped to a specific competency from Henrich et al. Of the 49 IM interns in the 2024-2025 cohort, 44 completed the pretest and 28 completed the posttest. Knowledge was assessed with 15 questions and Confidence was measured by assessing learners' perceived independence performing 10 WH skills. After the AHD, learners had significant improvements in their knowledge (mean prettest score 8.3, mean posttest score 10.9, p<.001) and in their confidence performing the following: prescribing contraception (p<.001), taking a history for abnormal uterine bleeding (p=.036) or menopause (p=.002), ordering appropriate labs/imaging for abnormal uterine bleeding (p=.005), and completing a vaginal speculum exam (p=.003), pap smear (p=.003), or STI testing (p=.002). According to the prettest, only 11.4% and 25% of learners reported routinely performing indicated contraceptive counseling and cervical cancer screening, respectively. Learners will complete a 6-month posttest in Spring 2025 to assess knowledge retention, confidence-building, and behavior change.

/ REFLECTION / LESSONS LEARNED: This project illustrates the efficacy of dedicated, multi-modal WH education on improving resident knowledge and confidence. Our curriculum is one of the first built upon the 2023 SGIM core competencies and serves as a model for standardizing WH curricula across institutions. Next steps include expanding to other residency classes to address additional core competencies and addition of standardized patient experiences to improve physical exam skills. THE SEX AND GENDER HEALTH EDUCATION INITIATIVE OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION: RESULTS FROM A 2 YEAR STUDENT-LED PILOT Sneha M. Chaturvedi2; Iris Dupanovic1; Monica Ybarra3; Sarah Osborn4; Jeanna M. Arbesfeld-Qiu5; Julia Lorence7; MaCee Boyle6; Janice L. Werbinski8; Deborah Kwolek9. 1Extension School, Harvard University, Cambridge, MA; 2Department of Neuroscience, Washington University in St Louis, St Louis, MO; 3University of Houston, Houston, TX; 4St George's University School of Medicine, Saint George's, Saint George, Grenada; 5Harvard Medical School, Boston, MA; 6School of Medicine, University of Missouri, Columbia, MO; 7College of Health Solutions, Arizona State University, Tempe, AZ; 8Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, MI; 9Department of Medicine, Harvard Medical School, Boston, MA. (Control ID #4272370) SETTING AND PARTICIPANTS: Sex and gender-based medicine (SGBM) is pivotal to providing equitable patient care, but is often overlooked in medical curricula. To address this, the American Medical Women’s Association’s Sex and Gender Health Collaborative (AMWA-SGHC), launched an innovative, student-led pilot program from 2022 to 2024. To date, over 200 students and over 30 physician mentors have participated in creating SGBM educational materials through this international, virtual initiative. DESCRIPTION: Over the two-year pilot period, teams of 2-3 medical and premedical students, supported by physician mentors, conducted literature reviews of 75 common medical conditions. They then developed factsheets highlighting sex and gender differences in presentation, diagnosis, treatment, and outcomes. Each factsheet is peer-reviewed by a physician mentor who is a subject matter expert. Once approved, the student graphics team creates an infographic and tabular factsheet, which are in the process of being published on the AMWA website and social media. These materials inform healthcare professionals about the relevance of SGBM in a variety of conditions, such as depression, stroke, and human papilloma virus. EVALUATION: Three mixed-methods surveys were conducted to assess student participant experiences: a pre-survey (2022, N=206), an intermediate survey (2022, N=142), and a post-survey (2024, N=39). Before participation, 60.5% of medical students indicated that SGBM was not included in their curriculum outside of obstetrics and gynecology. After participation, students demonstrated a significant (20%, p=0.01) increase in awareness regarding SGBM in personalized medicine and a moderate (4%, p=5.08E-12) increase in awareness of available SGBM resources. The vast majority of students (92%, p=0.066) reported that factsheet creation increased their knowledge of SGBM. Inductive qualitative coding revealed common themes in students' responses, including collaboration, community, knowledge acquisition, and awareness of SGBM differences. Five medical students not involved in factsheet creation participated in cognitive interviews and reported that they felt more prepared to talk to patients after viewing two factsheets.

/ REFLECTION / LESSONS LEARNED: While this initiative increased students’ self-reported knowledge and awareness of SGBM, it also revealed curricular gaps. The creation of high-quality educational resources shows potential to fill educational gaps in medical curricula. This initiative demonstrates the power of student-led efforts to recognize and address unmet needs, thereby effecting meaningful change. Limitations include self-reported measures and recruitment of female-only participants through AMWA. Future efforts, supported by Scholar Rx’s MERIC grant, include the creation of a library of SGBM educational modules. We aim to expand this initiative through partnerships with medical schools across the US, with the goal of improving SGBM education and contributing to more inclusive patient care. ONLINE RESOURCE URL: https://www.amwa-doc.org/sghc/ USING SIMULATION TO TEACH CHALLENGING TOPICS IN WOMEN’S AND GENDER HEALTH Ilana Richman1; Mukta Dhond2; Allister Hirschman7; Joseph X. Canarie1; Tracy Rabin3; Cynthia F. McNamara4; Jadwiga Stepczynski1; Luz S. Vasquez5; Janet Henrich6. 1Department of Medicine, Yale University, New Haven, CT; 2Internal Medicine, Yale School of Medicine, Hamden, CT; 3Internal Medicine, Yale University School of Medicine, New Haven, CT; 4Medicine, Yale School of Medicine, New Haven, CT; 5General Internal Medicine, Yale Medical School, North Branford, CT; 6Internal Medicine, Yale University, New Haven, CT; 7Department of Surgery, Yale New Haven Health, New Haven, CT. (Control ID #4271282) SETTING AND PARTICIPANTS: This curriculum was developed by an interdisciplinary group of faculty at an academic medical center in the North East. Learners included all residents from three affiliated residency programs. DESCRIPTION: Simulation is widely used in medicine to teach a range of skills including procedures, communication, and decision-making. Our interdisciplinary group developed a half-day educational curriculum using 3 simulation methods: standardized patients, anatomic models for procedures, and an “escape room” to teach challenging topics in the care of women and gender diverse patients. Residents rotated through each simulation module in groups of 5-8 residents during a half day session. In module 1, residents developed and refined interview and communication skills with gender diverse standardized patients. Residents received real-time feedback on their communication, language, and adequacy of the history gathered. In module 2, residents learned a trauma-informed approach to the pelvic exam, then applied this approach using manequins. In module 3, residents worked through an extended clinical case of breast cancer screening and genetic testing for a person at elevated risk of breast cancer. The case used an “escape room” format in which residents completed a series of puzzles by answering questions about the case correctly. We evaluated the curriculum before and after using self-reported assessment among participants. Residents were asked to rate confidence in providing gender-affirming and trauma-informed care on a scale of 1 (not confident) to 10 (very confident) before and after participation. Residents were also asked to evaluate the relevance of the escape room activity for clinical care. EVALUATION: Among 78 residents who have participated in the curriculum to date, 77 completed a pre-curriculum evaluation and 75 completed an evaluation after the session. Self-reported confidence in ability to gather a sexual history increased from a mean of 5.2 to 6.8 (p<0.001 ) after participation. Confidence in the ablity to perform a trauma-informed pelvic exam rose from a mean of 4.9 to 7.0 (p<0.001), and confidence in ability to discuss organ-specific preventive care rose from 5.5 to 6.9 (p<0.001). Among respondents, 67% agreed that the escape room included clinical situations that simulated real world cases, and 67% agreed it was effective at identifying knowledge gaps.

/ REFLECTION / LESSONS LEARNED: We used diverse simulation approaches (standardized patients, mannequins, and an escape room activity) to teach topics that can otherwise seem abstract or challenging. Residents had meaningful improvements in comfort with the topics covered, suggesting that the opportunity to apply skills through simulation was effective. Our approach indicates that simulation can successfully be used to teach challenging topics and identify areas for growth in the care of women and gender-diverse patients. YOUR PREGNANCY TEST IS POSITIVE: A NOVEL CURRICULUM IN UNPLANNED PREGNANCY COUNSELING AND MEDICATION ABORTION FOR INTERNAL MEDICINE RESIDENTS Xanthia Tucker1; Virginia Sheffield2; Allison Ruff2. 1Internal Medicine, Boston Medical Center, Boston, MA; 2Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4269900) SETTING AND PARTICIPANTS: The curriculum took place at an academic medical center in the Midwestern region. Internal Medicine residents (PGY 1-3) on their ambulatory medicine block attended a mandatory 90-minute workshop. The session occurred once a month with three discrete groups of 19 learners (57 total). DESCRIPTION: Following a needs assessment survey of Internal Medicine (IM), Pediatrics (P), and Medicine-Pediatrics (MP) residents, we designed a workshop to address residents’ reported lack of confidence and pronounced interest in learning more about unplanned pregnancy counseling and medication abortion. The workshop included the following elements: information on the prevalence of and factors related to unintended pregnancy, a framework for options counseling, considerations for patients planning to continue pregnancy through parenting or adoption, a values clarification exercise, information on the prevalence of abortion, and instruction on medication abortion. The values clarification exercise used anonymous polling software to rate comfort with four fabricated patients requesting abortion. We first delivered this workshop electively to IM, P, and MP residents in Spring 2022. Based on positive feedback and perceived value, we progressed to an updated workshop for IM residents during their required ambulatory didactics in Spring 2024. This curriculum will be continued biannually, in keeping with the standard ambulatory curricular offerings. EVALUATION: Anecdotally, residents have valued the workshop. We plan on conducting surveys to gather formal feedback on the session and to assess knowledge of and attitudes towards pregnancy counseling and medication abortion from participants.

/ REFLECTION / LESSONS LEARNED: Patients with unintended pregnancy deserve comprehensive, evidence-based, and nonjudgmental care from their internists1. Resident physicians must reconcile core personal values with their duty to learn salient topics in Internal Medicine, including pregnancy counseling and medication abortion. Our workshop addresses knowledge gaps in reproductive health, facilitates self-reflection, and highlights the complexity of decisions around unplanned pregnancy from medical, ethical, legal, socioeconomic, and social justice perspectives. During trainings on these topics, an open-ended approach and interactive anonymous tools can fuel engagement from people who do not feel empowered to speak up. 1. Serchen J, Erickson S, Hilden D; Health and Public Policy Committee of the American College of Physicians. Reproductive Health Policy in the United States: An American College of Physicians Policy Brief. Ann Intern Med. 2023;176(3):364-366. doi:10.7326/M22-3316 Scientific Abstract - Adolescent Medicine A VOTE OF CONFIDENCE: ASSOCIATIONS BETWEEN ADOLESCENT EXTRACURRICULAR ENGAGEMENT AND BELIEF IN VOTING Rebecca K. Tsevat1; Anoushka Sinha2. 1Internal Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2Pediatrics, University of California San Francisco, San Francisco, CA. (Control ID #4269871)

In light of historically low voter turnout among young adults, confidence in the voting process among adolescents is of vital importance, given that civic engagement has been associated with health status in adults. Involvement in extracurricular activities also has been shown to have many health benefits for adolescents. However, less is known about how extracurricular engagement might be associated with aspects of civic engagement in this population. Therefore, the aim of this study is to describe the association between engagement in clubs and organizations outside of school and belief in voting among adolescents.

We analyzed the adolescent population file of the 2021-2023 California Health Interview Survey, a web- and telephone-based survey of a representative sample of adolescents in the state. Participants between the ages of 12 and 17 years reported on their involvement in clubs and organizations outside of school other than sports (e.g. YMCA or Boys and Girls Club) in the past year, their belief that “the way people vote gives them a chance to influence how things are run in their community and California” (hereafter referred to as belief in voting), and sociodemographic characteristics. A design-corrected F test was used to evaluate differences between those who did and did not express belief in voting. Weighted logistic regression tested whether involvement in clubs and organizations was associated with belief in voting, adjusting for age, sex, race and ethnicity, family income, and general health status.

The unweighted sample included 3,122 adolescents. Less than one-third (30.01%) reported involvement in clubs and organizations outside of school, and 68.31% somewhat or strongly agreed that the way people vote gives them a chance to influence how things are run in their community and California. Participants involved in clubs and organizations were more likely to express belief in voting than those without involvement (72.93% vs. 66.58%, p=0.01). After adjusting for sociodemographic characteristics, involvement in clubs and organizations remained positively associated with belief in voting (AOR 1.28, 95% CI 1.01-1.62).

Participation in clubs and organizations has many health benefits throughout adolescence, and this study suggests that civic engagement may be an additional unexamined dividend. Providers caring for adolescents might consider promoting involvement in extracurricular activities to increase their patients’ sense of agency and trust in the democratic process as they approach the cusp of voting age, as policies determined by elections have the potential to influence health outcomes for generations. COMPREHENSIVE ASSESSMENT OF LIVED EXPERIENCE AND BURNOUT IN CAREGIVERS OF TRANSITIONING YOUNG ADULTS WITH CHILDHOOD MEDICAL COMPLEXITY IN ALABAMA: A MIXED METHODS APPROACH Raksha Ramdas1; Carlie Stein2; Madeline Eckenrode3. 1Internal Medicine-Pediatrics, Heersink School of Medicine, The University of Alabama at Birmingham, Birmingham, AL; 2Medicine, UAB, BIrmingham, AL; 3Internal Medicine/Pediatrics, UAB, Birmingham, AL. (Control ID #4245261)

Adolescents with complex medical conditions, such as cerebral palsy, often require ongoing care of these diseases into adulthood. With advancements in treatment and management of these conditions, life expectancies have increased, and there is a greater need for primary care clinics to support patients with chronic conditions as they grow older. Evidence suggests that patients with complex medical conditions are susceptible to poor health outcomes, particularly during the transition to adulthood. The “Staging Transition for Every Patient” (STEP) program at University of Alabama at Birmingham (UAB) is a specialized clinic designed to prepare young adults with complex conditions to transition from pediatric to adult care. This mixed methods study provides a comprehensive understanding of factors contributing to caregiver burden and accounts for socio-cultural context and real-world lived experience.

After IRB approval, a 39-item survey was created to be administered to caregivers of 150 patients to assess demographics and barriers of those supporting patients with complex conditions at the STEP clinic. Once sufficient enrollment is reached, quantitative data analysis will be analyzed before selecting caregivers to participate in semi-structured interviews for qualitative data collection. Thematic analysis will be done to interpret qualitative data collected from interviews, followed by integration of quantitative and qualitative data.

Forty-five percent of caregivers are above 55 years of age. Forty-six percent of caregivers reported their status as full-time employees. The income of 55% of caregivers was at or below $49,000 in the past year. Ninety-six percent of surveyed participants have served as a caregiver for over 2 years. Seventy-eight percent of caregivers report feeling varying degrees of loneliness and isolation. Over 89% of caregivers report feeling varying degrees of stress in the past month. Over 72% of caregivers report feeling as though they were unable to cope with their responsibilities in varying degrees. Thirty-eight percent of caregivers report a lack of reliable transportation. Thirty-eight percent of caregivers report facing the possibility that services could be stopped at their place of residence in the past year.

Preliminary results are proving the significance of burden through the transition period for the caregivers of adolescents with medical complexity. Adding a qualitative component to these survey findings allows greater opportunity to develop interventions to reduce caregiver burden in this vulnerable population. Insights from the study may lead to holistic care models that not only consider the patient’s needs, but also the caregiver’s well-being. The study may introduce a need for educational programs or support groups for caregivers. Understanding caregivers’ experiences and challenges allows for clinicians to not only meet the caregivers’ needs and minimize burnout, but also optimize patient care and safety. DESCRIBING THE SYNDEMIC OF OBESITY AND VAPING AMONG EMERGING ADULTS AGED 18-25 IN THE NATIONAL HEALTH INTERVIEW SURVEY, 2022-2023 Alejandra Ellison-Barnes1; Priyanka Fernandes1; Kimberly A. Gudzune2; Jessica G. LaRose3; Wendy Bennett1. 1School of Medicine, Johns Hopkins Medicine, Baltimore, MD; 2American Board of Obesity Medicine, Denver, CO; 3Virginia Commonwealth University, Richmond, VA. (Control ID #4273123)

Emerging adulthood is a unique developmental period from ages 18-25 with importance in establishing habits and lifestyle that may persist throughout adulthood and contribute to an individual’s long-term health trajectory. Rates of overweight and obesity have been rising in this population, and emerging adults simultaneously have the highest rate of vaping of any age group. However, the overlap of these two chronic disease risk epidemics among emerging adults has not been well-described. Our objective was to describe the relationship between weight status and vaping in a large, nationally representative sample of emerging adults to inform a rationale for weight management interventions that additionally address other cardiometabolic risks like vaping.

We used data from the National Health Interview Survey (NHIS) years 2022 and 2023 and included emerging adults aged 18-25. Survey weights were used to account for complex survey design. Weight status was defined using body mass index (BMI) and classified as underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25-29.9 kg/m2), or obesity (BMI ≥30 kg/m2). Vaping status was defined as current, former, or never. We used descriptive statistics to evaluate the distribution of weight status and vaping, and a chi-squared test to examine the relationship between the two. Analyses were performed in Stata 17.

We included 4044 emerging adults. In the survey-weighted population, 48.8% were female, 52.7% were non-Hispanic White, 12.6% were non-Hispanic Black, and 24.3% were Hispanic. In terms of weight status, 23.8% had obesity and 24.7% had overweight. With regard to vaping, 14.5% reported current vaping and 20.3% reported former vaping. By weight status, 22.0% of those with underweight, 15.3% of those with normal weight, 13.1% of those with overweight, and 13.6% of those with obesity endorsed current vaping. There was no significant difference in vaping status by weight status (p=0.184). Of all emerging adults, 3.2% had both obesity and endorsed current vaping, and 3.3% had both overweight and endorsed current vaping.

Among emerging adults in NHIS, nearly a quarter have obesity and 14.5% currently vape. We did not find significant differences in vaping rate by weight status. This study suggests that there are approximately 2.09 million emerging adults who have overweight or obesity and also are currently vaping. These findings indicate a need for interventions at the individual, community, and policy levels to prevent and treat obesity and vaping dependence during emerging adulthood, potentially yielding lifelong reductions in subsequent cardiometabolic morbidity and mortality. Scientific Abstract - Ambulatory Medicine A COMPREHENSIVE REVIEW EVALUATING THE PRESENTATION AND DIAGNOSIS OF HERBAL-INDUCED LIVER INJURY SECONDARY TO TURMERIC USE Avneet Singh2; Alexander Garcia2; Tanay-Veer Gandhi1; Zehara Abidi3; Fariha Hasan2; Queenzy Jover6; Anand Thakkar4; Tommy Nguyen5; Kunal Dalal5. 1Student, Rowan University Cooper Medical School, Camden, NJ; 2Internal Medicine, Cooper University Health Care, Camden, NJ; 3Touro College of Osteopathic Medicine, Middletown, NY; 4Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 5Gastroenterology, Cooper University Health Care, Camden, NJ; 6Virtua Health Inc, Marlton, NJ. (Control ID #4267863)

Herb-induced liver injury (HILI) is a rare adverse effect to herbal supplements leading to acute liver injury or liver failure. Turmeric is a widely used natural remedy for many illnesses, and is now being used in the West as a non-FDA regulated natural supplement. This comprehensive review focuses on turmeric induced liver injury to build a clinical framework for future cases.

We conducted a comprehensive review of all HILI case reports on PubMED through February 2024 which resulted in 71 cases. Cases were excluded if completed in children (< 18 years), not on turmeric alone, or not in English. Data extraction and analysis was independently performed by two reviewers. Descriptive statistics were used to analyze abstracted data.

17 cases were analyzed with a mean age of 56.8 ± 10.99, with females comprising 82.4% of cases. Of the patients, 7/16 ( 43.8%) and 1/16 (6.3%) had a history of autoimmune or liver disease, respectively. 7/16 (43.8%) of the patients reported alcohol use and 6/15 (40%) reported use of other herbal supplements. The most common presenting symptom was jaundice (56.3%), followed by choluria (43.8%) and right upper quadrant (RUQ) pain (37.5%), while 2/16 ( 12.5%) were asymptomatic. Mean length of turmeric use was 99.07 ± 86.71 days, while mean turmeric dosage was 2353 mg ± 4499.55 mg. The mean R Factor was 31.81 ± 20.24. The mean ALT (1946 ± 1218.79) was greater than AST (1374.94 ± 861.44), while mean ALP was 227.92 ±117.16. Mean total bilirubin and direct bilirubin were 10.24 ±9.26 and 6.93 ± 7.31. ANA and ASMA were positive in 63.6% and 25% of cases. RUQ ultrasound was normal in 11/14 (78.6%) of patients and liver biopsy was performed in 10/14 (71.4%) cases. The main treatment was cessation of turmeric use and steroids were initiated in 3/16 (18.8%) of the cases. Liver markers normalized on average in 88.88 ± 93.96 days.

HILI is a rare occurrence, but we speculate an increase in cases with the use of non-FDA regulated supplements. We acknowledge limitations in the study, including accuracy of diagnosis despite histologic sampling, confounding factors, overlap of syndromes, cross contamination in procurement and lack of serologic full toxin analysis panels. However, in patients presenting with acute liver injury of unknown etiology, clinicians should consider supplements, such as turmeric, as possible culprits of HILI. This review has several key points to help clinicians diagnose and treat future cases of turmeric induced liver injury. A HYPOGLYCEMIA PREVENTION PROGRAM FOR PRIMARY CARE - DEVELOPMENT AND PILOT TESTING Scott J. Pilla1; Claire F. Snyder3; Nestoras Mathioudakis5; Susan H. Schrock4; Nisa Maruthur2. 1General Internal Medicine, Johns Hopkins University, Baltimore, MD; 2Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; 3Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD; 4Johns Hopkins Community Physicians - East Baltimore Medical Center, Baltimore, MD; 5Endocrinology, The Johns Hopkins University School of Medicine, Baltimore, MD. (Control ID #4271392)

Hypoglycemia due to diabetes treatment is a major cause of morbidity and impaired quality of life. Guidelines recommend routine hypoglycemia assessment and management in clinical encounters, yet this occurs rarely in primary care. To address this, we developed the Hypoglycemia Prevention Program (HPP), an intervention that integrates routine hypoglycemia assessment and prevention tools into a primary care workflow. This abstract reports the development of the HPP and preliminary data from its ongoing pilot study.

We developed the HPP using a participation action research process with input from people with diabetes, primary care providers and office staff. The HPP includes two components, built into the Epic health record system (Figure): 1) the Hypoglycemia Patient Profile comprised of patient reported outcomes measures for hypoglycemia and its impact; and 2) an Individualized Action Plan based on the patient’s responses including provider alerts, orders, and patient education. We are conducting a pre/post pilot study testing the HPP at one primary care practice. Eligible patients are adults with diabetes treated with insulin, sulfonylureas, or meglitinides. The primary outcome is acceptability; secondary outcomes include feasibility, hypoglycemia frequency by self-report and continuous glucose monitoring, and hypoglycemia communication quality in audio-recorded visit dialogue. We will conduct post-intervention focus groups to refine the HPP tools.

To date, we have enrolled 21 patients of target N=35. Mean age is 69 years, 45% are women, and race/ethnicity is 57% white, 24% Black, 10% Asian and 5% Hispanic. Most participants (76%) are treated with long-acting insulin, 43% with rapid-acting insulin, and 24% with a sulfonylurea. Participants’ self-reported hypoglycemia frequency was no recent episodes (38%), every 1-3 months (38%), and once per week or more (24%).

The HPP is an evidence-based and user-informed tool addressing critical gaps in hypoglycemia prevention in primary care. Our pilot study enrolled people with diabetes at high risk for hypoglycemia, and we will soon have data to report its acceptability, feasibility, and preliminary efficacy. Future work will include definitive effectiveness evaluation in a large pragmatic trial, and dissemination to primary care practices. A PRE-INTERVENTION ANALYSIS OF METABOLIC DYSFUNCTION–ASSOCIATED STEATOTIC LIVER DISEASE (MASLD) SCREENING PRACTICES IN AN INTERNAL MEDICINE RESIDENCY CLINIC Gabriel Alugba1; Karishma Narain1; Irha Jamshed1; Shalva Eliava1; Danielle J. Pope1; Dipal R. Patel1; Natasha Rastogi2. 1Internal Medicine, Englewood Hospital and Medical Center, Englewood, NJ; 2Internal Medicine, Englewood Health, Englewood, NJ. (Control ID #4272841)

Metabolic dysfunction–associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The progressive spectrum of MASLD includes metabolic dysfunction-associated steatohepatitis (MASH), the second-leading cause of cirrhosis and liver transplantation in USA and Europe, and ultimately ending in hepatocellular cell carcinoma (HCC). Risk factors for MASLD include cardiometabolic disorders such as obesity, insulin resistance, type 2 diabetes mellitus, high blood pressure, and dyslipidemia. However, obesity and/or type 2 diabetes are key factors in the progression of MASLD along its spectrum. The global prevalence of MASLD has significantly increased in the past three decades at an alarming rate5. This highlights the need to identify patients at risk of MASLD and halt its progression. In this preintervention analysis, we sought to examine the rate of screening for MASLD in high risk patients with diabetes and obesity in our resident-led outpatient clinic in order to improve its deficiencies.

This study analyzes patients who visited the North Hudson Community Action Corporation (NHCAC) in Englewood, NJ, from January 30th to April 23rd, 2024. NHCAC is a federally funded clinic that serves a high-risk population. The Internal Medicine clinic is staffed by residents from Englewood Health. IRB approval was obtained, and the eCW health record system was utilized to acquire data. We studied patients aged 18 years and older with obesity and diabetes. We reviewed medical charts and collected variables of interest including the presence or absence of hypertension, hyperlipidemia/treatment with statins, smoking status, CKD, documented screening with FIB-4 score, use of enhanced liver fibrosis test, and imaging modalities.

A total of 89 patients met the inclusion criteria and were analyzed, of which 60.7% were males. The mean age was 51.4 years. 76.4% (68) of the patients were Hispanic, 12.4% (11) were Black, and 3.4% (3) were Caucasian. 62.9% were uninsured, 15.7% of patients had abdominal imaging, and 1.1% had a documented FIB-4 score. Additionally, 70.8% of patients had hypertension, and 87.6% of patients had hyperlipidemia.

This pre-interventional study showed a low rate of MASLD screening rate in our high-risk patient population. Factors considered were resident knowledge and awareness of the disease process, health literacy and insurance status of patients, inconsistent follow-up, and limited educational resources. We plan to implement measures to increase the rate of MASLD screening in the clinic. ASSESSING THE PREVALENCE OF CLIMATE CHANGE HEALTH VULNERABILITY AMONG ESTABLISHED PRIMARY CARE PATIENTS AT AN URBAN SAFETY NET HOSPITAL SYSTEM USING ELECTRONIC HEALTH RECORD DATA Brittany M. Denzer. Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO. (Control ID #4267719)

There is a consensus that healthcare providers must mitigate the adverse health effects of climate change (AHECC) for their patients. However, there are few systems in place to facilitate this, including identifying at risk patients. Known risks for AHECC include chronic lung disease, diabetes, heart disease, chronic kidney disease, mental health disorders, pregnancy, the young and elderly, people of color, non-English as primary language, and uninsured status. The electronic health record offers the opportunity to develop tools to identify patients at risk. This study aims to understand the prevalence of various vulnerabilities of individuals to AHECC using existing Electronic Health Record (EHR) data with the goal of informing tools to help identify vulnerable patients.

This study was conducted at a large academic, safety net hospital system in the Northwest region. Epic’s Slicer Dicer was used to identify a population defined by patients seen in the last 5 years within the healthcare system’s primary care system and established in a primary care “medical home.” This population was organized by risk for adverse health effects of climate change including race, age, certain medical conditions, language, and insurance status to produce percentage of population with each vulnerability. Medical diagnoses were defined by the Snowmed ICD-10 code hierarchy.

94% of all patients of the defined population have at least 1 risk factor for AHECC. Mental health diagnoses were the most common medical comorbidity while racial groups and non-English as primary language were the most common social vulnerabilities.

Most patients in our patient population are at risk for AHECC based on EHR data. Interventions to help mitigate risk include counseling on behavioral adaptations, such as interpreting the air quality index or receiving weather alerts, as well as tailored medical plans, for example, adjusting diuretics during heat events. Tools to further risk stratify patients would be helpful in identifying the highest risk patients who would benefit most from intervention. This finding also could also suggest that screening patients is unnecessary, and universal intervention may be more impactful. ASSOCIATION BETWEEN LIPID TRENDS AND PERCENTAGE WEIGHT LOSS AFTER SLEEVE GASTRECTOMY Kunal Khurana1,2; Sarah Cho2; Luca Bertozzi2; Adam Odolil2; Vincent Xu2; Kelly Feng2; Hope T. Jackson3; Khashayar Vaziri2; Sean Lee2; Juliet Lee2. 1SGU School of Medicine, Grenada, Saint George's, Saint George, Grenada; 2The George Washington University School of Medicine and Health Sciences, Washington, DC; 3University of Michigan Michigan Medicine, Ann Arbor, MI. (Control ID #4234495)

Sleeve gastrectomy (SG) has been shown to reduce overall and cardiovascular mortality and is associated with a decrease in cardiovascular events in patients with obesity. This benefit has been attributed to an improvement in dyslipidemia amongst other factors. While the improvement in triglyceride and HDL levels after SG has been established, its effect on lowering LDL has been less consistent. Furthermore, the association between the degree of weight loss after surgery and the corresponding improvement in lipid parameters is unclear. The aim of this study was to determine the relationship between the percentage weight loss and trends in lipid parameters after sleeve gastrectomy.

Charts were retrospectively reviewed for 755 patients who underwent bariatric surgery from 2017-2021. Patients undergoing sleeve gastrectomy who had data available for weight, BMI, LDL, HDL, triglycerides, and total cholesterol at various points throughout the pre and post-operative period were included. A multivariate regression model was constructed to analyze the relationship between the percentage weight loss after surgery and the corresponding change in lipid biomarkers. The model was adjusted to account for various covariates, including demographics, comorbidities, and statin use.

Out of the original 755 patients, 84 patients met the inclusion criteria. 89.7% of patients were female and 65.5% of patients identified themselves as Black. The mean total weight loss after surgery was 15.6% of preoperative weight. Decreases in total cholesterol (p = 0.0071) and triglycerides (p = 0.0025) as well as increases in HDL (p = 0.0002) were positively correlated with percentage weight loss. In contrast, there was no statistically significant relationship between LDL levels and percentage weight loss (p = 0.9225).

Our data confirms the favorable effects of SG on total cholesterol, triglycerides, and HDL. We also found that the magnitude of these changes correlated with the percentage weight loss after SG. However, LDL levels did not change with weight loss. Prospective studies are needed in which lipid results are longitudinally monitored after surgery to confirm these trends. ASSOCIATION BETWEEN PRESERVED RATIO IMPAIRED SPIROMETRY (PRISM) AND CORONARY ARTERY CALCIFICATION (CAC) MEASURED BY CORONARY COMPUTED TOMOGRAPHY (CT) Richard Cartabuke1; Persaud N. Purnadeo2; Lauren Munoztremblay2; Vickram Tejwani2. 1Internal Medicine, Cleveland Clinic, Painesville, OH; 2Cleveland Clinic, Cleveland, OH. (Control ID #4229117)

Preserved ratio impaired spirometry (PRISm), defined by FEV1 <80% predicted and FEV1/FVC ≥70%, is linked to elevated risks of all-cause-, respiratory-, and coronary artery disease (CAD)-related mortality. Longitudinal studies propose PRISm as a precursor to COPD, emphasizing the potential for early intervention. While the connection between COPD and CAD is established, limited data on coronary artery calcification scores (CACS) exist for PRISm. This study investigates whether individuals with PRISm or COPD exhibit higher CACS as compared to those with normal spirometry. We hypothesize an association between PRISm and COPD with increased CACS.

This is a retrospective cohort analysis of existing data from 2,831 adult patients who enrolled in the Cleveland Clinic Executive Health Program (2000-2022) and met the following selection criteria: pulmonary function test completion, CACS based on coronary computed tomography (CT), and an outpatient screening visit performed by a physician, all within a 14-day period. Patients with cardiac complaints at their visit or with an unknown smoking history were excluded. We used a multivariable logistic regression model adjusted for age ( 55 years old), gender, smoking status, BMI, and comorbidity count to compare the probability of having any coronary artery calcification among individuals with normal spirometry (FEV1/FVC ≥0.7 and FEV1 ≥ 80% predicted), PRISm (FEV1/FVC ≥0.7 and FEV1 < 80% predicted), and COPD (FEV1/FVC < 0.7).

The 2,831 patients were categorized into normal (n=2327), PRISm (n=289), and COPD (n=215) based on spirometry results. The unadjusted odds of CACS > 0 in PRISm patients was 42.4% higher than normal patients (OR=1.42, 95% CI [1.11, 1.82]). The unadjusted odds of CACS > 0 in COPD patients was 55.9% higher than normal patients (OR=1.56, 95% CI [1.18, 2.06]). The adjusted odds of CACS > 0 in PRISm patients was 22.4% higher than normal patients (OR=1.22, 95% CI [0.93, 1.62]), although this did not reach statistical significance. The adjusted odds of CACS > 0 in COPD patients was 37.2% higher than normal patients (OR=1.37, 95% CI [1.00, 1.88]).

This screening cohort suggests an association between PRISm and COPD with elevated CACS, suggesting an underlying contributor to worse cardiac outcomes among those with PRISm. The association also suggests higher risks for CAD and offers better understanding of the increased mortality in this poorly understood phenotype. The study highlights the need for further study of the risk factors influencing CACS in PRISm patients and the need for a larger study as our study had limited power. Recognizing PRISm as a precursor to COPD or distinct entity underscores the potential benefits of early intervention due to its potential association with elevated CACS and CAD-related mortality. These findings may support CAC screening among those with PRISm and COPD, particularly if other cardiac risk factors are present. BALANCING PATIENT APPOINTMENT TIME AND VOLUME: IMPACT OF A SYSTEM-WIDE POLICY ON CLINICIAN COMMUNICATION AND DECISION-MAKING Stephanie Zhang1; Khemraj Hardowar2; Lisa Altshuler9; Kathleen Hanley8; Kevin Chen3; Ross Kristal4; Hannah Jackson7; Andrew Wallach5; Colleen Gillespie6; Sondra Zabar1. 1Medicine, New York University Grossman School of Medicine, New York, NY; 2PRMEIR, New York University, South Ozone Park, NY; 3Office of Ambulatory Care, New York City Health and Hospitals Corp, New York, NY; 4Office of Ambulatory Care & Population Health, New York City Health and Hospitals Corporation, New York, NY; 5Medicine, NYU/NYC Health + Hospitals, New York City, NY; 6PrMEIR/IIME, NYU Grossman School of Medicine, New York, NY; 7Office of Ambulatory Care + Population Health, NYC Health + Hospitals, New York, NY; 8Internal Medicine, NYU Langone Health, New York, NY; 9Medicine, NYU Langone Health, New York, NY. (Control ID #4272912)

To address unmet demand to access care, a large, urban safety-net health system reduced the duration of new patient primary care visits from 40 to 20 minutes. The impact of this policy on care quality, particularly for a safety-net population, is unknown. To assess whether the reduction influenced clinicians’ communication skills and clinical decision-making, we sent unannounced standardized patients (USPs) into clinics before and after policy implementation.

Results are based on 10 pre-policy and 9 post-policy USP visits to a hospital-based ambulatory care clinic. USPs portrayed a 40–50-year-old Black or Hispanic male with a history of hypertension, smoking, and financial insecurity. Clinicians were evaluated using a behaviorally anchored checklist completed by the USP immediately after the visit and a systematic chart review of the electronic health record. Wilcoxon tests were used to compare communication scores and clinical decisions before and after the policy implementation. As a subgroup analysis, visits were categorized by actual duration (≥30 min. vs <30 min.).

Pre-policy appointment durations averaged 36 minutes (range: 20 to 72 min.), whereas post-policy appointment durations averaged 33 minutes (range: 10 to 70 min.). Although USPs rated relationship development similarly pre- and post-policy (84% vs 84% well done), patient activation was lower post-policy (30% vs 18%, p=0.4). Post-policy, information gathering was less comprehensive, with significantly fewer inquiries about work history and education level (50% vs 11%, p=0.04). Physicians also elicited USPs’ financial concerns less frequently (70% vs 22%, p=0.07) and, when elicited, provided referrals for financial resources significantly less often (40% vs 22%, p=0.01). However, medication prescriptions were more common post-policy (50% vs 78%, p=0.2). These results remained when analyzing by actual visit duration. As for differences observed only in the actual duration analysis, not in comparing pre- and post-policy, physicians in visits of 30 minutes or longer received higher ratings for education and counseling (90% vs 67%, p=0.5) and management and treatment planning (88% vs 75%, p=0.4). In longer visits, it was also significantly more common for physicians to check whether USPs had a home blood pressure monitor (70% vs 22%, p=0.05) and inform USPs they could obtain a free one (100% vs 0%, p=0.02). In general, USPs felt that time was managed well regardless of the actual visit duration (90% vs 89%).

Following the policy change, physicians frequently continued to see patients for longer than the scheduled 20 minutes. Data suggests that physicians routinely chose to omit discussion of social dimensions like work/education and financial insecurity post-policy in favor of prioritizing other health concerns; this is likely due to the perceived time pressure of the shorter visit length. Next steps will involve re-examining the results once additional support staff are hired. BLOOD PRESSURE CONTROL USING LAST IN-OFFICE MEASUREMENT VS AVERAGE MEASUREMENT BY RACE/ETHNICITY Joseph Cotton1; Kelsey B. Bryant1; Abigail Feinberg2; Jennifer L. Cluett3; Eugene Yang6; Nausheen Singh4; Nikita Barai5; Shahrin Islam1; Mary Fishman1. 1Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2General Internal Medicine, Mount Sinai Health System, New York, NY; 3Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 4Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; 5Division of Internal Medicine, Mount Sinai Health System, New York, NY; 6University of Washington, Seattle, WA. (Control ID #4271120)

Controlling hypertension is essential to reduce cardiovascular disease morbidity and mortality. In 2017, the AHA/ACC guidelines redefined hypertension as blood pressure (BP) >130/80, however the National Committee for Quality Assurance (NCQA) continues to define BP control as <140/90. Further, the AHA/ACC guidelines emphasize the importance of using average BP readings, in contrast to the NCQA approach of using the last single reading in a calendar year. Prior analyses have shown that the last BP is a reasonable proxy to identify population control, however, differences by race and ethnicity have not yet been studied. This study evaluates the difference in BP control as defined by last BP versus average BP by race/ethnicity in a large urban health system.

Office BP measurements were analyzed for patients aged 18–85 with hypertension who had at least three outpatient readings between January 1, 2023, and December 31, 2023, at a large academic medical center in New York City. Patients were categorized by self-reported race/ethnicity as Non-Hispanic (NH) White, NH Black, NH Asian, and Hispanic. BP control rates were compared for each group using last BP and average BP.

Office BP measurements were analyzed for 66,047 patients. BP control rates at the <140/90 threshold using last BP and average BP for non-Hispanic (NH) white patients were 74.52% and 74.44%, respectively (Δ -0.08). For Hispanic patients, control rates using last BP and average BP were 70.70% and 68.76%, respectively (Δ -1.94). For NH Black patients, control rate using last BP and average BP were 64.77% and 60.78%, respectively (Δ-3.99). For NH Asian patients control rates using last BP and average BP were 75.41% and 71.06%, respectively (Δ -4.35). Using <130/80, control rates for NH white patients were 37.27% and 37.89%, respectively (Δ 0.62). For Hispanic patients, control rates were 25.41% and 32.15%, respectively (Δ 6.74). For NH Black patients, control rates were 28.98% and 24.36%, respectively (Δ -4.62). For NH Asian patients, control rates were 37.72% and 36.61%, respectively (Δ -1.11). P-values within each group at both thresholds were <0.0001.

In our cohort, utilizing last BP versus average BP to determine BP control varied by race/ethnicity. This difference was most pronounced amongst NH Black and NH Asian patients using the <140/90 threshold. This pattern was again observed using the <130/80 threshold in NH Black and NH Asian patients, however improved control rates by average were observed among Hispanic and NH white patients. Further, the difference in control when using a more intensive <130/80 threshold is substantial across all groups, suggesting subpar BP control among all patients. These data suggest that using the last BP as a proxy for BP control may underestimate disparities in hypertension control. CHANGES IN WEIGHT AND BLOOD PRESSURE WITH SEMAGLUTIDE OR TIRZEPATIDE FOR OBESITY IN CLINICAL PRACTICE Hamlet Gasoyan1; W. Scott Butsch3; Rebecca Schulte2; Nicholas J. Casacchia1; Phuc H. Le1; Michael B. Rothberg1. 1Center for Value-Based Care Research, Department of Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; 2Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 3Department of Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH. (Control ID #4270903)

Outside randomized clinical trial settings, data on weight reduction and changes in blood pressure with tirzepatide or semaglutide for obesity are scarce.

This retrospective cohort study used data from electronic health records from one health system in Mid-West and Southern regions, including linked Surescripts pharmacy dispensation records, from January 1, 2021, to July 1, 2024. We identified adults with body mass index (BMI) ≥30 kg/m2 or BMI≥ 27 kg/m2 and ≥1 weight-related comorbidity, who did not have type 2 diabetes, filled an initial prescription for injectable semaglutide or tirzepatide from January 1, 2021 to December 31, 2023, and had baseline as well as ≥1 follow-up weight measurements between 30 and 365 days after treatment initiation. Outcome measures included percentage of weight change and absolute change in systolic blood pressure, from baseline through 12 months. A multivariable logistic regression model was used to examine the association of index medication, medication’s maintenance dosage, and obesity pharmacotherapy discontinuation with the odds of ≥10% weight reduction at year 1, controlling for baseline BMI, age, sex, Charlson comorbidity index, prediabetes status, race, and ethnicity. Discontinuation was defined as a gap of >90 days between end of previous supply and next dispense or end of last supply and study follow-up and classified as early (<3 months of the index date) or late (within 3-12 months).

We identified 7913 adults, with a mean baseline BMI of 39.8 ±7.8 kg/m2 and systolic blood pressure of 129.9 ±14.7 mmHg; 75.1% were female, 77.8% White, 15.7% Black; 6.1% Hispanic. Overall, 6141 patients received semaglutide and 1772 tirzepatide. During the first year, 23.0% (1412) of patients who initiated treatment with semaglutide and 17.8% (316) of those with tirzepatide discontinued obesity pharmacotherapy early and 29.6% (1816) with semaglutide and 30.2% (536) with tirzepatide later. Overall, mean weight reduction at 1 year was 7.7% (95% CI, 7.4, 8.0) with semaglutide and 12.4% (95% CI, 11.8, 13.0) with tirzepatide. The reduction in systolic blood pressure was 3.0 (95% CI, 2.2, 3.8) mmHg with semaglutide and 5.2 (95% CI, 3.7, 6.8) mmHg with tirzepatide; it was 0.4 (-1.2, 1.9) mmHg among those who discontinued obesity pharmacotherapy early, 2.0 (0.6, 3.3) mmHg in those who discontinued late, and 5.7 (4.8, 6.7) mmHg in those who did not discontinue treatment. In the multivariable model, the odds of achieving ≥10% weight loss at 1 year were higher with tirzepatide (vs. semaglutide, AOR, 2.53, 95% CI, 2.19, 2.93), high dose (vs. low, AOR, 2.50, 95% CI, 2.15, 2.91), no discontinuation (vs. early discontinuation, AOR, 4.71, 95% CI, 3.92, 5.67) or late discontinuation (vs. early, AOR, 1.82, 95% CI, 1.50, 2.22).

In this large cohort of individuals who received obesity pharmacotherapy with semaglutide or tirzepatide, treatment discontinuation was common and was associated with less reduction in weight and systolic blood pressure. CHARACTERISTICS OF YOUNG ADULTS PRESCRIBED STATINS FOR PRIMARY PREVENTION OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASE: A MULTI-CENTER COHORT STUDY Alan Manivannan1,2; John M. Stone3; Om A. Kothari3; Alejandro E. Segarra Concepción3; Sophie E. Claudel4; Nicholas Bosch5,2. 1General Internal Medicine, Boston Medical Center, Boston, MA; 2Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 3Internal Medicine, Boston Medical Center, Boston, MA; 4Nephrology, Boston Medical Center, Boston, MA; 5Pulmonology and Critical care, Boston Medical Center, Boston, MA. (Control ID #4270783)

We describe the characteristics of young adults prescribed statins for ASCVD prevention, given the limited guidance available for this age group.

In a retrospective cohort study of 1,038,518 adults aged 20-39 across 87 U.S. health systems, we examined statin prescriptions within one month of LDL-C testing (2022-2023) using the TriNetX database. Exclusions included ASCVD, familial hypercholesterolemia, or pre-existing statin use. Patient characteristics were compared using standardized mean differences and PREVENT 10-year ASCVD risk scores were calculated for average, lower-risk, and higher-risk profiles (pooled values one standard deviation below and above the mean).

Statins were initiated in 11,684 of 1,038,518 (1.13%) patient encounters. Statin recipients were older, more likely male, and had higher LDL-C, systolic blood pressure, hemoglobin A1c, and BMI (Table 1). PREVENT 10-year risk scores were higher in statin-prescribed patients for average (2.7% vs. 0.3%), lower-risk (0.2% vs. 0.1%), and higher-risk profiles (14.7% vs. 4.1%).

In a multi-center cohort, only 1.1% of 20 to 39-year-old patients received statins within a month of initial LDL-C testing. Despite higher cardiac risk factors, the average patient prescribed statins wouldn't have qualified for statin therapy based on their PREVENT risk percentile. COMPARING TREATMENT RATES BETWEEN HYPERTENSION AND DEPRESSION BY ETHNICITY AND LANGUAGE IN A PRIMARY CARE SAFETY NET SETTING. Elena Byhoff1; Dang H. Dinh2; Jennifer A. Lucas3; Miguel Marino2; John Heintzman3,4. 1Medicine, University of Massachusetts Chan Medical School, Worcester, MA; 2Family medicine, Oregon Health & Science University School of Medicine, Portland, OR; 3Family Medicine, Oregon Health & Science University, Portland, OR; 4Oregon Community Health Information Network, Portland, OR. (Control ID #4271957)

Disparities are well documented in timely diagnosis and treatment in many chronic conditions, including depression and hypertension. Hispanic populations experience similar or higher rates of mental health diagnoses compared with non-Hispanic Whites, but are less likely to receive treatment. While Hispanic populations have similar hypertension prevalence to non-Hispanic populations, treatment rates are significantly lower. Evidence suggests that co-morbid hypertension and depression can have negative effects on treatment of both chronic diseases. However, it is unknown how language barriers might further exacerbate disparities in the treatment of co-morbid hypertension and depression. The study compares relative risk of timely treatment of both depression and hypertension by ethnicity and language in primary care safety net settings.

Using Electronic Medical Record data, we conducted a retrospective data analysis of patients aged 40-60 with a new diagnosis of both depression and hypertension receiving care at a national network of Community Health Centers from 2012-2019. Demographic, health care utilization, comorbidity, and treatment variables were extracted. The primary outcome was receipt of timely treatment (within 6 months) for newly diagnosed depression and hypertension by ethnicity and language. Hypertension treatment was defined as a new prescription for an anti-hypertensive medication. Depression treatment was defined as either a visit with a mental health provider or a new prescription for an anti-depressant. Multinomial regression estimated relative risk ratios (RR) of receiving both treatments vs other cases: including only mental health treatment, only hypertension treatment, or no treatment after new diagnoses of hypertension and depression by ethnicity/language adjusted for relevant covariates.

Of the 25,153 patients with both hypertension and depression who received care during the study period, 14.6% (3,683) received only depression treatment, 23.9% (6,016) received only hypertension treatment, 51.1% (12,843) received treatment for both and 10.4% (2,611) received no treatment. Hispanic English- and Spanish-preferring patients had higher risk of receiving only hypertension treatment (RR= 1.51, 95% CI 1.32-1.73 and RR= 2.14, 95%CI 1.85-2.47) or no treatment (RR=1.68, 95%CI 1.41-2.00 and RR=1.82, 95%CI 1.48-2.23) compared with non-Hispanic Whites who had both treated.

Spanish preferring patients had higher relative risk of receiving either hypertension treatment only or no treatment at all compared to Non-Hispanic White patients. All groups had similar relative risk of receiving mental health treatment only compared to treatment for both. This work confirms results from prior studies showing that overall co-treatment rates are high in patients with co-morbid depression and hypertension, and adds new insight into how potential language barriers may impact differential treatment initiation in two common chronic diseases. COMPARISON OF EFFICACY ON FIRST-LINE HELICOBACTER PYLORI ERADICATION BETWEEN POTASSIUM-COMPETITIVE ACID BLOCKER (P-CAB)-BASED THERAPIES VERSUS PROTON-PUMP INHIBITOR (PPI)-BASED THERAPIES: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS Kangning Peng1,2; xiaoyu wan4; Heng Jiang3. 1Internal Medicine, Cambridge Health Alliance, Cambridge, MA; 2Harvard Medical School, Boston, MA; 3Internal Medicine, Westchester Medical Center, Valhalla, NY; 4HTI, The Hong Kong Polytechnic University, Hong Kong, Hong Kong. (Control ID #4272420)

Helicobacter pylori (H. pylori) is a gram-negative bactrium that infects over half of the world population, accountable for 89% of all gastric cancer cases globally. It poses a serious threat to individual and public health. With the increasing global antimicrobial resistance, the efficacy of proton-pump inhibitor (PPI) based-triple therapy are declining, while the novel potassium-competitive acid blocker (P-CAB) based therapy brings new hopes. However, it remains unclear regarding the optimal duration and co-medication(s) of P-CAB-based regimen, which P-CAB is the best-in-class, and whether P-CAB performs better than all PPIs. The study is set to compare the efficacy on first-line H. pylori eradication between P-CAB-based therapies versus PPI-based therapies.

Systematic review on randomized controlled trials, with network meta-analysis conducted under the Frequentist approach. The P-score method was used to rank the probability of being the best intervention.

For the first-line treatment eradicating H. pylori infection, the 7-day vonoprazan-based triple therapy (VAC7) has the highest P-score for probability of being the best intervention (0.98). VAC7 has a significantly higher eradication rate for H. pylori than most PPI-based therapies, including rabeprazole-, lansoprazole-, pantoprazole- and omeprazole-based regimens, as well as than the other P-CAB, tegroprazan, based regimen (odds ratio 2.41, 95% confidence interval [1.13, 5.15]).

In this study, vonoprazan-based triple therapy (VAC7) was found to be more efficacious than the majority of PPI-based triple therapies, as well as tegroprazan-based therapy, for eradicating H.pylori infection. It remains unclear whether VAC7 is superior over vonoprazan-based dual therapy (VA7). More RCTs are needed for such head-to-head comparisons. Overall, VAC7 should be recommended for clinical and public health interventions, with VA7 as a possible alternative considering the local antimicrobial resistance profile to clarithromycin. CONTINUITY OF CARE IN TEACHING CLINICS: WE CAN ONLY IMPROVE WHAT WE CAN MEASURE! Channing Brown2; Carlos Estrada1,2; Meghan Black1,2. 1VA Clinic Birmingham, Birmingham, AL; 2General Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #4247117)

In graduate medical education (GME), internal medicine residents must have clinical experiences in outpatient settings – including clinics that provide longitudinal care to a defined patient panel. Given the multiple educational experiences and various clinical structures maintaining continuity is challenging. However, both patient and provider continuity is vital to the clinical experience and something institutions strive to improve.

Design: Educational quality improvement. Setting: Internal medicine resident teaching clinics (VA and University-based), cohorts of 120 residents. June 2019- April 2024. Interventions: multiple structural changes (clinic templates, return to clinic timing, schedule release), educational detailing, clinic scholars recognition (share best practices). Data: Number of patient encounters. Outcomes (continuity of care): Modified Modified Continuity Index (MMCI), a patient-level metric which measures the dispersion between residents and is based on the number of residents and number of visits only; values range from 0 (each visit made to a different physician) to 1 (all visits made to a single physician). Percentage of patients seen by the same resident (once, 2-5 times, >5 times), a resident-level metric.

At the VA Clinic, the mean MMCI appeared to increase over the three time periods studied, 38.3 (SD 37.2), 44.7 (SD 35.5), and 48.4 (SD 35); respectively. The MMCI range per resident varied widely (minimum 2.4, 1.4, 1.5; maximum 100 each period). At the University Clinic, the mean MMCI appeared to decrease over the two time periods, 35.1 (34.5) and 32.7 (33). The MMCI range per resident also varied widely (minimum 1; maximum 99, 100). The resident-level continuity increased over time at the VA Clinic (P<0.001) and at the University Clinic (P=0.01)(using Chi-square)(Table).

The continuity as measured by MMCI appeared to improve and increased over time as measured by the resident metric at the VA. However, the striking feature of this analysis was the wide variability in continuity. Within the same clinic with the same system practices some patients always saw the same physician to some who never saw the same physician. The same was true when looking at resident level, where some routinely saw patients they had seen at least twice to some rarely seeing the same patient. The variability signifies the impact of structural interventions to improve continuity was modest or not effective. It is suggestive that improvements in continuity may be more at resident or patient level. More data is needed to investigate these factors. DOES MODERATE ALCOHOL INTAKE MAKE ANY DIFFERENCE IN TERMS OF LIVER STIFFNESS AMONG MASLD PATIENTS? Akif Altinbas1; Avishag Ashkenazi2; Lucas Biran2; Wynee Lou1. 1Internal Medicine, UConn Health, Farmington, CT; 2University of Connecticut School of Medicine, Farmington, CT. (Control ID #4272776)

Metabolic dysfunction-associated steatotic liver disease (MASLD) was defined as hepatic steatosis with one of the identified cardiometabolic criteria. However, there is still debate about the cutoff of the alcohol levels, and even moderate alcohol consumption could contribute to the severity of underlying liver fibrosis. Thus, we aimed to assess the possible impact of moderate alcohol consumption on liver fibrosis in the setting of MASLD.

We conducted a cross-sectional analysis by using data from the 2017–2018 NHANES cycle. Exclusion criteria included participants younger than 18 years old, with pregnancy, history of any cancer, substance or steroid abuse, and diagnosis of secondary liver disease. Of the 2,516 participants meeting initial eligibility, 1,010 were excluded due to alcohol intake exceeding MASLD thresholds (≥21 drinks/week for men and ≥14 drinks/week for women), yielding a final study population of 898 individuals. Hepatic steatosis was identified using a controlled attenuation parameter (CAP) score of ≥275 dB/m. After determining the presence of liver steatosis, the presence of one of five cardiometabolic criteria was used for the diagnosis of MASLD. Descriptive analyses, including both parametric and non-parametric methods, were employed to explore the relationship between alcohol consumption and hepatic steatosis.

Out of 898 MASLD subjects, 500 (55.7%) were male, 398 (44.3%) were female, and the average age was 40.9 (+/- 12.3) years old. A comparison of liver stiffness severity revealed no statistically significant differences among the 500 male patients with MASLD. When the patients were grouped based on their daily alcohol consumption (0, 1, or 2 drinks), only 13.7%, 9%, and 12.9%, respectively, fell into the moderate and severe fibrosis categories in each group. Similarly, among the females included in the analysis, 9.5% of those who drank no alcohol and 5.9% of those who consumed one drink per day had moderate to severe liver fibrosis.

Our study indicates that moderate alcohol consumption among MASLD patients did not make a statistical difference in terms of underlying liver fibrosis. In this study, we assessed only the impact of moderate alcohol consumption on liver fibrosis status. Further longitudinal studies are needed to investigate the impact of moderate alcohol consumption on both the liver and overall cardiovascular health in MASLD patients. ENHANCED PATIENT PORTAL TICKLER EMAIL TO IMPROVE MESSAGE READ RATES AND PREVENTIVE MEASURE COMPLETION: A RANDOMIZED CONTROLLED TRIAL OF 35,000 PATIENTS Richard K. Leuchter1,2; Jose Arellano3; Silvia Saccardo3; Jeff Borenstein1; Jana Gallus4; Craig R. Fox4; Leah Mireles7; Suzette Ma7; Sitaram Vangala5; Hengchen Dai6. 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; 3Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA; 4Anderson School of Management, UCLA, Los Angeles, CA; 5Medicine, University of California, Los Angeles, Los Angeles, CA; 6Anderson School of Management, University of California Los Angeles, Los Angeles, CA; 7UCLA Health, Los Angeles, CA. (Control ID #4255287)

Patient portal message read rates are below 50%, hampering population health initiatives. Patient portal messages trigger a generic “tickler email” sent to patients’ personal emails prompting them to login to their patient portal. We hypothesized that enhancing the tickler email using behavioral principles would improve the rates at which patients read and act on patient portal messages.

The experiment was embedded within an existing intervention: patients overdue for at least one of the nine preventive measures in the Table received a patient portal message in the month after their birthday prompting them to visit an appointment scheduling page to address the outstanding preventive measure. Between November 2023-February 2024, patients were randomized to be notified of this portal message by either the standard tickler email (status quo) or enhanced tickler email. We designed the enhanced tickler email using the following behavioral principles: 1) Personalization: subject and signature lines were changed from a generic health system notification to the patient’s primary care physician, 2) Timeliness: informed patients that an outstanding preventive measure had just been detected, rather than simply informing them of a new portal message, 3) Urgency: new text prompting patients to address preventive measures quickly, 4) Process simplification: changed the message hyperlink to navigate directly to the patient portal message rather than the patient portal homepage, 5) Cognitive simplification: removed 31 words (50%) from the tickler email. Preregistered outcomes were (clinicaltrials.gov #06131723): patient portal message open rates and scheduling page visit rates at seven days from receiving the message, and rates of acting on and subsequently completing at least one outstanding preventive measure after six months. Differences in outcomes between arms were assessed using chi-squared tests. This was an interim analysis of the first 3 months of data (total trial planned to last 12 months).

A total of 34,616 patients were enrolled in the trial (Table). Compared to the control group, patients who received the enhanced tickler email were significantly more likely to open the patient portal message (28.1% v. 23.8%, p<0.001) and to visit the preventive measure scheduling page (14.3% v. 10.8%, p<0.001). As a result, patients receiving the enhanced tickler email were significantly more likely to take action on any outstanding preventive measure (7.7% vs. 5.9%, p<0.001), and there was near-significance for completing at least one measure (15.3% vs. 14.6%, p=0.06). This interim analysis achieved statistical significance in addressing four preventive measures and promising trends towards significance for four others (Table).

Our enhanced tickler email, designed using five behavioral principles, led to significantly higher rates of opening the patient portal message, visiting the scheduling page, and subsequently addressing outstanding preventive measures. EVALUATION OF A PHARMACIST’S IMPACT ON MEDICARE ANNUAL WELLNESS VISITS WITHIN AN INTERNAL MEDICINE CLINIC Emily Bowman1; Morgan Lockhart1; Donna M. White1; Kimberly Dowdell2. 1Pharmacy, UVA Health, Charlottesville, VA; 2Medicine, University of Virginia, Charlottesville, VA. (Control ID #4268996)

Medicare Annual Wellness Visits (AWVs) provide personalized preventive health services each calendar year to Medicare enrollees at no charge. Despite the perceived benefits of Medicare AWVs, national completion rates are around 24% for eligible beneficiaries with lack of awareness of the visits and time constraints hindering delivery. Therefore, institutions are challenged to implement strategies to increase AWV completion. Prior studies demonstrate clinical pharmacist involvement in AWVs can improve completion, generate revenue, and result in identification of care-gaps. In 2023, a part-time clinical pharmacist was hired to assist with AWV completion rates at an internal medicine clinic which empanels 5,182 patients including 2,366 AWV eligible patients. The clinic’s AWV completion rate from 8/7/2022 to 8/6/2023 was 31.5%. The purpose of this study was to evaluate the impact of a pharmacist’s involvement on Medicare AWVs.

This study was a retrospective, observational chart review of patients with a completed AWV between 8/7/2023 and 8/6/2024. Data were collected from the electronic medical record and an institutional data repository. Patients were eligible for inclusion if enrolled in Medicare Part B or a Medicare Advantage Plan and outside of their initial 12-month enrollment period. The primary endpoint was the AWV completion rate with the addition of a pharmacist. Secondary endpoints included pharmacist interventions recommended and completed, vaccination rates for herpes zoster and pneumonia, the number of advanced directives filed and/or modified, and the number of resolved care-gaps. Billing codes were collected for each completed encounter with pharmacist involvement and will be used to measure direct and indirect financial benefits.

For the study period, 1040 patients (44.0%) were identified to have a completed Medicare AWV. Visits reviewed thus far have yielded 375 included patients and 39 pharmacist driven AWVs (10.4%). In pharmacist driven visits, vaccinations were recommended to 35 patients (89.7%), labs to 18 (46.2%), preventative screenings to 26 (66.7%), and specialist referrals for 9 (23.1%). Additionally, 100 herpes zoster and 54 pneumococcal vaccines were recommended overall. Vaccination completion rates were 20.5% and 50% for herpes zoster and 88.6% and 36.8% for pneumococcal vaccines following standard and pharmacist driven AWVs, respectively. Rates of newly filed advanced directives were similar between groups. Finally, among 365 patients with active health maintenance data, 483 total care-gap closures were captured with 10.6% of these resulting from pharmacist driven AWVs.

The addition of a part-time pharmacist contributed to increased AWV completion rates from 31.5% to 44.0% in an internal medicine clinic within 1 year. Pharmacist involvement in AWV delivery was an optimal strategy to expand patient access to preventative care measures. Direct and indirect financial benefit will be assessed. EXAMINING PRIMARY CARE PROVIDER COMMUNICATION ABOUT LUNG CANCER SCREENING: A QUALITATIVE ANALYSIS GUIDED BY THE CDC SHARE MODEL Francesca Minardi1; Kyle Koster2; Nihal Mohamed3; Cardinale Smith4; Minal S. Kale5. 1Medicine, Icahn School of Medicine at Mount Sinai Department of Medicine, New York, NY; 2Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 3Urology, Icahn School of Medicine at Mount Sinai, New York, NY; 4Medicine, Icahn School of Medicine at Mount Sinai Tisch Cancer Institute, New York, NY; 5Medicine, Mount Sinai Health System, New York, NY. (Control ID #4273012)

Shared decision-making (SDM) is a critical component of lung cancer screening (LCS), ensuring patients are informed, involved, and supported in making healthcare choices aligned with their preferences and values. The Centers for Disease Control and Prevention (CDC) SHARE model offers healthcare providers a structured framework for approaching key elements of SDM, including patient engagement, information-sharing, and support. This study analyzes provider-patient discussions about LCS and explores opportunities to enhance SDM.

A thematic content qualitative analysis was conducted by four trained coders on transcripts from primary care provider (PCP) visits with 36 LCS eligible patients recorded between September 2022 and May 2024 using ATLAS.ti. Consultations were analyzed guided by the CDC SHARE model for SDM, which includes five pillars: Seek, Help, Assess, Reach, and Evaluate. Inter-rater agreement coefficient ranges from 83.8% to 92.3%. Differences in coding were resolved by research team discussions. Prevalence of codes (i.e., groundedness) was measured through frequency counts across all encounters.

Four of the five key themes from the SHARE model were identified: (1) Seeking patient participation in the SDM process by explicitly communicating that a choice about LCS exists (n = 16); (2) Helping patients explore the risks and benefits of LCS, including clarifying potential outcomes (n = 19); (3) Assessing patient values and concerns regarding LCS, such as fears about false positives or financial burden (n = 13); and (4) Reaching a decision about LCS, where PCP guided patients through the decision-making process and confirmed next steps (n = 42). In addition to the themes derived from the SHARE model, two new emergent themes were identified: (a) providing supportive talk and reassurance (n = 18) to address patient uncertainty and encourage engagement, and (b) addressing smoking cessation if applicable (n = 11), which occurred in 6 out of 13 applicable encounters (46%), with discussions initiated primarily by PCP and narrowly focused on pharmacological treatments. Notably, LCS decision aids were neither used nor recommended in any consultation.

This study, informed by the CDC SHARE model, highlights both strengths and gaps in provider communication during LCS discussions. While providers were frequently found to assess patient risk factors and facilitate a decision about the screening, significant gaps in the decision making process emerged. These included limited provider efforts to actively seek patient participation, help patients explore the risks and benefits of LCS, and assess patient values and concerns. Additionally, supportive reassurance and meaningful discussions about smoking cessation were infrequent. Notably, decision aids were absent from all encounters, underscoring a critical missed opportunity to enhance the quality of shared decision-making and support informed, patient-centered care. EXPLORING THE ASSOCIATION BETWEEN SUBCLINICAL THYROID DISORDERS AND DEPRESSION: INSIGHTS FROM THE NIH ALL OF US DATASET Julia Constable3; Fred W. LaPolla2; Calogero DiMaggio3; Gaby Mayer3,1; Aaron Chen3; Geordyn Hoge3; Minh Thu T. Nguyen3,1. 1New York City Health and Hospitals Gouverneur, New York, NY; 2NYU Health Sciences Library, NYU Langone Health, New York, NY; 3Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4272746)

MDD is a prevalent mental health disorder in the US, affecting over 20 million adults annually, with ~5% experiencing functional impairment. Physicians often test thyroid function in these patients but focus mainly on overt thyroid conditions. For MDD patients with subclinical thyroid conditions, the evidence for thyroid treatment is mixed. Clarifying this relationship could transform management of these overlapping conditions and improve patient outcomes.

We conducted a cross-sectional study using data collected by the NIH All of Us Research Program, which collects health data from over one million U.S. adults. We looked at adults (age 18-75) whose data contained a TSH level, a normal free T4 level (0.8-1.9ng/dL), and a PHQ-9 score. We excluded those with overt thyroid disorders and those taking thyroid hormone replacement therapy. The Kruskal-Wallis test , a nonparametric statistical analysis used to compare 3 or more independent groups, compared PHQ-9 scores among those with subclinical hypothyroidism, subclinical hyperthyroidism, and normal thyroid function. A multivariate regression model examined the association between thyroid function and depression while adjusting for confounders.

Among n = 38,278 participants with normal free T4 levels, 90% had normal thyroid function (TSH 0.5-4.5 μU/mL), 6.1% had subclinical hyperthyroidism (TSH > 4.5 μU/mL), and 3.9% had subclinical hypothyroidism (TSH < 0.5 μU/mL). Only 322 participants had PHQ-9 scores. A Kruskal-Wallis test was conducted to compare PHQ-9 scores among participants of three groups - those with subclinical hyperthyroidism (TSH 4.5 μU/mL). The results indicated a statistically significant difference in PHQ-9 scores among the three groups, χ2 = 6.5, p = .03. Multivariate regression analysis (adjusted for age, gender, race, antidepressant use, and thyroid status) showed subclinical hypothyroidism was significantly associated with depression (β 5.07, 95% CI 0.99–9.16, p = .016) and that subclinical hyperthyroidism was not (β -1.03, p = .57).

Subclinical hypothyroidism was significantly associated with higher PHQ-9 scores, even after adjusting for confounders. This suggests that individuals with subclinical hypothyroidism may be at increased risk for depressive symptoms, underscoring the importance of thyroid screening in MDD patients and vice versa. Limited PHQ-9 documentation suggests mental health screening is not routine in this population. Further research is needed to determine whether PHQ-9 is the optimal tool for detecting MDD in patients with thyroid dysfunction or if targeted instruments are required. Lastly, our study did not assess whether treatment of subclinical hypothyroidism might impact depressive symptoms - this remains a promising area for future research efforts. FROM FIRSTHAND ACCOUNTS OF PRACTICING GENERALISTS - HOW IM RESIDENCY TRAINING AFFECTS THE PURSUIT OF A PRIMARY CARE OR HOSPITALIST CAREER Matthew N. Metzinger1; Justin Q. Wang2; Lane Alexander3; Megan Hamm3; Tanya Nikiforova4. 1Division of General Internal Medicine, UPMC, Pittsburgh, PA; 2Internal Medicine, UPMC, Pittsburgh, PA; 3Medicine, University of Pittsburgh, Pittsburgh, PA; 4Internal Medicine, University Of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4234704)

The US shortage of primary care physicians (PCPs) is predicted to grow to 40,000 by 2036. US trends demonstrate that internal medicine residency program (IMRP) graduates increasingly pursue hospitalist careers over primary care. In this qualitative study, we explore factors influencing entry into the primary care (PC) or hospital medicine (HM) workforce from the perspective of recent IM graduates.

We conducted 60-minute semi-structured interviews with a purposeful sample of eight PCPs and eight hospitalists who graduated from a Midatlantic academic IMRP in the past seven years. Participants received a $100 incentive. The careership sociological theory, which states that career choice is based on the individual’s pragmatic decision making, interactions with others in the field, and current life factors, informed interview guide development. Interviews were conducted over Zoom and transcribed verbatim. The codebook was developed using inductive and deductive approaches. Saturation was determined when no new codes were generated. Using NVivo software, all 16 transcripts were co-coded and adjudicated by two members of the study team trained in qualitative methods. The main author completed thematic analysis, with triangulation and agreement on the themes reached by the study team.

The 16 interviewees represented a variety of GIM careers, including clinician, clinician-educator, clinician-researcher and clinician-administrator. Five were VA employees. Thematic analysis revealed sustainable careers in PC and HM are rooted in a combination of clinical work and an additional focus (education, research, leadership). Agency over work schedules drives satisfaction for both PCPs and hospitalists. Both specialties feel undervalued in healthcare. Three themes were specific to PCPs: 1) The pursuit of a PC career is a leap of faith for many PCPs, who felt ill-prepared to practice PC upon graduation; to bridge this leap, mentors play an important role in forming a supportive community; 2) Additional training that more accurately represents real-world PC practice during residency is needed; 3) The VA may represent an influential training site for future PCPs. Three themes were specific to hospitalists: 1) Flexible scheduling and high patient acuity drove interest in HM; 2) Residents trained in an IMRP that provides autonomy through resident-led rounds felt prepared for independent practice after graduation; 3) Hospitalists questioned the long-term sustainability of HM; some considered PC to be a back-up plan.

To address the US PCP shortage, it is crucial to understand how and why trainees choose careers in GIM. Effective mentorship is key to recruiting the next generation of PCPs, as mentors can help residents prepare for the leap of faith described by new PCPs. Pursuing educational, research and/or administrative roles is a major perk of both PC and HM careers, thus deliberate and early exposure to these roles is key to recruiting the next generation of generalists. GASTROINTESTINAL TOLERABILITY OF RAPID DOSE TITRATION OF METFORMIN FOR TREATMENT OF ACUTE INFECTION WITH SARS-COV-2 Nandini Avula1; Esteban Lemus Wirtz2; Tanvi Mehta2; Thomas A. Murray2; Carolyn Bramante1. 1Medicine, University of Minnesota Medical School, Minneapolis, MN; 2University of Minnesota Twin Cities School of Public Health, Minneapolis, MN. (Control ID #4247988)

Although an established type 2 diabetes medication, metformin has also been investigated for its antiviral and anti-inflammatory properties. The COVID-OUT trial was a decentralized, quadruple-blinded randomized control trial that investigated the effects of metformin versus placebo as outpatient treatment of SARS-CoV-2 infection. However, metformin’s gastrointestinal (GI) side effects were a concern when designing a trial that required rapid dose escalation, as normally metformin is dose-titrated over several weeks to months. In this analysis, we describe the GI tolerability of metformin and placebo rapidly titrated over seven days in the setting of a viral infection.

Participants were between 30-85 years old, had a BMI>25 kg/m2, provided a documented positive COVID test within 3 days of enrollment, had symptoms for <7 days, and were not currently on metformin. The dosing for metformin or placebo was one 500 mg dose on day 1; 500mg twice per day on days 2-5; and 500mg in the AM and 1,000mg in the PM on (1500mg total) days 6-14. The main outcomes analyzed were symptom frequency and severity, as documented in participant-reported symptom logs, and gastrointestinal distress, defined per the Patient-Reported Outcome Measurement Information Systems (PROMIS) Gastrointestinal Symptom Scale.

1323 participants were included in the present analysis with a mean age of 46.4 years (SD=11.1) and consisting of 741 females (56%). The metformin group included 663 participants; 660 received placebo. The highest prevalence of nausea, vomiting, and diarrhea were reported on treatment day 2, decreasing by day 14. On day 2, the proportion of participants experiencing nausea was 33% for metformin and 29% for placebo; and the proportion experiencing vomiting was 6.3% for metformin and 6.9% for placebo. Diarrheal symptoms occurred in 48.5% in the metformin group and 33.7% in placebo. Most GI symptoms were mild to moderate in severity with severe nausea, vomiting (>4 episodes/ day), and diarrhea (>4 episodes/ day) occurring in less than 5%, 2%, and 6% of participants, respectively. No statistical difference was observed in PROMIS scores between metformin and placebo groups on day 1 and 2. At Day 7, the PROMIS score was 3.92 points greater than placebo (p<0.001). This difference corresponded with dose escalation to 1500 mg on day 6.

This analysis focused on GI symptoms during a randomized trial of immediate release metformin escalated to 1500 mg over seven days. Nausea was experienced by 4% more participants in the metformin group. Metformin also resulted in a higher diarrheal symptom score; however, the score was not above the threshold considered the minimal clinically noticeable difference (PROMIS score difference of 5.0). Symptoms were typically transient and mild-to-moderate. Metformin has shown to be effective against other viruses, and the gastrointestinal effects of this titration pattern can be helpful for the medical community to understand. HEALTHY BEHAVIORS AMONG ADULTS WITH PREMATURE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE Prem N. Patel. Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4273613)

Primary care providers play a critical role in supporting healthy behaviors among adults with premature atherosclerotic cardiovascular disease (ASCVD). The American Heart Association (AHA) emphasizes specific lifestyle recommendations for this population, including regular physical activity, smoking abstinence, maintaining a healthy BMI, timely influenza vaccination, and limiting alcohol consumption. However, adherence to these guidelines varies, and little is known about how sociodemographic factors influence adherence patterns.

The Behavioral Risk Factor Surveillance System (BRFSS) survey data from 2019 to 2023 were analyzed to identify adults aged 18 to 55 years. Cardiovascular comorbidities, including hypertension, dyslipidemia, diabetes, and chronic kidney disease, were self-reported by participants. Premature ASCVD status was determined based on participants' responses to the question: “Have you ever had coronary heart disease or myocardial infarction or stroke?” Adults aged 18 to 55 years who answered affirmatively were classified as having self-reported premature ASCVD. Cross-sectional data were analyzed using survey weights provided by the Centers for Disease Control and Prevention. Associations between sex and categorical variables, including adherence to healthy behaviors were evaluated using Chi-square tests.

Between 2019 and 2023, 955,128 adults aged 18-55 years were identified, of whom 28 600 (3.0%) had self-reported premature ASCVD. Of these, 51.3% were men. Adherence was 63.9% for leisure-time physical activity, 63.0% for smoking abstinence, 59.4% for limiting alcohol intake, 38.2% for timely influenza vaccination within the past 12 months, and 21.7% for healthy BMI. Compared with healthy population, adults with premature ASCVD were less likely to participate in leisure-time physical activity (-15.3%) and smoking abstinence (-17.1%, p < 0.05 for all). However, adults with premature ASCVD were more likely to obtain timely influenza vaccination (+22.0%), maintain healthy BMI (+6.8%), limit alcohol intake (+0.8%, p <0.05 for all).

Adults with premature ASCVD demonstrate significant variation in adherence to AHA-recommended healthy behaviors, with notable strengths in timely influenza vaccination and limiting alcohol intake compared to the general population. However, considerable gaps persist in smoking abstinence, leisure-time physical activity, and maintaining a healthy BMI, highlighting critical areas for improvement. These disparities in adherence are concerning given the pivotal role of these behaviors in secondary prevention of ASCVD. Targeted interventions by primary care providers are urgently needed to address these gaps, particularly in promoting smoking cessation and physical activity. Future research should explore barriers to adherence, develop tailored interventions, and assess the longitudinal impact of adherence on clinical outcomes. HIGH DROPOUT RATE IN COVID RECOVERY CLINIC Sohail Alikhan. Internal Medicine, Advocate Lutheran General Hospital, Park Ridge, IL. (Control ID #4271672)

An estimated 30% of people with COVID-19 infection continue to have chronic symptoms. These patients are referred to as having post-COVID syndrome. Symptoms include dyspnea, fatigue, brain fog, and mood disorders. With the large influx of these patients entering the medical system, medical groups have created COVID Recovery Care Clinics (CRCC). The purpose of this study is to investigate the high dropout rate of patients attending CRCC following their initial visit and explore potential reasons for the dropout rate. The study tracks patients over several months, measures their clinical improvements using standardized questionnaires, and highlights the concern that a significant number of long COVID patients are not receiving continuous care despite their need for long-term follow-up.

Our group developed multiple CRCCs in 2021 located throughout the Chicago area. Patients who establish at CRCC receive coordinated care including medical assessments from the PCP. The nurse assists with filling out questionnaires, coordinating follow-up visits and arranging referrals to specialists. Comorbidities were noted including a history of COPD, CHF, asthma, CAD, OSA, pulmonary embolism, DVT, anxiety, depression, and dementia. CRCC patients were asked to follow up every 3 months and complete questionnaires before every visit. The questionnaires are displayed in Table 1.

We recorded 354 CRCC patients at their initial visit. Only 102 patients returned for their first 3 month follow-up visit, a dropout rate of 71%. Only 11 patients came back for their second follow-up visit, and just 2 patients returned for their third follow-up visit. Out of the 354 CRCC patients, 123 were male and 227 were female. The first follow-up visit dropout rate between males and females was similar at 71%. The average age of patients who were lost to initial follow-up and the patients with at least one follow-up visit were 45 and 47, respectively. The prevalence of comorbidities between the groups was also similar. It is worthy to note that among the CRCC patients that returned for the initial 3-month follow-up visit, the average CFS-11 score from the initial visit to the follow-up visit improved from 22 to 19.6. The average IES-6 and mMRC scores also improved from 11.3 to 9.8 and 1.68 to 1.37, respectively.

Although a number of patients scheduled initial visits at our CRCCs, 71% did not return for their initial follow-up visit. This high dropout rate is concerning, since long COVID is a disabling condition, potentially benefiting from long-term tailored treatment. Potential reasons for this high dropout rate include travel difficulty, financial burden, or worsening health. Future research is planned to further characterize dropouts and to develop methods to improve patient return rates. HYPERTENSION MEDICATION DEPRESCRIBING AFTER LIFESTYLE INTERVENTION IN THE ENHANCING LIFESTYLES IN METABOLIC SYNDROME (ELM) MULTISITE CLINICAL TRIAL Laura J. Zimmermann1,4; Betty M. Drees2; Kelly Karavolos4; Steven K. Rothschild5; Jacinda M. Nicklas3; Sumihiro Suzuki4; Lynda H. Powell4. 1Internal Medicine, Rush University, Chicago, IL; 2University of Missouri-Kansas City, Kansas City, MO; 3General Internal Medicine, University of Colorado School of Medicine, Aurora, CO; 4Family and Preventive Medicine, Rush University, Chicago, IL; 5Family and Preventive Medicine, Rush University, Chicago, IL. (Control ID #4242665)

Metabolic syndrome (MetS) affects 37% of US adults. MetS is defined as abnormality in ≥3 of 5 components: waist circumference, triglycerides, HDL, blood pressure, fasting plasma glucose. Lifestyle changes in diet, physical activity, and particularly weight loss have independent blood pressure lowering effects may lead to a decreased need for hypertension (HTN) medications. Deprescribing has been studied in the elderly/frail and those with terminal illness but not in relatively healthy community-dwelling individuals undergoing lifestyle intervention. Published HTN guidelines offer little in regard deprescribing medications in the setting of lifestyle change. We hypothesized that deprescribing would occur and that weight loss would be associated with fewer HTN medications at 24 months of lifestyle intervention for MetS.

The ELM multi-site trial is a multi-center, randomized, controlled trial testing whether a 6-month habit-based (dietary, physical activity, and mindfulness habits) group intervention can produce sustained MetS remission at 24 months. Participants with the MetS were randomized to either group lifestyle treatment or an enhanced standard of care with education and fitness wearable. The primary outcome was MetS remission at 24 months. We describe changes in the number of HTN medications prescribed at baseline vs 24 months in all randomized participants with HTN and then by intervention arm. Chi-square or Fisher’s exact test were used to compare categorical variables.

Of 618 randomized participants, mean age was 55.5 years, 24.3% were male, 25.5% were non-White, 9.7% were Hispanic, 83.0% had obesity (body mass index >30) and 86.2% (n =533) had HTN at baseline. Age, gender, and education attained did not differ significantly between those with HTN and those without HTN; 18% of those with HTN were Black vs. 8.2% of those without HTN. 24-month data on prescribed HTN medications were available on 341 (86%). Most participants (70%, N=237) had no change in the number of medications. Deprescribing did occur; comparing baseline to 24 months, 2%(N=9) of participants were prescribed two fewer medications and 14% (N=47) one fewer medication. More group-based participants were deprescribed HTN medications at 24 months (20%, N=33) compared to the enhanced usual care arm (13%, N=23). Increases in medications also occurred: 12% (N=40) had one more medication prescribed, and 13% (N=8) had two or more additional medications prescribed. Twenty participants (12%) in the group-based arm were prescribed more medications (range 1-4 additional medications), and 28 participants (16%) in the enhanced usual care arm were prescribed more HTN medications (range 1-3 additional medications). Loss of >=5% of body weight was associated with fewer HTN medications at 24 months (p=0.03).

Lifestyle interventions that prompt modest weight loss in individuals with MetS may lead to deprescribing of HTN medications in a clinically significant proportion of individuals. IMPACT OF A HIV PATIENT NAVIGATION STRATEGY ON HIV PREP CARE ENGAGEMENT AND SUSTAINMENT IN PRIMARY CARE/FQHC SETTINGS SERVING BLACK/LATINO COMMUNITIES Bryant N. Gomez3,4; Debjyoti Datta1; Eli A. Andrade1; Alexa Beacham3,4; Sarit Golub3,4; Robert Beil1,2; Viraj V. Patel1,2. 1Division of General Internal Medicine, Albert Einstein College of Medicine, New York, NY; 2Medicine, Montefiore Health System, New York, NY; 3Pyschology, Hunter College, New York, NY; 4CUNY Graduate Center, New York, NY. (Control ID #4273616)

Black and Latino individuals continue to face structural barriers to PrEP uptake, such as prohibitive cost, access, and lack of information and person-centered care. Healthcare navigation can offer a person-centered, low-threshold strategy to increase and sustain PrEP use. Additionally, when PrEP is prescribed, retention and continuity have been low nationally. However, there is limited data rigorously assessing impact of care navigation on PrEP care outcomes, especially for primary care/FQHC settings. We implemented a PrEP navigation strategy and assessed its impact on care engagement in nine NYC FQHCs located in a high HIV incidence county.

The navigation strategy consisted of 1) use of a real-time dashboard to identify patients prescribed PrEP, virtual outreach and semi-structured assessments by English/Spanish bilingual patient navigators, who then provided support for five PrEP care services (appointments, PrEP education, cost/payment assistance, lab testing, and prescription fill support). Navigators documented engagement and support provision using structured templates in the EMR. We extracted electronic medical record (EMR) data on navigation services attempted/delivered, HIV prevention service delivery (i.e., HIV testing, PrEP Rx, PrEP care visit), and demographic characteristics. We analyzed differences in care engagement by navigation success (being reached and receiving one or more PrEP care activities from the navigator).

Overall, we identified 303 patients eligible for PrEP navigation between 03/2021-04/2022 (27.4% Black, 48.8% Latino), of whom 31.4% were successfully navigated. Patients who were navigated (n=95; 31.4%) compared to those who were not, had significantly greater care engagement during the study period, including higher rates of HIV testing (82% vs. 52%), STI testing (74% vs. 44%) and PrEP prescription refills (61% vs. 42%), all P <.001. In addition, patients who were successfully navigated were more likely to have had timely care engagement (follow-up HIV testing <6 months: 57% vs 33%; follow-up visit <6 months: 25% vs 7%), all P<.01. There were no differences in being navigated by demographic factors examined (i.e., sex in EMR, sexual orientation, race/ethnicity, age, insurance status). Navigation support most used were for appointments (78%), PrEP education (28.4%), and Rx refills (14.7%).

Patients who were navigated had significantly greater care engagement outcomes during the study period (HIV/STI testing, medication refills), suggesting it can reduce barriers to PrEP care and improve PrEP sustainment in primary care settings. However, additional strategies are likely needed to engage patients not successfully navigated to ensure effective prevention. IMPACT OF POINT-OF-CARE ULTRASOUND ON PATIENT EXPERIENCE IN OUTPATIENT INTERNAL MEDICINE A PROSPECTIVE SURVEY STUDY Joshua D. Overgaard1; Bright Thilagar1; Mohammed N. Bhuiyan2; Ivana T. Croghan3. 1Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 3General Inernal Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4271544)

Point-of-care ultrasound (POCUS) is increasingly used across medical specialties for clinical decision-making, enabling faster and more accurate diagnoses. It has also been shown to positively affect patient experience in multiple settings, including primary care, emergency medicine, and the hospital. Positive patient experiences improve adherence to recommendations and healthcare outcomes and are increasingly tied to value-based reimbursement models. While its impact on diagnostic accuracy is well-documented, understanding its influence on patient experience—especially in our unique practice environment—remains underexplored. Our clinic enjoys very high satisfaction scores at baseline, so we questioned whether a "ceiling effect" might exist, limiting the capacity for a positive response. This study assesses how incorporating POCUS into consultative internal medicine practice impacts patient experience.

This prospective, cross-sectional study was conducted at a consultative outpatient general internal medicine practice in a destination medical center. A convenience sample of 100 patients who underwent POCUS as part of their clinical evaluation completed an anonymous survey after their visit. After their visit, they were presented with a tablet and informed of the purpose of the study. After the physician left the room, and if they agreed to the electronic consent, they had the opportunity to complete the survey. The survey assessed patients' perceptions regarding how well-informed they were about the exam, its integration into the visit, and its effect on their overall care experience. Data were collected via the REDCap® platform and analyzed using descriptive statistics.

The study sample was predominantly male (64%) and white (89%), with 60% of patients over age 50. Results showed that 100% of patients felt adequately informed about the POCUS exam, with 93% finding the procedure unburdensome. Most patients (95%) considered the POCUS to be a natural part of their consultation, and 94% felt more thoroughly examined due to its inclusion. Additionally, 96% believed the exam improved the level of service, and 95% felt it enhanced the overall quality of care. In open-ended comments, many patients noted improvements in their communication with clinicians, with 75% reporting enhanced contact with their doctor during the POCUS examination.

Incorporating POCUS into consultative internal medicine practice significantly improves patient experience, particularly in communication, understanding of health, and perceived quality of care to a similar degree that has been found in other settings. This argues against a ceiling effect in satisfaction. Clinicians and healthcare administrators should consider supporting a robust POCUS program to improve patient satisfaction in addition to diagnostic accuracy and timeliness. IMPLEMENTING A MULTIDISCIPLINARY APPROACH TO IMPROVE BLOOD PRESSURE CONTROL AT AN URBAN PRIMARY CARE TEACHING CLINIC Satvinder Guru, Ramsis Ramsis, Tina Kana, Emily Rodriguez, Moein Bayat Mokhtari, Ashley Rose, Mark Arbuiso, Erica Pena, Steven L. Sivak, Soyoun Im. Department of Medicine, Lenox Hill Hospital, New York, NY. (Control ID #4272349)

Uncontrolled hypertension (HTN) is a widely prevalent yet modifiable cardiovascular risk factor that contributes to increased morbidity and mortality. The literature demonstrates that a multidisciplinary approach to treating hypertension is effective and can improve blood pressure control. In our study, we implemented multiple interventions at the level of care of various healthcare professionals and measured the effects on blood pressure at an urban primary care teaching clinic.

There were 1,105 patients seen at our clinic over the course of two months. Of these patients, 563 patients had a diagnosis of HTN and specifically, 178 of these patients had a systolic blood pressure (SBP) >140 prior to our intervention. We scheduled follow-up with these patients within 3 months of our intervention and measured their blood pressure. At the end of our study, blood pressure prior to our intervention was compared to blood pressure after our intervention and success was defined as a SBP of <140. Multiple interventions were implemented at the level of care of different health care professionals. At the beginning of the academic year, an educational session for resident physicians was conducted, teaching them how to properly measure blood pressure, and emphasizing the importance of standardizing blood pressure management through an institutional protocol. Interns demonstrated proficiency in measuring blood pressure correctly, with direct observation and feedback from their senior residents and attendings. Resident physicians were also asked to schedule close follow up with patients who were not meeting their blood pressure goal. Medical assistants were taught how to measure blood pressure accurately and asked to check blood pressure twice if an initial reading was SBP >140. Nurses were asked to provide patients with home blood pressure logs and teach patients the correct way to take ambulatory blood pressure readings.

After our intervention, 54% of 178 patients with a SBP >140 achieved a SBP <140 (n=96), 16% of patients did not achieve a SBP <140 (n=28) and 30% failed to follow-up within the post-intervention time frame of three months (n=54). Of the female patients (n=111), 54% achieved a SBP <140 (n=60) and of the male patients (n=67), 52% achieved a SBP <140 (n=35).

Our study highlights the importance of implementing a multidisciplinary team to improve blood pressure control in a teaching clinic. The data demonstrates that our interventions resulted in an overall improvement of SBP by 54% in our target population of 178 patients. However, the findings of our study should be interpreted in light of its strengths and limitations. We acknowledge that there may be confounding variables that affected blood pressure readings other than our intervention. Furthermore, the validity of our study could have been stronger if there was a control group. IMPROVING PREVENTIVE CARE IN RESIDENT CLINIC: IMPLEMENTATION OF A NOVEL EMR REMINDER SYSTEM FOCUSED ON ANNUAL HEALTH MAINTENANCE Prem N. Patel, Ashley A. Seymour, Thomas Mengesha, Neeraj H. Tayal. Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4273219)

Preventive health care (PHC) is a focus for value-based care and ambulatory resident education. Historically, our institutional electronic medical record (EMR) lacked an indicator of last completed and billed PHC visits. Lacking an indicator, PHC was fragmented and often occurred over multiple visits. Consequently, billed PHC services were often omitted. This problem was particularly common in resident continuity clinic, where patient care is managed by rotating resident teams. Improving quality measure performance and revenue were identified as goals for this project.

We collaborated with key stakeholders (practice leadership, IT staff, and chief residents) to develop a Preventive Health Care Gap reminder. Our tool replaced a prior reminder reliant on ICD-10 codes, many unrelated to preventive health services. The new reminder now resets to twelve months when a PHC CPT code is billed. This reminder is prominently placed in the EMR cueing physicians to complete a comprehensive PHC service and submit a PHC CPT billing code. A pilot project was implemented in two resident clinics and one attending clinic, and included an educational session on billing best practices, documentation, and tool utilization. Financial, clinical, and survey data were collected pre- and post-implementation using Qlik Sense® analytics and Microsoft Forms.

From 2017–2020 (pre-intervention), PHC billing rates in resident clinics were 19.3%, increasing to 55.8% post-implementation. Pre-intervention, residents and attendings billed a monthly average of 126 and 2,109 PHC units, respectively, which grew to 302 and 3,060 units by 2023. Corresponding monthly PHC revenue rose from $17,257 to $44,844 for residents (159% increase) and from $303,637 to $462,073 for attendings (43% increase). Survey results revealed that 88% of attending preceptors strongly agreed the tool was easy to locate and access. Additionally, 68% reported that preventive health visits were more frequently completed in their own clinics as a result of the tool. However, only 47% felt the tool had a similar impact in their precepting resident clinics. Notably, all respondents (100%) supported integrating the tool for all primary care patients.

Implementing an enhanced EMR reminder system improved preventive care billing rates, revenue, and workflow efficiency in both resident and attending clinics. The tool's ease of access and utility were well-received with strong support for broader integration. These findings highlight the importance of targeted EMR updates and education in addressing gaps in PHC delivery and billing performance, particularly in the resident clinic setting. IMPROVING THE LOGISTICAL AND EMOTIONAL PROCESSING OF PATIENT DEATH FOR PRIMARY CARE CLINICIANS Jessica A. Erickson1; Bridget C. OBrien2; Sarah Nouri3. 1Division of General Internal Medicine, UCSF Medical Center, San Francisco, CA; 2Medicine, Univ of California, San Francisco, San Rafael, CA; 3Medicine, University of California, San Francisco, San Francisco, CA. (Control ID #4269880)

Navigating the logistics and emotions surrounding a patient’s death is an inevitable and often challenging part of many physicians' roles. While various interventions have been developed to help inpatient clinicians process patient death, less work has been done to support primary care physicians (PCPs) in these situations. Prior research indicates that PCPs often experience isolation, lack of clarity in logistical procedures, and inadequate opportunities to honor deceased patients. This project aims to enhance support for PCPs at an academic institution by simplifying administrative burdens, increasing access to grief resources, and fostering community within the primary care setting.

A 10-minute, anonymous pre-intervention survey was distributed via email to four academic primary care clinics (N=230). Based on PCP-identified needs, three interventions were implemented across the four clinical sites: (1) memorial tree murals to commemorate deceased patients, (2) educational resources including a video and EMR smartphrases to guide PCPs through the logistical and emotional steps following a patient death, and (3) an on-call support person to debrief with PCPs in real time after a challenging death. These interventions were launched in December 2024, with a post-intervention survey planned for collection one year later.

Pre-intervention survey data (N=47 clinic providers) revealed minimal standardization for patient death notifications, with PCPs being notified in varied ways (e.g., electronic messages, family calls, death certificate requests). Providers expressed confusion around death logistics, with 41% not confident in completing death certificates, 50% uncertain of the expected procedural steps and 42% uncertain who to notify. Regarding emotional support, 48% of respondents felt their clinic did not provide adequate time or space for grieving, and 67% reported no suitable venue to commemorate patients. Most participants (59%) were unaware of available support resources, and 25% expressed a desire for an on-call person to help process patient deaths in real time.

This project addresses the often-overlooked impact of patient death in outpatient settings and represents a vital step toward enhancing the well-being of PCPs. By providing logistical and emotional support resources, these interventions aim to foster a more compassionate and resilient medical community. INNOVATION CONTEST AND PERCEPTIONS OF WORK AMONG EMPLOYEES IN PRIMARY CARE Olivia Jung1; Ilana Graetz2; Denise Moultrie3; Christopher Masi4. 1School of Public Health, University of California Los Angeles, Los Angeles, CA; 2School of Public Health, Emory University, Atlanta, GA; 3Primary Care, Emory University, Atlanta, GA; 4Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4242072)

Innovation contests provide a mechanism to foster a supportive work environment and positive work experience. These contests capture frontline workers’ voices and encourage decentralized, bottom-up problem-solving and innovation. Managers can use contests as opportunities to respond to worker input and facilitate communication about issues that workers want to see changed. We explored the association between implementing an innovation contest and employees’ work experience in Primary Care.

We conducted an innovation contest among 778 staff and providers from 52 clinics in Primary Care between May and June 2023. Participants included medical assistants (MAs), nurses, patient service coordinators (PSCs), providers (physicians and APPs), nurse managers, and operation leaders. Employees submitted ideas on recruitment and onboarding, engagement and retention, and workflow. Submitted ideas were shared and employees were invited to vote for the best ideas from each role group. Each of the 16 winners received a $100 VISA gift card while each of the 16 runners-up received a $50 VISA gift card. A follow-up survey was administered in December 2023 to assess study outcomes, which were 1) employee feelings of being heard, 2) organizational identification (the extent to which employees identify with organizational goals and values), 3) job satisfaction, and 4) burnout. A separate section of the survey asked whether the employee had been aware of the contest, participated by submitting ideas or voting, and/or observed idea implementation. We then assessed the association between contest implementation and study outcomes by conducting linear regressions with robust standard errors. We calculated the marginal effects of being aware of the contest taking place, participation, and observation of idea implementation using the Stata margins postestimation command.

157 ideas were submitted by 99 employees. Winning ideas included improved pay for MAs and nurses, flexible work schedules for nurses, and standardized workflow and job descriptions across practices, among others. 399 employees (51% response rate) completed the follow-up survey. Employees who said they were aware of the contest were more likely to report feeling heard (p=0.07) and organizational identification (p=0.005) compared to those who were not aware. Employees who observed winning ideas being implemented were more likely to express feeling heard (p=0.028), organizational identification (p<0.001), and job satisfaction (p<0.001) compared to those who did not.

These findings suggest that interventions that invite employees to voice input on ways to improve the work environment and then act on the input have the potential to 1) help employees feel heard, 2) increase employee identification with organizational goals and values, and 3) enhance employee job satisfaction. Continued work is needed to understand and amplify the voices of frontline employees so they are better able to deliver high-quality care. INTERPRETATION OF HOME BLOOD PRESSURE READINGS IN HYPERTENSIVE PATIENTS Kunal Khurana1,4; Nicole Casasanta3,4; April Barbour4; Sean Lee2; Parvinder Khurana4. 1SGU School of Medicine, Grenada, Saint George's, Saint George, Grenada; 2Office of Clinical Research, The George Washington University School of Medicine and Health Sciences, Washington, DC; 3Yale University Department of Internal Medicine, New Haven, CT; 4Department of Internal Medicine, The George Washington University Hospital, Washington, DC. (Control ID #4272242)

Home blood pressure monitoring (HBPM) is integral to diagnosing and treating hypertension. However, there is tremendous variability in physician recommendations and interpretations of home blood pressure readings. The AHA and AMA guidelines recommend taking a minimum of 2 readings per sitting and using the average of these readings for management decisions. These recommendations are largely based on expert opinion. However, systematic reviews have indicated that therapy modification based on office or home blood pressure measurements often results in an overestimation of blood pressure. The gold standard for diagnosing hypertension is 24-hour ambulatory blood pressure monitoring (ABPM). However, the correlation of HBPM readings with ABPM has been modest at best. We conducted a study to determine if there is a significant difference between multiple consecutive home blood pressure readings in hypertensive patients.

Study cohort consisted of 55 hypertensive patients seen in a primary care clinic at an academic medical center. Two office BP readings were taken for each patient on the day of study enrollment. Patients were then instructed on home BP measurement technique and asked to measure their blood pressure twice a day for one week. For each measurement sitting, they were asked to take 3 consecutive readings separated by 1-2 minutes each. Patients used their own automated digital home machines with an arm cuff.

The mean age of the study cohort was 71 years. 71% of patients identified themselves as black, and 80% were female. For office BP measurements, the difference between the average and the lowest reading was 6.6 mmHg. For home BP measurements, the average BP was calculated by two different methods - either based on the first 2 readings or on the basis of all 3 readings. The lowest BP reading was found to be 20.8 mmHg lower than the 3-reading average and 22.2 mmHg lower than the 2-reading average. When 3 readings were taken per sitting, the third reading was generally the lowest reading (68% of patients). Nearly 48% of patients would be considered above goal (>130/80 mmHg) based on the average BP, whereas only 13% would be considered above goal based on the lowest BP. Overall, there was a statistically significant difference between the average and lowest BP reading in both office (p<0.001) and home settings (p<0.001).

Home and office blood pressure readings show marked variability when multiple consecutive readings are taken in the same sitting. Specifically, there is a statistically significant difference between the average and lowest blood pressure reading. This has tremendous implications for hypertension management, as the decision to escalate therapy is based on the interpretation of home blood pressure readings. Further research is needed to determine which blood pressure measurement is best for determining whether blood pressure is adequately controlled. MISCLASSIFICATION OF HYPERTENSION STAGE FROM ONE OFFICE BP TO TWO OFFICE BP MEASUREMENTS Aayush Visaria. Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. (Control ID #4273372)

BP measurement protocols from major trials that have shaped our hypertension (HTN) management guidelines utilized the average of at least 2 consecutive readings; this unfortunately remains a challenge in our fast-paced primary care environment. It is unknown whether one BP measurement is sufficient to capture true protocol-driven BP measurements. We sought to determine the extent of misclassification of hypertension stage and BP from 1st measurement to 2nd measurement.

This was a cross-sectional, nationally representative study of the 2017-2020 U.S. National Health and Nutrition Examination Survey (NHANES). All adults included had 3 consecutive, sitting automatic BP readings done 60 seconds apart in a mobile examination center. Prior to the first reading, they were seated for 5 minutes. We categorized the 1st initial BP reading and 2nd consecutive BP reading into normotension, elevated BP, stage 1 HTN, and stage 2+ HTN per the 2017 ACC/AHA guidelines. We assessed the percentage of adults with discrepant BP classifications from 1st to 2nd reading, with particular attention to determining the prevalence of Stage 1 and 2 HTN misclassified as normotension or elevated BP with just 1 BP reading. All analyses accounted for the complex survey design and utilized post-stratification weights to obtain nationally representative estimates.

Among 7,870 adults (representing 223 million adults; mean age 53y, 61% non-Hispanic White, 49% female), 42% had normotension, 13% had elevated BP, 22% had stage 1 HTN, and 23% had stage 2+ HTN. Among people with elevated BP, 22% (representing ~6.6M adults) had BP in the Stage 1 HTN range on their 2nd reading. Among people with stage 1 HTN, 13% (representing ~6.3M adults) had BP in the Stage 2 HTN range on their 2nd reading. Approximately 5% (~11.5M adults) of participants had an increase >10 mmHg in their SBP from 1st to 2nd reading. In contrast, 27% of adults with elevated BP, 25% with stage 1 HTN, and 19% with stage 2 HTN had lower BP readings on their 2nd BP measurement (Table).

There is substantial BP category misclassification from the 1st BP to 2nd BP reading across all initial BP categories. While lower BP readings on subsequent measurements may indicate a white coat-like effect, higher BP readings suggest a possible misdiagnosis of BP category and reinforces the need to do multiple BP measurements. It remains to be seen whether these misclassifications lead to differential clinical decisions and end-outcomes. MULTIDISCIPLINARY DIABETES MANAGEMENT AND CONTINUOUS GLUCOSE MONITORING IN PRIMARY CARE FOR A VULNERABLE POPULATION: A PILOT STUDY Britt Marshall, Martina Abuphilipous, Saria M. Hassan, Karlene Wortham. Emory University, Atlanta, GA. (Control ID #4271300)

Social determinants of health (SDH) have a profound impact on the ability of persons with diabetes (DM) to effectively manage their disease.Recent technologies such as continuous glucose monitoring (CGM) are emerging but still hard to access in some populations. This cycle of health inequity burdens patients and the healthcare system. Primary care clinics (PCCs) are the front-line for DM management and have become more essential as endocrinology subspecialists have had limited capacity. Our objective was to assess the effectiveness of an Integrated Multi-Disciplinary Diabetes Clinic in Primary Care (IM-DCP) on diabetes metrics.

Primary care patients at an academic center in the southeastern United States with a hemoglobin A1c (HbA1c) ≥9% and not followed by an endocrinologist were referred to the IM-DCP. The IM-DCP includes an internal medicine resident and attending, registered nurse trained in DM education, dietitian; psychologist as part of our collaborative care model and social work services were available as needed. At initial visit, patients are screened for depression, anxiety, and food and housing insecurity. They are assisted with obtaining CGM and optimizing their medication regimen. The primary outcome of interest was change in HbA1c. The secondary outcome was proportion of persons who reduce their HbA1c below 9%. Independent variables of interest included: race/ethnicity, age, insurance status, CGM utilization, and insulin utilization. Chi-squared and Fisher exact test were used to look at association of independent variables with the primary and secondary outcomes.

185 patients participated in the IM-DCP and 137 patients had a starting HbA1c>9%. Average age was 58.3 years (SD 12.3), 84.8% identified as Black and 54% were female. Average HbA1c for patients who met inclusion criteria for IM-DCP and had at least 1 appointment decreased from 11.65% to 9.66% (Δ=1.99%; p<0.0001). Fifty-six percent of patients dropped their HbA1c below 9%. Secondary analyses were suggestive that type of insurance (i.e. Medicare, Medicaid, or commercial insurance, p=0.005), clinic engagement (i.e. number of visits attended, p=0.002), and insulin prescription/use (p=0.008) were associated with reduction of HbA1c below 9%. Use of CGM was not associated with reduced HbA1c.

An IM-DCP successfully improved DM metrics. We believe this is an important and feasible model for use in primary care to improve DM management and reduce disparities. Future work will seek to understand the role of CGM and strategies to address remaining SDH barriers to improved DM metrics. NATIONAL ESTIMATES OF 30-YEAR ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK AMONG US ADULTS AGED 30 TO 59 YEARS Timothy Anderson1; Linnea Wilson2; Jeremy B. Sussman3. 1Medicine/General Medicine, University of Pittsburgh, Boston, MA; 2General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 3Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4273076)

Estimating 10-year atherosclerotic cardiovascular disease (ASCVD) risk is recommended to guide primary prevention blood pressure and cholesterol treatment decisions. Estimates of longer term cardiovascular risk may futher help primary care clinicians counsel patients, particularly younger and middle aged adults. In 2023, the American Heart Association developed the Predicting Risk of CVD EVENTs (PREVENT) equations to estimate 30-year risk of ASCVD for adults age 30 to 59 years. We sought to describe estimates of 30-year ASCVD risk in a nationally representative US population.

We analyzed the 2017-2020 cycle of the National Health and Nutrition Examination Survey (NHANES). We included non-pregnant adults ages 30 to 59 without known ASCVD. We calculated both 10-year and 30-year ASCVD risk using the PREVENT risk calculators which include values for age, sex, total and high-density lipoprotein cholesterol, systolic blood pressure (BP), diabetes status, smoking status, estimated glomerular filtration rate, antihypertensive medication use, and statin use. We classified ASCVD risk as low (20%) consistent with current national guidelines. We assessed ASCVD risk factor control among patients with high 30-year ASCVD risk and the potential population health impact of expanding primary prevention statin reccomendations based on 30-year risk.

The study included 3,229 adults, which after survey weighting, was representative of 101.9 million (95% CI, 92.2 – 111.6) US adults (weighted mean [SD] age 44.6 [8.8] years, 49.8% female, 6.1% Asian, 10.8% Black, 17.3% Hispanic, and 61.1% White). The mean estimated 10-year ASCVD risk for the cohort was 2.0% (95% CI, 1.9% to 2.1%) and 97% of the cohort had low (<7.5%) 10-year risk. The mean estimated 30-year ASCVD risk across the cohort was 9.7% (95% CI, 9.4% – 10.1%) and 44% had intermediate 30-year risk and 9% had high 30-year risk. Elevated 30-year risk was highly concentrated by age, with over 20% of adults ages 50 to 59 estimated to have high 30-year risk compared to less than 1% of adults ages 30-39. Most patients with high 30-year risk had at least 3 uncontrolled modifiable risk factors of which the most common were BP > 130/80 mmHg (70.8%), diabetes (61.4%), obesity (59.9%), and total cholesterol > 200 mg/dL (56.2%). Expanding primary prevention statin recommendations to adults with high 30-year ASCVD risk would change recommendations for 2.5 (95% CI, 1.9 – 3.2) million adults not currently receiving statins, with an average number needed to treat over 10 years to prevent one ASCVD event of 78.3 (95% CI, 76.5 – 80.1), comparable to the average number needed to treat for adults currently recommended but not using primary prevention statins of 86.5 (95% CI, 80.5 – 92.4).

Use of the PREVENT 30-year ASCVD risk equations would identify a population of US adults with low 10-year but high 30-year who may warrant enhanced primary prevention strategies. PATTERNS IN HOME BLOOD PRESSURE MONITORING Kunal Khurana1,3; Connor Perlin2; Hirsh Shah3; Parvinder Khurana3; April Barbour3; Dominic Raj4. 1SGU School of Medicine, Grenada, Saint George's, Saint George, Grenada; 2The George Washington University School of Medicine and Health Sciences, Washington, DC; 3Department of Internal Medicine, The George Washington University Hospital, Washington, DC; 4Department of Nephrology, The George Washington University Hospital, Washington, DC. (Control ID #4271609)

Home blood pressure monitoring (HBPM) is integral to hypertension management. It presents an accurate representation of blood pressure in the absence of fluctuations resulting from a patient’s presence in a doctor’s office. Current office BP guidelines recommend using the lowest reading when multiple readings are taken, while HBPM guidelines recommend taking the average. However, these guidelines are based largely on expert opinion. Furthermore, there is significant variability in the degree to which clinicians and patients actually comply with HBPM guidelines. The aim of this study was to determine the trends in HBPM practices among both patients and clinicians.

We surveyed a group of 50 providers and 150 patients at an academic hospital on their HBPM practices. Patients were taken from an outpatient primary care clinic. Providers were distributed between four specialities (internal medicine, cardiology, nephrology, and geriatrics) and included attendings, trainees, PAs, and NPs.

Providers: Only 37% of providers stated their patients were being adequately instructed on proper HBPM technique. There was disagreement on how many readings patients should take per sitting. While 39.1% of providers said they instruct patients to take at least 2 readings, the majority of providers (54.3%) instruct patients to take only 1 reading. When multiple HBPM readings are taken, 91.5% said they use the average for management decisions. In contrast, when it came to office BP measurement, 54.3% stated they used the lowest reading for management, while 41.3% continued to use the average. Patients: 41% of patients said they measure their BP once a week, while 39% measure BP 2-3 times per week. While 45% of patients take only 1 reading per sitting, 40% said they take 2 readings, and 15% said they take 3 or more readings. 60% believed that the average is the most accurate reading, while 23% believed the lowest is most accurate. 50% stated that they had never been adequately instructed on HBPM, but 48% said they are confident in their technique. 73% believed their HBPM method does not overestimate their blood pressure.

There is widespread variability in the methodology and interpretation of blood pressure measurement throughout clinical practice. This variability persists among both patients and providers. The majority of providers stated their patients were not being adequately instructed on HBPM technique, and patients seemed to agree. There was considerable discrepancy among patients and providers on how many readings to take per sitting. While most patients and providers felt that average BP is the most accurate reading, nearly half of patients said they only take 1 reading to begin with. According to providers, the main barriers to proper HBPM are limited access to HBPM machines, the burden on patients to self-record, difficult patient lifestyles and circumstances, as well as the questionable accuracy of patient self-reporting. PATTERNS OF DIAGNOSTIC AND THERAPEUTIC PROCEDURE UTILIZATION AMONG TINNITUS PATIENTS Mingee Kim1; David Friedland2; Jazzmyne A. Adams1; Masoud Khani3; Jake Luo3. 1Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI; 2Department of Otolaryngology – Head and Neck Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA; 3Department of Health Informatics and Administration, University of Wisconsin-Milwaukee, Milwaukee, WI. (Control ID #4268318)

Tinnitus, characterized by a persistent ringing in the ears, affects approximately 10% of U.S. adults, with 5 million experiencing a chronic form of the disease and 2 million finding it debilitating. Prior research has shown that tinnitus patients may exhibit increased healthcare utilization, but specific patterns of subspecialty resource usage have not yet been investigated among U.S. adults. Building on our prior findings of generalized increased utilization in visits, medications, and procedures among tinnitus patients, the present study focuses on procedural utilization, emphasizing diagnostic versus therapeutic procedures across specialties.

This retrospective cohort study included 6,236 patients diagnosed with tinnitus and 6,236 age-, sex-, and race-matched controls without a diagnosis of tinnitus 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, medications, procedures, and diagnoses for other conditions. Odds ratios with 95% confidence intervals were calculated for categorical analyses and Student t-test used for continuous variables.

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, tinnitus patients demonstrated significantly elevated utilization of both cancer- and neuro-related procedures compared to controls. Cancer-related procedures were largely diagnostic, such as prostate cancer screening (odds ratio, 8.9; 95% CI, 7.0-11.4) and mammography (odds ratio, 7.3; 95% CI, 5.9-9.0), while neuro-related procedures included both diagnostic tests, such as brain MRI (odds ratio, 20.5; 95% CI, 15.3-27.5), and therapeutic interventions, such as radiofrequency ablation (odds ratio, 21.4; 95% CI, 90.3-249.7).

The increased utilization of health resources, specifically procedures, reflects a broader pattern of specialized care among tinnitus patients. The distinction between diagnostic-focused utilization in oncology and a mix of diagnostic and therapeutic procedures in neurology suggests that tinnitus patients may require more ongoing evaluation, management, and intervention for neurological conditions. These may include tinnitus itself or related conditions such as hearing loss, auditory nerve tumors, migraines, or other nerve disorders associated with tinnitus. Future research should explore the potential link between tinnitus and underlying comorbidities, as well as evaluating the effectiveness of these targeted interventions in optimizing the frequency and necessity of diagnostic and therapeutic procedures. POPULATION HEALTH APPROACH TO BLOOD PRESSURE CONTROL USING APP-MANAGED REMOTE PATIENT MONITORING Karly Pikel1; Shreyas Menon4; Alexis Sassower1; Emily Tuchman1,3; Kristin Burger1; Micah J. Eimer2,4; Karin B. Ulstrup1,3; Stephen Persell1,3; James Paparello3. 1Internal Medicine, Northwestern Medicine Lake Forest Hospital, Lake Forest, IL; 2Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL; 3Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; 4Cardiology, Northwestern Medicine Lake Forest Hospital, Lake Forest, IL. (Control ID #4269774)

Globally, hypertension (HTN) is the leading preventable risk factor for cardiovascular disease (CVD). National studies estimate 56.3% of US adults with HTN have uncontrolled blood pressure (BP≥140/90). Current guidelines recommend using home BPs for HTN diagnosis and medication titration. A remote BP monitoring program managed by an advanced practice provider (APP) was implemented in the Internal Medicine (IM) department at a Midwest academic medical center to improve patient BP control.

The population health dashboard of the electronic medical record (EMR) identified patients with HTN and recent clinic BP ≥140/90, based on the National Committee for Quality Assurance (NCQA) measure. Provider notes, outside records, and patient messages were reviewed for a more recent controlled home BP reading. If found, the home BP was recorded discretely in the patient’s chart, and the patient was classified as having white coat HTN where BP is high in clinic but controlled at home. All other patients were contacted about remote monitoring. Participants received an Omron BP7250 monitor and cellular transmitter that automatically sends home BP readings to the EMR. The APP reviewed transmitted readings and conducted visits with patients to discuss lifestyle and start or adjust medications using an algorithm based on contemporary HTN guidelines. The visits continued until average home BP over one month was <140/90. The resultant change in BP control was measured against a comparison group of IM patients at another location within the same institution that did not implement remote BP monitoring. A paired t-test and pooled proportion statistical difference test were performed to determine statistical significance.

A total of 1,455 patients were assessed. A home BP reading was recorded discretely in the EMR for 291 (20%) of these to document whitecoat HTN. Remote monitoring was offered to 1,192 patients, and 382 (32%) participated. Of 282 (74%) who had 7 or more BP readings using the program-provided monitor, 127 (45%) had white coat HTN and 155 (55%) had sustained uncontrolled HTN. From May to November 2024, the average systolic and diastolic BP of participating patients improved from 150/83 to 126/78 (p<0.001). Due to this, the percentage of all patients at the medical center with HTN and a BP reading <140/90 improved from 66.7% to 73.3%. This 9.8% relative increase in percentage of patients with controlled BP is significantly greater than the 2.2% relative increase amongst the comparison group (p<0.001).

Overall, this APP-managed program effectively documented and improved BP among participating patients, leading to improvement in the clinic achieving NCQA quality measure targets. It is an ongoing project expected to cause further improvement in BP control and thus lower CVD risk as more patients participate. A future goal is to increase patient uptake of remote BP monitoring and implement it across different healthcare systems to reach a larger population. POST-COVID-19 VACCINATION AND LONG COVID: INSIGHTS FROM PATIENT REPORTED DATA Tom C. Quach4; Mitchell Miglis2; Lu Tian3; Hector Bonilla1; Phillip C. Yang1; Amogha Paleru4; Vincent Xin4; Anushri Tiwari5; Robert W. Shafer1; Linda N. Geng1. 1Medicine, Stanford University School of Medicine, Stanford, CA; 2Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA; 3Biomedical Data Science, Stanford University, Stanford, CA; 4Stanford University School of Medicine, Stanford, CA; 5Case Western Reserve University School of Medicine, Cleveland, OH. (Control ID #4215666)

COVID-19 vaccinations reduce the severity and number of symptoms for acute SARS-CoV-2 infections and may reduce risk of developing Long COVID, also known as post-acute sequelae of SARS-CoV- 2 (PASC). Limited and heterogenous data exist on how these vaccinations received after COVID-19 infection might impact the symptoms and trajectory of PASC, once persistent symptoms have developed.

We investigated the association of post-COVID-19 vaccination with any SARS-CoV-2 vaccine(s) on PASC symptoms in two independent cohorts: a retrospective chart review of self-reported data from patients (n=128) with PASC seen in the Stanford PASC Clinic between May 2021 and May 2022 and a 2023 multi- national survey assessment of individuals with PASC (n=484). Categorical variables were summarized using counts and proportions and compared using Fisher's exact test. Continuous variables were summarized using median and quartiles and compared using the analysis of variance. The statistical significance level is set at the two-sided 0.05 level. R 4.1.1 (The R foundation for Statistical Computing) was used to conduct the analysis.

Within the PASC Clinic patient cohort (n=128), 58.6% (n=75) were female and 41.4% (n=53) were male, and 50% (n=64) were white and 38.3% (n=49) were non-white. 60.2% (n=77) of PASC Clinic patients reported no change in their PASC symptoms after vaccination, 17.2% (n=22) reported improved symptoms , and 22.7% (n=29) reported worsened symptoms. In the multinational survey cohort, 380 were from the U.S. and 104 were from outside the U.S., 88.4% (n=428) were female and 11.6% (n=56) were male, and 88.8% (n=430) were white and 11.2% (n=54) were non-white. The distribution of survey self-reported vaccine effects on PASC symptoms was 18.6% worsened (n=98), 55.7% no effect (n=293), and 17.7% improved (n=93). In both cohorts, demographic features, including age, sex, and race/ethnicity, were not significantly associated with post-vaccination PASC symptom changes. There was also a non-significant difference in the median dates of COVID infection among the different outcomes. BMI was significant for symptom improvement (p=0.026) in the PASC Clinic cohort, while a history of booster doses was significant for symptom improvement (p<0.001) in the survey cohort.

Most individuals with PASC did not report significant changes in their overall PASC symptoms following COVID-19 vaccinations received after PASC onset. Further research is needed to better understand the relationship between COVID-19 vaccinations and PASC. PREVALENCE, CORRELATES, AND PHARMACOLOGIC IMPACTS OF PHYSICIAN CARE DISCONTINUITY AMONG US ADULTS WITH DIABETES: A NATIONAL FOUR-YEAR LONGITUDINAL STUDY Sarah V. Harrison1; Rikesh Karki1; Avery Forrow2; Danny Do3; Jesse Bossingham2; Samantha McKnight2; Kangning Peng2; Shaheen Chowdhury2; Adam Gaffney4; Charlotte Rastas1. 1Internal medicine, Cambridge Health Alliance, Cambridge, MA; 2Internal Medicine, Cambridge Health Alliance, Cambridge, MA; 3Medicine, Cambridge Health Alliance, Cambridge, MA; 4Medicine, Harvard Medical School, Boston, MA. (Control ID #4272425)

Medical management of diabetes is paramount to reducing morbidity and mortality from this common chronic condition. High-quality care necessitates regular contact with a diabetes provider; guidelines recommend diabetes visits at least every 6 months. However, it is unknown how many Americans with diabetes, including those with severe disease, face discontinuities in care over protracted periods; which groups are at elevated risk for discontinuity; and whether discontinuity in physician care leads to reduced uptake of prescription drug therapy.

We analyzed panel 23 (2018-21) and panel 24 (2019-22) 4-year longitudinal data from the Medical Expenditure Panel Survey. Our study population included adults with a baseline diagnosis of diabetes. Our primary measure was diabetes physician visits, defined as those to a primary care physician or endocrinologist; our focus was the prevalence of “discontinuous” care defined as 1+ calendar years with zero such visits over a 4-year period. We assessed multiple correlates of discontinuous care, including race/ethnicity and insurance. We then examined the association between discontinuous care (across years 1-4) with pharmacologic treatment (in year 4) of diabetes, hypertension, and hyperlipidemia, with adjustment for potential confounders, using MEPS’ prescribed medicines files.

Our population included 1,228 adults with diabetes (weighted n=23.8 million). These individuals had a mean age of 59.9 years and 46.7% were female; many had co-morbidities (e.g. 71.6% with hypertension) and 30.7% used insulin. 49.8% (11.9 million individuals) experienced discontinuous care, including 29.5% (7.0 million) who went 2+ years without a visit and 5.9% (1.4 million) who saw no outpatient doctors over the 4-year study period. Among those with severe diabetes (prescribed insulin, or with diabetic renal or eye complications), slightly fewer (46.1%) experienced discontinuous care; 4.5% never saw a diabetes physician over four years. Black and Hispanic, and chronically uninsured individuals with diabetes were more likely to experience discontinuous care vs. non-Hispanic White, or insured, individuals (p<0.05 for each comparison). After adjustment for potential confounders, those who went 2+ years without a visit (vs. no years without a visit) were more likely to be untreated with medication for diabetes (adjusted odds ratio 2.71; 95% CI 1.44, 5.09) and hypertension (adjusted odds ratio 2.47; 95% CI 1.37, 4.44); those with even a single year without care were more likely to go untreated with medication for hyperlipidemia (adjusted odds ratio 2.06; 95% CI 1.18, 3.58).

Among US adults with diabetes, underuse of physician care is common, disproportionately affects marginalized populations, and is associated with worse care. Policies to improve insurance coverage, reduce or eliminate out-of-pocket costs for clinician visits, and expand primary care infrastructure might reduce physician underuse. PREVALENCE OF ANTINUCLEAR ANTIBODIES IN PATIENTS WITH CORONARY ARTERY DISEASE Manisha J. Antony1; Christina Thymalil1; Stephaie Nagy4; Kayvan Amini3; Marc M. Kesselman2. 1 Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University - Fort Lauderdale/Davie Campus, Nova Southeastern University, Fort Lauderdale, FL, US, academic, Land O Lakes, FL; 2Division of Rheumatology, Nova Southeastern University Dr Kiran C Patel College of Osteopathic Medicine, Fort Lauderdale, FL; 3Division of Cardiology, Nova Southeastern University Dr Kiran C Patel College of Osteopathic Medicine, Fort Lauderdale, FL; 4Rheumatology, Nova Southeastern University, Fort Lauderdale, FL. (Control ID #4248730)

Coronary artery disease (CAD) is a classification of cardiovascular disease and is one of the most common causes of death worldwide [1]. CAD is characterized by atherosclerosis and inflammation of the intima layer in blood vessels [1]. Autoimmune diseases have a well-established association with CAD, which is accredited to the role immune modulators play in atherogenesis and autoimmune disease [2]. Antinuclear-antibody (ANA) is an immunoglobulin that attacks nuclear and cytoplasmic components within cells, serving as a biomarker for many autoimmune conditions [3]. This study evaluates whether ANA titers serve as an independent risk factor for CAD and its clinical manifestations.

A scoping review was conducted using the following databases: CINAHL, Embase, ProQuest, OVID Medline, and PubMed. The search terms “Coronary artery disease” OR “Coronary disease” OR “Coronary aneurysm” AND “Antibodies, Antinuclear” were used to search for articles from 2000 to 2024. Inclusion criteria consisted of population over the age of 18 with a positive ANA titer and evidence of coronary artery disease, articles that were peer reviewed and in English language. Exclusion criteria included patients with established autoimmune disease diagnosis and articles that were scoping reviews, editorials, opinion pieces, abstracts, or had no full text available. The final articles were evaluated using the Joanna Briggs Institute critical appraisal checklists.

The initial search identified 442 articles and a total of 13 articles were included in the final results for data extraction. After analysis, 329 patients with CAD were found to have positive ANA titers, where a titer greater than 1:40 was considered positive. Among these patients, the most prevalent titer was 1:160 (0.31, n=103). Confounding rheumatological factors were evaluated: anti-cardiolipin (aCL) IgG and IgM were the second most common antibodies (0.39, n=130) (0.37. n=123). Furthermore, a strong positive association between ANA titers and the number of stenotic coronary vessels were seen in the coronary artery ectasia (CAE) population. Hypertension was the most frequently observed comorbidity. Although smoking and male is a common risk factor for CAD, a study by Solow et al. found that ANA titers were most prevalent in female nonsmokers [4].

Results indicate that positive ANA titers could be an independent risk factor for CAD in patients without established autoimmune disease. This is evidence, particularly among patients with CAE, that severity of ectasia in the coronary vessels is correlated with strength of ANA titers. As autoantibodies cause endothelial dysfunction, ANA may play a role in the pathophysiology of CAD. This investigation suggests that patients with positive ANA titers should undergo preliminary cardiovascular screening. Further research is needed to isolate ANA from traditional risk factors of CAD and to explore the potential use of ANA titers as a screening tool for CAD. RURAL-URBAN DIFFERENCES IN NON-DRUG THERAPY USE AMONG US MILITARY VETERANS PRESCRIBED LONG-TERM OPIOID THERAPY FOR CHRONIC PAIN Elizabeth S. Goldsmith3,2; Collin Calvert1,2; Patrick Hammett1,2; Barbara Clothier1; Siamak Noorbaloochi1,2; Erin E. Krebs3,2. 1Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Arden Hills, MN; 2University of Minnesota Medical School, Minneapolis, MN; 3Medicine, Minneapolis VA Health Care System, Minneapolis, MN. (Control ID #4272326)

Long-term opioid therapy has demonstrated limited benefit for chronic pain and carries risks including overdose and opioid use disorder. Non-drug therapies (NDTs) are first-line chronic pain treatments with fewer risks and additional benefits, but access to NDTs may be limited by rural residence. Our objectives were to compare rural and urban US military veterans’ meaningful use of NDTs for pain, and to evaluate rural and urban NDT use trends over time through early 2020.

Effects of Prescription Opioid Changes in Veterans (EPOCH), a nationally representative prospective longitudinal cohort study begun in 2016, annually surveyed US Veterans Affairs (VA) patients prescribed long-term opioid therapy for chronic pain. Participants reported behavioral (psychotherapy, relaxation, meditation), exercise (stretching/strengthening, aerobic, yoga, and tai chi), and manual (acupuncture, chiropractic, and massage) NDT use. Investigator/clinician consensus defined cutoffs for meaningful NDT use. Descriptive statistics and generalized estimating equations models compared meaningful NDT use between rural and urban residents, adjusting for age, sex, race, and ethnicity.

Among EPOCH survey participants with complete rural/urban status (baseline N=9,248), 45% (4,120) resided in rural areas and 55% (5,128) resided in urban areas. Meaningful behavioral therapy use was less common among rural residents (33%) than among urban residents (37%; RR=0.88, 95%CI 0.83-0.95), particularly psychotherapy. Meaningful exercise therapy use was less common among rural (36%) than among urban residents (40%; RR=0.92, 95%CI 0.85-0.99), particularly stretching/strengthening and yoga. Meaningful manual therapy use was less common among rural (31%) than among urban residents (35%; RR=0.88, 95%CI 0.82-0.95), particularly acupuncture. Rural-urban differences in meaningful NDT use persisted in longitudinal models, and trends within rural and urban subgroups fluctuated similarly over time.

Overall, meaningful NDT use for pain was less common among rural residents than among urban residents within a nationally representative cohort of US military veterans prescribed long-term opioid therapy for chronic pain. Investigating barriers and facilitators to NDT use for pain among rural residents may improve health equity in first-line chronic pain care. SEMAGLUTIDE USE ASSOCIATED WITH DECREASED RISK OF ASTHMA EXACERBATIONS IN A NATIONAL COHORT OF PATIENTS WITH COMORBID OBESITY Stanley Chan1; Hannah Beaman2; Noor Hamideh2; Fred W. LaPolla3; Kiarra Levesque1. 1Internal Medicine, NYU Langone Health, New York, NY; 2Medicine, NYU Langone Health, New York, NY; 3NYU Health Sciences Library, NYU Langone Health, New York, NY. (Control ID #4272555)

Asthma is episodic wheeze, cough, and/or breathlessness from underlying airway hypersensitivity and inflammation. Asthma affects an estimated 20 million, or 8% of US adults, and carries an annual cost of $56 million nationally. Obesity is a known risk factor for asthma incidence and severity, and studies have shown that weight loss is associated with improved asthma control. Semaglutide, a subcutaneous glucagon-like peptide-1 (GLP-1) agonist, is FDA-approved for weight loss in individuals with obesity, but has not been evaluated for reduction of asthma exacerbations in individuals with comorbid obesity. AllofUs is a large national database of US adults that includes electronic health records and survey data. This retrospective cohort study asks: In adult patients with asthma and body mass index (BMI) ≥ 30 kg/m2, is use of semaglutide ≥ 1mg associated with risk of acute asthma exacerbation (AAE)?

This retrospective cohort study analyzed patient records from the AllofUs national database. Our study period was May 2020-May 2022. 5,590 patients met the following inclusion criteria: ≥ 18 years by May 2020, asthma diagnosis, BMI ≥ 30 kg/m2. Participants were categorized by whether they were prescribed subcutaneous semaglutide ≥ 1mg at any point during the study period. The risk of having ≥ 1 coded AAE was calculated in each group and compared.

258 qualifying patients (4.6%) were prescribed semaglutide ≥ 1mg during the 2 year study period, compared to 5,332 (95.4%) qualifying patients who were not. For patients with semaglutide prescriptions, the risk of ≥ 1 AAE over the study period was 0.28 compared to 0.37 (RR: 0.77, CI: 0.82-0.96) among those who did not receive a semaglutide prescription.

In a national cohort of patients with asthma and a BMI ≥ 30, being prescribed subcutaneous semaglutide ≥ 1mg weekly was associated with decreased risk of having ≥ 1 AAE. This adds to the body of literature suggesting that semaglutide is a promising adjunctive therapy for asthma in patients with comorbid obesity. SODIUM-GLUCOSE COTRANSPORTER-2 INHIBITOR DRUG UTILIZATION AMONG PATIENTS WITH HEART FAILURE IN A PRIMARY CARE NETWORK Michael Chiu2; Lisa Yanek3; Jiajun Wu2; Samantha I. Pitts1. 1Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD; 2Medicine, Johns Hopkins University, Baltimore, MD; 3Medicine, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4273452)

While clinical trials show that SGLT2 inhibitors (SGLT2i) reduce the risk of hospitalization in heart failure (HF) patients, the utilization of these drugs among HF patients receiving primary care in the US remains unclear. Existing real-world studies provide limited data because they examine utilization among patients with diabetes and chronic kidney disease (CKD) or fail to evaluate prescription patterns among patients in primary care. We sought to describe SGLT2i utilization among HF patients in a primary care setting.

We conducted a cross-sectional study of HF patients ≥ 18 years old with at least one visit in 2023 in a primary care network affiliated with an academic medical center. We analyzed data from the electronic health record and classified patients with HF and medical comorbidities based on ICD-10 codes. Our primary outcome was an SGLT2i prescription in 2023, defined as at least one order of empagliflozin, dapagliflozin, canagliflozin, ertugliflozin, or bexagliflozin. We classified patients who were prescribed SGLT2i at any time before 2023 as prevalent users and those who were prescribed SGLT2i for the first time in 2023 as new users. We used logistic regression to estimate the association between receiving an SGLT2i prescription and demographic and clinical factors, including diagnoses of diabetes and renal disease, use of renin angiotensin system (RAS) inhibition, hospitalization, and length and frequency of primary care.

Among the 7,922 patients with HF, 1,592 (20%) received an SGLT2i in 2023, and an additional 499 (6%) who had not received an SGLT2i in 2023 had been prescribed one in a prior year. Among the 1,592 patients who received an SGLT2i in 2023, 866 (54%) were prevalent users while the remaining 726 (46%) were new users. Among hospital departments, primary care (53%) and cardiology (39%) were responsible for most of the earliest prescriptions received by these patients. The regression analysis showed that age, female sex, prior RAS inhibition, enrollment in care for the past 12 months, and hospitalization were significantly associated with a lower probability of receiving SGLT2i while prior SGLT2i use, current RAS inhibition, diabetes, private insurance, and number of primary care visits were significantly associated with a higher probability of receiving SGLT2i.

Despite clinical evidence of benefit, overall SGLT2i utilization in HF patients receiving primary care was low. Further understanding of this gap is needed to increase SGLT2i prescribing among HF patients in primary care. THE DANISH EFFECT: THE PRACTICE OF ICD IMPLANTATION FOR PRIMARY PREVENTION IN PATIENTS WITH NONISCHEMIC CARDIOMYOPATHY Ashley Wong1; Zahra Ukani2; Benjamin L. Taber4; Alejandro Velasquez4; Alayna Gallagher1; Aditya Maddali1; Marco Mercader3; Jay Yang5. 1Internal Medicine, The George Washington University Department of Medicine, Washington, DC; 2Internal Medicine, The George Washington University Hospital, Washington, DC; 3Cardiology, George Washington University Medical Faculty Associates, Washington, DC; 4Medicine, The George Washington University Milken Institute School of Public Health, Washington, DC; 5Radiology, Jefferson Health Einstein Healthcare Network, Philadelphia, PA. (Control ID #4271011)

The American College of Cardiology guidelines recommend implantable cardioverter-defibrillator (ICD) therapy for primary prevention of sudden cardiac death in patients with nonischemic cardiomyopathy (NICM) and reduced ejection fraction (EF < 35%) on guideline-directed medical therapy. However, these recommendations remain controversial with studies such as the DANISH trial finding no significant overall mortality benefit with single or dual chamber ICDs in NICM patients. Furthermore, recent studies suggest potential mortality benefit with cardiac resynchronization therapy with a defibrillator (CRT-D) use, also known as biventricular ICD. Our study assessed whether recent trials have influenced provider recommendations, with momentum towards CRT-D therapy over single or dual chamber ICD therapy for primary prevention of sudden cardiac death in patients with NICM.

A retrospective study compared the rates of device (ICD vs CRT-D) implantation in patients with NICM. We identified patients from 2012 to 2023 who underwent device placement for primary prevention of sudden cardiac death. Exclusion criteria included patients with ischemic cardiomyopathy, who underwent percutaneous coronary intervention coronary artery bypass grafting, or evidence of multivessel coronary artery disease. We then compared ICD implantation practices before and after 2016, when the Danish Trial was published. Chi-squared was used for statistical analysis.

From January 2012 to December 2023, 579 charts were reviewed of patients who had procedures at a mid-Atlantic academic center, and identified patients with NICM who received ICD implantation for primary prevention. Between January 2013 and December 2015, 109 patients with NICM had a device implanted for primary prevention with the average age of 58, 58% of whom were male. Of the devices placed, 78.9% were single or dual chamber ICDs. Between January 2021 and December 2023, 42 patients with NICM had a device implanted for primary prevention with the average age of 62, 57% of whom were male. Of these devices placed, 71.4% were single or dual chamber ICDs. Although not significant, we observed a trend towards CRT-D implantation over single/dual chamber ICD (p=0.33).

Since the release of the DANISH trial in 2016, studies have evaluated the role of ICDs for primary prevention in patients with NICM. Our study revealed that the practice of ICD implantation is becoming more selective towards CRT-D rather than single or dual chamber ICDs. This shift may be shaped by the findings of the DANISH trial in combination with a more conservative approach to ICD implantation, although we cannot ignore the effects of the COVID-19 pandemic on decreased elective procedures. This study highlights a shift in clinical practice based on current evidence. Understanding the evolving landscape of ICD implantation practices is vital for internists, as they often serve as the first point of contact for patients with heart failure and cardiomyopathy. THE IMPACT OF PREVENTATIVE ASPIRIN USE AND SEX AT BIRTH ON THE RECOGNITION OF MYOCARDIAL INFARCTION SYMPTOMS Lauren Rouse, Rosario Colombo. Miller School of Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4268599)

Aspirin is a common preventative medication recommended to patients with an elevated atherosclerotic cardiovascular disease risk to aid in decreasing the risk of myocardial infarction (MI). While the most common presentation of an MI includes chest pain, there can be a variety of atypical symptoms, especially in women, that should alert a patient to seek medical attention. The objectives of this study were to determine if there was increased recognition of various MI symptoms among patients taking aspirin daily for cardiovascular disease prevention and among women.

Data from the 2023 Behavioral Risk Factor Surveillance System on daily aspirin use, MI symptoms, and sex at birth were analyzed in SPSS. Individuals were asked if they recognized shortness of breath, arm pain, chest pain, lightheadedness, and jaw pain as an MI symptom. Responses from individuals taking aspirin daily for cardiovascular disease prevention and those not taking aspirin were included in the analysis. Binary logistic regression models were used to determine the associations and odds ratios between daily aspirin use or sex at birth and recognition of MI symptoms.

There was a 31.8% increase in odds of recognizing jaw pain as an MI symptom with daily aspirin use (p<0.001, 95% CI [1.153, 1.506]). There was a 23.8% and 23.4% decrease in odds of recognizing lightheadedness and shortness of breath as an MI symptom with daily aspirin use (p<0.001, 95% CI [0.670, 0.865]; p=0.002, 95% CI [0.648, 0.905]), respectively. There was not a statistically significant relationship between recognizing chest pain or arm pain as an MI symptom and daily aspirin use (p=0.130, 95% CI [0.665, 1.054]; p=0.089, 95% CI [0.975, 1.421]), respectively. There was a 159% and 75.3% increase in odds of women recognizing jaw pain and arm pain as an MI symptom (p<0.001, 95% CI [2.108, 3.181]; p<0.001, 95% CI [1.322, 2.324]), respectively. There was not a statistically significant relationship between sex at birth and recognition of chest pain, lightheadedness, or shortness of breath as an MI symptom (p=0.161, 95% CI [0.905, 1.826]; p=0.108, 95% CI [0.964, 1.449]; p=0.193, 95% CI [0.918, 1.534]), respectively.

Daily aspirin use was not associated with an increased understanding of various MI presentations, other than an increased odds of recognizing jaw pain as a symptom, despite taking aspirin to decrease MI risk. Women had increased odds of recognizing arm and jaw pain but no significant difference in odds of recognizing lightheadedness or shortness of breath as MI symptoms, despite women experiencing more atypical MI symptoms. Increased patient counseling of MI presentations, especially among individuals at increased risk for an MI and among women, can help reduce the time it takes to recognize symptoms and seek medical attention to help improve outcomes. THE MAGIC OF 'EVER TOLD': UNVEILING FATTY LIVER RISK Akif Altinbas1; Avishag Ashkenazi2; Lucas Biran3; Wynee Lou4; Varalakshmi Niranjan5. 1Internal Medicine, UConn Health, Farmington, CT; 2School of Medicine, University of Connecticut, Storrs, CT; 3Medicine, University of Connecticut School of Medicine, Farmington, CT; 4Internal Medicine, University of Connecticut School of Medicine, Farmington, CT; 5Medicine, University of Connecticut, West Hartford , CT. (Control ID #4273212)

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects around one-third of the U.S. population and significantly increases cardiovascular and liver-related mortality. Early detection is vital, but current screening methods are resource-intensive, limiting access in underserved areas. This study explores the use of self-reported cardiometabolic conditions to identify individuals at risk for steatosis.

We conducted a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) 2017–2018 cycle, excluding individuals younger than 18 years old, or with incomplete liver elastography, a history of pregnancy, cancer, substance or steroid abuse, and secondary liver disease causes. Of 2,516 eligible participants, 1,010 were excluded for alcohol consumption exceeding MASLD thresholds, leaving a final sample of 1,503. Hepatic steatosis was defined by a controlled attenuation parameter (CAP) score ≥248 dB/m. Self-reported cardiometabolic risk factors were assessed through NHANES "ever been told" variables for conditions like hypertension, diabetes (DM), and heart disease. Descriptive statistics and logistic regression were used to explore the associations between these conditions and steatosis.

Of the 1,503 participants, 56.5% were male, with a mean age of 39.8 ± 12.7 years. Hepatic steatosis was found in 54% of the cohort, and those with steatosis were older and had a higher BMI (p < 0.001). Self-reported diagnoses of DM, prediabetes, gout, and cardiovascular diseases (CAD and CHF) were significantly associated with hepatic steatosis (p < 0.05), while no significant associations were found with hypertension or stroke. Steatosis prevalence increased with higher BMI categories.

Our results highlight the value of using patient-reported diagnoses to identify hepatic steatosis risk, especially in resource-limited primary care settings. Self-reported diagnoses of prediabetes and DM are strong predictors for steatosis and could supplement traditional screening methods. A history of prediabetes or DM significantly increases the likelihood of hepatic steatosis, with MASLD risk doubling in those with DM (Cusi K). Our findings emphasize the role of BMI in risk stratification, with prevalence rising from 8.1% in those with BMI <25 to 78.6% in those with BMI ≥40, underscoring the need for targeted screening in obese patients. Gout was identified as a significant risk factor (Schlesinger N), as well as CAD and CHF. Future studies should further explore these relationships with more comprehensive data. In conclusion, recall-based metrics can enhance MASLD screening, especially in resource-limited settings, improving early detection and patient outcomes. Prospective studies should validate the reliability of self-reported data and its integration into screening frameworks. UNDERSTANDING HOW PATIENTS PREPARE FOR PRIMARY CARE CLINIC VISITS: AN EXPLORATORY QUALITATIVE STUDY Jessica J. Zhang1,2; Gery W. Ryan3; Anne Walling1,4; Karen Grimley5,6; Joann G. Elmore1,2. 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 David Geffen School of Medicine, Los Angeles, CA; 3Department of Health System Sciences, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA; 4VA Greater Los Angeles Healthcare System, Los Angeles, CA; 5UCLA Health, Los Angeles, CA; 6UCLA School of Nursing, Los Angeles, CA. (Control ID #4272092)

With ~400 million primary care clinic visits annually in the United States, engaging patients in pre-visit planning is a critical opportunity to improve patient care, patient experience, and clinic efficiency given time-limited visits. While national organizations recommend clinical teams implement eight steps of pre-visit planning, there is surprisingly limited understanding of what patients actually do to prepare. This study aims to address this gap by conducting semi-structured interviews to explore how patients prepare for primary care clinic visits.

This is an exploratory qualitative study of ~30-minute interviews with adult patients who recently attended an in-person primary care clinic visit (eg, wellness, follow-up, or urgent). Using a convenience sampling approach in the clinic waiting and checkout areas, we are recruiting English- and Spanish-preferring patients from two internal medicine clinics at an academic health center and an affiliated community health center to include a range of patient characteristics and insurance types that reflects the breadth of primary care. Interviews are conducted in-person or via phone as soon as possible within one week after the visit based on patient preference. Using a semi-structured framework, we invite patients to describe how they prepared, if at all, for their recent clinic visit. We explore preparation before the visit including thoughts, emotions, actions, and context. We inquire about general clinic experience (eg, How does this compare to prior visits?), experience with clinic pre-visit planning recommendations, and sociodemographic factors. Using a multi-step iterative thematic analysis process we will recruit patients until thematic saturation is reached (ie, anticipate ~20-30). Using a deductive approach facilitated by reflexive memo writing by the interviewer and reviewing the transcripts as a team, we will create an initial codebook of potential themes. Then, using an inductive approach, we will code transcripts to identify themes and subthemes. We will highlight illustrative quotes for each theme and subtheme.

We’ve conducted eight interviews in English and through reflexive memo writing and reviewing the transcripts identified early hunches about potential themes including 1) the variation in patient goals for primary care clinic visits (eg, check-in on chronic conditions, diagnosis, task completion), 2) how preparation (ie, physical, cognitive, emotional) depends on goals, and 3) contextual factors such as prior healthcare experiences and the patient-clinician relationship on preparation. We anticipate completing all interviews and identifying themes, subthemes, and illustrative quotes by the national meeting.

Gaining a better understanding of how patients prepare for clinic visits may help health systems to engage with patients to support and develop more person-centered pre-visit planning processes and improve quality of care. UNDERSTANDING THE LACK OF AWARENESS OF HEPATIC STEATOSIS: PREVALENCE AND ASSOCIATED RISK FACTORS AMONG U.S. ADULTS Aayush Visaria1; Sarah Abdel-Meguid2. 1Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; 2Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. (Control ID #4272549)

Hepatic steatosis is increasing in prevalence, alongside rises in obesity and insulin resistance. Despite this increase, there is still a lack of diagnosis and awareness of the condition. Contemporary national survey data and real-time online search data provide us the opportunity to understand the prevalence of disease and risk factors driving lack of awareness.

In this cross-sectional, nationally representative analysis of the 2021-2023 U.S. National Health and Nutrition Examination Survey, we included adults with Fibroscans. We excluded individuals with cirrhosis, autoimmune liver disease, or positive hepatitis serology. We first determined the national prevalence of hepatic steatosis, as defined by a Fibroscan-based Controlled Attenuation Parameter (CAP) > 230 dB/m. Awareness was defined as a self-reported history of hepatic steatosis. Amongst participants with Fibroscan-based hepatic steatosis, we identified demographic, sociobehavioral, clinical, and healthcare utilization factors associated with lack of awareness using multivariable logistic regression, accounting for the complex survey design to achieve nationally representative estimates. Finally, we used U.S. search data from Google Trends 2021-2024 to estimate the increase in searches for hepatic steatosis.

Among 4,077 adults (mean age 53, SD 18 years, 62% non-Hispanic White, 49% female), 67% (representing 106,249,668 U.S. adults) had Fibroscan-based hepatic steatosis, with 96% of them unaware. Hepatic steatosis prevalence differed significantly by age group (18-35y: 53% vs. >65y: 70%; p<0.001), gender (Male: 70% vs. Female: 64%; p=0.0030), and routine primary care (Yes: 69% vs. No: 58%; p<0.001). In addition, nearly 12% had clinically significant (F2) liver fibrosis. Among participants with hepatic steatosis, Black race (OR [95% CI]; unadjusted: 4.47 [1.23,16.23], adjusted: 4.25 [1.04, 17.37]), Lack of PCP (unadjusted: 3.66 [1.05,12.75]), adjusted: 3.47 [0.90,13.35]), A1c% (unadjusted: 0.87 [0.81,0.94]), adjusted: 1.01 [0.87,1.18]), waist circumference (unadjusted: 0.98 [0.96,0.99], adjusted: 0.98 [0.97,0.99]) were significantly associated with lack of awareness. Accordingly, while Google searches for Hepatic Steatosis or related terms increased significantly by 76% from 2021 to 2024, questions most commonly searched included, “what is fatty liver”, “fatty liver symptoms”, “fatty liver causes”.

Nearly 2 in 3 U.S. adults have hepatic steatosis. The majority of adults remain unaware, with race, no routine primary care, and better metabolic health seemingly driving risk factors. The increased public interest in hepatic steatosis provides a ripe opportunity for providers to counsel patients on common queries and undergo screening if indicated. Further efforts are necessary to address racial disparities and improve use of primary care. UNDERSTANDING THE PERCEPTION OF CVD RISK AMONG BLACK YOUNG ADULT PARENTS Amrik S. Khalsa1,4; Carson Richardson9,10; Sara Conroy3,2; Alec Lohiser4; Amanda Draeger4; Carla K. Miller5; Kyung E. Rhee6; HyunYi Cho7,8. 1Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, OH; 2Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH; 3Center for Perinatal Research, Nationwide Children's Hospital, Columbus, OH; 4Center for Child Health Equity and Outcomes Research, Nationwide Children's Hospital, Columbus, OH; 5Department of Applied Health Science, School of Public Health, Indiana University Bloomington, Bloomington, IN; 6Department of Pediatrics, University of California San Diego, La Jolla, CA; 7School of Communication, The Ohio State University College of Arts and Sciences, Columbus, OH; 8Division of Health Behavior and Health Promotion, The Ohio State University College of Public Health, Columbus, OH; 9Center for Biostatistics,, The Ohio State University, Columbus, OH; 10Biostatistics Resource at Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH. (Control ID #4272828)

Young adult Black parents often have at least one cardiovascular disease (CVD) risk factor, although discussion regarding CVD risk rarely occurs in the primary care setting. The presence of a CVD risk factor in young adult Black parents increases their child's future risk of CVD as well. Prevention through lifestyle behavior change can reduce CVD risk for both parents and children but requires accurate risk perception of CVD risk. Research is needed to examine the perception of CVD risk in young adult Black parents and factors associated with this perception. The objective of this study was to determine the cognitive, behavioral, and demographic factors associated with young adult Black parents' perception of their own and their child's CVD risk.

We recruited young adult Black parents (N=230) with a school aged child who had Medicaid insurance, from a large academic medical center and its affiliated primary care clinics either at their child’s or their own clinic visit between June and December 2023. Perceived susceptibility and severity of CVD risk for both parent and child were assessed using the Adapted Risk Behavior Diagnosis Scale, which was modified to a 12-item survey to determine parents' perception of their current and longitudinal CVD risk along with their child's longitudinal CVD risk. Cognitive (e.g., knowledge, beliefs), behavioral (e.g., dietary, physical activity, sleep), and demographic (e.g., household income) factors were also assessed. Spearman correlations were used to determine the monotonic relationship between these factors and perceived susceptibility of CVD.

Most parents were female (n= 200), with a mean age of 32.0 ± 7.8 (range=24-52) years, had graduated high school (73%), were employed (64%), and had “low” health literacy scores (Newest Vital Sign mean score 2.1± 0.7). While parents had high mean scores of perceived severity of CVD risk (mean ± SD: 4.59 ± 0.55; Range 1-5), their perceived susceptibility of CVD was lower (mean ± SD: 2.58 ± 0.55; Range 1-5) despite a majority having at least one CVD risk factor (62.5%). There was a minor difference in the mean scores between parent and child perceived susceptibility (0.6) and moderate differences in the mean scores between parent susceptibility and parent self-efficacy (1.6), parent response efficacy (1.5), child self-efficacy (1.7) and child response efficacy (1.5). CVD knowledge, parent self-efficacy, parent response efficacy, specific lifestyle behaviors of the parent, and demographic variables were not highly correlated with perceived susceptibility or perceived severity of the parent.

Young adult Black parents are aware of the severity of CVD however, the perception of their current and longitudinal CVD risk was low despite their presence of risk factors. Interventions should consider effective risk communication strategies for lower health literacy populations as a starting point for behavior change counseling. UNMASKING ALLERGENS: A RETROSPECTIVE INSIGHT INTO ALLERGEN TESTING PATTERNS AND THEIR IMPACT ON ASTHMA MANAGEMENT IN OUR PRIMARY CARE CLINIC Mridula Sree Naagendran1; David Wozny1; Madura Saravanan2. 1Internal Medicine, UConn Health, Farmington, CT; 2Medicine, UConn Health, Farmington, CT. (Control ID #4272618)

Asthma affects 339 million people worldwide,imposing a significant burden on morbidity and mortality.Environmental allergens are well recognized critical triggers for exacerbations and uncontrolled asthma.Current Global Initiative for Asthma (GINA) guidelines advocate for serum inhalant IgE testing in high-risk asthma patients to provide a tailored management plan. However, the implementation of these guidelines can vary based on healthcare system constraints,access to testing,and lack of physician education and awareness leading to underutilization of primary care provider (PCP)-initiated testing [1].Our study evaluated the patterns and impact of allergen testing among asthma patients in our primary care clinic,highlighting the gaps in timely identification and intervention of allergic triggers.

We present a retrospective review of 151 asthma patients treated at a medically underserved primary care clinic.Data collected included allergen testing rates,hospitalization rates for asthma exacerbations,allergen sensitization profiles,referral patterns and treatment delays.Results were contextualized with evidence from prior studies emphasizing the utility of early inhalant allergen testing and its potential to improve asthma control [2,3].

Among 151 asthma patients,only 15 (9.93%) underwent blood inhalant allergen testing.Of the patients who underwent allergen testing,none were initiated by PCPs and sensitization rates to common allergens were as follows:dog dander (26.7%),cat dander (20%),dust mites (20%),oak pollen (13.3%), and cockroach (6.7%).Pulmonology referrals occurred in 53 (35.1%) of asthma patients with only 3 of those patients being referred to an allergist.There were 15 asthma-related hospitalizations over a period of 2 years with 3 of these hospitalizations exacerbated by seasonal allergies. Among 2 patients receiving biologics (i.e.mepolizumab), 50% reported reduced exacerbations and improved control of seasonal allergies.

This study highlights significant gaps in allergen testing and referral processes within asthma management,particularly in primary care settings. The absence of PCP-initiated allergen testing represents a critical missed opportunity for early identification and management of asthma triggers.As outlined in the GINA guidelines, prompt allergen identification could reduce exposure to known triggers and potentially prevent exacerbations.Given the stark contrast between the relatively low cost of allergen testing ($200 to $300) and the high cost of asthma-related hospitalizations (exceeding $9,000) implementing routine allergen testing in PCP offices for high-risk asthma patients could significantly improve patient outcomes and reduce healthcare costs.Physician education and awareness to integrate allergen testing into routine practice could effectively bridge gaps in care,improve patient outcomes,and reduce reliance on high-cost,specialized care. WEIGHT LOSS MEDICATION USE BY PRIMARY CARE PATIENTS IN THE MAINTAIN PRIME PRAGMATIC CLINICAL TRIAL Kayla E. Jordanova1; Maribel Cedillo2; Polina Kukhareva3; Chaorong Wu4; Jesell Zepeda2; Bernadette Kiraly1; Michael Flynn5; Kensaku Kawamoto3; Molly Conroy2. 1Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, UT; 2Division of General Internal Medicine, University of Utah Health, Salt Lake City, UT; 3Department of Biomedical Informatics, University of Utah Health, Salt Lake City, UT; 4Division of Epidemiology, University of Utah Health, Salt Lake City, UT; 5Department of Internal Medicine and Pediatrics, University of Utah Health, Salt Lake City, UT. (Control ID #4269854)

The availability of effective weight loss medications has increased in recent years. In particular, glucagon-like peptide 1 receptor agonists (GLP1-RAs) offer improved weight loss results compared to other medication classes. In our pragmatic clinical trial on a health coaching intervention, some participants utilized weight loss medications as part of their routine health care. We analyzed patient characteristics and weight outcomes associated with weight loss medication use at 6 and 12 months of participation in the MAINTAIN PRIME trial compared to baseline.

MAINTAIN PRIME is a 24-month randomized controlled trial of 268 adult patients recruited from primary care practices affiliated with an urban academic medical center between September 2021 and April 2023. Eligible participants had lost at least 5% of body weight though healthy means and had a BMI of 25 or greater prior to weight loss. Participants completed surveys on self-reported weight loss medication use at baseline, 6 months, and 12 months. Medications were manually reviewed and classified as GLP1-RA or other. Demographics, vital signs, medical comorbidities, and Patient-Reported Outcomes Measurement Information System (PROMIS) measures were collected at baseline. We analyzed change in weight loss medication use, participant characteristics, and percent weight change at follow up visits compared to baseline, using t-tests, z-tests, and chi-square tests.

An average of 71.3% of participants responded to follow up surveys (200 at 6 months, 182 at 12 months). Reported weight loss medication use during the trial did not change significantly from baseline, with 17.2% (46/268) at baseline, 17.5% at 6 months (35/200, p=>0.99) and 18.1% at 12 months (33/182, p=0.89). Participants using weight loss medications at 12 months were more likely to have a history of diabetes (p<0.01), lower self-reported vigorous activity (p=0.04), lower physical function (p=0.02), and higher fatigue (p=0.05). There was no association between medication use and participant race/ethnicity, marital status, education, blood pressure at baseline, or other select comorbidities. Of patients taking a weight loss medication, the proportion using GLP1-RAs did not change significantly, with 50.0% at baseline (23/46), 57.1% at 6 months (20/35, p=0.68) and 66.7% at 12 months (22/33, p=0.21). Weight loss medication use was associated with no significant difference in percent weight change at 6 months (-3.2% vs -1.0%, p=0.06), but greater percent weight change at 12 months (-3.6% vs 0.1%, p=0.01).

Despite increased availability of weight loss medications, their use did not increase at 12 months of our trial. However, at 12 months, medication use was associated with greater weight loss. Understanding the use and impact of medications for weight loss management can help determine how to balance medications with lifestyle interventions in research and primary care settings. WHAT STANDS OUT: UNDERSTANDING ESSENTIAL ASPECTS OF FIBROMYALGIA CARE THROUGH A QUALITATIVE STUDY OF PATIENT FEEDBACK Catherine Pressimone, Caroline Cao, Jillian Kyle, Rachel Vanderberg. Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #4272538)

Fibromyalgia affects 2-10% of Americans and is commonly seen in primary care. However, individuals with fibromyalgia often report feeling unheard, misunderstood, and inadequately treated. In this qualitative study, we analyzed patient feedback in a general internal medicine-based Fibromyalgia Clinic regarding important patient-identified aspects of care.

Data was gathered from a large academic medical center Fibromyalgia Clinic created as a collaboration between the Divisions of Rheumatology and General Internal Medicine. Patients were referred to the Fibromyalgia Clinic after rheumatology ruled out autoimmune disease. Fibromyalgia Clinic internists then confirmed a fibromyalgia diagnosis, identified pain triggers, provided empathetic listening and education, and engaged with embedded pharmacists to create tailored pharmacologic and non-pharmacologic health treatment plans. After completing at least two visits, patients were asked to complete a survey in writing or verbally over the phone inquiring about general perceptions of the clinic. Data was transcribed into NVivo. Thematic analysis and constant comparative methods were used to analyze the data. Two internists individually coded the text and iteratively reviewed, discussed, and modified codes until 100% agreement was reached. Coding was used to organize the data and identify themes.

40 patients provided feedback, and 3 themes were identified: 1) the importance of creating a safe space, 2) negative prior healthcare experiences, and 3) specific features that were important to optimizing fibromyalgia care. Patients reported that validation and active listening in the Fibromyalgia Clinic were instrumental in creating a safe space. They contrasted this with prior interactions with the healthcare system that ended in feeling shamed and dismissed. Features of the clinic that patients found beneficial included: interdisciplinary providers, continuity, access to virtual appointments, individualized care plans, and education linking their symptoms with fibromyalgia.

This study highlights the need for a different approach to fibromyalgia care as current care models lead to negative experiences. Patients highlighted that listening and validation allowed them a safe space to share their symptoms and experiences. Additionally, patients identified important aspects of care including individualized treatment, education, virtual options, and knowledgeable providers. Moving forward, further exposure to and education on fibromyalgia should be incorporated into medical training to both improve provider knowledge and garner respect for a wide range of patients’ lived experiences. WILDFIRE PREPAREDNESS AMONG PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND ASTHMA Brittany Chatterton1; Brooks Kuhn2; Reshma Gupta3. 1General Internal Medicine and Bioethics, University of California Davis Department of Internal Medicine, Sacramento, CA; 2Division of Pulmonary and Critical Care, University of California Davis Department of Internal Medicine, Sacramento, CA; 3Department of Internal Medicine, University of California Health or University of California Davis Health, Morgan Hill, CA. (Control ID #4273280)

Wildfires have increased in the setting of climate change, particularly in the State of California, resulting in increased adverse health impacts. Patient with underlying lung disease – chronic obstructive pulmonary disease (COPD) and asthma – are among the highest risk to be affected by poor air quality from wildfires. To better understand the impact to our patients, we sought to understand wildfire preparedness among our patient population.

At a large west coast academic health system, primary care patients identified as having a diagnosis of COPD or asthma on our population health registry were recruited to participate in an online survey-based study. Data was analyzed with description statistics.

Of the 1,913 patients invited 169 consented to participate in the study. Participants were 69% female, 75% Caucasian, mean age 66 ± 15 years (rage 21-91), and 21% live in an area with a Healthy Places Index of 50% or less. In the proceeding 6 months prior to the survey, 38% of the patients reported needing to contact a medical professional due to worsening breathing symptoms and only 47% of participants reported having a COPD/Asthma action plan for worsening respiratory symptoms. Most (74%) were familiar with air quality index (AQI) and use one or more outlet to check the AQI. The vast majority of patients (78%) did not have an emergency “go bag” containing medications and respiratory equipment in case of need to evacuate their residence. Due to poor air quality, 22% of participants report difficulty obtaining their regularly prescribed medications and 14% report difficulty attending medical visits.

Survey data from patients in our COPD/asthma population registry provide several areas to intervene for wildfire preparedness. Interventions targeting completion of COPD/asthma act plans and instructions on creation of a “go bag” in case of emergency evacuation or inability to access medications and attending medical visits due to wildfires are actionable items to help increase wildfire preparedness among a very vulnerable population. Scientific Abstract - Career Development, Professionalism, and Wellness A NEW START FOR THE CLINICAL LEARNING ENVIRONMENT: COUNSELING A TRAINEE EXPERIENCING DISCRIMINATION Amber Whitley, Renee Heller, Barbara Porter, Richard E. Greene, Sondra Zabar, Christian Torres. Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4272907)

Discrimination toward trainees is pervasive and surveys show that it is often perpetrated by patients. Trainees are especially vulnerable to discriminatory behavior, with negative impacts on their education and wellbeing. Fellow clinicians, including faculty and advanced practice providers (APPs), play an important role in managing these issues and ensuring a safe and inclusive clinical learning environment. Clinicians who are new to an institution, however, have heterogenous training and lack experience and familiarity with local resources and policies. It is critical to share these, along with institutional values, with new clinicians.

Our medical school and internal medicine (IM) residency program has curriculum for faculty, house staff, and students on best practices for responding to discrimination by patients. We recently developed Objective Structured Clinical Exam (OSCE) cases to reinforce these skills among the same groups and targeted new clinicians as a high-priority subgroup. A previously developed simulation case was adapted and incorporated into a 3-station virtual experiential onboarding program. The case focuses on a standardized trainee (ST) who appears to be struggling on the wards/in clinic, and reveals they have experienced multiple episodes of discrimination from patients, resulting in burnout. Case objectives include addressing discrimination and its impact and providing support and a plan for follow-up. Following the 10-minute encounter, STs completed a 19-item behaviorally anchored checklist to evaluate skills as not, partly, or well done (WD), and delivered verbal feedback. Clinicians debriefed with facilitators and received an institutional guide with a framework for supporting learners and other resources, then completed a post-program evaluation.

63 new clinicians (43 MD, 20 APPS) participated in the program; data was gathered from 53 checklists. Clinicians scored highly on information gathering (70% WD) and relationship development (72% WD) but scored lower on education/counseling (49% WD) and most case-specific skills, including explicitly acknowledging incidents as discrimination (30% WD), communicating concern about the impact of discrimination (38% WD) and sharing resources for continued support (36% WD). In the post-program evaluation survey (n=42), 100% of respondents agreed that the onboarding program helped them feel more confident about supporting a colleague experiencing discrimination and improved their ability to recognize, respond, and provide resources.

This simulation experience showed the heterogeneity of skill and comfort among new clinicians when responding to discrimination against trainees. Through a targeted simulation experience coupled with debriefing and a resource guide, clinicians reported improvement in their ability to respond. As part of a required onboarding experience, this case established a safe and inclusive clinical learning environment as a high priority at our institution. ASSOCIATION OF INCOMPLETE TEAM STAFFING WITH BURNOUT, WORK INTENTIONS, AND ELECTRONIC HEALTH RECORD TIME AMONG US PHYSICIANS Lisa Rotenstein1; Purva Shah2; Tait Shanafelt4; Christine Sinsky3. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2American Medical Association, Chicago, IL; 3Professional Satisfaction, American Medical Association, Chicago, IL; 4Stanford Medicine, Stanford, CA. (Control ID #4272042)

On a background of COVID-19 pandemic-triggered workforce changes and high rates of burnout across the US healthcare workforce, inadequate healthcare staffing has become increasingly common. We sought to characterize the prevalence of incomplete staffing, and how incomplete team staffing is associated with burnout, work intentions, and EHR use patterns among physicians nationwide.

This was a cross-sectional analysis of physicians who responded to the following question on their organization’s 2023 dissemination of the American Medical Association Organizational Biopsy survey: “What percent of time do you work with less than your fully staffed team?” We descriptively characterized respondents’ demographics, answers to the staffing question, and answers to questions regarding burnout, intent to reduce hours devoted to clinical care, intent to leave the job, and time spent on the EHR outside of scheduled patient contact hours. We then built multivariable models assessing the association of incomplete team staffing >25% of the time with each of 1) burnout; 2) intent to reduce clinical hours; 3) intent to leave the job; and 4) time spent on the EHR outside of scheduled hours. Models adjusted for years in practice, gender, race/ethnicity, clinical setting, specialty grouping, and full-time vs. part-time status. Models for the EHR time were stratified by full vs. part-time status.

The sample consisted of 970 physicians (53.1% male, 64.4% who worked in the outpatient setting only, and 80.6% who worked full-time). Respondents were split between primary care specialties (32.7%), medical specialties (35.5%), surgical specialties (9.4%), and other specialties (e.g., radiology, anesthesia; 22.3%). Nearly half (47.9%) of respondents reported working with an incompletely staffed team >25% of the time (including 14.9% experiencing this >75% of the time). 47.9% endorsed symptoms of burnout, 26.4% indicated they were definitely or likely to reduce their clinical care hours, and 15.4% indicated they were definitely or likely to leave the job. About half (52.4%) reported they spent >4 hours weekly on the EHR outside of scheduled hours. In adjusted analyses, working with an incomplete team >25% of the time was associated with greater odds of burnout (OR 2.29 (95% CI: 1.68, 3.13), intent to reduce clinical hours (OR 1.58 (95% CI: 1.13, 2.21), and intent to leave the job (OR 1.65 (95% CI: 1.07, 2.53). It was additionally associated with higher levels of weekly time on the EHR outside working hours in part-time physicians (OR 2.89 (95% CI: 1.44, 5.81).

In this nationwide study, we find a substantial prevalence of incomplete staffing, and that this is associated with significantly greater odds of burnout, intent to reduce clinical hours, intent to leave the job, and among part-time physicians, greater EHR time. Our findings emphasize that adequate team staffing should be a priority for healthcare leaders seeking to retain the full clinical effort of the physician workforce. BURNOUT, WORKPLACE DRIVERS OF BURNOUT, AND TURNOVER INTENT: A PILOT MIXED METHODS STUDY OF VA PRIMARY CARE PROVIDERS AND STAFF Eric A. Apaydin1,2; Eleni Skaperdas1; Darren Lov1,3; Alison Hamilton1,4; Elizabeth M. Yano1,3; Paul Shekelle1,2. 1Center for 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; 3Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA; 4Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA. (Control ID #4236079)

Burnout is a major problem in VA primary care, affecting 30-55% of primary care providers (PCPs) and staff over the past decade. The phenomenon is primarily fueled by workplace drivers, and is linked to many negative outcomes, like turnover. The Areas of Worklife (AWS) model presents six major domains of workplace drivers of burnout: workload, control, rewards, community, fairness, and values. Understanding these drivers will facilitate our future efforts to develop interventions to reduce burnout. Our objective was to analyze the relationships among burnout, workplace drivers, and turnover intent using surveys and interviews with VA PCPs and primary care staff at five pilot sites.

We administered electronic and paper surveys to PCPs, registered nurses, nursing assistants, and medical assistants at 2 VA hospitals and 3 clinics in 2 healthcare systems. Surveys contained modules measuring burnout using the Maslach Burnout Inventory (domains: emotional exhaustion; depersonalization; reduced personal accomplishment), turnover intent, and AWS workplace drivers. Quantitative results were summarized descriptively and analyzed using bivariate models. We conducted semi-structured interviews on drivers of burnout and turnover intent with the same population to understand how quantitative findings could be explained qualitatively. Interviews were audio-recorded, transcribed verbatim, and coded using content analysis.

Burnout was reported by 38% respondents who returned the survey (n=81; 41% response rate). Respondents were 28% PCPs, 29% White, 32% aged 30-39, and 69% female. AWS domains were neutral on average (average scores of 3.03-3.63 on a scale of 1-5). Good work control was linked to lower odds (Figure 1) of emotional exhaustion (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.16-0.67) and depersonalization (OR 0.42, 95% CI 0.18-0.94). In interviews (n=41), participants connected burnout to a lack of control over their daily schedule, and work control being inhibited by specialty and non-clinical services offloading work onto primary care. Reasonable workload was also linked to lower exhaustion (OR 0.48, 95% CI 0.26-0.87) in the survey. Interviewees across roles expressed feeling overwhelmed by administrative work, leading to symptoms of burnout. Turnover intent was reported by 34% of survey respondents; interviewees that discussed turnover intent were mostly interested in other jobs in VA or government. Turnover intent was also higher among those with exhaustion (OR 6.94, 95% CI 2.46-19.57) and depersonalization (OR 8.32, 95% CI 2.16-32.00).

Unreasonable workload and poor work control may drive the high burnout and turnover intent found among PCPs and staff. Most of those with turnover intent expressed a desire to leave their clinic but stay in VA or government. We will use these findings, including those concerning administrative workload and overreliance on primary care, to develop future interventions to reduce burnout. COMPARING HAZARDOUS DRINKING AND MEDICAL ERRORS ACROSS PHYSICIAN TRAINEES, ADVANCE PRACTICE PROVIDERS AND ATTENDING PHYSICIANS Jane Liebschutz1,3; Scott D. Rothenberger1; Jon Arnold1,3; Sansea Jacobson1; Andrew J. Klein1,3; Yihao Zheng2; Jennifer Berliner3,1. 1Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 3Medicine, UPMC, Pittsburgh, PA. (Control ID #4236086)

Hazardous drinking confers personal safety risk and has been associated with self-reported medical errors among surgeons. Worldwide prevalence of hazardous drinking among attending physicians is estimated at 9-35%, with conflicting data on trainees (physician residents and fellows) and no data on advanced practice providers (APPs). We compared the rates of hazardous drinking among trainees, APPs and attendings at a large health system and examined whether hazardous drinking may impact self-reported errors differently among trainees and APPs than attendings.

We analyzed the 2020 and 2022 UPMC Physician and APP Well-Being Survey results administered to trainees, APPs and attendings at a large academic health system. The survey, administered by a national consortium on physician well-being includes validated measures in multiple domains related to physician well-being. We defined hazardous drinking as consumption of 4 (female)/5(male) or more drinks in a single day on a monthly, weekly, or daily basis in the past year. The primary outcome was self-reported medical errors that could have or did result in harm in the past year. We compared the prevalence of hazardous drinking among trainees, APPs and attendings and used mixed effects logistic regression to examine relationships between hazardous drinking and medical error. Covariates included anxiety, depression, specialty, age, gender and survey year. In interaction-based modeling, we tested whether professional status moderated the relationship between hazardous drinking and medical error.

We analyzed 11928 responses from 7673 respondents (3520 attendings, 2376 APPs, 1777 trainees), a 57% response rate. The prevalence of hazardous drinking was 8.9% for attendings, 14% for APPs, and 16.8% for trainees over the two survey rounds. Prevalence of self-reported medical error was 10.7% for attendings, 4.9% for APPs and 24% for trainees, p<0.001. Hazardous drinking was associated with self-reported medical error in unadjusted analyses, 2.0 OR (95%CI, 1.7, 2.3) and in adjusted analyses 1.52 OR (95%CI 1.3, 1.8). Moderation analyses revealed no statistically significant interaction between professional status and hazardous drinking on medical error, including when adjusting for covariates.

One in ten attendings and one in six APPs and trainees reported monthly or more frequent hazardous drinking. The increased odds of reporting medical errors among those with frequent hazardous drinking was similar between attendings, APPs and trainees, although the rates of error and drinking reporting differed among the groups. While this does not point to a causal relationship, it does alert health systems to consider screening for and counseling physicians, APPs and trainees on the risks of hazardous drinking. CURRENT PHYSICIAN DOCUMENTATION WORKFLOWS AND PERCEPTIONS ON EFFICIENCY Natalie Griffin1; Shirin Nour1; Meiyappan K. Udayappan1; Sara L. Bonnes1; Adam P. Sawatsky2; Ivana T. Croghan1. 1General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2General Internal Medicine, Mayo Clinic, Rochester, MN. (Control ID #4234052)

Increased documentation time worsens documentation burden, and is associated with physician burnout. Physicians adopt different documentation workflows to reduce burden. It is hypothesized that documenting during encounters, with the patient, reduces documentation time and thus burden. No studies examine current physician practices and perceptions on documenting during versus after encounters, or the impact on efficiency and documentation accuracy. This study aims to fill in these gaps to guide further study of optimizing documentation practices.

100 physicians were surveyed via Redcap. The survey was pilot-tested among 10 physicians in other practices, with only minor revisions. The survey consisted of 8 questions taking 5-10 minutes to complete, assessing current physician documentation preferences and perceptions of time spent with patients and completing documentation.

A total of 39 physicians completed the survey. Of those, 30 (76.9%) document solely after the encounter, while 4 (10.3%) dictate and 5 (12.8%) type during the encounter. Of those documenting after encounters, 15 (50%) noted concern for patient satisfaction as a factor in not documenting during encounters, and 9 (30%) felt their documentation more accurate. Of those documenting during encounters, 1 (11.1%) felt patients were more satisfied, 7 (77.8%) perceived greater efficiency, and 1 (11.1%) felt this documentation more accurate. However, both groups reported similar perceived time (in minutes) spent with the patient and completing documentation after the encounter.

Physicians documenting during encounters perceived improved efficiency, but most physicians avoided documenting during encounters, worrying about patient dissatisfaction. However, one prior study showed no difference in patient satisfaction if documenting in encounters, suggesting patient satisfaction is not a barrier to documenting during encounters with the goal of efficiency. Interestingly, physicians reported similar time spent with the patient and completing documentation after encounters. While further study with objective time measurement is needed, this raises the possibility of no inter-physician difference in efficiency between the two methods. The question remains whether perception of efficiency could result in perception of decreased documentation burden, requiring future study. It is also possible that documentation workflows are unique personal choices with different impacts on each physician. For some, documenting during encounters may decrease individual time spent documenting, and this would require additional study. Both groups reported perceptions of improved documentation accuracy, and more studies are needed to determine objective differences in accuracy. While documenting during encounters has potential to improve documentation burden, further studies are needed to assess objective impact on efficiency and documentation accuracy, as well as physician perceptions of documentaiton burden. EXPLORING THE RELATIONSHIP BETWEEN RESIDENCY SPECIALTY CHOICE AND PROFESSIONAL IDENTITY ESSAYS (PIES) IN MEDICAL STUDENTS Joshua Adams1; Verna Monson4; Abigail Henderson1; Lynn Buckvar-Keltz1; Adina Kalet2; Lisa Altshuler3. 1Medicine, New York University Grossman School of Medicine, New York, NY; 2Medical College of Wisconsin, Milwaukee, WI; 3Medicine, NYU Langone Health, New York, NY; 4Monson Consulting and Evaluation, Minneapolis, MN. (Control ID #4272286)

There is a growing emphasis on Professional Identity Formation (PIF) in medical schools. One measure of a learner’s stage of PIF is the Professional Identity Essay (PIE); nine open-ended prompts exploring perceptions of future medical roles and expectations. Our study examined the relationships between choice of residency specialty and PIE scores or trajectories.

Subjects were 135 medical students who completed PIEs three times during medical school as a routine part of their educational experience and consented to an IRB approved educational registry. PIE scores range from 2 to 4.5 in .5 intervals, with higher scores reflecting more advanced development. We examined PIE 3 (post-clerkship) and PIE developmental trajectories (categorized into “Increase,” “Same,” and “Decrease” trajectories based on change from first to last PIE). Residency specialties were grouped as “Cognitive”, having a high reliance of analysis (e.g. medicine, pediatrics, psychiatry), or “Procedural,” requiring more physical engagement (e.g. surgical fields).

82 learners completed PIE 3, (52 in “cognitive” residency group and 30 in “procedural”). For trajectory analysis, 75 learners were included (49 “cognitive”, 26 “procedural”). A chi square test revealed statistically significant differences in PIE 3 scores between residency groups, with a greater percentage of higher scores in the “cognitive” group (p=.03). Comparing trajectories of, "cognitive” vs. “procedural” groups: 57% cognitive vs. 35% procedural group increased, 31% vs. 58% did not change, 12% vs. 8% decreased. The chi-square test for trajectories did not reach statistical significance (p = .07).

Learners choosing “cognitive” residencies demonstrated proportionally higher scores compared to those choosing “procedural.” This suggests that learners more interested in “cognitive” fields tend to have a self-identified professional identity and “procedural” fields have a greater emphasis on team perspectives to guide their identity. Although the trajectories did not reach statistical significance, the trends observed warrant further investigation. Understanding PIE results in relation to residency choice can inform advising practices and help tailor the support medical students receive based on PIE scores and trajectories. Future research should explore PIE results beyond medical school to assess the ongoing development of professional identity throughout residency and its impact on long-term professional growth. INVESTMENT IN FACULTY DEVELOPMENT PROMOTES ENGAGEMENT, SCHOLARSHIP AND LEADERSHIP – EVALUATION OF 20 YEARS OF A JUNIOR FACULTY DEVELOPMENT PROGRAM Jennifer S. McCall-Hosenfeld, George Blackall, Lawrence Kass, Jennifer E. Nyland, Daniel A. Waschbusch. Penn State College of Medicine, Hershey, PA. (Control ID #4269803)

Investment in faculty development is crucial for academic growth and institutional success. The Junior Faculty Development Program (JFDP), initiated in 2002 at a Mid-Atlantic Academic Medical Center, exemplifies how structured initiatives can catalyze career success in academic medicine. Designed with educational theory as its foundation, the JFDP features two components: 1) weekly professional development sessions addressing a broad range of skills essential to navigating an academic health system, and 2) an individual scholarly project guided by a senior faculty mentor. Participants submit a project proposal and obtain a nomination by their chair/chief to join the program. In 2024, we conducted a comprehensive evaluation of the first 20 years of JFDP to identify key features of the JFDP and evaluate its perceived impact on faculty development.

We created, pilot-tested, and distributed two mixed-methods surveys to assess opinions across five domains: career progression, scholarship development, educator skills, retention, and engagement. The participant survey included 65 questions, and the chair/chief survey included 20. We targeted all 548 JFDP graduates from the first 20 cohorts (2004-2023) for whom email addresses were available (N=333). A separate survey was sent to current chairs/chiefs to measure the perceptions of leaders who regularly supported JFDP participation. Surveys were distributed via email, and descriptive statistics and qualitative themes were used to summarize findings.

Among the JFDP participants, 111 (33%) responded, with 40% identifying as assistant professors and 41% as associate professors; 85% were non-tenure line faculty. Most respondents agreed or strongly agreed that JFDP significantly enhanced their career progression (89%), promotion (67%), navigation skills (82%), networking (89%), scholarship development (64%), educator skills (74%), and leadership (69%). The JFDP fostered ongoing relationships including professional collaborations (39%), mentorship (24%) and friendships (46%). Thirty-three leaders who regularly interact with JFDP also participated, with 71% identifying as chiefs and 23% as department chairs. Leaders agreed or strongly agreed that JFDP was important for recruitment (71%), retention (73%), scholarly productivity (81%), engagement (84%), and leadership (74%). Qualitative findings highlighted three themes: (1) the importance of investing in the faculty, (2) the value of developing meaningful interpersonal connections, and (3) the role of JFDP as a launchpad for future success.

The JFDP’s 20-year evaluation shows the program’s critical role in fostering faculty engagement, scholarship, and leadership. Participants and senior leaders recognized its contributions to academic success, recruitment, and retention. As academic institutions innovate new models of faculty development, prioritizing engagement and connectivity will remain critical for catalyzing faculty success and institutional growth. IS FELLOWSHIP WORTH IT? A FINACIAL ANALYSIS OF FELLOWSHIP TRAINING AFTER INTERNAL MEDICINE RESIDENCY Roop S. Parlapalli1; Noora Akram3; Michael Madden2. 1Hospital Medicine, Geisinger Health, Danville, PA; 2Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA; 3Cleveland Clinic, Cleveland, OH. (Control ID #4270889)

Internal Medicine (IM) Physicians working complete a residency training, and some pursue additional fellowship of their preferred specialty of choice. Among Internal Medicine Physicians, Hospitalist practice is fastest growing job force compared to new specialists. Fellowship training duration varies depending on chosen specialty from one to three additional years after residency. We simulated the long-term financial impact of pursuing fellowships compared to hospitalists, measured in terms of Net Present Valvue (NPV) and Return on Investiment (ROI) analysis using Monte Carlo Simulation

We used data obtained from AAMC 2024 Resident Fellow Salary database and the average starting salary obtained from Society of Hospital Medicine Annual Report & Doximity 2024 Annual compensation database. To determine NPV, following assumptions are made: annual discount rate of 3%, total expected work life of 40 years with salaried positions. We have not included specialties which have one-year training duration. We have done fixed end point simulation of NPV [reflecting cumulative lifetime earnings, at the time of starting attending level job for hospitalist or specialist] and also a Return on Investiment (ROI) by continuous simulation of NPV over time in reference to hospitalist positions.

The mean NPV of the hospitalist job at the time of starting is $3,780,00 with SD of $380,000. The specialty with highest NPV after initial fellowship is Cardiology ($6,021,000 with SD of $593,000) and the specialty with least NPV after fellowship is Endocrinology ($3,033,000 with SD of #301,000). The ROI with undergoing further fellowship trainign of trainee choice ranged from approx. +$2million to -$500 thousand. The ROI is significantly higher in the following specialties compared to hospitalists: Cardiology, Gastroenterology (GI), Hematology & Oncology (Hem-Onc) and Critical Care Medicine (CCM). The remainder of the studied specialties have lower ROI compared to Hospitalists. Specialties with higher ROI compared to Hospitalists, still take 4-5 years for Cardiology and GI to cross over the Hospitalist's ROI after graduation from IM residency, likewise longer 6-7 years for CCM and Hem-Onc. Our goal was to provide monetary effects of pursuing addtional training with NPV analysis to provide an approximate estimate of average lifetime earnings. This analysis is to observe the financial impact with additional investment of time and pursuing fellowship of interest to graduating IM residents, not to differentiate overall advantages and disadvantages of doing undergoing medical training.

The Monte Carlo Simulation demonstartes that from an NPV and ROI perspective three specialties have a clear advantage: Cardiology, GI and Hem-Onc. Other specialties such as CCM are beneficial financially over the longer term while other offer no clear financial benefit. This research adds to the armamentarium of faculty providing recommendations regarding fellowship. LEADERSHIP AND GENDER DISPARITIES IN BURNOUT IN A MULTI-YEAR STUDY Andrew J. Klein1; Scott D. Rothenberger2; Jon Arnold1; Jennifer Berliner1; Yihao Zheng3; Jane Liebschutz1. 1Hear and Vascular Institute, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Medicine, University of Pittsburgh, Pittsburgh, PA; 3Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4272530)

Leadership quality has been associated with reduced rates of burnout among their physician teams. At the same time, burnout has been shown to disproportionately affect female physicians more than male. We examined whether more highly rated leaders can close gender disparities in physician burnout.

We analyzed results of the Healthcare Professional Well-being Consortium survey of physicians at a large academic health system in 2018, 2020, and 2022. 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 linear mixed effects regression models adjusted for demographics (age, years practicing, and specialty). We a priori identified additional variables as potential confounders 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 over time.

We analyzed 2576 responses (66% response rate) in 2018, 2457 responses (51%) in 2020, and 2200 responses (43%) in 2022. Approximately 40% in each year identified as female. Mean burnout score was 3.10 (SD 2.04), 2.78 (SD 1.96), and 2.89 (SD 2.00) in 2018, 2020, and 2022, respectively. The mean overall leadership quality increased between years, 2.60 (SD 1.01), 2.76 (SD 0.98), 2.82 (SD 0.96) in 2018, 2020, 2022, respectively (p<0.01). In 2018, leadership quality impacted burnout in males more than females. This differential impact was attenuated in 2020 and absent in 2022 (Figure 1).

Although leadership more greatly impacted burnout in males than females in 2018, this differential was absent by 2022. These results suggest that COVID-pandemic related changes in leadership or workplace environment may have improved gender disparities in the impact of leadership quality on burnout. MED GROUPS: ADAPTING A BOTTOM-UP RESIDENT WELLNESS SUCCESS FOR ATTENDINGS Patrick Kukulich1; Jillian Cooper1; Gretchen Colbenson2; Alan Kubey1. 1Hospital Medicine, Thomas Jefferson University, Philadelphia, PA; 2Mayo Foundation for Medical Education and Research, Rochester, MN. (Control ID #4273156)

In response to clinician burnout, residents at a major Mid-Western hospital created Resident Experience Discussion (“RED”), a resident-led form outside of formal programs to promote wellness. RED focuses on unique challenges and emotions faced during training in a casual format focused on non-judgmental discussion which prioritizes reflection rather than solution generation. RED has successfully persisted for nearly a decade and has been duplicated with similar longevity and success in another residency at a large Mid-Atlantic hospital. Attending clinicians face similar stresses with potentially more professional isolation and ever-more-complex professional and non-professional sphere demands and tensions. We sought to adapt RED to “MED” (Medicine Experience Discussion) for attendings and assess benefit.

MED was designed similar to RED groups: pre-planned topic chosen by participants, dinner at attendings home followed by discussion with the same RED ground rules. To accommodate schedule constraints, we chose a less frequent cadence, hosting at most monthly and sometimes quarterly. We first trialed MED at a Mid-Atlantic hospital in February 2022. We used the same feedback system as RED to iteratively adjust sessions to attendees’ preferences. All attendings except senior leadership were invited. After success at this institution we trialed MED groups at a large Mid-Western hospital in June 2023.

We received 51 responses across 14 MED sessions surveyed (not all sessions were surveyed). 51/51 (100%) of physicians agreed the topic was relevant to them. 50/51 (98%) responded that they would attend again (the single “no” answer was a physician moving to another state). Topics discussed in MED groups are at times similar to RED groups and are sometimes more attending specific. They continue to touch on themes outside formal curriculum and continuing medical education. Similar topics include: A Difficult Patient; When A Case Hits Close to Home; Family Expectations of 'The Doctor in the Family'; and The Patient is Suffering and I Cannot Help. MED specific topics have included: I Feel Guilty for Not Doing More; The Lonely Attending: Transitioning to Life After Residency – When All Your Friends Chose Fellowship Out of State; Medicine - What I Thought It Is and What I Have Learned It Is; But Really, I'm the Attending?! -- Leaning Into Imposter Syndrome; Review By The Faceless, Anonymous, Aggregate Mob: How to Face Teaching After That Annual June Summary PDF; HM Telomeres: How to Sustain a Hospital Medicine Career Without Reducing Time; and The Healthcare System is Broken; I am the Face of it.

MED is a success at two institutions and can be reproduced elsewhere to provide a valuable experience for our attending peers. It is a cherished venue to discuss some of the most charged and impactful aspects of physician life that may not otherwise be explored. Focusing on attending-specific topics and allowing scheduling flexibility has helped to sustain MED. PREVALENCE OF INSTITUTIONAL POLICIES AND RESOURCES TO ADDRESS STAFF TRAUMATIC STRESS IN ADULT INTENSIVE CARE UNITS: A NATIONAL SURVEY Brooke Schroeder1; Christopher Cox2; Ernestine C. Briggs3; Kimberly Johnson4; Samantha Morrison5; Maragatha Kuchibhatla5; Muhammed S. Bah6; Francisca A. Hammond6; Brittany McCluskey2; Deepshikha C. Ashana7. 1Duke University School of Medicine, Durham, NC; 2Medicine, Duke University Health System, Durham, NC; 3UCLA/Duke University National Center Child Traumatic Stress, Durham, NC; 4Medicine/Geriatrics, Duke University School of Medicine, Durham, NC; 5Department of Biostatistics & Bioinformatics, Duke University, Durham, NC; 6Population Health Sciences, Duke University, Durham, NC; 7Medicine, Duke University, Durham, NC. (Control ID #4273147)

Medical professionals in intensive care units (ICUs) experience high rates of post-traumatic stress disorder, which may also impact quality of patient care. Contributing factors include the frequency of patient death, high emotional burden of patient care, and potential for moral injury. There is a need for institutional policies and resources that address the mental health of ICU staff. Since a systematic evaluation of such policies and resources had not previously been conducted, we performed a national, cross-sectional survey of adult ICUs in the United States (US).

We iteratively adapted the National Child Traumatic Stress Network’s Trauma-Informed Organizational Assessment to query how organizations detect and mitigate staff traumatic stress. Among 2,392 hospitals that responded to the American Hospital Association’s 2020 Annual Survey and contained an adult ICU, we randomly sampled 25% (n = 613) within strata of hospital type (e.g., for-profit) and US region. Federal hospitals were sampled with 100% probability. Surveys were distributed via email to ICU clinical leaders (e.g., nurse managers) who received $40 upon survey completion. Descriptive statistics were calculated for without reweighting.

In total, 229 ICUs from 182 hospitals responded (33% response rate among hospitals still in operation). Responding ICUs were geographically diverse (Midwest: n = 42, 23%; Northeast: n = 38, 21%; South: n = 75, 41%; West n = 27, 15%) and the majority were the sole ICU at their hospital (n = 154, 85%). Most hospitals were not-for-profit (n = 128, 70%). Less than one-half of institutions reported always providing staff education on traumatic stress (n = 102, 45%) or structured peer support programs for their staff (n = 103, 45%). One-third (n = 77, 34%) of respondents indicated that their institution did not solicit staff feedback on mental health, and approximately 1 in 5 (n = 40, 18%) stated that their institution was not responsive to staff feedback. Additionally, 17% indicated that their ICU's policies did not consistently support staff physical safety and emotional well-being (n = 38), while 13% indicated that institutional policies did not effectively contribute to staff retention (n = 30) (Figure 1). For those experiencing symptoms of traumatic stress, 51% of respondents reported their institutions connect staff to mental health treatment (n = 117) or allow the use of paid time off for this care (n = 117) (Figure 1).

This national cross-sectional survey reveals that only approximately 1 in 2 US adult ICUs offer education about traumatic stress, peer support programs, or mental health resources to their staff. Approximately 1 in 6 ICU clinical leaders do not believe that their institution promotes staff safety, well-being, or retention. These data affirm the need for continued attention to ICU professionals’ mental health and structural interventions to improve the mental health of ICU professionals. THE DISCUSSION OF WELLBEING BETWEEN MENTORS AND MEDICAL TRAINEES Catherine Y. Liu1; Melanie Knoepfler2; Bryan Cao1; Anita Narkhede3; Shanu Gupta1. 1College of Medicine, University of South Florida, Tampa, FL; 2College of Medicine, University of South Florida Morsani College of Medicine, Tampa, FL; 3Morsani College of Medicine, University of South Florida, Tampa, FL. (Control ID #4270463)

Mentorship is a critical component of medical training, shaping the personal and professional development of medical students and residents. Existing literature highlights the positive effects of mentorship on career development and research productivity but offers limited insight into how mentors address trainees’ personal well-being. This study primarily aimed to evaluate potential differences in the aspects of mentorship that are emphasized by mentors of different genders. A secondary objective arose to explore how mentors of medical trainees incorporate discussions of personal well-being in their mentorship, focusing on how these conversations differ across various mentorship relationships and the background of the mentors themselves.

Semi-structured interviews were conducted with mentors of medical trainees at a medical school in the southern United States. Physicians on lists of mentors available to medical students were invited to participate. Interviews were transcribed and analyzed using qualitative thematic analysis. Two independent researchers coded the transcripts, with a third researcher resolving any discrepancies. The analysis focused on identifying key themes related to mentorship practices. The five primary themes that emerged were coaching, networking, friendship, wellbeing, and role modeling.

Sixteen physicians of 10 specialties and clinical experience spanning 4 to 35 years who mentor medical students and residents participated in interviews. Wellbeing, broadly defined to include advice on mental and physical health, was highlighted in 15 of 16 interviews. Work-life balance emerged as the most frequently discussed wellness-related topic, with all 15 mentors emphasizing its importance for long-term career satisfaction and success. Seven mentors discussed navigating personal relationships as a medical professional, including starting a family, selecting a supportive partner, and making time for children. These conversations were similarly distributed across male and female mentors. Emotional well-being, including managing perfectionism and self-doubt, was raised in six interviews, exclusively by mentors with over 15 years of clinical experience (n=9), who linked these issues to burnout prevention.

Our study highlights the consistent recognition of well-being as an essential aspect of mentorship for medical trainees. Mentors emphasized work-life balance, family life, and self-care, tailoring their advice based on personal experiences and career stages. These findings suggest that integrating wellness-focused mentorship into medical training could help mitigate burnout and support sustainable medical careers. Future research should explore how structured mentorship programs can best incorporate well-being discussions and whether targeted mentorship pairings impact career longevity or subjective personal satisfaction. THE EFFECTIVENESS OF THE ALLIED HEALTH INTERNSHIP: AN EARLY CAREER PROGRAM TO ADDRESS WORKFORCE SHORTAGE AND ENHANCE DIVERSITY IN THE ALLIED HEALTH PROFESSIONS Gloria E. Moon, Diana L. Ambrosio, David Rincon, Florence Lyn C. Bansag, Carol Mangione. Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4273154)

Patients treated by culturally and linguistically similar providers often experience better health outcomes. While many universities have programs to recruit underrepresented minority (URM) students into medical school, there are few that recruit URM students into the allied health professions, where careers critical for care delivery are less visible. In response to lack of diversity and a statewide allied health workforce shortage, a public university partnered with their health system and private donors to create opportunities and reduce disparities by designing and implementing a pathway program for URM high school students. The program provides a real-world introduction to careers in allied health accompanied by intensive life skills support and scholarships for needed training.

The program recruits from youth-serving community organizations and high schools in URM neighborhoods. Participants apply using an online form, followed by an on-campus interview. Recommendations over GPA carry more weight in the selection process. Participants must receive federal aid (e.g. reduced lunch) and demonstrate an interest in health care careers. Five days of in-residence shadowing and activities expose students to 100 professions in 20 departments, followed by monthly career development workshops and case management during the following year. Scholarships for tuition, referrals to social services, and peer support are some strengths-based approaches that model a clinical wraparound.

From 2017-2024, there have been 321 participants, 96% who identify as non-white and 93% as first generation. To date, 80% of participants are pursuing allied health, by training or employment. In 2024, 98% of participants reporting an increase in self-efficacy towards pursuing health careers after participation, 95% strongly-agree/agree that the program developed meaningful peer relationships, and 92% found the program to be a positive career building experience. Since 2017, the program has awarded 81 needs-based scholarships which participants use towards training in EMS, Phlebotomy, Medical Assistant, and CNA fields. The program’s success hinges on tailored interventions by former participants. An assessment of barriers to entry in healthcare revealed financial barriers as most significant, followed by competitive environment, and fear of inadequacy. Most pathway programs have an end date and lack continuity, whereas our longitudinal wraparound model uses an individualized needs driven framework to decrease risk factors and increase protective factors to promote empowerment over time.

A tailored program design that prioritizes protective factors offers an innovative approach for workforce development. Early exposure to allied health careers will build agency in URM populations to fill critical workforce shortages. We anticipate a ripple effect as URM students occupy these fields, inspiring representation in the allied health workforce that best reflects the populations served. THE IMPACT OF EMOTIONAL INTELLIGENCE ON PHYSICIAN SATISFACTION, ANXIETY, STRESS, AND BURNOUT: A META-ANALYSIS Meher Garg1,2; Medha Venigalla5; Shriya Prakash3; Sudeep Sharma4. 1Southern Illinois University School of Medicine, Springfield, IL; 2Springfield School District 186, Springfield, IL; 3Conestoga High School, Berwyn, PA; 4University of Illinois Springfield, Springfield, IL; 5The University of Chicago Medicine, Chicago, IL. (Control ID #4244485)

Emotional intelligence (EI) is the ability to recognize, understand, and manage one's own emotions and the emotions of others. EI is crucial because it enhances personal well-being and improves physician-patient relationships, decision-making, and conflict resolution. It is key to both personal success and professional effectiveness, as well as to physician satisfaction. This meta-analysis aims to evaluate the association between EI and burnout, stress, and anxiety in healthcare providers and medical trainees.

We conducted a meta-analysis of studies published between 2001 and 2024 that examined the relationship between EI and burnout, stress, or anxiety in healthcare providers. A systematic search was performed using the terms ‘Emotional intelligence burnout,’ ‘Emotional intelligence anxiety,’ and ‘Emotional intelligence stress’ in the PubMed database. Studies published in English with quantitative analyses focusing on healthcare providers or trainees were included. We excluded non-quantitative studies, review articles, and irrelevant studies. The analysis assessed whether theoretical and methodological moderators influenced effect size heterogeneity. We computed effect sizes and conducted the moderator analyses using Version 3 of the Comprehensive Meta-Analysis software, based on the Hedges and Olkin (1985) approach. Zero-order correlations, t-tests, and F ratios were conducted based on the reported means, standard deviations, raw proportions, and other relevant statistics.

Our initial search yielded 3,217 articles. After applying the inclusion criteria related to healthcare providers, 24 relevant studies with 6501 participants, including 2,841 males and 3,469 females were identified. We examined the effect sizes based on correlations between EI and our dependent variables (anxiety, burnout, and stress). The results revealed a significant negative effect size for EI, showing that greater EI of healthcare providers and trainees is associated with less anxiety (r = -0.23, k = 6), burnout (r = -0.39, k = 24), and stress (r = -0.29, k = 22). The 95% confidence intervals (CIs) around the mean values excluded zero for anxiety (-0.31, -0.14) and burnout (-0.66, -0.02), but not for stress (-0.59, 0.09). No gender-based differences were observed. High heterogeneity in all three effects indicates significant variance across findings, warranting further investigation into theoretical and/or methodological moderators.

The findings indicate that higher levels of EI correlate with lower levels of burnout, stress, and anxiety, as well as higher professional satisfaction among healthcare providers. The results of this meta-analysis further suggest the importance of measuring the EI of healthcare providers. Developing continuing medical education programs to improve EI and incorporating strategies to enhance EI among physicians and medical trainees may be a critical approach to mitigating physician burnout and promoting mental health and professional satisfaction. THE ROLE OF GENDER IN MENTORSHIP OF MEDICAL TRAINEES Melanie Knoepfler, Catherine Y. Liu, Anita Narkhede, Bryan Cao, Shanu Gupta. Morsani College of Medicine, University of South Florida, Tampa, FL. (Control ID #4271610)

Mentorship is a critical component of medical training. Prior research has demonstrated that female mentees have a greater preference for gender-concordant mentoring for advice on work-life balance, starting families, and other personal advice. However, it remains unclear whether this preference is due to differences in the mentorship provided by male and female mentors. This study aims to explore mentors’ perspectives on mentorship relationships and potential differences in the aspects of mentorship emphasized by those of different genders.

108 physicians in formal mentorship programs or on lists of research or specialty mentors available to students at a medical school in the southern United States were invited to participate in semi-structured interviews. Saturation was reached after 14 interviews when no new themes were identified with 2 additional interviews conducted to confirm. Interview transcripts were thematically analyzed with deductive and inductive coding by two researchers with a third resolving disagreements. Themes uncovered were compared by participant gender.

16 mentors, 8 men and 8 women, participated. Five main themes were identified: coaching, networking, friendship, role modeling, and well-being. Coaching, defined as giving academic direction or career advice, was the predominant theme for both men (40.16% of codes) and women (41.98% of codes). Male and female mentors emphasized each of the main themes at similar rates. Additionally, the majority of both groups indicated that sharing values with their mentees, rather than gender, race, or life experiences, was most important to a successful pairing. Although most female mentors did not think gender-concordance was important to a successful mentorship relationship, the majority still expressed a preference for themselves or their female mentees for gender-concordant pairings. Gender bias in medicine, compensation, maternity leave, childcare, and work-life balance were issues that they discussed specifically with their female mentees. Male mentors did not express any preference in mentoring male or female students or discuss any preference that they perceived from their mentees.

Our study demonstrates that male and female mentors emphasize the same themes of mentorship at similar rates to medical trainees and highlights the importance of sharing values in mentorship relationships. These findings suggest that preferences for gender-concordant mentorship among female mentors and mentees is likely due to additional factors. Future research should explore the reasons that mentors and mentees choose their pairings and potential biases that play a role. Limitations of this study include possible participant self-selection bias for those with interest in gender in mentorship. Scientific Abstract - Clinical Informatics, Artificial Intelligence, and Health Information Technology ARTIFICIAL INTELLIGENCE CAPABILITY TO TREAT INFECTIOUS AGENTS COMPARED TO WHO GUIDELINES. Rami Dali1; MOHAMMAD AL-HADIDI2; Zeeshan Javed3,1; Tina Izad1; Deema Abdullah4. 1Medical School, Oakland University William Beaumont School of Medicine, Rochester, MI; 2Radiology, Wayne State University School of Medicine, Detroit, MI; 3Medical Student, Oakland University William Beaumont School of Medicine, Rochester, MI; 4Pre-med Student, Wayne State University, Detroit, MI. (Control ID #4273090)

AI, such as ChatGPT, has shaped the field of medicine through both the delivery of care and knowledge. While ChatGPT, uses deep learning and extensive pre-training on textual data to perform tasks, its true capabilities are still unknown, leading this research to compare its effectiveness in medical interventions against WHO guidelines for five infectious agents, evaluating accuracy, complexity, and applicability.

Five infectious agents were identified based on factors including commonality, defined pharmacological treatment, and a wide range of pharmacological classes. The combination of these factors yielded the analysis of Trichomonas vaginalis, Candida albicans, Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum. Guidelines were pulled from WHO based on their global use and open access to BIG REC’s database. The study utilized a categorical match analysis to compare the recommendations from ChatGPT against those from WHO. Using three subsectors of score, each recommendation obtains a set value of one of the following: 1 for an exact match in drug, dose, and treatment; 0.5 for partial matches with correct secondary treatments or varied dosages; and 0 for irrelevant matches. Scores were then added and converted to a percentage to quantify AI’s accuracy.

The researcher noted ChatGPT’s accuracy to be similar to that of WHO guidelines, obtaining an overall 80% match. Notably, exact matches included Chlamydia trachomatis, Treponema pallidum, and Candida albicans. Contrary to this, Trichomonas vaginalis and Neisseria gonorrhoeae received a partial match. While the correct drug class was recommended for T. Vaginalis, it differed in first-line treatment but accurately provided secondary treatments and pregnancy considerations. For Neisseria gonorrhoeae, ChatGPT correctly identified the first-line drug but diverged in dosing from WHO, considering patient weight—a factor not in WHO recommendations. Finally of note, ChatGPT provides the correct first two line options for Chlamydia trachomatis but proposes levofloxacin as a third-line treatment, despite WHO advocating erythromycin, ofloxacin, or tetracycline.

Although ChatGPT’s 80% match highlights its potential utility within medicine, issues like partial matches and dosing inaccuracies still persist, exemplifying its limitations. Given AI’s reliance on training data and lack of access to real-time data, updates to guidelines might not be reflected. Ultimately, while AI tools like ChatGPT can offer valuable insights into treatment based on patient presentations, they must be used as complementary tools rather than replacements for clinical judgment. DEMYSTIFYING LARGE LANGUAGE MODELS FOR ABSTRACT SCREENING FOR SYSTEMATIC REVIEWS Shanshan Lin1; Ravi Gupta2; Renee f. Wilson3; Michael J. DiStefano4; Halima Amjad1; Hyun Yi (Jacqualine) Woo7; Emily Mao5; Emmanuel F. Drabo6; Jodi B. Segal2. 1School of Medicine, Johns Hopkins University, Baltimore, MD; 2Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; 3HPM, Johns Hopkins University, Baltimore, MD; 4Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Denver, CO; 5Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD; 6Health Policy and Management, Johns Hopkins University, Baltimore, MD; 7Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4273126)

Artificial intelligence-powered platforms and large language models (LLMs) can streamline systematic reviews by automating abstract screening at low cost. To demonstrate their potential, we used ChatGPT in an ongoing systematic review on patient preferences for dementia interventions (PROSPERO #CRD42024601055). We aimed to evaluate the performance of different prompting strategies.

We prepared a dataset of 979 abstracts that were previously screened and adjudicated by two independent reviewers. From these, we randomly selected 150 excluded and 50 included abstracts to test the performance of different prompting strategies for abstract identification. We employed a zero-shot learning prompting technique wherein the LLM model (GPT-4o-mini) was not pre-trained on the task but relied solely on instructions provided within the prompt. We developed 3 prompts, ordered by increased complexity. These included a combination of the following: the screening goal, detailed inclusion and exclusion criteria, and additional instructions to guide the output. We iteratively refined the final prompt (Prompt 4) to maximize the sensitivity based on output stating reasons for incorrect abstract exclusion. We then ran each prompt five times for cross validation. We applied the most sensitive prompt to our full set of screened abstracts, and evaluated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and Matthew’s correlation coefficient (MCC), an overall measure of how well the classification aligns with human decisions.

Across all prompts, Prompt 1, which included the screening goal, inclusion criteria, and exclusion criteria, without additional instructions, had the highest specificity (0.94) and PPV (0.68) when setting the threshold to 1.0, meaning only including an abstract if it is included in all five screening iterations. Prompt 2, which included instructions around the screening goal, inclusion criteria, with no exclusion criteria, and instructions to preferentially include uncertain articles, had a sensitivity (0.56) and specificity (0.82) at threshold 1.0. Prompt 3, which included all components, had the highest MCC with a 1:5 threshold for abstract inclusion, resulting in a sensitivity of 0.81 and specificity of 0.71. Prompt 4, which refined based on Prompt 3, had the highest sensitivity (0.92) and included the highest number of abstracts (116) at a 1:5 threshold. When Prompt 4 was applied to the full set of abstracts, the sensitivity ranged from 0.74 to 0.86 and the specificity from 0.55 to 0.74, resulting in 491 abstracts (50%) included.

LLM has utility for abstract screening with a well-crafted prompting strategy that includes the comprehensive inclusion and exclusion criteria needed for qualitative studies. Therefore, if we apply the most sensitive prompt to the entire dataset, which includes more than 8000 abstracts, we could reduce our abstract screening workload by 50% for $10. DEVELOPMENT OF THE SHORT HOSPITALIZATION ADMISSION PREDICTOR (SHAP) MACHINE LEARNING MODEL ACROSS TWO HOSPITALS Richard K. Leuchter1,2; Valiollah Salari3; Eilon Gabel3. 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; 3Department of Anesthesiology & Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4269925)

An estimated 10-20% of hospital admissions could be cared for in an ambulatory setting, but accurately predicting which patients can be safely discharged from the emergency department (ED) at the time of admission is challenging. Hospital short stays are a surrogate for low-acuity admissions, with shorter length of stays (LOS) correlating with avoidable hospitalizations that could be managed in clinics.

Using only data available at the time of ED admission orders, we developed machine learning (ML) models to predict which ED admissions would have a LOS under either 48 or 72 hours. The most notable advancement in these ML models was the development of a target encoding protocol to convert categorical ICD-10 codes attributed to a patient’s problem list into numeric representations that directly reflected their probabilistic contribution to LOS. This mitigated issues such as sparsity, imbalance, and high dimensionality, which are common in healthcare datasets with many categorical variables. The prediction models were trained using 2 ML algorithms, (XGBoost and Random Forest) and compared to logistic regression, with the training and test set split in a 7:3 ratio. Patient were excluded if their primary admitting diagnosis was not suitable for a general internal medicine service (e.g., respiratory arrest, hemothorax). Model performance was assessed based on area under the receiver operator curve. A Shapley Additive Explanations analysis depicted relative feature importance.

The final sample contained 13,501 patients who were admitted to one of two academic hospitals between 03/17/21-08/22/24. The Random Forest models were the highest performing at predicting LOS under 48 hours (AUC=0.92; 95% CI 0.91-0.93) and under 72 hours (AUC=0.97; 95% CI 0.96-0.98). Other model performance, including logistic regression, are depicted in the Figure. The most important features contributing to the models were target encoded ICD-10 codes attributed to a patient’s problem list, cumulative number of ED admissions and hospital bed-days utilized in the prior 12 months, BMI, age, time of day, zip code, payor type, and primary language.

These ML models were able to predict hospital short stays lasting under 48 and 72 hours with an exceptionally high degree of accuracy, and substantially outperformed historical models designed to predict length of stay. Given that these models used only data available to providers at the time of ED admission, they could be used in the future to identify avoidable hospitalizations in real-time and have an enormous impact on operational efficiency and hospital avoidance initiatives. DIAGNOSIS AID: DEVELOPMENT OF AN ARTIFICIAL INTELLIGENCE-BASED DIAGNOSTIC PERFORMANCE FEEDBACK SYSTEM FOR INTERNAL MEDICINE RESIDENTS Verity Schaye1; Daniel Sartori1; Lexi Signoriello1; Kiran Malhotra1; Ilan Reinstein1; Benedict Guzman2; Jesse Burk-Rafel1. 1New York University Grossman School of Medicine, New York, NY; 2MCIT, New York University Grossman School of Medicine, New York, NY. (Control ID #4238523)

Learning to diagnose a patient is an essential skill acquired during medical training. However, diagnostic errors remain a significant problem. Implementation of feedback on diagnostic performance remains challenging. The use of artificial intelligence (AI) can help overcome barriers. Here, we describe the development of an AI-based diagnostic performance feedback system for internal medicine residents.

We are focusing on diseases that contribute most to diagnostic errors, starting with venous thromboembolism (VTE). We extracted a retrospective dataset of resident admissions from January-December 2023 (N=10,346 admissions). We aimed to identify cases of missed diagnostic opportunities (MDOs) using generative AI (GAI), Llama 3.1-70b, to detect discordance between the differential documented in admission notes and confirmed diagnosis as determined by GAI identifying VTE in relevant radiology reports (CTA, doppler, ventilation/perfusion scan, CT/MR venogram) OR ICD-10 final diagnosis. We used chain-of thought prompt engineering to develop prompts that answered whether: 1) VTE was a diagnostic consideration in admission notes and 2) a diagnosis of VTE was confirmed in radiology reports. We ran the final prompts on a prospective validation set from January-December 2024 (N=332 notes and N=1522 imaging reports across the 5 types) and calculated accuracy, sensitivity, and specificity as compared to human review. Finally, we ran the prompts on the retrospective dataset to identify potential cases of MDOs where VTE was not considered on admission but was the final diagnosis. Two hospitalists reviewed the cases using a validated tool to confirm cases of MDOs. Discrepancies were adjudicated.

The note prompt had an accuracy of 98%, sensitivity of 98%, and specificity of 97%. Across imaging types the accuracy ranged from 97-99.7%, sensitivity 94-99.3%, and specificity 98-100%. In the retrospective dataset, 2,240 of admission notes considered the diagnosis of VTE, 343 of admissions were VTE by imaging or ICD-10 alone, 63 cases were potential MDOs. Of the 63 cases, 17 were confirmed MDOs, 24 were in-hospital complications (23 of which had a time from admission to imaging of >7 days), 22 cases were false positive MDOs for varying reasons: false positive imaging prompts, incidental findings of VTE, and potential documentation issues.

We report high performance of a GAI strategy to identify diagnostic consideration of VTE in admission notes and confirm diagnoses in imaging reports. Our next steps are to optimize the identification of MDOs which is more complex than discordance between admission consideration and final diagnosis of VTE. An initial step will be implementing a time to imaging cutoff of < 7 days to eliminate in hospital complications. We anticipate that the development of the GAI strategy described here will help overcome barriers to implementing a robust diagnostic performance feedback system enabling automated feedback that is timely and actionable. EVALUATING AI-ECG AGAINST BNP AND NT-PROBNP FOR MORE ACCURATE DETECTION OF REDUCED LVEF Nihit Goli, Lars R. Hegstrom, Heather M. Alger, Wui Ip, Samir Awasthi. Clinical Science, Anumana, Wilmington, MA. (Control ID #4272863)

Accurate detection of Left Ventricular Ejection Fraction (LVEF) abnormalities is crucial for the diagnosis and management of heart failure. Biomarkers such as the Brain Natriuretic Peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are well-established tools for assessing cardiac function. However, their diagnostic accuracy varies from case to case with factors such as age, obesity, renal dysfunction, and coexisting cardiovascular diseases. In this context, the emergence of artificial intelligence (AI) -enhanced electrocardiograms (ECG-AI) presents a noninvasive, rapid innovation in cardiac diagnostics. ECG-AI, being noninvasive, ensures patient comfort and can detect LVEF abnormalities without requiring invasive blood draws. Limited research directly compares BNP/NT-proBNP and ECG-AI performance head to head within a narrow time window.

This retrospective cohort included patients with ≥1 BNP or NT-proBNP measurement and an ECG within 180 days of their first TTE from a large, multi-state health network. The validated ECG-AI algorithm was applied to ECG data to predict LVEF. The AUC, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated and compared to measurements derived from TTE, which is considered the gold standard. Reduced LVEF was defined as <40%.

The ECG-AI cohort included 148,324 patients, of which 51.5% male. The BNP cohort consisted of 9509 patients, and the NT-proBNP consisted of 9497 patients with similar demographics to the ECG-AI cohort. The ECG-AI model achieved an AUC of 0.942 in detecting reduced LVEF within its full cohort, demonstrating a sensitivity of 0.867 and specificity of 0.878 .When applied to BNP and NT-proBNP subcohorts, ECG-AI maintained high AUCs (0.916 and 0.925). In the BNP subcohort, ECG-AI showed a sensitivity of 0.893 and specificity of 0.775, outperforming BNP’s sensitivity of 0.565 and specificity of 0.839 (AUC 0.788). Similarly, in the NT-proBNP subcohort, ECG-AI demonstrated a sensitivity of 0.906 and specificity of 0.797, surpassing NT-proBNP’s sensitivity of 0.640 and specificity of 0.766 (AUC 0.781). A kernel density estimation (KDE) plot compared BNP/NT-proBNP/ECG-AI thresholds against EF values, categorizing results into true and false positives and negatives.

The use of ECG-AI demonstrated superior performance in detecting LVEF compared to BNP/NT-proBNP, suggesting complementary utility. This study demonstrates that ECG-AI achieves diagnostic accuracy comparable to BNP and NT-proBNP for detecting reduced LVEF. Moreover, ECG-AI is noninvasive, widely accessible, and affordable, making it a cost-effective option for cardiac diagnostics. The algorithm's robust performance in challenging subpopulations highlights the potential for its use as a screening tool in diverse clinical settings. Integrating ECG-AI may reduce reliance on costly biomarkers. Further prospective validation and cost-effectiveness evaluation are needed. EVALUATING AN ARTIFICIAL INTELLIGENCE SCRIBE FOR CLINICAL DOCUMENTATION Jordan Alpert1,2; Robert Saper3; Eric Boose4; Jessica Ruff3; Kevin Hopkins4; Devyn Gaskins3; Ning Guo5; Jakob P. Schneider6; Aryn G. Scibona3; Michael B. Rothberg7. 1Center for Value-Based Care Research, Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; 3Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH; 4Primary Care Institute, Cleveland Clinic, Cleveland, OH; 5Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 6Information Technology, Cleveland Clinic, Cleveland, OH; 7Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4257999)

The electronic health record (EHR) contributes to physician burnout. Medical scribes can reduce EHR documentation burden, but are expensive. Artificial intelligence (AI) based ambient listening technology can perform scribing functions. In simulated encounters, AI improved documentation quality and operational efficiency, and surveyed physicians thought the technology increased productivity. No studies have evaluated AI’s effects on workflow in a real-world setting. We conducted a prospective cohort mixed methods study to understand the impact of an AI scribe on burnout, mental demand, and EHR use.

Participants were primary care physicians who worked at least 0.6 full-time equivalent (FTE) and were in the top 20% of EHR Time Outside Scheduled Hours (TOSH). In February 2024, consented participants completed a baseline survey, followed by training and installation of an AI scribe. Participants activated the scribe at the beginning of appointments using a computer or phone, and a note was generated within seconds post-appointment. Physicians completed a survey at baseline and 4 weeks, followed by semi-structured interviews.

Of forty invited physicians, 10 enrolled. Mean age was 52 years, 70% were female, 70% White, and 10% Hispanic. Half were internal medicine and half family medicine. Physicians used the scribe for a median of 61 encounters (IQR 9.5-75). Mean likelihood to recommend was 6.5/10. There were no significant pre-post changes in any measure except mean characters typed (-15,398 (p=0.03)). Compared to those who used the scribe less than the median (61 encounters), those using it more reported reduced physical (P=.03) and mental (P=.01) demand. Changes in other measures did not differ significantly. Interviews revealed the tool’s benefits and barriers. Benefits included 1) accuracy, 2) paying more attention to patients, and 3) usage became easier with familiarity. Barriers were 1) challenges adapting to a new technology, 2) incompatibility with existing workflows and note structure, and 3) inefficiencies for patients with multiple issues. Overall, physicians felt the scribe had minimal impact on workload.

Using an AI scribe significantly reduced typed characters, but had no effect on other outcome measures. High utilizers experienced reduced mental and physical demand with the scribe. Interview data reinforced these findings—physicians had to change their note writing, but using the scribe improved with practice. The scribe did not affect perceptions of burnout, same-day chart closures, or TOSH. Future work should analyze other AI scribes and more physicians. EVALUATING THE IMPACT OF TELEMEDICINE ON GLYCEMIC CONTROL IN PRIMARY CARE AMONG PATIENTS WITH TYPE 2 DIABETES Jorge A. Rodriguez, Chenxi Gao, Nicolás Prada-Rey, Wenyu Song, Stuart Lipsitz, Lipika Samal. General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA. (Control ID #4272817)

Telemedicine presents an opportunity to increase care access and improve clinical outcomes, including glycemic control in patients with type 2 diabetes mellitus (T2DM). Yet, there is limited literature evaluating the impact of telemedicine on HbA1c. We compared longitudinal glycemic control among patients with T2DM with varying proportions of telemedicine use.

We identified adult patients with T2DM who had primary care telemedicine visits between May 2020-May 2021 (baseline period). The analysis was restricted to patients with telemedicine access, defined as having completed at least one telemedicine visit during the baseline period. Patients were excluded if they lacked baseline or follow-up HbA1c or did not have any primary care visits between May 2021-May 2023 (outcome period). Our exposure was the proportion of telemedicine visits in the outcome period. This ranged from 0% (only in-person visits) to 100% (only telemedicine visits), allowing for a continuous assessment of telemedicine use. Our primary outcome was change in HbA1c at 12-months. Using inverse probability weighting to adjust for baseline HbA1c, we fit a linear mixed-effects model to predict and compare mean HbA1c over time by the proportion of telemedicine visits.

There were 16,349 patients in the study cohort: 7,716 (47.2%) received only in-person care, 8,375 (51.2%) received mixed care, and 258 (1.6%) received only telemedicine care. During the outcome period, the patients had an average of 4.2 HbA1c’s measured. Patients who only received telemedicine care were younger, more likely to be White, and had a higher baseline HbA1c compared to the other groups. At 12-months, patients who received only telemedicine care had significantly higher HbA1c compared to those who received only in-person care (0.34%, 95% CI: 0.08-0.60, p=0.01) and those who received mixed care (0.56%, 95% CI: 0.07-1.04, p=0.03) (Figure). There was no difference in HbA1c when comparing only in-person care and mixed care (-0.22%, CI: -0.48-0.04, p=0.10).

Within our primary care cohort, patients using only telemedicine visits had significantly higher 12-month HbA1c compared to those using other types of care. Limitations include observational design and unmeasured confounders. Further research must determine optimal telemedicine integration for T2DM care. EVALUATING USE OF A PASSIVE VERSUS INTERRUPTIVE ELECTRONIC HEALTH RECORD-BASED MEDICATION COST ESTIMATOR AMONG PRIMARY CARE PATIENTS WITH MULTIMORBIDITY Ryan M. Kane1,2; Sarah Morton-Oswald3; Yuliya Lokhnygina3; Matthew Maciejewski4; Caroline Sloan5. 1General Internal Medicine, Duke Health, Durham, NC; 2Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC; 3Biostatistics, Duke University School of Medicine, Durham, NC; 4HSR&D, Durham VA Medical Center, Durham, NC; 5Internal Medicine, Duke University, Durham, NC. (Control ID #4271936)

Electronic health record (EHR) real-time benefit tools (RTBTs) display out-of-pocket (OOP) medication cost estimates and lower-cost alternatives (if available) to clinicians during clinical encounters. When clinicians use RTBTs, OOP costs decline, and medication fill rates increase. RTBTs can be user-directed (clinicians must click to activate) or interruptive (pop-up alert if a pre-specified cost threshold is reached). When RTBTs are user-directed, primary care providers (PCPs) view cost estimates in only ~1% of encounters. In January 2023, Duke Health changed its RTBT from being user-directed to interruptive. We assessed whether this configuration change was associated with increased RTBT use.

In a retrospective, EHR-based cohort study of adults aged ≥18 with multimorbidity (≥2 chronic conditions) prescribed >1 medication in 2022-2023, we compared outcomes in the user-directed (2022) vs interruptive (2023) periods. We used Chi-squared tests to compare encounter-level RTBT display frequency in 2022 vs 2023 for direct patient encounters (in-person and telehealth) and orders-only encounters (e.g., refill requests).

Most (72-82%) of the 1,007 primary care providers (PCPs) in 2022 and 1,030 PCPs in 2023 were physicians and 51-62% had <10 years’ experience. The number of providers with ≥1 RTBT views each year nearly doubled from 28% in the 2022 user-directed RTBT period to 48% in the 2023 interruptive RTBT period. The number of patients who received ≥1 RTBT cost estimates each year increased nearly 8-fold, from 2.4% of 46,854 patients in 2022 to 19.1% of 41,527 patients in 2023. The frequency of RTBT cost estimate displays increased from 0.5% of encounters (1,179/235,843) in 2022 to 6.0% (10,650/177,805) in 2023 (p<0.0001). In the subgroup of direct patient encounters, RTBT display frequency increased from 1.4% (1,092/79,087) in 2022 to 14.3% in 2023 (9,652/67,494). RTBT display frequency varied by month (Figure 1).

RTBT display rates increased dramatically after Duke’s RTBT changed from being user-directed to interruptive. Future work will assess whether this configuration change was associated with increased switching to lower-cost medications and increased medication fill rates. EXPLORATION OF HEART FAILURE CONTENT ON TIKTOK Farhaad Khan1; Ubayd Haq1; Ajay Vaidya2. 1Internal Medicine, University of Southern California, Los Angeles, CA; 2Cardiology, University of Southern California, Los Angeles, CA. (Control ID #4271864)

TikTok has recently emerged as an important source of health information in the United States. In light of the ongoing discussions on whether to ban the platform in the country, we conducted a cross-sectional study to evaluate engagement, quality, and viewer experience of TikTok content related to heart failure.

We selected the top 100 all-time videos that resulted when searching for ‘heart failure’ using TikTok’s search algorithm. Two videos were deleted prior to being rated, so 98 videos were included in the analysis. Two physicians independently evaluated the videos using the DISCERN and Armstrong Viewer Assessment (AVA) scores. DISCERN is a validated quality grading system that uses a 16-item assessment to give a quality score on a scale from 1 to 5. The AVA system assesses the overall experience of the viewer on a scale from 1 to 4. Viewer engagement was also calculated using a ratio (combined number of likes and comments / views). Statistical analysis was done using two-tailed t-tests with a significance level of 0.05.

More non-healthcare professionals created videos about heart failure compared to healthcare professionals (68.4% vs. 29.6%). Females created more videos than males (69.2% vs. 30.8%). The majority of videos were anecdotal (54.1%), and only 40.8% of videos were primarily educational. Personal experience was the most common content category (45%) followed by symptoms (24%). There was no significant difference in viewer engagement between healthcare professionals and non-healthcare professionals (.036 ± 0.005 vs .042 ± 0.004, p: 0.41). Healthcare professionals created significantly higher quality videos compared to non-healthcare professionals (DISCERN 3.32 ± 0.16 vs 1.81 ± 0.10, p < 0.001). Healthcare professionals also created content with better viewer experience (AVA 2.06 ± 0.05 vs 2.02 ± 0.02, p < 0.001).

The results of our study show that heart failure content on TikTok varies significantly in quality and viewer experience. While healthcare professionals had higher quality and viewer experience scores, they created fewer videos than nonhealthcare professionals, leaving viewers with less access to high-quality content. Amongst both groups, we found that videos often oversimplified topics and none of the videos cited sources. As more people begin to use TikTok as their primary source of health information, our study demonstrates the need for more accurate and evidence-based content on heart failure, especially in light of discussions regarding the platform’s ban in the US. FACILITAROS AND BARRIERS RELATED TO SMART HEALTH DEVICE USE AMONG MINORITY OLDER ADULTS Jany Sun1; Yanjun Dong2; jimmie Boliboun3; Katherine Koo3; Michael Cui3; Victoria M. Rizzo2; Jeannine M. Rowe4. 1Rush Medical College, Rush University Rush Medical College, Chicago, IL; 2University at Albany, Albany, NY; 3Rush University Medical Center, Chicago, IL; 4University of Wisconsin-Whitewater, Whitewater, WI. (Control ID #4235715)

Smart health devices (SHD) are increasingly used to manage chronic health conditions among older adults. Despite SHD offers a promising solution to improve disease self-management, less than 4% of SHD users are African American and Latinx, even though they have higher morbidity and mortality rate from chronic health conditions. Promoting the use of SHD among minority older adults will likely improve health outcome and reduce health care disparity. There are a limited number of studies evaluating individual characteristics, like age, gender, ethnicity, and race, and their impact on SHD use. However, these studies provide little guidance on how to intervene and increase SHD use among minority older adults. We aim to identify mutable factors, including predisposing, enabling, and need factors, that impede the utilization of wearable SHD among minority older adults.

An interview study was conducted with 20 English speaking minority older patients (age 60+) who have hypertension and were prescribed a smart blood pressure monitor. Andersen’s Expanded Behavioral Model, which is a culturally sensitive framework for examining predisposing, enabling, and need factors in health service utilization, was used to guide the study. Thematic and classical content analysis are used to identify and quantify dimensions and themes within these factors.

The average age of participants was 70.7 (M = 70.7, SD = 10.3). The majority were African American (95%, n = 19) and women (55%, n=11). Among the predisposing factors, level of knowledge of SHD (100%, n=20), social network support (100%, n=20), perceived control (85%, n=17), and positive attitude toward daily health monitoring (80%, n=16) increase participants’ engagement with SHD. Accessibility issues (35%, n=7) and affordability (30%, n=6) negatively impact participants’ willingness to continue using the device. Among the enabling factors, device benefits and convenience (85%, n=17) enhance the use of SHD, but technical problems (90%, n=18) and stress associated with daily monitoring (20%, n=4) are the barriers. Among the need factors, commitment to health management (85%, n=17) and healthcare provider’s recommendation for daily monitoring (55%, n=11) facilitate the use of SHD.

This study highlights the complex interplay between predisposing, enabling, and need factors in SHD use among minority older adults. Identifying these factors provides a starting point for healthcare providers to design and implement strategies to enhance utilization of SHD among minority older adults, ensuring equitable access. Healthcare providers are encouraged to facilitate the discussion of using SHD for health monitoring with their patients. Healthcare providers may also wish to collaborate with other health professionals, like social workers, to develop community programs to promote the use of SHD and address behavioral and financial barriers. HOSPITAL USAGE OF MACHINE LEARNING TOOLS IN A NATIONALLY REPRESENTATIVE SURVEY Kaustav Shah2,1; Matthew J. Klebanoff2; Amol Navathe3,1; Gary E. Weissman4. 1Medicine, Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA; 2Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 3Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 4Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4216757)

Although some hospitals have started using artificial intelligence (AI) and machine learning (ML) based tools to improve clinical and operational performance, the hospital characteristics associated with AI/ML use are unknown. Previous work has shown higher concentration of AI-related administrative claims in academic hospitals, metropolitan regions, and high-income zip codes. However, this approach likely underestimates the true usage of AI/ML tools because comparatively few currently have reimbursable medical service and procedure codes. Therefore, we sought to estimate self-reported AI/ML usage in a national hospital survey and identify hospital characteristics associated with its use.

The 2022-2023 American Hospital Association (AHA) annual survey and information technology (IT) supplement was used to obtain hospital characteristics and self-reported AI/ML usage. We fit a logistic regression model to estimate the association between hospital and county factors and use of AI/ML. Inverse probability weights were used to account for non-response to the IT supplement. County-level economic and social deprivation index (SDI) data was obtained from the American Community Survey.

The overall survey included 5,921 hospitals of which 2,881 (49%) responded to the AI/ML usage question. Among respondents, 1083 hospitals (38%) said they used AI/ML models, 865 (30%) said they use non-ML predictive models, and 933 hospitals (32%) said they use neither. In weighted analyses, there was a significant difference between AI/ML usage in small (36%), medium (32%), and large (43%) hospitals. AI/ML usage was equivalent between teaching and non-teaching hospitals. In a multivariable regression model, hospitals affiliated with a health system had increased AI/ML usage (OR 3.56, 95% confidence interval [2.8,4.5]) compared to non-affiliated hospitals. In contrast, rurality was associated with decreased AI/ML usage (OR 0.55, [0.44, 0.70]) along with higher quartile of SDI (which indicates higher deprivation, compared to lowest quartile as a reference, highest quartile OR 0.67 [0.50, 0.90]).

In this nationally representative hospital survey from 2022-2023, more than a third of hospitals reported using AI/ML tools. Larger hospitals more frequently reported AI/ML use compared to medium and small hospitals although there was no difference in usage based on teaching status which differs from a prior claims-based analysis. Non-rurality, health system membership, and lower SDI were all associated with increased usage of AI/ML. These findings underscore the rapid pace of AI/ML uptake despite limited evidence that AI/ML tools can improve clinical outcomes and lower active AI/ML usage in lower-resourced settings. Limitations of this study include heterogeneity in what hospitals may consider AI/ML and non-response to the IT supplement. IMPACT OF PATIENT PORTAL USE ON CARDIOVASCULAR HEALTH OUTCOMES: A PROPENSITY MATCHED STUDY Aysenur Musaogullari1; Jeffrey Moorehead2; Kwonho Jeong2; Kaleab Z. Abebe2; Ellen J. Kinnee2; Jared Magnani2; Amber E. Johnson3. 1Pritzker School of Medicine, University of Chicago, Chicago, IL; 2University of Pittsburgh School of Medicine, Pittsburgh, PA; 3The University of Chicago Medicine, Chicago, IL. (Control ID #4272036)

Online patient portal use has been associated with improvements in chronic disease management via enhanced patient involvement. Whether the use of patient portals is associated with improved cardiovascular disease (CVD) outcomes by different sociodemographic strata is less known. Among a cohort of health system patients with CVD, we examined the association of patient portal use with clinical outcomes.

De-identified (electronic health record) EHR data for adult patients who had a cardiac admission within our academic medical center between January 2018-October 2021 were included. Patients were classified as either a portal user or non-user. We adjusted for sociodemographic factors available in the EHR. Additional geospatially-derived social factors were obtained using patient 9-digit ZIP Codes and used for propensity score matching. Primary outcomes were likelihood of emergency department (ED) visit, cardiac readmission, or all-cause readmission. A Cox proportional hazards model was created adjusting for weighted propensity scores.

A total of 109,716 patients were identified for our analysis, with about half (n=60,530 [55.1%]) being portal users. The mean age of portal users was 66 years compared with 72 years for non-users (p<0.001). There were significant differences in portal use by age, race, level of English proficiency, marital status, insurance type, clinical characteristics, as well as geospatially-derived variables like neighborhood racial composition and distance to nearest cardiologist. Adjusted propensity weighted analysis revealed that portal use was associated with higher risks of ED visits (HR 1.07, 95% CI [1.05, 1.10], p<0.001) and all-cause readmissions (HR 1.08, 95% CI [1.06, 1.10], p<0.001) at one year, but not cardiac readmissions.

Sociodemographic factors are associated with an institution’s patient portal use. Contrary to our hypothesis, we found that portal use portends increased ED visits and hospitalization. These data suggest that irrespective of patient sociodemographic status, patient portal access and closer clinician scrutiny may lead to increased health services utilization. INTERCEPTED DIAGNOSTIC IMAGING ORDER ERRORS. Isaac Peabody1; Jo R. Applebaum1; Yelstin Fernandes1; Jonathan Elias2; Jiheum Park1; Jason Adelman1; Jerard Z. Kneifati-Hayek1. 1Medicine, Division of General Medicine, Columbia University Irving Medical Center, New York, NY; 2Primary Care, Weill Cornell Medicine, New York, NY. (Control ID #4271553)

Diagnostic errors occur frequently and contribute largely to patient mortality. Diagnostic imaging is a critical part of the diagnostic process; incorrectly ordered imaging can lead to breakdowns. Despite this, little is known about how frequently these errors occur or what contributes to them. To better understand these diagnostic imaging order errors, we investigated imaging orders intercepted by radiology—before the error reached the patient.

We conducted a retrospective cohort study from January 1st, 2021, to December 31st, 2021, using recorded healthcare data across several emergency departments, inpatient facilities, and their associated outpatient practices. All imaging orders placed on patients were included in the study cohort. The primary outcome was defined as an imaging order that was canceled by radiology. Radiology included physicians, technologists, technicians, advanced practice providers, and nurses. Patient, clinician, and order-level data were extracted from the data warehouse. A multivariable logistic regression was conducted using all variables. XGBoost was used to determine the feature importance of risk factors for making an error. A final multivariable logistic regression model was performed using the top ten features identified by XGBoost.

Three percent of all imaging orders placed were intercepted by radiology. The multivariable logistic regression (not shown) identified several risk factors. XGBoost (not shown) identified the top ten features contributing to diagnostic imaging order errors. Figure 1 shows a multivariable logistic regression with variables sorted by feature importance rank from XGBoost. While ordering a study with contrast (OR 2.41, 95% CI [2.35-2.47]) was identified as the most important risk factor by XGBoost, mammograms (OR 4.00, 95% CI[3.88-4.12]) had the highest risk of being intercepted by radiology.

For every 100 orders placed by clinicians, three are intercepted by radiology before reaching the patient. We identified several important risk factors. On the order level, orders involving contrast, mammograms, and nuclear medicine imaging. On the patient level, women, Spanish-speaking, and Hispanic/Latino patients. On the clinician level, clinicians in the emergency department and outpatient locations, students/residents, and advanced practice providers. These risk factors can serve as targets to improve ordering habits and ultimately reduce diagnostic imaging order errors. INTERROGATING TRENDS IN CARDIAC DYSRHYTHMIA MORTALITY USING MULTILAYER PERCEPTRON ANALYSIS James Pollock, Ashley Mason, Hibah Virk, Chandler Richardson, Logan Carlyle. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4272527)

Despite advances in the management of chronic pathological rhythms, there continues to be an increase in the incidence of sudden cardiac death attributable to acute dysrhythmias like ventricular fibrillation each year. We hypothesized that a multilayer perceptron (MLP) could appropriately scale the multiplicity of variables associated with dysrhythmia mortality and relay their respective importance for further epidemiological analysis.

We trained an MLP model in SPSS to identify counties within the United States that would undergo an increase, decrease, or constant rate of cardiac dysrhythmia mortality over a 10-year-window using data from the CDC Interactive Atlas of Heart Disease and Stroke.

543 counties reported dysrhythmia mortality data between the periods of 2008-2010 and 2018-2020. The MLP correctly adjudicated county-wide data most reliably for areas undergoing a decrease in dysrhythmia mortality, with area under the receiver operator curve (AUROC) 0.844. This was followed by areas undergoing increased (0.834) and constant (0.803) dysrhythmia mortality rates. Significant disparity in mortality rates between sexes (100%), Hispanic population proportion (61.8%), and increased rates of dysrhythmia hospitalization (52.9%) were of the greatest normalized importance.

The MLP was able to correctly forecast trends in cardiac dysrhythmia mortality with appreciable fidelity, in addition to identifying important prognostic indicators for county-wide performance. Further consideration should be given on how to reduce the impact of these influential factors, especially in areas of the country that have demonstrated year-over-year increases in sudden cardiac death attributable to dysrhythmias. INVESTIGATING THE UTILITY OF CHATGPT IN LOCATING LITERATURE GAPS IN GASTROENTEROLOGY Arif Sarowar3; Hamza Ali1; Rami Dali4; MOHAMMAD AL-HADIDI2. 1Student, Wayne State University School of Medicine, Detroit, MI; 2Radiology, Wayne State University School of Medicine, Detroit, MI; 3Medicine, Wayne State University, Detroit, MI; 4Medical School, Oakland University William Beaumont School of Medicine, Rochester, MI. (Control ID #4270984)

Artificial Intelligence (AI) has significantly impacted various medical fields, offering tools to enhance efficiency and innovation. ChatGPT, a language model developed by OpenAI, has been explored for its potential to identify knowledge gaps in research. While prior studies have assessed AI’s role in literature reviews, its utility in gastroenterology remains underexplored. This study investigates whether ChatGPT can effectively generate novel, under-researched topics in gastroenterology, focusing on three domains: general gastroenterology, gut microbiota, and inflammatory bowel disease.

ChatGPT was used to generate potential systematic review topics in three areas of gastroenterology: general gastroenterology (10 ideas), gut microbiota (5 ideas), and inflammatory bowel disease (5 ideas). Each idea was then evaluated for novelty by searching for existing research in PubMed, EMBASE, and Cochrane. A topic was considered novel if it had fewer than 15 non-systematic reviews and no systematic reviews published. This process helped determine whether the topics ChatGPT generated were truly unexplored and suitable for systematic review research.

ChatGPT demonstrated varying success rates in generating novel systematic review topics across the three categories. For general gastroenterology, 50% of the generated ideas were identified as novel, while for gut microbiota and inflammatory bowel disease, 40% of the ideas met the novelty criteria. Non-novel topics had an average of 243 non-systematic reviews and 3.45 systematic reviews, indicating these areas were already well-researched. In contrast, novel topics averaged only 3.55 non-systematic reviews and no systematic reviews, making them relatively unexplored. Notably, ChatGPT generated at least one topic in each category that had zero existing articles in the searched databases, representing completely unexplored research areas.

ChatGPT shows promise in identifying novel and under-researched topics in gastroenterology but has limitations in accuracy. While it cannot replace thorough literature searches, it serves as a helpful tool to generate initial ideas and identify potential gaps in research. Future improvements in AI tools and integration with real-time databases could enhance their reliability and usefulness in medical research. LEVERAGING LARGE LANGUAGE MODELS FOR CHARACTERIZATION OF PATIENT CAREGIVER STATUS Theodore M. Hill1; Serena Y. Chen2; Sean P. Heffron4; Robin Ortiz3. 1New York University Grossman School of Medicine, New York, NY; 2New York University, New York, NY; 3Pediatrics and Population Health, New York University Grossman School of Medicine, New York, NY; 4Leon H. Charney Division of Cardiology, NYU Center for the Prevention of Cardiovascular Disease, New York University Grossman School of Medicine, New York, NY. (Control ID #4269217)

Young adulthood is a critical period for cardiovascular health (CVH), with evidence suggesting that significant declines occur during this time. Hypotheses for this deterioration include the competing demands of employment and childcare responsibilities, but empirical data on this are sparse. A major barrier to improved understanding of this critical period is the basic identification of caregivers, as this status is not collected in a standardized format in traditional medical encounters. This study evaluated the ability of large language models (LLMs) to identify caregivers aged 19-39 from unstructured clinical notes, aiming to fill a critical gap in understanding and supporting this at-risk group.

Using a keyword search targeting terms related to children and caregiver status, we compiled a dataset of 199 deidentified clinical notes from outpatient visits across various medical specialties within a large academic healthcare system. Of these, 100 notes included one or more relevant keywords, whereas 99 contained none. Using our institution's generative AI private environment with GPT-4 (version “2024-02-01”) and a model temperature of 0.2, we tested multiple prompting strategies to classify patients as caregivers ("Yes"), non-caregivers ("No"), or ambiguous ("Maybe"), based upon note contents. Results were compared against a “gold standard” manual review to evaluate model performance by calculating accuracy, sensitivity, specificity, positive predictive value, and negative predictive value over 3 model runs. Additionally, the model and manual review provided justifications for each classification, which were qualitatively analyzed to better understand model behavior.

The model outperformed keywords in distinguishing caregivers and non-caregivers (Table). The model exhibited variability in reasoning with limited information: it correctly inferred caregiver status for a patient with an ill child, yet did not recognize that a previously pregnant patient with a “recent delivery” might soon assume caregiving responsibilities. GPT-4 classified only 4 notes as ambiguous, typically assigning definitive classification even when presented with vague or contradictory information.

GPT-4 demonstrated high accuracy in classifying patient caregiver status from unstructured clinical notes, with minimal rates of model hallucination. These findings suggest that LLM-based analysis could support healthcare providers in delivering personalized CVH interventions to caregivers. This approach also shows promise for identifying myriad patient characteristics not routinely recorded in the EMR, offering a powerful tool for both clinical and research applications. QUALITATIVE PERSPECTIVES OF GOVERNANCE GROUPS ON BEST PRACTICE ADVISORIES (BPAS) AND CLINICAL DECISION SUPPORT (CDS) Afifah Khan1; Jeffrey L. Schnipper2. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4273515)

The electronic health record (EHR) has many methods of CDS that are intended to 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. BPAs fire so frequently in the EHR that most are ignored, almost entirely defeating their purpose.

This project involved semi-structured interviews with members of governance boards and members of information systems (IS) teams who govern and create inpatient facing BPAs at an academic medical center in New England. We qualitatively assessed what governance and IS stakeholders think about BPAs and how CDS could be modified to be more effective. We conducted thematic analysis of interview transcripts using the constant comparative method. Inductive and deductive coding were used to identify themes.

Participants noted systems level governance had low tolerance for false negative BPAs (i.e., not firing when they should), a high tolerance for over-alerting end users, and often created BPAs as a reactive response to recent safety events or new regulations. Participants felt the broader administrative system defined successful BPAs as those that functioned as designed, i.e., using their internal logic, and provided accurate information to end-users. BPA success was not defined by end-user acceptance rates or assessment of helpfulness, impact on clinician workflow or cognitive load, unintended consequences, or patient outcomes. Another recurring theme was reluctance by stakeholders to add new BPAs, though only 0-2 BPAs were modified or retired monthly from an existing pool of thousands. Among some of the governance-level barriers to successful CDS identified by stakeholders were excessive bureaucratic procedures, limited time and resources to devote towards CDS, and technological limitations inherent to the EHR.

Governance and IS teams prioritized regulatory compliance, safety, and medical legal risk when creating CDS. The systems level governance culture had low trust in clinicians to make appropriate clinical decisions without nudges from CDS, with little regard for the effects of BPA over-alerting on clinicians or patients. Health systems have limited resources devoted to CDS development and maintenance. Each group involved in CDS governance typically only sees a piece of the puzzle and lacks perspectives of others in the organization. REAL-WORLD EFFECTIVENESS AND SAFETY OF RESPIRATORY SYNCYTIAL VIRUS PROTEIN SUBUNIT VACCINES IN U.S. ADULTS AGED ≥60 YEARS, 2023–2024 Sarah Fry1; Pauline Terebuh1; David Kaelber2; Rong Xu1. 1School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; 2Internal Medicine, Pediatrics, and Informatics, The MetroHealth System/CWRU, Cleveland, OH. (Control ID #4267681)

Respiratory syncytial virus (RSV) poses a significant health risk for adults aged 60 years and older. With the 2023 FDA approval of two protein subunit RSV vaccines, there is a critical need for comprehensive data on both vaccine effectiveness (VE) and safety. Understanding adverse events associated with these vaccines is essential, as safety concerns could influence provider practices and guidelines. This study addresses existing knowledge gaps by evaluating VE and safety of these vaccines, including among immunocompromised populations, using a large-scale electronic health record (EHR) dataset.

We conducted a test-negative case-control study using Epic Cosmos, a dataset comprising over 270 million de-duplicated patient records from across the United States. The study included adults aged ≥60 years who were tested for RSV during the 2023-2024 season. VE was estimated by comparing the odds of vaccination between RSV-positive cases and RSV-negative controls. Additionally, a self-controlled case series design was employed to assess the risk of Guillain-Barré Syndrome (GBS) and immune thrombocytopenia (ITP) following vaccination.

We analyzed data from 787,822 individuals, including 53,963 cases and 733,859 controls. The overall VE against RSV-associated medically attended respiratory illness was approximately 75% across all age groups. Immunocompromised individuals showed a slightly lower VE (65-75%), particularly among those with hematopoietic stem cell transplants (29-44%). Results from over 3.6 million vaccinated patients indicated increased risk of GBS, particularly with the Pfizer vaccine, but no significant increase in ITP.

This study provides insights into the effectiveness and safety of RSV vaccines in older adults, highlighting reduced effectiveness in certain immunocompromised groups and an elevated risk of GBS associated with the Pfizer vaccine. These findings are needed for informing vaccine recommendations and guiding future research. REMOTE PATIENT MONITORING FOR HYPERTENSION WITH AUTOMATED PROACTIVE PATIENT FEEDBACK: FEASIBILITY AND 6-MONTH PILOT TESTING Stephen Persell1,2; Lucia C. Petito3; Yaw A. Peprah4; Ji Young Lee5; Hironori Sato6. 1Medicine, Northwestern University, Evanston, IL; 2Northwestern Memorial HealthCare, Chicago, IL; 3Preventive Medicine , Northwestern University, Chicago, IL; 4General Internal Medicine, Northwestern Universiry, Chicago, IL; 5School of Medicine, Northwestern University, Chicago, IL; 6Omron Healthcare Kabushiki Kaisha, Muko, Kyoto Prefecture, Japan. (Control ID #4271986)

Remote patient monitoring (RPM) enables blood pressure (BP) management based on repeated home values. Automated messages may help overcome clinician and patient inertia. We hypothesized that, among patients with elevated office BP, RPM with automated patient messages delivered through an EHR portal would improve home blood pressure levels and antihypertensive medication intensification.

At a regional health system affiliated with an academic medical center, we piloted a hypertension RPM program with automated patient advice delivered through a patient portal based on the results of directly transmitted home BP measurements. We used these RPM BPs in a deterministic algorithm to automatically send patients messages about: 1) reminders to monitor, 2) what to do if mean BP is not at goal, 3) advice about very high or very low values, 4) positive feedback when goal BP is achieved, and 5) advice when BP may be over treated. Eligible participants at primary care and nephrology clinics had last two office BP ≥140/90 mm Hg and increased risk from comorbidities (cardiovascular disease, renal disease or diabetes mellitus). Outcomes were mean change in home BP between baseline and 6-months, antihypertensive medication net increases or decreases, and mean number of automated messages sent and read. Because 31% of enrolled patients had controlled home BP at baseline (systolic BP <130 mm Hg), we presented results stratified by baseline home BP.

Of 285 eligible patients cared for by the seven participating clinicians, the clinicians gave approval for 234 patients (82%) to be contacted, of whom 70 (30%) enrolled; 31% were non-Hispanic White and 60% were non-Hispanic Black, 69% were female. Baseline mean (SD) office BP was 143 (16) / 79 (11) mm Hg. Among the 62 patients with home BPs measured at 6 months, mean change in BP was -11 (18) / - 6.6 (10) mm Hg, p<0.0001. Twenty-two participants (32%) had baseline home SBP <130 mm Hg, [mean home BP 121 (7) / 73 (11)] and 48 had baseline BP ≥130 mm Hg [mean 150 (11) / 88 (13)]. At 6-months, mean home BP had changed little in the group controlled at baseline, +1.7 (14) / + 0.5 (8.7) mm Hg, and changes substantially, -17 (16) / -10 (9) mm Hg, in the home SBP ≥130 group. Among the <130 mm Hg group, 68% had no medication change or a medication reduction, and 52% of the baseline SBP ≥130 group had antihypertensive therapy increased (p=0.19). By 6 months, patients had received a mean of 8.8 (5.8) messages and read 85% (26%).

This pilot demonstrates the feasibility and acceptability of delivering automated feedback through a patient portal based on BP RPM results. A large proportion of participants had white coat hypertension. Among those with sustained hypertension (elevated home BP at baseline), there were large declines in home BP at 6 months and medication increases were common. Larger-scale testing is warranted. STAKEHOLDERS’ PERCEIVED BENEFITS AND CONCERNS REGARDING ARTIFICIAL INTELLIGENCE IN THE CARE OF OLDER ADULTS: A QUALITATIVE ANALYSIS Kacey Chae1; Jacqueline Massare2; Sato Ashida3; Thomas K. Cudjoe2; Peter Abadir2; Alicia I. Arbaje2,4; Mathias Unberath5; Phillip Phan6; Nancy L. Schoenborn2. 1General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; 2Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD; 3Department of Community and Behavioral Health, The University of Iowa College of Public Health, Iowa City, IA; 4Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; 5Computer Science, Johns Hopkins University, Baltimore, MD; 6Johns Hopkins Carey Business School, Baltimore, MD. (Control ID #4270747)

Artificial Intelligence (AI) applications in healthcare have an immense potential to address unmet needs of older adults and enhance their healthcare delivery. For successful adoption and implementation of AI in the care of older adults, understanding stakeholders’ perspectives is critical. However, few studies have explored relevant stakeholders’ perception of the use of AI specific to the care of older adults. Thus, the objective of the study was to explore perceived benefits and concerns among diverse stakeholders about AI applications in the care of older adults.

We conducted individual, semi-structured interviews with five groups of stakeholders: older adults and caregivers, clinicians, health system and health insurance plan leaders (payers), investors, and technology developers. Interviews asked about the perceived role of AI in the care of older adults, the perceived benefits and concerns regarding AI, and suggestions for mitigating the concerns. Interviews were audio-recorded and transcribed verbatim. We used thematic content analysis to code the transcripts.

Forty-nine participants completed the interviews: older adults/caregivers (n=15), clinicians (n=15), payers (n=8), investors (n=5), and technology developers (n=6). We identified three themes. 1). Stakeholders had overall positive perceptions about AI and identified several roles for its use in the care of older adults, such as making existing tasks more efficient, relieving burden, avoiding adverse health events, and addressing unmet needs. 2). Stakeholders expressed notable concerns about AI, such as worsening social isolation, propagating ageism, and high cost. 3). Stakeholders suggested potential solutions, such as setting appropriate guardrails, to mitigate concerns about AI.

Although stakeholders had an overall positive perception regarding the use of AI in the care of older adults, they also had notable concerns. Given the significant unmet needs and complexity of caring for older adults, the benefits of AI can be tremendous while concerns can also be heightened. Appropriate guardrails are needed to leverage the benefits of AI while mitigating potential harms. These findings have implications for future AI development and implementation to incorporate stakeholders’ perceived roles of AI during the design process, to consider appropriate guardrails, and to critically evaluate a product for potential bias/ageism as end-users of technology. THE IMPACT OF AI SCRIBES ON CLINICIANS’ ELECTRONIC HEALTH RECORD TIME: INITIAL RESULTS FROM THE AMBIENT CLINICAL DOCUMENTATION COLLABORATIVE Lisa Rotenstein2,1; Sara Murray2; Maria Byron2; Jacqueline G. You3; Reema Dbouk4; Scott MacDonald5; Karandeep Singh6; Devin Mann7; Katharine Lawrence7; Rebecca G. Mishuris8. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2University of California San Francisco, San Francisco, CA; 3Pathology, Massachusetts General Hospital, Boston, MA; 4Medicine, Emory University, Atlanta, GA; 5University of California Davis, Davis, CA; 6University of California San Diego, La Jolla, CA; 7Population Health, NYU Langone Health, New York, NY; 8Digital, Mass General Brigham Inc, Boston, MA. (Control ID #4271523)

Time spent on the electronic health record (EHR) is linked to burnout among physicians. While human scribes have been shown to reduce EHR time, their scalability is constrained by cost and workforce limitations. Artificial intelligence (AI)-based technologies like ambient documentation support could ease the EHR burden without these limitations. Healthcare organizations across the U.S. are now testing the ability of AI-powered scribes to reduce documentation load and improve clinician experience. However, knowledge gaps remain about the diversity of AI scribe deployment settings, clinician types, and the impact on EHR time.

The Ambient Clinical Documentation Collaborative includes nine U.S. healthcare organizations spanning community and academic centers in regions such as the Mid-Atlantic, New England, Southern, and Northwest. All sites use Epic Systems as their EHR and have adopted AI scribes. For each site, we characterized: 1) vendor(s) used; 2) AI scribe implementation timelines; 3) clinician and clinical settings targeted. For sites with preliminary data, we assessed the impact of AI scribes on EHR time using Epic’s Signal database. A difference-in-difference approach with matched control clinicians will further evaluate changes in total EHR time, documentation time, and EHR time outside of scheduled hours. Additional analyses will identify clinician demographics, EHR usage patterns, and technology features associated with time reductions.

Study sites use at least one of three vendors (Table). Rollouts began in July 2023, primarily in outpatient (OP) settings, with limited emergency (ED) and inpatient use. At a New England academic center, one vendor’s users (n=83) saw a 17.8% reduction in median (IQR) time spent in notes per appointment (8.4 to 6.9 minutes) and a 6.8% increase in same-day closures. Another vendor’s users (n=106) experienced a 9.3% reduction in note time (9.7 to 8.8 minutes) with stable same-day closures. At a West Coast academic center, among 173 providers, average note time decreased by 14.8% (-2.9 minutes/hour), EHR time by 0.1% (-0.1 minute/hour), and patient instruction time by 17.8% (-0.2 minutes/hour). Pooled cross-site analyses and multivariable modeling are ongoing.

The approach to implementation of AI scribes has varied across large healthcare systems. Early data suggests they have the potential for reducing clinicians’ EHR time expenditure. THE PROMISES AND PITFALLS OF AI-GENERATED DRAFT REPLIES TO PRIMARY CARE PATIENT PORTAL MESSAGES A QUALITATIVE THEMATIC ANALYSIS OF AI-GENERATED DRAFTS. Natalie S. Lee1; Nathan Richards3; Jodi M. Grandominico-Bradford2; Daniel E. Jonas2. 1The Ohio State University Wexner Medical Center Department of Internal Medicine, Columbus, OH; 2Internal Medicine, The Ohio State University, Columbus, OH; 3Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4258125)

High volumes of patient-generated messages pose an increasingly untenable burden for primary care providers (PCPs). A novel generative artificial intelligence (genAI) tool can draft replies for PCPs. Early data describing the impact of this tool on provider satisfaction and work metrics are mixed; further insights are needed to shape its use in the primary care inbox. A small cohort of PCPs piloted GenAI drafts at a Midwestern academic medical center. We then applied a medical communication framework to systematically articulate strengths and limitations of the genAI replies, seeking to inform future optimization efforts.

We conducted a thematic analysis of 201 genAI replies to real patient messages. GenAI prompts underwent 4 to 5 rounds of iterative revision to instruct the model appropriately. Prompts were tailored to messages that were “clerical” (pertaining to results, refill requests, paperwork) vs “general” (all others), as categorized by the vendor’s proprietary algorithm. We applied five domains of medical communication: 1) Building rapport; 2) Gathering information; 3) Delivering information accurately and professionally; 4) Facilitating next steps and patient decisions; and 5) Responding to emotion. Two PCP reviewers developed a codebook defining strengths and limitations for each domain. We used Cohen’s Kappa to assess interrater agreement and reconciled all discrepancies through discussion.

We combine reporting for general (n=139) and clerical messages (n=62), as results were similar (Figure). Interrater agreement was moderate (Cohen’s Kappa 0.55 and 0.59 for general and clerical messages, respectively). Strengths were observed more frequently than limitations in the domains of “Rapport Building” and “Enabling next steps.” Limitations were more common in the remaining domains, especially for “Information delivery” (44%,89 of 201 messages). Information delivery fell short because the reply did not address the patient’s informational need (65%, 58 of 89 messages); made incorrect assumptions about clinical context or workflow (36%, 32/89); or was simply wrong (24%, 21/89). The reviewers also determined whether they would use at least a portion of the genAI draft in their own reply. On average, 45% (for clerical) to 57% (for general) message drafts were usable; of usable messages, many required major edits (75% of usable replies to general, 32% for clerical). Interrater agreement on message usability was “fair” (Kappa 0.26), likely reflecting differing communication styles. [JD1]Give the n/N and % for each to be consistent throughout, regarding what is in parentheses in the results. Would this be 89/201=44%?

While GenAI drafts often contain usable portions, net value added may be limited by inadequacies in more cognitively demanding, critical domains like providing accurate information, asking key questions, and responding to patient emotions. Further optimization is needed to genuinely enhance patient care and provider experience. UNLOCKING THE POWER OF ONE-LINERS: A NEW APPROACH TO ENHANCING INTERPRETER SERVICES IN HEALTHCARE Miguel Linares, John Novoa-Laurentiev, Nuoya Jiang, Sigfredo Salguero, Yilu Ma, Li Zhou. Brigham and Women's Hospital, Boston, MA. (Control ID #4272648)

Effective communication is critical for the 26 million individuals in the U.S. with non-English language preference (NELP), yet use of interpreter services (IS) remains inconsistent. Accurate documentation of language preference and IS in medical notes is key for ensuring quality of care. Clinicians’ one-liners (OL), concise summaries of relevant patient information in medical notes, offer a unique opportunity to enhance visibility of language needs and improve quality of care. This study investigates how including language preference in OLs impacts IS use and examines its potential to influence documentation practices across medical teams through a spillover effect.

We analyzed medical notes for adult patients with NELP admitted to inpatient medicine Jan 2019-Dec 2023. Using natural language processing, we extracted clinicians’ OLs, the inclusion of the patient’s preferred language in the OL and documented use of IS. We also examined actual use of IS (remote and in-person). A random-effects linear regression model assessed the spillover effect of including NELP in OLs from general medicine admission notes (H&Ps) OLs on total IS use during admissions, adjusting for length of stay (LOS), number of specialist notes (proxy for illness severity), year, gender, insurance type, and age. A subgroup analysis was conducted for patients with non-Spanish NELP. We conducted a secondary binomial regression analysis to explore whether the inclusion of NELP in general medicine H&P OLs influenced specialists’ documentation of IS and language preference in their OLs (spillover effect).

The study included 1,540 patients, 2,406 admissions, and 25,223 notes. The nested model showed that the medicine admitting team's inclusion of NELP in the OL was associated with an average increase of 2.43 IS encounters per admission (95% CI 0.49–4.36). In the non-Spanish NELP subgroup, the increase was 4.60 IS encounters (95% CI 0.83–8.37). For the secondary outcome, 57% of admissions included at least one note by a specialist team. After adjustment, the inclusion of the patient’s preferred language in the general medicine team’s H&P increased the likelihood of specialists documenting IS use (aOR 1.43, 95% CI 1.22–1.68) and documenting the patient’s preferred language in their OLs (aOR 1.51, 95% CI 1.17–1.95).

This study demonstrates that documenting a patient’s preferred language in clinicians’ OLs is associated with a significant increase in IS use during an inpatient admission. Additionally, including NELP in general medicine teams’ H&Ps triggers a spillover effect, increasing the likelihood of specialist teams documenting IS use and NELP in their OLs. These findings highlight the potential that NELP inclusion in the one-liner can improve IS utilization, communication, quality of care, and patient outcomes. Adopting this practice across medical teams should be prioritized to promote more inclusive and effective patient care. USE OF ARTIFICIAL INTELLIGENCE TO DELIVER LOW-LITERACY EMERGENCY DEPARTMENT DISCHARGE INSTRUCTIONS IN ENGLISH AND SPANISH: A MIXED METHODS STUDY Elaine Khoong1; Chris A. Pineda1; Leonardo A. Garcia Heglund1; Alina Truong2; Mario Gonazalez Ramirez1; Andersen Yang1; Alicia Fernandez1. 1Medicine, University of California San Francisco, San Francisco, CA; 2California Northstate University College of Medicine, Elk Grove, CA. (Control ID #4269869)

Patients with low health literacy or English proficiency often cannot understand discharge instructions (DCI) written by emergency department (ED) clinicians. We conducted a mixed-methods study to examine 1) whether Azure ChatGPT 4.0 can safely rewrite patient DCI to improve readability, and 2) patient preferences for original or GPT-rewritten DCI (in English and Spanish).

We randomly selected 50 sets of DCI (25 from an academic tertiary hospital; 25 from a public hospital), which contained 316 sentences. We used best practices in prompt engineering to instruct GPT to rewrite instructions to optimize understanding for limited health literate patients and accurate machine translation for non-English speaking patients. Quantitative analysis: We coded rewritten DCI for 1) medical jargon (ex: medical terminology, atypical use of words in healthcare), 2) non-standard English (ex. spelling/grammar errors, abbreviations), 3) Flesch-Kincaid score, 4) meaning (level of meaning maintained), 5) potential for harm due to meaning change after being rewritten. Using chi-squared tests, we compared the original vs rewritten DCI in the use of medical jargon, non-standard English, and readability. Qualitative analysis: Four sets of rewritten and original DCI were purposefully sampled for increasing levels of complexity. We used GPT to translate DCI into Spanish; translations were verified. Twenty patients (10 English & 10 Spanish-speaking, mean age 59, 12 women) - blinded to the source of the instructions - were interviewed by a bilingual team member and asked whether they were neutral, preferred, or strongly preferred one instruction set. This resulted in 40 total preferences for each language. The order of whether the original or GPT-written instructions were presented first changed between each set to avoid recency bias. Interviews were recorded, transcribed, and coded for themes about the rationale for preferences.

GPT reduced sentence count (316 vs 294). GPT improved readability and reduced medical jargon, spelling/grammar errors, and abbreviations but increased use of synonyms and colloquial English (Table). Clinical meaning was preserved in 41 of 50 DCI (82%) though 4 rewritten sets (8%) had potential for harm. Patient preferences varied. English speakers more often preferred/strongly preferred GPT instructions (22 vs 16), while Spanish speakers preferred/strongly preferred the original instructions more frequently (19 vs 11). Patients who preferred the original DCI associated detailed information with higher quality, more empowering care, while preferences for GPT-written DCI were due to reduced medical jargon and improved comprehension.

GPT effectively rewrote ED DCI to improve readability and reduce spelling and grammar errors while retaining most clinical meaning, though some changes risked harm. Patient preferences varied for and against GPT-rewritten instructions, underscoring the need to tailor information delivery to individual preferences. USER-CENTERED DESIGN OF A PATIENT-GENERATED HEALTH DATA DASHBOARD FOR PRIMARY CARE VISITS FOR OLDER ADULTS WITH CHRONIC PAIN Alan T. Kelley1,2; Bryan S. Gibson2,3; Usman Sattar2,3; Joshua Judd2; Sara J. Knight2,4; Randall W. Rupper2,5; Jorie M. Butler2,4. 1Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT; 2VA Salt Lake City Health Care System, Salt Lake City, UT; 3Bioinformatics, The University of Utah School of Medicine, Salt Lake City, UT; 4Epidemiology, The University of Utah School of Medicine, Salt Lake City, UT; 5Geriatrics, The University of Utah School of Medicine, Salt Lake City, UT. (Control ID #4232656)

Chronic pain affects >30% of older US adults and causes significant disability in this population. Effectively addressing chronic pain often requires extensive contextual information and complex care plans due to etiologies that are multifactorial and involve patient-specific combinations of physiologic injury and psychosocial factors. Our objective in this study was to develop an application that captures and displays contextual patient-generated health data (PGHD) to facilitate patient-centered care for older adults with chronic pain during primary care visits.

We conducted user-centered design (UCD) interview sessions among a geographically diverse sample of primary care clinicians in the Department of Veterans Affairs (VA) who care for older adults with chronic pain. We first elicited perspectives relating to information needs, goals, and potential challenges in collecting PGHD. We then showed an application mockup to elicit preferences about information to collect; input on the app’s content, functionality, and visual design; and optimal workflows to implement its use. Concurrently, we conducted an online survey among VA clinicians to further assess utility of potential data elements in the application.

From UCD sessions (N=21), we identified three overarching themes: (1) access to specific contextual information (i.e., app data elements) could facilitate patient-centered care for older adults with chronic pain, including photos from inside their home, photos/symbols/text representing “what is important” to them, and self/caregiver-reported functional status and home support; (2) providers have specific desired uses for PGHD (i.e., app functional requirements), including availability of PGHD prior to the clinical encounter, data summaries designed for both the patient and provider, easy “drill-down” of summary data to underlying responses, clear delineation of responses from patients versus caregivers, and seamless integration of PGHD into the medical record; and (3) providers believe that how PGHD is integrated into clinical practice (i.e., app implementation) could impact its effectiveness and adoption over time, with consideration for endorsements from colleagues, provider training, patient education and assistance; and app-optimized solicitation of data detail and app-enhanced data synthesis to minimize patient-provider burden. From the survey (N=43), providers reported the most useful data elements as photos of the patient's home, medication storage, and scenes or objects of meaning or importance to the patient; anxiety and pain catastrophizing scores; and self-rated functional ability.

Clinicians have a favorable view toward app-based capture and display of contextual PGHD for older adults with chronic pain, especially toward visual data and data on patient function and meaning; however, how PGHD is captured, accessed, and integrated will be critically important to its implementation and potential for improving patient-centered care. USING A LARGE LANGUAGE MODEL TO ASSESS DATA IN PUBMED ABSTRACTS Harry Burke1; Viktoria Gagarin2; Albert Hoang2. 1Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; 2USUHS, School of medicine, Henry M Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, MD. (Control ID #4269140)

PubMed stores and indexes medical abstracts and is the largest biomedical database in the world; consisting of 24,358,442 records and containing 122 GB of data. We are interested in using the knowledge in PubMed to advance medical research and the practice of medicine. To achieve this goal, we enlisted a large language model (LLM). LLMs can input and output natural language meanings and they can make inferences based on meanings. We hypothesize that an LLM can detect medical information, categorize and tabulate frequencies, and associate and summarize the medical information contained in PubMed abstracts. Our target condition is ductal carcinoma in situ (DCIS).

We investigated changes in the types, frequencies, and efficacy of DCIS treatments and the role biomarkers played in directing treatment in papers published from 2014 through 2023. We used the key words ductal carcinoma in situ or DCIS and randomized clinical trial. We report the comparison of the two-year time intervals 2014-2015 and 2022-2023. We used python to clean and format the abstracts, we created prompts that included the abstracts, we entered the prompts into the LLM Gemini Pro 1.5, and we assessed the output and refined the prompts to generate the final LLM results. The treatments were: surgery alone, radiotherapy alone, endocrine therapy alone, surgery and radiotherapy, surgery and endocrine therapy, combination endocrine therapy, vaccine therapy, and active surveillance. The results were checked by a human rater.

Comparing the two time intervals, the LLM found that as a percentage of all treatments in each time interval; surgical treatment increased from 11% to 36%, radiation decreased from 30% to 14%, endocrine therapy remained approximately the same at 15% to 14%, active surveillance increased from 7% to 14%, surgery plus radiation decreased from 30% to 9%, surgery plus endocrine remained approximately the same at 7% to 9%, vaccine therapy increased from 0 to 4%, dietary modification occurred in 2 trials, and vitamin/mineral supplementation occurred in 2 trials. In terms of biomarker-directed treatment, the LLM found that DCIS patients positive for erbb-2 benefited from radiotherapy and those positive for PDGFRb did not benefit from radiotherapy, that ER positivity predicted benefit from tamoxifen and aromatase inhibitors whereas COX-2 positivity predicted resistance to aromatase inhibitors, and that erbb-2 positive patients responded to vaccine treatment. The results were checked and they were correct.

These findings suggest a shift in clinical trials toward surgical interventions for DCIS and a away from studies investigating radiotherapy, either alone or in combination with surgery. Large language models are a powerful tool for mining PubMed. Not only can they reliably find information in abstracts, they can tabulate frequencies, and they can associate and summarize information within and across abstracts. VALIDATING AN AUTOMATED METHOD TO DETECT WRONG-SIDE DIAGNOSTIC IMAGING ORDER ERROR Isaac Peabody1; Jo R. Applebaum1; Jiheum Park1; Yelstin Fernandes1; Jonathan Elias2; Charles Baillie1; Jason Adelman1; Jerard Z. Kneifati-Hayek1. 1Medicine, Division of General Medicine, Columbia University Irving Medical Center, New York, NY; 2Primary Care, Weill Cornell Medicine, New York, NY. (Control ID #4270390)

Diagnostic errors are common and contribute significantly to patient mortality. Imaging plays a crucial role in the diagnostic process. Incorrectly ordered diagnostic imaging contributes to breakdowns in this process. One example is wrong-sided (e.g., right instead of left) diagnostic imaging orders. We designed a query using an existing health information technology (IT) tool—the retract-and-reorder (RAR) method—to identify near-miss, wrong-side diagnostic imaging order errors. The RAR method previously was used to identify wrong-patient order errors with a high positive predictive value. We set out to apply two validation methods to validate the automated detection of wrong-side diagnostic imaging order errors.

This retrospective cohort study used healthcare data recorded from January 1st, 2021, to December 31st, 2021. Using the RAR method, we developed a query to identify near-miss, wrong-side diagnostic imaging order events--defined as an imaging order specifying a side placed on a patient, retracted, and reordered on the contralateral side. We executed the query retrospectively to identify these events. An error was defined as discordance between the initial order and the chart documentation. We implemented two validation methods. First, a clinician reviewer conducted a chart review on a random sample of 100 events to determine if the events were order errors. A second reviewer will verify 20% of the random sample. Second, we used Natural Language Process (NLP) to identify discordance between the documentation and the initial order placed on all the events. We will report the positive predictive value (PPV) and 95% confidence interval for each validation method. The agreement between the methods will also be reported.

During the study period, a total of 369,362 imaging orders placed specifying a side. The query identified 2431 events. The validation process is still underway. Currently, 33 out of 35 (PPV: 94.3%, 95% CI [0.80 – 99]) cases from the random sample of 100 events were determined to be errors by a single reviewer. We expect the second reviewer to obtain similar results. We expect the NLP to identify discordant events with similar results.

This automated method to detect near-miss, wrong-side diagnostic imaging order errors is being validated, with initial results yielding a high PPV. A valid automated method to detect near-miss, wrong-side diagnostic imaging order errors can provide insight into the epidemiology of these errors and be used as an outcome indicator for targeted interventions. Furthermore, adapting the RAR method to identify near-miss diagnostic imaging order errors is a proof of concept to investigate other types of order errors. VARIATION IN REPORTED COPAYS FOR PORTAL MESSAGES AMONG OLDER ADULTS Terrence Liu1; Matthias Kirch2; Erica Solway3; Dianne C. Singer3; Scott Roberts4; Jeffrey T. Kullgren5; Tammy Chang6. 1Internal Medicine, University of Michigan, Ann Arbor, MI; 2IHPI, University of Michigan Michigan Medicine, Ann Arbor, MI; 3Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI; 4School of Public Health, University of Michigan, Ann Arbor, MI; 5Internal Medicine and Health Management and Policy, University of Michigan, Ann Arbor, MI; 6Family Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4232739)

Beginning in 2020, clinicians may bill for complex patient portal messages that require time for medical decision-making. Copays associated with portal messages may discourage patients, especially low-income or older adults with multiple chronic conditions, from communicating important health information through the portal. Our objective was to characterize reported copays for portal messages by health insurance among older US adults who utilize portal messaging.

In February 2024, we surveyed a nationally representative sample of adults ≥50 years through the National Poll on Healthy Aging. Respondents (n=3379) were asked whether they had a patient portal, whether they sent a message to a healthcare provider through the portal, and whether they were charged a copay for sending messages. We used multivariable logistic regression to estimate associations between receiving a copay for sending a portal message (primary outcome) and type of health insurance (main predictor)

Overall, 76.2% (95% CI, 72.9% - 79.1%) of adults ≥ 50 years reported having a patient portal, 64.7% (95% CI, 62.3% - 67.2%) reported sending a portal message in the past year, and 13.1% (95% CI, 11.4% - 15.0%) reported receiving a copay with sending portal messages. Across health insurance types, most older adults sent a portal message in the past year, ranging from 58.6% for those with traditional Medicare without supplemental insurance (95% CI, 44.3% – 72.8%), to 75.2% of those with VA coverage (95% CI, 67.9% - 82.5%). (Figure 1) A minority of respondents were charged copays for portal messages, with the highest estimate being 16.6% for those with private insurance (95% CI, 11.2% -21.9%), followed by 15.9% for those dual-eligible or with Medicaid (95% CI, 4.5% - 27.4%) (Figure 1)

In this nationally representative study of older adults, most individuals reported sending portal messages to their healthcare provider in the past year, with a minority reporting copays for such messages. Medicaid-eligible respondents had similar estimated prevalences of reported copays compared to individuals who were privately insured, highlighting a potential gap where Medicaid-eligible individuals may not experience the same degree of cost-sharing reduction that they typically receive for many other clinical services Scientific Abstract - Geriatrics and Palliative Care APPLICATION AND VALIDATION OF A CLAIMS-BASED LOW-VALUE PRESCRIBING METRIC WITHIN THE VETERANS HEALTH ADMINISTRATION Aimee N. Pickering3; Kelvin Tran1; Elijah Lovelace1; Carolyn T. Thorpe2,1; Walid F. Gellad3,1; Thomas R. Radomski3,1. 1VA Pittsburgh Healthcare System, Pittsburgh, PA; 2Pharmaceutical Outcomes and Policy, The University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC; 3Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #4273053)

Low-value prescribing (LVP) is common among older adults and can lead to adverse drug events, unnecessary healthcare costs, and increased risk of hospitalization and death. However, LVP has not been comprehensively studied within the Veterans Health Administration (VHA). This study aimed to (1) assess LVP frequency among Veterans using a novel claims-based metric (2) validate the metric through an electronic health record (EHR) review.

We conducted a cross-sectional study of a national sample of VHA-enrolled Veterans aged ≥65. LVP was identified using the EVOLV-Rx metric, a claims-based metric designed to detect LVP in older adults. This metric includes 18 of the most scientifically valid and clinically relevant LVP practices, as determined by an expert Delphi panel. We applied EVOLV-Rx to prescription records from the VA Corporate Data Warehouse to determine the count and percentage of Veterans affected by each LVP practice in CY21. To validate each LVP algorithm in EVOLV-Rx, two study team members independently conducted an EHR review for 50 patients selected at random who satisfied 17 of the EVOLV-Rx criteria. After reconciling differences, we calculated the specification validity (i.e., does the metric measure what it intends) for each LVP algorithm by dividing the number of patients characterized via the EHR review as having received a low-value prescription over the random sample of 50 patients who satisfied the EVOLV-Rx criteria, with a target specification validity of 80%.

The study cohort included 3.7 million Veterans, with a mean age of 76 (SD 7.1); 97% were male and 69% non-Hispanic white. A total of 1,157,289 (31.1%) Veterans received at least one LVP practice as identified by EVOLV-Rx. The most common LVP practices were prolonged use of proton pump inhibitors, affecting 572,747 (15.4%) of Veterans, followed by ineffective use of gabapentinoids for non-neuropathic pain, affecting 336,753 (9.0%) Veterans; inappropriate B12 supplementation, affecting 235,652 (6.3%) Veterans; potentially unsafe use of muscle relaxants, affecting 166,599 (4.5%) Veterans; and ineffective use of docusate for constipation, affecting 133,252 (3.6%) Veterans. The remaining LVP practices occurred at lower rates. The specification validity was > 80% for 13 of 17 LVP practices included in EVOLV-Rx. The specification validity of the metric was 100% for proton pump inhibitors, 98% for muscle relaxants, 96% for docusate, 56% for gabapentinoids, and 24% for B12. Lower specification validity for gabapentinoids and B12 resulted from diagnoses in free text not captured by claims.

Among older U.S. Veterans, LVP was common. We also demonstrated that a novel claims-based metric can effectively identify LVP, although incomplete capture of diagnoses in claims limits the validity of some LVP measures. This work can be extended to systematically examine LVP in other healthcare systems and may inform interventions aimed at reducing LVP. ASSOCIATION BETWEEN POLYPHARMACY AND PHYSICAL FUNCTION IN MIDDLE-AGED ADULTS: FINDINGS FROM THE CARDIA FUNCTION STUDY Caroline Sloan1,2; Ashner C. Marissa1; Cara McDermott3; Brett T. Burrows4; Carl Pieper1; Ankeet S. Bhatt5; Kelley P. Gabriel6; Barrett Bowling7,1. 1Duke University School of Medicine, Durham, NC; 2Duke University Margolis Institute for Health Policy., Washington, DC; 3Medicine, Duke University School of Medicine, Durham, NC; 4Augusta University, Augusta, GA; 5Kaiser Permanente Northern California, Oakland, CA; 6The University of Alabama at Birmingham School of Public Health, Birmingham, AL; 7Durham VA Health Care System, Durham, NC. (Control ID #4272490)

Polypharmacy (>5 prescription medications) and potentially inappropriate medications (PIM) are common both in older age and in midlife. PIMs are defined by the Beers criteria and include medications such as benzodiazepines and anticholinergics. Polypharmacy and PIM use are associated with poor physical function and adverse health outcomes in older age, but the effects of polypharmacy and PIM use on physical function in middle-age are not well understood. Our objective was to estimate the associations of polypharmacy and PIM use with physical performance in middle-age.

We conducted a cross-sectional analysis of the Coronary Artery Risk Development in Young Adults (CARDIA), a prospective cohort study that enrolled 5115 Black and White men and women aged 18-30 in 1985-1986 from four sites (Birmingham, AL; Oakland, CA; Minneapolis, MN; and Chicago, IL). We included participants who completed a physical performance battery (gait speed, grip strength, 30-second chair stand, single-leg balance, 6-minute walk test [6MWT]) and had data on self-reported medication use at the year 35 in-person exam (2020-2021). The CARDIA Physical Performance (CAPP) score was calculated by assigning points to sex-specific quartiles for each performance test (0=not attempted, 1-4 for each quartile) and summing points across all five tests (0-20, higher scores reflect greater function). We used multivariable linear regression to estimate the associations of 1) polypharmacy with CAPP score, 2) PIM use with CAPP score, and 3) PIM use with each test, adjusting for clinical and demographic characteristics. For PIM use analyses, we ran a second model further adjusting for polypharmacy.

Among 1842 participants (age 60 years +/- 4; 49% female, 44% Black race), 29% had polypharmacy and 25% used >1 PIM. Estimated CAPP score was 1.24 points lower among participants with polypharmacy vs. no polypharmacy (95% confidence interval [95%CI] -1.58, -0.90; p<0.001). Estimated CAPP score was 0.88 points lower among participants with PIMs vs. no PIMs after initial adjustment (95%CI -1.22, -0.54; p<0.001). In the second model further adjusting for polypharmacy, PIM use was associated with 6MWT but not with overall CAPP score or the 4 other tests included in the CAPP score. Those taking PIMs walked on average 18 fewer meters than those not taking PIMs (95%CI -31, -6; p=0.004).

Polypharmacy is associated with lower physical function and PIM use may be associated with lower cardiovascular endurance after accounting for polypharmacy. Age should not be the only parameter for considering the negative effects of polypharmacy and PIM use on physical function. Clinicians should consider systematically assessing physical function in their middle-aged patients who have polypharmacy or who use PIMs, to capture physical decline earlier in the lifespan. BEYOND ACCESS TO INTERPRETATION: MULTI-LEVEL APPROACHES TO IMPROVING PALLIATIVE CARE FOR PATIENTS WITH PREFERRED LANGUAGE OTHER THAN ENGLISH Donetta Ghosh, Danae Dotolo, Emily Ahrens, Katyayani Strohl, Syeda F. Ahmed, Rashmi K. Sharma. Medicine, University of Washington, Seattle, WA. (Control ID #4273005)

Patients with serious illness who prefer a language other than English (PLOE) are at high risk for sub-optimal end-of-life care. Multi-level (individual, clinical encounter, healthcare system, community, policy) interventions are required to mitigate the complex and multi-faceted inequities experienced by patients with PLOE. However, few studies have identified specific targets beyond increasing access to interpreters. We sought to better understand barriers to equitable healthcare and identify targets for multi-level interventions to improve palliative care for patients with serious illness and PLOE through interviews with interpreters.

As part of two larger mixed-methods studies, we interviewed professional medical interpreters from two large US health systems, in the Pacific Northwest, who work with Chinese, Spanish, Vietnamese, or Somali-speaking patients with advanced cancer or dementia. Interviews were conducted from October 2022-December 2024, audiotaped, transcribed, and coded by four investigators using an inductive iterative approach. Themes were organized into levels using the socio-ecological model.

Interviews were conducted with 20 interpreters (9 Spanish, 4 Mandarin/Cantonese, 4 Vietnamese, and 3 Somali). Interpreters were 70% female, and had 1-25 years of experience (mean 9.5 yrs, SD 8.0). Four themes emerged: 1) high levels of family distress from clinician-patient/family conflict over cultural preferences for high-intensity end-of-life care, coupled with heightened social and healthcare navigation needs due to language barriers; 2) challenges interpreting for patients with dementia alongside interpreter distress about limited patient ‘voice’ in clinician-patient-family discussions; 3) lack of structured approaches to facilitate clinician-interpreter partnership in navigating complex discussions about palliative care; and 4) lack of culturally- and linguistically-appropriate palliative care resources. These data suggest multi-level intervention targets to improve palliative care for patients with PLOE: 1) individual: training interpreters about palliative care and how to navigate interpretation with patients with dementia; 2) clinical encounter: structured clinician-interpreter pre-meetings to facilitate partnership; 3) health system: programs that combine interpretation with patient navigation (e.g., CCMs) as well as early palliative care referral to help address high levels of distress; and 4) community, policy level: increasing culturally and linguistically-appropriate and accessible palliative care resources.

We identified key targets for intervention at the individual, clinical encounter, healthcare system, and community levels to improve palliative care for patients with advanced cancer or dementia with PLOE. Our findings highlight the need to expand beyond access to interpretation to address the unique barriers patients with serious illness and PLOE face, informing future intervention development. BRIDGING THE GAP: SCOPING REVIEW OF DECISION SUPPORT TOOLS IN END-OF-LIFE CARE Marie Hamel1; Susanny J. Beltran2; Grace Plonsky2. 1The Warren Alpert Medical School, Brown University, Providence, RI; 2School of Social Work, University of Central Florida, Orlando, FL. (Control ID #4263354)

Internal medicine physicians frequently manage the complex care of older adults with terminal illnesses, often navigating challenging decisions about end-of-life (EOL) care. Despite advancements in palliative and EOL care, significant gaps remain in timely referrals and care planning, which can compromise patient outcomes and satisfaction (1). Decision support tools (DSTs) have become increasingly integrated into medical care to aid physicians in making appropriate care referrals (2,3). The specific application of DSTs to end-of-life care holds promise as one approach to improving the quality of care for terminally ill patients. These tools come at a time when much improvement is needed surrounding palliative care referrals according to EOL care providers (4,5). This scoping review aimed to map the existing literature on the development, implementation, and evaluation of DSTs for end-of-life (EOL) care among older adults in the inpatient setting.

A comprehensive literature review was conducted across PubMed, MEDLINE, CINAHL, and five additional medical journals using terms related to decision support tools, prognostic tools, end-of-life care, older adults, and intervention studies (6). Studies were selected using inclusion criteria focusing on DSTs for terminally ill patients, EOL care interventions, and outcomes. Data extraction and subsequent content analysis included study characteristics, DST types, diagnoses targeted, intervention outcomes, and implementation barriers and facilitators.

30 articles were identified that met inclusion criteria across multiple continents, decades, and care settings. Findings include a synopsis of current DSTs, their applications, and the facilitators and barriers to their successful use. Two primary DST categories emerged: prognostic tools (PTs) and clinical decision support tools (CDSTs). PTs were frequently used to estimate survival and identify patients for palliative care referrals. CDSTs supported clinicians in structured, informed decision-making. These tools targeted a range of conditions, including terminal cancer, heart failure, advanced organ failure, and neurodegenerative diseases. Many studies demonstrated significant improvements in identifying patients at high risk of mortality, increasing referrals to palliative care, and enhancing EOL discussions with patients and families.

This review highlights and describes the expanding use of DSTs in the care of terminally ill patients. This underscores an increasing focus on advancing and broadening the functionality of EOL care tools, leveraging sophisticated data analysis and predictive modeling to improve patient outcomes. While advancements in AI and data-driven models enhance DST precision, further efforts are required to ensure equitable outcomes and broader usability. Future research should focus on refining these tools and addressing technological and systemic barriers to optimize their impact on EOL patient care. CHALLENGES WITH ACCESSING HOME CARE AMONG MEDICAID BENEFICIARIES IN NEW YORK STATE: A SECRET SHOPPER STUDY Peggy B. Leung, Jennifer Sugijanto, Abigail Shilvock, Daniel Spertus, Madeline R. Sterling. Weill Cornell Medicine, New York, NY. (Control ID #4272487)

Nearly 75% of older adults want to stay at home as they age and avoid nursing homes, a concept known as aging in place. To do so, many require formal long-term care at home (i.e. home care), with Medicaid serving as the primary payer for these services. Yet accessing and obtaining home care is complex and challenging. New York State, which spends more per capita on home care than other states, offers a unique lens to examine these challenges. To that end, we aimed to understand the experiences of Medicaid recipients and their caregivers in accessing home care services, including quantifying availability, hours, time to receipt of care, and cost.

We conducted a telephone-based secret shopper study of a random sample of Medicaid-funded licensed home care services agencies (LHCSAs) in New York. Investigators contacted LHCSAs using a standardized script which pertained to a family member who required personal care at home. Main outcomes included: availability of home care (home health aides and attendant [HHA] services), time to receipt of care, and cost. Organizational data on LHCSAs were collected from public sources. We used descriptive statistics to summarize quantitative data and conducted a thematic analysis of interviews.

Of the 1,429 total LHCSAs in New York, 331 were selected as a random sample; a total of 169 were successfully contacted and comprised our analytic sample. Of these, 89.5% were for-profit and 73.9% accepted Medicaid. Interviews with LHCSA staff lasted for a total of 8.1 minutes (SD 3.9). The majority of LHCSAs (83.5%) were able to provide HHA-care; 6.5% were not and 10% were unsure. Long wait times (>7 days) for nurse- evaluations (which are required before care can be rendered) were common (44.4%). Estimating granted hours was difficult for agency staff, with 79.9% of respondents unable to provide an estimate. Among those who did (n = 34), most (73.5%) estimated 10-30 hours per week could be afforded. The average cost per hour for additional hours (beyond what Medicaid would cover) was $33.35. Qualitative analysis of call interviews with LCHSA representatives revealed five key themes: 1) Accessing home care through Medicaid is a complex, multi-step process; 2) Obtaining enough home care hours is challenging; 3) Paying privately can be used to get more hours; 4) Workforce related factors (i.e. shortages) influence ability to access home care; 5) The experience of connecting with LHCSAs to obtain care is highly variable.

Findings demonstrate that Medicaid beneficiaries seeking home care for family members may encounter challenges. Connecting with staff can be difficult, coverage may be insufficient, and wait times for care are long. Variability in LHCSA agency knowledge and assistance may further burden families. Improvements in long-term care delivery are needed at the patient, family, state, and system levels to improve healthcare processes and reduce administrative barriers to home care access. CLINICIAN PERSPECTIVES ON TAILORING THE DIABETES PREVENTION PROGRAM FOR OLDER SPANISH-SPEAKING HISPANIC ADULTS Elaine De Leon1; Maya Clemente4; Tiffany Martinez3; Jeannette Beasley2. 1Internal Medicine, NYU Langone Health, New York, NY; 2Nutrition and Food Studies, New York University, New York, NY; 3New York University Steinhardt School of Culture Education and Human Development, New York, NY; 4New York University, New York, NY. (Control ID #4273180)

Hispanic and/or Latino individuals experience disproportionately high rates of prediabetes. Engagement in the CDC’s National Diabetes Prevention Program (DPP) among this population is low, with poor attendance and high attrition compared to White participants. Adapting the DPP for Spanish speakers aged 65 and older requires a systematic approach incorporating clinician perspectives to ensure its relevance and effectiveness for this group.

As part of a broader project to adapt the BRinging the Diabetes Prevention Program to Geriatric Populations (BRIDGE) intervention for older Spanish-speaking Hispanic and/or Latino adults, we conducted semi-structured key informant interviews with physicians, nutritionists, and nurses at a large federally qualified health center (FQHC) in Brooklyn, NY. Participants with regular experience providing health education to Spanish-speaking Hispanic and/or Latino individuals were recruited via email. Interviews explored barriers and facilitators to promoting diet and physical activity changes among Hispanic and/or Latino patients with prediabetes and gathered clinician perspectives on intensive lifestyle interventions like the DPP. Data were thematically analyzed using inductive and deductive approaches to generate actionable insights for cultural and linguistic adaptation of the BRIDGE intervention.

Seven clinicians (three physicians, two nutritionists, two nurses) who frequently provide education on lifestyle modification to Spanish-speaking older adult FQHC patients were interviewed. Thematic analysis revealed several challenges, including competing life priorities, low education levels, limited health literacy, lack of culturally relevant materials, and insufficient access to external native language resources for referral. One nutritionist also highlighted that some patients experience limited access to healthy foods and inadequate facilities for meal preparation. Facilitators for behavior change included family involvement, culturally tailored communication, and creative physical activity recommendations. Clinicians emphasized the value of bilingual materials, visual aids, personal testimonies, and external community resources to enhance engagement and sustain health behavior changes.

Key informant interviews identified critical factors for tailoring DPP interventions for older Hispanic and/or Latino adults with prediabetes who receive care at an FQHC. Barriers to lifestyle modification span individual (e.g., education, health literacy) to community-level factors (e.g., lack of native-language resources). However, family involvement and personalized communication strategies present opportunities to enhance health behavior change and program engagement. These findings underscore the need for culturally tailored health education materials and lifestyle intervention curricula and will inform the design of a feasibility pilot for the adapted DPP intervention. COGNITIVE LEVELS PREDICT PLANNING FOR SUPPORT NEEDS IN ALZHEIMER’S DISEASE. Amber Winder, Raven Relerford, Allison Schierer, Charlie Olvera, Alaine Murawski, Vanessa Ramirez-Zohfeld, Lee Lindquist. Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4272069)

Although cognitive impairment (CI) is common, many older adults do not foresee themselves developing Alzheimer’s Disease (AD) in the future. Therefore, they delay or neglect planning for their support needs (e.g. in-home caregivers; safe living arrangements) as their AD progresses. When a crisis happens due to impaired cognition, families and patients are often unprepared and scramble to establish support. We sought to evaluate how cognitive decline among a cohort of older adults affected their planning for AD support.

The Plan Your Lifespan study examines the longitudinal decision-making process of long-term care (LTC) and in-home support for community-dwelling older adults aged 65 and older. Participants are asked if they were to develop AD, if they’ve decided on LTC living arrangements and in-home caregiver support preferences. Subjects are surveyed via telephone every 6 months for 36-months. At the 24 and 36-month time-points, the Montreal Cognitive Assessment (MoCA) was administered to detect for subject CI. The following scores corresponding to severity: Severe CI (score=0-9), Moderate CI (score=10-17), Mild CI (score= 18-25) and Normal cognition (score = 26+). Generalized Linear Mixed Modeling was used to examine the relationship between cognition and planning for AD support.

Of 240 subjects, (mean age 73.8 years, 76.3% female, 36.3% URM). Mean MoCA score was 25.67 points (SD 3.13) with 1.67% (n=4) having moderate CI, 57.08%, n=137) having mild CI, and 41.25% (n=99) having normal cognition. The level of CI was determined to be a significant predictor of planning for in-home caregiver support. For each point of decrease in the MoCA score below the mean (m=25.67), subjects displayed an 11% increase in the likelihood of planning for AD in-home caregiver support (p<0.05, OR 1.11). N=28 had a decline in score from the 24 to 36-mont time-point. N=15 subjects scores fell below levels of cognitive normalcy (< 26) between time-points. For each point of decrease in the MoCA score (below the mean=25.67), subjects reported a 26% increase in the likelihood of planning for in-home AD support (p<0.10, OR 1.26), and a 23% increase in the likelihood of planning for AD LTC living arrangements (p<0.05, OR 1.23).

Older adults who test positive for cognitive impairment, with the MoCA, are more likely to plan for their support needs. These findings indicate that older adults delay planning until after they detect cognitive decline. Since memory is tested annually during the Annual Medicare Wellness visit, providers should respond to detected cognitive loss by initiating or revisiting discussions about planning for future support needs. Conversely, providers could educate older adults on the importance of planning for AD support before signs of CI appear.airment. COMPARISON OF END-OF-LIFE CARE PROCESSES AND OUTCOMES AMONG OLDER ADULTS BY PHYSICIAN AND PATIENT SEX Hiroshi Gotanda1; Kimberly Narain2,3; Debra Saliba4,5; Alexandra M. Klomhaus6; Haiyong Xu7; Yusuke Tsugawa2,7. 1Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 2Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; 3Iris Cantor-UCLA Women’s Health Center, Los Angeles, CA; 4RAND, Santa Monica, CA; 5Medicine -Geriatrics, UCLA Borun Center, VA GRECC, RAND, Los Angeles, CA; 6Department of Medicine, Statistics Core, UCLA, Los Angeles, CA; 7Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #4266933)

Existing research indicates that female and male physicians practice medicine differently, with female physicians spending more time communicating with patients and being more likely to adhere to clinical guidelines. However, little is known as to whether female and male physicians provide different end-of-life (EOL) care. The primary objective of this study was to compare EOL care processes and outcomes between female and male physicians and examine whether the associations vary by patient sex.

We conducted a cross-sectional study using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died in 2016-2020. We examined nine measures related to EOL care, categorized into two areas: (i) advance care planning (ACP) and palliative care, and (ii) high-intensity care at the EOL (Table).

We included 630,643 patients, of whom 157,791 (25.0%) were treated by female physicians. Patients under the care of female physicians experienced a higher likelihood of receiving palliative care counseling, compared to those treated by male physicians (Table). We found no evidence that other EOL care processes and outcomes differed between the two groups. We found similar patterns for both female and male patients.

Patients treated by female physicians were more likely to receive palliative care and less likely to experience aggressive care at the EOL compared to those cared for by male physicians, for both female and male patients. COMPARISON OF RACIAL AND GENDER DISPARITIES IN POST-OPERATIVE MORTALITY BETWEEN PATIENTS WITH VERSUS WITHOUT DEMENTIA Ryu Yoshida1; Hiroshi Gotanda2; Ruixin LI3; Yusuke Tsugawa3,4. 1Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA; 2Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 3Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; 4Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. (Control ID #4266926)

Given that patients with dementia often find it harder to advocate for themselves, racial and gender disparities in post-operative mortality may be greater for patients with dementia compared to those without dementia. The primary objective of this study was to compare racial and gender disparities in post-operative mortality among older adults with versus without dementia.

We conducted a retrospective observational study of Medicare Fee-for-Service data in 2016-2019. The study included beneficiaries aged 65-99 years undergoing twelve common surgical procedures (repair of abdominal aortic aneurysm, coronary artery bypass surgery, appendectomy, cholecystectomy, colectomy, cystectomy, hysterectomy, laminectomy/spinal fusion, liver resection, lung resection, prostatectomy and thyroidectomy). The primary outcome was post-operative 30-day mortality, defined as death during hospital admission or within 30 days of surgical procedure. We compared the differences in post-operative mortality across the four race-gender groups (Black men [reference group], White men, White women, and Black women), stratified by dementia status.

A total of 1,282,945 beneficiaries were included, of whom 121,723 (9.5%) had a dementia diagnosis. Among patients with dementia, we found that the post-operative mortality was the highest for Black men (adjusted mortality, 6.55%), followed by White men (4.77%; adjusted risk difference [aRD], -1.78 percentage points [pp]; 95% CI, -2.70 to -0.86; p<0.001), Black women (4.29%, aRD, -2.27 pp; 95% CI, -3.40 to -1.13; p<0.001), and White women (4.18%; aRD, -2.37pp; 95% CI, -3.29 to -1.45; p<0.001) (Figure). A similar pattern was observed for those without dementia, although the differences were smaller compared with patients with dementia. Among patients without dementia, Black men showed the highest mortality (adjusted mortality, 3.26%), followed by White men (2.88%; aRD, -0.38pp; 95% CI, -0.60 to -0.16; p=0.001), White women (2.70%; aRD, -0.56pp; 95% CI, -0.78 to -0.34; p<0.001), and Black women (2.39%; aRD, -0.87pp; 95% CI, -1.15 to -0.59; p<0.001) (Figure).

We found that racial disparities in surgical care were exacerbated among patients with dementia compared to those without, suggesting potential implicit bias (i.e., ableism) against patients with dementia requiring surgical care. CONTRIBUTION OF HEALTH SYSTEM FACTORS TO EMERGENCY DEPARTMENT LENGTH OF STAY IN DEMENTIA Stephanie Nothelle2; Eric Slade1; Phillip Magidson3; Tanya Chotrani4; Halima Amjad2; Sarah Szanton1; Cynthia Boyd2; Jennifer L. Wolff5. 1Johns Hopkins University School of Nursing, Baltimore, MD; 2The Johns Hopkins University School of Medicine, Baltimore, MD; 3Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; 4Medical Communications, Boston Strategic Partners Inc, Boston, MA; 5Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4272419)

Persons living with dementia (PLWD) have longer lengths of stay in the Emergency Department (ED), which increases risk of delirium, falls and medication errors. Care of PLWD in the ED is complex and presence of dementia care specialists (geriatrics, neurology, psychiatry) may streamline care. We sought to understand the contribution of health system factors, including presence of dementia care specialists, to length of stay among PLWD.

We linked statewide ED visit data for Arkansas, Arizona, Florida and Massachusetts from the 2018 Healthcare Cost and Utilization Project State Emergency Department Database to American Hospital Association Annual Survey and Healthcare Information Technology supplement. We included ED visits by PLWD >64 years with an ICD-10 diagnosis of dementia. We built Poisson multivariable models to examine the association of ED length of stay in hours with health system characteristics (e.g. ownership type, teaching status), including dementia care services and connectivity (ability to access and use of outside electronic records). The unit of analysis was the health system associated with each ED.

We included 72,083 ED visits at 225 health systems. Median patient age was 83 years (IQR 67, 92), with females comprising a mean of 64% of visits, and mean length of stay was 9.3 hours (SD 16.3). Most EDs were non-governmental, not-for-profit health systems (n=159, 71%). Neurologic services were the most commonly available dementia care services (n=180, 80%), followed by psychiatric services (n=139 EDs, 62%) and geriatric services (n=132, 59%). In adjusted models, presence of geriatric services, but not neurologic or psychiatric services, was associated with a 20% lower length of stay compared to hospitals without geriatric services (IRR 0.80, p<0.001). Admission rate from the ED to the hospital was positively associated with length of stay (IRR 1.45, p=0.03). No other health system factors were significantly associated with length of stay.

Presence of geriatric services, was associated with a significantly shorter ED length of stay for PLWD. Few other health system characteristics were associated with ED length of stay for PLWD. These findings reinforce the potential value of the ongoing Geriatrics Emergency Department Accreditation programs. DEPRESCRIBING ASPIRIN IN A HOME-BASED PRIMARY CARE POPULATION John Hon6; Sunny Dizon1; Sally Ko2; Daniya Mathew2; Asantewaa Poku5; Konstantinos Deligiannidis3; Eun Ji Kim4. 1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; 2DGIM/Hofstra, Northwell Health, New Hyde Park, NY; 3Family Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; 4Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; 5Health Solutions, Northwell Health, New Hyde Park, NY; 6Division of General Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4271789)

Several early meta-analyses showed a modest benefit in daily aspirin leading to a USPSTF recommendation in 2016 for aspirin use for primary prevention in high-risk individuals. However, the ARRIVE and ASPREE trials found no evidence of cardiovascular benefit along with a higher risk of gastrointestinal bleeding associated with an increase in all-cause mortality. Home-based primary care through House Calls programs have seen a resurgence as evidence has shown an associated cost savings as well as a reduction in hospital admissions and readmissions. With over 2,000 enrolled patients, our health system’s House Calls program is one of the largest in the US and many are geriatric patients with multiple comorbidities and limited mobility. In this study, we examined the relationship between demographics and appropriate aspirin use in this population.

We conducted a cross-sectional analysis of patient characteristics in a House Calls program. A database of House Calls patients on aspirin was collated through the electronic medical record. We excluded patients in hospice care and patients under 18 years old. Two reviewers conducted chart reviews and assessed whether aspirin was prescribed appropriately or was a candidate for deprescribing based on several clinical practice guidelines, including the USPSTF, ACC, and AHA guidelines on the use of aspirin. Aspirin use was considered appropriate for secondary prevention of myocardial infarction, stroke, and transient ischemic attack. Appropriate use also included atrial fibrillation or vascular stenting as a guideline-directed indication. A chi-square test of independence was conducted on patient demographic data (age, sex, ethnicity, limited English proficiency).

There were 2,709 House Calls patients in the study, among them 408 were on aspirin. Of these, 24.8% (101/408) patients were inappropriately prescribed aspirin. The cohort was 39.46% male and 60.54% female. There was no significant association between appropriate use and ethnicity (p=0.35) or limited English proficiency (p=0.42). There was a significant association between appropriate use and age (p<0.05) and sex (p<0.05). Males were more likely to be appropriately prescribed aspirin, with 82.6% were appropriately prescribed as compared to 70.4% of females (p<0.05).

In this cross-sectional analysis of patients in a House Calls program, a higher percentage of older and female patients were prescribed aspirin inappropriately. Despite efforts to implement new aspirin guidelines, older and chronically ill patients remain a unique population to focus deprescribing efforts towards. DESCRIBING THE IN-HOSPITAL EXPERIENCE OF NURSING HOME PATIENTS WITH DEMENTIA Jordan Alpert1,2; Jeff D. Kovach3; David Harris4; Ardeshir Z. Hashmi5; Luke D. Kim6; Nicholas J. Casacchia1; Silvia Perez-Protto7; Matthew A. Pappas8; Michael B. Rothberg6,1. 1Center for Value-Based Care Research, Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; 3Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 4Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH; 5Center for Geriatric Medicine, Cleveland Clinic, Beachwood, OH; 6Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; 7Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH; 8Hospital Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4230412)

Hospital admissions among nursing home residents with Alzheimer’s Disease and related dementias (ADRD) are burdensome, expensive, and provide limited clinical benefits. Compared to other patients, those with ADRD are more likely to experience adverse events during hospitalization, including delirium, urinary infections, pneumonia, and functional decline. Previous research on nursing home residents has focused on the consequences of hospitalizations or analyzed the occurrence of individual adverse outcomes. Our objective was to describe the complete in-hospital experience of nursing home patients with ADRD.

We analyzed charts of patients aged 18+ years with an ADRD diagnosis ICD code; who reside in a nursing home, and were transferred to a hospital from January 2013 to July 2023. One randomly selected hospitalization per patient was included in the analysis. We used R 4.4.1 to conduct the descriptive analysis.

Of 10,195 patients, the median age was 84 years, 71% were white, 25% black, 61% female. The median length of stay was 5 days. During the hospitalization, 69% needed a sitter, 34% had a Foley catheter, and 4% died. 21% had delirium, 6% were put in restraints, 4% experienced a fall, and at least 1 anti-psychotic drug was administered to 28% of patients. 21% had renal failure, 16% respiratory failure, 16% pneumonia, and 15% sepsis. One-fifth (20%) of patients were sent to the ICU and 4% received mechanical ventilation; only 1% had a hospice consult, 0.4% had inpatient hospice. 5% had a palliative care consult, 0.1% inpatient palliative care, and 2% had a consult/referral to geriatrics. Less than half (45%) had a DNR order. More than 1/3 (34.8%; 3,546) of patients died within 6 months. Compared to patients who did not die within 6 months, those who did were more likely to have a DNR order, hospice, and palliative care services.

Nursing home patients with ADRD who were transferred to the hospital often endured distressing experiences, but rarely were referred to hospice or palliative care, despite high mortality. Patients and their family members should be informed about the hospital experience and offered hospice and palliative care services when appropriate. DEVELOPMENT OF A VIDEO-BASED DECISION AID FOR BREAST CANCER SCREENING AMONG OLDER WOMEN Meghan E. Lindsay2; Iyanuoluwa Odole3; Sadde Mohamed4; Ilana Richman1. 1Department of Medicine, Yale University, New Haven, CT; 2COPPER, Yale School of Medicine, New Haven, CT; 3Chartis, Chicago, IL; 4Yale University School of Medicine, New Haven, CT. (Control ID #4271281)

Whether older women benefit from screening mammography is uncertain, and shared decision-making approaches can be used to individualize screening decisions. However, traditional decision aids can be difficult to integrate into clinical visits and can be challenging for patients with low health literacy to understand. Video-based decision aids may overcome some of these challenges by reducing cognitive load. The goal of this study was to develop a video-based decision aid for older women who are considering breast cancer screening using patient-centered design techniques.

We first conducted formative focus groups to understand older women’s perspectives on breast cancer screening. We recruited older women (age >=70) with no history of breast cancer from community and clinical sources. Study investigators facilitated focus groups. Transcripts were coded using independently by two team members and analyzed using both inductive and deductive approaches. Using data from focus groups, along with established decision aid best practices, our team designed a video-based decision aid. The decision aid depicted an older woman who was considering breast cancer screening, and included absolute risks of breast cancer mortality, false positives, and overdiagnosis associated with continuing or stopping screening. We tested the decision aid in a second set of focus groups, which evaluated the content, intelligibility, and presentation. We made iterative changes to the decision aid in response to feedback.

We convened 6 formative focus groups with n=14 participants. Participants perceived screening as largely beneficial with few risks. Some risks, including overdiagnosis, were entirely unfamiliar to participants. Participants identified autonomy, health history, self-knowledge, and preferences as central to the decision-making process. Some participants valued quantitative information about screening, while others relied on their own self-knowledge and perceptions of risk to make screening decisions. We incorporated these perspectives into the framing, language, and narrative arc of the decision aid. After developing a prototype decision aid, we convened 6 focus groups (n=18 participants) to perform cognitive testing. Participants found the decision aid informative, engaging, and useful. Participants felt the decision aid was generally clear and easy to understand, but offered some specific suggestions to improve intelligibility, particularly around presentation of quantitative results. Our team incorporated this feedback into iterative versions of the decision aid.

Using a patient-centered, iterative approach, we developed a video-based decision aid for breast cancer screening. Our design, which drew on the beliefs, perspectives, and language of older women, was perceived as easy to understand, engaging, and informative. In future testing, we will assess the impact of the decision aid on decision quality, decisional conflict, and intention to screen. DOCUMENTATION OF INITIAL OUTPATIENT GOALS OF CARE CONVERSATIONS BY CLINICAL SPECIALTY Amy Linsky1,2; Julia Newman2; Melissa Wachterman1,3; Andrea W. Schwartz4,3; Shirley Qian5; Mark Glickman3; Benjamin E. Canter6; Renda S. Wiener1,2. 1Center for Health Optimization & Implementation Research, VA Boston Healthcare System, Boston, MA; 2Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 3Harvard Medical School, Boston, MA; 4Geriatric Research Education and Clinical Center, VA Boston Health Care System Jamaica Plain Campus, Boston, MA; 5Center for Health Optimization & Implementation Research, VA Bedford Healthcare System, Bedford, MA; 6Boston University Sargent College of Health & Rehabilitation Sciences, Boston, MA. (Control ID #4267818)

Goals-of-care conversations (GoCC) are critical for person-centered care, improving quality of life, and honoring patient wishes. Yet, they rarely occur—especially in outpatient settings— and when they do, they are frequently not documented in an easily identified manner. Many older adults have interdisciplinary care teams, adding ambiguity about which clinician should conduct and document GoCCs. We sought to characterize the distribution of initial documented GoCCs by outpatient medical specialties.

We conducted a national Veterans Affairs retrospective observational cross-sectional study, 3/2021-2/2023. We included outpatient clinics (primary care, geriatrics, palliative care, gastroenterology, oncology, cardiology, pulmonary, nephrology, infectious disease, endocrine, rheumatology, and neurology) and Veterans aged ≥50 years with ≥1 visit to these clinics. We used standardized electronic health record notes (“Life Sustaining Treatment” notes) to determine 1) proportion of initial outpatient GoCCs documented by each clinical specialty, and 2) clinical specialty rates of GoCC note writing for eligible patient visits (i.e., opportunities). Supplemental analyses determined clinician note writer characteristics and documented patient preferences for life sustaining treatment. We tested for unequal means or proportions using chi-squared or ANOVA F-tests, as applicable.

Within the study period, there were 21,939,008 total visits in the specified outpatient clinics, with 51,531 documented initial GoCCs; more than half were in primary care (n=27,795, 54%). Gastroenterology, neurology, infectious disease, endocrinology, and rheumatology each wrote <100 GoCC notes. Specialties varied in GoCC note writing rates (p<0.001). Patients were more likely to have GoCCs written in palliative care (17% of opportunities), followed by geriatrics (2.4%); all other specialties wrote GoCCs in <1% of total opportunities. Professional training of GoCC note writers varied (p<0.001). Across all specialties, fully trained physicians wrote the largest proportion of GoCCs. More than 20% of GoCCs were written by advanced practice providers in all clinical specialties except pulmonary, nephrology, and neurology. Most GoCCs resulted in no restrictions to life sustaining treatment (i.e., “full code”); yet, more than half of GoCCs written in palliative care resulted in Do Not Resuscitate (62%, p<0.001).

Few eligible patients have initial GoCCs in outpatient clinics, which may be due to time constraints, clinician comfort with end-of-life issues, and lack of role clarity about who should document initial GoCCs. Knowledge of factors that lead to GoCC documentation, including clinician specialty and professional training, can be leveraged to design and implement systemic improvements in advance care planning across different outpatient specialty clinics. DOES CANNABIS USE REDUCE SYMPTOMS OF ANXIETY, PAIN, DEPRESSION AND IMPROVE SLEEP AMONG OLDER ADULTS? A SYSTEMATIC REVIEW Kai Kohlwes2; Mariam Erika B. Jacob2; joyce do3; Deborah Korenstein4; Katherine Hoggatt2; Salomeh Keyhani2,1. 1Medicine, University of California San Francisco, San Francisco, CA; 2Center for Data to Discovery and Delivery Innovation (3DI), San Francisco VA Health Care System, San Francisco, CA; 3Research, University of California San Francisco, San Francisco, CA; 4General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273046)

Cannabis use is increasing among older adults. Multiple studies have noted that managing pain, insomnia, anxiety, and depression are the main reasons older adults report using cannabis. However, the efficacy of cannabis in managing these conditions is unknown. We conducted a systematic review to examine the efficacy of cannabis use for four conditions: non-cancer pain, insomnia, anxiety, and depression in older adults.

This systematic review identified articles from previously published systematic reviews (1/1/2012 to 10/31/2023) and in the primary literature (1/1/2019-10/31/23) through a search of PubMed, Embase, PsycINFO, and the Cochrane Library. Studies were included if in English and reported effects for managing any of the four conditions among adult over 50. The primary search was conducted in between 1/12019 and 10/31/23 and its purpose was to ensure we identified all original research articles not included in the systematic reviews. Studies were included if in English and reported effects for managing any of the four conditions among adult over 50.

We identified 67 systematic reviews identified that focused on pain (n= 43), insomnia (n= 6) anxiety (n=10) and depression (n=8), which resulted in n=2607 articles. The primary literature search yielded n=3962 articles (Figure 1). Among the articles identified (2607 + 3962, total 6569), 2604 were duplicates leaving 3965 abstracts (1770 on pain, 377 on insomnia, 802 on anxiety, and 981 focused on depression). Among the n=3965 abstracts, 3930 did not meet study inclusion criteria leaving 35 articles for full text review. Among the remaining 35 articles, 22 were not focused on the conditions of interest and were excluded, 10 had no control group, and 3 did not meet age criteria. After full text review, zero articles met criteria for inclusion in the literature review.

We did not identify previously published research articles that reported evidence of risks or benefits of cannabis use for managing symptoms of pain, insomnia, anxiety, and depression among older adults. Rather, research to date has focused on examining perceptions of cannabis use among older adults and perceived benefits. Given increasing use of cannabis among older adults, randomized clinical trials are needed to examine the cannabis-related risks and benefits that are specific to older adults. END-OF-LIFE CARE PROCESSES AND OUTCOMES FOR OLDER ADULTS TREATED BY PHYSICIANS WHO GRADUATED FROM INTERNATIONAL VERSUS US MEDICAL SCHOOLS Gillian Kaneshiro1; Anne Walling2,3; Neil Wenger2; David B. Reuben4; David S. Zingmond2; Cheryl L. Damberg5; Anupam Jena6,7; Nate Gross8; Hiroshi Gotanda9; Yusuke Tsugawa10. 1Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, NY; 2Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 3Greater Los Angeles Veterans Affairs Healthcare System, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 4Multicampus Program in Geriatric Medicine and Gerontology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 5Health Care, RAND Corporation, Santa Monica, CA; 6Department of Health Care Policy, Harvard Medical School, Boston, MA; 7Massachusetts General Hospital Department of Medicine, Boston, MA; 8Doximity Inc, San Francisco, CA; 9Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 10General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA. (Control ID #4271115)

International medical graduates (IMGs) comprise approximately a quarter of the US physician workforce. Although prior research suggests that cultural backgrounds influence attitudes towards end-of-life (EOL) care, it remains unknown whether IMGs and US medical graduates (USMGs) exhibit different approaches to EOL care processes and outcomes.

We conducted a cross-sectional study using a 20% random sample of Medicare fee-for-service beneficiaries aged 65 years or older who died in 2016–2019, attributing each beneficiary to the physician with the largest number of primary care service claims during the last 6 months of life. We examined eight EOL care-related measures, categorized into two areas: (i) advance care planning (ACP) and palliative care, and (ii) high-intensity care at the EOL (Table). We adjusted for beneficiary and physician characteristics. P-values were corrected using the Bonferroni-Holm method for multiple comparisons.

Among 391,425 beneficiaries, 117,754 (30.1%) were attributed to IMGs and 273,671 (69.9%) to USMGs. Beneficiaries treated by IMGs were slightly more likely to have billed ACP and slightly less likely to have emergency department visits in the last 30 days of life compared to those treated by USMGs (Table). We found no evidence of differences in other EOL care processes and outcomes between beneficiaries of IMGs and USMGs.

Differences in EOL care processes and outcomes between IMGs and USMGs were small and likely not clinically meaningful, despite potential cultural differences in attitudes toward EOL care. EVALUATING THE USABILITY OF NEGOTIAGE: AN AI-BASED NEGOTIATION TRAINING PROGRAM FOR FAMILY CAREGIVERS OF OLDER ADULTS WITH ALZHEIMER'S DISEASE. Alaine Murawski1; Marianne Tschoe3; Jeanette Cheng1; Vanessa Ramirez-Zohfeld1; Celie Joblin1; Charlie Olvera1; Lee Lindquist2. 1Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; 3Northwestern University Feinberg School of Medicine, Chicago, IL. (Control ID #4271029)

Family caregivers (CGs) of older adults with Alzheimer’s Disease (AD) may experience conflict when providing care to their loved one resulting in caregiver burden and stress. We created NegotiAge, an AI-based negotiation training program, which teaches CGs negotiation tactics. NegotiAge allows CGs to practice negotiating with avatars, which can help navigate real-life conflicts. We evaluated the usability and feasibility of NegotiAge for CGs of people with AD.

We conducted a Multiphase Optimization Strategy Trial (MOST) of NegotiAge with family CGs of older adults with AD. CGs were randomized to 1 of 8 conditions where they negotiated conflicts in real-time with AI-powered avatars simulating real-list interactions. Participants were surveyed immediately following the completion of the intervention, assessing the usability and feasibility of NegotiAge with the Usefulness-Satisfaction-Ease of Use (USE) Questionnaire and the System Usability Scale (SUS). CGs were also asked to share positive and negative aspects of the intervention. Open-ended responses were qualitatively coded using constant comparative analysis.

132 family caregivers, across 23 states (mean age 54 yrs, 77.3% female, 34.8% under-represented minority) completed the trial. NegotiAge received good usability marks, scoring a 70 on the System Usability Scale (0-100) and good acceptability, with a score of 5.47 on the USE Scale (0-7). CGs shared positive aspects of the training which were coded into the following themes: (1) Program content/resources, (2) Ease of use, (3) AI training methods, (4) Emotional regulation/communication, and (5) Relevance to real life. CGs found the training to be rewarding and were excited to apply what they learned to their daily life. Selected CG quotes: "Realizing that caregivers can utilize negotiation skills was novel and gave me a fresh perspective to my role." Another CG noted: "I really loved the simulator because it allowed to you to gain some real time practice on common scenarios you may encounter using the negotiation strategies learned." Negative aspects involved: (1) technical issues (which have since been corrected), (2) time limits, and (3) requests for additional situations.

NegotiAge, an AI-based negotiation training program, was well received by family CGs who reported good usability and acceptability scores. Quantitative scores were reinforced by positive qualitative feedback, demonstrating this program’s feasibility for teaching conflict resolution skills to family caregivers of older adults with AD. This AI-based training format may be transferrable to supporting caregivers and providers for additional skills training. FAMILY CAREGIVER DISTRESS, NURSING HOME PLACEMENT AND PSYCHOTROPIC DRUG PRESCRIBING AMONG CARE RECIPIENTS LIVING WITH DEMENTIA: A POPULATION-BASED PROPENSITY-MATCHED STUDY IN ONTARIO, CANADA Nathan M. Stall1,2; Vasily Giannakeas3,4; Kristina Kokorelias2,5; Andrea Gruneir6; Lisa Lix7; Kieran L. Quinn2,8; Lesley Wiesenfeld9,10; Christina Reppas-Rindlisbacher1,2; Michael Hillmer11,8; Paula Rochon3,4. 1Division of Geriatric Medicine, Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; 2Division of General Internal Medicine and Geriatrics, Sinai Health, Toronto, ON, Canada; 3Women's Age Lab, Women's College Hospital, Toronto, ON, Canada; 4Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; 5Department of Occupational Science and Occupational Therapy, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; 6Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, AB, Canada; 7Community Health Sciences, University of Manitoba Max Rady College of Medicine, Winnipeg, MB, Canada; 8Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada; 9Psychiatry, Sinai Health, Toronto, ON, Canada; 10Psychiatry, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; 11Planning, Research and Analysis Branch, Government of Ontario Ministry of Health, Toronto, ON, Canada. (Control ID #4271409)

Most people living with dementia (PLWD) reside in the community, often with the support of unpaid family caregivers. We evaluated the association between caregiver distress and nursing home (NH) placement and psychotropic drug prescribing among care recipients living with dementia.

Population-based propensity-matched cohort study of all PLWD aged ≥66 years who were receiving home care and had ≥1 family caregiver. We used linked databases held at ICES and included PLWD assessed with the RAI-HC tool (index date) between 2010–2021. Our exposure was caregiver distress identified on index home care assessment. Our primary outcomes were care recipient NH placement and psychotropic drug prescribing. Our secondary outcomes were care recipient all-cause mortality, emergency department (ED) visits and hospitalizations. We generated a propensity score for caregiver distress and matched PLWD with distressed caregivers to those without distressed caregivers. We followed PLWD for 365 days after index date (follow-up until June 30, 2022) or until death.

Among 130,416 older PLWD receiving home care (57.9% female; median age 84.0 years), 56,929 (43.7%) had distressed family caregivers. Between 2010–2021, the prevalence of caregiver distress increased from 32.4% to 58.9%. In the matched cohort of 39,092 PLWD, those with distressed caregivers were 34% more likely to be placed in a nursing home (HR=1.34; 95% CI=1.30–1.38) and 7% more likely to be prescribed psychotropic drugs (RR=1.07; 95% CI=1.03–1.10). Caregiver distress was not associated with significant increases in care recipient mortality, ED visits or hospitalizations.

Family caregivers for older PLWD experienced a near doubling of caregiver distress between 2010-2021. Caregiver distress was associated with increased NH placement and psychotropic drug prescribing among care recipients living with dementia. FRAILTY DETECTION IN AGING WORLD TRADE CENTER RESPONDERS: A COMPARISON OF THE FRAIL SCALE AND FRIED FRAILTY PHENOTYPE Chinmayi Venkatram1; Hannah Thompson3; Katherine Ornstein2; William Hung1; Ahmad Sabra4; Fred Ko1. 1Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 2School of Nursing, Johns Hopkins University, Baltimore, MD; 3Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY; 4The World Trade Center Health Program Data Center, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4272836)

Environmental exposures during and after the 9/11 rescue and recovery efforts may have predisposed World Trade Center (WTC) responders to accelerated aging and increased frailty. As a relatively younger population (median = 63.0 years, IQR: 58.1–69.3) with unique environmental risks, it is unclear whether established frailty tools-such as the telephone-based FRAIL scale and the Fried Frailty Phenotype-perform similarly in this group. This study compares the two tools, examining their agreement and associations with functional outcomes in this distinct population.

We enrolled WTC responders aged 50 and older who received annual health monitoring at a WTC Health Program clinic in an academic medical center in the Mid-Atlantic region. Frailty was assessed using the Fried Frailty Phenotype and the FRAIL scale, with participants categorized as frail, pre-frail, or non-frail according to each scale’s criteria. The performance and agreement between the two scales were compared using Cohen’s kappa statistic. Chi-Square tests examined associations between frailty status (frail, pre-frail, non-frail) and functional outcomes, including fear of falling (Falls Efficacy Scale-International, FES-I), fall risk, and activities of daily living (ADLs) for both scales.

Among 365 WTC responders with FRAIL scale data, 9.0% were classified as frail, 36.2% as pre-frail, and 54.8% as non-frail. For the 350 participants with Fried Frailty Phenotype data, 5.4% were classified as frail, 41.4% as pre-frail, and 53.1% as non-frail. Cohen’s kappa statistic for agreement between the two scales was 0.28, indicating fair agreement. Chi-Square tests revealed significant associations between frailty status, as assessed by the Fried Frailty Phenotype, and fall risk (p < 0.0001), FES-I (p < 0.0001), and ADL impairment (p < 0.0001). Similarly, significant associations were found between frailty status, as assessed by the FRAIL scale, and fall risk (p < 0.0001), FES-I (p < 0.0001), and ADL impairment (p < 0.0001).

Despite only fair agreement between the FRAIL scale and the Fried Frailty Phenotype-in contrast to prior studies showing moderate agreement-both tools demonstrated significant associations with functional outcomes, including fall risk, fear of falling, and ADL impairment. This discrepancy may reflect the heterogeneity of frailty in the WTC responder population, where unique exposures and health conditions create a complex frailty profile that each tool captures differently. Further research is needed to understand whether this agreement is seen across all frailty categories as well as whether performance differs based on sociodemographic characteristics. These tests, which capture different aspects of frailty, appear to have clinical utility in this population with additional research needed to understand the long-term utility. HOSPICE CARE KNOWLEDGE AND CONFIDENCE AMONG INTERNAL MEDICINE RESIDENTS June E. Criscione1; Alex Choi2; Louis S. Sussman3; Hinette S. Rosario2. 1Internal Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT; 2Internal Medicine-Palliative Care, Yale University School of Medicine, New Haven, CT; 3Internal Medicine-Palliative Care, Yale New Haven Health, New Haven, CT. (Control ID #4272197)

Hospice is under-utilized in the United States in part due to provider related factors. These deficits likely stem in part from inadequate post-graduate training. However, little is known about resident physicians’ specific knowledge gaps related to hospice care. In this study, we sought to identify these knowledge deficits and assess residents’ confidence in transitioning patients to hospice. We also evaluated for the impact of prior palliative or hospice care experience.

A survey was designed assessing knowledge of hospice care and confidence in completing tasks related to hospice transitions. The survey encompassed information deemed important for internal medicine resident training by several palliative care physicians. Data collection is ongoing among internal medicine residents at an academic medical center. Descriptive statistical analysis of preliminary results was performed by calculating average confidence (CS) and knowledge (KS) scores. An equal variance t-test compared CS and KS between respondents with and without prior palliative or hospice care experience. Average scores for individual questions were qualitatively reviewed to identify specific knowledge gaps.

Twenty-nine respondents completed the CS section. Twenty-six respondents additionally completed the KS section. The average CS was 21.9/30 (Standard deviation, SD = 5.72). The average KS was 15.1/21 (SD = 3.05). Respondents with no palliative or hospice care experience had significantly lower average CS and KS (19.7/30 vs. 24.7/30, p=0.016 and 13.9/21 vs. 16.4/21, p=0.035, respectively). Less than half of respondents (14/29, 48.3%) expressed confidence in transitioning patients to hospice. Most respondents (18/26, 69.2%) had misconceptions about hospice insurance coverage. Only one respondent correctly identified criteria for general inpatient hospice (GIP) and no respondents correctly identified the tasks necessary for transitioning a patient to GIP.

Despite average CS and KS scores above 70%, our results indicated significant confidence and knowledge deficits, in particular related to coordinating end-of-life care. These deficits may be mediated by prior palliative or hospice care experience, suggesting an opportunity for integrating more dedicated palliative and/or hospice care training into internal medicine residency programs. IMPACT OF FRAILTY ON CLINICAL OUTCOMES IN ELDERLY PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT Kadir Buyukcelebi1; Viet Nghi Tran1; Tahira Qadeer1; Roman Dhital1; Alexandr Ceban1; Angela S. Saab1; Doan Ngoc Chau Nguyen2. 1Dept. of Internal Medicine, Resilience Healthcare - Weiss Memorial Hospital LLC, Chicago, IL; 2Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX. (Control ID #4271842)

Frailty is prevalent among the geriatric population, often causing hesitation in recommending invasive procedures such as Transcatheter Aortic Valve Replacement (TAVR). This study evaluates the impact of frailty on in-hospital outcomes among geriatric patients undergoing TAVR, aiming to guide clinical decision-making for this population.

We conducted a retrospective cohort study on elderly patients (age ≥65 years) undergoing elective TAVR from the National Inpatient Sample database (2017-2021), divided by frailty status. We performed pre- and post- matching analyses and used logistic and linear regression models to evaluate the independent effects of frailty on in-hospital outcomes, including mortality, cardiogenic shock, blood transfusion rates, and length of stay (LOS), adjusting for demographic, hospital factors, comorbidity, and the Elixhauser index. Advanced statistical techniques were used in both analyses to account for the survey-weighted structure of the database.

The pre-matching analysis included 270,025 admissions of geriatric patients undergoing elective TAVR, of whom 9,025 were classified as frail. Mortality rates were nearly identical between frail and non-frail patients (0.94% vs. 0.93%, p=0.94), and logistic regression confirmed no significant association between frailty and mortality (OR: 0.76, 95% CI: 0.45-1.26, p=0.281). Similarly, rates of cardiogenic shock were comparable (frail: 0.89% vs. non-frail: 0.82%, p=0.76), with no significant association detected in regression analysis (OR: 0.91, 95% CI: 0.55-1.51, p=0.717). Blood transfusion rates were also similar (frail: 3.21% vs. non-frail: 3.56%, p=0.47), though regression analysis suggested lower odds of transfusion in frail patients (OR: 0.65, 95% CI: 0.48-0.87, p=0.004). Length of stay (LOS) was slightly longer for frail patients (mean: 2.46 days, 95% CI: 2.30-2.63 vs. 2.39 days, 95% CI: 2.35-2.43), but adjusted analysis showed a marginal reduction in LOS associated with frailty (coefficient: -0.24, 95% CI: -0.42 to -0.07, p=0.006). Using propensity score matching (multivariate logit model, odds matching, no replacement, caliper: 0.2), 8,680 matched admissions were included in each group. Post-matching analysis showed no significant differences between frail and non-frail patients in in-hospital mortality (frail: 0.92% vs. non-frail: 1.32%, p=0.26, OR: 0.69, 95% CI: 0.35-1.38, p=0.29) or cardiogenic shock (frail: 0.92% vs. non-frail: 1.32%, p=0.26, OR: 0.68, 95% CI: 0.34-1.36, p=0.28). Blood transfusion rates were also similar (frail: 3.17% vs. non-frail: 4.44%, p=0.06, OR: 0.73, 95% CI: 0.50-1.07, p=0.11). LOS showed no statistical difference after matching (frail: 2.46 vs. non-frail: 2.67 days, coefficient: -0.20, 95% CI: -0.41 to 0.01, p=0.06).

Frailty in geriatric patients undergoing TAVR did not independently affect in-hospital mortality, cardiogenic shock rates, blood transfusion requirements, and length of hospital stay, supporting TAVR’s feasibility in frail patients. IMPACT OF RELATIONSHIPS ON ILLNESS PERCEPTION AND SELF-MANAGEMENT BEHAVIORS IN PROSTATE CANCER SURVIVORS WITH HYPERTENSION Rebecca Zeidman1; Abigail Feinberg2; Juan Wisnivesky2; Jenny J. Lin2. 1Internal Medicine, Lenox Hill Hospital, New York, NY; 2Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4214960)

Prostate cancer survivors are more likely to die from comorbidities, such as hypertension (HTN), than their cancer. Previous research has found that illness beliefs may impact self-management behaviors (SMB) for HTN. Additionally, spousal/partner support is important for improving clinical outcomes in both cancer patients and non-cancer patients with HTN. We assessed the impact of marital status on HTN illness beliefs and SMB in prostate cancer survivors with HTN.

Prostate cancer survivors with pre-existing HTN who had completed first-line cancer treatment or were under active surveillance were enrolled. Patients were interviewed every 6 months for 12 months. Beliefs about prostate cancer and HTN were assessed using the Brief Illness Perception Questionnaire (BIPQ). The Hypertension Self-Care Activity Level Effects (H-SCALE) questionnaire is a scored scale and was used to assess adherence to diet, physical activity, weight management, smoking, and alcohol intake recommendations relevant to HTN management. Physical activity was assessed with 2 questions and has a range of 0-14. Mann-Whitney U tests assessed the impact of marital status on SMB and illness beliefs at baseline and 12 months.

Of the 156 participants, the mean age was 69 years. One hundred and twenty reported they were married/partnered (77%) and 35 were single/widowed. Most had attended at least some college (85%) and had a monthly household income over $2,000 (82%). Fifty-nine percent identified as White, 23% as Black, 6% as Hispanic or Latino, and 10% as other race. There was no significant difference in race/ethnicity between married/partnered and single participants. Additionally, there were no significant differences in illness beliefs, diet or weight management SMB by partnership status. At baseline, participants who were partnered reported more physical activity compared to those who were unpartnered (8 vs 5; p≤ 0.05). However, at 12 months, unpartnered participants reported increased engagement in physical activity, while physical activity for those who were partnered was unchanged (+2 vs 0, p≤ 0.05).

We found that partnership status may influence changes in physical activity among prostate cancer survivors with HTN. While it was surprising that unpartnered participants increased their physical activity, our results suggest that participation in this longitudinal study may have provided a source of support and encouraged participants to engage in exercise. Future studies can assess which interventions increase physical activity among these cancer survivors to improve overall morbidity and mortality. LEVERAGING ELECTRONIC MEDICAL RECORD DATA TO IDENTIFY MODIFIABLE CONTRIBUTORS TO POTENTIALLY PREVENTABLE ACUTE CARE USE IN DEMENTIA Stephanie Nothelle1; Lauren Russell1; Julia Loosen1; Claudia Boscio2; Cynthia Boyd1; Jennifer Wolff3. 1The Johns Hopkins University School of Medicine, Baltimore, MD; 2Ponce Health Sciences University, Ponce, Ponce, Puerto Rico; 3Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4272433)

Persons living with dementia (PLWD) are at increased risk of potentially preventable hospitalizations and emergency department visits (acute care visits), but modifiable contributors are poorly understood. We aimed to identify potentially modifiable factors from patient secure portal messages and outpatient clinical notes in the 30 days leading up to a potentially preventable acute care visit.

We examined data from the Johns Hopkins Health System electronic medical record from 2017-2022. We included adults >64 years with 2+ primary care visits during the study period, ICD-10 diagnoses of dementia and 1+ advanced chronic illness (advanced liver disease, chronic obstructive pulmonary disease, congestive heart failure, diabetes with complications, chronic kidney disease), and a potentially preventable acute care visit (per the Agency for ICD code-based quality metric). Two coders coded each message or note using a qualitative content analysis approach.

We examined 179 outpatient notes and 284 portal messages from 130 PLWD. We identified four themes regarding potentially modifiable contributors to the acute care episode: (1) Medication management was present in both notes and messages, with commonly noted discrepancies across personal and health system medication lists. Within notes only, clinicians frequently documented concerns about adherence. (2) Access to care was noted in both notes and messages and included challenges in scheduling specialty appointments and affording medications. (3) Care Coordination was a pervasive theme in messages, but not notes, and captured issues with communication across settings such as transmittal of orders, or patients and families using a message to update a clinician about changes to their care plan by another clinician. (4) Chronic Disease Self-Management was present in notes but not messages and included dementia-specific challenges to following recommendations like adhering to a medication schedule or dietary recommendations.

Portal messages and outpatient clinical notes prior to a potentially preventable acute care visit contain information about unmet care needs. Needs identified in this analysis may be addressable by a care manager to prevent unnecessary acute care use. LONG TERM OUTCOMES OF SURVEILLANCE MAMMOGRAPHY AMONG OLDER WOMEN WITH A HISTORY OF BREAST CANCER Ilana Richman1; Meghan E. Lindsay2; Meera Sheffrin3; Jessica B. Long4; Eliza Epstein5; Elizabeth Berger6. 1Department of Medicine, Yale University, New Haven, CT; 2COPPER, Yale School of Medicine, New Haven, CT; 3Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA; 4General Internal Medicine, Yale School of Medicine, New Haven, CT; 5Yale University School of Medicine, New Haven, CT; 6Department of Surgery, Yale University School of Medicine, New Haven, CT. (Control ID #4271280)

Current guidelines recommend annual surveillance mammography among women with a history of breast cancer. It is not known whether older women who have had breast cancer benefit from ongoing surveillance mammography. Surveillance mammography may detect early recurrence or a second primary breast cancer. However, surveillance mammography may also contribute to overdiagnosis, particularly among older women.

We used longitudinal data from SEER-Medicare to evaluate long term outcomes associated with surveillance mammography. Our cohort included women who had been diagnosed with non-metastatic breast cancer at age 67 or older, who continued surveillance mammography over the next 5 years, and who remained free of breast cancer. From among this group, we identified women who continued mammography over the next 2 year interval and those who did not. We followed women from time of that next mammogram (for those who continued surveillance), or a matched date (for those who did not), until diagnosis of a second primary breast cancer, death, or end of follow up at 12 years. We used competing risk regression, adjusting for characteristics of the initial breast cancer (stage and hormone receptor status), initial treatment (surgery, chemotherapy, radiation), use of endocrine therapy, age, race, frailty, comorbidities, Medicaid dual eligibility, and primary care use.

The cohort included 9,718 women, with a mean age of 81 years. Among the cohort, 4% were Black, 88% White, and 4% Hispanic. Most women had been diagnosed with early-stage (stage 0, 21%; stage 1, 54%) and hormone-receptor positive breast cancer (76%), initially. In the year before cohort entry, 45% had received endocrine therapy. All women had continued mammography for 5 years and cohort entry began in the next screening interval. At cohort entry, 77% continued mammography in the next screening interval and 23% did not. Women who continued mammography had on average 6.5 mammograms over the next 10 years while those who did not continue mammography in the next interval had an average 2.8 mammograms over the next 10 years. Continued mammography was associated with lower cumulative incidence of breast cancer death (5.23 breast cancer deaths (95% CI 4.70-5.84) per 100 women) versus 7.87 breast cancer deaths (95% CI 6.91-9.11) among those who did not continue mammography at 12 years. Continued mammography was also associated with higher cumulative incidence of second breast cancers compared to those who did not continue surveillance (6.03 breast cancers (95% CI 5.47-6.66) per 100 women versus 5.10 (95% CI 4.19-6.20).

Continued mammographic surveillance among older women with a history of breast cancer may reduce breast cancer mortality while also contributing to overdiagnosis. These data may help older women make informed decisions about the benefits and risks of continued mammographic surveillance. MEDICAL CANNABIS USE AMONG OLDER ADULTS WITH CHRONIC PAIN IN A PROSPECTIVE STUDY Justina L. Groeger3; Chenshu Zhang3; Yuval Zolotov3; Hanna Schoenbaum3; Haruka Minami1; Frances R. Levin2; Julia Arnsten3; Joanna L. Starrels3; Deepika Slawek3. 1Psychology, Fordham University, New York, NY; 2Psychiatry, Columbia University Irving Medical Center, New York, NY; 3Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY. (Control ID #4271614)

With increasing access to medical cannabis (MC) and decreased perception of harm from its use, older adults (>65 years old) are increasingly initiating MC for pain. However, little is known about high-risk MC use among older adults. High-risk characteristics of MC are high tetrahydrocannabinol (THC) content which can cause impaired cognition and inhaled route of administration which can cause chronic bronchitis. Thus, among older adults newly initiating MC for pain, we described prevalence of 1) high THC and inhaled MC at first use and 2) ever use of high THC MC over 18-months, and we examined whether these characteristics differed by unregulated cannabis (UC) use. We hypothesized that those using UC are more likely to initiate with inhaled and high THC MC and remain more likely to use high THC MC over time.

We conducted a secondary analysis of older adults in an 18-month prospective cohort of adults newly certified for MC for pain (11/2018 to1/2022). MC use was measured from web-based surveys every 2 weeks. Outcome variables were 1) any MC use, 2) predominant inhaled [ie. smoked flower or vape] route of administration of first MC use, 3) predominant high THC content of first MC use, and 4) any high THC use over the study period. We defined UC use as any use not from a state-registered dispensary (y/n) in the 30 days prior to baseline. To examine the association between UC use and the outcome variables, we conducted chi-square or Fisher’s exact tests.

Of 66 older adults, 22 (33%) used UC at baseline. Fifty-six (85%) used MC at least once during the study period; use of MC did not differ between those with (vs without) UC use (82% vs 86% p=0.63). Sixteen (29%) predominantly used inhaled products at first MC use; there was no difference between those with (vs without) UC use in inhalation as predominant initial route of MC administration (33% vs. 26%, p=0.59). Twenty-six (46%) predominantly used high THC content at first MC use; those with (vs without) UC use were more likely to predominantly use high THC content at first MC use (67% vs 37%, p=0.04). Over the study period, 48 (86%) reported use of any high THC MC, and there was no difference between those with (vs without) UC use (94% vs 82%, p=0.20).

Our findings suggest UC influences initial MC product preference; older adults with UC were more likely to initiate MC with high THC products. However, this difference was not sustained with >80% of both groups using high THC MC over the study period. While not a statistically significant difference, initial use of inhaled MC was more common among those with prior UC use and may be clinically meaningful. Our findings support a call for clinicians to ask older adult about their cannabis use and conduct harm reduction counseling, particularly about inhaled and high THC MC products. NATIONAL LANDSCAPE ASSESSMENT OF SEXUAL AND GENDER MINORITY INCLUSIVITY OF THE VA’S HOME BASED PRIMARY CARE SERVICES Joy L. Lee1; Michelle M. Hilgeman2; Tetla Menen3; Nicholas Sweeney4; Lorraine V. Stigar5; Jennifer Carnahan6. 1Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School TH Chan School of Medicine, Worcester, MA; 2Research & Development Service, Tuscaloosa VA Medical Center, Tuscaloosa, AL; 3Richard L Roudebush VA Medical Center, Indianapolis, IN; 4University of Massachusetts Chan Medical School TH Chan School of Medicine, Worcester, MA; 5Purdue University, West Lafayette, IN; 6Medicine, Indiana University School of Medicine, Indianapolis, IN. (Control ID #4270786)

Sexual and gender minority (SGM) adults represent a growing and underserved segment of the older adult population. Older SGM Veterans are more likely to require home care services to support aging in place. However, mistrust in the healthcare system and discrimination may deter them from seeking these supports. Health systems, including the U.S. Department of Veterans Affairs (VA), may lack programs, services, and staff equipped to provide identity-affirming care for this population. The objective of this landscape analysis was to assess team awareness, readiness, and experiences with older SGM veterans within the VA’s Home Based Primary Care (HBPC) program to identify gaps and opportunities for catalyzing change.

Using a multi-method approach, we conducted a 20-question survey of VA HBPC staff nationwide via email, five focus groups with HBPC staff at select sites, and interviewed four SGM Veterans enrolled in HBPC with their caregivers. Survey responses were analyzed using descriptive statistics. Focus groups and interviews were transcribed and analyzed using thematic coding to identify key themes.

From approximately 10,000 HBPC staff invited to participate, 321 completed the survey. Respondents included clinicians (44%; e.g., nurses, psychologists, physicians), social workers (20%), other staff (20%; e.g., nutritionists, administrators), and therapists (11%; i.e., occupational, physical, or speech). Most respondents reported minimal training on SGM care, with over half (54%) receiving three hours or less in the past five years, and 12% reporting no training at all. Despite the lack of training, 43% strongly agreed they were aware of the unique challenges faced by SGM Veterans, with another 46% somewhat agreeing. Regarding community resources for SGM Veterans, 71% expressed confidence in finding a respite facility safe from discrimination, but only 61% believed they could find an affirming one. Similarly, 29% expressed uncertainty in their ability to find affirming homemaker services, compared to 25% for finding safe ones. Focus groups revealed that staff had limited experience with SGM veterans. The groups highlighted concerns about the inclusivity of community resources and expressed a strong desire for training in gender-affirming care for transgender Veterans. They also noted the reluctance of some SGM Veterans to be fully “out” with VA staff. In Veteran interviews, Veterans noted appreciation for HBPC services but also endorsed high degrees of social isolation.

Our national landscape assessment found that many HBPC staff harbor concerns about the inclusivity and affirming nature of both VA and external services. HBPC care complements SGM care. Leveraging the synergy between these approaches can enable the VA’s HBPC program to deliver exemplary, affirming care for SGM veterans, fostering inclusivity and trust in the healthcare system. NAVIGATING THE HOME CARE LANDSCAPE FOR MEDICARE BENEFICIARIES: FINDINGS FROM A SECRET SHOPPER STUDY Peggy B. Leung, Abigail Shilvock, Jennifer Sugijanto, Daniel Spertus, Madeline R. Sterling. Weill Cornell Medicine, New York, NY. (Control ID #4251048)

Home health care (HHC) provides skilled nursing, physical and occupational therapy and some aide services to either to ease the transition from hospital-to-home, or to mitigate an acute worsening of symptoms at home. Despite the benefits of HHC, data suggest challenges exist with obtaining timely and adequate services. Here, we investigate the real-world experiences of Medicare beneficiaries and caregivers navigating HHC, specifically their ability to access services, time to start of care, hours provided, and the cost of additional services.

We conducted a secret shopper study of all Medicare Certified Home Health Agencies (CHHAs) in New York State between February 2024 and March 2024. A trained investigator, posed as a family caregiver seeking home care for an older adult with Medicare, contacted CHHAs by telephone using a standardized script. Qualitative and quantitative data were collected on: 1) ability to provide HHC, 2) acceptance of Medicare 3) time to start of care for HHC, 4) hours of HHC, and 5) cost per hour for additional services. Medicare’s Home Health Compare was used to obtain demographic and quality ratings (range 0 to 5). We used descriptive statistics to characterize characteristics and outcomes; we performed a thematic analysis of call notes.

Of 110 total CHHAs in New York, 86 were able to be contacted; of these, 48 (55.8%) were non-profit, 29 (33.7%) were for-profit, and 9 (10.5%) were government owned. They had a mean quality score of 3.37 (SD 0.74). Most were available for skilled nursing (72%) and unskilled aide services (66%), often citing workforce shortage(s) as limiting factors. 93% accepted Medicare. 78.9% could obtain insurance approval for HHC within a week, and 67.4% could perform an in-home start of care nursing evaluation within a week, but only 53.5% could start services within a week. 24.4% CHHAs offered an estimate to hours of HHC covered (ranging from 1-3x per week for 2-to-8-week duration), while 75.6% couldn't estimate due to evaluation factors. Only 5% offered private pay skilled services ($115-$300 per visit for nursing; $145-$230 for PT). 23.3% of CHHAs provided an hourly aide rate, with a mean rate of $35.60 per hour. The qualitative analysis of call notes` revealed three main themes: 1) numerous barriers to accessing HHC for patients and families, 2) HHC access and timeliness of start of care is highly variable; and 3) the call experience including obtaining key pieces of information is inconsistent across CHHAs.

While most CHHAs have the capacity to provide HHC services, delivering them in a timely manner remains problematic. Workforce shortages and cost impact service type and intensity. Patients and families may have trouble obtaining information and navigating the process of obtaining HHC. Improvements to accessing and paying for HHC are needed. OPTIMIZING ANTIPSYCHOTIC USE IN ELDERLY PATIENTS: ASSESSING PRESCRIPTION TRENDS AND SPECIALIST INVOLVEMENT IN ACUTE CARE SETTINGS Masaji Saijo1; Hisae Tanaka1; Kohei Hasebe2; Shadia Constantine1. 1Primary Center, Sapporo Tokushukai Hospital, Sapporo, Hokkaido, Japan; 2Sapporo Keijinkai Rehabilitation Byoin, Sapporo, Hokkaido Prefecture, Japan. (Control ID #4271177)

Japan’s aging population poses significant healthcare challenges, including rising costs and complex clinical scenarios. Hospital stays average 16 days—among the longest in OECD countries—and are often associated with polypharmacy and potentially inappropriate medications (PIMs). At our acute care hospital, delirium is common among elderly patients, frequently leading to antipsychotic use. Some patients are discharged to post-acute care facilities with antipsychotics, potentially hindering rehabilitation outcomes. This study evaluates antipsychotic use in elderly patients by assessing discharge rates of newly initiated antipsychotics, commonly prescribed agents, and the role of geriatric nurse consultations.

This retrospective cohort study analyzed electronic health records of elderly patients discharged from our institution between April and October 2024. We examined antipsychotic prescriptions, including type, indication, initiation during hospitalization, and involvement of specialists (geriatrics, psychiatry). Primary outcomes included the prevalence of new antipsychotic prescriptions at discharge and the frequency of specialist consultations.

Of 5,473 patients discharged during the study period, 254 were prescribed antipsychotics on a scheduled basis, with 22 receiving new prescriptions during hospitalization. Patient ages ranged from 52 to 99 years, with a mean age of 80.0 years. Risperidone and quetiapine were the most frequently prescribed agents. The primary indications were delirium, behavioral and psychological symptoms of dementia (BPSD), and insomnia, although documentation was inconsistent. All patients prescribed antipsychotics were evaluated by a psychiatrist, geriatrician, or dementia-care specialist. Eleven patients (50%) experienced a decline in activities of daily living (ADLs) compared to before hospitalization, which increased to 63.6% in patients aged 85 years or older.

Polypharmacy, defined as the use of six or more medications, is common in Japan and has been linked to poor rehabilitation outcomes. Matsumoto et al. reported polypharmacy in 43.8% of stroke patients in rehabilitation, with 64.8% prescribed at least one PIM, such as antipsychotics, benzodiazepines, or PPIs. Hasebe et al. found 9.1% of patients were transferred to post-acute care with antipsychotics initiated during hospitalization, rising to 12.1% in those aged 85 or older. At our institution, half of patients experienced a decline in ADLs with scheduled antipsychotics started during hospitalization, raising concerns about their impact on recovery. These findings highlight the need to optimize medication management and minimize PIM use in elderly patients. PHYSICIAN AND ADVANCED PRACTITIONER CONTRIBUTIONS TO CLINICAL CARE IN THE NURSING HOME: PERCEPTIONS OF NURSING HOME ADMINISTRATORS, CLINICIANS, AND DIRECT CARE STAFF Brandi Peacock1; Tetyana Shippee2; Kira Ryskina1. 1Medicine, University of Pennsylvania, Philadelphia, PA; 2Regents of the University of Minnesota, Minneapolis, MN. (Control ID #4269779)

The US nursing home (NH) physician workforce has experienced significant changes over the past decade. While the number of practitioners who see NH patients declined, physicians and nurse practitioners (NPs) who focus their practice on NHs nearly tripled, with NPs providing half of all visits. Yet, little is known about how other NH staff view the role of these clinicians in providing quality NH care.

This qualitative study used a grounded theory approach to analyze data collected from semi-structured interviews at 47 NHs in February–November 2023. Purposive sampling was used to recruit participants from a nationally representative sample of NHs into two groups: (1) 20 high performing and (2) 27 low performing NHs. The Nursing Home Compare metrics on residents’ outcomes (e.g., change in functional status) were used to categorize NHs as high vs. low performing. Eligible participants included all clinical and non-clinical staff who spoke English. A total of 65 participants (33 in high- and 32 in low-performing facilities) completed one-time telephone interviews.

Participants included administrators (35%), physicians or advanced practitioners (17%), nurses or nurse administrators(27%), and other staff (21%, e.g. social workers). Most of the participants were female (72%), white (86%), and 40 years old or older (60%). Three major themes emerged. First, NH staff valued clinician characteristics other than clinical expertise in NH care. Those characteristics included accessibility to NH staff, continuity of care and relationship with residents, bedside manner, teaching ability, and regulatory knowledge. Second, administrators and clinicians differed in their perceptions of the role of clinicians in care coordination: administrators did not perceive care coordination as a key responsibility of NH clinicians. Third, all participants shared concerns about external barriers to high-quality physician and advanced practitioner practice in the NH (e.g., remote location, limited access to subspecialists, challenges related to electronic medical records interoperability). Participants in low-performing NHs placed greater value on on-site presence of physicians or advanced practitioners, compared to the participants in high-performing NHs.

Key NH staff identified external barriers to and characteristics of high-quality physician/advanced practitioner care in the NH. The findings highlighted the importance of non-clinical attributes, the need for role clarity in care coordination, and addressing external barriers to enhance the quality of physician and advanced practitioner contributions in NHs. Stratified analyses suggest that daily on-site presence may not be a prerequisite to high quality clinician care in NHs. PRIMARY CONCERNS AND SELF-MANAGEMENT STRATEGIES AMONG OLDER ADULTS WITH ADVANCED CANCER Georgeann Booth1; Mazin Rahman1; Margaret Q. Rosenzweig2,3; Yael Schenker3,4. 1University of Pittsburgh School of Medicine, Pittsburgh, PA; 2University of Pittsburgh School of Nursing, Pittsburgh, PA; 3Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA; 4Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4273143)

Older adults receiving cancer treatment experience steep declines in quality of life. Seeking to understand the salient concerns of this historically understudied population can help to inform palliative oncology delivery models for older adults who are living longer with cancer. Consequently, we conducted a secondary analysis of audio-recorded primary palliative care visits with oncology infusion room nurses to characterize the concerns and self-management strategies (SMS) of older patients with advanced cancer.

We conducted a cluster-randomized controlled trial of an oncology nurse-led primary palliative care intervention for patients with advanced solid tumors receiving care at 17 community oncology clinics in the Mid-Atlantic region from 2016-2020. All visits were led by oncology infusion room nurses trained to address palliative care needs. Of 672 patients enrolled, 336 were randomized to the intervention arm, of this group, 179 were age 60 or older and the focus of this analysis. Audio-recorded initial study visits (N=179) were transcribed using TranscribeMe, Inc. We conducted a qualitative descriptive content analysis using mixed inductive and deductive methods. All transcripts were reviewed by two coders with disagreements resolved by consensus.

Patients were a mean age of 72+/-8 years, 51% (92/179) female, and primarily white (175/179, 98%). They were most frequently diagnosed with lung cancer (71/179, 40%) followed by gastrointestinal (28/179, 16%) and hepatobiliary cancers (27/179, 15%). Of the 19 patient concerns identified, the most frequent patient concerns were physical in nature with fatigue being the most common (78%, 140/179) followed by pain (54%, 96/179), and loss of appetite (53%, 94/179). Outside of physical symptoms, the most common patient concerns were feelings of anxiety (47%, 84/179), functional limitations (45%, 81/179), depressed mood (36%, 65/179), and issues with access and quality of care (31%, 55/179). Only one patient had no concerns. On average, patients had 5 concerns per visit. Of the 19 SMS identified, patients most frequently used supportive medications (64%, 115/179) followed by relationship with family (62%, 111/179), positive thinking (50%, 90/179), and using a nutrition plan (48%, 86/179).

Self-management strategies are increasingly recognized as a promising target for reducing symptom burden and empowering patients with cancer. Understanding the patient concerns and self-management strategies being employed by older adults with cancer can help to inform future palliative interventions in this growing patient population. PROVISION OF AIR CONDITIONING IN NURSING HOMES AND MORTALITY DURING EXTREME HEAT: A CASE-CROSSOVER STUDY IN ONTARIO, CANADA Gabrielle M. Katz3; Kevin A. Brown4,5; Sping Wang7; Aidin Kerem7; Qing Huang7; Vasily Giannakeas6,5; Kamil Malikov7; Michael Hillmer7,5; Nathan M. Stall1,2. 1Division of Geriatric Medicine, Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; 2Division of General Internal Mediine and Geriatrics, Sinai Health, Toronto, ON, Canada; 3University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; 4Public Health Ontario, Toronto, ON, Canada; 5University of Toronto Dalla Lana School of Public Health, Toronto, ON, Canada; 6Women's Age Lab, Women's College Hospital, Toronto, ON, Canada; 7Digital and Analytics Strategy, Government of Ontario Ministry of Health, Toronto, ON, Canada. (Control ID #4271516)

Extreme heat poses a serious health risk to older adults, and many nursing homes lack air conditioning (AC). In July 2020, Ontario, Canada promised to mandate AC in nursing homes, and nearly all (99%) had AC by May 2023. We examined mortality during extreme heat days in nursing homes with AC compared to homes without AC.

A time-stratified, case-crossover study of nursing home residents (n=615 homes) in Ontario, Canada from 2010-2023 during warm months (June–September). The study was self-controlled, with case days defined as when nursing home residents died of any cause and control days defined as 14 days prior to the date of death. An extreme heat day was defined as any day ≥90th percentile of heat index (incorporates ambient temperature and relative humidity) for that respective nursing home location during the study period. We applied logistic regression models over multiple lag periods (lag 0, 0-1, 0-3, 0-6 days) to calculate the relative odds ratio (ROR) of mortality on extreme heat days in nursing homes with AC compared to homes without AC.

There were 40,255 deaths in nursing homes with AC (mean [SD] age 86.8 [8.8], 65.6% women) and 33,323 deaths in nursing homes without AC (mean [SD] age 87.2 [8.7], 64.8% women). When the AC mandate was announced in July 2020, homes without AC (44.7%) were predominantly for-profit ownership (p<0.001) and had more residents per room (p<0.001). AC was associated with a significantly lower odds of mortality on extreme heat days (ROR=0.93, 95%CI=0.87-0.99). The association was significant across lag periods 0-1 days (ROR=0.93, 95%CI=0.87-0.99) and 0-3 days (ROR=0.92, 95%CI=0.87-0.99), but not 0-6 days (ROR=0.95, 95%CI=0.89-1.02).

Mortality was lower during extreme heat days in nursing homes with AC compared to homes without AC. Lagged results suggest the effects of extreme heat persisted 3 days beyond the initial exposure. AC provision in nursing homes and other congregate care settings may be important for preventing mortality in older adults during extreme heat. RACIAL AND ETHNIC DIFFERENCES IN END-OF-LIFE CARE FOR OLDER ADULTS WITH DEMENTIA Deborah M. Oyeyemi Walton1,2; Debra Saliba3; Ryo Ikesu1; Keith C. Norris1; Anne Walling4; Alexandra M. Klomhaus4; Haiyong Xu1; Hiroshi Gotanda2; Yusuke Tsugawa1. 1General Internal Medicine & Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; 2Medicine, Cedars-Sinai Medical Center, Los Angeles, CA; 3Medicine -Geriatrics, UCLA Borun Center, VA GRECC, RAND, Los Angeles, CA; 4Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4264964)

End-of-life care is a key component of dementia care. Evidence is limited as to whether end-of-life care for persons with dementia differs by race and ethnicity. The primary objective of this study was to evaluate for racial and ethnic differences in end-of-life care among older adults with dementia, and to determine whether physician practice pattern variations explained these differences.

We conducted a retrospective cohort study of Medicare Fee-for-Service beneficiaries aged 66 years or older with a diagnosis of Alzheimer’s disease or Alzheimer’s diseases related dementia, who had died between 2016 and 2019. The following end-of-life care and outcome measures were evaluated by race and ethnicity, with and without adjustment for physician fixed effects (effectively comparing treatment by the same physician): receipt of billed advance care planning before death; palliative care counseling and hospice use in the last 180 days of life; emergency department, hospital, and intensive care unit use, mechanical ventilation or cardiopulmonary resuscitation, and feeding tube placement in the last 30 days of life; and death in an acute care hospital.

Among 259,945 decedents with dementia (mean age 85.8 years, 60.4% female), 11,368 (4.4%) were Hispanic, 21,678 (8.3%) were non-Hispanic Black, and 226,899 (87.3%) were non-Hispanic White. After adjusting for potential confounders, Hispanic and non-Hispanic Black decedents with dementia were (1) more likely to receive billed advance care planning and palliative care counseling (2) less likely to receive hospice, (3) more likely to receive emergency department, hospital, or intensive care unit care, and (4) more likely to die in a hospital than non-Hispanic White decedents. These findings were qualitatively unchanged (except for hospice use) when we compared decedents treated by the same physician.

Despite higher utilization of billed advance care planning and palliative care counseling, Hispanic and non-Hispanic Black older adults with dementia experienced more intensive end-of-life care than their non-Hispanic White counterparts, even when they were effectively treated by the same physician. REDUCING THE BURDEN ON FAMILY CAREGIVERS OF PERSONS WITH ALZHEIMER'S THROUGH AN AI-BASED NEGOTIATION PROGRAM Celie Joblin1; Alaine Murawski1; Vanessa Ramirez-Zohfeld1; Charlie Olvera1; Lee Lindquist2; Johnathan Mell3; Jeanne Brett4. 1Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; 3Computer Science, University of Central Florida, Orlando, FL; 4Kellogg, Northwestern University, Evanston, IL. (Control ID #4272269)

When caring and advocating for persons with Alzheimer’s dementia (PWD), family caregivers (CGs) often experience conflicts that lead to CG burden. Examples of conflict include the PWD refusing help resulting in safety issues and sibling disagreements on the type of support needed for the PWD. To address this, we developed NegotiAge, a virtual artificial intelligence (AI)-based intervention to teach family CGs how to negotiate to create win-win scenarios. We then evaluated whether NegotiAge had an impact on family CG emotions and burden.

We carried out a national multiphase optimization strategy (MOST) factorial trial of NegotiAge with family CGs of PWD. The CGs were randomized to 1 of 8 conditions and negotiated conflict scenarios in real-time with AI-powered avatars simulating realistic behavioral and emotional interactions. We measured CG burden (Zarit) and positive and negative mood (PANAS) between baseline (T1) and 1-month post NegotiAge intervention (T3). We used dependent sample t-tests to analyze results.

Across 23 states, 132 family CGs of PWD (mean age 54 yrs, 77% female, 37% URM) completed the study. CG burden was significantly reduced (-3.24, p<0.002) between T1 and T3 and was significantly reduced in subjects who received two or more activities vs one (-5.28, p<0.04). Qualitative analyses of CG statements further supported these findings: “There was a time when my mother was sad and crying. Because of the training I was able to calm her.”; “I consciously thought out my 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.” We also observed a significant improvement (reduction) in Negative Affect (mean change=-2.1, SD=5.7, t=4.1, P<0.0001) between T1-T3.

NegotiAge, a virtual, AI-based negotiation training, significantly reduced burden and improved negative affect among family CGs of PWD. Engaging in more negotiation practice (2 or more NegotiAge activities) compared to just 1 activity further alleviated the burden for caregivers. NegotiAge has the potential to improve the lives of family CGs in caring for PWD. Further testing is needed to assess the impact on PWD, additional CG outcomes, and long-term effects. RELIGIOUS OR SPIRITUAL BELIEFS IN PATIENT-HEALTHCARE PROVIDER RELATIONSHIPS: A NATIONALLY REPRESENTATIVE SURVEY OF US ADULTS AGED 50-80 Jeffrey T. Kullgren1,2; LJ Brazier2; Preeti Malani2; Matthias Kirch2; Dianne C. Singer2; Erica Solway2; Scott Roberts2; Sydney Strunk2; Adam Marks2. 1VA Center for Clinical Management Research, Ann Arbor, MI; 2University of Michigan, Ann Arbor, MI. (Control ID #4273482)

Religious or spiritual beliefs can offer meaning and comfort to older adults facing health challenges. Consequently, providers are encouraged to ask routinely about such beliefs and to tailor their care accordingly. Yet, little is known about what older adults expect from patient-provider relationships around religious or spiritual beliefs.

In July 2022, 2,163 participants 50-80 years of age from the NORC AmeriSpeak panel completed a survey online or by telephone for the National Poll on Healthy Aging (completion rate 75%). All respondents were asked how important religious or spiritual beliefs were in their own life. Those whose religious or spiritual beliefs were somewhat or very important to them were asked if they were comfortable discussing their beliefs with providers, would like providers to inquire about their beliefs, felt it was important that their providers have similar beliefs, and had ever discussed their beliefs with a provider. Logistic regression was used to estimate associations between respondents’ age, gender, education, race/ethnicity, Census region, income, physical health, mental health, importance of religious or spiritual beliefs, and responses to each measure. Marginal estimates of the adjusted prevalence of each outcome are reported as a function of respondents’ characteristics. Analyses used sample weights to generate nationally representative estimates.

Overall, 83.7% of US adults aged 50-80 reported their religious or spiritual beliefs were somewhat or very important in their life. Among older adults whose religious or spiritual beliefs were somewhat or very important, 69.5% agreed they were comfortable discussing their beliefs with providers, 27.6% agreed they wanted providers to inquire about their beliefs, 16.4% agreed it is important their providers have similar beliefs, and 26.1% had discussed their beliefs with a provider. Compared with those whose religious or spiritual beliefs were somewhat important, those whose beliefs were very important were more likely to agree they were comfortable discussing their beliefs with providers (76.6% vs. 55.2%, P < 0.001), wanted providers to ask about their beliefs (34.5% vs. 13.3%, P < 0.001), and felt it important their providers have similar beliefs (20.5% vs. 7.2%, P < 0.001); and to have ever discussed their beliefs with a provider (33.1% vs. 11.4%, P < 0.001).

The majority of US adults aged 50-80 have religious or spiritual beliefs that are important to them. Among those with important beliefs most feel comfortable discussing them with providers, but few want providers to inquire about their beliefs, want to know or prefer concordance with providers’ beliefs, or have discussed their beliefs with a provider. Thus, older adults may prefer discussing their religious or spiritual beliefs with providers when they arise naturally during healthcare conversations, rather than providers routinely asking about them. SAFETY OF PERCUTANEOUS CORONARY INTERVENTION IN GERIATRIC PATIENTS WITH FRAILTY Viet Nghi Tran1; Doan Ngoc Chau Nguyen2; Tahira Qadeer1; Amal Qureshi1; Sila Cetik1; Ayat Alhakeem1; Sabah Khan1. 1Dept. of Internal Medicine, Resilience Healthcare - Weiss Memorial Hospital LLC, Chicago, IL; 2Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX. (Control ID #4271263)

Frailty is common among elderly patients and is often perceived as a risk factor for adverse outcomes of any procedure. Although percutaneous coronary intervention (PCI) can be a life-saving intervention in patients with acute coronary syndromes or coronary artery disease, the independent impact of frailty on in-hospital outcomes of PCI remains incompletely understood. This study aims to clarify the safety profile of PCI in geriatric patients with frailty, providing insights to guide decision-making and risk stratification.

We conducted a retrospective cohort study using the National Inpatient Sample (NIS) from 2017 to 2021, focusing on patients aged 65 and older who underwent PCI, categorized by frailty status. Primary outcomes were in-hospital mortality and length of stay (LOS). Logistic and linear regression models, adjusted for demographic factors, comorbidities, and hospital characteristics, were used to assess the impact of frailty. Propensity score matching was applied to minimize confounding, with weighted analyses pre- and post-matching to reflect the NIS’s survey structure.

Among 1,258,085 admissions meeting the criteria, 4,510 involved frail patients. Frail patients were older (80.4 vs. 74.9 years) and had higher Charlson Comorbidity Index scores, with a crude in-hospital mortality rate of 6.2% compared to 4.1% in non-frail patients (p=0.002). However, adjusted analyses revealed no significant increase in mortality due to frailty (OR 1.05, 95% CI 0.78-1.43, p=0.716). This finding was further confirmed in post-matching analyses, which showed no significant difference in mortality between frail and non-frail groups, with p-values of 0.251 for mortality rates (6.04% in frail vs. 4.76% in non-frail) and 0.252 for logistic regression (OR 1.29, 95% CI 0.84–1.98). On the other side, LOS was longer for frail patients, averaging 6.53 days (95% CI 6.11-6.95) compared to 4.40 days for non-frail patients (95% CI 4.37-4.43). This difference remained statistically significant after adjustment (coefficient 1.18, 95% CI 0.77-1.59, p<0.001). Post-matching analysis also confirmed frailty associated with prolonging LOS, with a coefficient of 1.04 (95% CI 0.47–1.60, p < 0.001) from multivariate linear regression.

Frailty is associated with prolonged length of hospital stay but not with increased in-hospital mortality in elderly patients who undergo percutaneous coronary intervention. Therefore, frailty alone should not deter the use of PCI in the geriatric population. SEX AND RACIAL DIFFERENCES IN END-OF-LIFE CARE IN TEXAN LUNG CANCER DECEDENTS Myrna K. Serna3; Aimee Rodriguez2; Anjali Ramachandran2; Efstathia Polychronopoulou1; Margaret Goodrich3; Sean O'Mahoney3; Mukaila Raji3; Yong-fang Kuo1. 1Biostatistics & Data Science, The University of Texas Medical Branch at Galveston, Galveston, TX; 2The University of Texas Medical Branch John Sealy School of Medicine, Galveston, TX; 3Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX. (Control ID #4254176)

In Texas, the five-year survival rate for lung cancer is significantly lower compared to the national average. The aim of this study is to assess sex and racial differences in end-of-life healthcare utilization, advance care planning (ACP) and associated outcomes among Texan Medicare lung cancer decedents.

We analyzed Texas Cancer Registry linked with Medicare data for patients aged 66 years and older who died 6 months to 5 years after receiving a diagnosis of primary lung cancer from 2010-2018. Patient characteristics are reported using descriptive statistics. Chi-square test, t-test or ANOVA were used as appropriate for categorical or linear variables to assess statistically significant differences in healthcare utilization, ACP and associated outcomes between groups in the last 30 days of life. Multivariable logistic regression models were used to assess differences in odds of inpatient admission and hospice enrollment in the last 30 days of life.

A total 12,951 decedents were included with 6,868 (53%) males and 6,083 (47%) females. Most (10,621 (82%)) patients were non-Hispanic White. Significantly more males had an emergency department (ED) visit, intensive care unit (ICU) admission, inpatient admission and more inpatient days when compared to females in unadjusted analyses. Males and females had low rates of ACP (<2%). However, more females were hospice enrolled. While multivariable logistic regression models did not show a significant difference in odds of inpatient admission, females had greater odds of hospice enrollment compared to males (odds ratio (OR) 1.28, 95% confidence interval (CI) 1.18-1.38). More non-Hispanic Black decedents, followed by Hispanic decedents, had ED visits, ventilator use, ICU admission, inpatient admission and more inpatient days in the last 30 days of life compared to non-Hispanic White decedents, respectively. ACP was low across all groups with no significant differences. More non-Hispanic White decedents were hospice enrolled. Multivariable logistic regression models showed that non-Hispanic Blacks had greater odds of inpatient admission (OR 1.39, 95% CI 1.21-1.60) and lower odds of hospice enrollment (OR 0.64, 95% CI 0.56-0.74) compared to non-Hispanic White decedents. Models also showed that Hispanics had more inpatient admissions (OR 1.38, 95% CI 1.19-1.59) and less hospice enrollment (OR 0.83, 95% CI 0.72-0.96) compared to non-Hispanic White decedents, respectively.

Among Texan Medicare lung cancer decedents, we found that males, non-Hispanic Black and Hispanic decedents had greater healthcare utilization and less use of hospice. These differences could be due to a variety of factors including cultural preferences and access to quality hospice and other services. ACP rates were low across all groups, possibly marking an important opportunity for providers to address patient priorities at the end-of-life. STIMULANT RELATED EMERGENCIES IN OLDER ADULTS: A CROSS-SECTIONAL TIME SERIES ANALYSIS Rachela Smith1; Nathan M. Stall3; Ania Sarnocinska5; Jagadish Rangrej4; Saad Rais4; Kamil Malikov6; Michael Hillmer4; Jonathan S. Zipursky2. 1Michael DeGroote School of Medicine, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada; 2Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada; 3Medicine, Sinai Health, Toronto, ON, Canada; 4digital analytics and strategy division, Government of Ontario, Toronto, ON, Canada; 5Health Data Science Branch, Government of Ontario Ministry of Health, Toronto, ON, Canada; 6Health Data Science Branch, Government of Ontario, Toronto, ON, Canada. (Control ID #4236211)

Most data on substance use in older adults have focused on alcohol, opioids, and cannabis yet there is growing concern about the use of other substances, including stimulants. Most people born between 1946-1964 (‘baby boomers’) are now over the age of 65 years, and this generation has historically used substances at higher rates than previous generations. While stimulant-related health care visits have increased over the last two decades, there are limited population-based data specific to older adults.

We conducted a population-based retrospective cohort study examining annual stimulant-related emergency department (ED) visits in older adults (≥66 years of age) between Jan 1/2010 and Dec 31/2023 in Canada’s most populous Province of Ontario (16-million residents). We used linked administrative data from the Ontario Ministry of Health, and the primary outcome was the annual rate (per 100,000 population ≥66 years) of ED visits in older adults for stimulant-related emergencies. We also examined demographic characteristics, medical comorbidities commonly associated with prescription stimulant use, and stimulant prescription fills. Statistical analyses were conducted using SAS v.9.4 (Cary, NC).

Between 2010 and 2023 there were 1,247 stimulant-related ED visits in older adults; median age was 69 years (IQR 67-73), 934 (74.9%) were male, and 579 (46.4%) were in the lowest income quintile. Rates of stimulant-related ED visits in older Ontarians increased from 1.4 to 12.6 per 100,000 population from 2010 to 2023. Among stimulant-related ED visits, 20 (1.6%) were preceded by a prescription fill for a psychostimulant drug within 90 days. 0 visits occurred in patients with narcolepsy, 23 (1.8%) with Parkinson’s disease, 8 (0.6%) with ADHD, and 34 (2.7%) in people living with dementia. 216 (17.3%) visits occurred in patients with a history of psychosis, 687 (55.1%) with substance use disorder, 415 (33.3%) with mood disorder, and 662 (53.1%) with anxiety disorder.

We observed a 9-fold increase in annual stimulant-related ED visits among Ontario older adults between 2010-2023. Few patients filled prescriptions for stimulants or had conditions commonly treated with stimulants. The observed increase in stimulant-related ED visits may be due to rising recreational stimulant use, misappropriation of prescribed stimulants, and increased risks of adverse drug events due to age-related physiological changes, polypharmacy, and multimorbidity. Healthcare providers should be aware of the rising harmful stimulant use in older adults, especially among low-income men and those with mental health and addictions disorders. Prescription and non-prescription stimulant use have been linked to an increased risk of adverse health outcomes in older adults including hypertension, stroke, myocardial infarction, and arrhythmia. Overall, there is a need for increased screening for stimulant use among older adults and enhanced clinical engagement to minimize substance-related harms. STRENGTHENING GERIATRICS TRAINING: A NEEDS ASSESSMENT FOR INTERNAL MEDICINE RESIDENTS Margaret Heller, Rachel Miller, Jessica Zuo, Eva P. Szymanski. Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4270530)

With an aging population, all internal medicine (IM) residency graduates should be skilled in geriatric principles. We gathered feedback from IM residents on our geriatrics curriculum for program evaluation and needs assessment.

Our geriatrics content is delivered through a well-established Aging and Transitions of Care theme in the IM ambulatory curriculum and required ACE unit rotation. In academic year 2023-24, we restarted nursing home and home care visits (on hold during Covid pandemic) and introduced inpatient geriatric conferences. To improve the curriculum, we developed a survey based on core geriatric IM competencies. Residents were asked to self-rate their performance on 15 geriatrics-related skills, provide free-response feedback on content areas of interest, and share planned career paths. The survey was distributed at the first geriatrics didactics of the year.

The response rate was 52% (98/189). PGY1s (46% of respondents) had not yet participated in the geriatrics curriculum, and self-rated performance was low in all areas. PGY1s who rated their performance as “very well” or “extremely well” ranged from 24% (incorporating patient goals into management plans) to 0% (evaluating cognitive impairment, performing geriatric assessment, identifying home/community resources). PGY2s and 3s had the highest self-rated performance in incorporating patient goals into management (55% rated “very well” or “extremely well”), recognizing and working up delirium (55% and 45% respectively) and guiding the advance care planning process (47%). Self-rated performance was lowest for recognizing and managing elder abuse (9%) and identifying home/community resources (8%). Stratifying PGY2s and 3s by program, primary care residents had 12 skills where at least 25% had high self-rated performance, compared to 7 skills for categorical residents.

There is variation in geriatrics skills based on IM program and training level. PGY1 data demonstrates a baseline high need across all domains, while PGY2s and 3s show improvement, especially in delirium management and incorporating patient goals. Upper-level primary care residents report higher performance than categoricals, but self-reported skills remain low in many areas. We plan to supplement this data with feedback from graduates and faculty, plus analysis of free-text responses. The results will help us strengthen the next iteration of our geriatrics curriculum for IM residents. THE ASSOCIATION BETWEEN PERCEIVED SOCIAL SUPPORT AND CARDIOVASCULAR DISEASE RISK IN A NATIONALLY REPRESENTATIVE SAMPLE OF OLDER ADULTS Joni S. Williams1,3; Zach M. Buehler2; Abigail Thorgerson3; Aprill Z. Dawson1,3; Rabia Amjad5; Leonard E. Egede4. 1Medicine, Medical College of Wisconsin, Milwaukee, WI; 2Northwestern Feinbgerg School of Medicine, Chicago, IL; 3Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI; 4University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY; 5Advancing Population and Health Science (CAPS), Medical College of Wisconsin, Milwaukee, WI. (Control ID #4273587)

Social support has been shown to improve health outcomes. However, the relationship betwen social support and health outcomes among older adults (≥50 years) is not well understood. Therefore, the study aim was to assess the relationship between perceived social support and cardiovascular disease (CVD) risk in a nationally representative sample of older adults.

Data for 30,899 adults (≥50 years) from the Health and Retirement Study (2006 – 2016) were analyzed. The dependent variables were binary indicators of CVD risk: Hemoglobin A1c (=7%); Systolic Blood Pressure (=180mmHg; Diastolic Blood Pressure (=90mmHg); Total Cholesterol (=200mg/dl). The independent variable was perceived social support measured as positive and negative social support from a spouse, children, family, or friends. Covariates included age, marital status, insurance, self-reported health, and comorbidities. Unadjusted and fully adjusted logistic regression models assessed the independent association between social support and CVD risk.

In the fully adjusted model, negative social support from a spouse was associated with a higher likelihood of poorly controlled A1c (OR=1.11; 95% CI,1.03-1.2). Positive social support from friends was associated with greater odds of high cholesterol (OR=1.07; 95% CI, 1.04-1.11). Positive social support from a spouse was associated with lower odds of poorly controlled A1c (OR=0.88; 95% CI, 0.81-0.95) 3) as well as lower odds of high cholesterol (OR=0.94; 95% CI, 0.9-0.99).

In this nationally representative sample of adults, negative support from a spouse was associated with poorly controlled A1c, while positive support from a spouse and friends was associated with lower A1c and higher cholesterol, respectively. Sources of perceived social support are targets for intervention to reduce CVD risk. TRENDS IN STATE VETERANS HOME STAFFING: DO THEY MEET THE NEW STANDARDS? Annie W. Yang1,2; Dana B. Mukamel4; Camilla B. Pimentel3; Christine W. Hartmann3. 1National Clinician Scholars Program at Yale University, New Haven, CT; 2VA Connecticut Healthcare System West Haven VA Medical Center, West Haven, CT; 3VA Bedford Healthcare System, Bedford, MA; 4University of California Irvine, Irvine, CA. (Control ID #4270240)

Nurse staffing impacts nursing home quality. The Centers for Medicare and Medicaid Services (CMS) recognizes the importance of nurse staffing and publicly reports these statistics on Nursing Home Compare and, in 2024, issued new Minimum Staffing Standards. Nearly 80% of nursing homes may not meet these standards. It is unknown how these new staffing standards may impact State Veterans Homes, which provide nursing home care to many veterans. The objective of this study is to answer the questions: (1) Do CMS certified State Veterans Homes meet these new staffing standards? (2) What are trends in State Veterans Homes Staffing over time?

We used the CMS Payroll Based Journal to identify CMS-certified State Veterans Homes and calculate quarterly staffing measures between 2018-2024. We calculated the following average staffing measures: registered nurse-only hours-per-resident-day (RN HPRD), licensed practical nurse (LPN) HPRD, and certified nurse assistant (CNA) HPRD. We also calculated “total-nurse” HPRD, which includes RN, LPN, and CNA hours. We compared these numbers to the 2024 CMS Staffing Standards. We assessed daily staffing variation using an “instability” measure, which represents the percentage of days in a quarter where staffing levels fell more than 20% below the quarterly average. To determine trends in nurse staffing over time, we constructed descriptive statistics of all measures.

Our sample included 109 CMS-certified State Veterans Homes. Between 2018-2024, average staffing levels remained largely stable. In the first quarter of 2024, the mean total-nurse HPRD was 5.0 (range 2.8-7.8), RN-only HPRD 1.1 (range 0.32-3.0), LPN 0.8 (range 0.2-2.0), and CNA 3.0 (range 1.6-5.1). When comparing the results from early 2024 to the new CMS Staffing Standards, about 4% (n=4) of State Veterans Homes were below the new total-nurse standards (3.48 HPRD), 11% below the RN-only standards (0.55 HPRD), and 17% below the CNA standards (2.45 HPRD). Between 2018-2024, the instability of LPN and CNA hours slightly increased then stabilized by early 2024, at 17% and 5%, respectively. Over the same period, the instability of total-nurse HPRD ranged between 25-29%.

State Veterans Homes have excellent staffing levels, which have been sustained over time. Most Homes will not be impacted by the new CMS staffing standards. Factors influencing the high staffing levels in CMS-certified State Veterans Homes’ over time should be studied further to identify practices that could be adopted by other community-based nursing homes. UNDERSTANDING PATIENT AND CAREGIVER PREFERENCES FOR DEMENTIA INTERVENTIONS: INSIGHTS FROM A SYSTEMATIC REVIEW OF METHODOLOGIES Ravi Gupta1; Michael J. DiStefano2; Jodi B. Segal3; Shanshan Lin1; Renee f. Wilson4; Halima Amjad3; Hyun Yi (Jacqualine) Woo4; Emily Mao3; Emmanuel F. Drabo4. 1Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD; 2University of Colorado Anschutz Medical Campus, Aurora, CO; 3Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; 4Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. (Control ID #4272993)

A growing number of studies explore interventions for dementia management, yet patients’ preferences remain poorly understood. Assessing these treatment preferences is challenging and may require methods tailored to cognitive abilities. As part of a systematic review about preferences for interventions for dementia treatment and management, we sought to classify methodologies used to evaluate patient preferences and examine how these methods have evolved over time.

We conducted a systematic search of PubMed, PsycInfo, and CINAHL through November 2024 to identify studies meeting our prespecified inclusion criteria. We identified studies that included individuals aged 55 or older living with mild cognitive impairment or Alzheimer’s disease and related dementias and examined medications, lifestyle interventions, caregiver interventions, or residential placement aimed at modifying cognition, function, quality of life, or other symptoms of dementia. Studies needed to also describe a preference from the patient or caregivers as surrogates about the intervention, an attribute of the intervention, or an outcome of the intervention. We used PICO Portal, a machine learning and natural language processing-based systematic review platform, to iteratively prioritize relevant abstracts. Two independent reviewers screened abstracts and reviewed the full text of included articles. We categorized the methodologies used by the included studies, overall and by publication year.

A total of 979 abstracts out of 8334 were screened, which was deemed sufficient to conclude that 86% of all potentially eligible articles were captured. Of the abstracts screened, 145 were retained for full text search, resulting in a total of 60 studies included, all published between 1985 and 2024. Most studies used surveys (45%) or qualitative individual interviews (33%) of patients or caregivers responding as surrogates. Less frequent was use of focus groups (10%), non-randomized interventional trials (13%), and randomized trials (7%). Five studies (8%) used discrete choice experiments to directly elicit preferences. A small number of studies involved both focus groups and interviews (8%), focus groups and surveys (5%), and surveys and interviews (7%). All studies using randomized trials and non-randomized interventions, whether involving discrete choice experiments or not, were published after 2008.

We found that most studies assessed patient or caregiver preferences for interventions regarding dementia management using surveys or interviews, with limited use of advanced preference-elicitation methods like discrete choice experiments. Methodological diversity has increased since 2008, highlighting a growing focus on more rigorous approaches to understand preferences. As treatment options for dementia expand, more robust methods are needed to ensure preferences of cognitively impaired patients and their caregivers align with their treatment goals. UNDERSTANDING PREDICTORS OF STRESS IN OBTAINING HOME CARE: FINDINGS FROM THE EMPIRE STATE POLL Daniel Spertus1; Megan Shen6; Joanna B. Ringel1; Judy J. Wang2; Kiran Abraham-Aggarwal3; Ariel C. Avgar3; David Grabowski4; Amanda Chen4; Lee Lindquist5; Madeline R. Sterling1. 1Medicine, Weill Cornell Medicine, New York, NY; 2New York Presbyterian Hospital/Weill Cornell Medicine, New York, NY; 3ILR School, Cornell University, Ithaca, NY; 4Department of Health Care Policy, Harvard Medical School, Boston, MA; 5Medicine - Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; 6Fred Hutchinson Cancer Center, Seattle, WA. (Control ID #4270320)

Most older adults prefer to age-in-place, but navigating home care (HC) is challenging. Indeed a recent national survey revealed that over 50% of adults 50+ years found the process to be anxiety producing and frustrating. However, less is known about what aspects of HC are most challenging from patient and family perspectives. We surveyed adults across New York state to 1) determine which individual-level characteristics were associated with stress when obtaining HC and to 2) identify the most challenging aspects of the HC process.

We added 6 novel questions in the Empire State Poll, an annual survey of adults aged 18+ residing in New York state, to assess perceptions of arranging HC. Questions asked how participants learned and paid for HC services, and the amount of stress the process caused. Self-reported stress (main outcome) was categorized on a five-point Likert scale ranging from “very stressful” to “not at all stressful;” we compared “very stressful” to all other responses. Participants were asked to describe the most challenging aspect of arranging HC in 1 open-ended question. We used a convergent parallel mixed-methods analytic approach. Quantitatively, we utilized chi-square and ANOVA tests to compare participant characteristics by stress level. We then used Poisson regression with robust standard errors to estimate the prevalence ratios for the association between an individual’s characteristics and a “Very stressful” response. Qualitatively, we coded all responses independently and resolved discrepancies with consensus.

Of the 3,394 participants surveyed, 27% (n=927) reported that they or a loved one had attempted to obtain HC services. Of the 912 participants who responded to the self-reported stress question, 25% (n=228) reported obtaining HC services was “very stressful”. Female gender (PR: 1.76, 95% CI: 1.21, 2.55), being married (PR: 1.57, 95% CI: 1.10, 2.25), paying for HC “out of pocket” (PR: 1.38, 95% CI: 0.96, 1.98), and how respondents learned about arranging HC (PR: 1.60, 95% CI: 1.14, 2.25) were independently associated with the process being very stressful. Qualitative analysis revealed 6 themes for primary challenges with HC: (1) finances, (2) service availability, (3) HC coordination, (4) quality of HC, (5) impact on personal life, and (6) comfort with providers. Participants who reported HC to be “very stressful,” identified finances, service availability, and HC coordination as the most challenging aspects at nearly twice the rate of those with less stress.

This state-wide, mixed-methods study found that married women and those paying for services beyond what insurance covers, experience high stress levels when obtaining HC. Among those who experience high stress, factors like financing, access, and coordinating HC were the main challenges. These results underscore the need for system and policy-level solutions to simplify obtaining HC. “I AM IN CONTROL OF MY DECISIONS”: IMPACT OF LOCUS OF CONTROL ON ADVANCE CARE PLANNING DECISION-MAKING AMONG OLDER ADULTS WITH HIV Laura Pax1; Emily Pinto Taylor2; Hafsa Bhatty4; Molly M. Perkins4; Vincent Marconi3; Sean Halpin4. 1Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2General Internal Medicine, Emory University School of Medicine, Atlanta, GA; 3Infectious Diseases, Emory University School of Medicine, Atlanta, GA; 4Emory University School of Medicine, Atlanta, GA. (Control ID #4271615)

Antiretroviral therapy (ART) has measurably increased life expectancy of people with HIV (PWH)(1). Consequently, approximately half of PWH in the US are over 50 years old(2). However, many have not engaged in advance care planning (ACP), such as completing an advance directive, and current HIV primary care guidelines do not address ACP(3). Further, low-income individuals are less likely to engage in ACP than wealthier counterparts(4). We aimed to better understand barriers and facilitators to ACP, specifically among low-income PWH, who have historically lower engagement in ACP.

We used a thematic analysis approach (5) to analyze transcripts from semi-structured interviews conducted among PWH, who were recruited from an urban comprehensive HIV clinic in the Southeast that serves a low-income population. Interviews were conducted as part of a broader study, and assessed social and structural factors that shape health outcomes among PWH, while this current study evaluated the impact of these factors on ACP.

Twenty-four PWH ages 50-64 (mean age 55) participated. Ninety-six percent of participants identified as African-American. Interviews ranged from 30-300 minutes (mean 150 minutes). Fifty-seven percent of participants indicated that they had not engaged in any ACP for end of life. Interconnected themes emerged, including poverty, relationships, and community. Overarching themes were identified as internalized and externalized locus of control.

Our analysis suggests that an externalized locus of control can be accompanied by a sense of powerlessness, which can reinforce learned helplessness. This can be a significant barrier to engaging in effective ACP, as patients may not believe their wishes will be followed. An internalized locus of control can diminish this helplessness, allowing for self-trust which can result in effective ACP. These results have important implications for HIV care providers. We recommend that practitioners be trained to have trauma-informed ACP discussions, which may lead to more goal-concordant care at the end of life. 1. Marcus JL, Chao CR, Leyden WA et al. Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care. J Acquir Immune Defic Syndr. 2016 Sep 1;73(1):39-46. 2. Centers for Disease Control and Prevention. Diagnoses, Deaths, and Prevalence of HIV in the United States and 6 Territories and Freely Associated States, 2022. HIV Surveillance Report 2024; 35. 3. Thompson MA, Horberg MA, Agwu AL, et al. Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIVMA of the IDSA, Clinical Infectious Diseases, Volume 73, Issue 11, 1 December 2021, Pages e3572–e3605. 4. Nouri S, Lyles CR, Rubinsky AD, et al. Evaluation of Neighborhood Socioeconomic Characteristics and Advance Care Planning Among Older Adults. JAMA Netw Open. 2020;3(12):e2029063. 5. Braun V & Clarke V. (2022). Thematic analysis: A practical guide. SAGE Publications Inc. Scientific Abstract - Healthcare Delivery and Redesign ANALYSIS OF UTILIZATION OF SODIUM-GLUCOSE COTRANSPORTER 2 INHIBITORS IN PATIENTS WITH DIABETES AND CHRONIC KIDNEY DISEASE AMONG MEDICAL RESIDENTS WITHIN A PRIMARY CARE SETTING Sydney Robbins1; Jodi M. Grandominico-Bradford2; Neeraj H. Tayal3; Lauren Kirk4; Cory P. Coffey5. 1General Internal Medicine - Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH; 2Internal Medicine, The Ohio State University, Columbus, OH; 3Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 4General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 5Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. (Control ID #4271296)

Recent landmark trials have shown significant cardiorenal protection with sodium-glucose cotransporter 2 inhibitors (SGLT2is). The 2022 KDIGO guidelines now recommend the initiation of SGLT2is in patients with type-II diabetes mellitus (T2DM) and chronic kidney disease (CKD) with an eGFR ≥ 20 mL/min/1.73m2. Despite updated recommendations, the uptake of SGLT2is in eligible patients is suboptimal. This study aims to evaluate the proportion of patients with T2DM and CKD receiving a SGTL2i. Secondary endpoints include the proportion of patients with T2DM and CKD (1) never prescribed an SGTL2i, (2) previously prescribed an SGLT2i but not currently on therapy, and (3) not currently on SGTL2i therapy but may qualify for initiation based on current clinical practice guidelines.

This study utilizes a third party, Health Insurance Portability and Accountability Act (HIPAA) protected, data analytics tool to identify patients with CKD and T2DM at two academic primary care clinics in the Mid-West comprised of >100 medical residents. Previously, a resident physician systematically used the platform to identify and diagnose patients with G3a and G3b CKD, defined as an eGFR of 30-60 mL/min/1.73m2. Patients empaneled to the resident physician between 7/1/2023 and 10/31/2023 were included. This newly diagnosed population was then cross-referenced for concomitant T2DM diagnoses. Retrospective chart review through the electronic health record (EHR) and the data analytics tool were used to collect demographic data and information regarding SGLT2i prescribing. Patients were excluded for the following criteria: undergoing dialysis, history of kidney transplant, established with nephrology or endocrinology (defined as a visit within the last 12 months), >12 months since last primary care provider visit, or if most recent eGFR is not indicative of G3a/G3b CKD.

A total of 240 patients were identified in the initial report. 169/240 (70.4%) were excluded based on criteria. After exclusions, 71/240 (29.6%) patients were included for analysis of primary and secondary endpoints. Among these, 27/71 (38%) were currently prescribed a SGLT2i while 44/71 (62%) were identified as potential candidates for therapy initiation. Of the 44 patients who could have benefited from SGLT2i initiation, 40/44 (90.9%) had never been prescribed an SGLT2i and 4/44 (9.1%) had previously been on a SGLT2i but discontinued therapy for various reasons.

Endocrinologists and nephrologists were 1.4 times more likely to initiate SGLT2is in patients with G3a/G3b CKD and T2DM than primary care trainees. This report highlights the underutilization of SGLT2is in eligible patients, despite updated standard of care recommendations. Pharmacists embedded in primary care clinics can assist physicians in applying the latest recommendations for disease state management, contributing to population health initiatives. AN ANALYSIS OF RECRUITMENT, ENROLLMENT, AND ATTENDANCE OF VIRTUAL DIABETES GROUP EDUCATION ACROSS HEALTH SYSTEMS (VIDA) Manuel Panzardi1; Courtney Borsuk2; Iridian A. Guzman3; Danielle Lazar4; Arshiya A. Baig5. 1Medical School, The University of Chicago Pritzker School of Medicine, Chicago, IL; 2The University of Chicago Division of the Biological Sciences, Chicago, IL; 3Advocate Aurora Health Inc, Milwaukee, WI; 4Research, Education, and Innovation, Access Community Health Network, Chicago, IL; 5General Internal Medicine, The University of Chicago, Chicago, IL. (Control ID #4230688)

Group education is an emerging model for chronic disease management, allowing small patient groups to receive joint education during a shared appointment. Despite the recent rise in telehealth, adapting in-person education to virtual settings remains understudied, especially across multiple health systems. This study aimed to evaluate participant recruitment and enrollment while assessing how implementation processes can improve broader application of this model.

A single-arm pilot study was conducted among adults with Type 2 diabetes at two community health sites in the Midwest—one from a private health system and one from a federally qualified health center (FQHC). Both sites held monthly virtual group education sessions over six months. Meetings lasted 60-90 minutes, with four to six adults participating, and were led by a Certified Diabetes Care and Education Specialist (CDCES). Patients were eligible if they were 18 or older, had an A1c ≥ 8% in the six months before the first session, spoke English, had attended at least one clinic visit in the prior year, and had an additional cardiovascular condition. Project coordinators tracked recruitment, enrollment, and attendance, and completed fidelity checklists for each meeting. Implementation outcomes, barriers, and facilitators were described using descriptive statistics with Excel and R.

Of the 97 eligible patients, 50 were contacted about the study. Thirty-nine declined enrollment, with the main reasons being “don’t think they need diabetes education” (21%) and “too busy with other responsibilities” (21%). Discomfort with (5%) or lack of access to (3%) internet/technology were not significant barriers. Ten patients enrolled, with 9 identifying as Black/African American, 8 as female, and 5 on Medicare. Common comorbidities included hypertension (9), hyperlipidemia (7), and BMI > 30 (4). Average attendance was 3.6 sessions (SD 1.96). Private system participants attended more sessions on average (3.83, SD 1.95) than FQHC participants (3.25, SD 1.92). They were also more likely to attend with video on (56% vs. 42% for FQHC) and had more calls and/or visits with their primary care providers in the 12 months before the first session (8.66 total interactions for private, 7.75 FQHC). Most participants attended via computer (65% private, 62% FQHC). Among participants with high attendance (three or more sessions), 66% were from the private health system, 83% were female, and none were Hispanic/Latino. None of the high-attendance participants had a pre-existing stroke, while 83% had hypertension, 83% had hyperlipidemia, 50% had a BMI > 30, and 17% had peripheral vascular disease.

Virtual diabetes education was successfully piloted in two health systems with minimal differences in attendance and engagement. The primary barrier to participation was a perceived lack of need for diabetes education rather than technological access issues. A QUALITATIVE STUDY ON CLINICIAN PERCEPTIONS OF AMBIENT SCRIBE DOCUMENTATION Angela Rui2; Gabrielle Choo-Kang5; Ivana Salmikova6; Christine Iannaccone4; Jacqueline G. You7; Christopher Holland6; Bryan Blanchette6; Reema Dbouk8; Rebecca G. Mishuris9; Lisa Rotenstein3,1. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Mass General Brigham Inc, Boston, MA; 3University of California San Francisco, San Francisco, CA; 4General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 5Brigham and Women's Hospital, Boston, MA; 6Emory University School of Medicine, Atlanta, GA; 7Pathology, Massachusetts General Hospital, Boston, MA; 8Medicine, Emory University, Atlanta, GA; 9Digital, Mass General Brigham Inc, Boston, MA. (Control ID #4271956)

Ambient documentation has the potential to reduce documentation burden and reduce clinician burnout. However, the impact on clinician experience has yet to be fully characterized. We present a qualitative analysis of survey comments from 2 academic institutions piloting ambient technology.

Ambient documentation was piloted with clinicians at Mass General Brigham (MGB), Boston, MA, and Emory Healthcare, Atlanta, GA, from July 2023 to July 2024. A survey was distributed 42-60 days after first use. MGB asked ambient users to provide general feedback, while Emory asked users with low technology usage to explain why. A reviewer from each institution independently reviewed and assigned codes to the comments, which an adjudicator reviewed to identify key concepts. Relationships between codes were identified to create themes representing clinicians' experiences.

Researchers analyzed 159 comments (139 MGB, 20 Emory) and identified four key themes: AI effectiveness, implementation, impact on burnout, and usability. AI effectiveness focused on the style and usefulness of AI-generated notes, with concerns about accuracy, hallucinations, and missing details. Errors decreased the tool’s perceived usefulness and increased editing of notes. Implementation involved added workload as AI notes weren’t integrated into EHRs, requiring manual edits. Impact on burnout included subthemes related to satisfaction, efficiency, workload, and patient perceptions. Clinicians satisfied with time-saving benefits were more positive, especially with positive patient feedback. Usability pointed to challenges integrating a AI tool into workflows and the need for more training, especially for those new to ambient scribing (table 1).

Most users viewed the ambient technology positively, especially for reducing notetaking. The AI's ability to generate notes and reduce administrative burden was valued, allowing clinicians to focus more on patients and capture encounters efficiently. Feedback highlighted areas for improvement to enhance user experience and increase adoption. Users felt that the technology could reduce clinician burnout but would require changes to reach its full potential in improving clinician experience documentation. Future steps include analyzing theme differences by institution, clinician type, and specialty. ASSESSING HOSPITALIST PERCEPTIONS OF THE IMPACT OF NEARBY HOSPITAL CLOSURES ON PROVIDERS AND PATIENTS Sarah Jung, Yoo Mee Shin, TaRessa Wills, Sara Turbow, Robert Parker, Mary Ann K. Hall. Department of Medicine, Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4271951)

The closure of a major Southern community hospital resulted in diversion of its patients to several nearby facilities. There is a gap in the literature regarding urban hospital closures; there are many studies of negative impacts of rural hospital closures, but few on urban hospital closures. Most analyses also focus on patient and economic impacts, rather than impacts on healthcare providers. We seek to describe how hospitalists perceive the impact of the urban hospital’s closure on hospital work culture, patient care, and work-life balance and wellness, and to develop recommendations for burnout mitigation. Our objective is to build the evidence base for impact on providers of nearby hospital closures. Long term, we hope to inform decisions regarding hospital closure and response by neighboring facilities to protect staff.

We are conducting structured in-depth interviews of physicians and Advanced Practice Providers across the hospitals that were responsible for accepting the patients of the closed hospital. Questions are focused on hospitalists’ work-life balance, hospital medicine service culture, and overall wellness, as well as perceptions of impacts on patient care and whether use of health information exchanges (HIEs) mitigated information discontinuity following the urban community hospital’s closure. We are using inductive and deductive coding approaches to analyze textual data.

Interviews are ongoing and will be complete in January 2025. In preliminary analysis, themes that have emerged are the universal perception at community and teaching hospitals alike of a large bolus of new, medically complex patients during a time when staffing levels had not yet recovered from the COVID-19 pandemic; negative impacts of a sudden high volume of high-acuity patients on work-life balance and hospitalist morale; and frustration when helping patients who were receiving specialized care when similar care is not available at the referral facility. Several hospitalists noted that colleagues resigned due to the challenges and frustrations of this wave of high-need patients without corresponding resources for their care. They found HIEs useful but often poorly organized, requiring searching to find pertinent information. Hospitalists frequently expressed concern for vulnerable patients. In general, participants felt that patient care was negatively impacted initially—not from challenges of high census, which providers perceived as burdensome but manageable by providers—but from disconnection to regular sources of care. Positive findings were the effectiveness of rapid leadership response to increase staffing and the impact of these efforts on hospitalist morale, gratitude and appreciation for ancillary staff (social workers, case managers).

Urban hospital closures have wide-ranging impacts on the work-life balance of providers at surrounding facilities, which may include domino-effect burnout and resignations in addition to negative impacts on patients. ASSESSING THE ADOPTION AND FIDELITY OF THE TEAMLET INTERVENTION IN PRIMARY CARE SETTINGS Tiffany R. Martinez, Aamina Ahmed, Cassidy Fitchett, Harris Bearnot, Antoinette Schoenthaler, Devin Mann, Saul Blecker. Population Health, New York University Grossman School of Medicine, New York, NY. (Control ID #4237329)

The Teamlet intervention aims to improve medication adherence and blood pressure control in primary care settings by integrating EHR-based workflows, including pharmacy fill data (measured by PDC), clinical decision support, and health coaching by primary care providers. The purpose of this study was to explore the barriers and facilitators to adoption and fidelity of the intervention.

We conducted monthly in-person implementation site visits across five primary care practices from October 2022 to September 2024 within a large healthcare network. The research team engaged in conversations with medical assistants (MA), primary care providers (PCPs), and management staff to gather insights on the intervention. We took detailed field notes, which were analyzed qualitatively using a deductive coding approach based on Proctor’s Implementation Outcomes Framework.

Across five practices, we conducted a mean number of 16 (range 7-23) site visits per practice. From these visits, we identified three major themes. Adoption. Support from practice managerial staff and tailored training sessions for both MAs and PCPs were reported to increase uptake of the Teamlet intervention. Following the initial go-live period, the study team developed tailored training sessions based on implementation barriers identified during site visits, with clinical managers and leadership actively facilitating these sessions. The tailored trainings sessions were well-received, with MAs and PCPs reporting that it enhanced their understanding and usage of the intervention. Positive Fidelity. Many MAs and PCPs reported consistently following the intervention workflow by reading the EHR-embedded barriers questionnaire verbatim and using passive alert tools to facilitate discussions about patient adherence.MAs and PCPs found the tools relevant, helpful, and compatible with their workflows. Negative Fidelity. Some MAs and PCPs struggled with using Teamlet intervention as intended, often canceling or ignoring alerts. They found alerts disruptive to their workflow and doubted the validity of the alerts, including the accuracy of PDC as a measure of medication adherence and elevated blood pressure based on white coat hypertension. Additionally, providers struggled to understand the underlying causes of patients’ nonadherence and suspect patients may misrepresent their level of adherence for various reasons.

While the intervention was generally well utilized by MAs and PCPs, challenges such as alert fatigue and skepticism about adherence measures negatively impacted its fidelity. Additionally, we found that leveraging supportive leadership can enhance the adoption and implementation of EHR-based team care interventions in primary care settings. The findings highlight both the strengths and challenges of implementing similar interventions aimed at improving medication adherence in primary care settings. ASSOCIATION OF STAFFING METRICS WITH ACCESS TO PRIMARY CARE WITHIN THE VETERANS HEALTH ADMINISTRATION Matthew R. Augustine1; Bjarni Haraldsson2,4; Peter J. Kaboli4,3; Amy M. O'Shea4,3. 1Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, New York, NY; 2Research, Veterans Health Administration, Washington, DC; 3Internal Medicine, Iowa City VAMC, Iowa City, IA; 4Research, Iowa City VA Healthcare System, Iowa City, IA. (Control ID #4270854)

Currently, the Veterans Health Administration (VHA) uses a panel fullness metric, which relies on five different data inputs for appropriate adjustments to identify and address staffing gaps. These inputs are often manually entered and subject to error. The ‘gap staffing metric’, developed in 2023, simplifies these inputs. Our study objective was to compare associations between the gap staffing and panel fullness metrics with access to primary care.

We performed a retrospective longitudinal analysis of all primary care clinics with at least 450 assigned patients from October 1, 2020, through September 30, 2024. Primary care staffing gaps were calculated in two ways: 1) the gap staffing metric, the ratio of maximum clinic capacity divided by patients assigned adjusted by provider type, and 2) panel fullness, the ratio of observed assigned primary care patients by the expected panel size. Panel fullness is adjusted by provider full-time equivalents, support staff, clinical rooms, provider type, and the number of women on panel. We categorized both metrics as ‘understaffed’, ‘marginally staffed’, or ‘overstaffed.’ Monthly outcomes included three measures of access: established patient wait-time (days from patient designated date of scheduling return visit), new patient wait-time (days from patient contact to appointment completion), and third next available appointment. Multi-level linear models were adjusted for clinic-level population characteristics (i.e., age, male, rural residence, area deprivation index, Nosos risk scores) and clinic factors (i.e., clinic type, size) with regional fixed effects and clinic-level random intercepts.

Among the 48-months of observations for 988 primary care clinics, 17.9% and 14.7% of clinic-months were determined to be understaffed by panel fullness and gap metric, respectively, while 27.1% and 57.0% clinic-months were determined to be overstaffed. Panel fullness and the gap metric were associated with prolonged established and new patient wait times and a longer time to third next available appointment (Table).

The gap staffing metric offers a simplified measure of staffing gaps, based on patients assigned and maximum clinic capacity derived from primary care provider full-time equivalents and provider type, that is associated with patient wait-times. Monitoring and responding to these gaps may assist regional medical centers and national VHA to deploy temporary or permanent providers in-person or via telemedicine to maintain access to care. ASSOCIATIONS BETWEEN INITIATION OF WHOLE HEALTH SERVICES UTILIZATION AND QUALITY MEASURES: A POPULATION-LEVEL RETROSPECTIVE COMPARATIVE STUDY IN THE VETERANS HEALTH ADMINISTRATION Xiaoyi Zhang1; Jamie Douglas3; Chase S. Eck5; Gang Luo4; Barbara G. Bokhour2; Steven Zeliadt3. 1Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle, WA; 2Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA; 3Health Systems Research Center of Innovation, Veterans Health Administration, Washington, DC; 4Biomedical Informatics and Medical Education, University of Washington, Seattle, WA; 5Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4272926)

Implementing a Whole Health system (WHS) of care has been a decade-long effort in the Veterans Health Administration (VA) aimed at improving patient-centered care. This study examines associations between use of Whole Health services (WHS) and population-level changes in standardized Healthcare Effectiveness Data and Information Set (HEDIS) quality measures.

We monitored 9 prevention-focused HEDIS-derived electronic quality measures for 5,977,381 eligible veterans across all VA facilities from October 2022 to March 2023. The outcome variable was the change in each measure from 1 month prior to 6 months post WHS initiation. We used χ2 tests of independence (α = .05) to compare outcomes between WHS initializers and the corresponding VA reference cohorts over the same time period.

548,968 veterans were identified as new users of WHS. Over 95% of the WHS initializers had primary care visits within the 6 months prior to the WHS utilization, while the reference cohorts varied from 76.5% to 96.0%. Significant improvements were observed in 8 out of 9 quality measures following WHS initiation compared to reference cohorts (Table 1). The most substantial gains were in diabetes management: BP control showed a net gain of 4.1 percentage points over reference cohorts, while HbA1c control and poor control showed net gains of 3.6 and 3.5 percentage points. Hypertension BP control showed a net gain of 1.0 percentage points. Preventive care measures also showed meaningful improvements, with net gains of 3.2, 2.9, and 2.3 percentage points for colorectal cancer screening, breast cancer screening, and pneumococcal vaccination. Modest gains were found in Statin therapy for diabetes patients but no significant improvement for cardiovascular disease.

Initiation of WHS in the VA was associated with meaningful improvements in multiple standardized quality measures among patients already engaged in primary care, suggesting WHS offers a potential benefit in enhancing overall care quality. BRIDGING THE DIGITAL DIVIDE IN CALIFORNIA'S SAFETY NET - AN ASSESSMENT OF DIGITAL NAVIGATION PRACTICES. Nilpa D. Shah1,2; Carmen Ma3; Sarah Rahman4; Marika Dy1,2; Kelsey H. Natsuhara1; Elaine Khoong1,2; Courtney Lyles5,6; Urmimala Sarkar1,2; Adrian Aguilera3,7; Anjana E. Sharma2,8. 1Department of Medicine, University of California San Francisco, San Francisco, CA; 2Action Research Center (ARC) for Health Equity, University of California San Francisco, San Francisco, CA; 3Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA; 4Information Systems, Alameda Health System, Oakland, CA; 5Department of Public Health Sciences, University of California Davis, Davis, CA; 6Center for Healthcare Policy & Research, University of California Davis, Davis, CA; 7School of Social Welfare, University of California Berkeley, Berkeley, CA; 8Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4270181)

Marginalized communities, including those facing poverty, structural racism, or of limited English proficiency (LEP), experience significant inequities in digital health access, known as the "digital divide." Digital navigation, which provides digital skills training and resources to patients, can improve telehealth access, particularly among racial minorities and older adults. Little is known regarding how digital navigation is implemented across California's (CA) primary care safety net. With 13 million Medicaid enrollees and 2,000+ Federally Qualified Health Centers (FQHC) sites serving 5 million patients annually, CA’s scale and diversity underscores the need to address these disparities. This study assesses CA’s landscape of digital navigation and recommends best practices.

We conducted a mixed-methods study in CA primary care safety net settings where at least 50% of the patient population were uninsured, have Medicaid, and have been economically, socially, or historically marginalized. We distributed an online survey to clinic representatives regarding digital navigation practices and challenges and conducted in-depth interviews with clinic leaders to explore digital navigation structure and workflows. Quantitative data supplemented qualitative analysis to identify barriers, facilitators, and models of digital navigation.

We surveyed 50 safety net clinics: 72% FQHCs, 24% state/county-funded health systems, and others from non-profit, academic, and community health centers serving geographically, culturally, and linguistically diverse populations. Among them, 80% had implemented digital navigation. Digital navigation models included an integrated approach, a discrete digital champion, an external volunteer or library-based program, and a centralized referral hub. Common services included digital literacy training (55%), internet access support (40%), and technical support (28%). Only 38% reported screening for digital inclusion, encompassing patients’ device access, internet availability, and skills for virtual health services. Older adults and patients with LEP were reported to be at a higher risk of exclusion from digital health services. Interviews identified implementation challenges including insufficient funding, staff shortages, inconsistent training, and organizational buy-in. Promoters of digital navigation were leadership engagement, external partnerships, and data-driven approaches.

Most surveyed primary care sites are implementing some form of digital navigation through a wide range of implementation models, but with limited use of screening data. Successful digital navigation implementation requires engaged leadership, integration into the organization’s strategic planning, and standardized referral processes, particularly so the digital divide does not widen for older patients and those with LEP. Tailored, data-driven digital navigation models have the potential to bridge the digital divide and improve health equity across CA. BRIDGING THE GAP IN NCD MANAGEMENT IN GHANA: THE NEED FOR A NEW CARE MODEL Raymond A. Aborigo1; Engelbert A. Nonterah2; Irene Kuwolamo1; Evan E. Alvarez3; Timothy Awine1; David J. Heller4. 1social science and public health, Navrongo Health Research Centre, Navrongo, Upper East Region, Ghana; 2Clinical Science, Navrongo Health Research Centre, Navrongo, Ghana; 3Global Health, Icahn School of Medicine at Mount Sinai, New York, NY; 4Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #4273513)

Non-communicable diseases such as hypertension account for about 43% of all deaths annually in Ghana. Despite efforts to improve case detection and management of the condition Ghana, gaps persist. The health policy environment and shortage of health professionals skilled in NCD management, limit early detection and management. This study aimed to expose the gaps in the management of NCD at the community level using hypertension as a tracer condition.

This cross-sectional survey was implemented in two health centres designated for Ghana’s new strategy for primary health care– the network of practice. The health centres received referrals for probable hypertensive cases from 10 community-based health planning and services (CHPS) compounds. Using the data base of a demographic surveillance system, we identified all individuals within the catchment areas of the CHPS compound who met our inclusion criteria (18 years and above) and invited them to temporary community clinics for screening for hypertension. The screening which involved 4129 people was conducted by community health nurses (CHNs). Hypertension was determined following three measurements over a 3-day period and an average of the blood pressure (BP) scores of the last two measurements.

Out of 4129 people screened, 407 (9.9%) had elevated BP and were referred to the health centre for confirmation and treatment. They had a mean systolic BP of 155.55 mm Hg (Std.19.76). The mean age of those referred was 57.85 with a standard deviation of 17.50. Of the 407 who were referred, only 180 visited the health center to confirm their results. About 75% (135) of those who visited the health centres were confirmed to be hypertensive. At 90 days follow up, only 15 participants turned up at the health centres to receive their medications.

Many community members with elevated BP do not arrive at the referral site for confirmation and treatment. Even fewer cases are retained in care which raises issues around equitable access to NCD treatment by rural and vulnerable populations.` BUILDING THE FUTURE OF PRIMARY CARE: ANALYZING INVESTMENTS IN ADVANCED CARE MODELS Amie Pollack1; Dru A. Ricci1; Zirui Song2; Russell Phillips1. 1Center for Primary Care, Harvard Medical School, Boston, MA; 2Department of Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4272959)

Primary care investment is increasingly recognized as a critical strategy to improve health outcomes, reduce costs, and promote equity, and efforts are being made to increase primary care investment by different stakeholders. However, provider organizations, payers, and policymakers often lack actionable guidance on how to allocate additional resources effectively. This study aims to learn from states and healthcare organizations that are leading in primary care investment about how they are making investments and the costs and impact of those investments.

Our project examines the experiences of provider organizations (PO) making investments in advanced primary care (APC), with participants from California, Rhode Island, Oregon, Oklahoma, and Massachusetts. These states have committed to public reporting of primary care investment and have worked to increase the share of spending devoted to primary care through legislation or state policy. The study focuses on PO investments in APC services, including behavioral health integration, population health, clinical pharmacists, community health workers, etc. From May 2024 to December 2024, 20 PO participated via in-depth interviews with their primary care leadership, and through surveys. Through May 2025, we expect the sample to reach 30 PO. Responses were thematically analyzed using NVivo software, focusing on APC services prioritized for investment, drivers of investment decisions, barriers, facilitators, and impacts of investments. Surveys completed by PO primary care leadership and finance teams contained data on costs and staffing associated with APC services.

Findings indicated that PO prioritized investment in patient support teams, behavioral health integration, and care management. Drivers of investment decisions included recruitment and retention of primary care clinicians, expanding patient access, and increasing the range and depth of services available to meet patient needs (e.g., behavioral health capacity). Barriers to the development of APC services included limited funding, unreliable funding, difficulties communicating return on investment to leadership, and variable engagement from clinical staff.

Findings highlight the importance of tailored investment strategies that align with organizational capacities and patient needs. Our project provides a decision pathway and framework for primary care investments, at a time when primary care financing is particularly dependent on such additional resources. These results are informing the development of a decision-support tool to inform strategic primary care investments for other organizations in additional states, and to identify barriers, opportunities, and best practices to optimize primary care investment. CARE TRANSITIONS IN AN URBAN SAFETY NET HEALTH SYSTEM: IMPROVING THE POST-DISCHARGE PRIMARY CARE EXPERIENCE Samantha F. Sanders2,1; Cherilyn Re2; Christine Zhang2; Andrew Wallach2,1. 1Medicine, New York University, New York, NY; 2Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY. (Control ID #4272537)

A patient’s outpatient continuity primary care team can serve as a nexus of care during the transition from an inpatient stay to the community. Studies highlight the importance of timely primary care post-discharge appointments, with emphasis on the protective effect of appointments within the first 7 days of discharge against readmission for higher-risk patients.

We analyzed post-discharge follow-up and readmission data at a large, urban safety net health system in the Mid-Atlantic region over the course of 6 months (4/1/2023 – 9/30/2023). Included inpatient discharges were from medical and surgical inpatient services to the community. We restricted our analysis to established patients – defined as having completed at least one visit with an adult primary care provider (PCP) within the previous 36 months at one of the system’s hospital-based outpatient adult primary care clinics. We excluded discharges from the emergency department, inpatient discharges to a skilled nursing facility, patients who expired during their admission, and patients admitted to a hospital outside our system.

Over the course of 6 months, 10,305 inpatient discharges occurred that met our criteria. Few of these discharges had an associated post-discharge primary care appointment scheduled within 7 days (8.2%), 14 days (16.3%), or 30 days (27.6%). Of those patients who did have scheduled appointments, show rates to post-discharge appointments were low; appointments scheduled within 7, 14, and 30 days of discharge were associated with show rates of 37.7%, 37.2%, and 38.1%, respectively. Notably, we found that scheduling an appointment directly with a patient’s PCP compared to an appointment with another member of the outpatient care team improved the show rate for post-discharge appointments from 40.2% (overall) to 53.8% (with PCP). Our overall 30-day readmission rate was 11.8%. The 30-day readmission rate was lower if patients completed a post-discharge follow up visit within 7 days of discharge (10.4%) or 14 days (10.9%), although readmission rate was comparable if a post-discharge visit was completed within 30 days (11.9%). Visits completed with a patient’s own PCP within 30 days of discharge were associated with a lower 30-day readmission rate (9.8%). Visits completed for high-risk patients (based on utilization) also appeared to reduce readmissions (20.6% 30-day readmission rate across the high-risk population vs. 16.9% if visit completed within 30 days of discharge).

Timely post-discharge appointments represent an area of need for patients requiring primary care follow up for longitudinal management of chronic conditions. However, even when such appointments are scheduled, show rates remain low. These primary care appointments are not globally protective against readmissions, but they are likely more protective if they occur within a week of discharge, occur with a patient’s own PCP, or occur for a high-risk patient. CHARACTERIZING GENERAL INTERNAL MEDICINE PRACTICE STRUCTURES AND SUPPORTS FOR MODERN PRIMARY CARE Estelle Martin2; Mitchell D. Feldman3; Mark Earnest5; Eve Kerr4; Ashok Reddy6; Jillian Gann7; Lisa Rotenstein1. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Department of Medicine, University of California San Francisco, San Francisco, CA; 3Medicine, University of California San Francisco, San Francisco, CA; 4Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; 5Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; 6Medicine, University of Washington School of Medicine, Seattle, WA; 7NA, SGIM, Alexandria, VA. (Control ID #4271550)

The expectations placed on academic general internal medicine (GIM) clinicians continue to evolve, with high PCP time expenditure in the EHR and more demand for asynchronous care layered on established patient care and academic responsibilities. National benchmarks regarding optimal GIM practice structures and supports remain limited, making it difficult for academic GIM leaders to know which practice and compensation innovations could optimize the experiences of their faculty. This study, led by the Association of Chiefs and Leaders in General Internal Medicine’s Compensation Workgroup, sought to address these knowledge and evidence gaps.

In a discussion-based session at the May 2024 SGIM Conference, 40 GIM leaders helped identify key questions for which they sought more evidence. Using rapid content analysis, we categorized these questions into 3 main themes and developed a semi-structured qualitative interview guide around these themes. Using convenience sampling, we identified 4 academic GIM practices that offered distinct approaches to these themes, then interviewed practice leaders at these sites to learn about innovative solutions. Zoom interviews were conducted individually and lasted about 45 minutes. Interview findings served as case studies, which were posted to the ACLGIM website. The questions and interview answers guided the development of a structured survey for nationwide dissemination to GIM division chiefs in winter 2025.

During the May 2024 SGIM session, academic GIM leaders identified 3 main themes that needed further elucidation to optimize innovations in academic general medicine practices: 1) PCP compensation structure; 2) ways to quantify and evaluate the work of modern primary care; and 3) managing staff and structure of a care team. Interviews with 4 GIM leaders from distinct sites identified exemplar models present at their practices related to compensation, quantifying PCP work, and team structure. These models included a capitated compensation model, a home-grown panel weighting system, and a One-Touch-Team (OTT) seeking to resolve incoming clinical questions in one interaction. We probed for specific impact of the innovation. At one site, after implementing the OTT, the number of providers citing the in-basket as their primary work challenge dropped from 92 to 16.

Academic GIM leaders seek more evidence regarding PCP compensation structure, quantifying work of primary care, and staffing and structuring primary care teams. Exemplar innovations on structuring team-based care, and panel-based compensation models, and approaches to asynchronous care helped optimize the academic GIM clinical experience at interviewed sites; these interventions may serve as important case studies for other academic practices. Future work, including a nationwide survey based on these study findings, should seek to further elucidate various nationwide approaches addressing the questions identified as well as barriers to implementing solutions. CHARACTERIZING PRIMARY CARE PHYSICIANS’ WORK EFFORT AND ITS DETERMINANTS Lisa Rotenstein2,1; Michelle Frits3; Christine Iannaccone4; Michelle L’Heureux5; John Fangman6; Moshe Rancier6; Richard Gitomer3; David W. Bates3; Bruce E. Landon7. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Division of General Internal Medicine, University of California San Francisco, San Francisco, CA; 3General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 4General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 5Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; 6Community Physicians Group, Mass General Brigham Inc, Boston, MA; 7Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4271318)

Health system leaders need to understand the factors affecting differential work effort in primary care. Despite research, there’s little agreement on the ideal patient panel size for a full-time PCP. We used health records and administrative data to explore yearly work effort per patient, FTE variation, and related factors.

We used descriptive statistics to summarize PCP and patient panel characteristics. Continuous variables were converted into tertiles based on distribution. We compared the characteristics of PCPs with ≤0.5 cFTE and >0.5 cFTE. We estimated the annual work effort per patient for each PCP by combining appointment time and time spent on the EHR outside scheduled hours using Epic Signal data. We then derived two measures: annual work effort per clinical FTE and per patient. We estimated a generalized linear model to identify patient and panel factors associated with PCPs' yearly work effort per patient. The model adjusted for the following variables: percentage of female patients, percentage of Medicaid patients, mean Elixhauser score, mean age, and academic practice site.

PCP and Patient Panel characteristics can be found in table 1. The median yearly work effort per patient was 75.8 minutes (IQR: [61.9, 95.0] 1.3 hours). The median yearly work effort per 1.0 cFTE was 124,323 minutes (IQR: [101,829, 152,376] 2,072 hours), equating to 45.01 hours per week for a 1.0 cFTE physician over a 46-week work year. In the generalized linear model, significant associations with additional PCP annual time expenditure per patient included: 1) having a panel in the highest Elixhauser score tertile (>1.76–3.86), with an additional 11.8 minutes per patient per year (p=0.02), and 2) having a panel in the 3rd tertile of female patients (>74.52%), with an additional 6.4 minutes per patient per year (p=0.04).

Our study shows that PCPs spend a median of one hour per year on each patient's care, leading to a conservative estimate of a 45-hour week for a full-time equivalent role. Factors like patient comorbidities and gender composition are important for understanding time differences across PCPs. These findings can help design primary care roles and adjust PCP panels to support the sustainability of primary care careers. CLINICIAN ADOPTION AND USE OF REAL-TIME PRESCRIPTION BENEFIT TOOLS Ishani Ganguli1; Nicholas Daley2; Mark J. Soto3; Foster R. Goss4; Anna D. Sinaiko3. 1Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; 2Department of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 3Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA; 4UC Health University of Colorado Hospital, Aurora, CO. (Control ID #4272061)

Patients commonly face high out-of-pocket prices for prescription drugs that present barriers to drug initiation and adherence. In efforts to mitigate these costs and associated harms, health systems increasingly offer electronic health record-integrated real-time prescription benefit tool (RTBT) alerts that present clinicians with out-of-pocket price estimates for the prescriptions they are ordering and offer lower-price alternatives. While these alerts have the potential to improve outcomes, they may also carry unintended consequences. Understanding how clinicians use these tools is key to effective design and implementation.

Using Epic data from 803 ambulatory clinics in a large integrated health system spanning Colorado, Wyoming, and Nebraska from July 2019 to June 2022, we described, and assessed characteristics associated with, clinicians’ responses to RTBT alerts. Our primary outcomes were clinician-level adoption (i.e., making at least one medication change in response to an alert) and degree of adoption (i.e., percentage of alerts for which changes were made). We examined clinician characteristics including sex, clinician type, specialty, years of US practice, and primary practice setting. We also examined drug class (cardiovascular, diabetes, psychotherapeutic, anti-asthmatic), whether a prescription was new or existing, and alert types, which included suggested changes to medication (i.e. molecule), formulation (i.e., dose, strength, or mode of delivery), quantity, or pharmacy.

Of 4894 clinicians, 4241 (86.7%) received at least one RTBT alert. Clinicians received a median (IQR) of 18.8 (9.8, 32.9) alerts per 100 orders and made changes in response to 11.4% of alerts. For alerts resulting in changes, clinicians rarely accepted one of the originally presented alternatives: 98.7% of all eventual changes occurred after additional medication searches. Changes were most often changes to the pharmacy (54.0%), followed by quantity (36.4%), formulation (5.5%), and medication (3.5%). Clinician-level adoption and degree of adoption varied by drug class and change type, but were similar for existing and new prescriptions. While primary care clinicians had the most alerts per clinician-month (7.4, compared to 2.8 for medical specialists and 3.0 for surgical specialists) and were more likely to adopt (86.7%, vs 76.6% and 68.8%), medical and surgical specialists had higher degrees of adoption (10.3% vs 13.4% and 11.3%).

Clinicians frequently received RTBT alerts and while most made at least one change, they made changes in response to a minority of alerts and rarely chose the presented alternatives. While RTBTs are promising ways to improve medication affordability, implementers should consider quality of alert information, clinician usability, time burdens, and alert fatigue. COLD WEATHER AND NEIGHBORHOOD-LEVEL SOCIOECONOMIC POSITION IS ASSOCIATED WITH VISIT CANCELLATIONS Alex Rennick2; Paul A. McVey3; Michelle Medina3; Robert W. Jones3; Michelle Edwards3; Jacquelyne Bailey2; Elizabeth R. Pfoh1,3. 1Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; 2Community Health and Equity, Cleveland Clinic, Cleveland, OH; 3Value Based Operations, Cleveland Clinic, Cleveland, OH. (Control ID #4272461)

Healthcare systems are innovating to increase primary care access by offering transportation and virtual visits. Freezing temperatures, which can make travel difficult, may disproportionally impact access to care for patients who live in areas with reduced transportation ease. The goal of this quality assessment was to identify the association between freezing temperatures and completed primary care appointments by neighborhood-level socioeconomic position.

This quality-assessment initiative focused on Medicare Advantage and Medicare Accountable Care Organization patients in a large-integrated health system. Patients were required to be ≥65 years of age, live in our local County, and have a scheduled office visit between January and May 2024. Our outcome, visit status, was grouped into completed versus canceled/no-shows. We obtained daily temperatures; readings ≤32.0°F were defined as “freezing” versus not. We measured neighborhood-level socioeconomic position using the Area-level Deprivation Index (ADI) total score, which we grouped into quintiles. The total ADI score includes a measure of households with a vehicle in its calculation. Using Stata 18.0, we ran multilevel logistic regressions (accounting for age and patient ID) to understand the association between 1) freezing temperatures, 2) neighborhood-level socioeconomic position, and 3) their interaction on visit completion. We conducted a sensitivity analysis using the percentage of vehicles in a neighborhood (instead of ADI), and the results were similar (not shown).

The population included 40,472 patients, with a median age 76 years (IQR: 71-82), 76% were White, 19% were Black, and 61% were female. The mean neighborhood-level socioeconomic position was 4.3 (range 1-10). There were 99,994 visits, of which 64% were completed. Over the 145 days, 24 (17%) were freezing. On freezing days, the predicted probability of visit completion was reduced (P[95%CI] -0.29, [-0.04. -0.02]). Patients living in neighborhoods with lower socioeconomic positions had a lower predicted probability of completion (quintile 1: P[95%CI] 0.67 [0.67,0.68] vs. quintile 5: P[95%CI] 0.62, [ 0.61,0.63]). In the interaction model, within each quintile, the predicted probability of visit completion decreased (p≤0.01), and it decreased most for patients living in neighborhoods with the lowest socioeconomic position (P[95%CI] -0.04 [-0.06, -0.02], comparing freezing to non-freezing days within ADI quintile 5).

Patients had a reduced probability of completing a primary care visit on freezing days, and this association was stronger among patients living in neighborhoods with lower socioeconomic positions. Health systems could proactively reschedule visits on days that are predicted to be freezing, particularly for patients living in neighborhoods with reduced transportation ease. COMPARING THE CLINICAL CHARACTERISTICS OF A COHORT OF VETERANS WITH HIV BETWEEN TWO CARE DELIVERY MODELS UTILIZED ACROSS THE VETERAN’S HEALTH ADMINISTRATION Nadine M. Harris2,1; Puja Van Epps3,4; Laura Hmiel3,9; Sandra Woolson5; Elizabeth M. Strawbridge5,6; Kayla W. Kilpatrick8; Lewis S. Musoke4,3; Nancy Liu7; Hayden B. Bosworth5,8. 1Medicine, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, GA; 2Medicine, Emory University, Atlanta, GA; 3Internal Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH; 4VA Northeast Ohio Healthcare System, Cleveland, OH; 5VA Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC; 6Durham VA Health Care System, Durham, NC; 7Morehouse School of Medicine, Atlanta, GA; 8Duke University Department of Medicine, Durham, NC; 9MetroHealth Medical Center, Cleveland, OH. (Control ID #4271950)

People with HIV (PWH) have up to 2 times higher risk of atherosclerotic cardiovascular disease (ASCVD) than those without. Historically, infectious disease (ID) providers have delivered comprehensive primary care to people with HIV, including management of ASCVD risk factors. There is growing support for a shift in primary care management of PWH to general practitioners (GP) with ID delivering only specialty HIV care. Within the Veteran’s Health Administration (VHA) both models of care exist.

Compare the ASCVD risk factor burden and control among PWH between the two care delivery models

PWH virally suppressed on antiretroviral therapy enrolled from 4 VHA facilities completed validated questionnaires on demographics, and other measures such as housing and food insecurity. Primary care and visit information, laboratory data and vitals were obtained from the electronic medical record. Patients were stratified as receiving primary care from ID providers or GPs based on provider assignment in the electronic medical record. Comparisons between the groups were tested using Chi-square statistics for categorical and Kruskal-Wallis for continuous variables

Of the 301 veterans enrolled in the study, most received primary care from ID (69% vs 31%). Amongst PWH who received primary care from ID providers or GPs respectively, age in years (medians 63.0 vs 61.0, p=0.06), birth sex (males: 93.8% vs 89.2%, p=0.17), race (Black: 79.8% vs 72.0%, White: 9.6% vs 19.4%, Other: 10.6% vs 8.6%, p=0.06), and time since HIV diagnosis in years (medians 22.0 vs 25.0, p=0.65) were similar between the groups . PWH who received primary care from ID were more likely to live in urban settings (97.6% vs 65.2%, p<0.001), suffer from food or housing insecurity (29.8% vs 16.1%, p=0.01) and were seen more frequently in clinic in the year preceding enrollment (medians 3.0 vs 2.0, p<0.001). Baseline systolic blood pressure was similar between PWH receiving care from ID providers and GPs (medians 134.7 vs 129.3, p=0.06) as was non-HDL cholesterol (medians 112.0 vs 120.0, p=0.06). 10-year ASCVD risk score was higher among those who received primary care from ID (medians 18.4 vs 13.7, p=0.02) and they were also more likely to be on statin therapy (74.5% vs 54.8%, p<0.001).

In this aging cohort of PWH, individual contributors of ASCVD such as baseline systolic BP and non-HDL were similar across the primary care models, but ASCVD risk score, statin use, and frequency of clinic visits were higher in those receiving primary care in ID clinics. PWH in more rural areas were more likely to receive primary care by a GP. These data could help clarify circumstances when one model may be better suited over the other for individual PWH. COMPARING VA’S NATIONAL CONTINGENCY STAFFING PROGRAM TO OTHER ALTERNATIVES FOR COVERING STAFFING SHORTAGES: SUMMATIVE EVALUATION 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 #4272853)

Five years into implementation, the Veterans Health Administration (VA) national Clinical Resource Hubs (CRHs) continue to provide contingency staffing using a “hub and spoke” model, where regionally based hubs provide mostly virtual primary care (PC), mental health (MH), and specialty clinicians to VA clinics with staffing gaps or patient access problems. We describe how the CRH compares to other options for PC and/or MH contingency staffing and gap coverage, based on the experiences and perspectives of CRH Directors.

Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured telephone interviews with 18 CRH Directors, representing 18 VA administrative regions. Interviews were recorded and transcribed, with a rapid analysis identifying key advantages and disadvantages of alternatives relative to CRH use.

The most frequently reported alternatives to CRH included virtual local facility gap/float providers and/or PC virtual “hubs”, fee- or contract-based providers, in-person facility gap/float providers, inter-facility consults, and community care. Advantages of local virtual PC gap coverage included a decrease in continuous gaps at specific facilities, and the ability for facilities to decide how often providers work in-person. Relative disadvantages included underutilization of virtual float providers or oversaturation, concerns about in-person facility staff all wanting to “go remote”, and limitations to working for sister facilities due to credentialing. Fee-based providers like locum tenens were described as more expensive, lacking local VA context and systems knowledge, and unable to fulfill the CRH mission of PCMH education to sites in distress. However, facilities had a higher level of oversight with fee- or contract-based providers. Facility gap/float providers can pivot quickly to be there in person and are part of VA’s regular workforce, but are sometimes underutilized, and often become a part of regular PCMH teams due to hiring restrictions and inability to cover the whole region/other facilities. Interfacility consults were perceived as comparable to CRH because providers can cover other facilities. However, PC coverage of patient panels can be more difficult. Community care was described as more expensive than CRH, with longer wait times, and not aligned to Veteran preferences. Less frequently mentioned alternate mechanisms included using VA part-time, retired, or trainee physicians, whose priorities might lie elsewhere.

Alternative contingency staffing mechanisms like virtual or in-person facility float providers and fee-based providers offer temporary solutions to staffing gaps, but perceived drawbacks include higher costs and limited scope of practice. Although some alternatives offer unique advantages, they were seen by CRH Directors as falling short of meeting the relative advantages of CRH program flexibility, quality, education, regional coverage, and Veteran preference. DETERMINANTS OF PRIMARY CARE IMPLEMENTATION OF CONTINUOUS GLUCOSE MONITORING Varsha Vimalananda1; Ben Kragen1; Alison J. Leibowitz2; Shirley Qian3,2; Jolie B. Wormwood3,6; Amy Linsky2; Patricia Underwood4; Paul R. Conlin5; Bo Kim5,2. 1Edith Nourse Rogers Memorial Veterans Hospital, Center for Health Organization and Implementation Research (CHOIR), Bedford, MA; 2VA Center for Healthcare Organization and Implementation Research, Boston, MA; 3VA Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; 4William F. Connell School of Nursing, Boston College, Chestnut Hill, MA; 5Harvard Medical School, Boston, MA; 6Psychology, University of New Hampshire, Durham, NH. (Control ID #4269358)

Continuous glucose monitors (CGMs) are wearable technologies that take regular measurements of patient blood glucose. CGMs are a significant advance in the management of insulin-treated patients with type 2 diabetes mellitus. Compared to self-monitoring with fingersticks, CGM use improves glycemic management, and reduces emergency room visits as well as hospitalizations. For this reason, the Department of Veterans Affairs (VA) recently expanded eligibility of CGM to include insulin-treated patients with type 2 diabetes, a policy shift that is being mirrored by many payers across the nation. However, PCPs have experienced difficulty integrating CGM into existing care workflows. Research is needed to understand specific barriers and facilitators that PCPs face as they implement CGM into patient care.

This study used a cross-sectional national survey of all VA PCPs (physicians, physician assistants, and nurse practitioners) from October 2023 - April 2024. The survey assessed five determinants of CGM implementation using multi-item scales developed from the Consolidated Framework for Implementation Research (CFIR) including; PCP Knowledge About CGM, PCP Workload Capacity, Benefits of CGM, Support from Leadership & Other Services, and Access to Resources for CGM. An additional item assessed PCP likelihood of initiating conversations about CGM with eligible patients in the next three months. Responses were recorded on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5). Survey data was combined with facility-level data on CGM uptake collected from the VA Corporate Data Warehouse. Analyses included bivariate and multivariable regression models that assessed the relationship between determinants of CGM implementation and 1) provider likelihood to discuss CGM with patients, and 2) facility-level uptake of CGM.

Of the 1373 PCPs who responded to the survey, many (39%) reported little to no experience with CGM. Looking at ceiling scores (the percent reporting ≥ 4 for scales), most providers believed in the Benefits of CGM (79%), while few providers indicated sufficient Access to Resources (8%) and Support from Leadership & Other Services (5%). Adjusted models found that provider intent to initiate CGM discussions with eligible patients was associated with all scales except Access to Resources for CGM. The strongest association was with PCP Knowledge About CGM (B=0.54, P<0.001). Facility-level uptake of CGM was associated with Benefits of CGM (B=0.10, P=.026) and Support from Leadership & Other Services (B=0.18, P<.001).

PCPs perceive clincial benefits of using CGM to manage insulin-treated patients with type 2 diabetes. However, they lack sufficient knowledge, resources, and workload capacity to implement the technology without additional support. PCP education about CGM, and teamwork with other services, such as pharmacy, may increase the likelihood that eligible patients use CGM. DEVELOPING CULTURALLY TAILORED STORYTELLING VIDEOS TO IMPROVE HYPERTENSION MANAGEMENT IN A SAFETY-NET HEALTH SYSTEM Citlali Perez1; Gloria E. Moon3; Stefanie D. Vassar2; Arleen F. Brown1; Alejandra Casillas1. 1Medicine, University of California Los Angeles, Los Angeles, CA; 2Division of Internal Medicine & Health Service Research, UCLA, Los Angeles, CA; 3Medicine, University of California System, Oakland, CA. (Control ID #4272625)

Hypertension (HTN) disproportionately impacts Latino and Black patients, particularly in diverse, medically-underserved communities where socioeconomic precarity, limited health literacy, and language differences contribute to poor health outcomes. Culturally tailored interventions are critical to reducing these disparities in HTN care. Narrative storytelling is one promising cultural strategy that can enhance patient motivation. We describe the development of a culturally tailored storytelling video intervention aimed at improving HTN care in a large, urban safety-net health system. We outline our process, offering insight into how storytelling can serve as a health education strategy for addressing health inequities.

The narrative videos were developed using a collaborative process informed by three years of community action board (CAB) meetings, stakeholder interviews, and focus groups conducted in English and Spanish. Latino and Black patients living with HTN in this safety-net (including Spanish-speaking) were identified as video candidates via referrals from health educators, aforementioned CAB members, and safety-net stakeholders. Filming sessions were limited to 30-60 minutes to minimize participant fatigue. Videos were reviewed and refined with input from CABs, health system leadership, and the research team to enhance cultural relevance, clarity, and alignment with community needs.

Seven participants shared their narratives related to HTN management, resulting in 1–3 minute culturally tailored videos for each patient. Video themes included lifestyle (e.g. dietary changes and physical activity), medication adherence, personal challenges with healthcare access, and the impact of peer support in motivating self-management; health literacy gaps and cultural perceptions of care were discussed as barriers. Participants emphasized that personal stories increased their understanding of HTN and inspired actionable changes. CABs and safety net leadership affirmed that culturally and linguistically tailored videos fostered trust, engagement, and relatability for safety-net patients.

By leveraging shared experiences and peer influence, storytelling makes health information relatable, fosters trust, and strengthens self-efficacy—empowering patients to take a more active role in health management. Future steps include the evaluation of videos on patient outcomes, care engagement, and clinical measures to manage blood pressure control. EMERGENCY CARE AT HOME: A RANDOMIZED CONTROLLED TRIAL David Levine1; Saheba Shaikh2; David Meguerdichian2; Justine Nagurney2; Stephen Dorner2; Sean Kukauskas2; John W. Campbell2; Korilyn Zachrison3; Karin Falkenberg2; Henry Ssemaganda2. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Health Care at Home, Mass General Brigham Inc, Boston, MA; 3Emergency Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4273599)

Brick-and-mortar (BAM) emergency department (ED) care delivers high-intensity care on demand to large populations and serves as an efficient gateway to hospitalization. However, some patients may not be well-served in the BAM, particularly older adults and those who are homebound. The ED may harm these patients due to delirium, pressure injury, infection, anxiety, and overcrowding. Emergency care at home (ECAH) instead of in the BAM has been trialed only in single-arm studies with positive results. The efficacy of ECAH instead of BAM is unknown.

We performed a parallel-group randomized controlled trial in a large health system in New England. Patients were referred by their primary care team and triaged by the ECAH nurse using the emergency severity index (ESI; range, 1-5; higher is less urgent). Patients were adults, had to live in greater Boston, had to triage to the ED or urgent care, and had to attest that they intended to go to the ED irrespective of randomization. Patients were excluded if they lived in a nursing facility, had active substance use, an acute psychiatric concern, intimate partner violence, or high risk signs (e.g., shock index >1) or symptoms (e.g., active chest pain). If eligible, patients were randomized 1:1 to receive ECAH or BAM. ECAH included an in-home mobile integrated health paramedic visit to facilitate a remote emergency medicine physician visit. The paramedic could perform in-home labs, ECG, and administer IV, oral, and respiratory medications. Our primary outcome was emergency department presentation, observation, or hospitalization within 9 days of the initial emergency care, analyzed by logistic regression clustering by emergency medicine physician. Secondary outcomes were time to care initiation, time spent receiving care, and the number of days at home within 9-days of emergency care.

We studied 229 patients (ECAH, 115; BAM, 114); groups were well balanced. Median age was 83 (IQR, 16), 67% were female, 86% were of White race/ethnicity, 59% had less than a college degree, and median area deprivation index was 3 (IQR 3; range 1-10; higher is more deprived). Respiratory (33%), genitourinary (21%), and digestive (17%) concerns were most common. 87% had an ESI of 3. Within 9 days of emergency care, 32% of ECAH patients and 16% of BAM patients had an ED presentation, observation episode, or hospitalization (p=0.006). Time to care initiation was not significantly different (293 minutes [SD, 356] for ECAH vs 417 minutes [SD, 378] for BAM; p=0.158). ECAH patients spent significantly less time receiving care (139 [SD 67] vs 401 [SD, 436]; p<0.001) and significantly fewer days at home within 9 days of emergency care (7.6 [SD, 2.6] vs 8.7 [SD, 1.1]; p<0.001). No unanticipated mortality occurred.

ECAH for select patients was unlikely effective in appropriately delivering care that addressed the emergent concern and prevented further BAM care. EMPOWERING PATIENTS TO CLOSE DIABETES CARE GAPS: RESULTS OF A PRAGMATIC RANDOMIZED CONTROLLED TRIAL EVALUATING A PATIENT PORTAL INTERVENTION William Martinez1; Jared G. Cobb2; Sapna Gangaputra3; Amber Hackstadt4; Lindsay S. Mayberry5,8; Lyndsay Nelson6; Neeraja B. Peterson7; S. T. Rosenbloom8; Zhihong Yu4; Tom Elasy1. 1Medicine, Vanderbilt University Medical Center, Nashville, TN; 2HealthIT, Vanderbilt University Medical Center, Nashville, TN; 3Ophthalmology, Vanderbilt University Medical Center, Nashville, TN; 4Biostatistics, Vanderbilt University Medical Center, Nashville, TN; 5Medicine, Vanderbilt University Medical Center, Nashville, TN; 6Medicine, Vanderbilt University Medical Center, Nashville, TN; 7Medicine, Vanderbilt University, Nashville, TN; 8Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4270829)

Many patients with diabetes fail to receive timely evidence-based diabetes preventive care, increasing the risk of complications. Patient portals provide scalable solutions for patient engagement but often lack functionality tailored to chronic disease management. This study evaluated a novel Diabetes Care Gaps Intervention (DCGI), embedded in patient portal at a large academic medical center. The DCGI aimed to reduce care gaps by notifying patients, providing brief, easy to understand descriptions of needed care, and empowering patients to “self-order” the care or report receipt outside the health system (eye exam only).

We conducted a pragmatic, two-arm randomized controlled trial involving adult patients with diabetes recruited from 14 primary care clinics affiliated with a large academic medical center. Participants were randomly assigned to the control group (standard portal access) or intervention group (portal with DCGI functionality). The DCGI addressed four key care gaps: diabetes eye exams, pneumococcal vaccination, hemoglobin A1c, and urine microalbumin testing. Data were collected via electronic health records and participant questionnaires at baseline, three months, six months, and twelve months. The primary outcome was number of care gaps through 12-month follow-up. Secondary outcomes included diabetes self-efficacy, understanding of diabetes preventive care, diabetes distress, and patient portal usability. A mixed-effects proportional odds model quantified the intervention’s effects, adjusting for baseline gaps and including patient-level random effects.

The study included 431 participants with a mean age of 57.6 years (SD=12.5), 34% aged 65 or older, 67% non-Hispanic White, and 31% had limited health literacy. Table 1 compares the proportion of participants within each arm by the number of care gaps at baseline and 12 months. The mixed-effects proportional odds model demonstrated that participants in the intervention group had significantly fewer diabetes care gaps compared to the usual care group through 12-month follow-up. Specifically, the odds of having more diabetes care gap was 55% less for those in the intervention group compared to those with standard portal access (odds ratio 0.45; 95% CI: 0.30-0.68, p<0.001). None of the secondary outcomes showed statistically significant differences between groups.

The patient portal intervention effectively reduced diabetes care gaps. The findings suggest that integrating this patient portal intervention into routine care may enhance patient adherence to preventive services, leading to improved health outcomes. Future efforts should explore broad implementation and applicability to other care domains, including cancer screening. EMPOWERING RESIDENTS: ENHANCING THORACENTESIS SKILLS AND CONFIDENCE THROUGH HANDS-ON TRAINING Sahalia Rashid1; Peter Morkos1; Jasdeep S. Bathla2; Pierre Tannous1. 1Internal medicine, Detroit Medical Center, Detroit, MI; 2Internal Medicine, Detroit Medical Center, Detroit, MI. (Control ID #4273611)

A lack of confidence and procedural skills in residents may lead to delays in thoracentesis for patients in academic institutions. Timely thoracentesis can impact patient outcomes by alleviating symptoms, preventing complications, and improving survival. Thoracentesis is therefore a critical procedure for internal medicine residents. A retrospective chart review was conducted at our institution, demonstrating >90% of all thoracentesis procedures were done by the interventional radiologist team. Our aim is to ultimately improve patient outcomes and prevent delays in obtaining crucial procedures such as thoracentesis by improving knowledge, skills and confidence in resident physicians.

We implemented a structured, hands-on quality improvement initiative in an academic internal medicine residency program to enhance residents’ proficiency in performing thoracentesis. A comprehensive training session was introduced, which included a lecture covering the relevant steps for thoracentesis. This was followed by hands-on practice using a mannequin and ultrasound equipment to simulate real-world conditions. The primary aim of this intervention was to assess changes in residents' knowledge and confidence regarding thoracentesis using anonymous pre- and post-training surveys were administered.

A total of nine residents participated in the thoracentesis education program. Response rates for the pre-assessment and post-assessment were 100% and 90%, respectively. The highest reported barrier to performing thoracentesis was the lack of procedural skills and the absence of formal education. Following the educational intervention, there was a 54.2% increase in confidence in performing thoracentesis procedures, alongside a 42% increase in confidence in identifying relevant anatomy with the use of ultrasound. Additionally, 85% of residents expressed high to very high interest in performing thoracentesis after the teaching session.

Recognizing that insufficient training represents a major obstacle to timely thoracentesis, we developed an intervention through integrating simulation technology aimed at equipping internal medicine residents with the skills and confidence necessary to perform this critical procedure. Our findings demonstrate marked improvements in both residents' procedural knowledge and their self-assessed confidence following the intervention. We intend to sustain this initiative, ensuring all residents gain hands-on experience with this essential bedside technique. Future efforts will focus on evaluating the program's long-term impact of this training on resident performance through evaluating the percentage of thoracenteses and effect on patient care. ENCOURAGING THE PRESCRIBING OF SGLT2I AND GLP-1RA MEDICATIONS TO REDUCE CARDIOVASCULAR AND RENAL RISK IN PATIENTS WITH TYPE 2 DIABETES: RESULTS OF A CLUSTER RANDOMIZED CONTROLLED TRIAL Nancy Haff1; Meekang Sung1; Caitlin Colling2; Daniel Gaposchkin2; Leigh Simmons3; Judy Yang2; James Yeh2; Julie Lauffenburger4; Niteesh K. Choudhry5. 1Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 2Massachusetts General Hospital Department of Medicine, Boston, MA; 3Medicine, Mass General Brigham Inc, Boston, MA; 4Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; 5Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, MA. (Control ID #4273277)

Sodium-glucose cotransporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP-1RA) medications reduce the risk of cardiovascular and renal disease among patients with type 2 diabetes but are underutilized. Barriers include insurance coverage, medication availability, and diffusion of responsibility of prescribing across providers, among others.

In this pragmatic randomized trial, primary care providers (PCPs) were randomized to: Peer Champion Support (PC), Peer Champion Support and Insurance Information (PC+II), or Usual Care (UC), with the goal of increasing appropriate SGLT2i and GLP-1RA prescribing. Four PCPs with high baseline SGLT2i and GLP-1RA prescribing were selected as peer champions and assigned to PCPs in the intervention arms. Emails encouraging prescribing and offering support were sent on behalf of the peer champions to initiate the intervention. Electronic health record (EHR) messages were then sent to PCPs before visits with patients with sub-optimally controlled diabetes and an indication for an SGLT2i or GLP-1RA, with the PC arm receiving tips to address common SGLT2i and GLP-1RA prescribing concerns and the PC+II arm receiving a list of which medications in these classes were covered by the patient’s insurance plus instructions on how to use a pre-existing EHR tool to estimate prescription out-of-pocket costs. The primary outcome was prescriptions for SGLT2i or GLP-1RA medications among patients who attended the targeted visits. Secondary outcomes were time to prescription, medication filling, time to filling, change in HbA1c, and specialist referrals.

A total of 191 PCPs and 1389 patients were included; 66 providers (484 patients) in the PC arm, 63 providers (446 patients) in the PC+II arm, and 62 providers (459 patients) in UC; 1079 patients attended a targeted visit and were included in the primary analysis. On average, patients were 66 years old, 46% female, 61% white, and 16% Hispanic. Rates of the primary outcome did not differ between arms (table). There was a non-significant trend towards more medication filling in the PC+II arm compared to UC (table). There were fewer nephrology referrals in both intervention arms (table). Other secondary outcomes did not differ between arms.

A peer champion intervention with or without insurance information did not increase SGLT2i or GLP-1RA prescribing in primary care. Likely reasons for these findings include medication shortages, high baseline prescribing rates, and high medication copays. Though not statistically significant, the trend toward more successful fills in the PC+II group suggests that additional information on insurance coverage may have helped providers select medications that were financially feasible for patients. ENDOSCOPIST RESPONSES TO SCENARIOS INVOLVING THE ASSIGNMENT OF GUIDELINE RECOMMENDED FOLLOW-UP TIME INTERVALS AFTER A COLONOSCOPY FOR COLORECTAL CANCER Kimberly Harris1; Katherine Gallagher1; Sonali Palchaudhuri2,3; James Richter2,3; Steven J. Atlas1,3. 1Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; 2Division of Gastroenterology, Massachusetts General Hospital, Boston, MA; 3Harvard Medical School, Boston, MA. (Control ID #4269751)

Colorectal cancer (CRC) screening with colonoscopy can reduce CRC incidence and mortality by removing precursor polyps and early detection of cancer. Benign, abnormal polyps are common, increase the risk of developing cancer, and a follow-up surveillance colonoscopy is recommended. Selecting the recommended follow-up time interval according to US Multi-Society Task Force guidelines requires information about the adequacy of current colonoscopy preparation and results, past colonoscopy results, and patient’s family history of CRC. Because endoscopists manually perform this process following a colonoscopy, we surveyed endoscopists and asked them to respond to different patient scenarios involving the selection of a follow-up time interval after a colonoscopy for CRC screening.

As part of a randomized trial of endoscopists from one academic medical center who performed colonoscopies on patients undergoing a colonoscopy for CRC screening (ClinicalTrials.gov NCT05631873), endoscopists were surveyed following the completion of the trial. Endoscopists from intervention and control groups, as well as new endoscopists who were not part of the trial, were invited to participate. In addition to questions about the process of sending patient result letters and updating the colonoscopy reminders in the electronic health record, endoscopists were also asked to provide recommended follow-up intervals for five patient scenarios. Scenarios included straightforward and nuanced situations. We report the number and percentage of correct responses to each scenario based on guideline recommendations (choices: colonoscopy in 1, 3, 5, 7 or 10 years) and whether the endoscopist was confident in their response to the scenario (choices: “not at all”, “not too”, “somewhat” vs. “very” confident).

Overall, 35 of 48 (72.9%) endoscopists completed at least two scenarios in the survey (17 intervention, 15 control and 3 non-study endoscopists). Characteristics of respondents included 15 female (42.9%) and 13 were 50 years of age or older (37.1%). The five scenarios, the guideline recommended follow-up interval, and the percentage with the correct response and reporting they were very confident in their response are provided in the table. Correct responses to the five scenarios varied from 31 to 77%, and 29-71% of endoscopists were very confident in their response.

Endoscopists performing colonoscopies for colorectal cancer screening varied widely in their response to different scenarios involving the assignment of guideline-recommended follow-up time intervals and the confidence of the response. Automated systems to assign follow-up time intervals could improve guideline recommended care. ENHANCING POST-HOSPITALIZATION FOLLOW-UP THROUGH VIDEO-ENABLED SCHEDULING: A RANDOMIZED CONTROLLED TRIAL William Turner1; Alicea Lieberman2; Hengchen Dai2; Erin Dowling3; Wendy Simon3; Brian Le3; Richard K. Leuchter1. 1Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2Anderson School of Management, University of California Los Angeles, Los Angeles, CA; 3Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4268341)

Unplanned readmissions in the U.S. cost over $15 billion annually, a burden that increasingly impacts health systems as more patients transition to fully capitated models. Despite evidence supporting the protective effect of post-hospitalization visits with primary care providers (PCPs), patient completion rates of these visits remain low. Barriers include provider availability and perceived lack of necessity, with many patients forgoing PCP visits in favor of specialists or missing appointments entirely. To address these challenges, the research team, in collaboration quality officers, implemented a novel intervention where post-discharge appointments were scheduled via video visits with the scheduling team. These video visits were designed to engender social accountability to attend the appointment through a personal connection with the scheduler, and utilized a face-to-face commitment to improve appointment attendance.

We implemented a room-based randomization scheme to evaluate this intervention: half of one unit in a large, academic medical center in the Southwest region were designated as 'treatment' rooms, with the remaining rooms serving as controls. Eligible patients included those discharged from treatment rooms, empaneled or willing to empanel to a system PCP, not in hospice, and discharging home. Treatment group patients were identified by discharge nurses the day before their expected discharge, enabling the scheduling team to arrange appointments. On discharge day, floor nurses and care partners facilitated a Zoom video call between the patient and a scheduling team member using an iPad, allowing the patient to schedule their follow-up appointment synchronously. This is in comparison to the standard process whereby schedulers call patients in the days following their discharge with pre-set appointments. The outcome was having a post-discharge follow-up appointment scheduled and completed within seven days of discharge.

A total of 41 patients were enrolled in this pilot RCT (14 in treatment group, 27 in control group). 86% (n=12/14) of patients in the treatment group had their follow-up scheduled within 7 days, compared to only 52% (n=14/27) in the control group (p=0.02). 64% of eligible patients in the treatment group completed their 7-day post-discharge follow-up, compared to only 37% in the control group (p=0.11). The treatment group also experienced a lower no-show rate (7.14%) compared to the control group (11.11%), with additional control no-shows being rescheduled within the 7-day window.

Compared to the standard post-hospitalization appointment scheduling method, this randomized pilot study of video-assisted appointment scheduling demonstrated a statistically significant increase in post-discharge scheduling rates (86% v. 52%) and non-statistically significant increase in post-discharge appointment completion rates (64% v. 37%). Larger studies are needed to confirm these findings and support broader implementation. EXAMINING FACTORS ASSOCIATED WITH ACUTE CARE UTILIZATION AMONG MEDICARE BENEFICIARIES IN PRIMARY CARE FIRST AT UCLA HEALTH Carlos Irwin Oronce1,3; Chad Villaflores3; William Turner2,3; Samuel A. Skootsky2; Richard K. Leuchter3; John N. Mafi3; Catherine Sarkisian3. 1Medicine, Greater Los Angeles VA Healthcare System / UCLA, Los Angeles, CA; 2Medicine, UCLA Health, Los Angeles, CA; 3Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4271086)

Medicare beneficiaries receive suboptimal care at a very high cost. The Center for Medicare and Medicaid Innovation introduced the Primary Care First (PCF) model in 2021 to improve quality and reduce medical expenditures for Medicare fee-for-service (FFS) beneficiaries. PCF uses a hybrid value-based payment model incorporating two-sided financial risk and population-based payments to incentivize adoption of advanced primary care functions to keep patients healthy and out of the hospital. This study identifies factors associated with lower all-cause hospitalizations and emergency department (ED) visits.

We analyzed Medicare FFS claims data for beneficiaries aged 65+, continuously enrolled for 12+ months at UCLA Health (2021–2023). Outcomes were clinic-level all-cause hospitalizations and ED visits per 1,000 per year, defined by NCQA HEDIS specifications and validated using national NCQA and Mililman benchmarks. We examined practice-level mean patient age, racial/ethnic demographics, Medicaid dual-eligibility, CDC Social Vulnerability Index (SVI), Hierarchical Condition Category (HCC) scores, and distance to practice across utilization quartiles. Multivariable Poisson regression models with year fixed effects, practice patient size as exposure, and standard errors clustered by practice were used to assess associations.

During 2021–2023, 21,832–27,779 patients were attributed to 40 UCLA primary care practices. Mean age was 74 years (SD 9); 59% female; 11% Asian, 5% Black, 7% Latino, and 61% non-Hispanic White. Mean SVI score was 38 (lower vulnerability), 12% were dual-eligible, and mean clinic distance was 35 miles (SD 212). The mean all-cause hospitalization rate was 168 per 1,000 per year (SD 53), ranging 73–376, and ED visit rates averaged 224 (SD 69), ranging 89-425. Clinics in the highest acute care quartiles had more racial and ethnic minority patients, Medicare-Medicaid dual-eligible patients, and higher HCC risk scores. Multivariable models found a 1-mile increase in distance (p<0.01), 1% increase in Asian patients (p<0.01), or 1% increase in White patients (p<0.01) were independently associated with 1% lower hospitalization rates. A 1% increase in dual-eligible patients was linked to a 1% higher hospitalization rate (p=0.02). Similar patterns were observed for ED visits.

In a large academic health system under a primary care payment reform model, practices with higher proportions of White patients and lower proportions of dual-eligible patients had lower acute care utilization. These findings highlight the need for targeted resource allocation and enhanced support for practices serving racial and ethnic minority and dually eligible Medicare populations in payment reform initiatives. FEASIBILITY AND ACCEPTABILITY OF MUSIC IMAGERY AND LISTENING INTERVENTIONS FOR ANALGESIA (FAMILIA): A PILOT STUDY IN VETERANS WITH CHRONIC MUSCULOSKELETAL PAIN Matthew J. Bair1,2; Kristin M Story1; Barry Barker1; James Slaven3; Sheri Robb4; Leah Whitmire1; Sally Wasmuth1; Dawn Bravata1,2. 1Center for Health Information and Communication, Indianapolis, IN; 2Medicine, Indiana University School of Medicine, Indianapolis, IN; 3Biostatistics, Indiana University School of Medicine, Indianapolis, IN; 4Nursing, Indiana University Indianapolis, Indianapolis, IN. (Control ID #4273125)

Chronic pain is common among military veterans and is associated with disability, poor quality of life, and psychological comorbidity. The Veterans Administration (VA) recommends an integrative approach to chronic pain management and has expanded telehealth to increase access to pain management services. Music interventions have shown promise as effective non-pharmacological options for chronic pain, but previous studies have examined less intensive, music listening interventions delivered in-person for persons with acute pain.

The Feasibility and Acceptability of Music Imagery and Listening Interventions for Analgesia (FAMILIA) Study examined the feasibility, acceptability, and preliminary effectiveness of two virtually delivered music interventions vs. usual care for Veterans with chronic musculoskeletal pain. FAMILIA was a 3-arm, parallel group, pilot trial. Sixty Veterans were randomized to one of three conditions: 1) 8-weekly one-on-one Music Imagery sessions; 2) a Music Listening protocol; or 3) usual care. We assessed feasibility metrics related to recruitment, retention, engagement, and completion of treatments and outcome assessments. Acceptability was measured through qualitative interviews, and assessments of treatment credibility, satisfaction, and safety. Interviews assessed participant experiences with the music interventions. Descriptive statistics were used for feasibility and acceptability outcomes. We also explored the preliminary effectiveness of interventions versus control on pain and associated outcomes. These outcomes were assessed through changes from baseline to follow-up assessments at 1, 3, and 4 months.

From March 2022 to July 2023, 60 patients underwent randomization; 30 patients were assigned to Music Imagery (MI); 15 patients were assigned to Music Listening, and 15 patients were assigned to usual care. The mean age of participants was 54.8 years; had an average pain duration of 35 years, 43% had moderately severe depression, and 38% had moderately severe anxiety symptoms.The feasibility metrics for recruitment, retention, delivery of study treatments in the allotted time, and completion of outcome assessments were met. A total of 226 out of 240 assessments were (94.2%) completed. The interventions were acceptable to and perceived favorably by study participants. Pain severity and interference improved across all three study arms but were more pronounced in the music imagery and music listening arms. Secondary outcomes (stress, depression, anxiety, catastrophizing) improved in the music arms but worsened in the usual care arm.

The FAMILIA study was feasible and the virtually-delivered music interventions were acceptable to participants. Participants were complex medically and psychologically. Pain outcomes improved across all three study arms but were more pronounced in the MI and ML arms. Secondary outcomes (stress, depression, anxiety, catastrophizing) improved in both music arms but worsened in the usual care arm. HOSPITAL CARE AT HOME READMISSION OUTCOMES IN SUBURBAN/RURAL LOCATIONS Andrea Huang1; Soumya Rangarajan2. 1University of Michigan, Ann Arbor, MI; 2University of Michigan Medical School, Ann Arbor, MI. (Control ID #4232032)

Michigan Medicine’s Hospital Care at Home (HCAH) Program was designed to provide eligible patients living in Southeast Michigan hospital level care from their own homes. Since the advent of the CMS Hospital at Home Waiver in Nov 2020, 93% of HCAH programs have been in urban locations, with prominent programs in cities such as Boston, Baltimore, and New York City. The Michigan Medicine HCAH program is unique from other Hospital at Home programs in its service area, caring for a range of patients in more suburban and rural locations.

Eligible patients were admitted from the Emergency Department (ED) or transferred from an in-hospital inpatient or observation unit. A small subset of patients were admitted directly from home. Traveling nurses visited patients twice daily, and physicians visited in-home once per day. According to the 2020 Census Bureau Urban Area classification, the cities of Ann Arbor, Chelsea, Dexter, Milan, and South Lyon are designated as urban areas. Any area not within these cities qualify as rural.

138 out of 298 total patients resided in urban areas, and 134 patients resided in rural areas according to census designations. By population density metrics alone, 157 patients resided in an area with a population density less than 1000 people per square mile. Out of 327 total HCAH enrollments, 60 (18.3%) resulted in a 30 day post-discharge ED visit. 44 enrollments resulted in a 30-day hospital readmission, either inpatient or outpatient, resulting in 13.4% 30-day hospital readmission rate. In patients living in census-designated urban areas, 31 out of 150 (20.67%) enrollments resulted in 30-day ED visits and 20 visits resulted in hospital readmissions (13.3%). In rural areas, 29 out of 177 (16.38%) visits resulted in 30-day ED visits, and 24 (13.56%) resulted in hospital readmissions. In a two-proportion z-test, no significant differences were found in rates between ED visits nor with readmissions for HCAH patients from urban and rural areas. During December 2021 to January 2024, all hospital ED utilization rates were 14.2%, and all hospital readmission rates were 12.4%. When comparing rates of followup ED visits in a two-proportion z-test, there was a significant increase (p = 0.03318) in hospital readmissions for HCAH compared to all hospital admissions. However, no significant difference was found between the two in ED utilization.

A large majority of Hospital at Home programs offering inpatient-level services do so in primarily urban areas, resulting in a disparity in rural healthcare access. The Michigan HCAH Program received a roughly equal mix of patients resident in rural and urban settings, and saw similar ED utilization rates in rural HCAH patients compared to urban HCAH patients. There was an increase in hospital readmissions for patients in our HCAH program compared to all hospital admissions, indicating there are areas for improvement in tailoring HCAH to more rural populations. HOW AND UNDER WHAT CONDITIONS DO PATIENT PORTALS IMPROVE CANCER SCREENING COMPLETION: A SCOPING REVIEW Rebecca S. Gold1,2; Nora B. Henrikson3; Rachel B. Issaka4,5; Erin Gillespie5; Linnaea C. Schuttner6,5; Bryan J. Weiner5; Leah M. Marcotte7. 1Internal Medicine, University of Washington, Seattle, WA; 2VA Puget Sound Health Care System Seattle Division, Seattle, WA; 3Kaiser Permanente Washington Health Research Institute, Seattle, WA; 4Fred Hutchinson Cancer Center, Seattle, WA; 5University of Washington, Seattle, WA; 6Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA; 7Medicine, University of Washington, Seattle, WA. (Control ID #4235402)

Despite evidence that screening is effective in cancer prevention, early detection, and improving mortality, screening rates continue to fall below national targets. Studies have shown that patient portals facilitate cancer screening but less is known about how facilitation occurs. Causal pathway diagrams (CPDs) can be used to understand how portal strategies work to improve screening. CPDs include mechanisms (i.e., processes through which strategies operate to effect outcomes) and moderators (i.e., factors that increase or decrease strategy influence). We conducted a scoping review of mechanisms and moderators to inform early CPDs of the portal as a strategy to improve cancer screening completion.

We conducted a comprehensive scoping review by searching PubMed for studies published from 2014–2024 in the US, including patients at average risk for developing cancer, interventions or evaluations including portals, and a primary outcome of colorectal, breast, cervical, or lung cancer screening. Two authors completed manuscript screening and data extraction using Covidence systematic review software and synthesized findings to create CPDs.

Our initial search criteria identified 566 studies. After title/abstract review, 87 studies advanced to full text review, and 32 studies met inclusion criteria. Studies were often set in large academic health systems (n=13) or utilized survey data from nationally representative cohorts (n=11); 6 were randomized controlled trials. Most studies focused on breast (n=10) or colorectal (n=9) cancer screening; 8 studies evaluated multiple cancers. The most frequently studied portal features were electronic access to records, secure messaging, and self-scheduling or self-ordering screening tests. Portal interventions included behavioral modifications and enhancing communication or counseling. Though not a central research question, we abstracted data on portal effectiveness: of the 21 studies comparing portal use to no use, 18 found portal use was associated with increased screening. Most proposed mechanisms and moderators were hypothesized and/or cited findings from prior literature rather than observed directly. Of the 6 studies that performed formal statistical analysis, significant findings included provider recommendation as a moderator for self-scheduling; nudge as a mechanism for behavioral modification; cancer worry and patient activation as mechanisms for general portal use; and sequential mediation of cancer fatalism and patient activation as mechanisms for secure messaging.

Our scoping review found that although portal use was associated with increased cancer screening, few studies have directly tested mechanisms and moderators, suggesting a significant research gap. More research is needed to further evaluate proposed mechanisms such as patient activation, cancer worry and fatalism, to better understand how portals facilitate screening and optimize implementation. IMPACT OF CONVERTING IN-PERSON TO ELECTRONIC SCREENING FOR ALCOHOL USE DISORDER IN PRIMARY CARE: A RANDOMIZED QUALITY IMPROVEMENT TRIAL Linnaea C. Schuttner3,4; John Geyer1,4; Eric Gunnink2; Chelle Wheat2; Jorge Rojas Jr.2; Madeline Frost3,6; Nilesh Shah5,7; Karin Nelson2,4; Ashok Reddy2,4. 1General Medicine Service, VA Puget Sound Health Care System Seattle Division, Seattle, WA; 2Primary Care Analytics Team, US Department of Veterans Affairs, Seattle, WA; 3Health Systems Research, VA Puget Sound Health Care System Seattle Division, Seattle, WA; 4School of Medicine, University of Washington, Seattle, WA; 5Office of Connected Care, US Department of Veterans Affairs, Washington, DC; 6School of Public Health, University of Washington, Seattle, WA; 7VA San Diego Health Care, US Department of Veterans Affairs, San Diego, CA. (Control ID #4271061)

Timely evidence-based screenings in primary care can identify at risk-patients. Traditionally in the Veterans Health Administration (VHA), some screenings are completed by staff as questionnaires delivered verbally during face-to-face encounters. However, in-person screening may reduce patient disclosure for stigmatized or sensitive topics. Additionally, in-person screening standards have led to disparities in screening completion for virtual visits as telemedicine use increases. To address these challenges, our regional health system piloted conversion of several common screenings to electronic modalities via automated email or text message delivered pre-visit (e-screening). Within this context, we compared e-screening for unhealthy alcohol use with the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) questionnaire to usual care (staff-delivered) in a pragmatic cluster-randomized quality improvement trial.

Over 6-weeks, primary care providers (PCPs, N=48) at two VHA clinics were randomized 1:1 (stratified by site) to have patients with upcoming visits receive e-screening vs. usual care. In the e-screening arm, PCP-enrolled patients due for screening were sent an e-screening >24h prior to their PCP visit; screenings not completed by the time of their PCP visit were captured by usual methods. In usual care, patients were directly screened by staff before PCP visits. We conducted intention-to-treat analyses via multivariable regression models clustered by provider, with a primary outcome of AUDIT-C completion within 1 day of a video or telephone visit. Secondary outcomes included completion for all visit modalities and screen-positive rates. Models were adjusted a priori for patient demographics for precision.

44 of 48 (92%) enrolled PCPs were retained in the trial. These PCPs saw 1731 patients (mean age 58y, 88% men) via an eligible healthcare visit (60.3% in-person; 17.7% telephone; 22.0% video). In the primary outcome of those seen in telemedicine visits, usual care patients had a 49.7% (95% CI: 31.9-67.5) adjusted predicted probability (aPP) of AUDIT-C completion, vs. 78.7% (72.2-84.0) in e-screening arm. Screen-positive aPP was 1.2% (0.5-3.2) in usual care vs. 3.9% (2.7-5.6) in e-screening arm. Among patients with all visit types, aPP of AUDIT-C completion was 71.9% (60.8-80.8) in usual care vs. 88.4% (85.5-90.8) in e-screening arm. Screen-positive aPP was 3.9% (2.8-5.5) in usual care vs. 7.7% (6.1-9.8) in e-screening arm.

In this trial, electronic screening for alcohol use disorder led to higher screening completion and more patients screening positive for unhealthy alcohol use, than usual staff-delivered screening. Electronic screening may reduce both workforce burden and screening disparities by visit modality, compared to screening delivered by staff. Additionally, disclosure of stigmatized or sensitive topics such as alcohol use may be improved by more impersonal electronic modalities. IMPLEMENTATION OF CHIEF WELLNESS/WELL-BEING OFFICERS (CWOS) IN US HEALTHCARE ORGANIZATIONS: WHAT WE KNOW Kimny A. Sysawang1; Jennifer Ferrin1; Vandana Teki1; Diana Zhang1; Aneesa Motala1; Kristina Oishi2; Alicia R. Gable2; Danielle Dunn2; Tanya T. Olmos-Ochoa2; Susanne Hempel1. 1Southern California Evidence-Review Center, University of Southern California, Los Angeles, CA; 2Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4272980)

Clinician well-being is critical for patient care. Systems-level approaches to alleviate burnout and reduce staff turnover are urgently needed. Some healthcare organizations have introduced Chief Wellness/Well-Being Officers (CWOs) to improve clinician well-being, yet CWOs and their work is understudied.

We engaged interest holders and conducted a scoping review of the literature to assess implementation of CWO initiatives. (osf.io/5vtcj) We conducted 14 key informant interviews with representatives from 4 frameworks identified by interest holders: consumers and community, policy and decision-makers, researchers, and clinicians/CWOs. Interviewed CWOs were from a variety of clinical contexts and disciplines, including an academic/teaching hospital, large healthcare system, non-profit healthcare system, rural healthcare system, and non-physician CWOs. The literature review searched 8 research databases and grey literature for information on CWOs.

We identified 26 publications that discussed the introduction of CWOs in healthcare organizations; all were US publications published between 2013-present. Research links the lack of support and resources for well-being resulting in burnout and staff turnover. Among key informants, the CWO role primarily derived from a task force focused on the well-being of physicians. The role evolved to drive organizational culture for physician engagement and professional fulfillment through systematic changes. Initiatives discussed in the literature includes raising awareness of issues impacting wellness/well-being; engaging with stakeholders to develop strategies and identify needed resources; introducing and evaluating programs to assist in addressing wellness/well-being issues on a macro level. For some CWOs, being able to assess the impact of their work has been challenging within organizations. Several CWOs work with their Human Resource department to gather data and analytics on employee well-being (e.g., burnout data by employee demographics). Surveys to inform wellness/well-being interventions have been developed and calculating return on investment to share with stakeholders in yearly reviews have been instrumental for strategic planning.

The CWO position is a systems-level approach to improve clinician well-being. The insights from these interviews and early experiences can inform leadership, clinicians, and staff to better support the implementation of CWOs. Evidence supports that initiatives and organizational changes led by empowered CWOs can effectively mitigate issues impacting burnout and improve overall clinician well-being. IMPLEMENTATION OF URINARY INCONTINENCE SCREENING WORKFLOWS IN PRIMARY CARE: ADOPTION, SCREENING, DETECTION, AND CHANGES IN TREATMENT IN A LARGE HEALTH SYSTEM Stephen Persell1; Tiffany Brown2; Sarah Collins3; Julia Geynisman-Tan4; Oliver Kennedy5; Ji Young Lee6; Lucia C. Petito7; Jing Song7; Gina Syed8; Kimberly Kenton3. 1Medicine, Northwestern University, Evanston, IL; 2Department of Medicine; Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; 3The University of Chicago Pritzker School of Medicine, Chicago, IL; 4Northwestern University Feinberg School of Medicine, Chicago, IL; 5Information Services, Northwestern Memorial HealthCare, Chicago, IL; 6School of Medicine, Northwestern University, Chicago, IL; 7Preventive Medicine , Northwestern University, Chicago, IL; 8Northwestern Memorial HealthCare, Chicago, IL. (Control ID #4272754)

Urinary incontinence (UI) is highly prevalent among women, has significant negative physical and mental health consequences, and is frequently under-treated. Routine screening is recommended.

We implemented a multi-faceted screening program at a large health system and here describe its adoption, reach, and effectiveness. Routine screening for UI was implemented at primary care preventive visits for female patients ages 18y+. Components included an automated pre-visit questionnaire, clinical decision support for rooming staff and physicians/advanced practice providers, an online interactive patient educational module, order set, and practice facilitation. Effectiveness outcomes included clinic-level monthly rates of both UI diagnosis and referrals for UI to pelvic floor physical therapy (PFPT) and specialty care. An interrupted time series approach (piecewise linear mixed model with a break at intervention start) using data from eligible visits between January 2021 and October 2024 was used to estimate the immediate effectiveness (“jump”) as well as differences in the monthly rate of change in each outcome.

Implementation began in January 2023. As of December 2024, 43 of 74 (58%) approached practices had implemented the program. Among eligible patients with preventive visits, 61,319 of 75,275 were screened (81%). There was practice-level variability in screening [median 81% (IQR 63 to 96)], but little variability by patient race, ethnicity or age. Of screened patients, 10,022 (16%) indicated they had any bothersome UI, and 5,529 (9.0%) reported bothersome UI and wanted to learn about treatment. Among all women attending preventive care visits at clinics that implemented the project procedures, the percentage who had ever received a UI diagnosis prior to implementation was low (4.2-4.7%) and slowly increased by 0.5% per year. In time series analysis, after implementation there was a “jump” in UI diagnosis of 0.6% (p=0.002). The difference in slope compared to pre-intervention corresponded to an additional 0.6% of women diagnosed with UI per year (p=0.017). After implementation, rates of PFPT referral per 1,000 women attending primary care preventive visits jumped by 4 per 1,000 (p<0.001) from 5 to 9 per 1,000 and rates of specialty referral jumped 3 per 1,000 (p<0.001) from 4 to 7 per 1,000. An additional 4 per 1,000 (p<0.001) and 1 per 1,000 (p=0.12) per year had PFPT or specialty referrals, respectively.

In practices that adopted workflows to screen for and address UI in women at preventive care visits, screening rates were high, many women without a prior UI diagnosis reported bothersome UI symptoms, and the rates of UI diagnosis and treatment in the overall primary care populations at these locations increased significantly. A large minority of practices chose not to implement these workflows, and there was variability in screening rates at the practice level. IMPLEMENTING ECONSULTS AT A LARGE PUBLIC HEALTH CARE SYSTEM Delia Shen1,2; Kerry K. Meltzer1,2; Emilie O'Neill1; Girisha Bharadwaj1; Christine Zhang1; Shakira Greene1; Sarah Rose Cass1; Hannah Jackson1. 1Office of Ambulatory Care + Population Health, NYC Health+Hospitals, New York, NY; 2Department of General Internal Medicine, New York University Grossman School of Medicine, New York, NY. (Control ID #4272891)

eConsults, or “electronic consultations,” enhance the accessibility of specialty care by improving coordination between primary care physicians (PCPs) and specialists and can eliminate the need for patients to see a specialist in person. In 2015, after a West coast safety net system implemented eConsults, they found that 25% of requests were resolved without a specialist visit and the median time to appointment decreased by 17.4 days, without any increase in specialist staffing. In 2018, our large public health care system in the Mid Atlantic serving consisting over 11 hospitals and more than 30 additional primary care sites, re-routed the vast majority of traditional referrals to “eConsults.” In this new system, specialists could either provide eConsult recommendations back to the PCP or request to schedule an appointment for the patient. However, as of March 2024, only 4% of referrals resulted in eConsult feedback to the ordering provider, 81% were referred to schedule, and the rest were denied. This resulted in an average of 58 days between referral and an appointment, only 50% of referrals were scheduled, and there was a 20% specialty no show rate.

In July 2024, the “Referrals 2.0” system, which separated true eConsults from scheduling requests, was piloted in a single facility’s urology department. By October 2024, this was live across the entire system. When ordering a urology referral, PCPs were prompted to either place an eConsult for specialist guidance or a referral for appointment scheduling. Clinical decision-making guidelines were embedded within orders, developed in collaboration with specialists and PCPs. Weekly quality assurance reports were generated and written feedback regarding comprehensiveness and clarity was given to ordering providers and specialists.

In July 2024, 36% (n = 15) of eConsults were successfully completed and 61% (n = 21) were converted to appointment requests. By November 2024, 61% (n = 52) of eConsults were successfully completed and 39% (n =38) were converted to appointment requests. From July to November, 321 eConsults were ordered and 99 providers (31%) received direct feedback on their orders. The quality of eConsults as well as specialist responses improved during this period.

Over the course of the rollout of “Referrals 2.0” for urology at a large public health care system, there were notable improvements in successfully completed eConsults. There was also a decrease in the number of eConsults converted to appointment requests, likely reflecting better understanding of the new system and the difference between eConsults and referrals. Further studies are needed to assess whether the increase in completed eConsults leads to decreased wait times for specialist appointments. Additional specialties will be added in the coming months. IMPLEMENTING PILOT VIRTUAL DIABETES GROUP EDUCATION: A MIXED METHODS STUDY Andrea Gomez1; Courtney Borsuk2; Iridian A. Guzman3; Danielle Lazar4; Arshiya A. Baig2. 1Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL; 2General Internal Medicine, The University of Chicago Division of the Biological Sciences, Chicago, IL; 3Advocate Health Care Inc, Downers Grove, IL; 4Access Community Health Network, Chicago, IL. (Control ID #4271393)

Group visits (GVs) provide diabetes education, social support, and support for goal setting. Virtual diabetes group education (VGE) extends this approach to digital platforms, offering scalability of diabetes education across systems but remains understudied compared to in-person GVs. A notable component of the intervention was the setting of Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) goals by patients. This study assessed trends in glycosylated hemoglobin (A1C) and SMART goal setting among patients with Type 2 diabetes mellitus (T2DM) across VGE visits.

The pilot study partnered with a Federally Qualified Health Center (FQHC) and a private, non-profit health system in the Midwest. Each site had a cohort of 5-7 adult patients with T2DM, aged ≥18 years, with an A1C ≥ 8% within six months prior to the first VGE, at least one additional cardiovascular condition, and were English-speaking. Ten patients participated in monthly VGE visits (60–90-minute sessions) for 6 months led by a Certified Diabetes Care and Education Specialist (CDCES) using a standard curriculum across both sites. Data was abstracted from electronic health records, and patient SMART goals were retrieved from project coordinator’s REDCap notes. Relationships between A1C changes, VGE attendance, and PCP visits were evaluated using Pearson correlation coefficients.

Of the 10 participants, 9 identified as Black/African American, 8 identified as female, and the mean age was 64 years old (SD 9). Five patients had a reduction in A1C from baseline to 2-5 months. One patient did not have a follow-up A1C measurement. Four patients showed an increase in A1C during the same period. The relationship between VGE attendance and A1C revealed a slight reduction in A1C with increased VGE attendance, with a correlation coefficient of –0.0122 (p = 0.975), which was not statistically significant. Patients who had more frequent PCP visits were associated with a slight increase in A1C, but this correlation was not statistically significant (r = 0.0977, p-value = 0.803). Qualitative data highlighted physical activity goals as the primary focus, followed by A1C monitoring, for patients across the 6 VGE visits. During the third VGE, patients were reminded about SMART goals, resulting in all attending patients establishing a SMART goal. By the fourth and fifth VGE visit, about half of participating patients set a SMART goal. More than half of patients met their goals from the previous session at each VGE.

While the pilot intervention demonstrated a trend towards improved A1C, the associations with VGE attendance and PCP visits were not statistically significant in this small sample size. SMART goal setting helped foster patient accountability and incremental progress in managing diabetes. The emphasis on physical activity goals and monitoring diabetes indicators during VGE visits suggests that structured group interventions can enhance patient engagement and self-management behaviors. IMPROVING SMOKING CESSATION DISCUSSIONS AND DOCUMENTATION IN THE PRIMARY CARE SETTING Aditya . Ghosh1; Ruben Ruiz Vega2; Andrew Strike3; Rana H. Asif4; Idopise Umana3. 1General Internal Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Hematology/Oncology, University of Florida, Gainesville, FL; 3Internal Medicine, Northeast Georgia Health System Inc, Gainesville, GA; 4Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, GA. (Control ID #4272373)

Tobacco smoking is a major public health challenge. Despite various smoking cessation (SC) interventions, there are significant gaps in smoking cessation education (SCE) for medical professionals. Effective documentation, interventions, and screenings are crucial for improving SC. To address provider-based barriers in primary care, a quality improvement initiative was implemented. The purpose of this pilot program was to assess documentation of smoking history and SCE in primary care and to evaluate internal medicine residents' baseline awareness of SC interventions while measuring improvements in their counseling knowledge and awareness after attending an in-person educational module focused on smoking cessation.

Retrospective analysis was conducted at a single institution in the US to determine whether physicians documented smoking history and provided SCE. Chart abstraction was performed from the electronic medical record, followed by statistical analysis. Essential components of SCE were compiled into a pre-educational survey and used to assess medical residents’ knowledge of SC strategies. A SCE module, which included evidence-based behavioral strategies, pharmacologic options and motivational interviewing techniques, was created and administered for residents. The aforementioned survey was also administered as a post-educational survey for knowledge assessments and to evaluate the effectiveness of the module.

Documentation of Smoking History and SCE Interventions Of 80,106 patient encounters, 7,601 (9.4%) were with active smokers, 20,641 (25.6%) were with former smokers, and 52,031 (65%) were with never smokers. Notably, smoking history was recorded for only 12.3% of active smokers and 49.4% of former smokers. Counseling for quitting was documented in just 51.5% of patients with a smoking history. SC Knowledge Assessment and SCE Intervention Two educational noon conferences were held for two separate groups of medical residents. The first was on 16 Oct 2023 and the second on 17 Mar 2024. For the 16 Oct 2023 Education Module, a total of 25 residents attended. A change from pre-test and post-test demonstrated significant improvement in knowledge and awareness of smoking cessation (average score of 49% pretest to average score of 80% posttest). In the 17 Mar 2024 Education Module, a total of 25 residents attended and once again a significant improvement was noted from pre to post test in knowledge and awareness of smoking cessation (average score of 54% in pretest to 79% in posttest).

This project emphasizes the need for streamlined processes to gather tobacco usage data and implement targeted interventions for internal medicine residents and practicing physicians. By equipping residents with essential skills, we can enhance patient outcomes and tackle the public health issue of smoking more effectively. It also highlights the potential for customized training in SC, stressing the importance of ongoing innovation in medical education. METRICS THAT MATTER: CAN MEASURES OF CONTINUITY, ACCESS AND TOTAL EMR TIME GUIDE US TO AN OPTIMAL PANEL SIZE FOR A PRIMARY CARE CLINICIAN? James A. Heckman1; Janice Valmassoi2; Chelsea Worthen3; James J. Perry4; Peter Lang5; Kelly A. Kieffer6. 1Internal Medicine, Dartmouth College Geisel School of Medicine, Hanover, NH; 2Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH; 3Primary Care, Dartmouth Health, Lebanon, NH; 4Value Institute Learning Center, Dartmouth Health, Lebanon, NH; 5Population Health Management, Dartmouth Health, Lebanon, NH; 6Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH. (Control ID #4272585)

How many patients can a primary care clinician (PCC) manage? Historically, this question has been framed around balancing supply and demand, using patient weighting systems and target panel sizes to “right size” panels. This method leads to variability in recommended panel sizes and how patients are weighted, with little evidence linking panel size to meaningful outcomes. Additionally, it doesn't fully consider practice patterns, difficult-to-measure patient complexities, or the impact of asynchronous care. We aimed to develop a model to assess panel size based on continuity, access, and total time in the EMR.

We analyzed EMR data from two primary care practices affiliated with an academic medical center from April 2023 to March 2024. Linear regression was used to assess the relationship between unweighted FTE-adjusted panel size and four metrics important to PCCs and patients: patients’ continuity with their PCC (PTcont), PCCs’ continuity with patients (PCCcont), percent of follow-up visits booked 30 days in the future (access), and weekly FTE adjusted EMR login time for PCCs. We then used each panels’ measured continuity and access relative to practice goals for each metric to identify and group panels with capacity for new patients (table 1). We performed a one-way ANOVA test to compare the relationship between groups and panel size. Post-hoc Two-tailed t-tests were performed to compare the mean panel size between distinct categories.

Practice A: Panel size correlated positively with PCCcont (R2= 0.43) and access (R2=0.48) and negatively with PTcont (R2=0.36). There was no correlation with EMR time (R2=0.01). One-way ANOVA compared mean panel size between P1 (n=4), P2(n=2),& P3 (n=11) and revealed a significant difference between at least two groups (F(2,14)= [3.92], p=0.04). T-test showed a significant difference in mean panel size between P1 & P2 (p=0.03), and P1 & P3 (p=0.02). There was no significant difference between P2 & P3. Practice B: Panel size correlated positively with PCCcont (R2=0.74) and access (R2=0.36) and negatively with PTcont (R2=0.27). There was no correlation with EMR time (R2=0.01). One-way ANOVA compared mean panel size betweenP1 (n=14), P2(n=0),& P3 (n=13) and revealed significant difference between P1 & P3 (F(1,25)= [56.75], p<0.001).

A composite endpoint of continuity and access can accurately group panels by size and capacity for new patients, potentially altering the paradigm of “right-sizing” a primary care panel. Rather than relying on predictions of supply and demand to set a target panel size one can track continuity and access, adjusting the rate of new patient visits relative to attrition to grow or shrink a panel to reach optimal size for a given microsystem. This strategy is agile, resilient and value-driven. Measuring clinician workload will be a key part of this approach. There was no correlation between EMR time and panel size, possibly due to variations in asynchronous care patterns. MISSED OPPORTUNITIES FOR HIV TESTING AMONG PATIENTS NEWLY DIAGNOSED WITH HIV IN A ROUTINE OPT-OUT TESTING ENVIRONMENT IN ATLANTA Sarah F. Gruber1; Megan Schwinne3,4; Chad Robichaux3,4; Valeria D Cantos5,6; Meredith Lora2; Kathryn R. Sharma7. 1Department of Medicine, Emory University School of Medicine, Atlanta, GA; 2Internal Medicine, Emory University, Atlanta, GA; 3Biomedical Informatics, Emory University, Atlanta, GA; 4Georgia Clinical and Translational Science Alliance, Emory University, Atlanta, GA; 5Infectious Diseases, Emory University, Atlanta, GA; 6Ponce de Leon Center, Grady Health System, Atlanta, GA; 7Internal Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4272972)

People living with undiagnosed HIV contribute to 40% of HIV transmission in the United States, highlighting the importance of early diagnosis via optimized testing strategies. The Centers for Disease Control and Prevention recommend routine opt-out HIV screening for all individuals aged 13-64 and annual testing for people with higher likelihood of HIV acquisition. This study evaluates missed opportunities for earlier HIV diagnosis in a routine opt-out HIV testing environment.

This retrospective cohort study analyzed adult patients diagnosed with HIV between 2015-2022 who had eligible encounters at our safety-net healthcare system 30-365 days prior. The primary outcome was missed opportunities (MO), defined as no HIV testing at any encounter in the year before HIV diagnosis. The secondary outcome, missed testing opportunity (MTO), referred to encounters over the same period where HIV testing was not completed but was likely indicated based on time (>6 months since last screening) or other sexual transmitted infection (STI) testing. Uni- and multivariate logistic regression identified factors associated with MO and MTO.

Of 713 patients with a new diagnosis of HIV and eligible encounters in the preceding year, 499 (70%) had MO. Of 1845 encounters, 1235 (67%) were MTO. Adults over 50 years of age were more likely to have MO (adjusted odds ratio (aOR) 3.4, 95% confidence interval (CI) [2.2-5.7], p<0.0001). Patients with sexual health related complaints had lower likelihood of MO (aOR 0.62, CI [0.42-0.90], p=0.013] and encounters with STI testing were also less likely to be MTO (aOR 0.36, CI [0.28-0.48], p<0.0001). Patients with MO were more likely to have CD4 < 350 cells/mm3 at time of HIV diagnosis (aOR 1.8, CI [1.2-2.9], p=0.011) and went three times longer between last negative screening and HIV diagnosis (715 days versus 194, respectively). MTO were more common in the outpatient setting, particularly primary care, compared to the emergency department (OR 0.67, CI [0.54-0.82], p<0.0001).

In an urban safety-net healthcare system with routine opt-out HIV testing, most individuals newly diagnosed with HIV who engaged in care in the year prior to their diagnosis were not tested for HIV. These missed opportunities led to delayed diagnoses and were associated with advanced disease. MO were more common among groups with lower perceived risk of HIV acquisition, such as older adults, and were less common in patients and visits with salient HIV risk factors including STI testing or other sexual health complaints. Future studies to identify barriers and facilitators to HIV testing in routine opt-out environments, especially for non STI or sexual health-related encounters, are needed to inform the development of strategies to optimize uptake of routine testing. ODDS OF EMERGENCY SERVICES USE BY ADULTS WITH DEVELOPMENTAL DISABILITIES RECEIVING INTEGRATED OR USUAL CARE Daniel Gilmore1; Emily Johnson2; Lauren Wang2; Corey Keeton2; Aurora Rivendale2; Lindy Weaver1; Susan Havercamp3; Ingrid Adams1; Brittany N. Hand4. 1Health and Rehabilitation Science, The Ohio State University Wexner Medical Center, Columbus, OH; 2Timothy Freeman Center for DD, UC Health Medical Center, Cincinnati, OH; 3Nisonger Center, The Ohio State University Wexner Medical Center, Columbus, OH; 4General Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4271491)

Adults with developmental disabilities (DD) frequently use the emergency department (ED) and are often hospitalized for psychiatric emergencies. Evidence indicates that use of emergency and hospital services is related to modifiable healthcare access issues in the community. Community healthcare models like integrated care that aim to promote access to primary care and mental health services may better meet the needs of adults with DD and reduce their use of emergency services and hospitalization. Our objective was to determine odds of all-cause and psychiatric-specific ED use and hospitalization among adults with DD receiving integrated care relative to those receiving usual care.

We conducted a cross-sectional retrospective cohort study of electronic health records for inpatient and outpatient encounters from 2022-2023 at a Midwest academic medical center. Adults with DD were identified with ICD-10 codes, and HCUP Clinical Classification Software was used to identify psychiatric hospitalizations and psychiatric ED visits. Logistic regression was used to determine odds of all-cause ED use, all-cause hospitalization, psychiatric ED use, and psychiatric hospitalization among patients receiving integrated versus usual care when controlling for demographic characteristics.

A total of N=6706 adults with DD were included (N=1395 integrated care). Most adults with DD were male, white, and the average age was 38 years old. Relative to adults with DD receiving usual care, those receiving integrated care had 50% lower odds of all-cause ED use (OR=0.50, 95% CI= 0.44 – 0.57), and 38% lower odds of all-cause hospitalization (OR=0.62, 95% CI=0.52 – 0.74). Odds of psychiatric ED use and psychiatric hospitalization were 72% (OR=0.28, 95% CI=0.17 – 0.44) and 65% (OR=0.35, 95% CI=0.19 – 0.65) lower for adults with DD receiving integrated care, respectively.

Integrated care was associated with lower odds of ED use and hospitalization among adults with DD and may be a promising model of service delivery for this population. Future longitudinal studies are needed to better understand the effect of integrated care on use of emergency services for adults with DD. OFFERING HEPATITIS A AND B SCREENING AND IMMUNIZATION AT A SYRINGE SERVICES PROGRAM: PEOPLE WHO INJECT DRUGS AND STAFF PERSPECTIVES IN MIAMI, FLORIDA Subul Malik, Marina Plesons, Monica Faraldo, David W. Forrest. Medicine, University of Miami Miller School of Medicine, Miami, FL. (Control ID #4271686)

Miami Dade-County has increasingly high rates of acute HAV and HBV rates, with injection drug use a common risk factor. People who inject drugs (PWID) are a vulnerable population in viral hepatitis transmission, highlighting a current need for creative interventions and implementation strategies to engage this population, including providing screening and immunization services at syringe services programs (SSP). SSPs have been increasingly utilized to engage PWID with other healthcare services given their established foundation of trust and provision of services that many PWID perceive as valuable and thus utilize regularly. Although many SSPs currently offer both HAV and HBV immunizations, limited qualitative research exists on the advantage of offering these services and the opportunities for service optimization, especially in Florida. This study sought to explore the barriers, facilitators, and opportunities for accessing HAV and HBV screening and immunization from the perspective of SSP clients and staff at the IDEA SSP in Miami, Florida. The IDEA SSP was the first established SSP in Florida and currently serves over 2,400 PWID through its fixed site and mobile unit.

We conducted in-depth semi-structured interviews with 15 PWID clients and 11 SSP staff and providers in May 2022. Interview transcripts were analyzed, and themes were identified using Dedoose. Quantitative data on the number of HAV and HBV vaccines administered at the site were also extracted from the SSP database.

Five themes were identified for barriers to accessing services, three themes were identified for facilitators when accessing services, and three themes were identified for opportunities for improvement in accessing services. Barriers for PWID participants included lack of knowledge and understanding of the virus and vaccine, stigma and discrimination faced, significant opportunity costs (i.e., housing, transportation, and insurance), and the number of hurdles experienced when navigating the healthcare system. SSP staff shed light on facilitators such as the unique model of offering on-demand and co-located services at one site rooted in a harm reduction approach to improve delivery of screening and immunizations without unnecessary delays. To further optimize delivery and acceptability of services, interviewees discussed opportunities to expand outreach through the mobile unit service, offer both financial and non-financial incentives, and enhance education and communication about the virus and the importance of the vaccine for PWID participants.

SSPs are an advantageous location for increasing HAV and HBV screening and immunizations among PWID, especially in cities with an increasingly high prevalence of HAV and HBV compared to the nation. OPPORTUNISTIC ANALYSIS OF CORONARY ARTERY CALCIFICATIONS IN SCREENING LOW-DOSE CT SCANS AND PREVALENCE OF PREVENTIVE PHARMACOTHERAPY Caroline B. McNaughton1; Carl R. Hashem1; Melanie Jay2; Daniel H. Sterman1; Jorge M. Mercado1; Abraham Chachoua1; Miriam A. Bredella1; Jeffrey S. Berger1. 1New York University Grossman School of Medicine, New York, NY; 2Medicine, New York Grossman School of Medicine, Brooklyn, NY. (Control ID #4272971)

Atherosclerotic disease is a common comorbid condition in the population of patients who are eligible for lung cancer screening with annual Low Dose CT scans (LD-CTs) due to their significant smoking history and increased age. Coronary artery calcifications (CACs) are increasingly used to identify high risk individuals for future cardiovascular events and may help motivate preventive measures. CACs are common incidental findings on these scans, and may help identify individuals who would benefit from preventive measures targeting atherosclerotic cardiovascular disease (ASCVD). Our purpose was to assess the prevalence and severity of CAC in a real world cohort of subjects undergoing LD-CT, and the use of lipid lowering medications in this high-risk cohort.

We conducted a retrospective chart review of all participants who underwent a first time screening for lung cancer with a low dose CT scan at a mid-Atlantic region academic medical center across three different locations as part of an established lung cancer screening program over a three-year period (2021-2023). We collected patient demographic information, diagnoses, prescription history, and biometric and laboratory data. We used the electronic health record (EHR) data analysis software for data collection with manual validation in 10% cases, and for certain metrics (CAD diagnosis, statin prescription and CAC reporting). CAC reporting was abstracted in plain language from the final radiology report. We assessed the frequency of statin prescription in LD-CT patients by levels of CAC.

In 4,726 patient scans, any mention of CAC was reported in 89.6% (4,235) scans. While 1086 (23%) had no calcification detected, the majority of participants (3146, [66.6%]) reported some degree of CAC, of whom 1429 (30.2%) had reported at least moderate CAC. After excluding 1657 (35.1%) with a known diagnosis of coronary artery disease (CAD), 1705 of 3069 (55.6%) had any degree of CAC reported. Among subjects without CAD, 57.6% (955/1441) persons with any CAC were on a statin. Among 573 participants without CAD and with at least moderate CAC, 372 (64.9%) of participants were on a statin.

A substantial proportion of LD-CT scans were reported to have at least moderate CACs. However, many of these patients did not have an active lipid lowering prescription. CAC reporting should be standardized, and interdisciplinary communication should be optimized to ensure that patients who undergo LD-CT screening and are found to have CAC may be identified by their providers, and potentially placed on more aggressive lipid lowering therapies. The LD-CT screening program has potential to be leveraged as opportunistic imaging to include CAC, and better identify patients who may benefit from more intensive preventive care. In so doing, both the cost-effectiveness and the health benefits of screening may be improved significantly. PATIENT AND CARE PARTNER PERSPECTIVES ON INTERHOSPITAL TRANSFERS Amy Yu1; Claire Westcott1; Sarah Mann1; Lauren McBeth1; Evangeline Grobbel1; Stephanie Mueller2; Christine D. Jones3. 1Medicine, University of Colorado, Denver, CO; 2Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA; 3Medicine, University of Colorado Denver School of Medicine, Aurora, CO. (Control ID #4270576)

The transfer of patients between hospitals, known as interhospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Despite poor patient outcomes, best practices to guide IHTs are lacking. To characterize the IHT process and identify key challenges and solutions to patient-centered IHT care, we examined the experiences of transferred patients and their care partners.

We conducted semi-structured interviews from 11/2024-12/2024 with adults and their care partners transferred from an outside hospital to internal medicine teams at an academic acute care hospital that accepts 5,000 IHT patients annually. We used a combined inductive and deductive coding approach guided by thematic analysis until thematic saturation was achieved.

We interviewed 26 participants. Among 14 patients, 8 (57%) were male, and 6 (43%) were in the 40-64 year-old age group. Among 12 care partners, 3 (25%) were male, and 6 (50%) were in the 65-79 year-old age group. Twenty-three percent of participants had a primary residence in the accepting hospital’s metroplex, 42% from elsewhere in the state, and 35% from out of state. Transferred patients reported positive experiences with transport between hospitals, citing excellent attention to their needs and comfort. Both patients and care partners expressed relief regarding clinical care advancement upon arrival at the accepting hospital. Participants reported a wide variety of communication and transfer preparation experiences. Patients and care partners described IHTs as challenging when 1) the timing of transfer was uncertain, 2) care partners were not prepared for the transfer, and 3) communication between the clinical care teams was incomplete. One care partner described their preparation for the IHT as thinking through the following: “What do I need to take care of while I’m in my house for a half an hour?” I tried to make lists in my mind. “What’s it gonna be like out there?” - Care Partner Patients and care partners suggested ways to optimize the IHT experience, including: 1) providing transfer timeframes and updates to both patients and care partners, 2) supporting care partners with logistical details (e.g., parking at the accepting hospital), and 3) streamlining communication between clinicians.

Overall, patients and care partners appreciated that transfers progressed patient care. We found variability in how IHT patients and their care partners experienced communication and logistical support, particularly related to the timing of transfer, care partner preparation, and clinical information shared between care teams. To provide more patient-centered care for IHT patients and their care partners, IHT best practices should include timely transfer updates, organization of logistical details to help care partners with travel preparation, and clear interdisciplinary communication about IHT care plans. PATIENT INTERACTION PHENOTYPES WITH A POST-DISCHARGE TEXT MESSAGING SERVICE AND THEIR ASSOCIATION WITH HOSPITAL REVISITS Klea Profka2; Agnes Wang4; Danielle Mowery4; Emily Schriver4; Anna U. Morgan3; Eric Bressman1. 1Internal Medicine, University of Pennsylvania Department of Medicine, Philadelphia, PA; 2Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 3Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 4University of Pennsylvania, Philadelphia, PA. (Control ID #4268312)

Text messaging has emerged as a compelling strategy to facilitate communication between patients and their primary care practice after hospital discharge. Understanding the unique ways in which patients interact with these messaging programs can inform future efforts to tailor their design to individual styles and needs. The aim of this study was to characterize patient interaction phenotypes with a post-discharge automated messaging program.

This was a secondary analysis of data from a trial which tested a 30-day automated text messaging intervention among primary care patients after hospital discharge. We analyzed messages and patterns of engagement among patients who received the intervention and engaged. We engineered features intended to describe patient interaction patterns along two axes: 1) Engagement style (rate of response to program check-in messages, frequency of inbound messages, average response time to program messages, request for help outside of a check-in, frequency of specific categories of need) and 2) Program conformity (error rate among messages sent and average message character count). We used an unsupervised machine learning approach (K-means clustering) to segment program participants into interaction phenotypes. Finally, we looked at the association between these phenotypes and 1) Patient demographic and clinical characteristics and 2) Hospital revisits. To test for differences across phenotypes, we use chi-square tests for categorical variables and ANOVA for continuous variables.

A total of 1731 patients engaged with the messaging intervention and were included in the analysis, among which 1060 (61.2%) were female; the mean (SD) age was 65 (16.1); and 782 (45.2%) and 828 (47.8) identified as Black and White, respectively (Table 1). Using K-means clustering, we observed 4 distinct clusters representing patient interaction phenotypes: 1) A high engagement, high conformity group (n = 1029); 2) A low engagement, high conformity group (n = 515); 3) A low engagement, low conformity group (n = 170); and 4) A high engagement with intense level of need group (n = 17). Differences were observed in demographic characteristics – including gender, race, and insurance type – across groups. The rate of 30-day hospital revisits was markedly higher for cluster 4 (52.9%) and was lowest for cluster 1 (15.8%).

We identified 4 patient interaction phenotypes with a post-discharge messaging program, and observed differences in both patient characteristics and outcomes across these groups. For health systems and practices looking to use text messaging to engage patients after discharge, this work offers two main takeaways: 1) Not all patients interact with text messaging equally, and some may require either additional guidance or a different medium altogether, and 2) The way in which patients interact with this type of program (in addition to the information they communicate through the program) may have added predictive signal toward outcomes. PATIENT PERSPECTIVES ON LIFESTYLE MEDICINE PRACTICE IN A SAFETY NET HOSPITAL: A QUALITATIVE STUDY John A. Sweeney2; Michael Charles1; Bernice Man1; Amanda Knepper1. 1Internal Medicine, University of Illinois Chicago, Chicago, IL; 2University of Illinois Chicago College of Medicine, Chicago, IL. (Control ID #4248503)

While an estimated 80% of chronic diseases (i.e., diabetes, heart disease, stroke, and cancer) and premature deaths are preventable with lifestyle changes, only 8% of US adults receive all recommended preventive services. Furthermore, the publicly insured population, comprising low-income and underserved individuals, is particularly vulnerable to system-level barriers and discrimination, which negatively impact their healthcare utilization and outcomes. Lifestyle medicine (LM), which focuses on a holistic, non-pharmacological, and non-procedural approach to treating and preventing disease, is a valuable, evidence-based adjunct to routine clinical practice to address health disparities, especially in resource-limited settings. This study explores the barriers and facilitators to accessing LM services in patients who receive care at a safety net public hospital.

The present qualitative research is part of a formative assessment to inform the development and implementation of a patient-centered LM practice within an urban, academic outpatient medical center serving a predominately publicly insured patient population. Semi-structured interviews (n=10) were conducted with a purposive sample of adult patients with one or more chronic disease conditions and who receive care at a safety net hospital. Interviews were conducted virtually and covered the following topical areas: Patients’ interest in LM services, delivery preferences, and anticipated barriers and facilitators to engaging with an LM program. Interviews were audio-recorded and transcribed for analysis, incorporating both inductive and deductive methods of coding, categorization, and thematic development.

Six key themes emerged: 1) patients recognized the value of lifestyle changes in chronic disease management and the reduction of pharmacotherapy; 2) they were interested in a LM practice that can be complementary to routine primary care services; 3) anticipated barriers to accessing LM were structural (i.e., transportation) and financial (i.e., insurance coverage); 4) anticipated barriers to following through on LM recommendations were psychological and rooted in past experiences with efforts to make lifestyle changes (likened to combatting a "drug addiction") and knowledge-related (i.e., lacking reliable information and guidance concerning healthful dietary patterns and food preparation); 5) patients emphasized a need for consistent guidance and support while initiating and maintaining lifestyle changes; 6) patients were attracted to telemedicine visits for improved accessibility.

Patients with limited resources desire sustained support from their healthcare system for greater, more personalized counseling in making the lifestyle changes necessary to mitigate their disproportionate burden of chronic disease. Institutions endowed with the care of this population must consider lifestyle medicine practices to bridge the gaps of traditional care. PATIENT PREFERENCES AND INSIGHTS FOR DRIVING TRANSFORMATIONS IN DIGITAL STRATEGY Ajeet Singh1; Kyunghoon Rhee1; Laura J. Zimmermann2; Michael Cui2. 1Clinical Informatics, Rush University Medical Center, Chicago, IL; 2General Internal Medicine, Rush University Medical Center, Chicago, IL. (Control ID #4267196)

Following the COVID19 Public Health Emergency, patients shifted from a constrained digital medium for care delivery to a hybrid state with greater choice in where they can quickly and conveniently access remote and in-person care. Ongoing digital transformations may improve access to care and health outcomes, but few studies have characterized US patient preferences in this hybrid environment. This research aims to detail patient preferences in a hybrid ambulatory care system to inform a competitive digital care transformation strategy in a large, urban, Midwest academic medical center (AMC).

To inform digital strategy, we designed a survey on patient preferences in the following ambulatory domains: digital vs in-person care, provider type, response time for asynchronous care, and navigation needs. Patients seen in our ambulatory clinics between June 5 and June 20 2024 received a medical practice survey via the Press Ganey platform and via email, in which they were offered an opportunity to join the AMC’s Engagement Community for ongoing feedback. Amongst those who joined, Press Ganey randomly selected half to receive our survey via text and email. Results were analyzed by cross-tabulation.

The survey response rate was 53.2% (2604/4895). Of those surveyed, 65% identified as women, 51% were aged 65 years or more, 40% resided within urban city limits with 37% in ZIP codes with a median household income above $100,000. Regarding access to care, 68% of respondents preferred hybrid access compared to 18% in-person only, and 68% were willing to see either an Advanced Practice Provider or Physician if it meant faster access, compared to 17% preferring physician only. Regarding asynchronous communication, 41% expect responses within 4 hours, and another 41% expected them within 8 hours. 75% wrote their greatest need from care teams was help in scheduling follow-up care. Free text queries revealed that the most requested services were: faster or same-day PCP access, assistance in accessing specialty care and navigating the health system, better coordination between their PCP and specialist care teams, and more support in understanding diagnoses and treatment plans.

This study indicates a strong preference for faster access to care, prompt responses from care teams, and more support in navigating one’s health through follow-up and specialty care. Investing in these domains is likely a high priority for a successful hybrid ambulatory care strategy in saturated, competitive markets. Next steps include piloting these strategies in hybrid primary, specialty, and urgent care clinic settings, using multidisciplinary clinical staffs and digital tools to meet these needs. Further research is needed to validate how these strategies impact patient satisfaction and the broader quintuple aim, while ensuring that communities already constrained by the digital divide do not experience worsened outcomes or exclusion from care. PEERS ENHANCING ENGAGEMENT FOR PAIN SERVICES: RESULTS OF A PILOT TRIAL Sara Edmond1,2; Daniel G. Rogers3,2; Anne Klee4,2; William Becker1,2. 1PRIME, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; 2Yale University School of Medicine, New Haven, CT; 3Research, VA Pain Research Informatics Multi-morbidities and Education Center, West Haven, CT; 4Mental Health, VA Connecticut Healthcare System, West Haven, CT. (Control ID #4272851)

Chronic pain is a complex chronic condition that is often difficult to treat, and novel strategies to support people with chronic pain are needed. Peer specialists are individuals with lived experience, hired and trained to provide support to people coping with chronic conditions. Peer specialists historically have worked in mental health and substance use disorder treatment settings and are often well suited to work with individuals who are harder to engage in services or those needing more support to promote self-management strategies. Peer specialists may be a key component to effectively treatment high impact chronic pain, but there is limited research in this area. Peer specialists are well-positioned to use approaches such as motivational interviewing and sharing their lived experience to promote uptake of evidence-based non-pharmacological pain treatments and self-management strategies, which may in turn lead to improvements in pain-related function and disability.

We developed a six-session intervention, Peers Enhancing Engagement for Pain Services (or “PEEPS”), led by a peer specialist to support patients with chronic pain being seen by an interdisciplinary pain clinic. The goal of our study (Funding: VAI21RX004381) was to examine the feasibility and acceptability of PEEPS; we set a priori benchmarks for feasibility and acceptability (e.g., targets for enrollment and retention). We collected patient reported outcomes at baseline and following intervention completion, including pain interference, pain coping, and healthcare engagement. We also conducted qualitative interviews with all patients willing to participate.

We enrolled 31 patients with chronic pain being seen by an interdisciplinary pain clinic at a VA Medical Center in New England; 18/31 completed follow-up measures. Patients were on average 62.5 years old, 74% men, and 68% White, with an average pain interference score of 6.6/10. Our enrollment rate was 23.6% (31/131) and our retention rate was 58%. Overall, patients reported intervention acceptability as indicated by scores on the Client Satisfaction Questionnaire. Ten patients participated in qualitative interviews about their experience with intervention, many participants expressed satisfaction. One participant said, “[I] was really impressed with him… I got the impression from the beginning that he was there for me. He cared about what was happening." Another noted, “It was just pleasant to know that… people care about you and they want to see the best that they can.”

Most feasibility and acceptability benchmarks were met. Incorporating peer support into pain clinics appears feasible and acceptable to patients; future work should evaluate how best to incorporate peer support and evaluate how peer support impacts patient outcomes. PREDICTORS OF PRIMARY CARE CLINICIAN LUNG CANCER SCREENING BEHAVIOR: A NATIONAL CROSS-SECTIONAL STUDY Jennifer A. Lewis2,5; Jacquelyn Pennings2,5; Lucy Spalluto2,5; Michael E. Matheny2,5; Christopher J. Lindsell3; Renda S. Wiener4; Christopher Slatore6; Hilary A. Tindle1; Christianne Roumie2,5; Tahseen Hussain5. 1Medicine, Vanderbilt University, Nashville, TN; 2GRECC, VA Tennessee Valley Healthcare System, Nashville, TN; 3Duke University School of Medicine, Durham, NC; 4Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA; 5Vanderbilt University Medical Center, Nashville, TN; 6VA Portland Health Care System, Portland, OR. (Control ID #4272815)

Lung cancer screening with low-dose computed tomography is underutilized. Primary care clinician engagement is critical for successful implementation. The Theoretical Domains Framework identifies 12 characteristics that influence provider behavior (behavioral determinants). We hypothesized that among these 12 behavior determinants, primary care clinician (1) knowledge, (2) social influences, and (3) environmental context and resources are associated with completed lung cancer screenings and performed exploratory analysis of the other nine behavioral determinants.

In this cross-sectional, nationwide survey, we sampled primary care clinicians in 2022 at 10 Veterans Affairs (VA) medical centers (VAMCs) to measure lung cancer screening behavioral determinants including: knowledge, cognitive/interpersonal skill, behavioral regulation, memory/attention/decision processing, professional role, beliefs about capabilities, beliefs about consequences, emotions, goals/intentions, reinforcement, environmental context and resources, and social influences. From VA electronic health record data, we obtained the number of lung cancer screening exams completed for each clinician in the year after the survey (outcome). Multivariable proportional odds regression modelled the association of each behavioral determinant and the number of lung cancer screenings completed. We report odds ratios with 95% confidence intervals (CIs) adjusting for VAMC, provider type, clinic setting, years in practice, and other behavioral determinants.

Of 830 clinicians invited, 268 responded (32.3% response rate). The analytical cohort consisted of 233 respondents who self-reported providing clinical care and were not missing role/specialty or any knowledge items. Respondents most frequently reported being female (64.4%), White (66.5%), physicians (59.2%), with 16-25 years in clinical practice (33.0%), and practice in a community-based setting (53.6%). Of the respondents, the median screenings completed per provider was 10 (interquartile range 2-26). Of the three behavioral determinants hypothesized, only provider knowledge was associated with completed lung cancer screenings; one correct knowledge score was associated with an aOR 2.3 (95% CI 1.3-3.9). Additionally, the goals/intentions behavioral determinant was associated with increased completed lung screenings (aOR 1.8, 95% CI 1.2-2.8).

We found that primary care clinician knowledge and goals/intentions were associated with lung cancer screening behavior. Interventions to increase lung cancer screening uptake should consider targeting these behavioral determinants. PREFERENCES FOR ORAL VS. LONG-ACTING ANTIRETROVIRALS AMONG PEOPLE LIVING WITH HIV ON A DAILY ORAL ANTIRETROVIRAL REGIMEN Nicole Miralles1; Charlotte-Paige Rolle2. 1College of Medicine, University of Central Florida, Orlando, FL; 2Orlando Immunology Center, ORLANDO, FL. (Control ID #4268587)

Daily oral antiretroviral therapy (ART) is the standard therapy for HIV and achieves viral suppression, reducing HIV-related health risks. New long-acting (LA) ART options require as few as six injections per year which offers alternatives for individuals who find daily regimens inconvenient, stigmatizing, or challenging due to privacy concerns. Clinical trials show high acceptance of LA ART; however, real-world studies indicate mixed interest due to barriers like injection discomfort and increased clinic visits. Study Objective: Survey people living with HIV (PLWH) on daily ART to assess interest in diverse LA ART options, identify predictors of preference, and explore optimal conditions for implementation.

A cross-sectional survey will be given to Orlando Immunology Center (OIC) patients on a daily ART who have attended a minimum of 2 clinic visits in the previous 12 months prior to screening. Study period: July 25, 2024 – November 1, 2024 Eligibility criteria a. Inclusion: 1. On stable one-daily ART regimen for the past 6 months. 2. Attended at least 2 clinic visits in the previous 12 months. b. Exclusion: 1. Patients under 18 years of age. 2. Patients with cognitive impairments preventing informed consent. The primary objective is to assess interest in various LA ART options. Secondary objectives are to identify demographic and clinical predictors of LA ART interest and to explore patient preferences under different real-world and clinical conditions. Demographics, lab values, and clinical parameters were extracted via chart review, and patient survey assessed LA ART interest, preferences for reasons of interest/disinterest, demographic characteristics, and preferences under real-world and clinical scenarios. Descriptive statistics, chi-square tests, logistic regression, and rank-order analysis were used to evaluate predictors of interest and ranked preferences.

Initial results reveal relatively equal preference for long-acting subcutaneous injections (every 1, 2, or 3 months), with higher preference for daily oral and weekly long-acting oral options. Monthly subcutaneous injections were the most frequently least preferred option. Furthermore, patients prioritize efficacy, safety, and convenience over logistical concerns for LA ART options.

Cross-Sectional Design Self-Report Bias Non-Response Bias

Efficacy and safety are primary concerns for LA ART adoption, emphasizing the need to build patient confidence. Key motivators include reducing the burden of daily medication and enhancing travel flexibility, while concerns like injection discomfort and stigma are less significant. Barriers such as frequent provider visits, increased lab monitoring, and higher co-pay costs highlight the importance of addressing financial and logistical challenges. Future research should explore how patient preferences align with adherence behaviors and outcomes, and how preferences evolve over time with greater experience in using LA ART options. PREVALENCE OF INTERPERSONAL VIOLENCE AND HEALTHCARE UTILIZATION AMONG VETERANS IN THE VA HEALTH CARE SYSTEM Jamie Marsal1,2; Mayuree Rao3,4; Alison L. Greene2,5; Alicia Cohen6,7; Rachel Kimerling8,2; Matthew Maciejewski9,10; Donna M. Zulman2,5. 1School of Humanities and Sciences, Stanford University, Stanford, CA; 2VA Center for Innovation to Implementation, Menlo Park, CA; 3Health services research & development, VA Puget Sound Health Care System, Seattle, WA; 4University of Washington Department of Medicine, Seattle, WA; 5Stanford University Division of Primary Care and Population Health, Stanford, CA; 6Center of Innovation in Transformative Health Systems Research to Improve Veteran Equity and Independence, Providence VA Medical Center, Providence, RI; 7Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; 8VA National Center for Post Traumatic Stress Disorder, Menlo Park, CA; 9HSR&D, Durham VA Health Care System, Durham, NC; 10Department of Population Health Sciences, Duke University, Durham, NC. (Control ID #4272103)

Interpersonal violence – physical, sexual, or psychological abuse by another individual – can have wide-reaching and long-lasting effects on both physical and mental health. Healthcare visits provide an opportunity to identify individuals experiencing violence and provide support. This study estimates the prevalence of self-reported interpersonal violence among Veterans in the Veterans Affairs (VA) health care system and describes their utilization of care in different settings (primary care, mental health, or the emergency department).

Responses from a 2024 social and financial needs survey distributed by web and mail to a stratified random sample of 13,510 VA patients who receive care in primary or mental health care settings were linked with VA electronic health record data for sociodemographic and clinical information. Two questions about experiences of interpersonal violence, one addressing verbal violence and one addressing physical violence, were adapted from the CMS Accountable Health Communities social risk screener. A Veteran was considered to report interpersonal violence if they answered “often” or “sometimes” (versus “never”) to either question. Data were weighted to adjust for complex sampling and nonresponse. We estimated survey-reported prevalence of interpersonal violence and EHR-derived rates of primary care, mental health, and emergency department visits in the prior year among individuals experiencing interpersonal violence.

Among 3430 respondents (response rate 25%), the weighted prevalence of interpersonal violence was 26.6% (95% CI, 24.6-28.7). Cisgender females (31.6%, 28.0-35.4) had a higher prevalence rate than cisgender males (24.1%, 21.9-26.4). Reported interpersonal violence was greater among younger (18-44 years) (36.1%, 31.4-41.1) versus middle-aged (45-64 years) (29.1%, 25.7-32.7) and older (65+ years) (18.9%, 16.2-21.9) Veterans. Individuals identifying as Black or African American (30.7%, 26.9-34.7) or as Hispanic or Latino (30.9%, 26.3-35.9) had higher rates of experiencing violence than those identifying as White (24.1%, 21.7-26.7). Among those reporting an experience of violence, 92.3% utilized primary care in the past year, compared to 52.6% utilizing mental health care and 20.2% emergency care.

In a national survey of VA patients, approximately one in four reported experiencing interpersonal violence. Nearly all survey respondents endorsing violence used primary care; however, a substantial portion also used mental health and emergency care, suggesting opportunities for screening and intervention in other settings. Future work should consider how screening programs can be tailored to different care settings to best serve the needs of Veterans experiencing interpersonal violence. PRIMARY CARE PRACTITIONER RESPONSE TO A POSITIVE IN-OFFICE SCREEN FOR ATRIAL FIBRILLATION FROM THE VITAL-AF TRIAL Steven J. Atlas1,2; Leila H. Borowsky1; Marisa A. Shea3; Steven McDermott1; Jeffrey M. Ashburner1,2; Patrick T. Ellinor3,2; Steven A. Lubitz4,2; Daniel E. Singer1,2. 1Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; 2Harvard Medical School, Boston, MA; 3Cardiology Division, Massachusetts General Hospital, Boston, MA; 4Demoulas Center for Cardiac Arrhythmias and Cardiovascular Research, Massachusetts General Hospital, Boston, MA. (Control ID #4269116)

Atrial fibrillation (AF) is common and increases the risk of stroke, which may be prevented with anticoagulants. Since AF may be asymptomatic, screening for undiagnosed AF is appealing. VITAL-AF was a pragmatic cluster-randomized trial (ClinicalTrials.gov NCT03515057) to assess the efficacy of screening for AF in older patients using a 30-second handheld single-lead electrocardiogram (SL-ECG) during check-in at routine primary care visits. We evaluated primary care practitioner (PCP) response to a positive AF screen and hypothesized that documented awareness of the result is associated with actions taken.

All patients ≥65 years attending an outpatient PCP visit in one of 8 practices randomized to AF screening during a 1-year screening period were eligible. Screening was offered by medical assistants using a SL-ECG device (AliveCor, US) at all encounters. PCPs of patients with a SL-ECG reading of “possible AF” were notified and managed results at their discretion. Manual electronic health record chart review was performed by two research nurses to abstract information on whether the PCP documented awareness of the abnormal screen in visit notes (“documented awareness”) and what actions were taken during the encounter.

Overall, 16,069 (91%) patients in an intervention practice completed ≥1 SL-ECG screening. Among patients without prevalent AF, 653 (4.1%) had a first episode of “possible AF” detected. AF was newly diagnosed in 92 of 653 (14.1%) patients during the study period. To date, chart review has been completed for 399 (61.1%) randomly selected patients. The patient’s listed PCP saw 288 patients (72.2%). PCPs documented awareness of the positive screen in 121 (30.3%). AF symptoms were documented in 74 (18.5%). Only 10 (2.5%) had a same-day visit to the emergency department. A 12-lead ECG was done in 242 (60.7%), heart monitoring was ordered in 31 (7.8%), an echocardiogram or stress test was ordered in 32 (8.0%), and a referral to cardiology was made in 31 (7.8%). Any 12-lead ECG or cardiology testing or referral order was noted in 254 (63.7%). The table shows actions taken by the PCP stratified by awareness of the positive screen.

Routine, clinic-based AF screening is feasible with most patients with a positive screen having a 12-lead ECG during the visit or referred for subsequent cardiology evaluation. PCP documentation of the positive screen was associated with cardiology testing (including 12-lead ECG) or referral being ordered during the encounter. PRIORITIZING OBESITY MANAGEMENT IN A PRIMARY CARE SETTING OF THE US: OPERATIONAL OUTCOMES OF A CARE DELIVERY PATHWAY PILOT Kelly Olsson1; Vaibhav Bansal2; Sheriden Beard2; Aimee Coughlin2; Anthony Fabricatore1; Katherine A. Ferro2; Tina Kelley2; Wojciech Michalak1; Joshua Toliver1; Girisha Kaur2. 1Novo Nordisk Inc, Plainsboro, NJ; 2Optum Inc, Eden Prairie, MN. (Control ID #4270704)

People living with overweight/obesity, estimated by body mass index (BMI), are at increased risk of developing various comorbidities and for mortality. However, diagnosis and prioritized treatment for overweight/obesity is rarely a primary target of clinical care by primary health care professionals (HCPs). A care delivery pathway (CDP) was designed to elevate overweight/obesity to the same level of clinical management as other chronic conditions. The research here describes the operational outcomes of the CDP pilot program.

Optum Life Sciences and Optum Care Southwest Medical Associates (SMA) designed the CDP, which was implemented at 3 SMA primary care practices over 6 months. The CDP, which was incorporated into routine primary care, consisted of a guideline-based framework embedded into the existing workflow within an electronic medical record (EMR) system. The framework was triggered by the HCP with a keyword that then populated the framework directly into the current patient note. The CDP also included patient-centric tools to facilitate clinical care as well as a shared decision-making process for the HCP and patient. HCPs tracked obesity-focused discussions/management via BMI z-codes following patient agreement to the conversation. To assess the operational outcomes, quantitative analysis was performed on an overweight/obesity diagnosis (as determined by BMI >30 or 27-29.9 with one or more obesity-related condition), referral utilization, and CDP utilization (defined by z-code). Qualitative HCP feedback was collected following completion of the pilot.

In total, 7740 patients with overweight/obesity had ≥1 visit during the pilot period. Of these, 559 (7.2%) had a BMI z-code indicative of having had ≥1 visit focused on the treatment of overweight/obesity. When comparing those with to those without an obesity-focused visit, those with had a higher percentage of female patients (69.6% vs 61.2%), a marginally lower mean age (43.9 vs 45.6), and a higher BMI (40.8 vs 34.8). Experienced HCP engagement was 100% across all facilities. Referrals for patients with a BMI z-code were observed in 110 cases (20%), with 40% of those being to a dietitian. During the pilot, only 2330 (30%) of patients with a BMI suggestive of obesity/overweight also had an ICD-10 diagnosis code (E66). Of the 559 patients with a BMI z-code, 468 (84%) had an E66 code. Qualitive feedback indicated that the ease of use of the pre-existing BMI z-codes was critical for HCP CDP utilization and that the CDP was integrated fully into the routine workflow of HCPs.

This program elevated HCP engagement in overweight/obesity management to the level of other chronic conditions, as demonstrated by the breadth of adoption of the CDP tools and resources as part of routine clinical care and existing systems. Despite this utilization, patient preference and shared decision-making choices were likely a factor in the 7.2% of documented discussions about overweight/obesity. REAL-TIME EXPERT SUPPORT FOR ADDICTION CARE ACROSS GENERAL MEDICAL SETTINGS: EVALUATION OF A CHAT-BASED INTERVENTION Katherine Ochoa1,2; Ashley C. Vincent1,2; Sarah Christensen1,2; Paul J. Christine1,2; Jarratt Pytell1,2; Troy Sterling2. 1General Internal Medicine, Denver Health Medical Center, Denver, CO; 2Internal Medicine, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO. (Control ID #4271765)

Patients with substance use disorders have many touchpoints with the healthcare system, and yet, few receive evidence-based treatment. Front-line clinicians need support to increase the provision of evidence-based addiction medicine interventions in general medical settings. At our urban, community-based, safety-net system we developed an innovative, chat-based solution (the “Chat”) allowing clinicians (internal medicine, family medicine, and OB/GYN) to pose addiction-related queries and receive near real-time response from experts. This study aims to describe the early characteristics of queries and evaluate the implementation-related outcomes.

The Chat was evaluated by collecting longitudinal data on queries posed, including the time and date a query was placed, answered, and the clinical question. We conducted a cross-sectional survey of clinicians who posed queries and addiction medicine experts who responded to assess implementation-related outcomes including reach (proportion using the Chat), implementation (responsiveness and helpfulness of responses), usability (System Usability Scale), and acceptability, appropriateness, and feasibility (Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure).

Over a 6-month period, 84 queries were placed; 98% were answered, with an average response time of 4 (SD 19) minutes. Most queries were related to opioid use (n=72, 86%) and medication management (n=60, 71%). Of the 218 clinicians able to pose queries, 28% (n=60) responded to the survey and 75% (n=21) of the 28 addiction medicine experts responded. Among clinicians, 68% (n=41) were aware of the Chat, and 40% (n=24) had used it. Average usability scores were 87 (SD 11) among clinicians and 87 (SD 10) among experts, indicating excellent usability (>85). Clinicians rated acceptability, appropriateness, and feasibility highly with mean scores: 4.5 (SD 0.06), 4.4 (0.7), and 4.4 (SD 0.5), respectively, with 5 being the highest possible score, indicating highly positive perceptions. Among the 28% (n=17) clinicians who knew of the Chat but had not used it, the most cited barrier to using the Chat was already having support available (n=10, 58%). The most cited barrier of the experts to responding to queries was lack of knowledge (n=10, 48%).

The Chat provided real-time addiction medicine support to front-line clinicians, while demonstrating high usability, acceptability, appropriateness, and feasibility, from both the clinicians who posed queries and the experts who responded. The Chat is an innovative solution to overcome barriers by providing clinicians in general medicine just-in-time, individualized, and evidence-based addiction treatment recommendations. Future studies will focus on sustainment of the Chat, adapting the Chat to new contexts, and assessing the impact on patient care and health outcomes. REDUCING INAPPROPRIATE OPIOID USE IN SENIORS IN OKLAHOMA (RISE-OK) STUDY: PATIENT OUTCOMES Lee A. Jennings1; Juell Homco2; Lourdes G. Planas3; Wato Nsa2; Heather D. Gamble4; Timothy VanWagoner4; Zsolt Nagykaldi4. 1Geriatrics and Palliative Medicine, The University of Oklahoma Health Sciences, Oklahoma City, OK; 2Department of Medical Informatics, OU Tulsa School of Community Medicine, Tulsa, OK; 3Dept. of Pharmacy, Clinical & Administrative Sciences, The University of Oklahoma Health Sciences, Oklahoma City, OK; 4Department of Family & Preventive Medicine, The University of Oklahoma Health Sciences, Oklahoma City, OK. (Control ID #4272173)

More research is needed to address chronic pain management challenges among older individuals, particularly in rural primary care. We implemented a multi-faceted chronic pain management program tailored for older adults in 30 Oklahoma primary care clinics from January 2022 to September 2023 using a 3-stage, modified stepped-wedge design with the primary study outcome of patient health-related quality of life. Quality benchmarking, performance feedback, academic detailing, practice facilitation, and technology support were used to help clinics adopt QI strategies.

Patients ≥60 years with non-cancer chronic pain were randomly selected from 3 practice cohorts (cohort 1=13 practices, 129 patients; cohort 2=12 practices, 115 patients; cohort 3=5 practices, 26 patients) and followed for 24, 18, and 12 months, respectively. We analyzed change in baseline and end-of-study scores for 3 patient outcome measures (i.e., PROMIS-29, Arthritis Self-Efficacy Scale (20-item), and the Pain, Enjoyment of Life, and General Activity (PEG) Scale) using paired t-tests. The PROMIS-29 assesses physical function, fatigue, pain interference, depressive symptoms, anxiety, ability to participate in social roles and activities, and sleep disturbance.

Most clinics (57%) were small (1-5 clinicians), health-system owned (50%), located in rural communities (53%). Patients (N=270) were 63% female, 81% White, non-Hispanic, mean age 70 years; 89% completed surveys. Among all participants, mean PEG score improved by 0.6 points (baseline 5.8 (SD 2.5), end-of-study 5.2 (SD 2.7), p<0.001); mean self-efficacy for pain management score improved by 0.3 points (baseline 5.1 (SD 2.3), end-of-study 5.4 (SD 2.5), p=0.03); and PROMIS-29 mental health summary score improved by 1.7 points (baseline 44.2 (SD 8.0), end-of-study 45.9 (9.1), p<0.001). There was no difference in scores for the PROMIS-29 physical health summary score or self-efficacy subscales for function or other symptom management.

Practice-based interventions to improve chronic pain management in older adults in primary care made small but significant improvements in scales that reflect outcomes that are important to patients. Future work will examine implementation outcomes to better understand the uptake of QI strategies for chronic pain management in rural primary care. REPEAT MULTIPLEX PCR GASTROINTESTINAL PANEL TESTING WITHIN 14 DAYS YIELDS MINIMAL ADDITIONAL DIAGNOSTIC INFORMATION: A MULTIHOSPITAL COHORT STUDY Jeffrey Shu1,2; Hannah Wang1,3; Anisha Misra1,3; Daniel D. Rhoads1,3; Amy S. Nowacki2; Jarrod E. Dalton4; Abhishek Deshpande5. 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; 2Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 3Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH; 4Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 5Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4263869)

Infectious diarrhea accounts for an estimated 179 million cases and 500,000 hospitalizations annually in the United States. Multiplex PCR gastrointestinal panels (GIPs) have emerged as standard of care, rapidly identifying >20 pathogens simultaneously. While clinical guidelines discourage repeat testing for Clostridioides difficile, evidence-based recommendations for repeat GIP testing are limited, leading to variable testing practices and potential resource overutilization. We aimed to evaluate the diagnostic yield of repeat GIP testing to inform evidence-based testing guidelines.

We conducted a retrospective cohort study of adults (≥18 years) tested with GIPs across 12 hospitals within a single health system (2019-2024). We analyzed the first diarrheal episode per patient, excluding cases with invalid/missing results. C. difficile results were excluded due to changes to target reporting during the study period. The primary outcome was positivity on repeat testing defined as any GIP performed ≤14 days after an index test. Positivity was defined as detecting any organism. We compared pathogen detection rates between index-negative and index-positive groups using Pearson's chi-square test with a p-value <0.05 considered significant.

Of 17,968 eligible patients, 541 (3.0%) underwent repeat testing with a median interval of 6.1 days (IQR 2.5 - 9.2). The overall positivity rate among repeat tests was 14%. Among repeat tests, 435 (80.4%) were performed in index-negative patients, with new pathogens detected in only 21 (4.8%) of cases. In contrast, of 106 (19.6%) index-positive patients who underwent repeat testing, 55 (52%) had positive results (p < 0.001). However, 58% of repeat testing from index-positive patients were discordant, primarily converting from “positive” to “negative.” New pathogen detection in index-positive patients was limited to norovirus and Salmonella, while norovirus and enteropathogenic E. coli were the most frequently newly identified organisms in index-negative patients.

In this large multi-hospital cohort, repeat GIP testing within 14 days rarely provided new diagnostic information, particularly in patients with initially negative results. Institutional guidelines limiting repeat GIP testing within 14 days may improve diagnostic stewardship. SAFE AT HOME: PATIENT SAFETY DURING HOME HOSPITAL David Levine1; Maela Whitcomb1; Julie Fiskio1; Cathy Yoon1; Meghan White1; Endel J. Orav1; Jeffrey L. Schnipper2. 1DGIM, Brigham and Women's Hospital Department of Medicine, Boston, MA; 2Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4273443)

Home hospital (HH) was developed to avoid the common harms associated with conventional brick-and-mortar (BAM) hospitalization. HH delivers physician evaluation and management, nurse care, 24/7 availability, intravenous medication, advanced diagnostics, and other hospital-level services in the home as a substitute for BAM care. Recent data show at least one adverse event (AE) occurs in 23.6% of BAM patients. Despite growth, the safety of HH care outside of small tightly controlled studies is relatively unknown.

We analyzed the electronic health record for all patients admitted into one of 3 HH programs in metropolitan Boston between 2/1/2020-8/10/2023 for heart failure exacerbation, pneumonia, and complicated urinary tract infection. We then created a propensity-matched cohort of up to 4 BAM hospitalized patients for each HH patient, excluding all patients who would not have qualified for HH (based on address, environmental, and general clinical criteria), matched by reason for admission, condition-specific clinical criteria, site, hospital day first eligible for HH, and a propensity score for being in the HH arm (caliper size 0.4). Automated trigger tools identified potential AEs for patients in both arms. For HH, we counted AEs whether they occurred at home or BAM. The primary outcome was the number of potential AEs per 100 patients. Secondary outcomes were the proportion of patients with at least one potential AE and rates by type of AE. Number of AEs per 100 patients were compared using Poisson regression. Physician adjudication and 13 other but less common reasons for admission were pending at time of submission.

We studied 4909 patients (1203 HH; 3706 BAM) with well-matched characteristics. Mean age was 75, 54% were female, 63% were of White race/ethnicity, 41% were partnered, 43% had less than a college degree, 38% had Medicare, and 19% were dual-eligible. HH patients had more hospitalizations in the prior year (66.8% HH vs 37.9% BAM had at least one). We identified 20.2 (95% CI, 17.9 – 23.0) potential AEs per 100 patients among HH patients and 95.1 (95% CI 92.1 – 98.3) potential AEs per 100 patients among BAM patients (incident rate ratio, 0.21; 95% CI, 0.19 – 0.24; p<0.001). There was at least one potential AE in 7.1% of HH patients and in 23.7% of BAM patients. HH patients had much lower rates of delirium (43 vs 2303 events per 100 patients). Potential AE rates were also lower for inpatient mortality, acute kidney injury, CAUTI, nosocomial MRSA, pressure injury, and hypoglycemia. They were higher for escalation to ICU and ED visit within 48 hours of discharge. Fifty-four (4.5%) HH patients were transferred back to the BAM during the acute care episode.

In an ongoing analysis of real-world data of over 4900 patients, HH appears to be safer overall and for most common AEs. Adjudication and preventability analyses are underway to identify potential opportunities for improvement. STABLE USE OF EMERGENCY CARE AMONG USERS OF A VA TELEHEALTH-BASED CARDIOLOGY CLINIC Rebecca L. Tisdale1,2; James Van Campen3,2; Alison L. Greene4,2; Todd H. Wagner5; Steven Asch1,2; Paul Heidenreich1,2; Tanvir Hussain6; Donna M. Zulman7. 1VA Palo Alto Health Care System, Menlo Park, CA; 2Stanford University School of Medicine, Stanford, CA; 3Ci2i, VA, Menlo Park, CA; 4HSRD, VA Palo Alto Health Care System, Palo Alto, CA; 5Surgery, VA and Stanford, Menlo Park, CA; 6Medicine, University of California System, Oakland, CA; 7Department of Medicine, Stanford University, Stanford, CA. (Control ID #4269838)

Specialist shortages have pushed health systems to consider innovative methods of reaching patients. Cardiology in particular faces major supply-demand mismatches in many regions necessitating new approaches. Telehealth-based clinics are one potential solution, but the safety of primarily- or entirely-telehealth-based cardiology clinics is unknown. We assessed emergency room visits among users of VA’s Clinical Resource Hub (CRH) telehealth-based clinic, which reaches patients across VA’s vast Sierra Pacific region encompassing Northern California, Nevada, and the Pacific Islands.

We created a cohort of Veterans with outpatient cardiology visits in VA’s Sierra Pacific region between July 1, 2021 and June 30, 2024, identifying CRH visits based on specific clinic codes. We collected data on sociodemographics and emergency room visits occurring at VA or in the community, then constructed a multivariable logistic regression model to assess the likelihood of visiting an emergency department within a year of establishing cardiology care among users of CRH and conventional VA cardiology clinics. The model was adjusted for age, sex, race, ethnicity, rurality, drive time to secondary care, and emergency department use in the year prior to establishing cardiology care within the study period (Figure).

Our cohort comprised 57,968 Veterans receiving cardiology care in the study period, of which 3,821 were CRH users. Of these, 6% were female Veterans; 24% lived in a rural or highly rural location; and at least 16% were considered to have low income. After adjustment for sociodemographic characteristics and past utilization, CRH users did not face an increased risk of visiting an emergency department in the year after establishing CRH care compared to users of conventional VA care (adjusted odds ratio 0.92, 95% confidence interval 0.85-0.99, p = 0.02).

Users of a telehealth-based cardiology clinic in VA’s Sierra Pacific region visited emergency departments slightly, but significantly, less often than users of conventional VA cardiology clinics in the same region. Subsequent work will examine whether this association persists in difference-in-difference models to further establish the safety of telehealth-based specialty care. SUPPORTING AUTONOMOUS MOTIVATION FOR HEALTHY BEHAVIORS: A MIXED METHODS ANALYSIS OF DATA FROM THE BEHAVIORAL ECONOMICS AND SELF-DETERMINATION THEORY TO REDUCE DIABETES RISK (BEST CHANGE) RANDOMIZED TRIAL Jeffrey T. Kullgren2,1; Harita Vadari1; Shelley Stoll1; Kenneth Resnicow1; Eli Carter1; William H. Herman1; H. M. Kim1,2; Laura McEwen1; Kevin G. Volpp3,4; Michele Heisler1,2. 1University of Michigan, Ann Arbor, MI; 2VA Center for Clinical Management Research, Ann Arbor, MI; 3VA Center for Health Equity Research and Promotion, Philadelphia, PA; 4University of Pennsylvania, Philadelphia, PA. (Control ID #4273455)

Self-Determination Theory posits that autonomous motivation, the internal drive to engage in activities that are personally meaningful or aligned with one's roles or values, is a vital component of long term behavior change. Autonomous motivation can be cultivated through 1:1 motivational interviewing, but this approach can be hard to scale. Autonomous motivation for healthy behaviors could be supported at the population level through digitally delivered, automated behavioral interventions.

We conducted an explanatory sequential mixed methods analysis of data from the BEST Change trial, in which 380 adults aged < 65 with prediabetes were randomized to 1 of 4 arms for 12 months. Control Arm participants received educational text messages. Tailored Messages Arm participants received the Control Arm intervention plus text messages that promoted autonomous motivation to prevent T2DM through tailoring to personal roles and values and emphasizing autonomy, competence, and relatedness. Incentives Arm participants received the Control Arm intervention plus monthly incentives of $50 to $250 for Diabetes Prevention Program participation or metformin use. Combined Arm participants received the Tailored Messages Arm and Incentives Arm interventions plus text messages to increase the personal salience of incentives. We used the Treatment Self-Regulation Questionnaire to measure autonomous motivation to prevent T2DM at baseline and 12 months (range 1-7 with higher scores being better). Multivariable linear regression was used to estimate 12-month differences in autonomous motivation between the Control Arm and the Tailored Messages and Combined Arms that sought to increase autonomous motivation. Data from semi-structured phone interviews with Tailored Messages and Combined Arm participants who did or did not report an increase in 12-month autonomous motivation to prevent T2DM were used to identify factors that facilitated or impeded this increase, respectively.

Compared to the Control Arm, participants in the Tailored Arm (+0.27, P=0.02) and the Combined Arm (+0.23, P=0.04) reported significantly greater autonomous motivation to prevent T2DM at 12 months. Interviews with 9 participants with increased autonomous motivation revealed facilitating factors such as perceived freedom to decide whether and how to reduce risk for T2DM and reminders of the personal importance of T2DM prevention. Interviews with 9 participants who did not have a 12-month increase in autonomous motivation highlighted impeding factors such as feeling that messages were not individualized enough or were too repetitive.

Automated text messages tailored to personal roles and values and such messages combined with incentives increased mean levels of autonomous motivation to prevent T2DM. Use of artificial intelligence might better tailor text messages over time to further increase population level autonomous motivation for healthy behaviors. TEAM-BASED CARE TO REDUCE REMOTE MONITORING ALERT FATIGUE IN PRIMARY CARE PHYSICIANS Pranava Mallu1; Eric Kim4; Thomas E. Love4; Nicholas Dreher4; David Kaelber2; Yasir Tarabichi4; Sonal Patil3; Douglas Einstadter5. 1Case Western Reserve University, Cleveland, OH; 2Internal Medicine, Pediatrics, and Informatics, The MetroHealth System/CWRU, Cleveland, OH; 3Family Medicine, MetroHealth Medical Center, Cleveland, OH; 4The MetroHealth System, Cleveland, OH; 5Internal Medicine, MetroHealth Medical Center, Rocky River, OH. (Control ID #4270549)

Remote blood pressure (BP) monitoring use to improve hypertension control is increasing but can lead to alert fatigue and primary care physician (PCP) inaction. The objective of this study was to understand how team-based care with nurses attenuates remote monitoring alert fatigue in PCPs and to determine the differences in the volume and outcomes of BP alerts by race and ethnicity.

A retrospective cohort study was conducted with 405 patients that graduated from a virtual care disease management program (VCDM) at a Midwestern health system since 2021. The 12-week VCDM program included remote BP monitoring with weekly web-based education and team-based care supported by two nurses. Alerts were programmed to trigger for out of range BPs and all alerts were reviewed by nurses every morning. PCPs received notifications if remote BPs demonstrated a trend of uncontrolled BPs over five or more consecutive days. Two investigators developed a codebook to classify alerts and their outcomes. Medication intensification data was extracted manually. Charts were reviewed until no new concepts emerged from reviewing the last 20 of 100 charts (thematic saturation was achieved). Chi square test was used to determine association between alert outcomes and race/ethnicity.

Thematic saturation was reached after reviewing 100 patient charts (mean age 65 years, SD 12, 42% Black, 48% female). Of the total recorded 340 alerts, 307 (90%) were managed by nurses without need for PCP notification. The most common follow-up nurse action for alerts (260/307; 85%) was to continue BP monitoring and education. Only 23 alerts led to PCP messages or visits. Medication intensification occurred in response to all PCP messages and visits, with additional treatment intensifications occurring at clinic visits during the 12 weeks of VCDM participation, resulting in a total of 25 medication intensifications in the reviewed 100 patients. There was no significant difference in alert volume by race and ethnicity and medication intensification was more frequent in Black participants compared to White participants.

Integrating nurse support in remote BP monitoring programs can significantly reduce PCP alert fatigue, enabling PCPs to focus on more complex cases requiring medication adjustments or in-person visits. Nurse monitoring enhanced patient safety through timely responses to abnormal BP readings and encouraged proactive hypertension management. Structured protocol for handling remote BP alerts was effective in managing 90% of remote monitoring alerts. Future research should explore long-term health outcomes and reimbursement structures to support remote monitoring with team-based care and improve hypertension outcomes. THE IMPACT OF PHARMACIST INTEGRATION IN PRIMARY CARE ON HEALTHCARE UTILIZATION AND COSTS: A SYSTEMATIC REVIEW Dru A. Ricci1; Anuja Bahulekar3; Amie Pollack2; Zirui Song4; Russell Phillips3. 1Center for Primary Care, Harvard Medical School, Boston, MA; 2The Center for Primary Care, Harvard Medical School, Boston, MA; 3Center for Primary Care, Harvard Medical School, Boston, MA; 4Department of Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4271515)

Pharmacists collaborate with primary care clinicians to assist with key activities regarding medication management and patient safety. Activities may include initiating and discontinuing medications, titration of medications to effective dosages, and chronic disease management. Previous research has shown promising results of pharmacist integration on completing medication reconciliation and reducing the use of unnecessary medications or those that may cause side effects or drug interactions. Less is known about the impact of integrated pharmacists on healthcare costs and service use.

We conducted a systematic review of two databases (PubMed and Health Policy Reference Center) for English language studies published in the United States from 2010 until inception of the review (September 2023). Search terms for cost, primary care, and pharmacy were created with the guidance of a medical librarian. We included studies that evaluated the cost of implementing pharmacy integration, and whether integration resulted in cost savings, return on investment, or reduced the utilization of downstream healthcare services (e.g., emergency department visits). Screenings of published papers were conducted by two reviewers following Cochrane guidelines, with disagreements being resolved by a third reviewer or consensus.

Our search identified 767 studies, of which 36 met our search criteria and identified the costs of pharmacist integration, and/or, the cost implications of integrated pharmacists. Twenty-six of 36 studies showed costs savings through reduced utilization of healthcare services or increased revenues attributable to the integrated pharmacists. Six of seven papers measuring billing or revenue showed savings ranging from $277.5/month to $14469.9/month. Twenty-one papers showed downstream savings through reduced utilization of healthcare services, such as reduced emergency department visits and hospitalizations avoided. Return on investment across nine papers ranged from 111% to 1619%, with a median of 150%. In 20 papers, chronic disease management was one of the services performed by pharmacists, and 13 papers used pharmacists for a specific disease group, such as diabetes (n=5), or for the management of a singular medication.

Preliminary results of a systematic review show cost savings associated with pharmacist integration in primary care. This was achieved through reductions in downstream utilization and averted hospitalizations, as well as the generation of increased revenue through billing. THE INBOX CONUNDRUM: STAFF EXPERIENCES USING STANDARDIZED RESPONSE PROTOCOLS FOR PATIENT PORTAL MESSAGES IN PRIMARY CARE Matthew Mulligan, Molly Conroy, Stacy Johnson. General Medicine, The University of Utah School of Medicine, Salt Lake City, UT. (Control ID #4231519)

Responding to patient messages is a significant cause of burnout for primary care providers (PCP). The American Medical Association recommends using team-based protocols to address patient messages. We developed protocols for primary care teams to respond to patient portal messages. Despite high protocol use, we observed little impact on PCP workload. To explore facilitators and barriers of protocol use we surveyed clinic staff (medical assistants and nurses).

We distributed an electronic survey to primary care clinic staff at a single primary care site within an academic health system in summer 2024 to identify facilitators and barriers of protocol use. Protocols were implemented through a quality improvement project in 2022 to empower primary care teams (primarily medical assistants and nurses) to respond to patient messages. A survey was emailed to all staff that were expected to utilize the protocols. Participants who completed the survey received a $20 incentive. Survey content was developed based on feedback received on the protocols. The survey utilized multiple question types including Likert scales. Likert scales were analyzed using median and interquartile range (IQR) or combining categories.

We received 39/60 (65%) responses: 87% were from medical assistants. When asked on a Likert scale from 1-very easy to 5-very difficult, staff reported the protocols were somewhat easy to use (median 2, IQR 2). Staff felt quite prepared to use the protocols (median 2, IQR 2; 1-extremely prepared to 5-not at all prepared). Most staff (87%) received training on the protocols, training was moderately effective (median 3, IQR 1, 1-extremely effective to 5-not effective), and 75% of these staff reported the duration of training was less than an hour. A significant portion of staff (24%) reported that PCPs asked them to deviate from the protocols half the time or more. When staff were instructed to deviate, they reported it was moderately difficult to adhere to the protocols for future messages (median 3, IQR 1, 1-not at all difficult to 5- extremely difficult). When a protocol recommended an appointment, only 62% of staff reported they could schedule an appointment within two weeks most of the time. Reasons an appointment was not scheduled within two weeks included: no appointments available with the patient’s PCP (88%) and the patient did not want to make an appointment (62%). Furthermore, 42% of staff reported patients were resistant to scheduling a primary care appointment more than half the time.

Standardized protocols for staff to respond to patient portal messages in primary care were easy to use with minimal training. However, limited availability for staff to schedule appointments, patients’ unwillingness to schedule an appointment, and PCPs instructing staff to deviate from the protocols presented barriers for staff to adhere to protocol recommendations. THE PATIENT ACTIVATED LEARNING SYSTEM INCREASES KNOWLEDGE UPTAKE AND TRUST IN EHEALTH INFORMATION Neil Lewis Jr.2; Elizabeth Baquero1; Teairah Taylor2; Bharathy Premachandra2; Joanna B. Ringel3; Monika M. Safford3. 1Medicine, Weill Cornell Medicine, New York, NY; 2Cornell University, Ithaca, NY; 3General Internal Medicine, Weill Cornell Medicine, New York, NY. (Control ID #4272153)

According to the National Assessment of Adult Literacy, half of people with less than high school education and 15% with high school education only - comprising 37% of the US population over age 25 - have low health literacy. Low health literacy creates barriers to successfully navigating the complexity of the US healthcare system, generating an estimated $100-200 billion in avoidable healthcare costs annually. We have developed the Patient Activated Learning System (PALS) (palsforhealth.com) to address this issue. This freely available health information platform incorporates Adult Learning Theory, Social Cognitive Theory, Fuzzy Trace Theory, and storytelling to engage learners, facilitate identification with the depicted characters, and activate patients to be receptive to medical advice. We conducted a randomized trial to test the hypothesis that viewing health information using the PALS leads to better knowledge uptake, trust in eHealth information, and understanding and motivation than viewing similar information on WebMD.

Participants with hypertension attending 4 safety net clinics in New York City and upstate New York were invited to view health information on a high blood pressure medication and on a statin. After obtaining informed consent, they were randomized to view this content on the PALS platform or on WebMD. The main outcomes were knowledge acquisition, trust in eHealth information, and understanding and motivation, using validated scales. Outcomes were compared between groups using Pearson’s chi-square and ANOVA tests.

The 234 participants had mean age 56 years, 41% were men, 30% self-reported Black race, 9% reported Latino ethnicity, 33% had high school education or less, and 41% reported annual income less than $40K. Participant characteristics were balanced across trial arms. Of participants viewing PALS content, 74% correctly answered the two knowledge questions vs. 33% viewing WebMD content (p<0.01). Trust in eHealth information and understanding and motivation scores were higher among participants viewing PALS content vs. WebMD content (p=0.03 and 0.01, respectively).

The PALS resulted in better knowledge uptake, trust in eHealth information, and understanding and motivation than WebMD in patients with hypertension attending rural and urban safety net clinics. This promising approach to patient education designed specifically for the large proportion of the US population with low health literacy should be tested for efficacy in lowering healthcare costs. THE ROLE OF MEDS TO BEDS IN 30-DAY READMISSION RATES: A QUALITY IMPROVEMENT STUDY Mohammed Abourahma1; Alexander O'Hara1; Michael Wesolowski2; Agnes Libot3. 1Internal Medicine, Loyola University Medical Center, Chicago, IL; 2Clinical Research Office, Loyola University Chicago, Chicago, IL; 3Associate Professor, Department Of Medicine, Loyola Medicine, Maywood, IL. (Control ID #4270153)

"Meds to Beds" (M2B) is an institution-wide quality improvement initiative designed to improve medication access, enhance patient understanding of their medications upon discharge, and promote adherence, all while aiming to reduce medication-related readmissions. For patients who agreed to enroll upon admission to the inpatient wards, pharmacists would hand-deliver medications to the bedside at discharge, explain the indications, review the medication list, and answer any additional questions the patient might have. We hypothesized that this intervention would reduce 30-day readmission rates.

M2B was implemented across multiple medical and surgical services in our center. We analyzed all admissions from January 1 to December 31, 2023, encompassing a total of 5,068 admissions. Of these, 3,008 patients enrolled in M2B, and 87 declined enrollment. A total of 1,973 patients were excluded from the analysis due to ineligibility- such as patients who were discharged on the weekend or holiday. Ultimately, Chi-square and Wilcoxon rank-sum tests were utilized to assess the effect of the M2B program on 30-day hospital readmissions.

Hospital readmission was not significantly associated with sex (p = 0.23), race (p = 0.29), ethnicity (p = 0.51), or M2B enrollment (p = 0.06). Although not statistically significant, hospital readmission rates differed meaningfully based on enrollment in the M2B program. In specific, 9.34% of patients enrolled in the Meds to Beds program were readmitted to the hospital, whereas only 3.45% of patients not enrolled in the Meds to Beds program were readmitted to the hospital. Hospital readmission did demonstrate a significant association with inpatient hospital length of stay (p < 0.01). Patients who were readmitted to the hospital had significantly longer inpatient hospital lengths of stay than patients who were not readmitted to the hospital (Median; IQR: 5.67 days; 3.84 – 8.92 vs. 4.43 days; 2.80 – 7.30). Enrollment in the Meds to Beds program was not significantly associated with sex (p = 0.45), race (p = 0.41), ethnicity (p = 0.12), or inpatient hospital length of stay (p = 0.87).

Interestingly, our analysis revealed higher readmission rates in the group that received the intervention. However, these findings are limited by the small sample size and susceptibility of selection bias in the non-enrolled group. Patients identified to have socioeconomic barriers, or complex chronic medical conditions, may have been more attentively enrolled, resulting in a healthier population being overrepresented in the non-enrolled group. Nevertheless, we plan to reanalyze the data to include patients excluded from this analysis to increase the sample size. Additionally, we theorize that further stratifying the groups by socioeconomic factors and insurance types would provide greater insight into the effect of M2B on readmission rates. TIME TO DIAGNOSTIC COLONOSCOPY AND CENTRALIZED PATIENT NAVIGATION IN FQHCS: A RANDOMIZED CLINICAL TRIAL Anisha Ganguly1,2; Meghan O'Leary3,2; Kevin Su2; Lindsay Stradtman2; Renee M. Ferrari3,2; Connor Randolph3,2; Xianming Tan3,2; Seth D. Crockett4; Alison T. Brenner1,2; Daniel S. Reuland1,2. 1Internal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; 2The University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center, Chapel Hill, NC; 3The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC; 4Oregon Health & Science University School of Medicine, Portland, OR. (Control ID #4271347)

Patients in federally qualified health centers (FQHCs) are at risk for delay in or non-completion of diagnostic colonoscopy after positive stool-based testing (SBT) for colorectal cancer (CRC) screening. Increased time to diagnostic colonoscopy is associated with increased CRC incidence, late-stage diagnosis, and mortality.

We analyzed time to diagnostic colonoscopy (TDC) among patients in a pragmatic patient-level randomized clinical trial of an intervention comprised of centralized mailed SBT outreach and patient navigation after positive SBT compared to usual care alone (NCT04406714). This analysis included patients with a positive SBT within the study population of FQHC patients in the Southern US randomized between July 2020 and September 2021. Intervention patients were offered phone-based navigation to diagnostic colonoscopy, including support with procedure scheduling, bowel preparation, and social needs. We compared restricted mean time to diagnostic colonoscopy (TDC) in an intention-to-treat (ITT) Kaplan-Meier survival analysis over 1 year of follow-up. Patients who did not complete diagnostic colonoscopy were censored by last observation date collected by chart review.

Among 4,002 patients randomized, 940 (23.4%) completed SBT, of whom 89 (10.6%) tested positive. Baseline characteristics and observation time were similar across trial arms. Most patients identified as white (59.6%) and 32.6% identified as Black. Most patients had no prior history of CRC screening (59.6%). Intervention patients were more likely to complete diagnostic colonoscopy during the 1-year follow-up period than control patients (83.3% vs 48.0%, p=0.002). In ITT analysis (Figure 1), the restricted mean TDC for intervention patients was 157.0 days (95% CI 120.0-194.1) compared to 237.4 (95% CI 181.9-293.0) for control patients, a difference of 80.4 days (95% CI 13.6-147.2, p=0.018).

Centralized patient navigation significantly increased diagnostic colonoscopy completion and reduced mean TDC after positive SBT among FQHC patients. Patient navigation is an important intervention to support equitable cancer screening and diagnosis in under-resourced settings. TRENDS IN COMMUNITY HEALTH WORKER PLACE OF EMPLOYMENT AND WAGES FROM 2012 – 2023 AND EFFECT OF CERTIFICATION AND MEDICAID REIMBURSEMENT Lauren Mitchell1; Betsy Q. Cliff4; Nikita Thomas1; Nayeli Shad3; Marcia Tan3; Elbert Huang2. 1General Internal Medicine, The University of Chicago Division of the Biological Sciences, Chicago, IL; 2Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 3Public Health Sciences, The University of Chicago, Chicago, IL; 4Public Health Sciences, The University of Chicago Division of the Biological Sciences, Chicago, IL. (Control ID #4273373)

Community health workers (CHWs) are increasingly viewed as critical team members for addressing social, medical, and public health challenges, especially for historically marginalized populations. The growth in CHW programs has also fueled interest in policies such as certification and Medicaid reimbursement for CHWs. However, less is known about CHWs as a workforce and the effect of relatively new certification and Medicaid reimbursement policies. The objective of this study is to describe trends in CHW place of employment and wages and the effect of certification and Medicaid reimbursement.

Using data from the Bureau of Labor Statistics (2012-2023), we describe changes in the size and composition of the CHW workforce over time and across industries. We performed a test of proportions to estimate population-levels differences in the proportion of CHWs employed in different industries over time and linear regression to compare wages between industries. We also performed a staggered difference-in-difference analysis to evaluate the effect of state certification and Medicaid reimbursement policies on the proportion of CHWs in each industry and on wages.

The CHW workforce has nearly doubled in size with 38,020 total CHWs in 2012 and 58,550 in 2023. By comparison, in 2023 there were over 3 million home health aides. In 2023, there were significantly more CHWs employed by insurance agencies, hospitals, ambulatory care facilities, and government entities, and significantly fewer employed by social assistance agencies as compared to 2012 (p<0.001 for each industry). Controlling for year, CHWs at social assistance agencies receive the lowest pay and make $7.15 less per hour than the highest paid CHWs, who work at insurance agencies (p<0.001). Certification resulted in a small decrease in the proportion of CHWs employed in government entities (-0.094, p=0.003) but did not have an effect on any other industry proportion or wages. Medicaid reimbursement resulted in an increase of $2.48 (p=0.03) per hour for hospital-employed CHWs, but did not have any effect on wages of other industries or the proportion of CHWs employed in each industry.

The CHW workforce is growing rapidly but remains small. More CHWs are shifting from social assistance organizations into the healthcare system and government entities and there are significant differences in pay between industries. Certification and Medicaid reimbursement appear to have had little effect on where CHWs are employed and wages. These findings are important for policy discussions around the growth and sustainability of the CHW workforce, as well as a foundation for further research into the organization and implementation of CHW programs. It will also be important to consider how shifts in employment and policies may impact the nature of community health work and how to preserve CHWs’ unique attributes and connection to the community. UNDERSTANDING MODELS OF PHYSICIAN-ADVANCED PRACTICE PROVIDER (APP) COLLABORATION Lisa Rotenstein2,1; Estelle Martin3; Christine Iannaccone4; Erin Sullivan5. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2University of California San Francisco, San Francisco, CA; 3Department of Medicine, University of California San Francisco, San Francisco, CA; 4General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 5Healthcare Administration, Suffolk University, Boston, MA. (Control ID #4271939)

APPs are integral to healthcare and outnumber physicians 50 to 1. Originally, they were meant to work under physician supervision, but 27 U.S. states now offer full-practice authority. There is a debate about their role, especially in primary care. Optimizing the healthcare workforce and promoting effective physicians-APP collaboration is crucial, as team integration is linked to an increase in physician productivity and patient satisfaction. This study explores three models of MD-APP collaboration: 1) Panel co-management, 2) Parallel work with on-demand care, and 3) APPs with their own panel.

We interviewed primary care practices in the U.S. that have implemented MD-APP collaboration models. A semi-structured interview guide was designed based on a literature review and focus group of stakeholders from across healthcare organizations in the U.S., aiming to gather details on training and onboarding, team structure, financial implications, benefits and challenges, and implications for provider and patient satisfaction. Practices were identified via the BWH Center for Physician Experience and Practice Excellence advisory board. Interviews with an MD, APP, and an administrator/leader from each site were voluntary, conducted individually, and lasted 30 minutes. Interview transcripts were deidentified prior to being thematically coded using NVivo.

Our final sample included 6 primary care practices and 20 interviewees from various U.S regions. APP licensing standards and scope of practice rules varied by state, influencing how each practice had constructed its model. Several practices offered year-long training, onboarding, and intensive mentoring programs for NPs and PAs to manage patient panels. Most interviewees noted some financial tension related to pay differentials between physicians and APPs, although some were working to make incentives available to APPs. Almost universally, physicians and APPs noted an increase in professional satisfaction as a result of practicing in these models and noted that it was “good for patients” in terms of increasing access to care and building relationships with the same team.

This study highlights the operational nuances and practice implications of physician-APP models. It emphasizes the need to tailor collaboration approaches to align with state licensing standards and shows that practices with robust training, onboarding, and mentoring programs for APPs appear better equipped to foster sustainable teams and improve care delivery. The findings suggest further research into the long-term outcomes of MD-APP collaboration models, including patient health outcomes, workforce retention, and financial sustainability. Comparative studies across different state regulatory environments could provide critical evidence to guide best practices and inform policy discussions. USE OF PATIENT-CENTERED OUTCOMES TO PRIORITIZE AMONG GUIDELINE-CONCORDANT CARE PROCESSES FOR PATIENTS WITH COMPLEX MULTIMORBIDITY Linnaea C. Schuttner1,2; Mariah A. Theis1; Edwin Wong2,3; Jonathan Staloff1,4; Robert McQueen5; Karin Nelson1,2; James D. Ralston3,6; Laura Coyle7; Scott Hagan2; Tamara Schult8. 1Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA; 2Department of Medicine, University of Washington, Seattle, WA; 3Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA; 4Department of Family Medicine, University of Washington, Seattle, WA; 5School of Pharmacy, University of Colorado System, Denver, CO; 6Kaiser Permanente Washington Health Research Institute, Seattle, WA; 7Office of Primary Care, Veterans Health Administration, Washington, DC; 8Office of Patient Centered Care and Cultural Transformation, Veterans Health Administration, Washington, DC. (Control ID #4269739)

Guideline-concordant preventative and chronic disease care processes (hereafter, care processes) are core components of Primary Care. While important, for patients with multimorbidity, some care processes may be inapplicable to individuals with extensive disease burden, or perceived as less urgent than competing needs. Little evidence exists to guide clinician decision-making for which care processes to address for an individual with multimorbidity. We aimed to a) clarify the criteria important to decision-making when choosing care processes to address for patients with multimorbidity, and b) develop recommendations on prioritization of care processes, according to specific patient-centered outcomes.

We used Multi-Criteria Decision Analysis, a group-based decision-making process permitting incorporation of multiple viewpoints and factors. We purposefully recruited Subject Matter Experts with relevant research, clinical, or health leadership expertise. Experts were sent 2 electronic survey rounds. Round 1 weighed 12 potential criteria (e.g., actionability, impact on safety) for relative importance when deciding which care processes to address for patients with multimorbidity if targeting 1 of 3 patient-centered outcomes (Physical/Cognitive Function; Mortality; Symptom Relief). Round 2 scored 53 care processes derived from clinical guidelines, relative to criteria. Results were combined as weighted sums to create recommendations for prioritizing care processes according to each patient-centered outcome (max 10.0, higher as more outcome-aligned). We used Monte Carlo simulation (5,000 randomizations) to evaluate confidence in the findings, described as percent of time that a process was at a rank.

20 Experts participated from 9 VA sites and 10 university affiliates. After additional input from patient and operational project partners, 7 final criteria were selected as the most important to decision-making for which processes to address: actionability; impact on safety; completion ease; impact on high-prevalence health issues; evidence quality; impact on long-term health outcomes; and validity. After scoring by criteria, ‘Tobacco use screening’ was the highest priority care process to complete for all 3 patient-centered outcomes (Function, Mean=6.9 (49% as #1 priority); Mortality, Mean=7.4 (27% as #1); Symptoms, Mean=7.1 (44% as #1)). Total scores and rankings for the other care processes varied by outcome.

With limited time to care for patients with complex health needs, clinicians must decide which routine care processes to prioritize. This study helps to clarify what criteria are most important to consider in this decision-making, and provides a recommended order to prioritize care processes if attempting to target specific patient-centered outcomes. This novel approach synthesizing structured input from participants with varied factors to consider is adaptable to other healthcare decision-making problems. UTILIZATION OF HEALTH INFORMATION EXCHANGE (HIE) AND BARRIERS TO USE AMONG INTERNAL MEDICINE AND EMERGENCY MEDICINE CLINICIANS Priscilla H. Kim2; Camille P. Vaughan2; Mohammed K. Ali3,4; Carolyn K. Clevenger1; Molly M. Perkins2; Sara Turbow2,3. 1Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA; 2Medicine, Emory University School of Medicine, Atlanta, GA; 3Family & Preventive Medicine, Emory University School of Medicine, Atlanta, GA; 4Global Health, Emory University Rollins School of Public Health, Atlanta, GA. (Control ID #4268679)

Health information exchange (HIE), the electronic transmission of clinical data across healthcare organizations, provides the opportunity to improve the efficiency, quality, and safety of patient care. While widely available, HIE is utilized in only 2-10% of patient encounters. Few studies have explored current barriers to use. The objective of this study was to evaluate clinician utilization of HIE and potential barriers to use.

We conducted a population-based survey of inpatient internal medicine (IM) and emergency medicine (EM) physicians, physician assistants, and nurse practitioners at 8 health systems in a city in the Southern U.S. from April 2023 to April 2024. Our survey was based on a 9-item questionnaire, the “Health Information Technology Survey for Physicians, Physician Assistants, and Nurse Practitioners,” which was developed by investigators in rural Nebraska in 2009 to assess users’ perceptions of HIE. The survey was edited to reflect the HIE landscape in our city, and a question on access to advance directives via HIE was added. Using a Likert scale, providers were asked to rate their ability to access various types of clinical data using HIE, how frequently they accessed such information, and specific barriers to HIE utilization. Survey responses were analyzed overall and by specialty.

Of 1239 clinicians who received our survey, 276 (22.3%) responded, with approximately 66% of respondents working in inpatient IM and 33% in EM. Most respondents were physicians (93.1%). About 80% of respondents reported using HIE at least once a day, while 4.8% reported never using HIE. Most clinicians used HIE at least once daily to access lab results (80.2%), clinical notes (81.9%), imaging reports (74.0%), and medication lists (71.2%), while only 30% used HIE to access advance directives. About 65% of respondents estimated ordering duplicate tests at least once weekly due to not accessing prior results via HIE. Only 56% of respondents agreed that they were able to access discharge summaries from patients’ recent outside hospitalizations. Even fewer providers (13.4%) agreed that they were able to access advance directives completed at other hospitals. The most reported barriers to HIE utilization included unavailability of needed information (66.4%), adding time to patient care (45.5%), and ease of simply reordering tests (31.6%). HIE use and reported barriers to use were similar across IM and EM providers.

While most clinicians reported accessing HIE daily, duplicate tests were frequently ordered, and advance directives completed at outside hospitals were rarely accessed. This highlights ongoing challenges with HIE use and its ultimate impact on patient care. We identified several barriers to HIE use, which can be used to develop targeted interventions to improve HIE utilization and impact patient care. VARIATION IN VIDEO CARE USE FOR PATIENTS WITH INCIDENT ATRIAL FIBRILLATION IN THE VETERANS HEALTH ADMINISTRATION Rebecca L. Tisdale1,2; Neil M. Kalwani3; Harrison Koos2; Jun Fan2; Natasha Din2; Alexander Perino2; David C. Chan1,4; Alexander Sandhu2,1; Paul Heidenreich1,2. 1Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, CA; 2Stanford University, Stanford, CA; 3Medicine, VA Palo Alto Health Care System, Palo Alto, CA; 4University of California Berkeley Haas School of Business, Berkeley, CA. (Control ID #4269899)

Video telehealth is a potential tool for alleviating geographic cardiology specialist shortages in the Veterans Health Administration (VA), but there is limited data regarding current video care use for common cardiology conditions, including atrial fibrillation (AF). We evaluated variation in video visit use in primary care and cardiology following incident AF diagnoses in the VA.

We constructed a cohort of patients with AF diagnoses made in the outpatient setting 1/2022-9/2023. We limited our sample to facility-specialty groups that had at least 20 visits between 1/2022-12/2023. We assessed the association of any video use for primary care or cardiology visits in the 90 days following a new AF diagnosis with patient and facility characteristics using logistic regression, including facility random intercepts. We evaluated facility variation in video care use via the median odds ratio (MOR).

Our cohort included 38,238 patients with new AF with a total of 85,115 visits across 125 facilities. Of these, 2,978 visits (3.2%) were delivered by video. Average age was 74, 2.9% were female, 75% were White, and average CHA2DS2-VASc was 2.8. For primary care, video visit use was more likely among Veterans who were younger, female, with diabetes, living at a moderate distance from care (>15 miles) or in urban settings, and receiving care at facilities designated as higher complexity or located in the West or Northeast. For cardiology, video visit use was more likely among younger patients and those receiving care at high-complexity facilities. There was significant variation in video care use across facilities (primary care range 0%-12.8%; cardiology range 0%-17.0%) with 41.3% of cardiology practices providing no video care (Figure). The adjusted MOR also suggested large variation in the likelihood that similar patients receiving care at similar facilities would have video telehealth for primary care (2.0 [95% credible interval: 1.8-2.3]) and cardiology (4.5 [3.2-7.1]).

Selected patient and facility characteristics were associated with video telehealth use following incident AF diagnoses, but there was significant variation in video care use across facilities not explained by these factors and no use of this modality at many VA cardiology practices. Standardizing video telehealth use across VA facilities may be a mechanism for improving access to AF care. “MY WORLD OPENED UP”: IMPACT OF A NOVEL STATE-SPONSORED PRIVATE HEALTH INSURANCE PROGRAM FOR UNDOCUMENTED IMMIGRANTS Christine C. Welles3; Katherine Rizzolo1; Carol Gorman2; Claudia Camacho3; Lauren McBeth3; Erika Becerra-Ashby4; Rachel M. Peters3; Nina Schwartz4; Lilia Cervantes3. 1Medicine, Boston Medical Center, Boston, MA; 2Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora, CO; 3Medicine/Hospital Medicine, University of Colorado, Aurora, CO; 4Connect for Health Colorado, Denver, CO. (Control ID #4253802)

Undocumented immigrants without health insurance often delay or forgo essential care, potentially leading to more severe disease presentations and higher healthcare costs. One novel solution is to provide state-subsidized private health insurance to undocumented immigrants. Understanding the health impacts of this unique program is essential to inform the adoption of similar healthcare policy in other states nationwide.

We performed semi-structured interviews with undocumented immigrants who enrolled in OmniSalud during 2023 and/or 2024 . Participants were recruited from one Latinx-based community health center in Denver, CO. From November 2023 to April 2024, three bilingual members of our study team conducted semi-structured interviews and collected demographic information. Eleven thousand people were offered private health insurance plans in 2024, and all spots were filled in less than 48 hours; as a result, some individuals were unable to enroll. Three categories of participants were interviewed: 1) individuals who had OmniSalud health insurance in 2023 and re-enrolled for 2024, 2) individuals who had OmniSalud health insurance in 2023 but were unable to re-enroll for 2024 due to spots running out, and 3) individuals who newly enrolled in 2024. Interviews were audio recorded, translated, and transcribed. The interviews were coded inductively using thematic analysis. We used the Consolidated Criteria for Reporting Qualitative Health Research to report this study.

Fifty-five individuals participated (58% women (n=32) and 42% men (n=23); mean [SD] age, 47 [10] years). Five themes were identified: 1) shift to proactive care rather than reactive treatment for advanced disease, 2) breaking down financial barriers to care, 3) relief from the distress of not receiving the standard of care, 4) experiences enrolling in insurance and navigating the healthcare system, and 5) gratitude, loss, and desire to expand the private health insurance program (Figure).

After receiving state-subsidized private health insurance, participants no longer avoided care due to cost. They sought care more proactively, with greater use of preventive care, better control of chronic disease, decreased anxiety, and less need for emergency care. Adoption of this healthcare policy in other states should be considered to provide higher value care to undocumented immigrant populations. Scientific Abstract - Health Care Policy and Health Services Research 10-YEAR FISCAL IMPACT OF EXPANDED MEDICARE COVERAGE OF NEWER ANTI-OBESITY MEDICATIONS Jennifer Hwang1; Neda Laiteerapong1; Elbert Huang2,1; Dariush Mozaffarian4; A. Mark Fendrick3; David D. Kim2. 1General Internal Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 2Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 3Internal Medicine, University of Michigan, Ann Arbor, MI; 4Friedman School of Nutrition Science and Policy, Nutrition Epi & Data Science, Tufts University, Medford, MA. (Control ID #4272522)

Despite the promise of glucagon-like peptide-1 receptor agonists (GLP-1RA) in promoting weight loss and reducing obesity-related comorbidities (e.g., diabetes, cardiovascular disease), Medicare Part D does not cover these treatments. Expanding coverage would increase drug spending but could improve equity and reduce Medicare's burden of obesity-related comorbidities.

A 10-year budget impact analysis using the validated Diabetes, Obesity, Cardiovascular Disease Microsimulation Model (DOC-M), incorporating assumptions of a 10% annual uptake rate for each new cohort, 40% adherence beyond the first year, and a 10% price discount starting in 2027 through Medicare price negotiations. The analysis examined critical variables over time, accounting for anticipated changes in drug acquisition costs and uptake rates. We included current and future Medicare beneficiaries with a BMI ≥30 kg/m2 or BMI ≥27 kg/m2 and at least one obesity-related comorbidity. We excluded those with diabetes and cardiovascular disease. We measured total Medicare spending on GLP-1RAs for obesity indications not currently covered by Medicare, long-term healthcare cost offsets from reducing obesity-related comorbidities, and the net fiscal impact under various pricing and uptake scenarios.

Among 28.7 million Medicare beneficiaries who could potentially be eligible for GLP1-RAs as obesity treatment, Medicare's total spending on GLP-1RAs was projected to reach $97.2 billion over the next 10 years, with 5.7 million GLP-1RAs recipients. Healthcare cost offsets from reduced obesity-related comorbidities were estimated at $30.3 billion, resulting in net spending of $66.9 billion. A 20% additional discount to the current net prices effective in 2027 would reduce net spending to $58.6 billion.

Expanding Medicare coverage for GLP-1RAs would increase access and reduce obesity-related complications but impose substantial costs over 10 years. Although price reductions through market competition and Medicare negotiation may moderate costs, the fiscal impact remains significant due to the large, unmet clinical need. Policymakers must balance the clinical benefits of these therapies with the potential financial strain on the Medicare program. ACCESS BARRIERS TO INSULIN AT THE YALE DIABETES CENTER IN 2024 Sefia Khan1; Nadera Rahman2; Darren Warren2; Megan E. Branda3; Laura M. Nally2; Kasia J. Lipska2. 1John Sealy School of Medicine, The University of Texas Medical Branch John Sealy School of Medicine, Galveston, TX; 2Internal Medicine, Yale University School of Medicine, New Haven, CT; 3Quantitative Health Sciences, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4270900)

Insulin is critical for managing type 1 and type 2 diabetes, but access barriers such as high costs, insurance delays, and pharmacy shortages can force patients to ration this life-saving medication. This study examined insulin rationing broadly, including due to cost, insurance hurdles, and supply chain disruptions.

A 22-question cross-sectional survey was conducted at the Yale Diabetes Center between April and July 2024. Eligibility criteria included: age ≥18, a diagnosis of type 1 or type 2 diabetes, an insulin prescription in the past 12 months, an in-person clinic visit, and English literacy. The primary outcome was insulin rationing due to access barriers, defined as taking less insulin, skipping doses, or delaying filling insulin because of cost, insurance delays, or pharmacy shortages. Multivariable logistic regression analyzed factors associated with insulin rationing including age, sex, race, type of diabetes, prescription insurance coverage, and household income.

Of 331 eligible patients, 199 completed the survey (response rate: 60.1%, 47.7% female, 64.1% white, 47.2% type 1 diabetes, 20.1% with Medicare, 40.7% commercial, and 32.3% Medicaid coverage). Insulin rationing due to cost was reported by 48 participants (24.1%), due to insurance delays by 34 (17.1%), and due to pharmacy shortages by 37 (18.6%), with 75 participants (37.7%) reporting insulin rationing due to any one of these causes. A higher proportion of participants with type 1 diabetes reported insulin rationing due to one of the access barriers (59.7%) compared to those with type 2 diabetes (40.3%, p = 0.01). In the multivariable adjusted model (which had a c-statistic of 0.72 showing good fit), the only factor that was significantly associated with insulin rationing was type of diabetes (p=0.03).Compared to patients with type 1 diabetes, those with type 2 diabetes had lower odds of rationing (OR 0.34, 95% CI: 0.13-0.87). Participants who rationed insulin were also more likely to report being unable to buy diabetes-related medical equipment compared to those who did not ration (42.5% vs 7.6%, p < 0.01).

When considering broader access barriers, more than 1 in 3 participants (37.7%) reported insulin rationing in the past year. Limitations to this study include its small sample size focused on a single center that may not represent the broader population and reliance on self-reported data. Nevertheless, these findings suggest continued challenges with access to insulin for patients with type 1 and type 2 diabetes. Despite policy changes and reduced prices for many insulin products in 2024, continued efforts to comprehensively address insulin access barriers are needed. ACCESS TO PRIMARY CARE AND ITS ASSOCIATION WITH ILLICIT DRUG USE: EVIDENCE FROM CALIFORNIA Vivian G. Cueto1; Ana Natale-Pereira3; Victor Cueto2. 1Public Affairs and Administration, California State University East Bay, Hayward, CA; 2Medicine, University of Miami Miller School of Medicine, Miami, FL; 3Medicine, Rutgers Health, Newark, NJ. (Control ID #4273069)

California has made great strides towards universal health insurance coverage, yet access to primary care providers (PCPs) for remains a concern for individuals at risk of drug abuse. This is particular concern as Illicit drug use remains a significant public health concern both in California and throughout the county. This study explores role of limited access to PCPs in illicit drug use.

This study used data from the 2023 California Health Interview Survey to examine the association between illicit drug use and various individual, systemic, and neighborhood-level factors. The primary dependent variable was self-reported use of heroin, methamphetamine, or a prescription drug not as directed in the past year. The primary independent variable was self-reported difficulty finding a primary care physician who accepted the respondent’s insurance. Bivariate analyses and a multivariable logistic regression were conducted to explore relationships between illicit drug use and co-variates. Covariates included an inventory of adverse childhood experiences (ACEs) and an index of psychological distress based on six questions about negative emotions in the past 30 days. Multivariable regression models were also adjusted for individual factors such as poverty, education status, marijuana use, cigarette smoking, recent police stops and neighborhood characteristics.

Of the 21,035 survey respondents, only 2% reported use of illicit drugs in the past year. Individuals reporting illicit drug use were more likely to have difficulty finding a provider that accepted their insurance. In the adjusted logistic regression, individuals who reported difficulty finding a primary care physician who accepted their insurance were significantly more likely to report illicit drug use (aOR = 1.86, p = 0.028). Respondents reporting psychological distress in the last 30 days (aOR 1.57, p = 0.013), and those with four or more ACEs (aOR 3.11, p < 0.001) also had increased odds of illicit drug use. Current marijuana users (aOR 2.46, p < 0.001), current smokers (aOR 3.56, p < 0.001), and those stopped by the police in the past three years (aOR 2.54, p < 0.001) also reported higher odds of illicit drug use. Comparatively, females had lower odds of drug use than males (aOR 0.65, p = 0.021), and respondents who have never-married had higher odds of illicit drug use (OR = 2.70, p < 0.001) compared married individuals.

In this cross-sectional survey of adults in California, limited access to a primary care provider that accepted a respondent’s insurance was associated with illicit drug use. This association was significant despite adjustment for other factors such as high-risk behaviors or ACEs. These findings represent an important consideration for expanding health access for individuals who are at risk of illicit drug use. A CROSS-SECTIONAL COMPARISON OF LEVEL OF EVIDENCE AND STRENGTH OF RECOMMENDATIONS IN MEDICAL SOCIETY CLINICAL GUIDELINE DOCUMENTS FROM 2019-2023 Omar Qureshi, Joseph S. Ross, Reshma Ramachandran, Anand Habib. Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4272243)

U.S.-based medical societies offer recommendations within clinical guideline documents (CGDs) to help clinicians provide evidence-based, high-quality patient care. Stronger recommendations purportedly have benefits that clearly outweigh risks, while weaker recommendations do not. It is unclear to what extent the strength of recommendations (SOR) within CGDs agree with their corresponding levels of evidence (LOE).

We identified 23 large, U.S.-based medical societies of varying specialties. For each society, we randomly selected up to 25 CGDs published between 2019-2023 using the ECRI Guidelines Trust database. For each CGD’s recommendations, we extracted SOR and LOE. Using societies’ methodology statements, we categorized SOR and LOE as: 1) strong, 2) moderate, 3) weak or very weak, or 4) none or unspecified. We considered SOR in agreement with LOE if LOE was at least as strong as the SOR (e.g., moderate strength recommendations informed by strong or moderate evidence had SOR-LOE agreement). We calculated descriptive statistics and used modified Cohen’s kappa [κ] statistics to quantify SOR-LOE agreement. We also categorized recommendations based on recommendation-, guideline-, and society-level variables.

We examined 309 CGDs containing 7,582 recommendations issued by 23 societies. Overall, 5,068 (67%) recommendations pertained to therapeutic interventions, 4,425 (58%) pertained to outpatient/ambulatory care, 4,474 (59%) were from medical specialty societies, 1,060 (14%) were from surgical societies, and 286 (4%) were from primary care societies. Societies graded 2,303 (30%) recommendations as strong, 1,351 (18%) as moderate, 2,028 (27%) as weak, and 1,900 (25%) had no strength. Regarding LOE, 768 (10%) recommendations were supported by strong evidence, 1,676 (22%) by moderate evidence, 2,421 (32%) by weak or very weak evidence, and 2,717 (36%) by no evidence. Overall, although there was substantial agreement between recommendations’ SOR and LOE (κ=0.67; 95% confidence interval [CI] 0.66-0.68), 2,494 (33%) recommendations had an SOR exceeding their LOE. Specifically, for strong recommendations, there was only fair SOR-LOE agreement (κ=0.27; 95% CI 0.25-0.28), with 1,690 (73%) strong recommendations having less than strong LOE. Recommendations issued by medical specialty (κ=0.68; 95% CI 0.67-0.69) and surgical specialty (κ=0.75; 95% CI 0.72-0.77) societies also had substantial SOR-LOE agreement, while recommendations offered by primary care societies had near-perfect agreement (κ=0.81; 95% CI 0.76-0.85).

Across CGDs by 23 societies, SOR and LOE had substantial agreement overall, with near-perfect agreement for primary care societies' recommendations. However, one-third of recommendations had SOR in excess of their LOE, with only fair SOR-LOE agreement for strong recommendations. While CGDs are a valuable resource, clinicians should exercise caution and appropriately scrutinize LOE when using CGD recommendations to guide clinical decisions. ADDRESSING SELECTION EFFECTS WHEN ESTIMATING COVID VACCINE EFFECTIVENESS Jeff Whittle1,2; Sadia Farzana3; Vladimir Atanasov4; John R. Meurer5; Bernard Black3. 1Primary Care, Zablocki VA Medical Center, Milwaukee, WI; 2Medicine, Medical College of Wisconsin, Milwaukee, WI; 3Kellogg School of Management, Northwestern University, Evanston, IL; 4Business, William & Mary, Williamsburg, VA; 5Institute for Health Policy, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4270558)

Most reports on COVID vaccine efficacy for mortality use observational data; potentially subject to health vaccinee bias. We illustrate the surprising magnitude of this bias and present a novel mitigation approach.

We combined linked mortality and vaccination data with population data for Milwaukee County to generate a synthetic population of 722,000 adults for whom we had data on age, gender, race/ethnicity, residence zip code, and dates of vaccination and death. We focus on 11/1/21 – 10/31/22, a period when COVID vaccine booster doses were available and encouraged by public health experts. We categorized vaccine status as 0, 2 doses (primary vaccination) and 3 doses (booster) and cause of death as COVID, non-COVID natural, or non-natural. We excluded one-dose recipients and individuals with impaired immunity. We measured mortality rates and period life expectancy within 5-year age groups, by gender, race/ethnicity, and vaccine status. We calculate vaccine effectiveness against death as percent reduction in COVID deaths adjusted for non-COVID natural deaths within the group.

The table shows illustrative mortality rates for persons aged 55-59 by gender and vaccine status. Men who received a booster had no COVID mortality during the study year versus 1.42 deaths/1000 for unvaccinated men, but had an even larger advantage for non-natural deaths (murder, accident, suicide) (1.02 vs. 3.76/1000). Period life expectancy across all ages is 4.5 and 10.9 years greater for women receiving 2 or 3 doses vs. unvaccinated women. For men, these differences are 8.7 and 15.4 years. Only a fraction of these gaps reflect COVID mortality; 31% for women and 19% for men. The gaps are similar if adjusted for race/ethnicity or area level socioeconomic status. Adjusting for non-COVID natural mortality reduced estimated vaccine effectiveness and highlighted greater Moderna vs Pfizer effectiveness for the elderly.

Healthy vaccinee bias is large and strongly affects estimates of COVID vaccine effectiveness. Non-vaccinee status is associated with diverse mortality causes, identifying a population needing targeted public health and research efforts. AMBULATORY CARE PATTERNS FOR INDIVIDUALS DUALLY ELIGIBLE FOR MEDICARE AND MEDICAID Yueming Zhao2; Danielle Browne1; Isabelle Carroll1; Austin S. Kilaru3; Aidan P. Crowley4; David Pagnotti5; Torrey Shirk6; Paula Chatterjee7; Amol Navathe6; Joshua Liao1. 1Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 2Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 3Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 4Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 5Perelman School of Medicine, Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 6Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 7University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. (Control ID #4272284)

Adults who are eligible for insurance through both Medicaid and Medicare (“duals”) have lower income and use disproportionately more acute care while having poorer outcomes compared to other individuals. While these dynamics have prompted policy and care redesign initiatives to improve outcomes among dual populations, there is a dearth of knowledge about how duals use ambulatory care – a particularly notable gap given concerns about duals’ access barriers and the prevalence and salience of ambulatory care to outcomes.

Using 2019 Medicare fee-for-service claims and other sources of patient, clinician, practice, and geographic data, we described care patterns for ambulatory services among dual versus non-dual populations. We analyzed care received from group practices, using concavity in Lorenz curves to identify unequal distribution of services (evaluation and management [E&M] and non-E&M) provided to duals across practices. We defined high-dual practices as those responsible for 80% of ambulatory services among duals. Practices responsible for 20% of services among duals were defined as low-dual, and practices providing no services to duals were defined as non-dual practices.

Our sample consisted of 1,213,249 dual and 4,516,583 non-dual individuals receiving a total of 71,969,675 ambulatory services from 115,902 practices and 803,074 clinicians. Duals were more likely to be of Black or other race, Hispanic ethnicity, or disabled compared to non-duals. Ambulatory care patterns between dual and non-dual individuals also varied. Duals received fewer ambulatory services than non-duals (14.0 versus 16.0), in particular fewer subspecialty care services (6.4 versus 8.2). Conversely, duals received slightly more primary care (3.4 versus 3.2) and APP (2.0 versus 1.6) services. For duals, services were provided by a smaller number of unique clinicians, in particular subspecialty physicians (3.4 versus 4.5). Of included practices, 0.3% were high-dual, 88.0% were low-dual, and 11.7% were non-dual. The majority of services were provided by a disproportionally small number of practices: thirty percent of ambulatory services were provided by 0.02% of practices, while 50% of services were provided by 0.06% of practices. High-dual practices provided services for more patients on average compared to low-dual practices and no-dual practices. Compared to patients cared for at non-dual practices, patients in high-dual practices were younger and less often women but more often Black or Hispanic.

Compared to non-duals, duals exhibited different ambulatory care patterns and received most of their care from a small group of high-dual practices. Practice and policy leaders should consider differences in ambulatory care patterns, and practices that provide the most care to duals, when designing policy and care redesign initiatives to improve outcomes among these populations. ANALYZING DIFFERENCES IN IMAGING UTILIZATION AMONG MEDICARE FEE-FOR-SERVICE VERSUS CAPITATED PAYMENTS AS A METHOD OF IDENTIFYING LOW-VALUE CARE Graham C. Treasure1; Chad Villaflores2; Catherine Sarkisian3; John N. Mafi1; Samuel A. Skootsky2; Richard K. Leuchter4. 1Medicine, University of California Los Angeles, Los Angeles, CA; 2General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; 3Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 4Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4273152)

Unwarranted variation in medical care can harm patients and increase wasteful spending. Given the incentives for Medicare Advantage (MA) plans to deliver care at low cost through capitated payments, we studied variation in utilization of imaging and cardiodiagnostics between Fee-For-Service (FFS) Medicare versus MA beneficiaries to identify opportunities to improve care quality and value.

At a large urban academic health system, we conducted a cross-sectional analysis using EHR data merged with claims data to obtain all imaging utilization from 2021-2023, both inside and outside the home institution. Patients included Medicare Primary Care First enrollees (PCF, an FFS model, n=113,053 enrollee-years) and MA enrollees (n=19,741 enrollee-years) attributed to the home institution. Our initial analysis compared the unadjusted rate of imaging studies per enrollee-year grouped by modality (e.g. CT, MRI, PET, etc.) and anatomic keyword (e.g. head, chest, etc.). Based on this, we analyzed cardiac stress testing by modality, clinic, and physician. We then estimated the cost savings of standardizing utilization to the institutional means, based on the Medicare Physician Fee Schedule. Finally, we performed a chart review to identify drivers of variation and to identify stress tests that could be converted to more cost-effective modalities using UpToDate’s algorithm.

MA and PCF populations had similar demographic characteristics including mean age (73.8 vs. 73.6 years in MA vs. PCF respectively), gender (58 vs. 59% female), and race (53 vs. 65% non-Latino white). PCF patients had higher utilization for most imaging modalities, particularly PET (17% higher in PCF) and MRI (13% higher). MA patients had higher utilization for nuclear studies (16%), entirely driven by nuclear cardiac stress tests. Provider-level analysis of all stress test modalities showed the top 5 physicians ordered 0.28 stress tests for every unique patient seen in 2023—more than double the average of the institution’s cardiologists (0.12, s = 0.07). Standardizing these physicians to the mean institutional rate would represent $620,000 in annual savings to MA and PCF plans alone. Manual review of 30 charts corroborated that 7/18 (39%) nuclear stress tests could be replaced with less costly modalities. Among the 27 negative or inconclusive stress tests, 11 (41%) received repeat stress testing within 14 months.

In unadjusted analyses of data from a large urban academic health center, MA beneficiaries undergo substantially fewer MRIs and PET scans than those in PCF. Contrary to our hypothesis, MA beneficiaries received more nuclear stress tests than PCF beneficiaries. Analysis of stress testing utilization demonstrated large provider practice variation in modality selection and ordering rate. This suggests opportunity for improved care value by building consensus and standardizing practice patterns. AN ANALYSIS OF RECRUITMENT RATES BY ADMITTING SERVICE FOR A RANDOMIZED CONTROL SMOKING CESSATION STUDY Kayla Koffler1; Scott Sherman2. 1New York Medical College, Valhalla, NY; 2New York University, New York, NY. (Control ID #4269776)

Recruitment into clinical trials is challenging and has a major effect on the feasibility and the generalizability of a study. We used data from a previously completed hospital-based smoking cessation study to determine if recruitment rates varied by hospital admitting service, specifically comparing Medicine and Psychiatry departments.

We examined recruitment rates in the Financial Incentives for Smoking Cessation (FIESTA) study, which was conducted at the Veterans Affairs New York Harbor Healthcare System. FIESTA tested the effectiveness of financial incentives on smoking cessation among hospitalized patients. A total of 268 patients were screened, with 182 enrolled in the original FIESTA study. In our analysis, a LASSO approach was applied to the data set to create a model looking at admitting service, sex, race and ethnicity, education, and number of cigarettes per day and their respective recruitment rates.

The recruitment rates were significantly higher for patients admitted to the Psychiatry service (80.2%) than to the Medicine service (61.4%). Additionally, significant differences emerged based on education level; patients with a high school education or less had higher recruitment rates (87.2%) than those with higher education (57.7%). Race did not significantly impact recruitment, with non-Hispanic Black, Hispanic, and non-Hispanic White patients enrolling at comparable rates.

This research suggests that smoking cessation programs can effectively recruit a diverse patient population, including typically underrepresented groups such as those with lower education status and those with mental health diagnoses. Findings also emphasize the potential of urban hospital settings to support equitable recruitment efforts. Future research should explore additional demographic factors, such as comorbidities and confidence in quitting, to better understand motivations for participation. AREA-LEVEL SOCIOECONOMIC DISADVANTAGE AND ACCESS TO PRIMARY CARE: A SYSTEMATIC REVIEW Jonathan A. Staloff1; Anna M. Morenz2; Sophia Hayes5; Ananya Bhatia-Lin4; Joshua Liao3. 1Family Medicine, University of Washington, Seattle, WA; 2Department of Medicine, Banner - University Medical Center Tucson, Tucson, AZ; 3Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 4University of Washington, Seattle, WA; 5VA Puget Sound Health Care System Seattle Division, Seattle, WA. (Control ID #4273086)

Social drivers of health can aggregate in geographic areas, affect health outcomes, and contribute to health inequities. Over the last several decades, composite measures have been developed to capture community-level socioeconomic disadvantage. Two of the most widely studied and publicly available of these measures are the Area Deprivation Index (ADI) and Social Vulnerability Index (SVI), wherein higher scores reflect higher area-level disadvantage. One component of addressing health inequity is ensuring that communities of varying socioeconomic disadvantage have access to high quality primary care. This study was meant to address evidence gaps in understanding the relationship between ADI and SVI as area-level measures of socioeconomic disadvantage and primary care access via a systematic review.

We incorporated observational cohort and cross-sectional studies published prior to January 19, 2024 that examined the association between ADI and/or SVI as the primary exposure or mediator and primary care access as either the primary or secondary outcome. We searched PubMed, Web of Science, Embase, and Cochrane registries. In addition to peer-reviewed journal articles, we also included abstracts from conference proceedings that had been peer-reviewed.

We included and analyzed 21 studies (ADI=11, SVI=10). Most studies (67%) found that greater area-level social disadvantage was associated with reduced access to primary care, with this relationship more frequently reported in ADI studies (N=8/11) than SVI studies (N=6/10), and for primary care access as measured by self-report (N=2), telemedicine use (N=3), and vaccine uptake (N=2).

Findings from this systematic review suggest that area-level measures ADI and SVI can be associated with reduced primary care access, in particular when assessed through low-self reported access to primary care, higher use of telephone than video telemedicine for primary care, and low vaccine uptake. However, the existing literature base is still limited due to differing types of primary access, mixed findings within some of these types, and the need for future research involving hypothesis-testing and multi-level modeling. Future research can build on these findings and identify potentially actionable mechanisms for the relationship between area-level social disadvantage and reduced primary care access. ASSOCIATION OF HEALTH INSURANCE STATUS AMONG PERSONS WITH DIABETES AND MEDICARE VERSUS NO MEDICARE, THE HISPANIC COMMUNITY HEALTH STUDY/STUDY OF LATINOS (HCHS/SOL) Sana G. Rahman1,2; Eliseo J. Perez-Stable10; Erik Rodriquez3; Joel Willis3; Saida I. Coreas5; Martha L. Daviglus6; Linda C. Gallo7; Krista M. Perreira8; Earle C. Chambers4; Gregory A. Talavera9. 1National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; 2Georgetown University School of Medicine, Washington, DC; 3Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD; 4Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY; 5Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA; 6Institute for Minority Health Research, University of Illinois Chicago, Chicago, IL; 7Department of Psychology, San Diego State University, San Diego, CA; 8Department of Social Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; 9Division of Health Promotion and Behavioral Science, San Diego State University, San Diego, CA; 10NIMHD, National Institutes of Health, Bethesda, MD. (Control ID #4270730)

The prevalence of type 2 diabetes among Hispanic/Latino adults is double that of the general U.S. population. Less access to quality healthcare has disproportionately affected Hispanic/Latino populations who have the highest rate of being uninsured of any race and/or ethnic population in the country. We evaluated associations between health insurance status among individuals with and without Medicare and management of diabetes in the HCHS/SOL cohort.

Data from Visit 1 (2008-2011) and Visit 2 (2014-2017) of HCHS/SOL were analyzed. The analytic sample included persons who completed both Visit 1 and Visit 2. Diabetes was diagnosed using standard blood tests, reported diagnosis from clinican, and verification of medications. Change in health insurance status between Visits 1 and 2 were compared to create four mutually exclusive categories: uninsured at both visits, insured at both visits, lost health insurance between visits, and acquired health insurance between visits. We categorized the sample into “Medicare” or “No Medicare” groups. Multivariable logistic regression assessed the relationships between health insurance status at each visit and suboptimal HbA1c of >9%.

Of 8,503 participants without Medicare at both visits, 2,582 had diabetes. Among 2,515 participants with Medicare at both visits, 1,330 individuals had diabetes. Overall, among those without Medicare, 26.0% of individuals were uninsured, while only 38.1% of individuals were insured at both visits. Among persons with diabetes, 41.3% were insured at both visits compared to 37.3% of persons with no diabetes. Individuals with Medicare had lower proportions of poor diabetes control, with 11% having HbA1c >9% compared to 17.9% of those without Medicare having HbA1c >9%. The proportion of individuals who reported needing health care in the past year but could not get it decreased from 16.6% to 6.3% between Visits 1 and 2 among all participants with diabetes. Among individuals with diabetes and no Medicare, those with no health insurance at both Visit 1 (aOR =1.75, 95% CI = 1.17, 2.63) and Visit 2 (aOR =1.59, 95% CI = 1.09, 2.31) were significantly more likely to have suboptimal control of HbA1c at their respective visits when compared to those with health insurance.

Health insurance coverage helps improve diabetes control among Hispanic/Latino individuals without Medicare. BANKRUPTCY AND CLOSURE AFTER PRIVATE EQUITY ACQUISITION OF US HEALTH CARE DELIVERY ORGANIZATIONS Christopher Cai1; Benjamin N. Rome2; Suhas Gondi3; Zirui Song4. 1Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, 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; 3Medicine, Brigham and Women's Hospital, Boston, MA; 4Department of Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4271051)

Health care delivery organizations have been increasingly acquired by private equity (PE) investment firms. There have been several high-profile instances of bankruptcy or closure after PE acquisition of US health care delivery organizations, prompting Congressional legislation and investigation. However, the empirical association between PE ownership and bankruptcy or closure in health care remains unknown.

We identified health care delivery organizations—defined as hospitals, outpatient clinics, nursing homes, and home health organizations-- acquired by PE firms between 2000-2024. We compared them to organizations acquired by non-PE for-profit (“corporate”) firms. We excluded companies which switched ownership in the five years prior to index acquisition and those with a history of bankruptcy or closure. We used Cox regression to compare a prespecified composite endpoint of bankruptcy or closure through 15 years, using propensity-score weighting to adjust for differences in pre-acquisition profitability, acquisition year, geographic region, previous consolidation and industry sector.

We compared 4,726 PE-acquired to 4,608 corporate-acquired health care organizations. PE-acquired organizations were more likely to be profitable at the time of acquisition (8.3% vs. 4.3%) and less likely to have been previously consolidated with another company (75.9% vs. 87.9%). Bankruptcy or closure occurred in 47 PE-acquired organizations (2.0% per 10 organization-years of follow-up) and in 26 corporate-acquired organizations (0.8% per 10 organization-years of follow-up), with an unweighted Cox proportional hazard ratio of 2.9 (95% CI, 1.8 to 4.6; p<0.001). The difference in composite outcome was primarily driven by a difference in closure rate: 34 in the PE group (unweighted 1.4% per 10 organization-years of follow-up) vs 11 in the corporate group (unweighted 0.3% per 10 organization-years of follow-up), or an unweighted HR of 4.7 (95% CI, 2.3 to 9.3; p=0.003). The rate of bankruptcies was similar (though we were not powered to detect this in our pre-specified protocol) for an unweighted HR of 1.7 (95% CI , 0.9 to 3.3 p=0.110). In propensity score-weighted analyses, PE-acquired firms also had higher rate of bankruptcy or closure compared to corporate-acquired firms (weighted HR of 3.4; 95% CI, 1.7 to 6.9; p<0.001). Results were similar in subsets of acquisitions (clinics vs hospitals vs nursing homes vs home health agencies) and in sensitivity analyses.

Despite being more likely to be profitable at acquisition, PE-acquired health care organizations were about 3 times as likely to undergo bankruptcy or close as those acquired by non-PE for-profit corporations through 15 years post-acquisition. Policies that ensure financial stability post PE-acquisition may be needed to protect patient access to care. BREAST MRI AMONG U.S. WOMEN AGED 40-74 UNDERGOING SCREENING MAMMOGRAPHY Gianna Aliberti1; Mara A. Schonberg2. 1Medicine, Massachusetts General Hospital, Boston, MA; 2Medicine, Beth Israel Deaconess Medical Center, Brookline, MA. (Control ID #4242518)

There are currently no guidelines on use of supplemental breast MRI for women of average breast cancer risk, but studies have shown improved early diagnosis of breast cancer in women with dense breasts. However, the effect on mortality is unknown and MRI is not without harms, including increased false positives, incidental findings, gadolinium reactions, and potential out-of-pocket costs. Among US women undergoing mammography screening, we aimed to determine the proportion receiving supplemental breast MRI and factors associated with its receipt.

Our sample included women aged 40-74 without history of breast cancer who responded to the 2023 National Health Interview Survey (NHIS) and reported receiving a routine mammogram in the past 2 years. Among these women we examined reported receipt of breast MRI in the past two years and reasons MRI was performed. We used logistic regression to identify sociodemographic and clinical factors including family history of breast cancer and receipt of genetic testing associated with receipt of breast MRI.

8100 women aged 40 to 74 reported undergoing mammography screening in the last two years, representing 62.9 million US women. Of these, 12.5% were non-Hispanic Black, 6.2% were non-Hispanic Asian, and 16.0% were Hispanic, and mean age was 58.0 years (SD 10.1). One-third (33.6%) reported a family history of breast cancer, 9.3% reported discussing genetic breast cancer risk testing with their doctor and 5.4% had genetic testing for breast cancer. Overall, 4.4% of women reported receiving a breast MRI in the last two years; 43.8% because of an abnormal mammogram or breast problem, 15.4% because of being high-risk, and 38.7% as part of a routine exam. Non-Hispanic Black and Hispanic women were more likely to have breast MRI than non-Hispanic white women (7.7% vs. 3.9% aOR 2.3 [95% CI 1.3-4.1]; 5.1% vs 3.9% aOR 1.7 [95% CI 1.1-2.7], respectively). Women who had a wellness visit or physical more than 1 year ago were less likely to have had breast MRI than those who had a wellness visit or physical in the last year (1.2% vs. 5.0% aOR 0.22 [95% CI 0.09-0.56)]. Women who reported discussions about genetic cancer risk testing (10.5% vs. 3.8% aOR 1.8 [95% CI 1.1-3.0], underwent genetic testing (11.2% vs 4.0% aOR 1.8 [95% CI 1.0-3.2]), or breast cancer family history (7.7% vs. 3.6% aOR 1.9 [95% CI 1.4-2.7]), were more likely to have breast MRI than those who did not. There were no significant differences by age, educational attainment, region, insurance status, or poverty level.

Among US women ages 40-74 undergoing mammography screening, 4.4% also report having breast MRI, representing 2.8 million US women, including many without family history of breast cancer (>700,000 women). MRI use is rising among US women (previous studies over the past decade report 0.4-2% of US women receiving MRI) and especially from underrepresented minority women. Future work will need to examine if increased breast MRI use improves outcomes. CHANGES IN THE MEDICARE PART D MARKETPLACE AFTER THE INFLATION REDUCTION ACT Christopher Cai1; Aaron S. Kesselheim3; 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; 3Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4272772)

Medicare Part D prescription drug coverage is administered via private insurance companies. The Inflation Reduction Act (IRA) introduced changes to Medicare Part D in 2025, including a $2000 annual out-of-pocket spending limit and increased plan liability for patients with high drug costs. To stabilize patient costs as these changes take effect, the law restricted plans from increasing premiums in subsequent years. To understand how plans responded to these changes, we measured annual trends in Medicare beneficiaries affected by deductible increases, premium increases, or plan exits.

We performed a cross-sectional analysis of the Centers for Medicare and Medicaid Services (CMS) Part D landscape files (2018-2025) and monthly enrollment files (2018-2024). Each year, we compared plan characteristics (premium and deductible) with characteristics of the same plan in the following year. We stratified plans by stand-alone Part D plans (PDPs) and Medicare Advantage prescription drug plans (MAPDs); we excluded plans for which drug benefit data were missing. We also calculated the percentage of beneficiaries enrolled in Part D plans that left the marketplace the following year and those who experienced increases in plan premiums. For patients in plans that had deductibles lower than the “standard deductible” (the maximum allowed, $590 in 2025), we calculated the percentage who had a higher deductible in the following year. Costs were adjusted for inflation using the consumer price index.

From 2018 to 2023, the percentage of Medicare beneficiaries enrolled in a Part D plan that left the marketplace in the following year ranged from 6-12%; the percentage with premium increases ranged from 30-42%; and the percentage with deductible increases ranged from 3-23%. In 2024, 16% of beneficiaries were enrolled in plans that left the marketplace in 2025. This affected 5.9 million total beneficiaries, including 20% (3.7 million) of PDP enrollees and 11% (2.3 million) of MAPD enrollees. Additionally, 27% of beneficiaries were in plans that increased deductibles in 2025, affecting 10.4 million beneficiaries (1.1 million [6%] in PDPs and 9.3 million [46%] in MAPDs). Finally, 19% of beneficiaries were in plans with premium increases, affecting 7.3 million beneficiaries (5.9 million [32%] in PDPs and 1.4 million [16%] in MAPDs).

Compared to Part D beneficiaries in 2019-2023, we estimate that fewer 2024 beneficiaries will experience premium increases but more will experience increases in deductibles or lose access to their plan. Although patients who use costly medications will now be protected by the $2000 annual limit, millions will need to select new plans and others may have higher out-of-pocket costs before reaching this threshold, trends which could adversely affect medication adherence. If these continue, Congress may need to act to prevent plans from exiting the market and maintain lower out-of-pocket costs for patients who do not reach the $2000 annual limit. CHANGES IN THE USE OF MONTELUKAST FOR ASTHMA AFTER AN FDA BOXED WARNING Hariharan Shanmugam1; Benjamin N. Rome2. 1Harvard Medical School, 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 #4272209)

In March 2020, the US Food and Drug Administration (FDA) issued a boxed warning about neuropsychiatric side effects of the asthma medication montelukast based on growing, but still inconclusive, observational data. We measured changes in the use of montelukast after the boxed warning.

Using national commercial claims data from October 2017 to December 2022, we compiled monthly cohorts of individuals aged ≥6 years with diagnosis codes for asthma. We used segmented linear regression to perform interrupted time series analyses measuring changes in the monthly incidence and prevalence of montelukast use after the boxed warning in March 2020. Patient covariates were measured to assess for confounding, and stratified analyses were examined by age (<18 vs 18-64 vs ≥65 years) and indicators of more severe asthma such as inhaled corticosteroid (ICS) use and ≥1 asthma-related hospitalization in the prior year.

The number of asthma patients included in study increased from 594,253 to 614,637. In October 2017, 59% of the asthma cohort was female, 19% were age <18 years, 49% used an ICS, and 18% had ≥1 recent asthma-related hospitalization. Prior to the boxed warning, the average monthly incidence of montelukast use was 5 new users per 1000 asthma patients, and 160 per 1000 asthma patients used montelukast each month, with no significant trends. After the boxed warning, the level of monthly montelukast incidence decreased by 1.73 new users per 1000 (95% CI 1.26 to 2.20 per 1000) and the monthly trend in montelukast prevalence decreased by 0.85 per 1000 asthma patients (95% CI 0.56 to 1.14 per 1000). The decrease in the trend in monthly montelukast use was observed in all age groups and was more pronounced among patients who used ICS (1.27 per 1000, 95% CI 0.97 to 1.56 per 1000) compared to those who did not (0.26 per 1000, 95% CI 0.02 to 0.49 per 1000) and those with asthma-related hospitalizations (1.10 per 1000, 95% CI 0.74 to 1.45 per 1000) vs those without recent hospitalizations (0.76 per 1000, 95% CI 0.43 to 1.09 per 1000).

After a new boxed warning was added to its labeling, montelukast use decreased among patients with asthma of all ages, with greater reductions among those with indicators of more severe asthma. Although a causal association between montelukast and neuropsychiatric side effects has yet to be established, this regulatory action clearly affected how asthma is treated in the US. CHANGES IN THE USE OF ONCOLOGY MEDICATIONS AFTER WITHDRAWAL OF ACCELERATED APPROVAL Catherine S. Hwang1,2. 1Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA; 2Oregon Health & Science University, Portland, OR. (Control ID #4270388)

The US Food and Drug Administration (FDA) Accelerated Approval Program allows certain medications treating serious conditions to be marketed based on preliminary evidence of efficacy demonstrated by surrogate outcome measures. If the post-approval confirmatory trials fail to demonstrate clinical benefit, the indication is supposed to be removed from FDA-approved labeling. However, medications with other approved indications remain available in the US and can continue to be prescribed “off-label” for the withdrawn indication. We investigated how use of cancer drugs changed after negative confirmatory trials and formal removal of accelerated approval indications from FDA-approved labeling.

In this serial cross-sectional study, we identified 3 cancer medications granted accelerated approval for indications that were later removed from FDA-approved labeling between 2020 and 2022: atezolizumab for breast cancer and urothelial cancer, idelalisib for follicular lymphoma, and romidepsin for peripheral T-cell lymphoma (PTCL). Using a national commercial claims database, we created 4 cohorts of individuals with the withdrawn indications. Individuals were followed during each eligible calendar month; we measured the monthly number of incident medication users, defined as no use of the drug in the prior 365 days, and prevalent users, relative to the date of accelerated approval, first public reporting of negative confirmatory trial results, and withdrawal of the indication from the labeling.

Of the 762,752 patients in our study, mean ages ranged from 68 years (PTCL) to 75 years (urothelial cancer), the percent of female patients ranged from 25% (urothelial cancer) to 99% (breast cancer), and more than 72% were insured by Medicare Advantage plans. The time between accelerated approval and first publicized negative trial results was 12-113 months, and the time from reporting of trial results to regulatory withdrawal was 1-47 months. The incidence and prevalence of atezolizumab use for breast and urothelial cancers and idelalisib use for follicular lymphoma declined following reporting of the negative trial results and approached zero by the time the indications were withdrawn. Romidepsin continued to be used off-label for PTCL after withdrawal.

The use of most oncology drugs decreased after confirmatory trials failed to demonstrate efficacy, suggesting that prescribing responded quickly to new evidence. The exception was romidepsin, which continued to be used for PTCL, possibly because the confirmatory trial was conducted in a different population of PTCL patients and there was a signal for efficacy in a sub-group of those patients. There were often delays between accelerated approval, publicization of the negative confirmatory trial results, and formal FDA withdrawal. Ensuring timely completion of post-approval studies and enforcing appropriate regulatory actions based on negative trial results can minimize patient exposure to ineffective or unsafe medications. CHARACTERISTICS OF NOVEL AND SUPPLEMENTAL DRUG PRODUCT APPROVALS BY THE FDA FROM 1997-2023 Samuel Yoon1,5; Joshua D. Wallach2,5; Ayman Mohammad3,5; Reshma Ramachandran4,5; Joseph S. Ross4,5. 1School of Medicine, Yale University School of Medicine, New Haven, CT; 2Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA; 3School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; 4Internal Medicine, Yale School of Medicine, New Haven, CT; 5Yale University Collaboration for Research Integrity and Transparency, New Haven, CT. (Control ID #4271173)

The U.S. Food and Drug Administration (FDA) has traditionally required the use of clinical outcomes as clinical trial endpoints to support the approval of new drugs. However, clinical outcome trials are typically larger, take more time, and are more costly. In response, Congress has enacted several regulatory programs to facilitate FDA approval of new drugs on the basis of surrogate markers, endpoints that are reasonably likely to predict clinical benefit, as trial endpoints. However, the evidence demonstrating the validity and reliability of surrogate markers is mixed, creating uncertainty for patients and physicians about the true clinical benefits of new drugs approved on the basis of surrogate marker trials. Accordingly, to better understand the extent to which surrogate markers are being used, we characterized the pivotal trial endpoints for new and supplemental indication approvals by FDA for drugs and biologics from January 1997 to December 2023.

We used the Drugs@FDA database to identify all new drug and biologic approvals and supplemental indication approvals for those new products from January 1997 to December 2023. We excluded approvals for diagnostic agents. For each approved drug, we determined the indication, year of approval, special regulatory pathway designations (priority review, accelerated approval, fast track, and breakthrough designation), and pivotal trial primary efficacy endpoints, classified as surrogate markers or clinical outcomes. The primary efficacy endpoints were determined through reviewing a drug product’s label and FDA review documents. Additionally, indications were classified based on expected length of treatment as acute (less than 1 month), intermediate (between 1 month and 2 years), or chronic (greater than 2 years). We used descriptive statistics to summarize approvals based on the features described above.

Between January 1997 and December 2023, FDA approved 876 new drugs and biologics and 708 supplemental indications for those novel agents. Among the 876 new approvals, 407 (46.5%) were based on pivotal trials using surrogate endpoints, as were 313 (44.2%) of the 708 supplemental indication approvals. Approvals based on pivotal trials using surrogate endpoints were more likely for biologics (53.7%) than drugs (44.3%), agents with orphan designation (64.1% vs 35.3%), and for drugs with longer expected treatment lengths (chronic 45.2%, intermediate 70.1%, acute 12.6%), as well as for approvals within special regulatory pathways, including priority review (60.0% vs 34.0%), breakthrough designation (72.1% vs 43.2%), and fast track (60.0% vs 40.0%).

Surrogate markers are commonly used as pivotal trial endpoints to support new and supplemental indication approvals by FDA for drugs and biologics since 1997, potentially creating uncertainty for patients and physicians about the true clinical benefits of these therapeutic interventions. CHARACTERIZING DOCUMENTATION OF COGNITIVE IMPAIRMENT IN THE ELECTRONIC MEDICAL RECORD Lauren Russell1; Julia Loosen1; Claudia Boscio2; Cynthia Boyd1; Jennifer L. Wolff1; Stephanie Nothelle1. 1The Johns Hopkins University School of Medicine, Baltimore, MD; 2Ponce Health Sciences University, Ponce, Ponce, Puerto Rico. (Control ID #4271676)

Clinicians utilize clinical notes to understand a patient’s cognitive status over time and colleagues’ plans of care. Inconsistent documentation may perpetuate communication gaps. We sought to understand how cognitive impairment is documented in the medical record across specialties for patients with dementia.

We extracted outpatient notes from the Johns Hopkins electronic medical record on adults ≥65 years with dementia and select chronic conditions in the 30-days prior to hospitalization from 2017-2022. Two coders independently identified when cognition was mentioned and resolved discrepancies with discussion. Using descriptive statistics and qualitative content analysis, we characterized how cognition was mentioned across specialty, visit type, and note section.

We included 179 notes from 123 older adults (mean age 83 years, 60% female) across Primary Care (62%), Medicine Specialties (24%), and Surgery (14%). Primary care notes mentioned cognition most (82%, n=111), most commonly in the assessment and plan. Surgical notes mentioned cognition least (36%, n=25), most commonly listing dementia in past history. Twenty-three notes (73% primary care) documented that cognitive impairment interfered with care through chronic condition self-management, functional ability, and caregiver burden. As a primary care note described, “unable to complete [pulmonary test] due to confusion.” Among patients with multiple notes across specialties (n=21), 29% of patients had notes that were discordant across specialties in their description of cognition’s impact on health or did not document cognitive limitations consistently. For example, a primary care note documented confusion with an insulin regimen; the endocrinology note did not describe confusion and intensified insulin dosing.

Documentation of cognitive impairment varied across specialty. Although we identified instances of cognitive impairment interfering with care, there was discordance in clinicians’ documentation of adjusting the care plan to accommodate these challenges. Documentation discrepancies indicate care coordination issues, providing targets for physician education. CLINICIAN-REPORTED BARRIERS TO DIAGNOSIS AND TREATMENT OF HEART FAILURE WITH PRESERVED EJECTION FRACTION IN PRIMARY CARE Yulia Khodneva1; Megan Nordberg1; Pankaj Arora2; Larry Hearld3; Andrea Cherrington4. 1Medicine, University of Alabama Birmingham, Birmingham, AL; 2Medicine, The University of Alabama at Birmingham College of Arts and Sciences, Birmingham, AL; 3Health Services Administration, University of Alabama at Birmingham, Birmingham, AL; 4Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL. (Control ID #4271513)

Despite rapidly rising prevalence, heart failure with preserved ejection fraction (HFpEF) remains challenging to diagnose early in primary care. Most HFpEF patients are diagnosed during acute decompensation in the hospital, which presents a missed opportunity for early intervention and is associated with negative health outcomes. We investigated clinician-reported barriers to early diagnosis and treatment of HFpEF.

Semi-structured in-depth individual interviews were conducted with primary care providers (PCPs) from a variety of settings. Interviews were transcribed and thematic analysis was conducted using NVivo 14.

We recruited 12 PCPs via professional networks; 3 (27%) were African American non-Hispanic, 5 (36%) white non-Hispanic and 4 (36%) Asian adults; 10 were from urban and 2 - from rural areas; 7 were from community, 3 - from academic and 2 - from Veteran Administration-affiliated practices. Overall, we observed great variability in how clinicians approached HFpEF in primary care. Three main barriers to early HFpEF diagnosis and care included poor access to cardiology and echocardiography (ECHO), complexity of HFpEF patients, and insufficient clinician’s medical knowledge regarding HFpEF. Poor access to cardiology was especially prevalent in rural and safety net practices. Patient complexity was related to multiple comorbidities present in patients with HFpEF and poor adherence to medications and lifestyle modifications among patients with HFpEF. Clinicians reported insufficient medical knowledge related to current HFpEF diagnostic criteria, difficulty in interpreting ECHO reports, and unfamiliarity with the most recent clinical guidelines. Some clinicians were not comfortable with starting new pharmacological agents for HFpEF, citing a lack of prior experience. A few clinicians reported treating HFpEF the same as they would treat heart failure with reduced ejection fraction (HFrEF) and did not differentiate HF subtypes. Finally, most clinicians reported a need to get more continuous medical education regarding HFpEF.

Clinician-reported barriers to HFpEF diagnosis included poor access to cardiology, complexity of HFpEF patients and insufficient clinicians’ medical knowledge on HFpEF. Programs focusing on continuous medical education on HFpEF for PCPs and remotely-delivered cardiology consultations in rural areas may be warranted. COMPARING PROCESSES AND OUTCOMES OF CARE FOR PATIENTS ADMITTED WITH ACUTE MYOCARDIAL INFARCTION (AMI) OR HIP FRACTURE AT AFFILIATED SAFETY NET AND NON-SAFETY NET HOSPITALS Susan Landon1; Sunita Desai2; Sherry Glied3,4. 1Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; 2Department of Population Health, New York University Grossman School of Medicine, New York, NY; 3New York University Robert F Wagner Graduate School of Public Service, New York, NY; 4National Bureau of Economic Research, Cambridge, MA. (Control ID #4271590)

We compare processes and outcomes of care for patients hospitalized for ST-Elevation Myocardial Infarction (STEMI), Non-ST Elevation Myocardial Infarction (NSTEMI), and hip fracture across pairs of closely affiliated safety net and non-safety net hospitals in New York and California.

Using AHRQ HCUP State Inpatient Database files for New York and California, we compared regression adjusted (age, sex, Elixhauser mortality index, and payer) rates of procedures, length of stay, and mortality rates for patients (excluding transfers in or out) admitted with STEMI, NSTEMI, or hip fracture across affiliated safety net and non-safety net hospitals between 2007-2011. We conducted a secondary analysis using New York data from 2017-2019 to assess trends over time.

We identified 10 pairs of affiliated safety net and non-safety net hospitals. After excluding transfers in and out, our sample consisted of 6,335 patients admitted with STEMI (4,207 to non-safety net hospitals, 2,128 to safety net hospitals), 15,486 patients admitted with NSTEMI (10,085 to non-safety net hospitals, 5,401 to safety net hospitals), and 7,962 patients with hip fracture (4,777 to non-safety net hospitals, 3,185 from safety net hospitals). Rates of reperfusion for AMI patients and rates of total hip arthroplasty (THA) in hip fracture patients were lower in safety net hospitals. In adjusted analyses, odds of in-hospital mortality were higher in safety net hospitals (ORSTEMI=1.95 [1.31, 2.89], ORNSTEMI=1.34 [1.02, 1.76], ORHipFx=2.07 [1.47, 2.92]). Hip fracture patients at safety net hospitals had longer length of stay (Mean difference=3.22 [1.51, 4.92]). Results in 2017-2019 New York data were similar.

Processes and outcomes of care for AMI and hip fracture patients admitted to safety net and non-safety net hospitals with institutional affiliations and overlap of trainees in New York and California were significantly different. These findings suggest that hospital- and system- level factors contribute to variation in care, even after accounting for differences in patient and physician populations. COMPARING TELEHEALTH UTILIZATION AMONG NON-OBESE AND OBESE INDIVIDUALS IN AN ACADEMIC HEALTH SYSTEM FROM 2022-2024 Timothy M. Bober1; Yuhe Gao2; Haley Grant3; Linda-Marie Lavenburg1; David Rometo4; Autumn Boyer5; Allison Bradley2; Nickie Cappella2; Characterizing Obesity Collaborative1,6; Kathleen M. McTigue7. 1Department of Medicine, University of Pittsburgh, Pittsburgh, PA; 2Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA; 3Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; 4Endocrinology and Metabolism, UPMC, Pittsburgh, PA; 5Medicine, University of Pittsburgh, Pittsburgh, PA; 6Pfizer Inc, New York, NY; 7Medicine, University of Pittsburgh, Pittsburgh, PA. (Control ID #4267874)

The COVID-19 pandemic led to an unprecedented shift towards virtual care utilization, which was shown to be effective for managing obesity and can overcome structural barriers to accessing care. Less is known about telehealth utilization in the later years of the COVID-19 pandemic.

We performed a cross-sectional analysis of electronic health record data from an academic health system in the mid-Atlantic region of the United States from January 2018 to August 2024. Included adults were ≥18 years of age with BMI >/=18.5 kg/m2 and 2 in-person outpatient visits in last 2 years at least 3 months apart. We evaluated descriptive differences in telehealth care utilization by BMI category (non-obese, i.e., healthy weight or overweight, versus obese) and among people with obesity and differing comorbidities (type 2 diabetes [T2DM]; atherosclerotic cardiovascular disease [ASCVD]; non-alcoholic steatohepatitis/fatty liver disease [NASH/NAFLD]). Outcomes trends were tested across an ordinal variable of BMI categories with a Cochran-Armitage test for all binary outcomes.

Overall, telehealth encompassed 1.8% of all ambulatory visits (540,288/30,653,655 visits) - including 1.7% of all ambulatory visits for non-obese individuals and 1.9 % of all ambulatory visits for people with obesity (Table 1). Despite lower overall ambulatory visits, patients with obesity and NASH/NAFLD with and without T2DM had higher percentage of unique patients with at least one telehealth visit (31.3% and 27.3%, respectively) compared to the overall cohort (16.3%).

In this cross-sectional analysis, a higher percentage of adults with obesity and additional comorbidities used telehealth compared to adults living with healthy weight or overweight despite lower numbers of ambulatory visits overall. People living with obesity have increased risk of comorbidities that can affect health-related quality of life and could be using telehealth to relieve their healthcare-associated burden. COMPARISON OF THIRTY-DAY RE-ADMISSIONS AND MORTALITY BY INSURANCE STATUS AMONG PATIENTS WITH CIRRHOSIS Sung In H. Kim-Vences1,2; Jacqueline Hirth1; Tzu-Hao Lee2. 1Department of Family and Community Health, Baylor College of Medicine, Houston, TX; 2Department of Internal Medicine, Baylor College of Medicine, Houston, TX. (Control ID #4271036)

Cirrhosis is associated with high 30-day re-admission rates nearing 40%, surpassing rates in heart failure and end stage renal disease. Despite higher incidence and worse survival outcomes among socioeconomically disadvantaged patients with cirrhosis, prevalence of uninsured patients with cirrhosis or their clinical trajectories are not well known in literature that rely on patient self-reports, single health system chart review, or administrative claims. By integrating regional health information exchange (HIE) to hospital electronic health records data, we aimed to more accurately track re-admission and death among patients with cirrhosis.

Patients who presented to either the emergency center or were admitted to our instutition between Jan 1, 2021 and Nov 30, 2023 with billing diagnosis of cirrhosis or at least one related complication were included in this retrospective cohort study. Baseline data for main exposure (insurance status, categorized as Medicare/private, Medicaid, or uninsured) and co-variates (sex, age, race/ethnicity, and Model for End-Stage Liver Disease 3.0 score) were extracted from BSLMC; we then linked the patients to HIE to obtain a comprehensive list of co-morbidities and dates of all subsequent regional hospital encounters and death occurring after index discharge. A multinomial, multivariable logistic regression model was used to compare the odds of 30-day re-admission or death by insurance status; a binomial model compared the odds of re-admission to outside (v. index) facility among patients re-admitted within 30 days.

We identified 3,615 patients with cirrhosis; of these, 238 (6.6%) died during the index encounter and were excluded from analysis. Uninsured patients represented 6.5% (n = 218) of patients and tended to be younger (49.6 ± 10.5 years, compared to the overall mean 59.5 ± 14.0 years) with slightly higher median MELD-3.0 (median 21; IQR 15-28, compared to overall median 20, IQR 14-26). Medicaid enrollees had 36% higher odds re-admission (OR 1.36, 95% CI 1.07-1.72) compared to patients with Medicare/private insurance. There was no significant association between uninsuredness and re-admission (OR 0.84, 95% CI 0.62-1.14) or mortality (OR 0.90, 95% CI 0.37-2.17); uninsured patients, however, were significantly more likely to present to outside hospitals (OR 1.77, 95% CI 1.09-2.90) when re-admitted.

While we failed to detect significant differences in 30-day re-admission or mortality comparing uninsured to patients with Medicare/private insurance, our data showed that uninsured patients are significantly more likely to present to outside hospitals when re-admitted. This finding highlights the challenges in tracking longitudinal outcomes among uninsured patients (which may be improved by HIE integration). More frequently fragmented care across multiple health systems is also expected to increase duplicate testing, delay diagnosis/treatment, and increase acute care utilization among uninsured patients with cirrhosis. COST-RELATED GUIDANCE IN U.S.-BASED MEDICAL SOCIETIES’ CLINICAL PRACTICE RECOMMENDATIONS—A CROSS-SECTIONAL ANALYSIS Anand Habib, Omar Qureshi, Reshma Ramachandran, Joseph S. Ross. Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4272305)

The American Board of Internal Medicine’s Choosing Wisely campaign sought to identify low-value clinical services and to promote costs-of-care discussions. Whether medical societies now systematically incorporate cost-related information in their clinical guideline documents (CGDs) to inform cost-conscious clinical care is unknown.

For this cross-sectional analysis, we used the ECRI Guidelines Trust database to randomly select up to 25 CGDs published between 1/1/19-12/31/23 for each of 23 large, U.S.-based medical societies. For each recommendation within each CGD, we determined presence of 1) an upfront cost-related statement and 2) a narrative cost discussion. We also determined 1) each society’s approach to considering costs of care when making recommendations, which we categorized as “explicitly considered,” “ambiguously considered,” “costs not mentioned,” or “costs excluded,” based on each society’s CGD methodology statement, and 2) whether a recommendation was issued by a primary care society. We calculated descriptive statistics and used multilevel, multivariable logistic regression to assess the relationship between explanatory variables and the two outcomes.

Of the 23 medical societies, 3 represented primary care, 10 outpatient specialties, 4 hospital-based specialties, 3 surgical specialties, 1 obstetrics/gynecology, and 2 psychiatry/neurology. Based on societies' CGD methodology statements, 13 (57%) explicitly considered costs, 6 (26%) ambiguously considered costs, 3 (13%) never mentioned costs, and 1 (4%) excluded cost from consideration. Overall, 309 CGDs containing 7,582 recommendations were randomly selected. Of the recommendations, 5,068 (67%) related to therapeutic interventions, 4,425 (58%) applied to ambulatory care, 286 (4%) were issued by primary care societies, and 3,533 (47%) were published by societies explicitly considering costs. Overall, 287 (4%) recommendations contained an upfront cost-related statement, and 1,706 (23%) had a narrative cost discussion. Using multivariable analysis, primary care societies’ recommendations were more likely to have upfront cost-related statements (odds ratio [OR]=7.11; 95% confidence interval [CI], 1.68-20.02; p=0.008) and to narratively discuss costs (OR=3.37; 95% CI 1.07-10.57; p=0.04). Although a society’s approach to considering costs was not significantly associated with upfront cost-related statements, recommendations by societies explicitly considering costs had greater odds (OR=5.18; 95% CI, 1.002-26.82; p=0.05) of having narrative cost discussions.

Despite the Choosing Wisely campaign, few recommendations within CGDs issued by a diverse set of U.S.-based medical societies mentioned costs of care, with primary care societies and societies explicitly considering costs more likely to provide cost guidance. This paucity of cost-related information may hinder clinicians’ ability to practice evidence-based, cost-conscious care and to discuss costs with patients. COST-RELATED INSULIN RATIONING AT THE YALE DIABETES CENTER THEN AND NOW: 2017 VS. 2024 Nadera Rahman1; Sefia Khan4; Darren Warren2; Megan E. Branda3; Laura M. Nally2; Kasia J. Lipska2. 1Internal Medicine, Yale University School of Medicine, New Haven, CT; 2Yale University School of Medicine, New Haven, CT; 3Mayo Clinic Minnesota, Rochester, MN; 4John Sealy School of Medicine, The University of Texas Medical Branch John Sealy School of Medicine, Galveston, TX. (Control ID #4271637)

Insulin is a life-saving medication for people with diabetes, but high costs can lead to rationing. In a 2017 survey study at Yale Diabetes Center (YDC) by Herkert et al., 1 in 4 patients reported cost-related insulin underuse. Given recent legislation, including Connecticut House Bill 6003 (2020) and the Inflation Reduction Act (2023), rates of insulin rationing may have improved since 2017.

Two cross-sectional surveys were conducted at YDC: between April and July 2024 and between June and August 2017 among patients who met the following inclusion criteria: a) age ≥ 18 years, b) diagnosis of type 1 or type 2 diabetes, c) prescription for insulin within the last 12 months, d) an in-person visit at YDC, and e) English literacy. The primary outcome was insulin rationing due to cost, defined as positive responses to identical questions about the following: not starting insulin, not filling an insulin prescription, using less insulin than prescribed, stretching out insulin supply, taking smaller doses of insulin than prescribed, or stopping insulin entirely due to cost. The surveyed samples and the proportions of patients who reported cost-related insulin rationing in 2024 were compared to 2017. The characteristics of participants who rationed insulin in 2024 and in 2017 were compared using z-statistics with a two-sided alpha of 0.05.

In 2017, of 354 eligible patients, 199 completed the survey, with a response rate of 56.2% (50.8% women, 60.8% white, and 41.7% type 1 diabetes). In 2024, of 331 eligible patients, 199 completed the survey, with a response rate of 60.1% (mean age of 40.7 years old, 47.7% female, 64.1 % white, and 47.2% type 1 diabetes). Cost-related insulin rationing was reported by 51/199 (25.5%) in 2017 vs. 48/199 (24.1%) in 2024 (p = 0.41). Of those who reported rationing, most patients did not discuss the cost of insulin with their clinician in either year (60.8% in 2017 vs. 80.8% in 2024). Moreover, in 2017, those with lower incomes were more likely to report cost-related underuse, whereas in 2024, there was no significant association between income and rationing. The characteristics of participants who reported cost-related insulin rationing in 2024 and in 2017 were similar, including insurance coverage and family income levels. However, a larger proportion of participants who reported cost-related insulin rationing was comprised of adults with type 1 diabetes in 2024 (63%) compared with 2017 (43.1%, p = 0.05).

Despite significant policy changes, 1 in 4 patients at Yale Diabetes Center rationed insulin in 2024, which is unchanged from 2017. These findings suggest that there remains an urgent need to continue addressing insulin affordability and accessibility. DEFINING SAFETY-NET HOSPITALS: CORRELATION, VARIATION, AND CONSISTENCY ACROSS CANDIDATE MEASURES Kano Amagai2; Torrey Shirk2; Joshua Liao3; Amol Navathe2; Paula Chatterjee1. 1Medicine , University of Pennsylvania, Philadelphia, PA; 2Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 3The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4257534)

Safety-net hospitals (SNHs) provide health care for low-income, uninsured, and underinsured populations in the United States. Despite their importance, there is no universal definition for SNHs and little consensus on how SNHs should be defined. This has made it difficult to design and target policies to support care delivery for low-income patients. In this study, we evaluate correlation, variation, and consistency across several candidate definitions for SNHs.

We created a hospital-year panel dataset (2014-2022) using Healthcare Cost Reporting Information System data, Medicare Fee-For-Service claims, and the American Community Survey to evaluate 14 candidate definitions for SNHs. We identified hospitals in the top quartile of Medicare’s Disproportionate Share Hospital (DSH) index, Medicare inpatient day share, Medicare Safety Net Index, dual-eligible or Low-Income Subsidy inpatient day share, Medicaid inpatient day share, uncompensated care share, operating margins, teaching status, public ownership status, and location in areas with high proportions of Black or Hispanic populations, high Area Deprivation Index (ADI), high Social Vulnerability Index, and low median household income. We compared hospital characteristics by each definition, sample correlations between pairs of SNH definitions, and stability of SNH samples produced by each measure over time.

Our sample included 4,531 short-term, acute care hospitals in 2022. Between 992 and 1,326 were categorized as SNHs depending on the definition. SNHs defined using Medicare DSH index and Medicaid inpatient day share shared similar hospital characteristics and had the largest correlation (55% of SNHs overlapped across these 2 definitions). The smallest correlations were between SNH definitions based on Hispanic population share and both median household income and ADI (12%). SNHs defined using public ownership status, largest share of Black population, largest share of Hispanic population, and teaching status produced the most stable SNH samples over time with 83%, 82%, 81%, and 74% of the same hospitals meeting safety-net criteria in 2014, 2018, and 2022. The least stable measures were operating margin, uncompensated care share, and Medicare inpatient day share with 15%, 20%, and 37% of the same hospitals meeting SNH criteria in 2014, 2018, and 2022.

There are important tradeoffs when defining SNHs including the types of hospitals represented and the stability of different measures over time. Transparent policy goals, such as minimizing a hospital’s financial precarity, or supporting provision of service to low-income or marginalized patients, should motivate the choice of SNH definition by policymakers. DETAILED EXAMINATION OF SUICIDES AFTER PRESCRIPTION OPIOID REDUCTION: RECURRENT THEMES Stefan Kertesz7,8; April Hoge1; Megan McCullough2; Adam J. Gordon6,3; Kate Nicholson4; Allyson L. Varley7,8; Mary F. Gilmore7; Kevin R. Riggs7,8; Thomas Joiner5; Lera A. Fuqua8. 1Health Services Research and Development, US Department of Veterans Affairs, Washington, DC; 2Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Washington, DC; 3Department of Internal Medicine, University of Utah Health, Salt Lake City, UT; 4NA, The National Pain Advocacy Center, Boulder, CO; 5Psychology, Florida State University, Tallahassee, FL; 6VA Salt Lake City Health Care System, Salt Lake City, UT; 7Birmingham Alabama VA Health Care System, Birmingham, AL; 8The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL. (Control ID #4270912)

Suicide after prescription opioid reduction is reported in retrospective databases, but these events have not been closely examined. Structured qualitative examination of these suicides for personal, interpersonal, health care, and community-related contributors could produce actionable insights. We offer preliminary observations from the first 28 such examinations, derived from public recruitment.

Study recruitment combined advertising, a screening survey, and qualitative interviews of suicide loss survivors whose reports met criteria for pain, opioid reduction, and apparent suicide. Interviews were recorded and transcribed. The interview covered factors such as family, work, pain history, disability, sleep, financial status, social support, the decedent’s perceived burdensomeness to others, and aspects of health care known to the informant. Transcriptions underwent template coding through consensus of a multidisciplinary team which deliberated over the content and confidence inferable for each interviewee.

From 12/1/2020 to 12/05/2024, 236 persons responded to the detailed screener survey, and 122 (for 120 deaths) met criteria for likely suicide following opioid reduction. As of 12/10/2024, 28 interviews had been completed for 26 decedents. One death was determined by the team not to be suicide after the interview and outreach to a coroner. Age at death averaged 51 (sd=14), with 70% of decedents male and 15% Veterans. Interview Results: Pain-related histories often included multiple failed interventions after traumatic injuries, and significant mental health challenges, sometimes diagnosed (including post-traumatic stress disorder) and sometimes only suspected by the informant. Family histories of strained relationships or suicide among family members were common. The period prior to death was marked -variably- by loss of mobility, social withdrawal, and often, imminent financial deterioration. Informants routinely assessed the decedents as perceiving themselves to be a burden to others. Reductions in opioid receipt often occurred weeks to months prior to death, rather than days. They were sometimes tied to moving between states or retirement of a physician. In some instances, the informants believed a death reflected suicidal intent but said others disagreed. Mental health care was rare. In two instances there was family agreement that death by suicide was the most appropriate response in light of the pain history and the limitations to available care.

Suicidal events that occur after prescription opioid reduction are likely to reflect a confluence of vulnerabilities and major health system shortfalls. Some reflect the life and pain history of the decedent in a social context, while also signaling remediable mishaps in health care delivery. Public-facing recruitment of suicide-loss survivors is difficult, but offers a unique window to these events, one not available from large database analyses. DISPENSING OF HIV PRE-EXPOSURE PROPHYLAXIS MEDICATIONS TO U.S. YOUNG ADULTS, 2016-2023 Nina Hill1,2; Sijia He2; Kao-Ping Chua2. 1Internal Medicine, University of Michigan, Ann Arbor, MI; 2Pediatrics, University of Michigan, Ann Arbor, MI. (Control ID #4229634)

Young adults account for a disproportionate share of new HIV diagnoses in the U.S. HIV pre-exposure prophylaxis (PrEP) is effective for preventing HIV infection. No national study has examined recent trends in PrEP dispensing to young adults specifically. We evaluated trends in PrEP dispensing to U.S. young adults from 2016 to 2023.

We conducted a serial cross-sectional analysis of the IQVIA Longitudinal Prescription Database, which includes 93% of prescriptions dispensed in U.S. pharmacies. The sample included prescriptions for PrEP dispensed during 2016-2023 to young adults, defined as patients aged 18-25 years at the time of dispensing. Outcomes were the quarterly PrEP dispensing rate (number of young adults with PrEP dispensing per 100,000 U.S. young adults), quarterly PrEP initiation rate (number of young adults with a new PrEP prescription per 100,000 U.S. young adults), and quarterly mean PrEP persistence (number of days covered by an active PrEP prescription in the 180 days after the end of a new PrEP prescription). Persistence was only calculated for patients initiating PrEP during the quarter. We used joinpoint regression to identify changes in the slope of trends and to calculate the quarterly percentage change (QPC) in each segment. We stratified analyses by age group.

Analyses included 1,450,296 PrEP prescriptions dispensed between 2016-2023 to 239,780 young adults. The quarterly PrEP dispensing rate increased sharply between 2016 and 2018, from 26.4 to 100.7 prescriptions per 100,000 people (QPC: 12.5%, 95% CI: 10.0 to 15.1). Afterwards, this rate increased gradually to 208.4 prescriptions per 100,000 people in 2023 (QPC: 3.5%, 95% CI: 2.7 to 4.3). Trends in the quarterly PrEP initiation rate were qualitatively similar to the trends in the dispensing rate. From 2016 to 2023, quarterly mean persistence decreased from 111.6 to 98.4 days (QPC: -0.4%, 95% CI: -0.6, -0.2). Compared with patients aged 22-25 years, those aged 18-21 years had lower quarterly PrEP dispensing and initiation rates throughout 2016-2023 (Figure 1). Persistence was lower in these younger patients in 2016, but the gap narrowed over time.

Dispensing and initiation of PrEP among young adults is increasing. However, the duration of treatment episodes is decreasing, and PrEP dispensing among patients aged 18-21 years lags that of patients aged 22-25 years. Efforts are needed to ensure retention in PrEP therapy among all young adults and to increase PrEP dispensing among those aged 18-21 years. EFFECTS OF CO-PAYS ON ADHERENCE TO ANTIHYPERTENSIVE MEDICATIONS AMONG VETERANS RECEIVING CARE WITHIN THE VETERANS HEALTH ADMINISTRATION Alexander Chaitoff1,6; Alexander Zheutlin2; Daniel Addo3,7; Joshua Jacobs3,7; Catherine G. Derington4; Eric Stulberg5; Jordana Cohen5; Adam Bress3,7. 1Internal Medicine, University of Michigan, Ann Arbor, MI; 2Northwestern Memorial HealthCare, Chicago, IL; 3University of Utah Health, Salt Lake City, UT; 4University of Colorado System, Denver, CO; 5University of Pennsylvania, Philadelphia, PA; 6VA Ann Arbor Healthcare System, Ann Arbor, MI; 7VA Salt Lake City Health Care System, Salt Lake City, UT. (Control ID #4273542)

Half of adults with hypertension have poorly controlled blood pressure (BP). This is often due to suboptimal adherence to antihypertensive medication. Although medication costs have declined—many patients now spend under $25 per year on antihypertensives—it remains unclear whether even minimal out-of-pocket costs impact adherence. We examined the association between the absence of out-of-pocket care costs and adherence to antihypertensive regimens among Veterans utilizing the Veterans Health Administration (VA) system.

We performed a retrospective cohort study of Veterans receiving care at the VA from 2000 through 2022. We included Veterans with incident hypertension, newly initiated antihypertensive medication, >12-months of follow-up for antihypertensive medication fills, and membership in Priority Group 1 (PG1, no co-pay) or Priority Group 2 (PG2, small co-pay). In the VA, patient co-pays are determined by assignment to 1 of 8 Priority Groups. Veterans in PG1 have $0 care and medication co-pays while those in PG2 have small co-pays. Priority Group assignment depends on several factors, but all Veterans with a service connection >30% can qualify for PG2 status and all with >50% can qualify for PG1 status. Our exposure of interest was co-pay status. Our outcome of interest was medication adherence, defined as having a 1-year proportion of days covered (PDC) >80%. We employed fuzzy regression discontinuity using a two-stage least-squares regression approach to assess the association between medication co-pay status and adherence leveraging the increased proportion of patients qualifying as PG1 at the 50% service connection threshold. We conducted several sensitivity analyses, including using traditional adjusted inverse probability weighted quasi-Poisson regression models assessing the effects of PG1 versus PG2 membership on adherence, to assess robustness.

Among 374,467 Veterans (mean age 56 years, 8% female, 61% non-Hispanic White), 70% had no co-pay (PG1, n= 263,413). Differences between Veterans across PG1 and PG2 were generally small (absolute standardized mean differences <0.1 for most variables). In our primary analysis, the 50% threshold of service connectedness was associated with 3.5 times the odds of PG1 membership, and the effect of having no co-pay at the 50% threshold of service connectedness was associated with higher adherence to anti-hypertensive medications (OR 1.43, 95%CI 1.42-1.44). Findings were consistent across sensitivity analyses.

By employing a fuzzy regression discontinuity design that compares patients above and below the 50% service-connected disability threshold—thus leveraging the similarity of patients with nearly identical disability levels and controlling for potential confounders—our findings suggest that even small out-of-pocket medication costs can negatively influence adherence to antihypertensive therapy. Future work should determine whether these adherence differences affect clinical outcomes. EFFECTS OF STATE ADOPTION OF AUTOMATED MEDICAID ELIGIBILITY RENEWALS ON INSURANCE ENROLLMENT CHURNING Daniel B. Nelson1; Anna L. Goldman2; Fang Zhang3; Hao Yu3. 1Medicine, Oregon Health & Science University, Portland, OR; 2Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 3Population Medicine, Harvard Medical School, Boston, MA. (Control ID #4273318)

For people enrolled in Medicaid, transitions from Medicaid to other coverage types or to uninsurance (“churning”) are common and lead to coverage gaps, fragmentation in care, and adverse health outcomes. One cause of churning is the requirement to renew eligibility for Medicaid at least annually. To help reduce enrollee administrative burdens and limit churning, states are required to use existing state data to automatically renew Medicaid coverage whenever possible. Not all states implemented this policy immediately and states are not uniformly successful in processing applications automatically. This study evaluated whether states adopting an automated renewal mechanism had lower rates of churning among Medicaid enrollees.

We used longitudinal data from the Medical Expenditure Panel Survey from 2015-2019 on nondisabled children and adults under age 65 who were enrolled in Medicaid, as this group was subject to the automated renewal policy. Data on the timing and success of state implementation of automated renewals was taken from KFF. Using two-way fixed effects regression, we evaluated the effects of state adoption of automated renewals on churning. Our two primary outcomes were the likelihood of any transition in coverage source and the likelihood of any transition to uninsurance. We estimated linear regression models adjusted for individual sociodemographic and state-level characteristics and adjusted for the complex survey design. Adults and children were analyzed separately. We performed subgroup analyses among states by Medicaid expansion status and sensitivity analyses using alternative definitions of the automated renewal treatment variable (e.g., performing ≥75% of renewals via automated renewal) and alternative regression specifications and clustering strategies.

Among states not performing automated renewals, the annual likelihood of transitioning from Medicaid to another source of coverage was 15.4% in 2015, rising to 18.2% in 2019. Among states performing ≥75% of Medicaid eligibility renewals via automated renewal, the annual likelihood of transitioning from Medicaid to another coverage source was 17.2% in 2015 and 15.8% in 2019. In two-way fixed effects regression, adoption of automated renewals was not associated with changes in the likelihood of any transition in coverage source among adults (2.2 pp [95% CI: -3.7, 8.0]) or children (0.3 pp [-4.0, 4.7]), nor was it associated with changes in the likelihood of transitions to uninsurance (Adults: 3.1 pp [-1.5, 7.7]; Children: -0.9 pp [-4.2, 2.3]). These findings were robust to alternative model specifications and were also observed in subgroup analyses.

We did not identify significant changes in Medicaid churning associated with state adoption of automated eligibility renewals but could rule out sizable policy effects. Future work should explore barriers to implementing automated renewals and the possibility of unintended consequences with improved state access to enrollee income data. ENHANCING PHYSICIAN VOTER ENGAGEMENT: THE DEVELOPMENT OF A HEALTHCARE CENTERED VOTER GUIDE Stephanie Dong1; Pranita Devaraju1; Brayton Johnson2; Libby Crockett3; Stephanie Hartman1,3. 1College of Medicine, University of Nebraska Medical Center, Omaha, NE; 2University of Nebraska at Lincoln, Lincoln, NE; 3Nebraska Alliance for Physician Advocacy, Grand Island, NE. (Control ID #4272583)

Physicians have historically exhibited lower voter participation rates compared to the general population and similarly educated professionals. Between 2004 and 2018, their voting rates were 12% lower than the public, with 70% citing work conflicts as a barrier. However, recent trends show an increase in physician voter turnout, aligning with and surpassing the general population in 2018 and 2020, respectively. This shift reflects a growing commitment to healthcare reform and civic responsibility. To foster physician civic engagement, we developed a health-focused voter guide aimed at encouraging greater participation.

In collaboration with the Nebraska Alliance for Physician Advocacy (NAPA), we created a voter guide for the 2024 General Elections. We surveyed 48 Nebraska State Senate candidates on their positions using a 5-point Likert scale and asked them to prioritize issues focusing on key health policy issues such as food security, healthcare affordability, prescription drug prices, rural healthcare, mental health, reproductive health, and transgender care.

A total of 11 responses were received; 10 were included after consolidating a duplicate response, representing 9 of Nebraska’s 25 unicameral districts with elections. The guide was formatted into a pdf document, distributed through NAPA’s listserv, website, and social media to inform healthcare professionals. The guide summarized candidates' positions on healthcare issues in Nebraska, including affordability, mental health services, rural healthcare, and reproductive rights. Most candidates supported improving access to healthcare, expanding Medicare, and addressing mental health needs. Opinions varied on topics such as abortion, transgender care, and physicians' right to refuse care. Rural healthcare and food security were common priorities, with many candidates supporting workforce development and community programs.

The 2024 Nebraska Healthcare Voter Guide provided healthcare professionals with detailed information on candidates' positions on key healthcare issues. With only 11 out of 48 candidates responding, more proactive strategies, such as additional follow-up reminders or incentives, are needed to increase participation. Expanding the guide’s distribution to a broader network of healthcare organizations, public forums, and professional networks could enhance reach. Additionally, tracking the guide’s influence on voter behavior would provide valuable insights for future iterations. Initiatives like this are valuable for fostering healthcare professionals' policy engagement and encouraging further physician turnout. This guide's structure can be adapted for future elections and healthcare-related issues, amplifying its impact on healthcare professionals' political involvement. It can also help readily identify those elected officials with health policy interests' physicians can partner with for meaningful legislative efforts empower healthcare physicians in their advocacy efforts. ESTIMATING INDIVIDUAL AND POPULATION IMPACTS OF MISCALIBRATION IN PREDICTING RISK OF CARDIOVASCULAR EVENTS (PREVENT): IMPLICATIONS FOR SETTING TREATMENT THRESHOLDS AND CLINICAL DECISION MAKING Joshua Rager1,2; David Ratz3; Rodney A. Hayward4,3; Tanner Caverly5,3; Jeremy B. Sussman6,3. 1Division of General Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; 2Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, IN; 3CCMR, VA Ann Arbor Healthcare System, Ann Arbor, MI; 4Internal Medicine, U. Michigan, Ann Arbor, MI; 5Learning Health Sciences, University of Michigan, Ann Arbor, MI; 6Internal Medicine, University of Michigan, Ann Arbor, MI. (Control ID #4271996)

PREVENT estimates ASCVD risk ~40% lower than those of the pooled cohort equations, potentially altering statin treatment recommendations for millions of US adults and raising controversy about current statin treatment thresholds. Guideline groups have long differed about at what level of ASCVD risk a statin should be recommended. It is also known that risk models are prone to miscalibration across different populations, but little research has been done quantifying the individual and public health impact of miscalibration. We sought to understand how potential miscalibration in PREVENT could impact treatment recommendations and outcomes at various risk thresholds and how these differences compare to the range where guidelines presently vary on starting a statin.

We created a nationally representative, simulated sample of 1.3 million adults aged 40-80y with no prior ASCVD history based on NHANES. Using a microsimulation model which assesses lifetime QALYs with 5 years of statin treatment, we examined how both 50% overprediction and 50% underprediction in PREVENT would impact statin recommendations at treatment thresholds of 7.5%, 5% and 3% ASCVD risk. We assessed average baseline ASCVD risk and QALYs saved per 1000 people for four groups at these thresholds: those always treated despite miscalibration, those never treated despite miscalibration, those newly treated because of overprediction, and those no longer treated due to underprediction. We compare these outcomes to an “acceptable range” of ASCVD risk (5-12%) and QALYs (8-28 per 1000) where guideline groups presently vary on when to start a statin.

Results can be found in the table. At the current threshold of 7.5% endorsed by the American Heart Association, miscalibration results in potential treatment changes and outcomes where guidelines still vary in their recommendations. However, at a 5% risk treatment threshold, overprediction results in treating a low-risk group falling below any current guideline (3.1 QALYs saved per 1000 treated). At a 3% threshold, patients whose statin recommendation changed due to overprediction had negative QALYs saved (-1.2 per 1000 treated).

If decision-makers accept the possibility of PREVENT being miscalibrated to some degree for broader populations, lowering the treatment threshold to 3% or 5% should be avoided, as this results in outcomes that no longer fall within a range where guideline groups vary about starting a statin. EVALUATING THE CONTENT OF NONPROFIT HOSPITALS’ COMMUNITY HEALTH NEEDS ASSESSMENTS AND IMPLEMENTATION PLANS Pranathi Pilla1; Aman Narayan2; Arthur Hong3. 1General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 2Internal Medicine, The University of Texas Southwestern Medical Center Department of Internal Medicine, Dallas, TX; 3Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4272979)

To maintain federal nonprofit status, hospitals must provide community benefit. To ensure that this benefit is directed to community health and less to individual patient care, the Affordable Care Act (ACA) required hospitals to engage stakeholders and identify community needs on a triennial basis with a Community Health Needs Assessment (CHNA). Nonprofit hospitals must also develop an implementation plan (IP) which outlines strategies to address the needs identified by the CHNA. Internal Revenue Service (IRS) regulations simply require that these reports exist, in addition to key process features such as the mechanism for obtaining community input. The literature has reported on the prevalence of these plans, but there is no research on the quality of their content.

We identified nonprofit hospitals from a list of Medicare-participating providers in 2023 and narrowed to 2,924 Acute Care or Critical Access facilities by excluding pediatric and psychiatric hospitals. We randomly selected 2 facilities per state (plus the District of Columbia), for a total of 102. We searched each hospital's website for the CHNA and IP from 2021 – 2024. We iteratively developed a codebook to grade Implementation Plans, according to the existence of measurable activities, goals, activity expansion, and evaluation of prior activities. This process resulted in seven criteria, including: 1) the existence of any quantifiable measure to track progress; 2) ≥50% of strategies with quantifiable measures; 3) any quantifiable measure with a numeric goal; 4) ≥50% of quantifiable measures and numeric goals; 5) ≥2 clear new initiatives or definable expansion of prior activities; 6) a clear linkage between each CHNA community need and implementation plan goal; 7) Current CHNA referring to progress since prior CHNA

Among the 102 nonprofit hospitals, 99 (97%) CHNAs and 103 (91%) IPs were easily retrievable. In general, most strategies within the IP were abstract goals (e.g. “improve community engagement”) rather than quantifiable action items. In fact, of the available IPs, 45 (44%) did not identify a single quantifiable outcome measure and 69 (67%) did not establish a single numeric goal. Only 38 (37.3%) clearly articulated a commitment to an expansion of existing or creation of new activities. Almost one-third (28%) of CHNAs did not reference progress made since the prior IP, despite an IRS requirement to do so.

The IRS CHNA requirement was intended to encourage hospitals to focus on community health needs. Although we found widespread adherence to the letter of the law, we find several dimensons where the spirit of community-engaged care may be lacking, including variability in the specificty of plans, and lack of reference to prior reports. Many plans laid out vague plans and lacked measurable objectives. Although creating the reports imposes a substantial burden on hospitals, a lack of accountability on report quality may undermine the intended community benefit. EVALUATION OF A LARGE ACADEMIC HEALTH SYSTEM’S INTERVENTIONS FOR PATIENTS ENROLLED IN CMS’ KIDNEY CARE FIRST PROGRAM Chad Villaflores1; Carlos Irwin Oronce2; Ashley L. Hopkins1; Samuel A. Skootsky6; Manying Cui3; William Turner4; Richard K. Leuchter5; Sitaram Vangala6; Catherine Sarkisian7; John N. Mafi8. 1General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA; 2Medicine, Greater Los Angeles VA Healthcare System / UCLA, Los Angeles, CA; 3General Internal Medicine, University of California Los Angeles Health System, Los Angeles, CA; 4Medicine, UCLA Health, Los Angeles, CA; 5Division of General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 6Medicine, University of California, Los Angeles, Los Angeles, CA; 7Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 8Medicine, University of California Los Angeles, Los Angeles, CA. (Control ID #4263813)

Misaligned financial incentives are often implicated in driving poor health outcomes and high costs in chronic kidney disease (CKD). The CMS Innovation Center’s Kidney Care First (KCF) program is a nephrologist-focused advanced alternative payment model (APM) that incentivizes better management of CKD Stages 4, 5, and end-stage kidney disease (ESKD). This study evaluated the rollout of a novel Kidney Care Medical Home (KCMH) model launched at a large urban academic health system in response to KCF.

We analyzed universal medical claims and electronic health record (EHR) data from UCLA to identify all Medicare enrollees with CKD 4, 5, and ESKD between 1/1/2021-12/31/2023. The intervention group consisted of individuals identified by CMS to be eligible for KCF, based on having 2 or more in-network nephrology visits in the past 15 months prior to enrollment and did not have a kidney transplant in the past 13 months. The control group included patients enrolled in traditional Medicare and Medicare Advantage plans who met similar eligibility criteria but not included in KCF by CMS. Nephrology visits, lab values and documented diagnosis were required for control group patients. Outcomes included the rates of ED visits and inpatient hospitalizations. Upon verification of parallel pre-trends, we employed a heterogeneous differences-in-differences (DiD) design to measure the impact of program participation on outcomes, accounting for potential heterogeneity in treatment effect over time as the program evolved.

Between 1/1/2021-12/31/2023, we identified 926 KCF (treatment) patients and 626 control patients. Patient demographics and prevalence of comorbidities were similar between treatment and control groups. Mean age was 78 years, 47% female, 8% African American, 13% Asian-American, 12% Latino, 48% non-Latino white. Time trends for both ED visit and inpatient hospitalization showed decreasing rates in 2022 followed by increasing rates in 2023. Controlling for age, gender, social vulnerability index (SVI), dual eligibility, and comorbidities, KCF enrollment decreased ED visits by 10.1 per 100 patients (p = 0.013) compared to the control group in Q4 2022 but also showed an increase of 8.3 per 100 patients by Q4 2023 (p = 0.021) compared to the control group. The rate of transplant referrals increased by 1.5 and 1.7 per 100 patients (p = 0.028, p = 0.007) in Q3 and Q4 2022, respectively.

The KCMH model was associated with a reduction in ED visits hospitalizations, and an increase in transplant nephrology referrals, among CKD 4-5 and ESKD patients in the year following program launch. However, these improvements slowed in the second year of the program, possibly in association with program staff turnover. Programs launched in response to CMS’ Kidney Care First program appear to improve health outcomes among CKD patients, and further research is needed to determine sustainability of program benefits. EXAMINING ALLOCATION OF PAYMENTS TO ACCOUNTABLE CARE ORGANIZATIONS AFTER STANDARDIZING AN AREA-LEVEL MEASURE OF DEPRIVATION Aidan P. Crowley2,3; Kano Amagai1; Jingsan Zhu1; Torrey Shirk5; Deborah Cousins5; Joshua Liao6,3; Austin S. Kilaru4,3; Amol Navathe5,3. 1Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 2Health Care Management, University of Pennsylvania Wharton School, Philadelphia, PA; 3Leonard Davis Institute of Health Economics, Philadelphia, PA; 4Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 5Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 6Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4273229)

Social risk adjustment modifies payments to healthcare providers to account for socioeconomic needs that influence health outcomes beyond clinical risk adjustment. The Center for Medicare and Medicaid Innovation (CMMI) has incorporated social risk adjustment using the Area Deprivation Index (ADI), a neighborhood-level composite measure of socioeconomic disadvantage. However, ADI has been critiqued for underestimating disadvantage in urban areas. In 2025, CMMI will replace ADI with the Community Deprivation Index (CDI), a new measure that standardizes ADI’s component variables. Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) is a population-based payment model with benchmarks adjusted for ADI via the Health Equity Benchmark Adjustment (HEBA). Our objective was to determine how replacing ADI with CDI would reallocate payments to ACOs serving marginalized beneficiaries in ACO REACH.

We conducted a cross-sectional study using a random 20% sample of Medicare fee-for-service beneficiaries. We identified beneficiaries attributed to ACO REACH participants and calculated ADI and CDI for each beneficiary based on 9-digit ZIP using American Community Survey data. We computed each beneficiary’s HEBA score based on ADI and CDI. We also examined excess mortality at the beneficiary level, controlling for clinical risk, grouped by ACO. Finally, we compared changes in payments for ACOs in the highest quartile shares of Black, Hispanic, dual-eligible, and urban beneficiaries as well as mean excess mortality.

In our final sample of 5,129,014 beneficiaries, 55% were female, 17% were dual-eligible, 7.9% were Black, and 5.3% were Hispanic. After switching from ADI to CDI, 776,244 (15%) beneficiaries experienced a benchmark increase (mean $11.95, SD $4.64), while 848,303 (17%) beneficiaries experienced a decrease (mean $-10.94, SD $2.95). Twenty-one percent of beneficiaries who experienced an increase were Black or Hispanic, while 10% of beneficiaries who experienced a decrease were Black or Hispanic. Compared to ACOs that experienced a benchmark decrease, those with an increase were 3.9 times more likely to serve the highest quartile share of Black or Hispanic beneficiaries (26% versus 7%) and 2.5 times more likely to serve the highest quartile share of dual-eligible beneficiaries (24% versus 9%). ACOs that experienced a decrease were 1.8 times more likely than those that experienced an increase to serve the highest quartile of rural beneficiaries (22% versus 12%) and 1.5 times more likely to be in the top quartile for average excess mortality (30% versus 20%).

Modifying a commonly used area-level measure of social risk shifted dollars toward Black, Hispanic, and dual-eligible beneficiaries, while shifting dollars away from beneficiaries in rural areas and areas with high excess mortality. Changes to risk adjustment may inadvertently shift resources away from ACOs that serve populations with the worst outcomes. GENDER DIFFERENCES IN PRIMARY CARE PHYSICIAN EARNINGS AND OUTCOMES UNDER MEDICARE ADVANTAGE VALUE-BASED PAYMENT Ishani Ganguli1; Nicholas Daley1; Lauren Polt2; Victoria DiGennaro3; Benjamin Kornitzer2. 1Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; 2Agilon Health Management Inc, Austin, TX; 3Pioneer Physicians Network, Akron, OH. (Control ID #4273062)

Despite some evidence of better patient outcomes, women physicians experience a large, persistent wage gap compared to their men counterparts. This gap may be due in part to still-dominant productivity-based payment models, as women primary care physicians (PCPs), on average, spend more time on patient care per visit and between visits, resulting in fewer billable visits and lower fee-for-service revenue. In theory, value-based payment models, such as the increasingly common full-risk-sharing capitated arrangements used by some Medicare Advantage (MA) plans, may improve gender pay equity by incentivizing care quality over visit volume, but this has not been studied.

We assessed gender differences in quality and earnings among PCPs in full-risk-sharing arrangements with MA plans using 2022 MA claims and Medicare Star quality data across 5 national and 8 regional payers. We measured per-patient fee-for-service payments and value-based payments, as well as Star quality measures, utilization, and provider rating scores, and used logistic, linear, negative binomial, and gamma regression models adjusted for physician and patient covariates and practice group fixed effects. Patient-level models were weighted or offset by member-month with standard errors clustered at the physician level.

We included 878 PCPs (40.2% women) working in 15 practice groups across 6 states and 225,006 patients. Men and women PCPs had similar degrees and specialties. Women PCPs’ panels had fewer MA enrollees and higher proportions of female patients. Comparing men and women PCPs in the same practice groups, women PCPs’ patients had better Hemoglobin A1c control (1.3pp difference, 95%CI 0.49, 2.2), eye exam receipt (2.8pp, 95%CI 1.4, 4.3), and composite quality scores (0.56pp, 95%CI 0.15, 0.97), as well as fewer ED visits (5.5% difference, 95%CI -9.2, -1.7) and hospitalizations (7.7%, 95%CI -11.4, -3.9), but women received worse provider rating scores (-2.7pp, 95%CI -5.0, -0.45). Women PCPs had similar earnings to men via fee-for-service (-$12.98 difference, 95%CI -29.37, 3.42) and more earnings per-patient via value-based payment ($273.03, 95%CI 56.06, 50490.01).

When compared to men PCPs in the same practice groups, women PCPs had equal or better quality outcomes and higher value-based earnings for their MA patients in value-based payment models. These results substantiate prior evidence on women performing better on process and outcome measures yet receiving lower ratings from patients. The reversal of the gender wage gap under value-based payment may reflect better alignment of value-based models to traditionally female practice patterns, such as more face-to-face time per visit. This alignment could, in turn, contribute to reduced burnout and improved retention of the increasingly female primary care workforce to care for the aging US population. Future studies should explore how pay equity and outcomes changes with greater shares of patients in these arrangements. HIV TESTING AND CARE AMONG MEDICAID ENROLLEES WITH SCHIZOPHRENIA: IS THERE A BENEFIT TO DUAL ENROLLMENT IN MEDICARE? Karly A. Murphy1; Marilyn Thomas1; Paola Alonso-Fraire2; Alexander R. Bazazi2; Paul Wesson3; Christina Mangurian2. 1Medicine, University of California San Francisco, San Francisco, CA; 2Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA; 3Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA. (Control ID #4272333)

People with schizophrenia experience gaps along the HIV care continuum, with Medicaid covering almost 90% of this population. Non-elderly Medicaid-enrollees with schizophrenia may be dually eligible for Medicare based on disability due to functional impairment from mental illness. Dual enrollment is a marker for heightened social vulnerability and complex care needs, but prior Medicaid-based studies on HIV care excluded dual enrollees with schizophrenia. This study examined the role of public insurance on HIV testing and retention in care among dual versus Medicaid enrollees with schizophrenia.

We used Medicaid Analytic eXtract and Medicare files from 2008-2012. Participants had schizophrenia, aged 20-64, lived in one of 45 states, and enrolled in Medicaid at least 11 months per year. Dual enrollees were also enrolled in Medicare at least 11 months per year. We measured a) HIV testing rates among participants without HIV and b) retention in HIV care (two HIV viral loads or CD4+ T-cell counts >90 days apart) among people living with HIV (PLWH). We calculated average annual rates using average marginal estimates from multivariable logistic regression, adjusted for demographics, comorbidities, and calendar year, and clustered by individuals across years.

We identified 2,707,205 people without HIV and 42,747 PLWH, of whom 46.6% and 25.0% were dually enrolled respectively. Fewer dual enrollees (vs. Medicaid) were of Black race, Hispanic ethnicity, or had a substance use disorder or STI. Among people without HIV, the average annual rate of HIV testing was 4.9% among dual enrollees and 7.4% among Medicaid enrollees (p<0.001). Testing rates were highest among those aged 20-39 (8.3 vs. 10.3%), Black race (7.3 vs. 9.7%), had an opioid use disorder (12.7 vs. 16.6%) or STI (23.3 vs. 31.7%) and lowest among ages 50-59 (3.7 vs 5.7%), Asian race (3.5 vs. 4.2%), White race (3.7 vs. 5.2%), or had diabetes (5.2 vs. 7.5%). Among PLWH, the average rate of retention in HIV care was 54.7% among dual enrollees and 44.7% among Medicaid enrollees (p<0.001). Retention rates were highest among those aged 50-59 (58.6 vs. 47.0%), had an STI (60.9 vs. 45.3%) or dyslipidemia (61.4 vs. 48.5%), and lowest among ages 20-39 years (39.0 vs. 32.2%), or cocaine use (52.2 vs. 40.7%).

Lower rates of HIV testing among dual enrollees (vs. Medicaid) and lower retention rates among Medicaid enrollees (vs. dual) highlight social and structural barriers faced by people with schizophrenia. Moreover, testing based on infectious risk factors may overlook those with schizophrenia who face other risks such as intimate partner violence or stigma. For PLWH and schizophrenia, dual enrollment might reflect a better ability to navigate the healthcare system or the receipt of more coordinated care. While we used pre-Medicaid expansion data, much work is needed in local and national public health engagement with people with schizophrenia for HIV testing and retention. HOSPITALIZED PATIENTS WITHOUT RECENT AMBULATORY CARE: PATIENT AND HOSPITAL CHARACTERISTICS ASSOCIATED WITH POST-DISCHARGE VISIT COMPLETION, 2010-2022 Katherine M. Morgan1; Timothy Anderson2; Jeffrey Souza3; Vilsa E. Curto5; Eran Politzer6; John Z. Ayanian4; Bruce E. Landon3,7. 1General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 3Health Care Policy, Harvard Medical School, Boston, MA; 4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; 5Health Policy and Management, University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, CA; 6The Hebrew University of Jerusalem Federmann School of Public Policy & Governance, Jerusalem, Israel; 7General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4250854)

Optimizing care transitions post-hospitalization could play a pivotal role in improving health outcomes and reducing spending. Additionally, hospitals seeking to reduce unnecessary readmissions under the Hospital Readmissions Reduction Program (HRRP) and outpatient clinics participating in Accountable Care Organizations (ACOs) or other value-based payment programs may prioritize post-discharge visits. Patients without established ambulatory care prior to admission, however, may face barriers to post-discharge follow-up. This study aims to describe trends in post-discharge visit completion for Medicare beneficiaries without established primary or specialty care, and patient and hospital characteristics associated with post-discharge visit completion.

Using a serial cross-sectional design, we identified all fee-for-service (FFS) Medicare beneficiaries discharged from a hospital to the community between 2010 and 2022. We classified patients according to the type of outpatient care received in the 12 months prior to the admission as primary care (PC), specialty care only (SC), or neither, and examined completion of an outpatient visit within 30 days of hospital discharge. We examined associations between visit completion and patient or hospital characteristics, and how visit completion changed over time.

We studied 79,505,575 admissions from 2010 to 2022; 13.1% of patients had no ambulatory visits of any type, 6.4% had only SC visit(s) and 80.5% had PC visit(s) in the year prior to admission. Compared to those with PC and/or SC visit(s) in the prior year, a greater proportion of those with no ambulatory visit were younger than 65 years (26.7 v. 20.3%), male (53.5 v. 44.8%), Black or Hispanic (25.0 v. 16.7%), and dually eligible for Medicaid (41.2 v. 26.8%). Across all years, 13.5% of patients without ambulatory visits completed an outpatient visit within 30 days of discharge (13.3% in 2010; 13.6% in 2022). A greater proportion of those completing visits were White (14.0 v. 12.7%), male (14.2 v. 12.8%), not dual-eligible (14.3 v. 12.5%), or affiliated with an ACO (27 v. 11.8%). We also observed variation by hospital in visit completion for patients without recent ambulatory care that appeared stable over time: hospitals in the 10th v. 90th percentile ranged from 6.7 v. 21% in 2010 and 7.6 v. 20.4% in 2022 (adjusted data).

Despite the risk of financial penalties under the HRRP and the growth of value-based payments, rates of timely post-discharge follow up for FFS Medicare beneficiaries without prior ambulatory care have remained stably low over time. Our results suggest that patient factors such as race/ethnicity and dual-eligibility may be associated with likelihood of patients having pre-admission ambulatory care, and that post-discharge visit completion for patients without a recent ambulatory visit varies by ACO affiliation and by hospital. HRSA-FUNDED HEALTH CENTERS REDUCE HEALTH CARE EXPENDITURES OF COMPLEX CALIFORNIA MEDICAID MANAGED CARE BENEFICIARIES Nadereh Pourat2,1; Weihao Zhou1; Leigh Ann Haley1; Jamie Ryan3; Alek Sripipatana3. 1Center for Health Policy Research, University of California Los Angeles, Los Angeles, CA; 2Fielding School of Public Health, Department of Health Policy and Management, University of California Los Angeles, Los Angeles, CA; 3Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, MD. (Control ID #4263704)

Evidence suggests that primary care providers (PCPs) differ in their ability to address patients who have high needs and incur high costs (HNHC). These differences may be mitigated under managed care as plans can promote access to specialty and other needed services. However, information on whether health care expenditures of HNHC patients vary by type of PCP under managed care is limited. HRSA-funded health centers provide high-value primary care that is comprehensive and integrated; therefore, we hypothesized that this approach results in lower expenditures for health center patients versus patients of other PCPs.

We utilized California Medicaid administrative data for beneficiaries with at least one primary care visit, and calculated predicted expenditures in 2018 per service category, including primary, specialty, mental health, substance use treatment, outpatient pharmacy, emergency department (ED), hospital, and long-term facility stays. We calculated and added propensity score weights to address the likelihood of provider selection bias and further controlled for patient demographics, health status, and total expenditures in the past year using a doubly robust estimation methodology. We calculated predicted expenditures per category using ordinary least squares regression models and compared patterns of expenditures between PCP type, including health centers, solo providers, group practices, and other community clinics.

Adjusted predicted probabilities showed that patients of health center providers had fewer total expenditures than patients of group practices ($1,960 or 9% less). Health center patients had higher primary care, mental health, and substance use treatment expenditures, but lower ED, hospital, and long-term facility stay expenditures than patients of other providers.

Findings suggest that lower total expenditures for health center patients may be due to provision of more comprehensive and integrated care compared to other PCP types, and these differences in care delivery models may help minimize costs of care in acute or long-term care settings. Findings highlight the potential role of systemic differences in care delivery approaches by PCP type on health care expenditures. Further assessment of the approaches taken by health centers may inform cost containment and care quality improvement efforts for HNHC patients. IMPACT OF COST-GROWTH TARGET MODELS ON TOTAL MEDICAL EXPENDITURE Aleena Imran1; Carlos Irwin Oronce3; John N. Mafi2. 1Internal Medicine, University of California Los Angeles, Los Angeles, CA; 2Medicine, University of California Los Angeles, Los Angeles, CA; 3Medicine, Greater Los Angeles VA Healthcare System / UCLA, Los Angeles, CA. (Control ID #4273355)

Rising medical costs are increasingly straining patients, households, and society. Recently, U.S. states have implemented cost-growth target models, which set an annual rate of per capita cost growth to slow medical expenditure growth. To date, their effectiveness remains empirically unexamined. We evaluated the impact of these models on total medical expenditures (TME) using publicly available CMS State Health Expenditure Accounts (SHEA) data from 2009-2020.

Dataset. CMS SHEA data provides inflation-adjusted annual per capita expenditure estimates, derived from CMS actuaries who developed payer-specific estimates using survey and administrative claims data. We identified three states that implemented cost growth policy targets with an adequate timeframe to estimate impact: Massachusetts(2013), Maryland(2014), and Vermont(2018). Nine control states were matched based on pre-policy expenditure trends over a three-year period prior to implementation, using slope analyses to ensure pre-period parallel trends (within a 5% margin). The primary exposure variable was the enactment of cost growth policies (e.g., penalties to health systems), defined as the post-policy period in treatment states, and our primary outcome was TME. Analysis. We conducted a difference-in-differences analysis with linear regression models to evaluate the impact of cost growth policies on TME, as well as commercial, and Medicare expenditures (Medicaid expenditures did not have pre-parallel trends). We analyzed three years of pre- and two years of post-policy data, excluding the implementation year to avoid transitional effects. Models incorporated year-fixed effects to account for secular trends.

The sample included 60 TME, 51 commercial, and 45 Medicare state-year observations. Prior to policy enactment, the baseline sum of annual per capita TME was $58,158 across 3 treatment states and $130,014 across 9 control states, increasing to $64,640 and $146,417 in the post-policy period, respectively. Difference-in-differences (DiD) analyses indicated a non-significant $338 [95% CI: -2224.8, 2900.7] (p=0.79) increase in annual per capita expenditures in the post-policy period. Across 3 treatment and 6 control states, the sum of pre-policy annual per capita Medicare expenditures was $66,050 and $121,810, which changed to $44,479 and $130,895 in the post-policy period, respectively. Across 3 treatment and 7 control states, the sum of pre-policy annual per capita commercial expenditures was $14,395 and $29,011, rising to $14,969 and $32,279 in the post-period, respectively. DiD analyses indicated a non-significant -$1,419 [95% CI: -7102.8, 4265.5] (p=0.62) decrease in annual per capita Medicare expenditures and a non-significant -$260 [95% CI: -775.7, 255.8] (p=0.31) decrease in commercial expenditures.

State cost growth target policies were not associated with significant reductions in TME. These findings suggest stronger economic levers may be warranted to curb medical expenditure growth. IMPACT OF THE 2019 MEDICARE 7-DAY LIMIT ON OPIOID PRESCRIBING OUTCOMES AMONG POST-OPERATIVE ADULTS WITH DISABILITIES Bryant Shuey2; Alyssa Burnett5; Stephanie Argetsinger1; Katie Suda6; Jane Liebschutz3; James Franklin Wharam7; Hefei Wen4. 1Department of Population Medicine, Harvard Medical School Department of Population Medicine, Boston, MA; 2University of Pittsburgh, Pittsburgh, PA; 3Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 4Department of Population Medicine, Harvard Medical School, Boston, MA; 5Health Policy and Insurance, Harvard Pilgrim Health Care Inc, Wellesley, MA; 6Medicine, University of Pittsburgh, Pittsburgh, PA; 7Duke University, Durham, NC. (Control ID #4273070)

Effective January 2019, all Medicare Part D plans were required to implement a 7-day limit on initial opioid prescriptions intended to reduce overdose risk and long-term opioid use. Unlike state opioid limits implemented across 35 states from 2016-2018 which relied on clinicians to change prescribing in “good faith,” this national “hard limit” policy prevented pharmacists from filling a new opioid prescription >7-days duration. We assessed the 7-day limit impact on postoperative opioid use among adults with disabilities who shoulder both a disproportionate share of opioid-related harms and surgical procedures that may be complicated by uncontrolled pain.

Using Medicare Advantage claims in Optum’s de-identified Clinformatics® Data Mart Database, we followed a rolling cohort of opioid-naïve adults aged 18-64 with disability entitlement across 30 pre-policy months (July 2016-December 2018) and 30 post-policy months (January 2019-June 2021) who underwent 1 of 24 common surgeries. Our outcome for the initial fill was a binary measure for supply >7-days. Our outcomes in the 30-day postoperative period included a binary measure for having >1 fill (to assess for compensatory prescribing) and a continuous measure for total morphine milligram equivalents (MME, to determine how subacute dosages were impacted). We used an interrupted time series design to study changes in opioid prescribing outcomes associated with the 7-day limit by fitting segmented linear regression models adjusted for sociodemographic characteristics and mental health conditions. We present modeled versus expected (counterfactual) differences in January 2019 (1st policy month) and June 2021 (last study period month).

Our sample included 24,971 adults (mean age 55.5 years, SE 0.05; 57.9% female, SE 0.003). In the pre-policy period, 23.1% (SE 0.4) filled an initial prescription >7-days’ duration, 29.7% (SE 0.4) filled >1 prescription in the 30-day postoperative period, and the 30-day MME was 439.2 (SE 4.6). In January 2019, the 7-day limit was associated with an immediate 12.0 pp reduction (95% CI -13.5, -10.4) in initial opioid fills >7-days’ duration and a 35.9 30-day MME reduction (95% CI -53.7, -18.1), but no change in filling >1 prescription in the 30-day post-operative period. Yet, by June 2021, there was a 7.0 pp increase (95% CI 2.8, 11.2) in patients filling >1 prescription in the 30-day period, a 95.2 30-day MME increase (95% CI 56.9, 133.6), and no change in fills >7-days’ duration.

The 2019 Medicare 7-day limit was associated with large immediate reductions in initial fill duration and 30-day MME. But, by June 2021, these reductions were offset by a large increase in 30-day MME, driven by increases in >1 fills in the 30-day postoperative period. Our findings suggest this policy was ineffective and lead to unintended consequences among postoperative adults with disabilities. Policymakers might amend the policy to allow physicians to write longer durations at their discretion. IMPLEMENTING PARTNER PERSPECTIVES ON COMMUNITY HEALTH CENTER RESPONSE TO CALIFORNIA’S POPULATION HEALTH MANAGEMENT INITIATIVE Robin Ji2; Yolanda O'Neal1; Jacob P. Tanumihardjo1; Monica E. Peek1; Melissa Hafner3; Marshall H. Chin1. 1Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 2The University of Chicago Pritzker School of Medicine, Chicago, IL; 3American Institutes for Research, Arlington, VA. (Control ID #4273078)

The Population Health Management Initiative (PHMI), introduced in 2022 to improve health equity for Medi-Cal (California Medicaid) beneficiaries, initially aimed to strengthen federally qualified health centers (HCs) in four foundational areas: financial and operational sustainability (business case), assignment of patients to care teams (empanelment), team-based care, and data quality/reporting. PHMI supports HCs with coordination and technical assistance from practice coaches and subject matter experts, and implementation guides, peer learning opportunities, grant funding for program adoption, and a data platform. PHMI attempts to align with state and national value-based care (VBC) and alternative payment model (APM) reforms. Understanding HC’s reception and challenges with this innovative initiative is critical to its success.

15 semi-structured interviews were conducted with 23 stakeholders (e.g., coaches, subject matter experts, internal program leads, external collaborators) who actively support PHMI across 32 California HCs. Interviews focused on understanding the reception, resistance, and barriers to PHMI implementation. Transcripts were analyzed using an iteratively developed codebook. Themes were synthesized to identify best practices.

HCs were receptive to PHMI competencies when they aligned with ongoing transitions to value-based care, supported long-term goals such as improving patient outcomes and financial sustainability, or refined existing practices. HCs valued responsive coaching, high-quality resources, and regional collaboration, which enabled sharing of best practices. Capacity building across the HCs led to skill and knowledge improvements, a shift towards an innovative mindset, and formulations of multidisciplinary teams. Resistance emerged when PHMI competencies were perceived as redundant, not seen as a priority, or met with general reluctance for change. Financial constraints and workforce shortages were frequently cited as implementation barriers, and technical hurdles included data system variations. External challenges included lack of external data for patient engagement and limited incentives to engage with California’s APM 2.0 program given current fee-for-service environment. These challenges limited the use of available tools (e.g., business case tools, PHM platform) and hindered HCs’ ability to fully engage in the initiative’s benefits and meet equity-related goals.

Insights from the implementation partners reveal the benefit of targeted technical support and the challenges of aligning with external payment policy shifting from fee-for-service to APMs. Areas of opportunity include improving data integration and use of technology to facilitate PHM and providing technical support that aligns with HCs’ current systems. Addressing these challenges could enable more effective adoption and implementation of PHMI competencies. These insights offer valuable guidance for broader healthcare reform innovations. INFLUENCE OF INTERNET USE ON WELCOME TO MEDICARE OR ANNUAL WELLNESS VISIT UTILIZATION AMONG MEDICARE BENEFICIARIES WITH TYPE 2 DIABETES Jaeyi J. Hahn1; Boon Peng Ng2,1. 1Medicine, University of Central Florida College of Medicine, Orlando, FL; 2College of Nursing, University of Central Florida, Orlando, FL. (Control ID #4235971)

Health information has become increasingly available online and the COVID-19 pandemic highlighted the necessity of utilizing digital resources to access health information. Especially for older adults who face greater health risks, active use of the Internet to access health resources can significantly influence care-seeking behaviors. The purpose of this study was to investigate the relationship between access to health information and provider via the internet and Welcome to Medicare (WTM) or Annual Wellness Visit (AWV) utilization among Medicare beneficiaries with type 2 diabetes.

This study analyzed data from the 2021 Medicare Current Beneficiary Survey Public Use File, a nationally representative survey of Medicare beneficiaries aged ≥65 years with type 2 diabetes (n = 1,444). The binary dependent variable was WTM/AWV utilization. Key independent variables included whether beneficiaries (1) looked up health information online, (2) scheduled a healthcare appointment online, and (3) communicated with a provider online. A survey-weighted logistic model examined the association between WTM/AWV utilization and Internet use for healthcare access, adjusted for sociodemographic factors (e.g., race/ethnicity, sex, income) and comorbidities (e.g., number of chronic conditions, functional limitations).

Of the study population, 57.5% reported using WTM/AWV. Among those who reported using WTM/AWV and those who did not, 56.1% and 42.5% (p < 0.001), respectively, reported looking up health information via the Internet. Among those who reported using WTM/AWV and those who did not, 31.6% and 26.1% (p = 0.024), respectively, reported scheduling an appointment with a provider via the Internet. Among those who reported using WTM/AWV and those who did not, 39.8% and 34.3% (p = 0.049), respectively, reported communicating with a provider via the Internet. The adjusted analysis revealed a significant, positive association between looking up health information via the Internet and the use of WTM/AWV (OR: 1.76, 95% CI: 1.36-2.28, p < 0.001). However, the other two key independent variables were not statistically significant.

Use of the Internet for health information was associated with increased utilization of WTM/AWV. While no significant associations were observed for Internet use in scheduling appointments or communicating with providers, these may represent missed opportunities for preventive care engagement. Limited digital literacy or access could impact older adults’ ability to adopt these tools effectively. Future efforts to improve WTM/AWV utilization may benefit from prioritizing Internet access, digital literacy, and targeted education on health information-seeking and communication among Medicare beneficiaries and their support networks, potentially addressing gaps in preventive care for older adults with Type 2 diabetes. INSULIN RATIONING IN STATES WITH AND WITHOUT INSULIN COPAY CAPS: A CROSS SECTIONAL STUDY Tiffany E. Jiang1; Reshma Ramachandran2; Kasia J. Lipska2; Joseph S. Ross2. 1Internal Medicine, Yale University School of Medicine, New Haven, CT; 2Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4273151)

Over the past 20 years, out-of-pocket copay costs associated with insulin have grown, leading to an affordability crisis among patients and widespread insulin rationing, particularly among younger adults, non-Hispanic Black patients, and both middle-income and uninsured patients. In 2022, the US Congress passed the Inflation Reduction Act, which capped out-of-pocket copay costs per insulin product at $35 per month for all Medicare beneficiaries. However, prior to this, several state-specific insulin copay caps had been enacted. We examined whether there were differences in insulin rationing and diabetes management-related stress between patients who live in states with and without insulin copay caps.

We used data from the 2021 National Health Interview Survey (NHIS), a nationally-representative survey of the civilian noninstitutionalized population in the US, accessed through the National Center for Health Statistics (NCHS) Research Data Center. We identified all adults who self-reported any history of diabetes and reported using insulin and identified states that had insulin copay caps in effect in 2021. Our main outcomes were self-reported insulin rationing and diabetes management-related stress, ascertained through self-reported survey questions. We used descriptive statistics to estimate insulin rationing and diabetes-related stress overall and Chi-Square statistics to compare respondents by state insulin copay cap status. Analyses accounted for the NHIS complex survey sampling design and were done using R software (R version 4.2.3).

There were 982 respondents to the 2021 NHIS who self-reported a history of diabetes and used insulin, representative of 7.6 million U.S. adults. Overall, 16.5% (95% CI, 13.8-19.6) of respondents reported rationing insulin and 18.1% (95% CI, 15.5-20.9) diabetes management-related stress. There were no differences between respondents who lived in states with and without insulin copay caps in insulin rationing (16.6% [95% CI, 10.8-24.6 %] vs. 16.5% [95% CI, 13.5-20.0%]; p=0.98; Table 2) or diabetes management-related stress (15.4% [95% CI, 10.6-21.8%] vs. 18.8% [95% CI, 15.8-22.1]; p=0.32).

Using 2021NHIS data, we found no differences in insulin rationing and diabetes management-related stress between patients who lived in states with and without insulin copay caps. Several reasons may explain why our findings contradict expectations, including that copay caps may reduce out-of-pocket costs but not change insulin use, as well as that state-specific copay caps apply only to state-regulated insurance plans, and our analysis was limited by lack of data on whether patients’ insurance plans were state-managed. Nevertheless, copay caps may affect out-of-pocket costs among patients in non-state-regulated plans, possibly due to patients preferentially switching plans or private insurers updating coverage policies. Longer-term impacts of insulin copay caps will require further study. LONG-TERM IMPACT OF CRITERIA-BASED SERUM 25-HYDROXYVITAMIN D TESTING: A POPULATION-BASED RETROSPECTIVE ANALYSIS William K. Silverstein1; Jagadish Rangrej2; Kamil Malikov2; Sping Wang2; Shengli Shi2; Jonathan S. Zipursky3; Michael Hillmer2. 1Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; 2Health Data Science Branch, Government of Ontario, Toronto, ON, Canada; 3Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada. (Control ID #4269080)

Routine serum 25-hydroxy vitamin D (vitamin D, hereafter) testing is not recommended in the general population. Despite this, approximately three quarters of tests may be ordered inappropriately. To limit unnecessary vitamin D testing, Canada’s largest Province of Ontario (population = 16 million) implemented criteria-based testing on December 1, 2010, only funding testing for patients with osteoporosis, osteopenia, Rickets, malabsorption syndromes, chronic kidney disease, and patients taking drugs that affect vitamin D metabolism. Media promotion of this policy started in August 2010. The long-term impact of this policy on vitamin D test ordering is unknown.

We performed a population-based, cross-sectional time series analysis using linked health system administrative databases at the Ontario Ministry of Health, from April 1, 2005 to March 31, 2024 to assess the impact of criteria-based testing on the number of serum vitamin D tests ordered. Ontario residents have universal access to medically necessary services (including laboratory testing) under the publicly funded Ontario Health Insurance Program (OHIP). Health records are captured using established, routinely collected administrative health data. We included all persons in Ontario eligible for OHIP. The primary outcome was the monthly rate of vitamin D tests ordered per 1000 patient visits, which were standardized to the age-sex distribution of the 2011 population. We used interrupted time series regression to determine if there were significant changes in testing after implementation of criteria-based testing. Research Ethics Board approval was obtained.

From April 1, 2005 to March 30, 2024, a total of 8,738,113 vitamin D tests were ordered. In the year prior to implementation of criteria-based testing, the number of tests ordered peaked at 30.4 per 1000 monthly patient visits (730,813 tests); in the year following implementation of criteria-based testing, testing decreased by 77%, to a nadir of 5.3 per 1000 monthly patient visits (166,723 total tests) (p<0.01). Testing increased in the years following implementation of criteria-based testing, with an increase in the slope of 1.8 monthly tests per 1000 monthly patient visits. In the 2023 fiscal year (April 1, 2023 – March 31, 2024), there were 30.2 tests ordered per 1000 monthly patient visits (1,131,517 tests), representing 99% of the ordering volume seen in the peak year prior to implementation of criteria-based testing. Physician standardized testing rates were similar, regardless of years in practice.

The substantial decreases in vitamin D testing observed after the introduction of criteria-based testing were not sustained in the ensuing 14 years. Future studies should examine drivers of this trend, to inform quality improvement initiatives aimed at encouraging evidence-based vitamin D testing. MEASURING ADHERENCE TO MULTIPLE MEDICATIONS FOR HEART FAILURE Eli Reynolds1; Amrita Mukhopadhyay4; Xiyue Li2; Samrachana Adhikari2; Ian M. Kronish3; Carine Hamo4; Saul Blecker2,1. 1Internal Medicine, New York University Grossman School of Medicine, New York, NY; 2Population Health, NYU Langone Health, New York, NY; 3Medicine, Columbia University Medical Center, New York, NY; 4Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York, NY. (Control ID #4272789)

Poor medication adherence in heart failure (HF) is associated with increased hospitalization and readmission. Although medication adherence is commonly measured for a single drug class using the proportion of days covered (PDC) method, it is unclear how best to measure adherence to guideline-directed medical therapy (GDMT), which includes 4 different medication classes to improve outcomes in HF.

This was a retrospective cohort study of patients with HF at a large, urban, academic health system. We included patients with a diagnosis of HF or an ejection fraction <= 40% who had at least one clinical encounter between 4/1/2021-10/31/2022. Our primary measure of interest was medication adherence, assessed as PDC over a 6-month time interval. PDC was defined as the ratio of the number of days that a medication was available (based on pharmacy fills), over the number of days with an active prescription (based on the electronic health record). We calculated PDC for GDMT using seven distinct definitions to account for multiple medications (Table 1). Three of the definitions were continuous and four were dichotomous, based on PDC>80% (adherent) and PDC<=80% (non-adherent).

We included 34,720 patients with HF. When using the dichotomous definitions, the proportion of patients that were adherent to GDMT was 30.6%, 69.5%, 54.4%, or 59.1%, depending on the definition used (‘all’, ‘at least one’, ‘each’, and ‘average-each’, respectively). When using the continuous definitions, the average PDC (SD) was 0.53 (0.34), 0.78 (0.34), or 0.72 (0.34), depending on the definition used (‘minimum’, ‘maximum’, and ‘average,’ respectively).

Our findings highlight 7 distinct approaches to calculate adherence for multiple medication classes, which resulted in a wide range of measurements. Adherence was lowest when measured using the ‘all’ definition, and was highest when measured using the ‘maximum’ definition. The wide variability demonstrates the need for careful selection of adherence measurement approaches when using PDC for research, quality improvement, and policy-level initiatives. MEASURING TELEHEALTH USE: KEY CONSIDERATIONS TO INFORM RESEARCH AND QUALITY IMPROVEMENT STUDIES Jacqueline Ferguson1; Charlie Wray5,2; Josephine Jacobs4; Kayla Gray1; Cindie Slightam1; Donna M. Zulman1,3. 1Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA; 2Medicine, University of California San Francisco, San Francisco, CA; 3Department of Medicine, Stanford University, Stanford, CA; 4Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA; 5San Francisco VA Health Care System, San Francisco, CA. (Control ID #4272213)

Although telehealth is now widely integrated into practice, there is no consensus on how to measure telehealth utilization and its impact on care quality and outcomes. Measuring telehealth can be challenging as many individuals receive care through a mix of modalities (i.e., in-person, telephone, and video) and visit patterns vary across clinical scenarios and time. We sought to 1) quantify, and 2) describe the relative merits of different ‘telehealth utilization measures’ in the current published literature to facilitate implementation and effectiveness evaluations.

We conducted a review of peer-reviewed studies of synchronous telehealth care. The review was designed to inform Veterans Health Affairs (VHA) research efforts, and therefore focused on VHA telehealth studies. From over 350 published studies between January 2018 and April 2024, we identified analyses that included outcomes related to patient health or experience, health care access or utilization, and health system or patient costs. First, we abstracted, and quantified, and categorized the ‘telehealth utilization measures’. Then, we discuss their strengths, limitations, and applications for healthcare operations and research.

We identified four ‘telehealth utilization measures’: binary, count, rate, and percentage-based measures. Binary measures (i.e., any vs no telehealth use) are the most used telehealth measure, useful for assessing access and initial telehealth use or in situations where a single visit can have significant impact (e.g. follow-up after hospitalization). Yet, binary measures cannot quantify the impact of additional visits beyond an initial visit. Count measures quantify the absolute amount of care (i.e., number of visits) that are not standardized to time while rates (i.e. visits per unit time) standardize the number of visits relative to a unit of time. Rates are easy to interpret but can be biased by high utilizers or differing care needs, requiring statistical adjustments to account for these issues. Percentage-based measures represent telehealth as a percentage of all care received. Although rarely used, these measures can help healthcare systems monitor the proportion of care delivered via video and telephone. The relative percentage of phone care may also be of interest, especially when evaluating equitable access to care among individuals with limited access to broadband and/or technology. Percentage-based measures are sensitive to the number of visits in the denominator and require a large range of total visits for more continuous distribution.

This review highlights the strengths and limitations of different ‘telehealth utilization metrics’, emphasizing the need to base measure selection on the research question and the patient population of interest. Understanding the advantages and constraints of each measure is essential to ensure that evaluations accurately assess telehealth outcomes and can inform healthcare strategies and policies. MEDICAID POLICY CHANGES RESULT IN INCREASED CONTINUOUS GLUCOSE MONITOR USE IN FEDERALLY QUALIFIED HEALTH CENTERS Walter Solorzano1,2; Ligaya Scarlett2; Kathyana Santiago Mangual2; Marielle Tavarez2; Cynthia J. Santana2; Tannaz Moin1,2; Estelle M. Everett1,2. 1Division of General Internal Medicine (GIM) and Health Services Research (HSR), University of California Los Angeles, Los Angeles, CA; 2University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4272118)

Although continuous glucose monitors (CGMs) offer significant benefits in diabetes management, studies show disparities in their use among racial-ethnic minorities, lower socioeconomic groups, and those with public insurance. In January 2022, a new California Medicaid policy shifted coverage of CGMs from a Durable Medical Equipment benefit to a pharmacy benefit, resulting in less restrictive insurance criteria for CGM approval. We aim to evaluate the utilization of CGMs following this policy change and examine patient experiences with CGM use in an urban, multi-center, federally qualified health center.

We conducted a retrospective study of patients with diabetes across three clinics from January 1, 2022, to June 30, 2023, excluding those not on insulin. We surveyed patients via telephone to evaluate their experience with CGMs. Descriptive statistics summarized patient demographics, clinical features, and survey results. Multivariate logistic regression was used to identify predictors of never using CGM.

We identified 239 patients who met the inclusion criteria. The majority were aged 45-64 (60%), female (57%), Hispanic (84%), Spanish-speaking (70%), and on Medicaid (63%). Most had type 2 diabetes (93%) with a mean HbA1c ≥ 10% (31%). By the end of the study period, 40% were current CGM users, 11% former users, and 49% never users. Of the CGM users, 51 were surveyed. CGM usage increased from approximately 10 per year between 2019 and 2021 to about 90 in 2022 after the January policy change. In an adjusted analysis, insurance type was the strongest predictor of never using CGM. Those without insurance, on My Health LA (OR 15.5, 95% CI 3.7-65.6), or self-pay (OR 10.0, 95% CI 1.77-56.3) were more likely to be never users. The top reasons for starting CGMs were reducing painful finger sticks (47%) and ease of blood sugar monitoring (37%). Consequently, the most liked features of CGM use were ease of blood sugar monitoring (31%), convenience (24%), and fewer finger sticks (24%). The primary complaint was alarms (18%), although 49% reported no issues.

In an underserved diabetic population, insurance status emerged as the primary barrier to CGM use, strongly correlating with never using the device. Preliminary survey data indicates that users appreciate the ease of monitoring and practicality, but dislike the alarms, emphasizing the need to highlight the benefits of CGMs while addressing these limitations during patient counseling. Next steps will identify additional barriers impacting CGM uptake, adherence, clinical outcomes, and patient experience. By addressing these factors, we can enhance CGM utilization and adherence in a population that faces significant challenges in managing diabetes and achieving optimal glycemic control. MEDICAID PRIOR AUTHORIZATION CRITERIA FOR ANTIOBESITY GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS Matthew J. Klebanoff1,2; Ashwin K. Chetty3; Jalpa A. Doshi1,2. 1Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 2Leonard Davis Institute of Health Economics, Philadelphia, PA; 3Yale University School of Medicine, New Haven, CT. (Control ID #4269798)

Glucagon-like peptide-1 receptor agonists (GLP-1s) and dual gastric inhibitory polypeptide/GLP-1s (here collectively referred to as GLP-1s) are effective but expensive medications for weight loss. Covering antiobesity medications (AOMs) is currently optional for Medicaid programs. The Centers for Medicare and Medicaid Services (CMS) recently announced a proposal to mandate coverage for AOMs in both Medicaid and Medicare. However, this proposal would not affect Medicaid programs’ ability to require prior authorization (PA) to limit use of high-cost AOMs. Little is known about PA requirements used by Medicaid programs that already provide coverage for GLP-1 AOMs. This study provides a recent snapshot of Medicaid coverage and PA policies for Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide).

In June 2024, we visited the websites for each state’s Medicaid fee-for-service (FFS) and managed care organization (MCO) programs to obtain formulary, preferred drug list, and PA documents. Details regarding coverage and PA requirements were extracted. We examined variation in coverage and PA policies across states, as well as among FFS and MCO programs located in the same state. We noted if PA requirements were more restrictive than FDA labeling.

Of 50 states and Washington, DC, 18 (35%) had Medicaid programs covering at least one GLP-1 AOM, 16 (31%) covered GLP-1s for adults (2 provided coverage only for children and young adults), 13 (25%) allowed use for weight loss (3 only covered Wegovy for cardiovascular disease), and 10 (20%) had publicly available PA policies. Among FFS programs, 9 (90%) permitted coverage for patients with obesity and no comorbidities, 10 (100%) permitted coverage for patients with overweight and weight-related comorbidities, and 2 (20%) permitted exceptions to weight-based coverage thresholds. Other notable criteria included a prior trial of a non-GLP-1 AOM (10%), a prior weight loss attempt (30%), and submission of a detailed antiobesity treatment plan (20%). A majority of FFS programs (70%) had more stringent requirements than FDA labeling. For instance, many required documentation of specific comorbidities detailed in PA policies (70%), and some required documentation of 2 or more comorbidities for patients with overweight (20%). Compared to FFS programs, MCOs demonstrated similar frequency of most PA requirements. Lastly, in some cases, FFS and MCO programs within the same state differed substantially in coverage and PA policies.

One-third of state Medicaid programs cover GLP-1 AOMs, with substantial variation in PA requirements across and within states. If the CMS proposal is finalized, de facto Medicaid coverage for AOMs will soon expand, but real-world access may remain uneven across states due to variable PA requirements. CMS should consider strategies to harmonize PA criteria across Medicaid programs in order to ensure equitable access to AOMs. NATIONAL TRENDS OF TELEHEALTH USE IN MEDICARE ANNUAL WELLNESS VISITS Jubi Y. Lin1; Jonathan A. Staloff2; Joseph H. Joo1; Anna M. Morenz3; Lingmei Zhou1; Bianca Frogner1; Joshua Liao4. 1Medicine, University of Washington School of Medicine, Seattle, WA; 2Family Medicine, University of Washington, Seattle, WA; 3Department of Medicine, Banner - University Medical Center Tucson, Tucson, AZ; 4Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4271935)

Telehealth has the potential to promote preventive services in primary care settings, such as Annual Wellness Visits (AWVs). Medicare began reimbursing telehealth AWVs during COVID-19. However, little is known about the nationwide adoption of telehealth AWVs during and after the pandemic.

Using 2020-2022 Medicare claims data, we analyzed total annual service counts and payments for AWVs (Current Procedural Terminology Codes G0438, G0439) and the subset of AWVs delivered via telehealth (denoted by 95, 93, GQ, GT, FQ modifiers). AWVs were also stratified by clinical specialties: primary care (e.g., family medicine, general practice, and internal medicine), medical subspecialists (e.g., cardiology, rheumatology), or other (e.g., general surgery, neurology).

Between 2020-2022, 24.7 million AWVs (corresponding to $3.2 billion in payments) were provided, with 3.8% (corresponding to $120 million in payments) delivered via telehealth. AWVs increased by 10% between 2020 (7.8 million) and 2022 (8.6 million), while telehealth AWVs decreased over that period (6.7% of all AWVs in 2020 to 2.1% of all AWVs in 2022). Most AWVs (97.5% overall, 96.8% of telehealth-delivered) were provided by primary care physicians. Among primary care physicians, family medicine physicians provided nearly half of AWVs, both overall and among telehealth-delivered services. Medical subspecialists provided 1.5% of all AWVs and 1.6% of telehealth AWVs. Other specialties accounted for 0.9% of total AWVs and 1.6% of telehealth AWVs.

As AWV services increased over time, telehealth-delivered AWVs decreased as a proportion of all services. These trends suggest potential barriers arising from financial incentives, implementation considerations, or clinician and patient education. Given potential suitability of telehealth for delivering AWVs, future research and policy should identify barriers and promote facilitators to optimize telehealth adoption of such services. NATIONAL TRENDS OF TELEHEALTH USE IN MEDICARE TRANSITIONAL CARE MANAGEMENT Jubi Y. Lin1; Alyssa N. Tijerina4; Joseph H. Joo1; Jonathan A. Staloff2; Lingmei Zhou1; Lucas M. Donovan3; Joshua Liao4. 1Medicine, University of Washington School of Medicine, Seattle, WA; 2Family Medicine, University of Washington, Seattle, WA; 3Health Services Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, WA; 4Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4272750)

Telehealth has the potential to improve care transitions for patients being discharged from hospitals. Although Medicare has reimbursed telehealth Transitional Care Management (TCM) since 2014, little is known about the utilization of telehealth TCM during the last decade.

Using Medicare claims data, total annual service counts and payments were calculated for TCM (CPT 99495, 99496), as well as those delivered using telehealth (identified by 95, 93, GQ, GT, FQ modifiers), between 2014-2022. TCM services were stratified by the following clinical specialty types: primary care (e.g., family medicine, general practice, and internal medicine), medical subspecialists (e.g., pulmonology, endocrinology), or other (e.g., general surgery, neurology).

Between 2014-2022, a total of 8.1 million TCM services ($1.6 billion in payments) were provided, with 3.3% (264,129) delivered via telehealth. Telehealth TCM increased from <0.1% of all TCM in 2014 to 6.7% in 2022, peaking at 12.1% in 2020. The growth in telehealth TCM corresponded to an increase in payments from $1,323 in 2014 to $14.6 million in 2022. Most telehealth TCM (94.2%) were provided by primary care physicians (PCPs), with minimal provision by medical subspecialists (5.0%) and other specialists (0.8%). Telehealth TCM provided by PCPs increased from 5 services in 2014 to 57,977 services in 2022, corresponding to an increase in physician payments from $997 to $13.7 million. Medical subspecialists provided 13,134 telehealth TCM services overall ($3.1 million in payments), in which nephrology, geriatrics, and cardiology were the three subspecialties providing the highest number of telehealth TCM (9,788 services total). Other specialists provided 2,257 telehealth TCM services ($462,779 in payments), in which 2,105 of those services were provided by physicians specializing in physiatry, hospital medicine, and emergency medicine.

While telehealth TCM increased over time, telehealth TCM comprised the minority (12.1%) of all TCM provided between 2014-2022 and most (99.8%) of telehealth TCM occurred during or after 2020. Future efforts should focus on assessing facilitators and barriers as well as populations that disproportionately benefit from, or are particularly well-suited to, telehealth TCM. NURSING HOME AVAILABILITY FOR INCARCERATED PERSONS GRANTED COMPASSIONATE RELEASE Gabriel Dayanim1; Megan Martin2; Joseph R. Junkin1; Bianca Bergsneider1; Michelle I. Suh3; Dianna Shaw1; Katherine Tsamourtzis1; Stephanie Grace Prost4; Justin Berk5. 1Warren Alpert Medical School, Brown University Warren Alpert Medical School, Providence, RI; 2Brown University Health, Providence, RI; 3The University of Chicago Medicine, Chicago, IL; 4University of Louisville, Louisville, KY; 5Medicine & Pediatrics, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4270325)

By 2030, one third of incarcerated persons in the United States will be considered geriatric (55+). Many states have created compassionate release laws, enabling ill and aging incarcerated people to transition to community-based health care settings better suited for geriatric care. However, these policies cannot ensure that compassionately-released individials find nursing facilities willing to admit them. This discharge planning challenge hinders the goals of compassionate release laws, forcing geriatric incarcerated people to remain in prisons unequipped for their needs. This public health issue is not well characterized in existing literature. We conducted a state-wide secret shopper study to assess the availability of nursing home resources for incarcerated geriatric patients granted compassionate release.

Using a secret shopper study design, we used a standardized call script to ask every nursing home in a New England state about bed availability for an ideal patient profile. Availability was categorized as “Available”, “Wait List”, and “Reject”. After the initial response, the caller disclosed the patient's incarceration and compassionate release status and asked how that may affect admissions. The call script also elicited facility representatives’ perceived barriers to admitting incarcerated patients. A chi-squared test was used to assess differences in responses before and after mentioning incarceration.

Of 74 nursing homes in the sample, 82.43% (n=61) provided information about bed availability and the impact of incarceration. Initially, 52.45% (n=32) of facilities endorsed bed availability within 1 month. Facility responses for availability significantly changed after mentioning the incarceration status of the patient (X2 (2, n=122) = 18.86, p < 0.0001). The percent of facilities that endorsed availability within a month decreased from 52.45% (n=32) to 24.6% (n=15) with incarceration mentioned. The percent of facilities with no availability increased from 9.83% (n=6) to 42.62% (n=26) with incarceration mentioned; an additional 40.98% (n=25) of facilities said incarceration might impact admission without explicitly rejecting the patient. For violent offenses, percent of facilities reporting no availability increased to 68.85% (n=42). In a survey of 45 facilities, 57.8% (n=26) cited safety as a concern with accepting an incarcerated patient.

While some nursing homes were willing to consider compassionate release patients for admission, most facilities either rejected incarcerated patients despite existing bed availability or expressed concern about incarceration status without explicit rejection. Our findings suggest that the limited state-wide availability of nursing home care to incarcerated individuals is a barrier to the widespread implementation of compassionate release laws. If this policy and market gap is not addressed, geriatric patients may continue to remain incarcerated and unable to receive appropriate nursing care as they age. OPTIMIZING ICD CODE ALGORITHMS FOR CHRONIC DISEASE CASE DEFINITIONS IN MULTIMORBIDITY MEASUREMENT Melissa Y. Wei1,2; Ashley J. Kang1; 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 #4273240)

ICD code-based multimorbidity metrics often underestimate disease cases and multimorbidity due to reliance on single-encounter diagnostic codes, which are prone to errors such as upcoding and incomplete or inaccurate documentation. Measures like the Chronic Conditions Warehouse address this by requiring 2 outpatient or 1 inpatient ICD code within 2 years to identify a case. However, these stricter criteria may reduce sample size, and the tradeoff between accuracy and sample size loss likely varies across diseases. We aimed to compare the accuracy of using 1 or more vs. 2 or more ICD codes and the associated sample size tradeoff for conditions in the multimorbidity-weighted index (MWI).

We used UCLA Health EHR data from 2013-2019 for 23 MWI conditions. Chart reviews were conducted on a random sample of adults aged ≥18 years with ≥1 or ≥2 ICD codes for each condition, identified using MWI-specific ICD-9-CM and ICD-10-CM codes across all encounter settings. For each condition, we reviewed charts for 20 patients with ≥1 ICD code and 20 patients with ≥2 ICD codes. A control group was randomly generated from the cohort, including patient-condition combinations without ICD codes for the condition. Trained reviewers and a nurse abstractor conducted the chart reviews. Gold standard determinations were based on objective data (e.g., pathology, imaging, labs, meds, procedures) and notes from primary care providers and specialists. Each chart was classified as a confirmed case or non-case. We calculated positive predictive value (PPV), negative predictive value (NPV), and Cohen’s kappa statistic (k) and assessed the percentage sample loss with ≥2 vs. ≥1 ICD codes.

For 22/23 conditions, the PPV for using ≥1 ICD codes exceeded the predefined threshold of 0.70. The exception was hyperthyroidism, with PPV 0.63. The mean PPV for ≥1 ICD codes across all conditions was 0.90. PPVs improved overall when using ≥2 ICD codes (mean PPV 0.94). However, at the individual condition level the impact varied: some conditions showed increases in PPV, while others had no improvement or decreases. NPV was high across all conditions, ranging from 0.87 (colon polyp) to 1.0 for 11/23 conditions, with a mean NPV = 0.98. Inter-rater agreement between the 2 reviewers was strong, with mean k = 0.96 (range 0.83-1.0). When requiring ≥2 ICD codes to define a case, the sample size loss ranged 19%-65%. Cancers were most consistently coded multiple times, while conditions such as colon polyps, peptic ulcers, and gynecologic conditions were more commonly billed with 1 ICD code.

For most conditions, it is sufficient to use ≥1 ICD codes to define a sample of adults with specific chronic conditions. PPV may increase by using stricter case definitions (e.g., ≥2 ICD codes), but this comes at a tradeoff of reduced sample size. The choice of case definition should be guided by the research objectives, whether to maximize sample size or diagnostic accuracy when recruiting patients with a given condition. PARTICIPATION AND ATTRITION IN THE MEDICARE SHARED SAVINGS PROGRAM Andrew Ryan2; Pedro Gozalo2; Adam Markovitz1. 1Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; 2Health Services, Policy and Practice, Brown University, Providence, RI. (Control ID #4272913)

The Medicare Shared Savings Program (MSSP) is the centerpiece of Medicare’s strategy to shift from fee-for-service to population-based payment. MSSP accountable care organizations (ACOs) are eligible to receive shared savings bonuses if they meet spending targets. Because the MSSP is voluntary, ACOs and clinicians have considerable flexibility to enter and exit. Although the MSSP is considered Medicare’s most mature value-based reform, this may mask underlying ACO or clinician churn in and out of the program, threatening the type of long-term practice transformation required to manage risk and coordinate care in new, challenging ways. In this context, we evaluated ACO and clinician trends in MSSP participation and churn over time.

We examined unadjusted trends in MSSP participation using publicly reported Medicare data on MSSP ACOs and beneficiaries from 2012 to 2022 and ACO Research Identifiable File data on clinicians from 2012 to 2021. Because ACOs typically sign 3-year participation agreements, we evaluated the probability of ACOs participating in the MSSP for at least 3, 6, and 9 years (i.e., 1, 2, or 3 full participation cycles) among ACOs starting in or before 2020, 2017, and 2014, respectively. Because clinician data ended in 2021 rather than 2022, we evaluated the probability of clinicians remaining in the program for at least 3, 6, and 9 years among clinicians starting in or before 2019, 2016, and 2013, respectively.

The total number of MSSP ACOs grew from 114 in 2012 to 548 in 2018 and fell to 482 in 2022 (Figure). The number of MSSP beneficiaries grew from 2.1M in 2012 to 10.1M in 2018 and then plateaued, reaching 10.4M in 2022. Across all cohorts, ACOs participated in the MSSP for 4.9 years on average from 2012 through 2022, with only 34% of ACOs participating in the MSSP for at least 9 years (3+ participation cycles). Clinician enrollment in the MSSP grew steadily from 39k in 2012 to 656k in 2021 but also demonstrated significant churn. Across all cohorts, clinicians participated in the MSSP for 3.6 years on average from 2012 through 2021, with only 23% participating in the MSSP for at least 9 years (3+ cycles).

Our study of the MSSP yielded two key findings. First, ACO and beneficiary MSSP participation stagnated from 2018 onward while overall clinician participation grew but with substantial churn. Second, there were high rates of churn, with only about half of ACOs and clinicians remaining in the MSSP for 6+ years or 2 contract cycles. Stagnation and churn in participation undermines the MSSP’s central role in payment reform. Although MSSP bonuses have grown over time – and now outpace ACO savings – high attrition suggests that bonuses may be too small to entice participants to remain in the MSSP. ACOs may also struggle to retain clinicians in the face of growing competition from consolidating health systems, private equity, and Medicare Advantage. For the MSSP to succeed, it must encourage long-term participation. PATIENT OUT-OF-POCKET COSTS FOR COPD HOSPITALIZATIONS AND 6-MONTH READMISSION RATE James D. Lee1,2; Nora V. Becker1. 1Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; 2Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI. (Control ID #4271981)

Patient cost-sharing has increased in recent years, with most individuals with commercial insurance now enrolled in high-deductible health plans. The high financial burden for patients has been shown to be associated with decreased healthcare utilization and negative health outcomes. Hospitalizations due to acute exacerbations of chronic obstructive pulmonary disease (COPD) are costly for patients and have high readmission rates. However, little is known about the relationship between patient out-of-pocket costs (OOPCs) from acute hospitalizations and subsequent readmissions. This study aims to explore patient OOPCs incurred from acute COPD hospitalizations and analyze their association with 6-month readmission.

Using the Merative MarketScan Commercial Database, we evaluated the association between patient OOPCs from acute COPD hospitalization and 6-month readmission rates in nonelderly adults with commercial insurance, using multivariate logistic regression analyses . We identified patients who were hospitalized due to COPD between January 2016 and December 2022 and were continuously enrolled in insurance for 6 months before and after the index hospitalization (n=15,809). Only the first COPD hospitalization was considered if the patient had multiple COPD hospitalizations. The main exposure variable was patient OOPC associated with the index hospitalization. The primary outcome measure was the likelihood of 6-month readmission.

Patient OOPC for COPD hospitalization varied significantly, with an average of $1,253.48 (SD $1,513.67; range $0 to $12,709.05). The overall 6-month readmission rate was 27.55% (SD 44.68%). In an adjusted logistic regression analysis adjusting for patient and geographic characteristics, health plan type, length of stay, and ICU utilization, patients in the highest OOPC quintile had significantly lower odds of 6-month readmission (adjusted odds ratio [aOR] 0.33, 95% CI 0.28-0.37) compared with those in the lowest OOPC quintile (aOR for second quintile 0.77, 95% CI 0.66-0.90; third quintile aOR 0.55, 95% CI 0.49-0.62; aOR for fourth quintile 0.39, 95% CI 0.34-0.44). In a sensitivity analysis using only readmission due to motor vehicle accidents and traumatic injuries as the primary outcome (n=7,434), the likelihood of 6-month readmission did not differ significantly between quintiles of OOPC (aOR for second quintile compares to lowest OOPC quintile 0.88, 95% CI 0.34-2.27; third quintile aOR 0.44, 95% CI 0.18-1.09; aOR for fourth quintile 0.91, 95% CI 0.44-1.86; aOR for fifth quintile 0.45, 95% CI 0.18-1.12).

In our study, OOPCs for COPD hospitalizations were associated with a higher likelihood of all-cause 6-month readmission. The result suggests that financial burden for patients may affect future healthcare utilization. Future research should also evaluate other patient outcomes and measures of utilization associated with OOPCs for acute hospitalizations. PATIENT RISK PERCEPTION AND DECISION-MAKING ABOUT REPEAT CANCER SCREENING Chris Gillespie1; Megan McCullough2; Anna Zogas1; Jacqueline H. Boudreau1; Shawn Dunlap1; Renda S. Wiener1; Christine M. Gunn4; Lori Bastian3; Barbara G. Bokhour1. 1Center for Health Optimization and Implementation Research, US Department of Veterans Affairs, Washington, DC; 2Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, Washington, DC; 3Internal Medicine, Yale University School of Medicine, West Haven, CT; 4Dartmouth University, Hanover, NH. (Control ID #4267596)

VA seeks to promote patient-centered care in which Veterans’ personal values, goals, and preferences drive healthcare plans. Involving patients in their care can produce better health outcomes. Routine lung cancer screening (LCS) through chest CT and breast cancer screening (BCS) through mammography involves repeated testing over sometimes inconsistent intervals over many years. These are essential sites to promote patient-centeredness. We currently have little understanding of how Veterans make decisions about returning for repeat screening, including how the results of prior screening tests affect their risk perceptions, and what other factors may influence adherence decisions.

This is a qualitative study using in-depth interviews with Veterans throughout the screening process for LCS and BCS. Veterans were interviewed at three points in time: 1) prior to the initial screening exam; 2) following that initial exam; and 3) after a subsequent screening exam. Interviews were conducted with 35 Veterans undergoing LCS and 30 women Veterans undergoing BCS (n=65). Participants were asked questions regarding their perceptions of risk for lung or breast cancer, their decision-making about initiating screening, their understanding of the screening process, and about their intentions regarding future screening exams.

RISK PERCEPTIONS: Risk perceptions motivated participants to agree to begin screening. These perceptions were influenced by age, smoking history (for LCS) or family history (for BCS). Veterans undergoing LCS considered convenience and favored the noninvasiveness of the screening method. Although Veterans undergoing BCS relayed expectations for painful or uncomfortable screening experiences, this did not typically deter Veterans from initiating screening. DECISION-MAKING and PREFERENCES: Participants identified several factors that influenced their decisions to initiate screening. For many, LCS and BCS were considered routine healthcare activities and many participants were motivated to follow their healthcare provider’s recommendation to get screened. Veterans with questions about screening often did not ask. Many participants were unaware of guidelines for how often repeat screening exams should occur and preferred to get these exams at intervals that exceeded those guidelines. For example, several women stated that subsequent mammograms should occur at 3-5 year intervals, rather than the recommended biennial exams. These preferences reflected perceptions of low risk for breast cancer.

Decision-making and intentions about repeat cancer screening accounts for factors that are often not accounted for in national guidelines. These factors include individual perceptions of risk, the experience of getting screened, and personal preferences about the frequency of screening. Patients were often not familiar with the screening process and recommended screening intervals and preferred longer intervals between screening exams. PATIENTS DIFFER ON THE IMPORTANCE OF LIFESTYLE PRACTICES FOR HYPERTENSION MANAGEMENT Elizabeth R. Pfoh1; Victoria Criswell1; Michael B. Rothberg2. 1Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; 2Internal Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4272962)

Hypertension is a leading risk factor for cardiovascular death, and uncontrolled BP rates are increasing. Understanding how patients successfully incorporate evidence-based practices into their lifestyle can inform quality improvement programs. The goal of this study was to identify the differences in beliefs and lifestyle practices between patients with hypertension who had controlled versus uncontrolled BP.

We interviewed patients with hypertension who had a primary care visit in our health system in spring 2023. We created “controlled” and “uncontrolled” groups based on patients’ last BP in 2022. We used stratified random sampling to recruit similar numbers of patients with controlled and uncontrolled BP by sending messages via MyChart and mail. We offered $25 incentives and stopped recruitment after reaching thematic saturation. The semi-structured interviews were conducted virtually and transcribed. We asked about awareness and lifestyle changes. Using grounded theory, we inductively coded interviews, and then compared codes generated across groups (axial coding) to identify the extent to which themes varied between groups.

We recruited 15 patients: 9 had controlled BP, and 6 had uncontrolled BP. We identified 4 themes. The first, “Having hypertension was surprising,” was universal. “I had a stroke….And that’s when I first found out.” Patients with controlled versus uncontrolled BP differed by theme. Theme 2. The importance of diet. Patients with controlled BP reported diet to be a more important factor to attaining BP control than patients with uncontrolled BP. A patient with controlled BP said, “Drink water. Eat right… those things are important.” In comparison, a person with uncontrolled BP stated, “I’ve done all the little nonsense things that they blame you for and [it] hasn’t changed my BP.” Theme 3. The role of social support. Patients with controlled BP found social support helpful. One said in relationship to exercising, “My sister motivates me to say, OK, it’s time to get up.” In comparison, a person with uncontrolled BP said, “I don’t have anyone right now that I [walk] with. If I really wanted to make it happen, I’m sure I could. But if the time is lacking.” Theme 4. Addressing stress is an important component of lowering BP. Patients with controlled BP augmented their treatment in response to stress. For example, one patient stated, “I was doing OK, but I went back to the higher dose because I had a death in the family and other stressors.” In comparison, a person with uncontrolled BP refused intensification during a stressful period.

Patients have different understandings of the impact of lifestyle and their ability to self-manage. These differences impact their ability to attain and maintain blood pressure control. PERFORMANCE OF PHYSICIANS AND HOSPITALS IN MEDICARE’S LATEST BUNDLED PAYMENT PROGRAM FOR LOWER EXTREMITY JOINT REPLACEMENT Aidan P. Crowley1,4; Austin S. Kilaru2,5; Qian E. Huang3; Erkuan Wang3; Jingsan Zhu3; Ayush Arora8; Kristin A. Linn7; Said Ibrahim8; Joshua Liao6,1; Amol Navathe3,1. 1Leonard Davis Institute of Health Economics, Philadelphia, PA; 2Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 3Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 4Health Care Management, University of Pennsylvania Wharton School, Philadelphia, PA; 5Leonard Davis Institute of Health Economics, Philadelphia, PA; 6Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 7Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA; 8Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA. (Control ID #4272321)

The Centers for Medicare & Medicaid Services have tested several episode-based payment models. In Bundled Payments for Care Improvement (BPCI) Advanced for lower extremity joint replacement, physician group practices (PGPs) have been the most common participant by episode volume. However, evaluations of the model have primarily focused on hospitals. It is essential to distinguish performance differences in anticipation of a forthcoming hospital-only model, Transforming Episode Accountability Model (TEAM). Our objective was to examine the association of treatment by physician and hospital participants in BPCI Advanced with healthcare spending, quality, and utilization in joint replacement.

We conducted a retrospective cohort study of Medicare beneficiaries treated by physicians in PGPs that participated in BPCI Advanced for lower extremity joint replacement, participating hospitals, and propensity-matched comparison groups of non-participants. We used a 100% sample of Medicare claims data from 2016 to 2019. We constructed joint replacement episodes by combining all claims 90 days after the index admission. We used difference-in-differences methods and generalized linear models with time, hospital, and diagnosis-related group fixed effects, adjusting for patient- and market-level characteristics.

The matched cohort included 846,529 beneficiaries with a mean age of 73.7 years (SD 8.3), 63.8% women, and 5.1% of Black race. At 90 days, receipt of joint replacement from physicians in participating PGPs was associated with a $855 differential reduction in spending (adjusted difference-in-difference [aDID] -$855, 95%CI -$1074 to -$636). Receipt of joint replacement from a participating hospital was associated with a $613 differential reduction (aDID -$613, 95%CI -$1039 to -$187). Joint replacements from physicians in participating PGPs were associated with a differential decrease in discharge to skilled nursing facility (SNF) (aDID -1.8pp; 95%CI -2.6 to -1.0), a differential increase in outpatient physician visits within 7 days of discharge (aDID 2.9pp; 95%CI 2.0 to 3.8), and no significant differential change in discharge to home health. In comparison, beneficiaries who received joint replacement from participating hospitals had a differential increase in discharge to home health (aDID 2.8pp; 95%CI 0.7 to 5.0), but no significant differential change in discharge to SNF or in 7-day post-discharge outpatient physician visits. Differential changes in mortality, readmissions, or complications were not observed.

Participation in BPCI Advanced for joint replacement was associated with differentially lower total spending and changes in utilization for both physicians and hospitals. Because physicians were responsible for a larger share of episodes than hospitals, these findings highlight the importance of encouraging alignment between hospitals and physicians in future bundled payment models, including those that restrict participation to hospitals. PHYSICIAN OWNED HOSPITALS: MORTALITY, READMISSIONS, AND COST FOLLOWING INPATIENT MEDICAL AND SURGICAL ADMISSIONS Afifah Khan1; Jeffrey L. Schnipper2. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Division of General Internal Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA. (Control ID #4273251)

Growth of physician owned hospitals (POH) in the United States has been restricted since the 2010 passage of the Affordable Care Act (ACA). This policy was enacted due to concerns that POH may “cherry pick” healthier patients, treat fewer Medicaid patients, and have higher service utilization due to inherent conflicts of interest. Data has shown an unclear effect of physician ownership on quality, utilization, and cost. More data is needed to determine the potential effects of POH status on healthcare delivery and inform future policymaking regarding regulation of hospitals by ownership status.

POH and non-physician owned hospitals (non-POH) participating in Medicare from 2009-2021 was our primary sample. Medicare inpatient claims from 2009 and 2021 were merged with the American Hospital Association Annual Survey results, which was used to identify POH. In addition, we manually confirmed POH status using news reports and Pitchbook. We then matched POH to non-POH by hospital size, profit status, teaching status, urban location, year, hospital region, and critical access hospital status. We restricted the analysis to episodes of care for ten leading procedures and medical conditions. Our primary outcome variables were mortality rate, readmission rate, total spending, and hospital operating margin across a 90-day episode of care. We used multivariable linear regression model adjusted for study year, diagnosis category as a categorical variable, Elixhauser medical comorbidity score, and patient demographic characteristics. We assessed the relationship between POH status and outcomes, including difference in y-intercept and slope over time.

We identified a net loss of 59 POHs from 2009 to 2021. Compared to non-POH, POH were more likely to be for-profit (86.1% vs 12.8%, p<0.001), and located in the South (66.4% vs 33.3%, p<0.001). Using linear regression, there were lower 90-day mortality rates in the POH group (difference in y-intercept -1%, -1.6 to -0.4%, p=0.0008), but similar readmission rates (-0.15%, -1.4 to +1.1%, p=0.81) and total costs (-$399, -$1,022 to +$224, p=0.21). POH were associated with an increased hospital operation margin (0.05 or 5%, 0.02 to 0.08, p<0.002) and a difference in slope trend of -0.4% (-0.004, -0.004 to -0.004, p = 0.00), where non-POH had an increased slope trend. There were no other differences in slope over time by POH status.

Overall, we found that physician owned hospitals were likely to be for-profit hospitals located in the south. POH were associated with slightly lower mortality rates, similar readmission rates and total payments, and higher hospital operating margins than non-POH. While these results do not rule out unmeasured confounding and “cherry-picking,” they likely rule out a large negative effect of POH on patient outcomes and costs. While further study of the underlying causes of these findings is needed, these results raise questions about the rationale for continued restriction on the growth of POH. PHYSICIAN TURNOVER AMONG GENERAL INTERNAL MEDICINE PHYSICIANS AND SUBSPECIALISTS IN THE UNITED STATES: 2014-2022 Jason Silva-Rudberg1; Bruce E. Landon2,3; Alice Guillemeteau1; Lisa Rotenstein1,4. 1University of California San Francisco Department of Medicine, San Francisco, CA; 2Health Care Policy, Harvard Medical School, Boston, MA; 3Beth Israel Deaconess Medical Center General Medicine Division, Boston, MA; 4Division of Clinical Informatics, University of California San Francisco, San Francisco, CA. (Control ID #4271187)

Leaving a medical practice can have negative consequences for patients by creating gaps in access to care and discontinuity of treatment. In addition, practices and health systems face high recruitment and onboarding costs every time they must replace a physician. We aimed to determine how often physicians in general internal medicine (GIM) and 10 related subspecialties leave their practices and what factors are linked to their departure.

Using a serial cross-sectional design, we analyzed data on GIM physicians as well as the 10 most prevalent internal medicine subspecialties within the CMS Physician Compare Database from 2014–2022. We defined practice separation as a physician's NPI no longer being associated with a specific group practice ID in the subsequent year's data, with both the physician and practice remaining in the dataset, excluding physician exits from the workforce (e.g., retirement) or practice closures. Separation was categorized as physicians changing practices within their local area or relocating to a new area. For physicians associated with multiple practices, we also identified those who left one or more of these practices. We estimated a Generalized Estimating Equations (GEE) model to examine physician- (sex, specialty, years in practice) and practice-level (region, rural/urban location, academic affiliation, size, neighborhood disadvantage index) factors associated with separation.

We studied 172,200 physicians across 29,366 practices, including 46% practicing GIM, 16% in cardiology, and 8% in pulmonology-critical care, among other specialties. Over this time period, 26.2% of GIM physicians separated from at least one practice, with separation rates across other specialties ranging from 11.0% in allergy/immunology to 38.4% in cardiology. In adjusted models, most subspecialties had significantly lower odds of separation when compared to GIM. In addition, male physicians had higher odds of separation than females (OR: 1.17, 95% CI: 1.15–1.19), and those with ≥25 years in practice had significantly lower odds compared to early-career physicians (OR: 0.45, 95% CI: 0.44– 0.46). Larger group sizes (≥100 providers) (OR: 1.96, 95% CI: 1.90–2.02), rural settings (OR: 1.39, 95% CI: 1.28–1.50) and location in more disadvantaged neighborhoods (OR: 1.06, 95% CI: 1.04–1.08) were associated with higher odds of separation, while academic practices had lower odds (OR: 0.80, 95% CI: 0.78–0.83).

Over a quarter of physicians left their practice from 2014 to 2022, with significant variation across specialty, demographic, and practice characteristics. These findings may reflect underlying trends that impact the sustainability of certain practice settings and specialties and highlight the need for targeted interventions to improve physician retention. POSTMARKET DRUG SAFETY-RELATED ACTIONS BEFORE AND AFTER THE FOOD AND DRUG ADMINISTRATION AMENDMENTS ACT (FDAAA) Harry Doernberg1; Joshua D. Wallach3; Nilay Shah4; Reshma Ramachandran2; Joseph S. Ross2. 1Internal Medicine, Yale University School of Medicine, New Haven, CT; 2Internal Medicine, Yale School of Medicine, New Haven, CT; 3Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA; 4Delta Air Lines Inc, Atlanta, GA. (Control ID #4269640)

The Food and Drug Administration (FDA) Amendments Act (FDAAA) of 2007 expanded the FDA's regulatory authority, aiming to enhance postmarket drug safety. However, FDAAA’s impact on drug safety surveillance remains unclear. We evaluated the frequency and timing of FDA postmarket safety-related actions for drugs approved before and after FDAAA implementation in March 2008, and examined the association between drug and regulatory characteristics and postmarket safety-related actions.

We used publicly available FDA materials to identify novel therapeutic agents approved by FDA between 2001 and 2015, excluding non-drug-based therapies, and to collect information on drug characteristics, including type, therapeutic area, first-in-class status, and orphan designation, and regulatory characteristics, including special regulatory pathways and boxed warnings at time of approval. We used multivariate logistic regression to compare the frequency and timing of postmarket safety-related actions—drug withdrawals due to safety, incremental boxed warnings, and safety communications—before and after FDAAA. We also investigated the association between drug and regulatory characteristics and postmarket safety-related actions for drugs approved post-FDAAA between 2012 and 2019.

From 2001 through 2015, FDA approved 392 novel therapeutics. FDA took a postmarket safety-related action for 105 (26.8%) therapeutics; median time to first action was 3.6 years (IQR: 1.7-5.3). Accounting for therapeutic and regulatory characteristics, FDA approval pre- or post-FDAAA was not associated with a difference in the likelihood of postmarket safety-related actions (HR 0.77, 95% CI 0.50-1.17, P=0.22), although the median time to first action was shorter (pre-FDAAA: 4.6 years, IQR (2.6-6.3) vs. post-FDAAA: 2.2 years, IQR: (1.3-4.8), P=0.002). Among drugs approved post-FDAAA, from 2012 through 2019, several therapeutic and regulatory characteristics were associated with the likelihood of postmarket safety-related actions, including small molecule type (HR=6.35, 95% CI 1.80-22.40, P=0.005), orphan designation (HR=0.13, 95% CI 0.05-0.36, P<0.0001), Fast Track regulatory pathway (HR=3.55, 95% CI 1.50-8.39, P=0.004), Breakthrough Therapy Designation (HR=6.29, 95% CI 2.42-16.39, P=0.0002), and FDAAA-mandated postmarketing requirement (HR=2.80, 95% CI 1.39-5.66, P=0.004).

FDAAA was not associated with a different likelihood of FDA postmarket safety-related actions, although these actions were taken more than two years earlier post-FDAAA than pre-FDAAA. Post-FDAAA, several drug and regulatory characteristics were associated with a greater likelihood of postmarket safety-related action. These findings suggest that the increased regulatory authority provided by FDAAA may have improved drug safety by enabling more rapid identification of drug safety risks arising in the postmarket period. PRIMARY CARE CLINICIANS’ VIEWS ON POLYGENIC RISK SCORES AND SHARED DECISION-MAKING IN PROSTATE CANCER SCREENING: INSIGHTS FOR DEVELOPING IMPLEMENTATION STRATEGIES Jason L. Vassy1; Chris Gillespie5; Lilly Cheam3; Ashley A. Antwi2; Ryan Cabrera3; Marla L. Clayman3,4. 1Medicine, Harvard Medical School at VA Boston Healthcare System, Boston, MA; 2General Internal Medicine, VA Boston Healthcare System, Boston, MA; 3Center for Healthcare Optimization and Implementation Research, VA Bedford Healthcare System, Bedford, MA; 4Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA; 5Center for Health Optimization and Implementation Research, US Department of Veterans Affairs, Washington, DC. (Control ID #4267785)

Emerging technologies, including multi-cancer early detection tests and novel genetics tests, are poised to usher in a new paradigm of precision prevention. One such example, polygenic risk scores, might help risk-stratify asymptomatic patients for cancer screening, identifying those who need earlier or more frequent screening and those who might be able to delay screening. Polygenic scores might be particularly useful for prostate cancer screening, where current practices with prostate-specific antigen (PSA) testing cannot distinguish low-risk and high-risk men. The implementation strategies needed to help clinicians incorporate polygenic scores into shared decision-making (SDM) conversations about precision screening are unknown.

We recruited a national sample of primary care physicians (MD/DO), physician assistants (PA), nurse practitioners (NP), and nurses (RN/LPN) from primary care practices at Veterans Affairs (VA) medical centers. Semi-structured interviews were used to assess their beliefs, attitudes, and perceived challenges around incorporating polygenic scores into SDM about prostate cancer screening, with the goal of informing the development of implementation strategies to support effective integration into clinical practice. Thematic analysis was conducted and emergent themes coded.

28 interviews have been completed to date (14 MD/DO, 7 NP/PA, 7 RN/LPN). Preliminary analyses from the first 10 interviews (4 MD, 5 NP/PA, 1 LPN) identified the following themes: 1) Changes in Screening Recommendations: Many clinicians indicated that polygenic score results would not change their approach to prostate cancer screening, but for those who would change, it was in the direction of more screening for high-risk men (starting earlier, continuing longer, more often). Very few clinicians anticipated recommending reduction in screening initiation or frequency for low-risk men. 2) Desire for Guidelines/Clinical Pathways: Clinicians indicated they would like more information, in the form of clinical study citations/summaries, or other training to facilitate their use of precision prostate cancer screening. They desired a discrete clinical pathway to inform decisions about whether and how to modify screening protocols based on the polygenic score results. 3) Challenges with Current Recommendations: Clinicians acknowledged not necessarily following current guidelines or engaging with patients in SDM prior to PSA testing in their current practice, making future SDM with polygenic scores even more challenging. No differences by clinical role were observed.

Primary care clinicians perceive value in precision screening for high-risk individuals but anticipate that adding polygenic score results will exacerbate the existing barriers to SDM and guideline-concordant screening. Future work in intervention mapping will further describe these barriers and identify potential strategies to overcome them. PRIVATE EQUITY OWNERSHIP OF US OPIOID TREATMENT PROGRAMS David T. Zhu6; Zirui Song2; Sneha Kannan3; Christopher Cai4; Simar S. Bajaj5; Suhas Gondi1. 1Medicine, Brigham and Women's Hospital, Boston, MA; 2Department of Health Care Policy, Harvard Medical School, Boston, MA; 3Healthcare Policy, Harvard Medical School, Boston, MA; 4Internal medicine, Brigham and Women's Hospital, Boston, MA; 5History of Science, Harvard University, Cambridge, MA; 6Virginia Commonwealth University, Richmond, VA. (Control ID #4270529)

Amid the ongoing epidemic of opioid use and overdose, private equity (PE) firms have acquired numerous opioid treatment programs (OTPs), sometimes referred to as methadone clinics. While PE ownership has been linked to adverse clinical events and increased prices in other health care settings, its role in addiction treatment is less understood. This cross-sectional study examined PE acquisitions of US OTPs.

Within a nationwide dataset of certified OTPs sourced from the Substance Abuse and Mental Health Services Administration, PE acquisitions were identified using Pitchbook and manually verified in January 2024. OTP locations were linked with sociodemographic data (race and ethnicity, income, unemployment, and health insurance status) from the 2022 American Community Survey by zip code. We analyzed characteristics of zip codes with at least 1 PE-owned OTP compared with those with non–PE-owned OTPs using the Wilcoxon rank sum test for income and chi-squared tests for other characteristics.

We identified 1932 OTPs across 50 states. Of these, 562 (29.1%) were PE owned. PE-owned OTPs belonged to 1 of 11 parent companies, each owned by 1 to 2 PE firms. The 3 largest parent companies accounted for 307 (54.6%) of all PE-owned OTPs nationwide. Acquisitions occurred over time: 86 in 1997, 153 in 2005, 193 in 2006, 151 in 2015, 64 in 2017, 57 in 2018, and 11 in 2019. States in the Midwest and South exhibited higher PE penetration. In 14 states, PE firms owned over 50% of OTPs, with 100% PE ownership in 3 states (Montana, Nebraska, and South Dakota). Zip codes with PE-owned OTPs had higher shares of non-Hispanic White residents, lower shares of non-Hispanic Black and Hispanic residents, and lower median household incomes compared with zip codes with non–PE-owned OTPs. Zip codes with PE-owned OTPs exhibited small differences in the average unemployment rate and health insurance payer mix. These differences were consistent in sensitivity analyses comparing zip codes with non–PE-owned OTPs with zip codes with 2 or more PE-owned OTPs or both types of OTPs.

This study found that 29.1% of US OTPs were owned by PE firms, exceeding PE penetration in other sectors of health care (2%-11%). Overall, 54.6% of PE-owned OTPs were owned by 3 parent companies, reflecting significant market concentration. PE-driven consolidation has been observed in other areas, including physician practices, motivating scrutiny from the Federal Trade Commission and legislators. The prevalence of PE ownership among OTPs raises concerns about competition, access, and quality of care including clinical outcomes. PE-owned OTPs tended to be in areas with higher shares of White individuals and those with lower income, possibly reflecting the historically higher prevalence of OUD in White populations, geographic preferences consistent with other PE health care acquisition trends, or strategic targeting of commercially insured patients. PROPORTION OF BEHAVIORAL HEALTH SPENDING BY PAYER AND VISIT MODALITY AMONG U.S. ADULTS WITH COMMERCIAL INSURANCE, MEDICAID, OR MEDICARE ADVANTAGE, 2019-2023 Artem Romanov1; Lauryn Walker2; Melody Craff3; Dale Skinner4; Michael Hadfield5; Lucinda B. Leung6; Jonathan Cantor8; John N. Mafi7. 1General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 2None, Virginia Center for Health Innovation, Midlothian, VA; 3MedInsight, Milliman Inc, Seattle, WA, US, Seattle, WA; 4MedInsight, Milliman Inc Seattle, Seattle, WA; 5Strategic Analytics, MCG Health, Seattle, WA; 6Division of General Internal Medicine, UCLA David Geffen School of Medicine & West LA VA Medical Center, Los Angeles, CA; 7Medicine, University of California Los Angeles, Los Angeles, CA; 8RAND Corporation, Santa Monica, CA. (Control ID #4273189)

The COVID-19 pandemic and changes in both federal and state policy caused transformative changes in behavioral healthcare delivery. Telehealth has become a key component of behavioral health services. However, changes in behavioral health spending during the rapid expansion of telehealth remain unknown. To inform this question, we use national claims data for commercial, Medicaid, or Medicare Advantage payers (83.3% of coverage in 2023). We quantify changes in the proportion of behavioral health spending across these payers and visit modalities during 1/1/2018-10/31/2023.

We performed a retrospective cohort analysis of claims from the de-identified Milliman MedInsight Emerging Experience Research Database, observing spending in U.S. dollars per patient from 1/1/2018-10/31/2023 across visit modality and payer. Spending included paid amounts to providers by both payer and patient. Our cohort consisted of adult patients enrolled in Medicaid, Medicare Advantage (MA), or commercial plans from all 50 U.S. states with continuous coverage over the study period. Behavioral health claims were defined by the AHRQ Clinical Classification Software Refined grouper for Mental, Behavioral, and Neurodevelopmental Disorders, including both mental health and substance use disorders.

Our cohort consisted of 2.6 million insured U.S. adults (mean age: 54.2 years, 55% female), exhibiting a 40% relative increase in overall behavioral health spending per member per month from 2019 to 2023. Over this time period, the proportion of behavioral health spending on services rendered by telehealth increased substantively, rising from 0.6% of 2019 cohort behavioral health spending to 19.3% in 2023 while in-person visits decreased (99.4% in 2019, 80.7% in 2023). There were differences in the growth rate by payer. The average proportion of behavioral health spending by the commercially insured rose from 20.9% of cohort behavioral health spending in 2019 to 23.8% in 2023, a 13.8% relative increase. Medicaid and MA exhibited relative decreases in their proportion of behavioral health spending over the same period (3.2% and 6.6%, respectively). There were further differences in the proportion of in-person behavioral health spending growth among payers between 2019-2023. In-person spending for Medicaid increased by 1.9% on the relative scale from 2019-2023. The commercially insured and MA exhibited respective 0.4% and 0.6% relative declines in in-person visit spending. The proportion of behavioral telehealth among payers also differed between 2019-2023, with decreases in Medicaid spending proportions contrasting with increases in commercial and MA behavioral telehealth spending (Medicaid: 62.6% in 2019, 18.3% in 2023; Commercial: 11.9% in 2019, 33.6% in 2023; MA: 25.4% in 2019, 48% in 2023).

Behavioral health spending rose between 2019-2023. Behavioral health spending increased among commercially insured and declined among Medicaid and MA, raising concerns about disparities by payer. PROVIDER PERSPECTIVES ON PRESCRIBING BUPRENORPHINE FOR CHRONIC PAIN: “IT’S ALWAYS MARRIED WITH OPIOID USE DISORDER” Abigail L. Haber1; M B. Hribar2; Laurie J Bauman3; Jessica S. Merlin4; Michele Buonora5; Ivelina I. Arnaoudova2. 1Division of General Internal Medicine, Albert Einstein College of Medicine, Albert Einstein College of Medicine, New York, NY, US, academic/medsch, New York, NY; 2Division of General Internal Medicine, Albert Einstein College of Medicine, New York, NY; 3Montefiore Medical Center, New York, NY; 4General Internal Medicine, University of Pittsburgh, Pittsburgh, PA; 5Department of Medicine, Montefiore Medical Center, New York, NY. (Control ID #4273010)

The partial opioid agonist buprenorphine is recently recommended as a first-line opioid when opioids are needed for chronic pain, including in the absence of opioid use disorder (OUD). However, many questions remain for prescribing buprenorphine for chronic pain in real-world settings. To inform future implementation efforts, we conducted a qualitative study to understand the determinants of provider adoption of buprenorphine for chronic pain.

We recruited primary care providers (PCPs) for semi-structured interviews. PCPs were purposively sampled to include those with and without experience prescribing buprenorphine. Interviews were conducted virtually by a study coordinator, lasted 30-40 minutes, and were audiotaped and transcribed. We used an inductive thematic analytic approach to analyze the data, developing and revising the coding scheme and identifying central themes.

We interviewed 12 PCPs with a mean of 11 years of clinical experience; 9 had prescribed buprenorphine for OUD and 4 had prescribed buprenorphine for chronic pain. PCPs recognized the advantages of buprenorphine over full agonist opioids for chronic pain, particularly regarding safety, but they were reluctant to use it. There was substantial agreement on the reasons. First, PCPs emphasized that buprenorphine is still an opioid; as such, they had concerns about risks (including physical dependence) and were not convinced about its benefit for chronic pain. Second, buprenorphine was seen as stigmatizing because it is used primarily as a treatment for OUD. PCPs were concerned that covering providers or pharmacists would assume the patient had OUD, and patients would reject taking a medicine used for OUD. Third, providers were uncertain about analgesic efficacy, risks, and how to initiate and dose buprenorphine for chronic pain. PCPs worried whether it would be effective for pain or if the evidence is robust enough to conclude that buprenorphine is the answer for chronic non-cancer pain. A less prominent concern was the time needed for “tricky conversations” with patients.

While acknowledging the safety benefit of buprenorphine over full opioid agonists, PCPs had serious reservations about prescribing buprenorphine for chronic pain. Interventions to increase use of buprenorphine for chronic pain will have to address two related barriers: provider and patient stigma due to its association with OUD, and PCP skepticism about its efficacy for chronic pain. More research is needed to better understand the roots of PCP clinical uncertainty and to build the evidence base to address it. REDRESSING RACE-BASED MEDICINE: A DIFFERENCE-IN-DIFFERENCES ANALYSIS OF HOW A NATIONAL WAIT TIME MODIFICATION POLICY AFFECTED KIDNEY TRANSPLANTATION INEQUITIES Rohan Khazanchi1,2; Aaron Fleishman7; Kenneth Michelson5; Nwamaka D. Eneanya4; Michelle Morse3; Martha Pavlakis6. 1Departments of Internal Medicine and Pediatrics, Brigham and Women's Hospital, Boston, MA; 2Harvard T H Chan School of Public Health Francois-Xavier Bagnoud Center for Health & Human Rights, Boston, MA; 3New York City Department of Health and Mental Hygiene, New York, NY; 4Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA; 5Department of Emergency Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL; 6Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 7Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA. (Control ID #4271502)

Chronic kidney disease (CKD) affects one in seven U.S. adults and has a disproportionate impact on marginalized communities. Although end-stage kidney disease incidence is four times higher among Black patients, White patients are more likely to receive a kidney transplant within three years of being waitlisted. Until 2021, national guidelines upheld race-based estimated glomerular filtration rate (eGFR) equations which inflated kidney function estimates by up to 21% for Black patients, delaying subspecialist referral and transplant waitlisting. In January 2023, the Organ Procurement and Transplantation Network (OPTN) mandated that all U.S. kidney transplantation programs submit wait time modifications for Black candidates whose waitlisting was delayed by race-based eGFR equations. We evaluated the impact of this policy on kidney transplantation trends.

We analyzed a national OPTN registry of all adult patients waitlisted for kidney transplant from 2022-2024, excluding a 3-month implementation “washout period” (1/1/2023-3/31/2023) with very few modification approvals. We excluded candidates who were prior transplant recipients, listed for multiple organs, or inactive on the waitlist. We performed a difference-in-differences (DiD) analysis using hierarchical logistic regressions with an interaction term between binary indicators for race (Black vs. non-Black) and time period (pre- or post-implementation), random intercepts for patients nested within centers, and covariates including age, sex, body mass index, ABO type, dialysis initiation, primary insurance, and OPTN region.

Among 51,297 Black and 112,310 non-Black waitlist registrations, 22,670 Black candidates received wait time modifications which added a median 1.6 years (IQR 0.7-2.8, max 21.2) and a total 47,706 years of additional waitlist time. In adjusted models, OPTN’s policy increased Black candidates’ overall monthly transplantation rate by 6.7 transplants per 1000 waitlist registrations (95%CI 5.0, 8.4), which corresponded to an estimated 218 additional Black transplant recipients (95%CI 163, 273) during the study period. The policy increased Black candidates’ rate of DDKT (DiD +7.9 per 1000 waitlist registrations [95%CI 6.1, 9.6]), pre-dialysis transplantation (+9.1 per 1000 [6.1, 12.1]), and post-dialysis transplantation (+6.2 per 1000 [4.5, 8.0]) with minimal effects on Black LDKT rates (-0.8 per 1000 [-1.5, -0.2]).

Two years after implementation, a nationwide restorative justice intervention to redress the harms of race-based eGFR led to over two hundred additional kidney transplants among Black patients, with minimal effects on Black living donors. Our findings can inform broader efforts to monitor and remedy harms caused by race-based clinical algorithms. SEVERITY OF ALCOHOL-RELATED HOSPITALIZATIONS FOLLOWING THE ONSET OF THE COVID-19 PANDEMIC: A POPULATION-BASED COHORT STUDY Wid Yaseen2; Brandon Zagorski1; Ping Li1; Donald Redelmeier2,1; Jonathan S. Zipursky2,1. 1ICES, Toronto, ON, Canada; 2Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, ON, Canada. (Control ID #4269823)

Alcohol use and alcohol-related hospitalizations increased during the COVID-19 pandemic; however, whether hospitalizations were more severe is unknown. The objective of this study was to examine the severity of alcohol-related hospitalizations following the onset of the COVID-19 pandemic.

We performed a population-based cohort study of alcohol-related hospital admissions in Ontario, Canada using administrative health data. We identified alcohol-related hospitalizations over a 6-year period (March 1, 2016 to February 28, 2022). We divided the study period into two phases: before pandemic (2016 to 2020) and during pandemic (2020 to 2022). To assess the severity of alcohol-related admissions, we used generalized estimating equations with a Negative Binomial distribution to compare hospital length of stay and other complications (critical care admission, in-hospital mortality, 30-day mortality, one year mortality, and 30-day readmission) in the two study periods.

We identified 165,001 (98%) alcohol-related admissions, of which 107,030 (65%) occurred in the 4 years before pandemic and 57,971 (35%) in the 2-years following the onset of the pandemic. The typical admitted patient was a 54-year-old male, living in an urban setting, with a history of alcohol use and anxiety. The mean length of hospital stay was 13.1 days (standard deviation [SD] 43.3) following the onset of the pandemic, and 12.1 days (SD 29.7) before the pandemic. After adjustment, hospital length of stay was marginally shorter for alcohol related admissions during the pandemic (relative risk [RR] 0.94; 0.91 to 0.97); which was mainly driven by shorter hospital stays for mental health admissions. Compared to alcohol-related admissions pre-pandemic, those during the pandemic were characterized by increased 30-day mortality (RR 1.09; 1.04 to 1.14), one-year mortality (RR 1.13; 1.08 to 1.18), 30-day readmission (RR 1.09; 1.06 to 1.14), and a decreased risk of ICU admission (RR 0.95; 0.93 to 0.98).

Compared to alcohol-related hospital admissions pre-pandemic, those in more recent years were associated with higher risks of re-admission, as well as mortality, thereby suggesting some increases in the severity of alcohol-related hospitalizations. Conversely, decreases in alcohol-related ICU admissions likely reflect critical care resource allocation to acute respiratory diseases. Targeted public health interventions, including alcohol use screening programs, risk factor mitigation, access to addiction treatment, and initiation of evidence-based pharmacotherapy are necessary to address alcohol-related health complications as well as long-term sequelae of alcohol use. SHOULD MENTAL HEALTH SCREENING FOR ADOLESCENTS BECOME A STANDARD OF CARE? REAL-WORLD RESULTS FROM THE ELEVATE TEEN PROGRAM Anika Sharma2; Anvi Atreja2; Ashish Atreja1. 1Internal Medicine, UC Davis Health, Sacramento, CA; 2Junior High, Davis, CA. (Control ID #4272633)

Adolescent mental health is a significant and growing public health concern, with depression and anxiety being the most prevalent yet frequently underdiagnosed conditions. These challenges are particularly pressing, as half of all lifetime mental health disorders emerge by age 14. To address gaps in early detection and intervention, we developed ELEVATE (Education, LEarning, Validated Assessment, Triage, and Empowerment) Teens—an interactive, digital mental health screening and risk-identification tool tailored specifically for adolescents.

We utilized a cross-sectional design to evaluate the prevalence and severity of depression and anxiety symptoms among middle school students aged 12–15 years participating in the ELEVATE Teens Program. The voluntary program was implemented following approval from school administration and teachers. Participants were recruited from a junior high school in California and completed a brief anonymized electronic survey derived from the validated PHQ-9 (Patient Health Questionnaire) and the Mayo Clinic Screening Inventory. Survey design was iteratively refined, and user acceptance testing (UAT) was conducted with 50 pilot surveys to ensure usability and reliability. We used R for statistical analysis and visual representations of our results.

A total of 100 students (30 seventh-graders, 70 ninth-graders) were invited to participate, with 91 completing the survey, achieving a response rate of 91%. PHQ-9 scores ranged from 0 to 27, with a mean score of 7.73, indicating moderate depression across the cohort. Overall, 57.1% (52/91) of participants reported symptoms consistent with mental health concerns, with the most commonly reported issue being "feeling tired or having little energy," experienced daily by many students. Alarmingly, 17.6% (16/91) exhibited symptoms indicative of moderately severe to severe depression, and 14.2% (13/91) reported having suicidal thoughts nearly every day. Nonparametric tests (Mann-Whitney U and Kruskal-Wallis) revealed no statistically significant differences in mental health scores by gender or race.

School-based mental health screening demonstrates high feasibility and acceptance among adolescents. More than half of the surveyed students exhibited some form of mental health symptoms, with 1 in 6 reporting severe depression accompanied by suicidal ideation, underscoring an urgent need for early identification and targeted intervention. Guidelines need to include universal mental health screening and future studies should evaluate if a hybrid interventional approach with self-care, mindfulness and digital resources for low risk students coupled with referral to medical care for high risk students- can be an effective strategy. SOCIODEMOGRAPHIC, HEALTH, AND UTILIZATION CHARACTERISTICS OF ADULT MEDICAID ENROLLEES UNAWARE OF THEIR COVERAGE STATUS Daniel B. Nelson1; Jane M. Zhu1; Kenneth J. McConnell2; Benjamin D. Sommers3,4. 1Medicine, Oregon Health & Science University School of Medicine, Portland, OR; 2Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, OR; 3Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA; 4Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4273004)

Many Medicaid enrollees mistakenly report that they do not have coverage when surveyed, a phenomenon that grew during the COVID-19 continuous coverage policy. Little is known about the sociodemographic characteristics, health status, and patterns of utilization of this enrolled and unaware population. If the enrolled and unaware avoid necessary care because they misunderstand their enrollment status, enrollment unawareness could pose a significant barrier in access to care.

We used longitudinal data from the Medical Expenditure Panel Survey from 2020-2022, exploiting the COVID-19 Public Health Emergency (PHE) pause on Medicaid disenrollment. Because Medicaid enrollees generally could not be disenrolled during the PHE (unless they moved states or requested disenrollment), we designated respondents as “enrolled and unaware” if they report having and subsequently not having Medicaid coverage during the PHE. Our analysis included nondisabled adults under age 65, as this group was subject to the PHE disenrollment pause. We used linear regression to evaluate the association between individual-level sociodemographic and health characteristics and whether someone is unaware vs. aware of enrollment status (among all Medicaid enrollees) or reports uninsurance vs. non-Medicaid insurance (among the enrolled and unaware). We then evaluated the association between insurance reporting and access and utilization outcomes by estimating linear regression models adjusted for sociodemographic and health characteristics.

Of those reporting Medicaid coverage, 16.8% subsequently reported not having Medicaid coverage, despite remaining enrolled. Of the enrolled and unaware, 41.1% reported being uninsured, 27.3% reported private group insurance, 8.6% reported Medicare insurance, and 23.0% reported another insurance source. Compared to those aware of their Medicaid enrollment, the unaware were disproportionately young, had higher incomes, and lived in the South. The enrolled and unaware who were female, had less than a high school education, were unemployed, lived in the South, or reported good baseline health were more likely to report being uninsured rather than non-Medicaid insurance. The enrolled and unaware were less likely to have a usual source of care (-5.4 pp, [95% CI: -10.2, -0.6]) and had fewer prescription fills (-0.09 [-0.16, -0.01]) and outpatient visits (-0.18 [-0.33, -0.03]). Enrolled and unaware adults who reported uninsurance were less likely to have a usual source of care (-13.8 pp [95% CI: -25.4, -2.3]) or any health care spending (-29.1 pp [-43.4, -14.8]) and had fewer prescription fills (-0.5 [-0.9, 0.1]) but were more likely to delay care due to cost (23.2 pp [5.2, 41.2]).

The enrolled and unaware reported more barriers to access and less health care utilization relative to those aware of their coverage status, with effects concentrated among those who reported uninsurance, suggesting the enrolled and unaware face underappreciated barriers to care. SPENDING & USE OF DENTAL AND VISION SERVICES AMONG VETERANS IN MEDICARE ADVANTAGE VS. TRADITIONAL MEDICARE Adam L. Beckman1; Dannie Dai2; Jose F. Figueroa2; Christopher Cai3. 1Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Harvard T H Chan School of Public Health, Boston, MA; 3Internal medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4272984)

Veterans with Department of Veterans Affairs (VA) benefits are increasingly enrolling in Medicare Advantage (MA) plans. This trend raises concerns about duplicative federal spending, as recent evidence found 1 in 10 such veterans had zero Medicare services in a given year paid by MA plans. In these cases, the veteran primarily receives care paid for by VA, while MA plans still receive ~$12,000 annual capitated rates from the government. Recently, some MA plans contended that their supplemental benefits, including dental and vision care, justify these payments. Therefore, the objective of this study was to compare spending and utilization patterns for dental and vision services among veterans enrolled in MA versus those in traditional fee-for-service Medicare (TM).

We identified veterans enrolled in Medicare using the Medical Expenditure Panel Survey (MEPS) from 2018 to 2021, a national survey of community-dwelling adults that captures dental and vision spending better than Medicare claims. We compared risk-adjusted dental visits and risk-adjusted spending on dental and vision services paid by Medicare using a series of linear regression models, which adjusted for age, sex, race/ethnicity, and the presence of chronic conditions. State-fixed effects were included in the models. MEPS survey weights were applied to results.

The study included 481 unique veterans enrolled in MA (695 person-years) and 677 unique veterans enrolled in TM (1,140 person-years) between 2018 to 2021, representing millions of veteran person-years after survey weighting. Weighted demographics included age (95.9% of MA-veterans and 92.9% of TM-veterans were aged 65 or older, SMD 0.13); sex (91.4% MA vs. 92.8% TM were male, SMD 0.4); White race (75.7% MA vs. 77 % TM, SMD 0.03), and comorbidities such as heart disease (43.6% MA vs. 39.9% TM, SMD 0.08) and emphysema (7.8% MA vs 11% TM, SMD 0.11). After adjustment for demographic and clinical characteristics, veterans in MA plans had higher spending on vision services paid by Medicare ($8.40 per person in MA vs. $2.30 in TM, adjusted difference +$6.10, 95% CI 0.30 to 12.00, p=0.04) and dental services ($85.60 per person in MA vs. $4.10 in TM, difference +$81.50, 95% CI 49.60 to 113.50, p<0.001). The number of annual dental visits did not differ significantly between groups (1.0 visit per year in MA and 1.0 visit in TM, difference 0.0, 95% CI -0.2 to 0.2).

Veterans enrolled in MA plans exhibited only modestly higher Medicare spending on dental and vision care compared with TM enrollees. These data do not support previous claims from MA plans that capitated ~$12,000 annual capitated payments are justified by the cost of supplemental benefits for vision and dental care, particularly for veterans in MA who receive all their medical care paid for by VA. Federal policymakers can consider reforms to MA payment structures to address duplicative federal spending. STATE REGULATION OF IV HYDRATION SPAS: A POLICY LANDSCAPE REVIEW Anishaa Sivakumar1; Howard Forman3; Joseph S. Ross2. 1Internal Medicine, Yale University School of Medicine, New Haven, CT; 2Internal Medicine, Yale School of Medicine, New Haven, CT; 3Radiology, Yale University School of Medicine, New Haven, CT. (Control ID #4240469)

Over the past decade, the number of IV hydration spas in the United States has grown. These facilities offer IV infusions of hydration solution and other supplements but are exempted from most routine FDA oversight as compounding pharmacies. Instead, state governments are predominantly responsible for regulation and oversight. We conducted a landscape review of existing state policies for regulation of IV hydration spas to better understand standards of care and procedures to ensure public health safety.

In June 2024, we conducted Google searches using standard terms for IV hydration and medical spa regulation and policies for all 50 U.S. states and the District of Columbia. State issued public-facing regulatory laws or statements were collected, including position statements or meeting minutes establishing board positions and association guidelines based on state regulatory codes; state policies regulating cosmetic medical procedures other than IV therapies were excluded. Content analysis was used to determine whether state policies explicitly addressed four aspects of IV hydration spa oversight: governance, prescriber credentials, dispensing practices, and compounding practices. We used descriptive statistics to summarize our findings.

No legislation had been introduced in any U.S. state or the District of Columbia to regulate IV hydration spas. Statements regarding governance of IV hydration spas were issued by 6 (11.7%) states, most commonly permitting the corporate practice of medicine (CPOM) if the physician, APRN or PA-C had exclusive authority over medical decision-making. While some states, like California, have extensive CPOM and scope of practice policies, they had not issued statements regarding IV hydration spas. Twelve (23.5%) states provided prescribing practice guidelines, typically requiring a licensed medical professional to prescribe IV therapy. Thirty-one (60.7%) states provided guidance on dispensing, including 17 (33.3%) that only issued statements on nursing scope of practice, most commonly whether licensed practical nurses can independently dispense IV fluids, with notable variation in scope of practice of different nurse certifications. Finally, 8 (15.6%) states issued guidance on compounding practices, although guidance varied widely. Four (7.8%) states, Alabama, North Carolina, South Carolina and Vermont, issued policies addressing all four oversight categories, while 31 (60.8%) states had issued policies addressing at least one oversight category.

While 31 states have issued some form of guidance regarding IV hydration spas, most were limited to guidance on dispensing that related to nursing scope of practice, leaving numerous gaps in state regulatory oversight. Inconsistent or limited regulation may not be sufficient to protect consumer health. Future work should investigate both the variation in state law and the impact of established stances on implementation of IV hydration spas. TEACH-BACK EFFECTIVENESS AND IMPLEMENTATION: A SYSTEMATIC REVIEW Judith Vick1,2; Rachel Pace3; Adelaide Gordon4; Morgan Jacobs4; Ryan Crossgrove4; Sarah Cantrell5; Jennifer M. Gierisch6,8; Karen Goldstein7,6. 1Internal Medicine, Yale University School of Medicine, New Haven, CT; 2Durham VA Health Care System, Durham, NC; 3Ambulatory Care Services, Durham VA Health Care System, Durham, NC; 4Health Research Services and Delivery, Veterans Health Administration, Washington, DC; 5Medical Center Library & Archives, Duke University School of Medicine, Durham, NC; 6Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT, Durham VA Health Care System, Durham, NC; 7Division of General Internal Medicine, Duke University School of Medicine, Durham, NC; 8Duke University School of Medicine, Durham, NC. (Control ID #4272472)

Teach-back is a communication strategy in which a healthcare professional gives information, and the recipient is asked to repeat back the information in their own words to ensure understanding. Effectiveness and optimal implementation of teach-back in real-world settings are incompletely characterized. Our aims are to synthesize existing evidence on teach-back effectiveness on proximal outcomes (Figure), and strategies for its implementation.

We assembled a multidisciplinary team via the VA Evidence Synthesis Program, including members with expertise in health education, clinical medicine, nursing, implementation science, and library science. We searched three databases (MEDLINE, Embase, and CINAHL) from 2018 to 2024 and hand-searched prior systematic reviews (the most recent of which was published in 2019) for additional eligible articles. Two independent reviewers screened titles/abstracts and assessed full texts for eligibility. Data extraction, risk of bias assessments, and preliminary analysis are currently underway. We a priori specified that we would prioritize extraction from randomized controlled trials (RCTs) assessing effectiveness and all implementation studies. To organize implementation strategies, we are using the Patient-Centered Outcomes Research Institute (PCORI) implementation strategy categories.

Our search yielded 4575 studies. After removal of duplicates, 2671 titles/abstracts were screened, yielding 170 for full-text review. Ultimately, 36 studies were eligible for inclusion. Per our a priori prioritization, we are abstracting outcomes data for 16 RCTs addressing teach-back effectiveness and 7 studies (6 pre-post study and 1 single-arm pilot) addressing implementation. Preliminary findings show that of the 16 RCTs, 2 took place in the US with the rest taking place in Sweden, Turkey, Iran, Australia, and China. The RCTs took place in a variety of settings (6 outpatient; 9 inpatient; 1 Emergency Department) and disease contexts including heart failure (n=3), diabetes (n=3), post-operative care (n=2), coronary artery disease (n=1), breastfeeding (n=1), myocardial infarction (n=1), rheumatologic diseases (n=1), obstructive lung disease (n=1), ophthalmologic disease (n=1), post emergency department care (n=1), and chronic Hepatitis B (n=1). Of the 7 studies that addressed implementation, all took place in the US with 6 in the inpatient setting and 1 in the outpatient setting. Studies typically used more than one PCORI implementation strategy such as “training site staff and clinicians” and “preparing sites for implementation.” Full data extraction, risk of bias assessment, and synthesis will be complete by February 2025.

Our systematic review includes 16 RCTs of teach-back effectiveness and 7 non-randomized studies evaluating the impact of implementation strategies in clinical settings. Included studies were conducted in heterogeneous countries, settings, and clinical contexts. THE APPLICABILITY OF A MEDICARE DEFINITION OF AVOIDABLE HOSPITAL VISITS Arthur Hong1; Pranathi Pilla2; Michael Dang2; Vincent Merrill4; Kathryn Anderson2; Ethan Halm3. 1Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 2General Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX; 3Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; 4Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX. (Control ID #4273037)

As part of the Outpatient Quality Reporting program, Medicare reports on potentially avoidable, acute hospital visits after chemotherapy, using fee-for-service claims. This measure aggregates emergency department visits, observations, and inpatient admissions for 10 avoidable conditions (e.g. pain, vomiting), within 30 days of a chemotherapy infusion. In the literature, largely only the avoidable diagnosis codes are applied: it can be impractical to apply clinic-level changes only to Medicare fee-for-service enrollees, and large, nationally-representative, hospital visit datasets do not contain chemotherapy infusion dates. There has been little scrutiny of using such variations of this measure.

We used a population-based cohort of incident cancers (2015-2023) from two sites: an academic medical center and safety-net health system, and identifiably linked patients to their comprehensive hospital use from a regional health information exchange (all non-federal hospitals within a 150-mile radius of Dallas, TX). We tracked avoidable hospital visits for each measure specification: diagnosis codes alone; within 30 days of chemotherapy; only the first visit in a 30-day span; only Medicare fee-for-service. We used mixed-effects (clustered to patient) multivariate logit to model avoidable visits occurring within or outside of a chemotherapy 30-day window; and avoidable vs. non-avoidable hospital visits across payors, adjusting for clinical, cancer, and demographic variables.

We linked 31,305 incident cancer diagnoses (mean age 64; 50.6% female; 57.7% Black or Hispanic; 23.6% advanced stage cancer; 19.2% gastrointestinal cancer, 12.2% breast, 9.2% lung) to 190,967 visits at 76 hospitals. Although 28.0% (n= 54,233) had a primary or secondary diagnosis of an avoidable condition, only 24.3% (n=13,179) of those were within 30 days of chemotherapy. After excluding multiple visits in the 30-day span, 9.1% (4,917 of the 54,233 avoidable conditions visits) remained, with 14.0% (n=689, or 1.3% of 54,233) under Medicare fee-for-service (1.6% Medicare Advantage, 30.2% commercial, and 54.4% uninsured/Medicaid). In adjusted analyses, avoidable conditions were significantly more likely to occur within 30 days of chemotherapy than outside of it (aOR 1.34, 95% CI: 1.27-1.40, p < 0.001); and compared to Medicare fee-for-service, commercially-insured encounters had significantly higher odds of avoidable hospital visit (aOR 1.31, 95% CI: 1.12–1.50, p < 0.001).

Three-quarters of hospital visits for avoidable conditions occurred outside of a 30-day span after chemotherapy, though in adjusted analysis, avoidable visits were more likely to occur soon after chemotherapy. As little as 1.3% of visits for avoidable conditions were captured by the Medicare definition used to report to hospitals, and commercially-insured visits had higher likelihood of an avoidable visit than fee-for-service Medicare. Further investigation of the clinical utility of this measure may be warranted. THE ASSOCIATION BETWEEN RECEIPT OF PHARMACOTHERAPY FOR SUBSTANCE USE DISORDER AND HEALTHCARE UTILIZATION AMONG US ADULTS WITH ALCOHOL OR OPIOID USE DISORDER, 2022 Daniel X. Pham1; Sneha Nagavally3; Laura Hawks2,3. 1Internal Medicine/Psychiatry, Medical College of Wisconsin, Milwaukee, WI; 2General Internal Medicine, Medical College of Wisconsin, Wauwautosa, WI; 3Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4271799)

Every year, millions of US adults with substance use disorders interface with the health care system, having higher rates of emergency department visits and hospitalization than the general population. FDA-approved medications exist for alcohol (AUD) and opioid use disorder (OUD), with some data suggesting that they decrease acute care utilization for addiction-related issues. The objective of this study is to determine the association between recipient of medication for alcohol use disorder (MAUD) or opioid use disorder (MOUD) and healthcare utilization in a cross-sectional nationally representative sample of US adults with AUD or OUD.

Using data from the National Survey of Drug Use and Health 2022, we included US adults with alcohol or opioid use disorder and tested the association between self-reported receipt of pharmacotherapy for addiction (compared to none), on health care utilization (inpatient, ER visits, and outpatient) using negative binomial regression models adjusted for socio-demographic covariates. The main outcome measures were self-reported number of visits to the emergency department, nights spent hospitalized, and number of outpatient visits in the past 12 months.

In a sample weighted to represent 30,625,613 respondents with substance use disorder, only 5.28% reported use of medication for addiction treatment in the past 12 months. In adjusted models, receiving pharmacotherapy for substance use was associated with increased outpatient use (IRR 1.48; 95% CI 1.10, 2.02); increased number of nights hospitalized (IRR 3.53; 95% CI 1.37, 9.11); increased number of times treated in the ED (IRR 1.78; 95% CI 1.17, 2.70).

In this nationally representative sample of adults with substance use disorder, receipt of medications for addiction in the past year was rare. Individuals receiving MAUD or MOUD reported have higher rates of all forms of healthcare utilization, but particularly in inpatient settings and ED settings. It is possible that people are often screened for and initiated on pharmacotherapy after a decompensation requiring acute care utilization. The findings underscore the need to identify best practices in outpatient settings to screen and initiate treatment for individuals with substance use disorders, ideally prior to a decompensation requiring higher level of care. THE ASSOCIATION BETWEEN TELEMEDICINE AND U.S. AMBULATORY CARE PATTERNS, 2018-2023 John N. Mafi1; A. Mark Fendrick2; Michelle S. Rockwelll3; Chi-Hong Tseng4; Sitaram Vangala5; Catherine Sarkisian4; Cheryl L. Damberg6; Artem Romanov7; Manying Cui8; Katherine L. Kahn1. 1Medicine, University of California Los Angeles, Los Angeles, CA; 2Internal Medicine, University of Michigan, Ann Arbor, MI; 3Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; 4Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 5Medicine, University of California, Los Angeles, Los Angeles, CA; 6Health Care, RAND Corporation, Santa Monica, CA; 7General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 8General Internal Medicine, University of California Los Angeles Health System, Los Angeles, CA. (Control ID #4273235)

The future of telemedicine payment policy remains uncertain, carrying implications for patients’ ability to access U.S. ambulatory care. Although research has previously focused on telemedicine’s overall association with care patterns, less is known about telemedicine’s heterogenous effects across various subgroups. We examined the association between greater regional telemedicine exposure and changes in ambulatory care visits across geographies, ruralities, and care settings.

We employed difference-in-differences analyses on total ambulatory visit rate changes in 1/1/2019-12/31/2019 vs 1/1/2021-10/31/2023. The study’s data source was the MedInsight’s de-identified multi-payer research database, which includes claims data from major payers across all 50 states. We created a cohort of 3.5 million continuously insured adults enrolled in Medicare fee-for-service, Medicare Advantage, Medicare-Medicaid, Medicaid, or commercial plans between 1/1/2018-10/31/2023. The study exposure was comparing patients living in the highest vs lowest hospital referral region (HRR) quintiles of telemedicine use occurring in 1/1/2020-12/31/2020. The primary outcome was total ambulatory visits, defined as the sum of telemedicine and in-person utilization including: primary care, specialist, USPSTF-recommended preventive screening (e.g., cancer screening), and emergency department (ED) visits per 100 patients-per-month. We estimated age-sex-comorbidity adjusted Poisson regressions of monthly total ambulatory visit counts, stratifying findings by U.S. census regions, rurality, and ED settings.

In 2019, the total ambulatory visit rate was 61/100 patients-per-month; mean age: 54.2 years, 56% female. During 1/1/2020-12/31/2020, telemedicine visits ranged from 33% (highest-HRR) to 5% (lowest-HRR). Greater telemedicine exposure in the highest HRR quintile was associated with 3.4% [95% CI 2.8%-4.0%] higher and 4.4% [4.0%-4.7%] lower total ambulatory visits in rural and urban areas, respectively. Telemedicine was not associated with total ambulatory visit changes in the Northeast, though total ambulatory visits increased 6.4% [5.9%-6.9%] and 5.4% [4.2%-6.6%] in the Midwest and West respectively, and decreased 3.1% [2.6%-3.6%] in the South. Telemedicine exposure was associated with reductions in ED visits across rurality and regions, ranging from 7.2% [2.8%-11.4%] fewer visits in the Midwest to 18.5% [23.4%-13.3%] fewer visits in the South.

Greater regional telemedicine exposure was associated with higher and lower total ambulatory visits in rural vs urban areas, respectively. Telemedicine exposure was associated with heterogenous effects based on U.S. census region and consistent reductions in ED visits regardless of location. As the debate over telemedicine payment policy continues, these findings underscore telemedicine’s complex relationship with ambulatory care patterns, which varies widely based on geography, rurality, and the setting of care. THE IMPACT OF SOCIAL RISK FACTORS ON MOBILITY IN 10 YEARS Ro-Jay Reid1; W. Marcus Lambert2; Parag Goyal1; Joanna B. Ringel1; Monika M. Safford1. 1Medicine, Weill Cornell Medicine, New York, NY; 2Epidemiology and Biostatistics, SUNY Downstate Health Sciences University, New York City, NY. (Control ID #4273262)

Mobility is essential to healthy aging and predictive of key outcomes such as mortality, hospital stays, and functional independence. Social risk factors (SRF) accelerate physical decline, but the cumulative impact of SRF on mobility remains poorly understood. We evaluated the relationship between SRF at baseline and mobility 10 years later using the Five-Times Sit-to-Stand Test (FTSST), a measure of lower body strength, and the 8-Foot Walk Test (8FWT), a measure of gait speed. We hypothesized that a greater baseline burden of SRF is associated with worse scores on each of these two tests in a biracial national sample of community dwelling adults.

We used data from the Reasons for Geographic and Racial Differences in Stroke study on 12,461 participants with available data. Baseline measures included health history, health behaviors, and physiologic measures. Mobility was assessed 10 years after baseline. SRF assessed at baseline included education, income, insurance, and neighborhood disadvantage and were quantified as a count (0, 1, 2, ≥3). The primary outcomes were the 10-year follow-up FTSST and 8FWT scores. Race stratified multivariable linear regression models were adjusted for demographics, health behaviors, and medical conditions.

The sample had mean age of 62.6 (8.15 ± SD) years at baseline with 35.2 % self-identified as Black, and 55.2 % as women. For lower body strength, in fully adjusted models among White participants, compared to those with 0 SRF, those with 1 SRF took 0.73 (95% CI 0.39-1.07) seconds longer, those with 2 SRF took 0.92 (95% CI 0.49-1.34) seconds longer, and those with ≥3 SRF took 1.74 (95% CI 1.08-2.39). In fully adjusted models among Black participants, compared to those with 0 SRF, those with 1 SRF took 1.22 (95% CI 0.69-1.76) seconds longer, those with 2 SRF took 1.25 (95% CI 0.68-1.81) seconds longer, and those with ≥3 SRF took 2.25 (95% CI 1.55-2.49) seconds longer to complete the FTSST; the minimal clinically important difference (MCID) is >2.3 seconds. For gait speed, in fully adjusted models among White participants, compared to those with 0 SRF, those with 1 SRF were 0.02 (95% CI 0.01-0.04) meters/second (m/s) slower, those with 2 SRF were 0.05 (95% CI 0.03-0.07) m/s slower, and those with ≥3 SRF were 0.07 (95% CI 0.03-0.10) m/s slower to complete the 8FWT. In age-adjusted models among Black participants, compared to those with 0 SRF, those with 1 SRF had 0.04 (95% CI 0.01-0.06) m/s slower, those with 2 SRF had 0.08 slower (95% CI 0.06-0.11) m/s slower, and those with ≥3 SRF had 0.11 (95% CI 0.09-0.14) m/s slower 8FW scores; MCID is ≥0.05 m/s slower.

A greater number of SRFs was associated with less mobility 10 years later, even after adjusting for multiple individual baseline characteristics. Deficits were greater for Black vs. White community dwellers. THE IMPACT OF THE RURAL RESIDENCY PLANNING AND DEVELOPMENT PROGRAM ON PHYSICIAN TRAINING IN RURAL AND UNDERSERVED AREAS John C. Lin1; Roshan Sapkota2; Cassandra J. Thompson3; Anusha R. Srinivasan4; Dang Nguyen5; Anthony Zhong6; Amber Bird7. 1Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 2University of Nebraska Medical Center College of Medicine, Omaha, NE; 3University of South Dakota, Vermillion, SD; 4Brown University, Providence, RI; 5Harvard T H Chan School of Public Health, Boston, MA; 6Department of Medicine, Harvard Medical School, Boston, MA; 7Medicine, University of Pennsylvania, Philadelphia, PA. (Control ID #4217176)

In 2020, only 2% of residency training occurred in rural areas, which comprise 14% of the US population. Physicians who complete at least 50% of their residency in rural settings are more likely to practice in these areas post-training. In response to physician shortages in rural regions, the Health Resources and Services Administration (HRSA) launched the Rural Residency Planning and Development (RRPD) program in 2019. This program allocated $62 million from 2019 to 2024 to support residency program startup costs, including accreditation, faculty development, and resident recruitment. However, the outcomes of the RRPD program have yet to be evaluated. This study aims to examine the impact of the RRPD on physician training in rural and underserved areas.

We used HRSA data to identify RRPD award recipients, tracking program details, grant amounts, specialty, and recipient organization characteristics. Organization type, location, tax status, and rural/urban designation were collected using state and IRS records and USDA Rural-Urban Commuting Area codes. Training site characteristics and rural or Medically Underserved Area (MUA) training time were obtained from HRSA. We further used Accreditation Council for Graduate Medical Education records and Health Professional Shortage Area (HPSA) designations to calculate training times in HPSAs. Descriptive statistics characterized program and recipient details; 2024-funded organizations were excluded from outcome analysis as their funding may not have yet been distributed.

Between 2019 and 2024, HRSA awarded $62,330,813 to 84 organizations, with median funding of $750,000. The majority of recipients were nonprofit healthcare systems (57%), public universities (26%), or nonprofit universities (10%), with 55% located in urban areas and 88% in HPSAs. Of the 69 organizations funded from 2019 to 2023, 66 residency programs and 312 training sites were established, primarily in family medicine (64%) and internal medicine (8%). Among these sites, 80% were rural, and 96% were in HPSAs. Most reporting programs (98%) allocated at least 50% of training time to rural areas, while 87% of training time was in MUAs or HPSAs.

The RRPD program successfully supported the development of 249 residency positions, primarily in rural and underserved areas, despite financial and management challenges faced by a few recipients. Compared to other funding initiatives, RRPD demonstrated high rural placement rates, with 98% of programs meeting rural training targets. Limitations include the study's retrospective design and reliance on HRSA data. Future research should examine the sustainability of RRPD-supported programs and rural practice patterns post-residency. Given its success, expanding RRPD funding could further enhance physician distribution in rural and underserved areas. THE IMPACT OF THIRD-PARTY CONVENERS ON CLINICIAN NETWORKS: EVIDENCE FROM THE MEDICARE SHARED SAVINGS PROGRAM Adam Markovitz1; Jay Shroff2; Hayden Rooke-Ley2; Andrew Ryan2. 1Internal Medicine, University of Michigan Michigan Medicine, Ann Arbor, MI; 2Health Services, Policy, and Practice, Brown University, Providence, RI. (Control ID #4272861)

Accountable Care Organizations (ACOs) – where clinicians form networks to take accountability for total costs – have emerged as Medicare’s key strategy to reduce cost growth. The Medicare Shared Savings Program (MSSP), Medicare’s flagship program, intends for ACOs to form local, clinically coherent networks that collaboratively care for mutual patients. ACOs earn bonuses if spending is below a target (benchmark). As clinicians struggle to meet MSSP demands, private consulting firms – or conveners – have emerged to help aggregate clinicians into ACOs. In theory, conveners can help ACOs pool financial risk and share panel management platforms. However, conveners may game benchmarks by cherry picking low-cost physicians anywhere in the country - regardless of whether those clinicians share mutual patients or coordinate care. Despite this, little is known about the impact of conveners in the MSSP. We study how geographic dispersion of ACO networks has evolved over time, if convener ACOs create more dispersed ACOs, and whether dispersed ACOs are more likely to beat regional benchmarks.

First, we used the MSSP research files (2012-2021) to measure geographic dispersion of ACOs. Higher ACO dispersion suggests less linkage and coordination between clinicians. Dispersion was measured via the Herfindahl-Hirschman Index (HHI): 0 being fully dispersed (no ACO clinicians in contiguous counties); 10,000 being fully concentrated (all clinicians in contiguous counties). Second, we estimated linear regression models to test whether convener ACOs were more likely to earn shared savings (2012-2021) or beat regional benchmarks (2019-2021). Because there is no national database of ACO conveners, we used industry reports to identify conveners and then established convener relationships using email addresses for ACO executives and contacts in public MSSP files. Third, we estimated linear regression models to test whether dispersed ACOs were more likely to beat regional benchmarks and whether this varied across convener vs. provider ACOs.

Mean HHI was 7747 (SD, 1901). Convener ACOs represented 22% of contracts. Convener ACOs became more dispersed over time, with convener and provider ACO HHI decreasing by 4.3% and 0.8% per year, respectively (Figure shows example of highly dispersed convener ACO). Convener ACOs were 13 percentage points (pp) more likely than provider ACOs to beat regional benchmarks (94% vs. 81%, 95% confidence interval [CI], 5pp, 21pp) and earned $104 more per beneficiary per year in shared savings ($247 vs. $143, 95% CI, $41, $168). Dispersed ACOs were not more likely to beat regional regional benchmarks or earn greater shared savings.

Driven by third-party conveners, MSSP ACOs are migrating toward dispersed, clinically incoherent networks of clinicians. These convener ACOs are substantially more likely to beat regional benchmarks. Whether convener ACO success is driven by true savings or gaming benchmarks via dispersed networks requires further study. THERAPEUTIC BENEFIT OF TOP-SELLING ONCOLOGY DRUGS IN MEDICARE Stephanie Wang1; Alexander Egilman2; Georg Hahn2; Aaron S. Kesselheim3. 1Harvard University, Cambridge, MA; 2Brigham and Women's Hospital, Boston, MA; 3Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4247717)

The rising costs of oncology drugs in the US have led many patients with cancer to experience financial toxicity and have strained the budgets of payors. With the passage of the Inflation Reduction Act of 2022, Medicare can negotiate the price of select top-selling drugs, considering factors such as therapeutic benefit compared to therapeutic alternatives. Since the US lacks a formal health technology assessment (HTA) organization, we used evaluations from the national HTA organizations of Germany and France to assess the added clinical benefit of top-selling oncology drugs in the US.

We categorized each of the 50 top-selling oncology drugs in Medicare in 2022 as having high (moderate or greater), low (minor), or no overall added therapeutic benefit based on the most favorable rating across Germany and France. Country-specific ratings were given based on the most favorable rating across patient populations, indications, and dosages.

Among the 50 top-selling oncology drugs in Medicare, 49 (98%) were rated by the national HTA agencies of Germany and/or France. Among the 49 drugs, 39 (80%) were classified as having overall high added benefit, 9 (18%) were classified as having overall low added benefit, and 1 (2%) drug was classified as having overall no added benefit. Oncology drugs with low or no added benefit accounted for $6.3 billion in annual net Medicare spending, or 20% of net Medicare spending on the 50 top-selling oncology drugs in 2022. Median estimated net Medicare spending per beneficiary on drugs with low ($55,038) and no ($77,955) added benefit surpassed drugs with high added benefit ($44,781).

Four-fifths of top-selling oncology drugs in Medicare provide high added clinical benefit according to evaluations from the national HTA organizations of Germany and France. While only one-fifth of top-selling drugs offered low and no added benefit, these products were higher cost than drugs with high added benefit and accounted for $6.3 billion in Medicare spending in 2022. Price negotiation of drugs offering marginal added benefits can help ensure that they are not more expensive than reasonable therapeutic alternatives. TRENDS IN FILLS, SPENDING, AND PRICES OF DOXEPIN FOR INSOMNIA Christopher Cai1; Aaron S. Kesselheim3; 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; 3Medicine, Brigham and Women's Hospital, Boston, MA. (Control ID #4272810)

Doxepin has been prescribed since the 1960s as a tricyclic antidepressant. In 2010, the US Food and Drug Administration (FDA) approved low-dose (3-6mg) doxepin under a new brand name (Silenor); generic versions became available in 2020. Low-dose doxepin is a recommended first-line treatment for insomnia, particularly in the elderly, because of its favorable safety profile compared to hypnotics, but its costs have remained high. We quantified low-dose doxepin use and measured savings had patients used liquid doxepin, a less costly formulation.

We performed a cross-sectional analysis of US retail spending (insurer plus patient spending, excluding rebates), use (30-day supplies), and prices (retail spending per 30-day supply) of doxepin using the 2023 IQVIA Prescription Audit, which estimates national spending and use based on data from 90% of retail pharmacies and 70% of mail-order and long-term care pharmacies. We separated doxepin strength and formulation combinations used to treat insomnia: generic and brand name low-dose tablets (approved for insomnia), 10mg capsules (approved for depression but lower than the recommended minimum daily dose and likely used off-label for insomnia), and oral liquid (approved for depression and also used off-label for insomnia). We compared doxepin use to other insomnia medications: trazodone, melatonin agonists, benzodiazepine receptor agonists, and dual orexin receptor antagonists (DORAs). We calculated potential savings if low-dose doxepin tablet users had instead used liquid doxepin.

In 2023, there were 2,616,768 30-day supplies of doxepin for insomnia, which was greater than DORAs (894,659), similar to melatonin agonists (2,620,966) and less than benzodiazepine receptor agonists (29,229,380) and trazodone (70,056,696). In 2023, there were 3,019 30-day supplies of brand-name low-dose doxepin tablets, 292,925 of generic tablets, 317,585 of liquid doxepin, and 2,003,240 of 10mg doxepin (Table). Mean prices per 30-day supply were $526 for brand name low-dose tablets, $252 for generic low-dose tablets, $11 for 10mg capsules, and $7 for liquid (Table). Generic tablets represented 11% of doxepin use presumed to be for insomnia, but 74% of spending. If low-dose doxepin tablets had been available at the same per-milligram price as liquid doxepin, spending would have been reduced by $73.9 million dollars (98%).

Despite generic competition, low-dose doxepin tablets approved for insomnia have substantially higher prices and fewer 30-day prescriptions than similar doses of capsules or liquid doxepin which can be used off-label to treat insomnia. This repurposed drug market failure may explain why low-dose doxepin is used infrequently despite being a first line recommended therapy. Liquid doxepin may be a viable, less-expensive alternative; alternatively, researchers could study whether the 10mg capsules are effective for insomnia without anticholinergic side effects. TRENDS IN LOW-VALUE CARE SPENDING FOR U.S. MEDICARE BENEFICIARIES WITH COGNITIVE IMPAIRMENT AND DEMENTIA Annie W. Yang1,7; Mei Leng4; Julia Arbanas3; Chi-Hong Tseng4; A. Mark Fendrick5; Catherine Sarkisian2; Cheryl L. Damberg6; Nina Harawa2; John N. Mafi2. 1National Clinician Scholars Program at Yale University, New Haven, CT; 2GIM & HSR, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 3University of Michigan School of Information, Ann Arbor, MI; 4Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA; 5Internal Medicine, University of Michigan, Ann Arbor, MI; 6Health Care, RAND Corporation, Santa Monica, CA; 7VA Connecticut Healthcare System West Haven VA Medical Center, West Haven, CT. (Control ID #4272805)

Older adults with mild cognitive impairment and dementia (MCID) are particularly susceptible to the harms of low-value care, such as a benzodiazepines leading to delirium and falls. Although low-value care contributes to wasteful spending, recent trends in Medicare expenditures for low-value medications and cancer screenings are unknown.

We used nationally representative survey data from the Health and Retirement Study (HRS) linked to Medicare fee-for-service claims to study trends in low-value care spending during 2010-2021. For each year, we identified beneficiaries ≥65 years old with MCID with ≥3 years of continuous Medicare Parts A, B and D coverage. We developed measures of low-value drugs and cancer screenings based on best practice guidelines, including Choosing WiselyTM, USPSTF, and American Geriatrics Society Beers Criteria. Low-value drugs included seven classes: anticholinergics, antipsychotics, appetite stimulant (mirtazapine), barbiturates, benzodiazepines, non-benzodiazepine hypnotics, and antibiotics for asymptomatic bacteriuria. Cancer screening included breast, cervical, colorectal, lung, and prostate cancer without appropriate use criteria (e.g., for colorectal cancer screening: no prior colorectal cancer, GI bleeding, iron deficiency anemia diagnosis, etc.). We calculated annual per capita and total annual expenditures, defined as paid amounts plus beneficiaries’ out-of-pocket costs, adjusted for inflation. We applied survey weights for representativeness and response rate.

We identified 1374-1943 beneficiaries with MCID per year, representing 5.4-7.3 million Medicare beneficiaries with MCID during the study period. Expenditures for low-value medications sustained over time from $118,000 (2010) to $113,000 (2021) per 100,000 beneficiaries, a five percent relative difference; total annual expenditures ranged from $580-920 million ($90,000-$142,000 per 100,000 beneficiaries). Expenditures for low-value cancer screening decreased by 57% over time, from $1400 (2010) to $600 (2021) per 100,000 beneficiaries; total annual expenditures ranged from $40-84 million. For low-value medications and cancer screening combined, Medicare spent $0.6-1 billion annually – an estimated $9.1 billion over twelve years. Low-value prescription medications contributed to 92% of total medical expenditures.

Medications comprised the bulk of the $9.1 billion spent on low-value services received by MCID patients during 2010-2021. Although cancer screening spending declined, medication spending has persisted over time, despite the widespread dissemination of Beer’s criteria and Choosing Wisely recommendations. In light of growing attention on health care waste, targeted policies should aim to reduce these potentially harmful services, leading to lower unnecessary spending and improvements in the quality of care. TRENDS IN PRIMARY CARE PHYSICIAN- AND PRACTICE-LEVEL CONTINUITY OF CARE, 2008-2022 Audrey D. Zhang1; Jeffrey Souza2; Bruce E. Landon2,1. 1General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2Health Care Policy, Harvard Medical School, Boston, MA. (Control ID #4271454)

Continuity of care (COC) in the primary care setting refers to the degree to which a patient consistently receives care from a single primary care provider (PCP) or group of providers over time. It has been defined as one of the 4 defining features of primary care, and is associated with improved satisfaction and lower costs and hospitalization rates. Recent trends in health care delivery, including a decline in physicians entering primary care, reduced physician work hours, and the rise of urgent care and retail clinics for problem-based care, have led to concerns that physician-level visit-based continuity has decreased over time. However, it is unknown the extent to which countervailing trends, including the growth of group practices and the advanced practice clinician workforce, may offset these concerns by serving as practice-level continuity anchors. We examined trends in primary care physician- and practice-level continuity of care from 2008-2022.

We conducted a serial cross-sectional study of primary care visits among Medicare beneficiaries using 100% Medicare FFS claims from 2008-2022. Within each calendar year, we attributed each beneficiary to a PCP by identifying the PCP who was responsible for the plurality of primary care visits. We defined continuity of care using the Bice-Boxerman COC index, a beneficiary-level measure of the concentration of a beneficiary’s ambulatory visits among one or more of their physicians (scaled 0-1; 1 represents continuous care with a single physician), then calculated a PCP-level continuity measure using the mean COC index across all beneficiaries in a PCP’s panel. The primary outcome was the mean PCP-level continuity of care across all PCPs per calendar year. We repeated analyses examining continuity aggregated at the primary care practice level, and evaluated changes over time using repeated measures ANOVA.

We included 63,428,962 unique Medicare beneficiaries enrolled in Medicare FFS for at least 1 calendar year from 2008-2022. Beneficiaries were 55.3% female, 80.4% non-Hispanic White, 9.1% Black, and 5.7% Hispanic. Beneficiaries were attributed to 305,283 unique PCPs; the share of beneficiaries who could be attributed to a PCP declined from 74.0% in 2008 to 71.0% in 2022. The mean patient COC index associated with each PCP decreased from 0.327 in 2008 to 0.237 in 2022 (p<0.001), representing a mean decrease in attributed PCPs’ share of all ambulatory visits from 47.6% in 2008 to 37.2% in 2022. These trends were consistent in direction but attenuated in analyses aggregated at the primary care practice level.

Continuity of care has declined over time, both at the individual clinician level and aggregated at the practice level. These findings likely reflect increased use of specialists over time, while the attenuated decrease at the primary care practice level likely reflects increased use of team-based care. More research is needed to understand how lower COC ultimately impacts care outcomes and spending. TRENDS IN PRIMARY CARE PHYSICIANS ACCEPTING NEW PATIENT VISITS, 2016-2022: EVIDENCE FROM MEDICARE Katherine M. Morgan1; Michael L. Barnett2. 1General Internal Medicine, Brigham and Women's Hospital, Boston, MA; 2Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA. (Control ID #4272715)

There is broad discussion among policy makers and the public that finding a new primary care physician is increasingly difficult. One potential mechanism driving this trend could be increasing numbers of clinicians “closing” their panels and not accepting new patients. However, there is little empirical evidence quantifying this, making it difficult to develop informed policy solutions. To investigate this possibility, we examined trends and variation in primary care physicians (PC-MDs) and advanced practice providers (PC-APPs) accepting new patients across the US.

Our descriptive, serial cross-sectional study examined Medicare Fee-for-Service (FFS) Public Use Files from 2016-2022. We first identified PC-MDs using claims-based specialty codes. Then, to identify primary care focused advanced practice providers, we captured the 100 medications most often prescribed by PC-MDs (87-88% of all PC-MD prescribing) and flagged advanced practice providers as PC-APPs if their total prescription volume had at least 85% overlap with these medications. We defined clinicians as “accepting new patients” if they billed at least eleven new patient evaluation and management (E&M) claims (99201-99205) in a year. Next, we calculated national and state-level counts of all E&M office visits provided by different types of primary care clinicians from 2016-2022. We estimated changes over time nationally and by state in patterns of clinicians accepting new patients and office visit volume.

In 2016, there were 55,079 PC-MDs and 16,388 PC-APPs who billed 3.40 million new patient visits. By 2022, the number of PC-MDs billing new visits decreased by 25% to 41,504 and the number of PC-APPs increased 73% to 28,404 PC-APPs, in total billing 3.32 million new visits. In 2016, 79% of new patient visits were billed by PC-MDs, decreasing to 60% by 2022. Accounting for changes in the FFS Medicare population, the number of PC-MDs billing for new visits per 10,000 FFS Medicare beneficiaries decreased from 14.3 to 11.8 from 2016 to 2022, an 18% relative decrease, compared with a 90% increase from 4.2 to 8.1 for PC-APPs. At the state level, there was a 21% average decrease in number of PC-MDs billing new visits per 10,000 FFS beneficiaries (IQR -25%,-7%) between 2016 and 2022. The mean percentage of PC-MDs billing any new visits by state in 2016 was 41% (IQR 32%,52%) and by 2022 fell to 34% (IQR 27%,42%).

The number of PC-MDs conducting new visits and the total number of new visits completed by these physicians steadily decreased between 2016 and 2022, even after adjusting for a decline in the FFS population. These findings are consistent with perceptions that it is becoming more challenging to find a PC-MD accepting new patients. Without rapid policy intervention to increase the number of PC-MDs in the workforce with capacity to accept new patients, access to primary care physicians will likely continue to decline. TRENDS IN RECEIPT OF WEIGHT LOSS TREATMENTS AMONG ALL OF US PARTICIPANTS, 2013 TO 2022 Olajide Adekunle1; Phuc H. Le3; Dev Yash Gupta2; Michael B. Rothberg1; Yue Yihua1; Ha T. Tran3; Hamlet Gasoyan4. 1Department of Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, OH; 2Case Western Reserve University, Cleveland, OH; 3Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH; 4Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH. (Control ID #4272842)

Despite the proven therapeutic benefits of weight loss treatments such as antiobesity medications (AOMs) and metabolic and bariatric surgery (MBS), their use remains low. We evaluated trends in AOM prescriptions and MBS among US adults with obesity from 2013-2022.

We conducted a cross-sectional analysis of the All of Us database. We included patients aged ≥18 years with obesity (body mass index [BMI] ≥30 kg/m2) or overweight (BMI ≥27) plus ≥1 obesity-related comorbidity. For the MBS analysis, we limited the sample to those with BMI ≥35. Primary outcomes included prescriptions for AOMs (naltrexone-bupropion, orlistat, phentermine-topiramate, liraglutide, and semaglutide) and International Classification of Diseases 9/10 or Current Procedural Terminology codes for MBS. We estimated the annual rate of use (per 1,000 persons) overall, by drug class, and by patient characteristics (age, sex, race/ethnicity, health insurance, BMI category). We assessed temporal trends using the JoinPoint software and reported the annual percentage change (APC).

The number of study participants ranged from 15,300 in 2013 to a maximum of 60,999 in 2019; 85% had BMI ≥35. Prescriptions for AOMs increased by 39.4% annually from 10.2 per 1,000 persons in 2013 to 19 per 1,000 persons in 2015, remained stable from 2015-18, and then increased to 32.8 per 1,000 persons in 2022 (APC = 14.7%). Use of AOMs was higher in women (vs. men), those aged 45–64 years (vs. 64), and those with BMI ≥40 (vs. <40) but did not differ by race/ethnicity or health insurance status. Use of liraglutide increased from 2013-16 then decreased significantly through 2022, while use of phentermine increased from 2013-16 then plateaued. Semaglutide prescriptions increased from 2018-22. In contrast, use of MBS decreased significantly from 10.5 per 1,000 persons in 2013 to 3.8 per 1,000 persons in 2022 (APC = -7.4%). Similar trends were observed across all patient subgroups. Women, Hispanic individuals (vs. non-Hispanic), and those with BMI ≥45 had higher rates of MBS.

In 2013, rates of AOMs and MBS were similar. Since then, as semaglutide rose in popularity, and prescriptions for AOMs tripled, while MBS declined by more than 60%. Despite the overall rise in treatment, most eligible patients did not receive either AOMs or MBS. VARIATION IN PATIENT PERCEPTIONS OF PERSON-CENTERED COMMUNICATION IN PRIMARY CARE: RESULTS FROM A PATIENT SURVEY Barbara G. Bokhour1,2; Juliet Wu1; Jamie Douglas3; Aileen McGrory1; Erum Abedin1; Alexandre Vilela Braga1; Rendelle Bolton1. 1Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA; 2Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA; 3VA Puget Sound Health Care System Seattle Division, Seattle, WA. (Control ID #4273194)

The US department of Veterans Affairs is transforming to a Whole Health System of Care. Central to this effort is the use of patient-centered communication to align care with what matters most to patients. We examined the extent to which a brief patient perceptions of patient-centered communication survey can distinguish among providers and identified patient-level predictors of these perceptions.

We selected three sites identified as mature in implementing Whole Health care in clinical settings. Patients received a brief survey via text or e-mail within one week of their primary care appointment. Questions included: 1) the CollaboRATE - a validated patient-centered communication measure (Thinking about your last appointment, how much effort (0-9) was made to a)understand your health issues, b)listen to what matters most to you and c)include what matters most in choosing what to do next?; 2) how well were your needs were met and 3) care satisfaction. Patients were asked about the visit type, their relationship with their provider, appointment acuity and modality, and demographics. Providers were rated on the percent of patients who reported top box scores of “every effort was made” on all 3 collaboRATE questions. We used spearman correlations to assess associations between collaboRATE mean scores and patient experience measures, and mixed effects linear regression to assess whether visit and patient characteristics explained differences in scores.

5,429 patients across 154 providers responded to the survey (response rate 26%). 118 providers had sufficient patient responses (≥20) to assess provider level performance. Providers ranged in having 41-95% of patients rate all 3 collaboRATE questions as 9 (top score). The distribution of provider scores varied across sites - 40% at site 1, 35% at site 2, and 10% at site 3 rating as excellent (at least 80% of a provider’s patients reporting top scores). Across all patients, collaboRATE scores were significantly correlated with reporting needs were met (0.68; p<. .001) and satisfaction with care (0.63; p<001). CollaboRATE scores varied based on first versus follow-up visit, appointment acuity, and in-person versus virtual modality (p<.05). Patients who were male (p<.01), over 65 (p< .001) and married (p< .001) reported higher scores. Scores were lower among those who identified as Hispanic, Asian, and native Hawaiian/Pacific Islanders.

We found that collaboRATE was an effective measure to distinguish among primary care experiences of patients. Identifying higher and lower performing providers allows for targeted interventions and trainings to raise the quality of communication across the system. Different approaches to communication may be needed depending on visit context and patient characteristics. That different VA medical centers had different patient ratings indicates that facility level factors may play a role in the extent to which providers are using patient-centered communication. VETERAN BURDEN OF MILITARY EXPOSURE CONCERN AND USE OF SOCIAL MEDIA Sydney H. Buchman1,2; Mhd Hasan Almekdash2,3; Tarek Kandakji1,2; Drew A. Helmer1,2. 1Department of Medicine, Baylor College of Medicine, Houston, TX; 2IQuESt, Michael E DeBakey VA Medical Center, Houston, TX; 3Radiation Oncology, Baylor College of Medicine, Houston, TX. (Control ID #4270746)

Most Veterans encountered environmental, occupational, and other hazards during military service collectively referred to as “military exposure burden” (MEB) leading to concern about long-term health effects. With the rise of social media use (SMU) for health information seeking and support, Veterans may be motivated to use platforms based on their level of concern or other characteristics such as education or gender. Few studies explore the relationship between MEB and SMU. Our study fills this gap by analyzing an online survey of 269 veterans to explore the association between exposure burden and social media use.

US military Veteran participants were recruited in Spring of 2022 through a community veteran service organization in a major metropolitan area to complete an online questionnaire. Survey items about military exposures, SMU, and sociodemographic factors were included in this analysis. The likelihood (1 very unlikely – 7 very likely) of 29 separate military exposures were analyzed and collapsed into a single summary scale of MEB. SMU of seven platforms were similarly collapsed into a SMU scale. Unadjusted univariate analyses were conducted using The Mann-Whitney U test assessed the association between MEB and SMU across two-group variables: of sex and ethnicity. The Kruskal-Wallis test was applied to multi-group variables of race, ethnicity, education, years of military service, and living situation. Multivariable regressive general linear model (GLM) examined the association between MEB and SMU, controlling for age, sex, ethnicity, education, military service, and living situation (p < 0.05 was significant).

Complete survey responses were available for 269 Veterans (42.8% male, 78.4% white, 14.1% black, 8.9% Hispanic). Most participants lived with family members and/or a partner (48%) and had a masters (32.7%) or a professional/doctorate degree (32.2%). Summary scales of SMU indicated mean (SD) of 5.39 (1.20) and median use of 5.7 (1 - 7 scale), and MEB of mean (SD) 5.32 (1.15) and median of 5.6 (1 - 7 scale). The Mann-Whitney U test showed a statistically significant difference in both MEB (z = -2.11, p = 0.035) and SMU (z = -3.65, p < 0.001) between groups based on sex. Across education groups, the Kruskal-Wallis test showed a statistically significant difference in both MEB (χ2(3) = 9.212, p= 0.027) and SMU (χ2 (3)= 38.288, p < 0.001).The results of the model showed that MEB was significantly associated with SMU (β=0.482, p<0.001), and for every one-unit increase in MEB, SMU increased by 0.482 units, holding all other variables constant.

This study demonstrates the association between MEB and SMU among Veterans.These results also highlight the impact of sociodemographic factors on how Veterans perceive military exposure risks and engage with social media. Future research should explore these relationships to develop strategies for leveraging social media to address Veterans’ exposure related concerns. VISITS ON THE GO: HOW OFTEN ARE PATIENTS OUT-OF-STATE (AND OUT-OF-COUNTRY) DURING TELEHEALTH APPOINTMENTS? Kaustav Shah2; Ateev Mehrotra3; Eric Bressman1. 1Internal Medicine, University of Pennsylvania Department of Medicine, Philadelphia, PA; 2Medicine, University of Pennsylvania, Philadelphia, PA; 3Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI. (Control ID #4270789)

During the COVID-19 pandemic, there was a surge in telehealth use across state lines. Under temporary waivers, physicians could conduct out-of-state telehealth visits through either reciprocal recognition of licensure or emergency pathways to state licensure. Most of these waivers have expired and physicians must be licensed in the state where the patient is physically located at the time of the visit. There is no enforcement of these regulations, however, and physicians may be unsure where a patient is actually located. We use telehealth vendor geolocation data to describe how often patients take telehealth appointments away from their home state.

The state of residence of adults with primary care telehealth visits[AM1] between March 2020 to May 2021 in a large academic health system in Pennsylvania and New Jersey was identified using the electronic health record (EHR). The IP address and associated geolocation during the telehealth encounter was provided by the telehealth vendor. The provider’s address was based on the state of their primary office, with offices located in either Pennsylvania or New Jersey.

Across the 157,220 primary care telehealth visits, there was a discrepancy between the patient’s home state (based on EHR listed address) and the state in which they accessed their telehealth visit in 11.3% of cases. During 0.13% of visits, patients were out of the country entirely. Patients called from 49 distinct states and districts and 53 countries (including from all continents except Antarctica). Patient flow is notable for highest density of interstate travel to bordering states, with lesser travel over greater distances (Figure 1). The patient (based on IP address) and clinician were in different states in 19% of visits.

Patients frequently access telehealth encounters from different states (and, rarely, different countries) than their home address, as listed in the EHR. Given that licensure rules rely on an honor system, future policy should reflect the reality that patients are often on the move, as this has implications for patient access and regulatory concerns. Limitations of this work include that during this period of the COVID-19 pandemic, patients were less likely to travel which may underestimate the true prevalence of state discrepancies. Use of IP addresses may also be impacted by virtual private networks or other software designed to mask physical location. Scientific Abstract - Health Equity, Diversity, and Inclusion A BILINGUAL QUALITATIVE STUDY OF PATIENTS’ PERSPECTIVES ON NAVIGATING ACCESS TO MEDICATIONS FOR DIABETES MELLITUS IN THE ERA OF 340B DRUG PRICING PROGRAM RESTRICTIONS Sarah Lalani1,2; Veena Kapadia1; Kasia J. Lipska3; Chelsea McKevitt1; Abmaridel Montosa1; Mario Ochoa-Prieto1; Mellisa Pensa1; Benjamin Oldfield1,3. 1Fair Haven Community Health Care, New Haven, CT; 2The University of Texas at Austin, Austin, TX; 3Internal Medicine, Yale School of Medicine, New Haven, CT. (Control ID #4272923)

To support medication access in safety-net settings, the U.S. Congress created the 340B Drug Pricing Program in 1992, which requires drug manufacturers to sell drugs at substantial discounts to certain entities that pass on savings to uninsured and underinsured patients. Since 2020, drug manufacturers have restricted the use of the 340B Program, leading to unexpected spikes in medication costs for uninsured and underinsured diabetic patients. We performed a qualitative study to explore experiences of medication access among uninsured and underinsured individuals with diabetes.

We used direct content analysis, grounded in Andersen’s Behavioral Model of Health Services Use. Individuals who were prescribed medications for diabetes in a multi-site, urban community health center in New England were purposefully sampled, seeking heterogeneity in age, preferred language, length of time living with diabetes, and insurance status. A bilingual analysis team coded all interview transcripts. We compared coded text to identify and expand upon themes until no new concepts emerged in subsequent transcripts.

We achieved thematic saturation after interviewing 25 participants (July – August 2024) whose demographics are found in Table 1. Three themes emerged. (1) Patients often navigate medication access alone, without perceived navigation support from health system staff. (2) Loved ones shape patients’ beliefs in and experiences of treatment access. (3) Language and culture of pharmacy staff are key enablers of medication access.

Each emerging theme has an implication for health systems managing diabetic patients impacted by 340B Program restrictions and details the role of pharmacies and their staff in the Andersen model. First, navigation processes are needed for patients who may face abrupt changes in medication cost, availability, or access. Second, education and resources from pharmacies and primary care settings targeting people with diabetes should involve and focus on the family/peer unit, in addition to the individual. Third, customer-service enhancements and structural competency in pharmacies may be important drivers of medication access and adherence. ACCESSIBILITY AND CONTENT OF HEALTH RESEARCH POLICIES IN PRISONS AND JAILS IN THE U.S. Shaheer A. Arif2; Syed E. Ahsan2; Zoë Senter2; Justin Berk1; Helen E. Jack2. 1Medicine & Pediatrics, Brown University Warren Alpert Medical School, Providence, RI; 2Division of General Internal Medicine, University of Washington, Seattle, WA. (Control ID #4273447)

To address public health challenges, it is crucial to include incarcerated people in medical research. However, a history of exploitation of incarcerated populations by researchers has created regulatory barriers and reluctance to conduct studies in jails and prisons. While some federal guidelines exist, they are very general. As a result, jails and prisons across the U.S. have developed their own research policies. Understanding these policies and their implementation can reveal the extent of variation, highlight barriers, and inform the development of more standardized national guidelines or best practices. This study aimed to characterize the availability and content of research policies in prison systems in all 50 states and the largest jail in each state by county population.

Websites of 95 prisons and jails (44 prisons, 6 unified prison-jail systems, 45 jails) were searched for publicly available research policies. If these were not available, outreach to prisons and jails was done via email and phone to request policies. Based on a carceral research ethics framework, a data extraction tool was created to characterize each policy in a standardized way. Data extraction included key policy components such as participant eligibility, compensation, ethical oversight, and operational procedures.

Policies from 40 of 44 state prison systems and all 6 unified prison-jail systems were acquired. 5 policies out of 45 jails were obtained. Analysis of the 51 total policies revealed that 19 showed existence of a research advisory group. Additionally, 24 policies mentioned involvement of prison staff in facilitating research, 11 mentioned security clearance needed for researchers, while just 4 acknowledged the disproportionate deference incarcerated people may show toward researchers.

The scan revealed a stark disparity in the accessibility of prison and jail research policies, with prisons and unified prison-jail systems being much more accessible than jails alone. Lack of accessibility of jail policies may be a barrier to research and regulation of research in these settings. Furthermore, few policies address key ethical considerations such as participant deference, which can impact the voluntary nature of participation and is especially important to consider with vulnerable populations. Addressing these gaps through more consistent national could help promote ethical research and support more equitable practices in correctional health. A MIXED METHODS STUDY EXAMINING PHYSICIAN PERSPECTIVES ON THE UTILITY OF RACE AND ETHNICITY ADJUSTMENTS IN CLINICAL TOOLS Anitra Persaud1,2; Vence Bonham2. 1Department of Medicine, Penn Medicine, Philadelphia, PA; 2Health Disparities Unit, National Human Genome Research Institute, Bethesda, MD. (Control ID #4273563)

Risk calculators and laboratory tests used across various subfields of medicine include race correction factors. The inclusion of race as a variable within clinical algorithms has received increased criticism for perpetuating health inequities. While physicians are the primary operators and interpreters of these calculators, few studies have examined physician views on such algorithms. The purpose of this study was to examine three cohorts of physicians from different subspecialties awareness of and perspectives on the use of race in clinical algorithms and its impact on clinical care.

30 board-certified physicians (10 each from cardiology, obstetrics and gynecology [OB/GYN], and pulmonology) actively providing clinical care were recruited and partcipated in the study. Convergent mixed methods were employed using surveys and semi-structured interviews. Surveys were analyzed using descriptive and inferential statistics. Interviews were coded and analyzed using thematic content analysis by three investigators.

Twenty-eight participants completed the electronic survey, and 30 participants were interviewed. Surveyed cardiologists exhibited higher scores on the Racial Attributes in Clinical Evaluation Scale compared to OB/GYNs (13.8 vs 6.78, p < 0.05), indicating increased self-reported use of race in clinical decision-making. Cardiologists also received higher scores on the Okah Beliefs Measure for genetics compared to OB/GYNs (2.9 vs 1.7, p < 0.01), indicating greater belief that racial differences in genetics explain racial differences in health. Qualitative analysis identified four themes: (1) perceived role of race and ethnicity in medicine and research; (2) considerations for evaluating race-based adjustments in clinical tool outputs; (3) benefits and risks of removing race-based corrections; and (4) institutional changes, challenges, and recommendations.

Considerable variability exists between specialties regarding the role and institutional use of race corrections within clinical decision-making. However, there was consensus that a need exists for robust physician education to avoid the misinterpretation and misapplication of race in medicine. In addition, more resources should be directed toward the critical appraisal of race across various medical contexts to reduce the risk of further exacerbating existing health disparities. ASSOCIATION BETWEEN RACE, PULSE-OXIMETRY, AND RETURN E.D. VISITS AND HOSPITALIZATIONS FOLLOWING A COVID-19 ENCOUNTER Max Jordan Nguemeni Tiako1; Deron Galusha2; Karen Jubanyik3; Karen Wang2; carol oladele2; Tara Rizzo2. 1medicine, University of California Los Angeles, Los Angeles, CA; 2medicine, Yale University School of Medicine, New Haven, CT; 3Emergency Medicine, Yale University School of Medicine, New Haven, CT. (Control ID #4272652)

Hypoxemia predicts returns to the emergency department (ED) after home discharge from COVID-19 encounters. Pulse oximeters detect hypoxemia at lower rates in people with darker skin. Studies show this difference is associated with delayed administration of medications and supplementation oxygen for Black patients with COVID-19. Differences in accuracy could similarly influence providers’ decision to discharge vs hospitalize a patient. This study examines racial disparities in return visits to the ED and hospitalizations by oxygen saturation (O2Sat) recorded at the index encounter.

This is a retrospective cohort study of 2733 ED patients with presumed COVID-19 who were discharged home from March to December 2020. Primary outcomes were return visit to the ED, and hospitalization within 14 days. Key covariates were race/ethnicity, maximum O2Sat during ED visit, age, sex, insurance, comorbidities, and COVID-19 wave. We used descriptive statistics and conducted Cox proportional hazards regressions to determine associations between covariates and the outcomes, with interactions between race and O2Sat, and clustered standard errors by COVID-19 wave. We conducted analyses in Stata.

The sample included 1146 (41.9%) Non-Hispanic White, 730 (26.7%) Black, and 857 (31.4%) Non-Black Hispanic patients. One in twenty had a maximum O2Sat below 95% (5.7%, n=128). About one in five (n=493, 18.0%) returned to the ED, and one in fifteen returned and were hospitalized (6.9%, n=188). Patients with a maximum O2Sat below 95% were more likely to return to the ED and be hospitalized (10.6%, n=20 vs 4.2%, n=108, P<0.001). Significantly fewer Black patients had a documented maximum O2Sat below 95% (2.6%, n=18) compared to White (6.2%, n=71, P<0.001) but not Hispanic patients (4.4%, n=39, P=0.05). In our adjusted regression with an interaction between race and O2Sat, Black (vs. White) patients independently had a higher HR of returning to the ED (1.76; 95%CI: 1.32–2.36; p<0.001). This risk difference was significantly modified by O2Sat, decreasing as O2Sat increased. For example, at O2Sat = 92%, Black patients’ HR was 4.60 (95% CI 3.68, 5.42) vs White patients’ 2.09 (95% CI 1.07, 3.10). However, at O2Sat ≥ 99%, the additive effect from the O2Sat was no longer significant (Black HR 1.91, [95%CI 1.36-2.46] vs White HR 1.48, [95%CI 0.91-2.06] at 99% O2Sat).

were similar with hospitalization as an outcome. At O2Sat = 92%, Black patients’ HR was 19.18 (95%CI 13.78-24.58) vs. White patients’ 6.58 (95% CI 3.78-9.34). At 99% O2Sat, Black patients’ HR was 4.38 (95%CI -1.19, 9.95) vs. White patients’ 3.65 (95%CI -0.92, 8.21).

Black patients discharged after COVID-19 ED visits had higher risks of return visits and hospitalizations than White patients, with a more significant difference at lower oxygen saturations, which may be driven by occult hypoxemia. Our findings add to existing evidence on the potential material impact of discrepancies in pulse oximetry by skin tone. ASTHMA MORTALITY BY COUNTY, RACE, ETHNICITY AND AGE IN THE UNITED STATES, 2000-2019 Jacqueline J. Pujol3,2; Gabriela Recinos4; Jordan J. Juarez4; Somy Hooshmand4; Amanda S. Hinerman3; Erik Rodriquez4; Christian S. Alvarez4,5; George Mensah6; Jason Y. Wong1; Eliseo J. Perez-Stable5,4. 1Epidemiology and Community Health Branch, National Heart Lung and Blood Institute, Bethesda, MD; 2Georgetown University School of Medicine, Washington, DC; 3Division of Intramural Research, National Heart Lung and Blood Institute Division of Intramural Research, Bethesda, MD; 4Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD; 5NIMHD, National Institutes of Health, Bethesda, MD; 6Center for Translation Research and Implementation Science (CTRIS), National Heart Lung and Blood Institute, Bethesda, MD. (Control ID #4242070)

Over 3,500 asthma-related deaths were reported in the U.S. in 2021. Limited literature exists on racial and ethnic disparities in asthma mortality by geographic location. Identifying asthma mortality trends across geography and racial and ethnic groups will inform development of targeted asthma prevention interventions.

Death registration data from the U.S. National Vital Statistics System and population data from the U.S. National Center for Health Statistics (2000-2019) were analyzed. Small-area estimation methods were applied to calculate mortality rates, adjusting for race and ethnicity misclassification on death certificates. Ages were standardized using the 2010 Census population and categorized: 45-64, and ≥65 years. Race and ethnicity were categorized into five mutually exclusive groups: American Indian and Alaska Native (AIAN), Asian, Black, Latino, and White.

From 2000-2019, the age-standardized asthma mortality rate in the U.S. decreased by 38% from 17.6 (95% Uncertainty Interval (UI): 17.0,18.1) to 10.9 deaths per million (UI: 10.6,11.3). The largest decline was in the ≥65 age group (-34.0 (UI:-37.6,-30.4)) with a smaller decline in the 45–64 age group (-6.8 (UI:-8.2,-5.5)). Black and AIAN populations consistently had the highest or second-highest asthma mortality rates across age groups. In 2019, within the ≥65 age group, AIAN had the highest mortality rate (55.3), followed by Black (49.3), Asian (48.0), Latino (35.0) and White populations (30.0). Among the 45-64 age group, mortality rates were highest for Black (33.5), followed by AIAN (22.3), White (10.6), Latino (10.3), and Asian populations (8.2). County-level analyses in 2019 revealed the highest asthma mortality rates in the Southern Delta and Northeast regions. Elevated rates were observed among Black populations in Mississippi, Alaska, and California; among AIAN in Alaska, California, Washington, and North Carolina; among Asians in California, Minnesota, and Hawaii; and among Latinos in New York, Massachusetts, Pennsylvania, and Hawaii.

Overall asthma-specific mortality rates declined over two decades, but significant disparities persist by race, ethnicity, age, and geography. These findings underscore the need for targeted interventions to address asthma mortality in the most affected populations. BLACK AMERICANS ARE MORE LIKELY TO HAVE THE COPS CALLED ON THEM IN THE HOSPITAL, TOO. Sophie Goldman, Emily S. Mitchell, Ravneet Waraich, Jacob Luty, Jeff Gold, Andrea Smeraglio. Medicine, Oregon Health & Science University, Portland, OR. (Control ID #4273391)

Deploying a police response within a hospital setting, known as a security emergency response code (SERC), has become commonplace to protect healthcare workers from harm by patients and visitors. While racial inequities are well documented in police responses outside of the hospital, there is limited national and regional data assessing racial and ethnic inequities in hospital SERCs, particularly on the West coast. A single East coast institution showed that Black patients have a higher odds of in-hospital SERC than white counterparts. The purpose of this study was to evaluate if racial inequities in hospital SERCs occurred at an academic hospital in Portland, OR.

This was a retrospective chart review of adult emergency department or wards encounters from January 2022 to July 2023. EHR notes documenting SERC events were extracted from the chart using note text search or code-specific EHR smart phrases and compared for validity against a public safety record kept by campus security. Analysis evaluated whether Black patients and all minority patients experienced a higher-than-expected proportion of admissions with SERCs compared to their proportion of all adult emergency department and wards admissions. Analysis was completed using chi-square test of proportions in R.

Over the study period, 411 SERCs occurred across 273 admissions. White patients made up 86.4% of all admissions (n = 52,686) and 87.9% of admissions with SERCs (n = 240). Black patients made up 5.0% of all admissions (n = 3034) and 6.6% of admissions with SERCs (n = 18). All minority patients (inclusive of Black, American Indian/Alaska Native, Other Pacific islander, Asian, and Asian Indian) made up 13.6% of all admissions (n = 8271) and 12.1% of admissions with SERCs (n = 33). White patients had an incidence of 0.007 SERCs per encounter over the study period while Black patients had an incidence of 0.011 with an incidence difference between races of 0.005 (95% CI 0.0006%, 0.0086%, p-value 0.004).

Black patients experienced a significantly higher incidence of SERCs per encounter than white patients, suggesting potential racial inequities in the deployment of these security measures. Though limited by the small proportion of minority patient admissions, these findings raise concerns that hospital responses to perceived threats may reflect the implicit biases seen in policing outside the hospital. Such biases can erode trust, safety, and the patient-provider relationship. As such, this study calls into question the appropriateness of police response teams in hospital settings, which should prioritize healing over harm. CHARACTERISTICS ASSOCIATED WITH PRIMARY CARE BASEDDEMENTIA SCREENING VISIT COMPLETION IN THE ERADAR STUDY Leah S. Karliner1; Judith M. Walsh2; Abisola Idu5; Sascha Dublin5; Rebecca Y. Coley5; Alana Elop4; Tyler Barrett5; Sei Lee3; Clarissa Hsu5; Deborah E. Barnes4. 1Medicine, UCSF, San Francisco, CA; 2Division of General Internal Medicine, UCSF, San Francisco, CA; 3Medicine-Geriatrics, University of California San Francisco, San Francisco, CA; 4Psychiatry, University of California San Francisco, San Francisco, CA; 5Kaiser Permanent Research Institute, Seattle, WA. (Control ID #4272634)

Nearly 7 million people in the U.S. are living with dementia; approximately half are undiagnosed. Targeted screening of higher-risk individuals may offer benefits for patients and families.

We completed recruitment for a pragmatic RCT of targeted dementia screening in two healthcare systems (Kaiser Permanente Washington-KPWA, University of California San Francisco-UCSF). Among primary care patients ≥ age 65, high-risk individuals were identified using a predictive algorithm and invited for a brain health screening visit (BHV). KPWA recruitment and study visits were in English; UCSF also included Chinese-speakers via trilingual staff, and Spanish speakers via interpreters. We describe BHV participation rates by race, ethnicity and language; and examine odds of participation via multivariable logistic regression adjusted for age, gender, prior (non-dementia) cognitive diagnosis, comorbidity score.

Among 1706 KPWA intervention patients, 505 (29%) completed a BHV; UCSF participation was similar (N=197/645; 31%). Compared with whites, rates were lower for Asian and Black patients at both sites, similar for Latinos at KPWA, but at UCSF lower for both English and Spanish speaking Latinos. At UCSF, rates for English-speaking Asians and Chinese-speakers were similar to each other. (Figure) These results changed little with multivariable adjustment.

Despite efforts to recruit a multi-racial, multilingual population, participation was highest among whites. As disease-modifying treatments increasingly become available, the research and clinical community should redouble efforts to understand and address reasons for lower participation among communities of color and non-English speakers to achieve health equity for all patients at high risk of dementia. CLINICAL CHARACTERISTICS OF BREAST CANCER AND SCREENING HISTORY AMONG SOMALI WOMEN IN MINNESOTA Ahmed A. Mohamed1; Jane W. Njeru1; Alanna M. Chamberlain2; Kathleen J. Yost2; Gregory D. Jenkins2; Mark L. Wieland1. 1Medicine, Mayo Clinic Minnesota, Rochester, MN; 2Quantitative Health Sciences, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4273282)

Breast cancer is among the most common malignancies in the Somali population. However, breast cancer screening adherence is low among Somali immigrants in the United States. When we looked at screening adherence from 2002 to 2022, the Somali population of Olmsted County had a lower annual breast cancer screening [relative risk (RR) 0.41 (95% CI 0.39, 0.43)] and lower biennial screening [RR 0.52 (95% CI 0.50, 0.54)] as compared to the non-Somali population. Low screening leads to delayed diagnosis and poor outcomes. Understanding clinical characteristics and screening behaviors in this population is necessary for developing targeted interventions to improve early detection and treatment.

This retrospective study was conducted in Minnesota, utilizing the Rochester Epidemiology Project record-linkage infrastructure to retrieve data on Somali patients diagnosed with breast cancer between 2002 and 2022. ICD-9 and ICD-10 codes were used to identify patients diagnosed with breast cancer. Chart reviews were performed to abstract additional clinical data, including tumor type, tumor stage, screening history, symptoms, age at diagnosis, and family history of cancer. Descriptive statistics were used to summarize the data.

A total of 11 cases were identified. Four patients had invasive ductal carcinoma, three had ductal carcinoma in situ, two had intraductal papilloma, one had adenocarcinoma, and one had spindle cell carcinoma. Of the nine patients with malignant neoplasms, seven had estrogen receptor positive neoplasms, five had progresterone receptor positive, and two had HER2/neu postive. Two patients without any screening had malignant neoplasms with TNM stages 3 or 4 and two patients had stage T2. Four with prior screening had stage Tis or T1. The majority with malignant neoplasms (7/9) presented with symptoms. The two with benign neoplasms aslo presented with symptoms and were previously screened. Diagnosis age ranged from 37 to 71 years for all neoplasms, but 6/9 patients with malignant neoplasms presented at less than 50 years of age. The two patients with benign neoplasms were above age 50. No patients had a family history of cancer.

Though the number of cases is limited, this study highlights the critical need for improved breast cancer screening among Somali immigrants in the United States. A large proportion of patients presented with symptoms, at less than 50 years of age, or with advanced-stage disease at the time of diagnosis. Prior studies have shown that immigrant and minority populations in the United States have higher morbidity and mortality due to breast cancer as compared to the general population. Furthermore, the Somali population in this study has had poor adherence to breast cancer screening during the study period, which may have resulted in the low number of cases diagnosed. The findings underscore the need for culturally tailored interventions to improve breast cancer screening adherence and outcomes in the Somali population. COMMUNITY-ENGAGED QUALITATIVE STUDY ON SUPPORTING TRANSGENDER AND GENDER-DIVERSE STANDARDIZED PATIENTS IN MEDICAL SIMULATION Steven Allon1; Andrew Kittleson2; Pepper J. Heifner3; David G. Schlundt4; Kemberlee Bonnet4; Arna Banerjee5; Christopher P. Terndrup1. 1Medicine, Vanderbilt University Medical Center, Nashville, TN; 2Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN; 3Program for LGBTQ Health, Vanderbilt University Medical Center, Nashville, TN; 4Psychology, Vanderbilt University College of Arts and Science, Nashville, TN; 5Anesthesia and Critical Care, Vanderbilt University Medical Center, Nashville, TN. (Control ID #4270431)

Transgender and gender-diverse (TGD) individuals often face negative healthcare experiences that discourage healthcare utilization and contribute to adverse health outcomes. Medical simulation offers a unique opportunity to foster affirming communication skills among trainees, but clinician-educators lack best practices for effectively incorporating TGD standardized patients (SPs). Scoping reviews emphasize that this gap limits the integration of TGD SPs into simulation training. Our study developed preliminary guidelines for recruiting, casting, and supporting TGD SPs, providing a framework to enhance simulation-based education.

We used a modified Delphi technique, a structured and iterative consensus-building approach, to develop preliminary guidelines for recruiting, casting, and supporting TGD SPs in medical simulations. Eligible participants included TGD adults and parents of TGD children from a metropolitan area in the Southern region served by an academic institution. We recruited participants using purposive sampling, with local institutional and community organizations serving the TGD community distributing a recruitment flyer to their members. In the first survey, participants shared their views on recruitment, casting, and support practices for TGD SPs. These responses were analyzed thematically to derive tentative guideline statements. Two additional survey rounds were conducted, during which participants provided feedback on the evolving guidelines. To be included in the final guidelines, statements needed at least 60% agreement among participants. Statements with ≥ 75% agreement were classified as strong recommendations, while those with 60-74% agreement were designated as conditional recommendations.

Our sample included 50 participants (96% TGD, 86% aged 18–44). We derived 44 consensus guideline statements (39 strong, 5 conditional) on recruiting, casting, and supporting TGD SPs. Key themes emphasized institutional trust, ethical recruitment practices, and transparent communication about the emotional labor of SP work. Participants recommended casting TGD individuals with lived experience to portray TGD roles, ensuring authenticity and enhancing learner feedback. They also identified a gradient of acceptable casting decisions, offering flexibility based on simulation context and SP-patient alignment. Participants recommended strategies to enhance TGD SPs' agency, ensure psychological safety, and process emotions during simulations.

This study offers a practical framework for the ethical recruitment, casting, and support of TGD SPs in medical simulations, addressing barriers to inclusivity. These guidelines can help clinician-educators develop TGD healthcare simulations and collaborate with local TGD community members to enhance relevance. While regionally limited, this work lays a foundation for future validation in diverse populations and advances TGD healthcare education through simulation. CORRELATES TO HIV TESTING IN GAY, LESBIAN, AND BISEXUAL ADULTS Alyssa M. Brown, Yendelela Cuffee, Alexandra Wynn. Health Sciences, University of Delaware, Newark, DE. (Control ID #4273376)

HIV testing is crucial to the management of HIV/AIDs and the prevention of HIV transmission. Understanding the correlates of HIV testing among US adults is important to increasing engagement with HIV testing services. Moreover, considering the differences between population subgroups helps to address disparities in HIV testing practices. This study aimed to assess HIV testing variation within queer adults, looking at differences between Lesbian, Gay, or Homosexual adults and their Bisexual counterparts.

Using the 2020 California Health Interview Survey data, we conducted a cross-sectional analysis of 1,685 adults. Participants self-identified as Lesbian, Gay, Homosexual or Bisexual. We examined factors associated with HIV testing including considering mental health, knowledge of PrEP/Truvada, and having a usual source of healthcare. Data were analyzed using descriptive statistics, chi-square test, and logistic regression models using STATA Version 18.

Our sample included 1,685 participants, with 47% identifying as Lesbian, Gay, or Homosexual and 53% as Bisexual. Sixty-seven percent of study participants were White, 11% were Asian, and 5% were Black. Fifty-three percent also identified as female and 47% as male. Seventy-two percent of Gay, Lesbian, or Homosexual adults and 57% of Bisexual adults have been tested for HIV. Overall, 68% of the sample has heard of PREP/Truvada. Our analysis indicated that individuals identifying as Gay, Lesbian, or Homosexual were 2.4 times more likely to have been tested for HIV compared to Bisexual individuals (OR = 2.41, p= < 0.001). Participants who were aware of PrEP or Truvada had higher odds of HIV testing (OR = 1.17, p= < 0.001). Additionally, a significant negative association was observed between HIV testing and not having a usual source of care (OR = 0.81, p= < 0.001) or not visiting a doctor within the past 12 months (OR = 0.79, p= < 0.001).

Our sample provided valuable insight into the difference in testing rates between Lesbian, Gay, or Homosexual and Bisexual adults. While most Lesbian, Gay, or Homosexual adults have been tested for HIV, only slightly over half of Bisexual adults have been. HIV testing has a significant relationship with mental health outcomes, as individuals who felt more depressed or hopeless had greater odds of getting tested for HIV. The findings of this study exemplify the need to conduct further research into the correlates of HIV testing and support patients at risk for low testing rates. Future research should explore other factors such as social support, insurance coverage, attitudes, and knowledge of HIV as they have been found to affect HIV testing rates in marginalized populations such as Lesbian, Gay, Homosexual, and Bisexual adults. COVID-19 VACCINE PERCEPTIONS AND UPTAKE AMONG THE CRIMINAL LEGAL-INVOLVED INDIVIDUALS Mariah Dimalaluan1; Jordy Rojas Antigua1; Lindsey Riback1; Chenshu Zhang1; Jamile Torres2; Amour Castillo2; Micaela Linder2; Ronald F. Day2; Aaron Fox1; Matthew J. Akiyama1. 1Medicine, Albert Einstein College of Medicine, Bronx, NY; 2Center for Research, Inquiry, and Social Justice, The Fortune Society, Long Island City, NY. (Control ID #4272089)

Criminal legal-involved individuals (CLI) face significant health disparities and are at heightened risk for infectious diseases like COVID-19. Historically, the CLI community exhibits lower vaccine uptake due to medical mistrust and systemic barriers. Little research exists on COVID-19 vaccine perceptions and uptake among CLI, which could enrich the existing understanding of vaccine hesitancy in this community and help inform future guidelines.

From April 2022 to May 2024, we enrolled 250 CLI released in the past 90 days. During the trial, we updated our survey to collect participants' self-reported rationale for getting vaccinated (N = 226). Participants were categorized into three mutually exclusive categories: unvaccinated, vaccinated voluntarily, and vaccinated due to incentives/requirements. Attitudes toward vaccine safety, societal benefits, and effectiveness were taken from the PhenX Toolkit and evaluated using a 4-item Likert scale. A composite average score was generated; higher scores indicated more positive perceptions. ANOVA and chi-square tests were used to compare composite scores, attitudes, and behaviors across groups.

Among the 226 participants, most were male (85.8%) and 42.4 years old on average (SD = 11.9). Half were Black (50.9%), and one-third were Hispanic (32.3%). Of the 74.3% who received at least one COVID-19 vaccine, 65.5% were voluntarily vaccinated, and 34.5% were vaccinated due to incentives/requirements. In total, 41.7% cited concern for personal health/health of others as a reason for getting vaccinated. Unvaccinated participants (25.7%) had significantly lower composite COVID-19 vaccine perception scores compared to those vaccinated due to incentives/requirements and those who were voluntarily vaccinated (2.3 ± 0.9 vs. 2.8 ± 0.8 vs. 3.3 ± 0.6, respectively; p < 0.001). Negative perceptions of vaccine safety were most prominent among unvaccinated participants: 46% strongly agreed vaccines have harmful side effects compared to 28% of incentivized or required participants and 8.3% of those voluntarily vaccinated (p<0.001). When comparing perceptions of different vaccines, unvaccinated participants had a more negative perception of COVID-19 vaccines compared to childhood vaccines (2.3 ± 0.9 vs. 2.8 ± 0.8, respectively; p < 0.001).

COVID-19 vaccine uptake in this cohort of CLI was comparable to U.S. averages despite historical inequities and mistrust. Many cited concerns for personal and other's health as the primary motivation for getting vaccinated, and just over a third cited incentives and requirements. Most notably, unlike vaccinated CLI, unvaccinated CLI had a significantly more negative perception of COVID-19 vaccines overall and compared to childhood vaccines. These findings underscore the need for a deeper understanding of trust-building, culturally sensitive interventions tailored to this population to continue lessening the gap in vaccine uptake. CULTURALLY-TAILORING HYPERTENSION PATIENT EDUCATION RESOURCES FOR 5 RACIAL AND ETHNIC COMMUNITIES IN A LARGE SAFETY NET HEALTH SYSTEM THROUGH PATIENT, PROVIDER, AND COMMUNITY ENGAGEMENT Jocelyn R. Lo1,5; Atkia Sadia1; Amelia R. Weldon2; Jessica S. McLaughlin1; Savanna L. Carson1; Myra Garcia3; Nina J. Park4,1; Alejandra Casillas1; Soma Wali5,1; Arleen F. Brown1. 1General Internal Medicine, University of California Los Angeles, Los Angeles, CA; 2Community Engagement and Research Program, University of California Los Angeles, Los Angeles, CA; 3Los Angeles County Department of Health Services, Los Angeles, CA; 4Health Services Administration, Los Angeles County Department of Health Services, Los Angeles, CA; 5Department of Medicine, UCLA Medical Center Olive View, Sylmar, CA. (Control ID #4271465)

Disparities in hypertension control disproportionately affect ethnically diverse, historically marginalized communities and necessitate customizable approaches to hypertension management. As part of a cluster randomized trial designed to promote equitable hypertension management in a large safety net health system, focus groups and interviews with patients and providers identified a need for culturally-tailored patient education resources.

We created and culturally-tailored a library of hypertension patient education resources using an iterative design approach involving patients, providers, and community members. Design of resources followed a stepwise process: (1) General template for comprehensive education booklet tailored to safety net health system; (2) Booklets culturally-tailored for 5 racial and ethnic communities; (3) Adaptation to posters and infographics. Frameworks and tools used to develop resources included: national societies’ hypertension guidelines, Common Strategies for Enhancing Cultural Appropriateness, CDC Clear Communication Index, and adapted implementation methodologies. Resources were refined and tailored using iterative reviews by healthcare providers with expertise in health education, nursing, medicine, and behavioral health; community action boards representing 5 racial and ethnic communities; patient focus group; and culturally concordant graphic designers. For each language, linguistic tailoring used a team-based approach: (1) forward translations by vendor, (2) revisions and a consensus meeting with 2-3 local native language speakers, and (3) dialogue between linguistic reviewers and vendor until consensus. Meetings were recorded and included 1-2 notetakers. Meeting notes and resources were reviewed at weekly research team meetings. Resources will be available on the health system website and communication platform.

A library of hypertension patient education resources was created and culturally-tailored in 6 languages for 5 racial and ethnic communities, including Black/African American, Chinese, Filipino, Korean, and Latino/Hispanic communities. Resources include 12 education booklets, 12 infographics, and 2 posters. Over two years, we conducted over 25 partner review sessions and over 9 linguistic-tailoring sessions in Korean, Simplified Chinese, Spanish, Tagalog, and Traditional Chinese. Review sessions identified several domains for (1) Content tailored to safety net health system, e.g. use simple recommendations, explain why, dispel common myths, below 6th grade reading level; (2) Cultural-tailoring, e.g. represent intersectional identities and views within communities, aim for universal baseline; and (3) Design, e.g. illustrations that resonate with community members.

We demonstrate the importance of partnered co-design and a stepwise approach to culturally-tailoring patient education resources. This enhances partnerships and brings real-world recommendations and lived experiences into resources. CURRICULAR INNOVATION TO REDUCE DISPARITIES IN RESIDENT TELEHEALTH DELIVERY Gail Berkenblit1; Lindsay Sheets2. 1IM, Johns Hopkins University, Baltimore, MD; 2Medicine-Pediatrics, Johns Hopkins Medicine, Baltimore, MD. (Control ID #4270451)

Telehealth has emerged as a crucial tool for healthcare delivery, particularly during the COVID-19 pandemic. However, concerns have arisen regarding disparities in telehealth utilization across various demographic groups. Training resident learners to identify and address these disparities will promote equitable access to telehealth for all populations.

A telehealth curriculum was administered to all PGY1 residents at a mid-Atlantic urban residency program. In 2021 the curriculum was enhanced to specifically address disparities in care. Information about disparities in telemedicine access were presented during the two hour didactic portion of the curriculum. Local practice patterns were visualized via geospatial data. Residents were provided with tools to increase telemedicine access utilizing alternate platforms. Data on visit type, completion rate, and patient location were obtained from EHR and viewed via dashboard (Tableau). Statistical analysis was performed using the Chi squared test.

A total of 1041 telemedicine visits were completed by 96 residents in FY 23 and 24. Among those who received the enhanced curricula, 9% of telehealth visits were conducted by telephone. In that same timeframe, 16% of telehealth visits were conducted by telephone among those who received the standard curriculum (p<0.05). Visits specifically scheduled as "audio-only" visits were nearly equivalent between the two groups of residents at 5% and 6% respectively. Among visits scheduled as video, the rate of conversion to audio only was 2.5 fold lower among those who received the enhanced curriculum. The two groups had near equal completion rate of telehealth visits (77% for standard curriculum versus 75% for enhanced curriculum), suggesting that untrained residents were more likely to convert visits to telephone if they were unable to easily connect by video whereas those who received the disparities training were more likely to achieve video connection. Maps displaying telehealth access at the beginning of the pandemic showed decreased video visit access among neighborhoods subjected to redlining. These maps were incorporated into the curriculum to help learners visualize local practice patterns within this historic context. Mapping of telemedicine access among patients of residents who received the enhanced curriculum demonstrated decreased disparities imprint in these neighborhoods. The greatest increases in percentage of completed video visits were seen among patients who self-identified in the EHR as Black/African American (12% versus 20%, p<0.05) or Hispanic or Latino (6% versus 22%, p<0.05).

Focus on disparities in telehealth access can lead to improved rates of completed video visits versus audio alone. Provision and visualization of local data can provide powerful stimulus for learners to change behaviors. Training in tools to improve video access should be incorporated within the curricula so that learners are empowered to overcome barriers. DEVELOPMENT AND PSYCHOMETRIC EVALUATION OF THE PERCEIVED EQUITY OF CARE INDEX (PECI) Renuka Tipirneni1,2; Wendy Furst1; Andrei Stefanescu3; Dominic A. Ruggiero4; Erin Beathard2; Erica Solway5; Dianne C. Singer2; John Z. Ayanian1; Eric Roberts6; Galen E. Switzer7. 1Internal Medicine, University of Michigan, 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; 4Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA; 5Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI; 6General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 7University of Pittsburgh, Pittsburgh, PA. (Control ID #4267421)

To measure health care equity, quality measures should incorporate patient-reported experiences of racism and discrimination. Current patient-reported outcomes focus almost exclusively on interpersonal experiences, i.e., interactions with physicians or nurses. The objective was to develop patient-reported measures assessing perceptions of structural racism and discrimination in access and quality of care, in addition to interactions with health care professionals. Here we report the development and field-testing of the Perceived Equity of Care Index (PECI).

1) We developed and refined items assessing individual perceptions of racism and discrimination in health care, informed by literature, an advisory committee, and semi-structured and cognitive interviews with Medicare beneficiaries. Final domains focused on physician care, prescription medications, and overall quality of care. 2) We conducted a field test and psychometric evaluation of 10 draft items (plus a follow-up question for those indicating negative experiences) via a cross-sectional national survey in Jan-Feb 2024, of 6,535 adults ages 65+ with Medicare coverage who self-identified as Black, Hispanic, or White. We used exploratory factor analysis (EFA) to identify latent factors represented by the items. Cronbach’s alpha was used to assess internal consistency among items and select which items to include in the PECI.

The EFA, using an eigenvalue cutoff of 1.0 and scree plots, yielded a single-factor solution, indicating that all 10 items represented a single latent factor. 5 items were selected for inclusion in the PECI as the strongest representatives of the underlying construct based on factor loadings and Cronbach's alpha (Table). The PECI was only weakly correlated with existing patient experience items from the Consumer Assessment of Health Providers and Systems Survey (CAHPS) (r<0.14 for all items).

We developed a meaningful and informative equity-focused index to measure patient perceptions of both structural and interpersonal racism and discrimination related to access, quality, and experiences of health care, with strong preliminary evidence of reliability and validity. The 5-item index measures dimensions of patient experience not captured by existing CAHPS items. The PECI can be incorporated as a new set of patient-reported quality measures that emphasize equitable care, including into Medicare’s star ratings program. DISPARITIES IN EARLY LECANEMAB UPTAKE AMONG U.S. MEDICARE BENEFICIARIES Frank F. Zhou1; Utibe R. Essien1; Jeffrey Souza3; Catherine Sarkisian1,5; Cheryl L. Damberg2; Bruce E. Landon3,4; 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; 2RAND Health, RAND, Santa Monica, CA; 3Department of Health Care Policy, Harvard Medical School, Boston, MA; 4Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 5Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA. (Control ID #4271095)

In July 2023, lecanemab became the first disease-modifying therapy for Alzheimer’s disease (AD) to receive broad Medicare coverage. However, patients seeking treatment face significant access barriers, including high out-of-pocket costs, cumbersome eligibility testing requirements, and the need for in-person infusion visits at specialized centers. We hypothesized that lecanemab use may be limited among individuals from racial and ethnic minoritized and socioeconomically disadvantaged populations disproportionately affected by AD.

We examined early trends in lecanemab uptake among 100% of Medicare fee-for-service beneficiaries aged ≥66 years with ≥11 months of coverage in the preceding year. Using HCPCS code J0174 in either the Part A or Part B claims files, we identified patients who had received at least one lecanemab infusion between July 1, 2023 and March 31, 2024. We compared the demographic characteristics of lecanemab users to all Medicare beneficiaries with diagnosed AD or mild cognitive impairment (MCI) as determined by ICD-10 codes, calculated relative lecanemab uptake rates by demographic group, and performed ANOVA testing for between-group differences in uptake rates. Sociodemographic variables of interest included age, sex, race/ethnicity, urban-rural status, and a proxy variable for socioeconomic disadvantage, defined as being eligible for either the Part D low-income subsidy or dually eligible for Medicare-Medicaid.

We identified 1,725 Medicare beneficiaries who used lecanemab during our study timeframe; their mean age at initiation was 75.7 years, 51.5% were female, 4.5% were Asian, Black, or Hispanic, 88.0% were from urban areas, and 1.3% were socioeconomically disadvantaged. Lecanemab uptake rates among all patients with AD or MCI were significantly higher for patients who were White (0.23% vs. 0.09% for Asian, 0.04% for Black, 0.07% for Hispanic, P<.001), from urban areas (0.22% vs. 0.14% for rural areas, P<.001), or socioeconomically advantaged (0.27% vs. 0.01% for socioeconomically disadvantaged, P<.001).

Early uptake of lecanemab among Medicare beneficiaries has been slow and marked by racial, ethnic, and socioeconomic disparities, consistent with a recurring historical pattern of unequal access to breakthrough therapies in the United States. This dynamic underscores how a costly and likely low-value treatment, which contributes to higher Medicare spending for everyone, is being disproportionately provided to advantaged populations. DISPARITIES IN ECMO UTILIZATION FOR ARDS: INSIGHTS FROM THE NATIONAL INPATIENT SAMPLE, 2017–2021 Doan Ngoc Chau Nguyen1; Jairah Shaikh2; Viet Nghi Tran3. 1Internal Medicine , Texas Tech University Health Science Center at Amarillo, Amarillo, TX; 2Internal Medicine, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 3Dept. of Internal Medicine, Resilience Healthcare - Weiss Memorial Hospital LLC, Chicago, IL. (Control ID #4273609)

Extracorporeal membrane oxygenation (ECMO) may be considered a salvage therapy for patients with acute respiratory distress syndrome (ARDS) who have severe gas exchange abnormalities. Access to ECMO remains a topic of concern. This report evaluates the prevalence of ECMO use in patients with ARDS, stratified by age, race, socioeconomic status, insurance coverage, and hospital characteristics.

We analyzed data from the National Inpatient Sample (2017–2021), focusing on adults diagnosed with ARDS who received ECMO treatment. Sampling-weighted methods were used for survey adjustment. We evaluated variations in ECMO utilization rates across demographics, insurance, and hospital characteristics. Statistical analyses included chi-square tests and logistic regression, adjusting for comorbidities, the Elixhauser Index, and hospital characteristics.

Over five years, 443,034 cases of ARDS were identified, with 11,750 patients receiving ECMO. Among these, 34.85% were female, and the mean age was 45.86 years. By race, 50.68% were White, followed by Asian (42.43%), Hispanic (20.71%), Black (17.79%), and Native American (15.1%) (p<0.01). After adjustment, ECMO prevalence was higher in Asian (OR 1.35, 95% CI: 1.07–1.70; p<0.05) and Hispanic patients (OR 1.28, 95% CI: 1.09–1.49; p<0.05) compared to White patients. Among ARDS patients receiving ECMO, 98.64% were treated in urban hospitals and 94.94% in teaching hospitals. After adjustment, ECMO prevalence did not differ significantly between urban and rural areas. However, teaching hospitals had significantly higher ECMO rates than non-teaching hospitals (OR 4.77, p<0.01). Hospital bed size was also a significant factor, with medium-sized hospitals (OR 2.1) and large hospitals (OR 8.16) having greater ECMO use compared to small hospitals (p<0.01). ECMO prevalence initially showed an inverse unadjusted relationship with income, with the lowest income quartile accounting for 29.98% of cases and the highest income quartile accounting for 19.43% (p=0.002). However, after adjustment, a direct association was observed, with higher income linked to greater ECMO prevalence (OR 1.45, 95% CI: 1.23–1.72; p<0.01 for the highest versus lowest quartile). Patients with private insurance had the highest ECMO prevalence (53.11%), followed by Medicaid (24.25%), Medicare (12.11%), and self-pay (4.65%) (p<0.01). After adjustment, ECMO rates were significantly higher in private insurance (OR 3.02), Medicaid (OR 1.78), and self-pay patients (OR 1.37) compared to Medicare (p<0.05).

Although ECMO has demonstrated mortality benefits in patients with severe ARDS across numerous studies, significant disparities in access persist based on race, socioeconomic status, insurance, hospital type, and bed size. Targeted interventions are needed to address these inequities and ensure equitable access to ECMO regardless of patient demographics or hospital characteristics. DISPARITIES IN PREHOSPITAL PAIN MANAGEMENT FOR PATIENTS WITH LANGUAGE BARRIERS Marissa L. Ding3; Christopher E. Warrington5; Chad P. Liedl5; Jennifer M. Manggaard2; Marvin C. Rogerson5; Jane W. Njeru1; Rozalina G. McCoy2,4. 1Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic Minnesota, Rochester, MN; 2Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic Minnesota, Rochester, MN; 3Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA; 4Division of Endocrinology, Diabetes, & Nutrition, Department of Medicine, University of Maryland Baltimore School of Medicine, Baltimore, MD; 5Mayo Clinic Ambulance, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4272944)

An integral part of Emergency Medical Services (EMS) patient care is the assessment and treatment of pain. Among the estimated 16 million annual EMS encounters in the United States, 20-30% of patients report moderate to severe pain and 10% report severe pain, yet only about 40% of pain encounters result in clinically significant pain reduction. Gaps in identifying and treating pain are likely even greater for people with limited English proficiency (LEP). In 2019, 67.8 million people in the U.S. (nearly one in five Americans) reported speaking a language other than English in the home, up from 23.1 million in 1980. In this study, we examined differences in pain assessment and management by EMS among LEP and non-LEP patients treated by a large, advanced life support ambulance service in the U.S. Upper Midwest

This retrospective cohort study used EMS patient care records to identify all EMS encounters involving language as a communication barrier between 1 January 2022 and 31 December 2022. Interfacility transports were excluded. EMS run reports were manually reviewed by the research team to exclude calls where communication barriers were not related to LEP. Patient demographics included patient age, sex, and date of birth. Using narrative text from runs, we identified how communication between patients with LEP and EMS providers was facilitated: caregiver, family member, language line (a virtual medical interpreter), passerby, and the patient (i.e., no support was available), or an unspecified individual or third party. We captured the number of pain assessments, the location of pain, and the severity of pain on a 0-10 scale. We then captured all pain treatments used, categorized as opioid or non-opioid. Statistical analysis was conducted at the call level rather than the patient level.

We identified 89,832 runs without evidence of LEP and 1122 runs with evidence of LEP during the study period. The number of pain assessments was lower for LEP patients (median 1 assessment, IQR [0,2]) compared to non-LEP patients (median 2 assessments, IQR [1,2]). There was no significant difference in the number of pain assessments between patients who used a non-language line interpreter and patients who used the language line. Administration rates of all classes of pain medications were lower for LEP patients than non-LEP patients. There was no significant difference in medication administration rates for these treatments by language line usage.

Pain is assessed and treated by EMS significantly less among LEP patients than non-LEP patients, and availability of interpreter services does not appear to modify this disparity. However, low availability and utilization of interpreter services may have precluded detection of benefit. Further studies are needed to investigate which interpretation strategies best correct gaps in care for patients with LEP. DO SURVIVAL DISPARITIES IN ANAL CANCER PERSIST AMONG NON-HISPANIC BLACK PATIENTS? Antoine Jeri-Yabar1; Liliana Vittini-Hernandez1; Luis Oller-Payano1; Marcos Rosa Santana2. 1Mount Sinai Morningside Hospital, New York, NY; 2Surgery, Lenox Hill Hospital, New York, NY. (Control ID #4273377)

The incidence of anal cancer has been steadily increasing, accompanied by significant racial disparities in survival outcomes, particularly among Non-Hispanic Black (NHB) patients. While previous research has highlighted these disparities, it remains unclear whether the survival gap has narrowed over time. This study evaluates whether racial disparities in anal cancer survival persist, with a focus on NHB, to better understand the risks faced by this group.

This retrospective cohort study used SEER data (2018–2021) on patients with confirmed anal cancer and complete data on race, stage, sex, age, socioeconomic status, and residence. Cancer-specific survival was analyzed using Cox regression to assess associations with demographic, clinical, and socioeconomic factors, with significance set at p <0.05.

Among 5,792 patients (65.94% female, 77.12% Non-Hispanic White [NHW]), Non-Hispanic Black (NHB) patients had higher mortality than NHW (aHR: 1.47, p<0.001), while other racial groups showed no significant differences. Most patients were diagnosed at Stage III (42.46%) and were aged 60–70 years (37.19%). Worse survival was associated with age ≥70 (aHR: 2.14, p=0.015), Stage IV disease (aHR: 17.70, p<0.001), and adenocarcinoma histology (aHR: 1.57, p<0.001), while female sex was protective. Socioeconomic status and area of living were not significant predictors.

NHB patients faced persistent cancer-specific survival disparities (2018–2021) compared to NHW. Advanced stage, older age, and adenocarcinoma histology were also linked to worse survival. Targeted interventions are needed to address these disparities and improve outcomes, with further research to uncover their causes and promote health equity in anal cancer care. ENHANCING PHYSICIAN-PATIENT COMMUNICATION: EVALUATING THE IMPACT OF A MEDICAL SPANISH COURSE ON STUDENT FLUENCY, CONFIDENCE, AND RAPPORT-BUILDING Amanda M. DiMartini1; Katherine O. Chebly2. 1Internal Medicine, New York University Grossman School of Medicine, New York, NY; 2Medicine, NYU Langone Health, New York, NY. (Control ID #4273169)

As the population of Spanish-speakers in the US grows, equipping future physicians with the tools to communicate effectively in Spanish and provide language concordant care is ever more essential. This study analyzes the impact of a long-standing Medical Spanish course at an urban medical school on students’ fluency, confidence, and rapport-building skills.

This mixed methods study measures pre- and post-course self-assessed fluency, confidence levels, and therapeutic alliance building skills when conducting medical interviews with Spanish-speaking patients. Qualitative comments were also collected regarding the impact of the course and its perceived limitations. Speaking and listening ability were self-scored using the Interagency Language Roundtable (ILR) numerical scale. Confidence levels and therapeutic alliance building skills were assessed via agreement with Likert scale statements. Qualitative feedback was coded using deductive content analysis to highlight recurrent themes.

There was no statistically significant change in students’ self-assessed speaking or listening language fluency between the pre- and post-course surveys. On the five point ILR scale, the pre-course speaking fluency average was 2.03 and the post-course was 2.23 (p-value 0.6857). The pre-course listening fluency average was 2.47 and the post-course was 2.69 (p-value 0.5027). Participants did note statistically significant gains in their relationship-building skills. Students’ average Likert scale response to the statement, “I feel confident in my ability to build rapport with Spanish-speaking patients,” was 2.33 in the pre-course survey and 3.15 in the post-course survey (p-value 0.0032). There was also a statistically significant difference in response to the statement, “I feel confident in my ability to express empathy to Spanish-speaking patients,” with an average response of 2.60 in the pre-course survey and 3.31 in the post-course survey (p-value 0.0143). Students identified the course’s 10 week time frame as a major limitation with 8 occurrences of this theme identified in the content analysis of the qualitative feedback.

This long-standing Medical Spanish course helped students increase confidence in building rapport during patient interviews at existing levels of Spanish fluency, but did not serve as a meaningful vehicle for increasing fluency. EVALUATING THE ROLE OF LANGUAGE PREFERENCE ON KIDNEY DISEASE MONITORING AMONG PATIENTS WITH TYPE II DIABETES Nicolás Prada-Rey1; Lipika Samal1,2; Jorge A. Rodriguez1,2. 1General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; 2Harvard Medical School, Boston, MA. (Control ID #4271324)

Chronic kidney disease affects 1 in 3 patients with type II diabetes (T2DM), making monitoring essential. The Kidney Health Evaluation for Diabetes (KED) metric requires annual monitoring of estimated Glomerular Filtration Rate (eGFR) and urinary Albumin-to-Creatinine Ratio (uACR), with some also advocating for cystatin C use. While KED fulfillment rates are below 40%, little is known about the role of language preference in monitoring. We examined the differences in CKD monitoring by language preference among patients with T2DM.

We identified patients with T2DM who had primary care visits in 2021 and 2022 at an academic medical center. Patients with T2DM were identified using billing codes, labs, and medications. We excluded patients with end stage renal disease or who were pregnant. Our exposure was language preference defined as non-English language preference (NELP) and English language preference (ELP). Our primary outcome was measurement of eGFR and uACR. Our secondary outcome was measurement of eGFR, uACR, and cystatin C. Generalized estimating equation logistic regression with clustering by PCP was used for adjusted analyses.

The cohort included 13,098 patients who had a primary visit during our study period, of whom 17% had NELP. Compared to patients with ELP, patients with NELP were older; more likely to be female, Hispanic; have public insurance; be on a renin-angiotensin-aldosterone system inhibitors; and had a higher HbA1c. In adjusted analyses, there were no significant differences by language preference in KED fulfillment (OR: 1.01, CI: 0.87-1.18, p-value: 0.9) or assessment of all 3 labs (OR: 1.07, CI: 0.80-1.43, p-value: 0.7) (Table).

We found no difference in kidney disease monitoring by language. While encouraging, these findings highlight the multilevel nature of CKD disparities. Study limitations include the single-site design which may limit generalizability. Future research should investigate other potential contributors to downstream CKD disparities. EXAMINING THE EFFECT OF THE USPSTF LUNG CANCER SCREENING RECOMMENDATION ON LUNG CANCER SCREENING DISCUSSIONS AND DISPARITIES: A SECONDARY ANALYSIS OF NATIONAL SURVEY DATA Amanda Gusovsky Chevalier1; Christine M. Swoboda1; Rachael Hawthorn1; Natalie S. Lee2; Daniel E. Jonas3. 1The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), The Ohio State University College of Medicine, Columbus, OH; 2National Clinician Scholars Program, University of Pennsylvania, Westerville, OH; 3Internal Medicine, The Ohio State University, Columbus, OH. (Control ID #4272000)

After the United States Preventive Services Task Force (USPSTF) updated lung cancer screening (LCS) recommendations in 2021 to expand eligibility, experts anticipated that the updates would lead to more discussions about LCS, increasing LCS overall and reducing disparities in lung cancer. This study examines LCS discussions by race and age before and after the USPSTF recommendations were updated in 2021.

Using the 2014, 2017, 2020, and 2022 Health Information National Trends Survey (HINTS), we examined patients 50 to 80 years old, current/former smokers, and those who visited a medical provider at least once in the past year. The primary outcome was patient self-report of an LCS discussion. Logistic regression was used to examine adjusted differences in LCS discussion by race group pre- vs. post-USPSTF updated recommendation with interaction terms for age and race, age and time, and race and time.

An LCS discussion was present in 11% and 12% of the pre- and post-USPSTF updated recommendation groups, respectively (p=0.756). Variables significantly associated with LCS discussion were (OR [95%CI]): age (1.05 [1.02, 1.08]), current smoker (2.95 [1.95-4.46]), uninsured (0.38 [0.18, 0.83]), and having more annual visits (number of visits in the prior year compared to 1-2: 3-4 (2.04 [1.32-3.14]); 5-9 (1.95 [1.12, 3.39]);10+ (2.53[1.51-4.24]). Data year (2022 vs. 2020 and prior), race, and the interaction terms were not significantly associated with LCS discussion.

Our findings suggest no significant increase in self-reported LCS discussions after the 2021 recommendation. LCS discussion rates should continue to be tracked moving forward because data were only available through 2022 and meaningful change may require more time. FACTORS ASSOCIATED WITH DISCORDANCE IN INFLUENZA AND COVID-19 VACCINATION STATUS Max Jordan Nguemeni Tiako1; Alexander Chaitoff2; Alysse G. Wurcel3; Marcella Nunez-Smith4; Kathryn Himmelstein5. 1medicine, University of California Los Angeles, Los Angeles, CA; 2Medicine, Brigham and Women's Hospital, Boston, MA; 3General Internal Medicine, Boston Medical Center, Boston, MA; 4medicine, Yale University School of Medicine, New Haven, CT; 5medicine, Boston Medical Center, Boston, MA. (Control ID #4273475)

Vaccines are evidence-based interventions that save lives. COVID-19 and influenza are two vaccines with clear evidence for efficacy and safety. Vaccine hesitancy rates increased in the US during COVID-19, in part due to political polarization. A recent study reported a divergence in attitudes toward the COVID-19 and influenza vaccines. We sought to describe the prevalence of and identify factors associated with discordance in influenza and COVID-19 vaccination status.

This is a cross-sectional study of a nationally representative sample of US adults from the 2022 National Health Interview Survey. The primary outcome was COVID-19 and influenza vaccination status discordance (vs receiving both vaccines) overall and considering the directionality of preference among those with discordant status. We defined vaccination status as respondents reporting receiving two or more COVID-19 vaccine shots and having received any flu vaccine in the preceding twelve months for the COVID-19 vaccine and the influenza vaccine, respectively. The secondary outcome was which factors were associated with having discordance in COVID-19 and influenza vaccination status. Factors explored included age, sex, race, marital status, insurance, self-reported health status, having a usual place of care, and family income to poverty ratio (FPL). For our primary analyses, we describe the population using descriptive statistics. We utilize multivariable logistic regression for our secondary outcome to estimate the associations between covariates and the dependent variable. We conducted analyses in Stata.

Among 45,565 individuals (unweighted), 60.1% had concordant vaccination status, with 48.8% receiving both and 11.3% receiving neither vaccine. In the discordant group, 28.5% received only the COVID-19 vaccine, and 11.4% received only the influenza vaccine. In multivariable regression analyses, older age (OR 0.40, 95% CI 0.37–0.42) and female sex (OR 0.77, 95% CI 0.73–0.81) reduced odds of discordance, while being Black (OR 1.53, 95% CI 1.39–1.68), Hispanic (OR 1.30, 95% CI 1.23–1.46), low income (FPL (OR 1.39, 95% CI 1.24–1.56), and uninsured (OR 2.21, 95% CI 1.94–2.52) increased those odds. Among discordant individuals, preference for the COVID-19 vaccine was higher among Black (OR 1.80, 95% CI 1.39–2.34), Hispanic (OR1.44, 95% CI1.01–2.06) and Asian people (OR 1.80, 95% CI 1.31–2.46) (vs White), those without a usual of care (OR 2.08, 95% CI 1.52–2.81) and those without insurance (OR 1.75, 95% CI 1.23–2.49).

Discordant COVID-19 and influenza vaccination status was more common among historically underserved groups. These groups were also more likely to report receiving the COVID-19 vaccine and not the influenza vaccine. These findings highlight nuances in vaccine decision-making and access and have implications for vaccine outreach and education efforts. GLP-1RA PRESCRIPTIONS FOR OBESITY TREATMENT ACROSS RACIAL AND ETHNIC GROUPS AT A UNIVERSITY-BASED HEALTH MAINTENANCE ORGANIZATION Alissa S. Chen1; Wendy L. Brunetto3; Maurren E. Canavan1; Kasia J. Lipska2; Elizabeth A. Richey3; Madeline S. Wilson3; James Zarro3; Joseph S. Ross2. 1Internal Medicine, Yale School of Medicine, Branford, CT; 2Internal Medicine, Yale School of Medicine, New Haven, CT; 3Yale Health, New Haven, CT. (Control ID #4240899)

While GLP-1RAs have revolutionized the treatment of obesity, national data has shown that Black adults and Hispanic adults have a lower receipt of GLP-1RAs. We hypothesized that within an integrated healthcare delivery system, which provides treatment for patients but also assumes financial risk for their care, racial and ethnic disparities in receipt of GLP-1RA for obesity treatment may be mitigated.

This cross-sectional study analyzed GLP-1RA prescriptions at a university-based staff model HMO, an integrated healthcare delivery model where the physicians and staff providing care are HMO employees and the healthcare facilities are owned by the HMO. Adult (≥18) members of the HMO were included in the analysis if they were eligible for treatment with GLP-1RAs for obesity (by body mass index and clinical conditions), not a student, and did not have diabetes. The outcome of interest was GLP-1RA prescription receipt. Prevalence of prescription receipt for eligible patients was calculated within racial and ethnic groups. A multivariable logistic regression model estimated odds of prescription receipt based on race and ethnicity adjusting for age, sex, BMI class, and obesity-related conditions.

Among 6,225 eligible adults (mean age = 46.2 years; 55.6% female; 5.0% Asian, 22.2% Black, 59.2% White, 8.0% other, 5.6% missing race; 13.1% Hispanic, 82.0% non-Hispanic, 4.9% missing ethnicity), 1,143 (18.3%) received at least one prescription for GLP-1RAs. Receipt of GLP-1RA prescription varied by race and ethnicity (10.3% Asian, 21.5% Black, 17.5% White, 23.7% other, 14.2% missing race [p<0.001]; 23.1% Hispanic, 18.1% non-Hispanic, 9.4% missing ethnicity [p<0.001]). After accounting for patient demographic and clinical characteristics, there were no statistically significant differences in GLP-RA prescription receipt among adults of Asian, Black, other, and missing race compared to White race (Table, p values<0.05), whereas Hispanic adults were more likely to receive a GLP-1RA prescription compared to non-Hispanic adults (OR=1.3, 95% CI, 1.0-1.6; p=0.02).

Within a university-based staff HMO, members of historically marginalized racial and ethnic groups did not receive GLP-1RA prescriptions at lower rates than White and non-Hispanic adults. These findings suggest that providing coverage for GLP-1RAs within an integrated healthcare delivery system was associated with equitable access to obesity treatment. HEALTHCARE ACCESS AND UTILIZATION AMONG TRANSGENDER AND GENDER DIVERSE ADULTS: AN ANALYSIS USING THE ALL OF US RESEARCH PROGRAM Daniel Swanson, Daniel Nguyen, JungAe Lee, Ben Gerber, Joy L. Lee. Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA. (Control ID #4272775)

Transgender and gender diverse (TGD) people have high rates of dissatisfaction with their healthcare and barriers accessing it. Prior studies are often limited by low sample sizes and consider all TGD people to represent one undifferentiated category. This limits our ability to understand the potentially diverse patterns of healthcare use among TGD people. To address this, we analyzed data through the NIH’s All of Us (AoU) Research Program that contains detailed information on gender identity.

We queried “The Basics Survey” and “Healthcare Access and Utilization Survey” within the AoU Controlled Tier v7 database on May 4 2023. We grouped participant gender according to their self-reported gender identity and sex at birth: (1) cisgender if their sex at birth aligned with their gender identity, (2) transgender if their sex at birth differed with gender identity while still in the gender binary, and (3) gender diverse if their self-reported gender identity did not fall in the binary categories. We computed descriptive statistics for demographic characteristics, healthcare access, and healthcare utilization. We developed multivariate logistic regression models (R version 4.3.1) to evaluate the relationship between gender and healthcare access barriers and use, controlling for age, race, and income.

Among the 145,204 participants in the analysis on affordability, gender diverse people were less able to afford healthcare than cisgender men (Adjusted odds ratio (AOR)=0.70, 95% confidence interval (CI), 0.59-0.83). Among the 150,982 participants in the analysis on respect, cisgender men reported feeling respected by their providers more often than cisgender women (AOR=0.7, 95% CI, 0.68-0.72), transgender men (AOR=0.49, 95% CI, 0.40-0.61), transgender women (AOR=0.48, 95% CI, 0.38-0.60), and gender diverse people (AOR=0.27, 95% CI, 0.24-0.30). Finally, the number of visits to the general doctor in the past twelve months was analyzed in 151,417 participants while adjusting for age and income. Fewer cisgender men had a high number of healthcare encounters (4+ per year) compared to cisgender women (AOR=1.09, 95% CI, 1.07-1.12), transgender men (AOR=1.38, 95% CI 1.09-1.73), transgender women (AOR=1.42, 95% CI 1.12-1.81), and gender diverse people (AOR=1.27, 95% CI 1.12-1.44).

Transgender men, women, and gender diverse people all reported greater difficulty affording healthcare and feeling less respect by providers, as well as fewer healthcare encounters than cisgender men. IMPACT OF INTEGRATED PRIMARY CARE ON CARE UTILIZATION AND PREVENTIVE CARE FOR PATIENTS WITH SICKLE CELL DISEASE Jennifer Y. Hong2; Yuchiao Chang2; Meghan L. Rieu-Werden2; Suzanne Brodney2; Caylin Marotta2; Aisha James2; Sharl Azar1; Jennifer Haas2. 1Hematology, Massachusetts General Hospital, Boston, MA; 2General Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4271161)

Sickle cell disease (SCD) is a severe, multi-organ disease that affects >100,000 Americans, mostly of Black/African or Latinx descent. Few multidisciplinary models exist for adult patients despite need, especially ones that include primary care physicians (PCPs). In this report, we compare patients at a New England academic comprehensive sickle cell disease center (CSCDC) with integrated adult PCPs with those at a comparative academic hematology clinic (CAHC). We hypothesized that patients cared for in the CSCDC would have fewer ED presentations and inpatient admissions and more preventive health screening than those who received care in the CAHC.

The CSCDC provides integrated visits with hematology, primary care, and access to an infusion center. Patients seen in the CSCDC were compared with patients established at the CAHC from July 2021 to March 2023. The last visit during this period at either clinic was considered patients’ index date. We compared the number of ED visits, inpatient admissions, and preventive health metrics (depression screening, age-appropriate cancer screenings) in the year prior to patients’ index date with the year post-index. Patients required >1 visits at their respective clinics to be included. If patients were seen at both clinics during this time frame, they were included in the cohort of their most recent visit.

The CSCDC and CAHC groups had 168 and 111 patients respectively. The CAHC group was significantly older than the CSCDC cohort (38.8yrs vs. 33.1yrs, p<0.001) and was more medically complex by Charlson score (2.6 vs. 1.4, p<0.001). Percentage of patients with at least 1 ED visit decreased in the year post-index compared to the year before at the CSCDC but increased among those at the CAHC (-7.2% vs. +9.6%, p=0.02). For the CSCDC cohort, inpatient admissions decreased and preventive health screenings improved (completion of depression screenings, age-appropriate breast, cervical, and colon cancer screening), but these were not statistically significant compared to the CAHC cohort. A larger percentage decrease in ED visits was observed for patients established at the CSCDC for >1 year compared to those <1 year.

The study suggests that PCP integration in comprehensive care models can lead to decreased ED presentations for patients with SCD. Infusion centers have previously been shown to decrease inpatient utilization, but both CSCDC and CAHC patients had this resource and differed in outpatient support, specifically PCPs. Our study was limited to a single health system and by sample size. Completion of preventive healthcare, such as mental health or cancer screenings, may increase with longer duration of clinic engagement. More research is needed to study the long-term effects of this care model, including impact on overall inpatient utilization, preventative health metrics, symptom severity, quality of life, and mortality. IMPROVING A COMMUNITY-BASED IMMIGRATION MEDICAL EXAM (IME) CLINIC FOR I-693 FORM Farah Shaheen3; Melanie Venegas2; Binui Jarvio1; Carlos M. Melchor1; Sharad Jain3. 1School of Medicine, UC Davis Health, Sacramento, CA; 2School of Medicine, University of California Davis School of Medicine, Sacramento, CA; 3Internal Medicine, University of California Davis Department of Internal Medicine, Sacramento, CA. (Control ID #4273353)

Being uninsured and undocumented is associated with increased health risks. Undocumented immigrants are less likely to have health insurance due to working jobs that lack employer-based health insurance; despite the recent health coverage expansion for undocumented residents in some states, many do not qualify, are confused about enrollment eligibility, and fear future legal status ramifications. The process of applying for permanent residency is complex and costly. There is a great need for the availability of low-cost immigration medical examinations, a required component of the I-693 form, for immigrants applying for permanent residency. A student-run clinic (SRC) providing immigration medical examination may be a cost-efficient resource for underserved immigrant populations undergoing the US permanent residency process. We introduced a survey to understand the patient experience with this process.

We created an immigration clinic at a student-run clinic to provide free or low-cost immigration exams for the I-693 form. Nine pre-surveys were administered via Qualtrics to adult patients completing their initial immigration medical exam. Pre-surveys collected data on their experience with the clinic, associated costs spent thus far in their process of applying for permanent residency, and demographics. Post surveys will be conducted at the final visit when the I-693 form is completed to assess the length of time, any barriers to completing requirements, satisfaction with care and recommendations for improvement.

Of the nine respondents, six patients reported feeling “Very Satisfied” and three reported feeling “Satisfied” with the length of time it took for them to get seen. Seven patients were seen alone while two patients were seen with their spouses. Individually, patients reported spending an average of $5,719 thus far in the process of applying for their permanent residency, not including costs associated with filling the I-693 form, while the two couples reported spending an average of $22,500 collectively. Seven patients reported being originally from Latin America, one from Canada, and one from Afghanistan.

The process of applying for permanent residency is costly, as demonstrated by the preliminary data collected. Although preliminary results show that patients feel satisfied with services provided by the rural student-run clinic, additional surveys will be administered to understand patient perception and experience with the clinic, associated barriers, financial costs, and to highlight sociodemographic data of the immigrant patient populations that are served. An immigration clinic at a student-run clinic is an effective way to support patients who need a medical exam for their permanent residency application. IMPROVING PATIENT-PROVIDER COMMUNICATION WITH PATIENTS WITH COMMUNICATION DISABILITIES IN THE PRIMARY CARE SETTING Megan Morris1; Kathryn Colborn2; Jennifer Duffecy5; Kori Eberle2; Michael M. McKee6; Bridget Mosley2; Jennifer Y. Oshita3; Sean Phelan7; Alicia Wong4; Russell Glasgow2. 1Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY; 2ACCORDS, University of Colorado Anschutz Medical Campus, Aurora, CO; 3Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY; 4Family Medicine, University of Colorado Denver School of Medicine, Aurora, CO; 5University of Illinois Chicago, Chicago, IL; 6University of Michigan Michigan Medicine, Ann Arbor, MI; 7Mayo Clinic Minnesota, Rochester, MN. (Control ID #4272382)

Research consistently demonstrates that patients with speech, language, voice, and hearing disabilities (collectively referred to as communication disabilities, or CD) experience significant health and healthcare disparities. Poor patient-provider communication is cited as a major barrier in decreased access to high-quality care for these patients. Despite this, little to no evidence exists on how to improve the quality of communication between patients with CD and their healthcare teams. The goal of the study was to compare two interventions aimed at increasing providers’ use of evidence-based communication strategies during primary care clinical encounters with patients with CD.

We conducted a stepped-wedge randomized control trial with 8 primary care clinics. We compared two interventions: provider and staff education on effective communication strategies with patients with CD vs. the aforementioned education + use of an electronic tool during a single encounter . The electronic tool lists 16 evidence-based communication strategies of which patients would select three strategies that they wanted the provider to use with them during a clinical encounter. They would then share the tool and selected strategies with the provider during the clinical visit. Outcomes included patient-reported quality of health as measured by the PROMIS Global Health measure, and patients’ perception of quality of communication as measured by the Communication Assessment Test (CAT).

A total of 687 patients participated across eight clinics in four healthcare systems and sites. Slightly more than half of the patients were white, non-Hispanic (54.6%) and male (51.2%). The average age of the participants was 63 years old and 63% of the participants had a hearing only disability. Across the two study arms, no differences were observed in the PROMIS Global Health measure and the CAT composite score. In secondary analyses, each item of the CAT measure was assessed. In the adjusted odds ratio models, three items reached statistical significance – “Provider treated me with respect” (2.33 OR [1.24, 4.41]), “Provider paid attention to me” (1.88 [1.00, 3.53]), and “Provider let me talk without interruptions” (2.01 [1.08, 3.72]). In exploratory subgroup analyses, patients who identified as non-white or Hispanic had a higher odds ratio as compared to white non-Hispanic for the overall CAT score and most of the CAT individual items.

In an intervention evaluating education versus education + a tool to improve primary care providers’ use of effective communication strategies, there were no differences in overall health or perception of communication. Patients who used the tool had an increased odds of reporting of feelings of respect, being paid attention to, and being able to talk without interruptions. Patients of color may have increased benefits of the intervention as compared to White, non-Hispanic patients, although further investigation is needed. INSURANCE-STATUS-RELATED DIFFERENCES IN OUTCOMES FOR HOSPITALIZED PATIENTS WITH DECOMPENSATED CIRRHOSIS IN THE UNITED STATES: A NATIONALLY REPRESENTATIVE STUDY Aagamjit Singh1; Bhavik Bansal2; Ritik Goyal3; Usman Bin Hameed4. 1Internal Medicine, Corewell Health Beaumont Hospital, Royal Oak, MI; 2All India Institute of Medical Sciences New Delhi, New Delhi, DL, India; 3Rutgers New Jersey Medical School, Newark, NJ; 4Internal Medicine, Corewell Health, Royal Oak, MI. (Control ID #4273503)

Healthcare inequalities remain a pressing issue, particularly for complex conditions like decompensated cirrhosis, which require intensive, multidisciplinary care. Lack of health insurance continues to be a major barrier to timely and adequate healthcare access in the United States, where millions remain uninsured. This study evaluates insurance-status-related disparities in the baseline characteristics and outcomes of hospitalized patients with decompensated cirrhosis using the National Inpatient Sample (NIS) 2020.

A retrospective cohort study was conducted using NIS 2020, a nationally representative database. Adults with cirrhosis and one or more portal hypertensive complications were included, excluding those with incomplete mortality data. Patients were stratified into insured (Medicare, Medicaid, or private) and uninsured (self-pay) groups. Baseline variables included age, sex, race, income quartile, hospital division, and Elixhauser comorbidity index. Outcomes assessed were mortality, length of stay (LOS), total hospital charges, and acute-on-chronic liver failure (ACLF), defined using the North American Consortium for the Study of End-Stage Liver Disease criteria. Outcomes were compared using nationally weighted estimates, adjusting for demographics, income, and comorbidities. Data analysis was performed using survey design methods in RStudio v4.4.1.

A total of 3,170 patients (37% female, median age 55 years) were analyzed, representing 15,850 weighted patients. Among them, 8% (1,275 weighted) were uninsured, and 92% (14,575 weighted) were insured. Uninsured patients were younger (median age 51 vs. 55, p<0.0001), less often female (29.4% vs. 37.4%, p=0.015), more frequently in the lowest income quartile (38.4% vs. 30.9%, p=0.022), and had lower Elixhauser comorbidity scores (16 vs. 19, p<0.0001). They were also more likely to be Hispanic (25.8% vs 18.5%., p=0.031) Adjusted analyses showed no significant differences in mortality, LOS, or ACLF rates, but insured patients had higher hospital charges ($15,545; 95% CI $1,049–$30,040; p=0.036).

Patients without health insurance were younger, had fewer recorded comorbidities, and were more socioeconomically disadvantaged, reflecting barriers to early care. Although clinical outcomes were similar in this sample, insured patients incurred higher charges, averaging an additional $15,000 per patient, suggesting greater resource utilization by this group. These findings underscore the structural inequities in healthcare access and delivery and highlight the need for policies addressing the vulnerabilities of uninsured populations to achieve equitable care. Further research with larger sample sizes is necessary to better elucidate differences in outcomes between insured and uninsured patients with decompensated cirrhosis, as a first step toward bridging the gap. LANGUAGE DISPARITIES IN CONTINUOUS GLUCOSE MONITORING PRESCRIBING AMONG PATIENTS WITH TYPE II DIABETES Jorge A. Rodriguez1; Nicolás Prada-Rey1; Chenxi Gao1; Wenyu Song1; Stuart Lipsitz1; Courtney Lyles2; Augusto E. Caballero3; David W. Bates1; Lipika Samal1. 1General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA; 2Public Health Sciences, University of California Davis, Davis, CA; 3Brigham and Women's Hospital, Boston, MA. (Control ID #4272180)

Patients with non-English language preference (NELP) face worse type 2 diabetes mellitus (T2DM) outcomes. Continuous glucose monitors (CGM) provide real-time glucose data and improve hemoglobin A1c (HbA1c). Language preference in CGM access is unexplored. The objective was to compare CGM prescriptions between patients with NELP and patients with English language preference (ELP).

The cohort consisted of adult patients with T2DM receiving primary or endocrinology care from 01/01/2022-12/31/2023. Language preference was dichotomized as NELP or ELP based on the EHR language field. Our primary outcome was CGM prescription (any EHR order placed before 12/31/2023). Covariates included age, sex, race and ethnicity, insurance, insulin use, diabetes control (HbA1c ≤9% vs >9%), and type of care (primary care, endocrinology, or both). We conducted sensitivity analyses focused on patients with uncontrolled diabetes or those on insulin. We performed subgroup analyses comparing Spanish-preferring to non-Spanish-preferring patients. Multivariable logistic regression including covariates was used for adjusted analyses.

The study included 69,269 patients with T2DM with a median age of 60 (interquartile range: 51-69). The sample was 50% female and 70% White, with 43% having public insurance. Patients with NELP comprised 12% of the population. Compared to patients with ELP, patients with NELP were older, more likely to be female, Hispanic, have public insurance, use insulin, and have uncontrolled diabetes, but less likely to have an endocrinology visit. Overall, 12% of patients had a CGM prescription. A lower proportion of patients with NELP had a prescription compared to patients with ELP (7.4% vs. 13%, p<0.001). In adjusted analyses, patients with NELP were significantly less likely to have a prescription (adjusted odds ratio: 0.57, confidence interval: 0.52-0.64, p<0.001) (Table). This difference persisted in sensitivity analyses. There was no difference between patients with Spanish-language preference compared to other non-English languages.

Patients with NELP had less access to CGM reflecting structural drivers of digital disparities. There is an urgent need to reduce the barriers to CGM adoption. LOST IN TRANSLATION: IMPROVING QUALITY OF CARE FOR HOSPITALIZED PATIENTS BY LEVERAGING INTERPRETER PERSPECTIVES. Sasha Raman, Edward Feller. Internal Medicine, Brown University Warren Alpert Medical School, Providence, RI. (Control ID #4267695)

Patients with limited English proficiency (LEP) in the United States face challenges navigating the health care system and experience disparities in care and outcomes. While professional medical language interpreters are known to improve the quality of care for LEP patients, the interpreter’s perspective on improving care for LEP patients remains underexplored. The objectives of this study are to (1) understand the professional interpreter’s perspective on barriers to interpretation when working with physicians and (2) identify strategies for physicians to improve interpretation and quality care for adult, hospitalized patients.

This study surveyed 193 medical language interpreters across the U.S. to gain insight into their perspectives on improving the quality of interpretation and care for LEP patients. The survey identified key barriers to interpretation, assessed the quality of clinical encounters using a Likert scale, and included open-ended questions about challenges faced when working with physicians and suggestions for improving care. Latent and expressed themes were extracted from the latter, qualitative data.

The top three barriers to interpretation were the use of non-professional interpreters (N=73), providers talking over patients or interpreters (N=68), and a lack of access to in person interpreters (N=64). While 38% of interpreters felt that physician use of nonfluent language skills contributes to rapport, 60% felt that physicians should not use their nonfluent language skills. Most respondents agreed that physicians are aware of virtual interpretation options (67%), fully answer LEP patients’ questions (56%), and adequately explain medical conditions (58%), physical exam (67%), and post discharge management (61%). Only 49% of respondents felt that patients are discharged with a comprehensive understanding of their condition and treatment. 42% felt that physicians do not give adequate context to interpreters when introducing the encounter. While 63% agreed that physicians provide high quality care to LEP patients, 38% felt that LEP patients receive lower quality care than EP counterparts. Thematic challenges in working with physicians included ineffective communication, a disconnect from the patient perspective, lack of collaboration with interpreters, time constraints, and the use of non-professional interpreters including family members or ad-hoc interpreters.

To improve the quality of care and interpretation, physicians should implement the following strategies: define medical concepts, contextualize the encounter for interpreters, minimize interruptions, allocate sufficient time for interpretation, prioritize professional interpretation, respect patients and interpreters, and receive cultural sensitivity training. Implementing these strategies may improve collaboration with interpreters, communication with LEP patients, and address disparities in health outcomes. METHODOLOGICAL CHALLENGES AND OPPORTUNITIES IN STUDYING ANTI-BLACK RACISM IN THE HEALTHCARE SETTING Lorraine M. Pereira3; Sofia Weiss Goitiandia2; Elizabeth Dzeng1. 1Medicine, University of California San Francisco, San Francisco, CA; 2Division of Hospital Medicine, University of California San Francisco, San Francisco, CA; 3Harvard Medical School, Boston, MA. (Control ID #4273118)

Ethnographic and qualitative methods explore the interplay of interpersonal, institutional, and structural factors shaping healthcare experiences, identifying targets for change. Despite growing attention to racism in healthcare, ethnographic and qualitative methods remain underused to examine and address racism’s impacts. Given the diversity of lived experience within the healthcare workforce (including personal experiences of racism, desire not to be perceived as racist, and perceptions of racial health inequities), interviewing on this topic can be challenging. This study examines methodological challenges and opportunities related to interviewing clinicians on race and racism.

We conducted semi-structured ethnographic interviews with clinicians at a West Coast academic medical center about their perspectives on racism in serious illness care. Interviewees were selected using convenience and snowball sampling. We developed our interview guide iteratively: we drafted questions using literature and our research aims, conducted pilot interviews, and convened to evaluate and revise. The guide underwent three cycles of revision.

We interviewed 14 clinicians in palliative care and hospital medicine (9 physicians, 3 nurses, 1 social worker, 1 chaplain). Many clinicians had limited experience caring for older Black adults, possibly due to systemic inequities in care access. Respondents struggled to recall specific experiences. Clinicians tended to share reflections on racism rooted more in ideas and principles than in experiences caring for patients. Our efforts to address these and other challenges are below.

We offer strategies to overcome challenges in discussing race and racism that can be used in interview-based studies to better understand and address racism’s impacts on healthcare. PARTICIPATION IN A MEDICAID HEALTH-RELATED SOCIAL NEEDS PROGRAM AND CHANGES IN SOCIAL NEEDS, DIET, STRESS, AND HEALTH CARE USE: A COHORT STUDY Anne N. Thorndike4; Jessica McCurley2; Yuchiao Chang4; Jessica Cheng1; Cheryl R. Clark3; Christine Vogeli5; Sydney McGovern4; Vicki Fung5; Douglas E. Levy5. 1Medicine, Massachusetts General Hospital, Boston, MA; 2Psychology, San Diego State University, San Diego, CA; 3Medicine, Brigham and Women's Hospital, Boston, MA; 4General Internal Medicine, Massachusetts General Hospital, Boston, MA; 5Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, MA. (Control ID #4271517)

Massachusetts implemented Flexible Services (Flex) under a Medicaid Section 1115 waiver to address food and housing insecurity for accountable care organization (ACO) beneficiaries. Little is known about the impact of Medicaid social needs interventions on social, behavioral, and clinical outcomes. The objective of this study was to compare 1-year changes in food and housing insecurity, diet, stress, and acute health care use of Flex participants to non-participants.

This was a prospective cohort of 855 adult Medicaid beneficiaries from 5 urban community health centers affiliated with one ACO and enrolled in the study between December 2019 and December 2020. Participants completed surveys and 24-hour dietary recalls at enrollment and annually for 3 years. Surveys measured food insecurity (10-item US Department of Agriculture module), housing insecurity (current housing, moving 2 or more times in past year, worry about losing housing), and stress (Perceived Stress Scale [PSS], range 0-40). Diet quality was measured with the Healthy Eating Index-20 (HEI-20, range 0-100). Acute health care use included annual number of emergency department (ED) visits and acute hospitalizations. Analyses compared changes in 1-year outcomes for Flex-enrolled participants and propensity score-weighted non-participants after vs. before Flex enrollment, using logistic regression for food and housing insecurity, linear regression for HEI-20 and PSS, and Poisson models for acute health care use. In-depth interviews were conducted with 27 Flex participants.

There were 153 Flex participants with a mean (SD) age of 43.6 (10.8) years; 129 (84.3%) were female, and 100 (65.4%) were Hispanic. Before Flex enrollment, 111 (72.5%) had food insecurity, and 68 (44.4%) had housing insecurity. There were no significant differences in 1-year changes for Flex vs. non-Flex participants in the proportion with food insecurity (7.1% [95% CI: -1.0%, 15.2%]) or housing insecurity (4.1% [95% CI: -4.1%, 12.2%]). There were also no significant differences in 1-year changes for HEI-20 (0.3 [95% CI: -2.2, 2.9]), PSS scores (0.4 [95% CI: -0.7, 1.5]), or number of ED visits and acute hospitalizations (0.10 [95% CI: -0.04, 0.23]). Participant interviews reflected a range of Flex experiences, from positive impact on social needs and health to persistent challenges related to the cost of food and limited housing availability.

Flex participation was not associated with short-term improvements in health-related social needs, diet, stress, or acute health care use, on average. Participants highlighted both benefits and challenges in addressing entrenched social needs through health system interventions. PERSPECTIVES ON CERVICAL CANCER SCREENING AMONG SOMALI WOMEN IN SOUTHEAST MINNESOTA Jissy Cyriac1; Xuan Zhu2; Abby M. Lohr3; Nicole L. Larson3; Khadija Ali4; Fatma Ahmed4; Fatuma Omer4; Lila J. Rutten5; Kathy L. MacLaughlin6; Jane W. Njeru1. 1Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic Minnesota, Rochester, MN; 2Kern Center, Mayo Clinic Minnesota, Rochester, MN; 3Division of Epidemiology, Mayo Clinic Minnesota, Rochester, MN; 4Pamoja Women, Rochester, MN; 5Quantitative Health Sciences, Mayo Clinic Minnesota, Rochester, MN; 6Family Medicine, Mayo Clinic Minnesota, Rochester, MN. (Control ID #4270480)

Cervical cancer screening (CCS) has greatly decreased cervical cancer incidence in the US via early detection and treatment of precancerous lesions. Racial and ethnic minority groups—including African born immigrant women—have lower rates of CCS completion. We conducted a survey to assess perspectives of Somali women on cervical cancer and screening in Southeast Minnesota.

Using a community engaged approach, we surveyed Somali women, aged 21-65 years in community settings. We assessed sociodemographics, self-reported screening status, knowledge, attitudes, barriers, and facilitators to CCS. Fisher’s exact test was used to evaluate associations between self-reported screening status and sociodemographic characteristics. This study was reviewed and approved by our institutional review board.

Respondents (N=23, median age: 42 years) were primarily foreign born (91%), married (57%), employed (52%), and insured (91%). Half (52%) reported adequate English proficiency and most (74%) spoke Somali at home. The majority (57%) did not know the causative relationship between HPV and cervical cancer, 39% did not feel at risk for cervical cancer, 36% did not know when to initiate screening, and 41% did not know recommended screening frequency. Most women (68%) reported feeling socially supported to obtain screening, but 64% felt that most women in their community did not complete screening. The most frequently reported barriers to CCS were: pain with exams (30%), embarrassment (22%), and lack of knowledge of how screening is done (22%). The top facilitators of CCS were provider recommendation (74%), community education (65%), and family recommendation (64%). Due to the small sample size, associations between reported barriers and self-reported CCS status could not be determined.

Somali women reported limited knowledge of cervical cancer and over a third of respondents perceived lower risk of developing cervical cancer. While the most frequently cited barriers were at the individual level, the CCS facilitators identified in this study suggest that community- and health systems-level interventions may help bridge screening gaps among Somali women. PREP PRESCRIBING LENGTH IS ASSOCIATED WITH PATIENT RETENTION AND ON TIME PRESCRIPTIONS Viraj V. Patel1; Lila Starbuck2; Robert Beil1; Bryant N. Gomez2; Sarit Golub2. 1Medicine, Albert Einstein College of Medicine, Bronx, NY; 2Psychology, Hunter College, New York, NY. (Control ID #4273606)

Physicians and providers have flexibility around length of HIV PrEP medications to include in a prescription. PrEP prescription length patterns have not been well-studied and could have implications for retention. In this analysis, we sought to explore (1) variation in prescription lengths at initiation and follow-up, overall and by patient demographics including race/ethnicity, (2) assess associations between prescription lengths and subsequent retention/continuity, and (3) explore associations between prescription length and HIV testing.

We conducted a secondary analysis of electronic health record (EHR) data for 11,072 PrEP prescriptions among 1,968 patients at a large health system in New York City, prescribed between 01/2015-04/2022 (35% Black; 46% Hispanic; 76% male sex in EHR; 33% aged 18-29; 48% Medicaid, 6% uninsured). We analyzed prescription length including refills, repeat prescriptions, and follow-up refill timeliness. Prescription length was defined as the total days of pill supply in a prescription, including all refills. Retention was defined as the total number of PrEP prescriptions each patient received. Continuity was defined as receiving a prescription renewal before running out of pills, assuming daily dosing.

There was wide variation in initial and follow-up prescription length (range: 30-360 days; only 25% of patients received consistent follow up lengths). Prescription lengths varied by provider type; infectious disease physicians favored 30-day starts and other providers favored 60+ day starts. The majority of patients (56%) received 30-day initial PrEP prescriptions, but these patients were more likely to experience a gap in PrEP coverage before their second prescription. Among initial prescriptions written by Infectious Disease providers, 70% were for 30 days, compared to 47% for Internal Medicine providers, and 50% for family medicine providers, p<.0001). Overall, longer prescriptions were associated with greater retention (i.e., higher total count of return prescriptions) and greater continuity (i.e., higher percentage of on-time renewals), p<.05 for both). Longer follow-up prescriptions were less likely to be given to Black and Hispanic patients compared to White patients (p<.01). Finally, shorter prescriptions were associated with HIV testing within 3-months of PrEP start.

PrEP prescribing practices are highly variable. Findings suggest that prescription length has critical implications for PrEP retention and continuity, with longer prescriptions promoting greater retention and fewer coverage gaps. Providers should consider the impact of prescribing practices on patient experience, engagement in care, and PrEP effectiveness and its implications on prevention disparities. PREVALENCE AND INTERVENTION OF FOOD INSECURITY IN RURAL POPULATION Damian N. Alpheaus1; Pamela Trio1; Kelly A. Kieffer2. 1General Internal Medicine, Dartmouth Health, Lebanon, NH; 2Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH. (Control ID #4262162)

Barriers to accessing affordable food can make it difficult for individuals to maintain a healthy diet, contributing to obesity and chronic diseases. In 2021, one in ten rural households experienced food insecurity and nine out of the ten counties with the highest levels of food insecurity were rural. A two question screening tool based on the U.S. Household Food Security Scale, developed as part of the Hunger Vital Signs initiative, can be used to screen for food insecurity in ambulatory settings. This research aims to assess the prevalence of food insecurity in a rural academic primary care clinic and evaluate the impact of offering shelf-stable food bags to patients experiencing food insecurity.

A rural general internal medicine practice in New England with an academic medical center (AMC) based site and a freestanding primary care clinic (PCC) utilizes a standardized two-item food insecurity screen in a pre-visit questionnaire. In addition to referral to a Community Health Worker, patients who screen positive are offered a shelf-stable food bag. We analyzed data from October 2021 to October 2023 to determine the percentage of patient encounters with a positive screen and to compare the number of positive screens to the number of food bags distributed.

At the AMC site the questionnaire was administered to 10,839 individual patients, with 8,270 (76%) completing the food insecurity questions at least once. Completion rates are not available for the PCC. At the AMC the screen was positive for 1,017 of 9,590 (10.9%) patient encounters with a completed screen, and 346 (34%) of patients with a positive screen accepted a food bag. At the PCC, 156 of 3,219 (4.8%) patient visits had a positive screen, with 38 (24.4%) accepting a food bag. Chi-Square test revealed a statistical difference between AMC and PCC in both positive screens (p < .001) and in the acceptance of food bags (p = .017).

These findings suggest that the prevalence of food insecurity at these academic primary care clinic sites is similar to national trends in rural communities. Differences between clinic sites likely reflect demographic differences in the populations they serve. Despite the availability of an emergency food aid option, a majority of patients declined assistance. Some patients who screen positive may not be experiencing food insecurity at the time of the screening, as the questionnaire enquires about food insecurity over the past 12 months. Patients might also decline assistance due to lack of access to food storage or preparation facilities, food preferences or dietary restrictions, or social and cultural factors. Further research will explore what factors contribute to low rates of accepting assistance. We will also compare rates of chronic disease and healthcare utilization in patients who screen positive with those who screen negative. PREVALENCE OF NEGATIVE AND POSITIVE DESCRIPTORS IN MEDICAL RECORDS OF PATIENTS WITH SICKLE CELL DISEASE COMPARED TO OTHER STIGMATIZED PATIENT POPULATIONS Austin Wesevich1; Dingfen Han2; Somnath Saha3; Mary Catherine Beach4. 1Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 2General Internal Medicine , Johns Hopkins University, Baltimore, MD; 3Medicine, Johns Hopkins Medicine, Baltimore, MD; 4Medicine, Johns Hopkins University, Baltimore, MD. (Control ID #4271962)

Clinicians use stigmatizing language in the electronic medical record (EMR) more commonly when describing Black patients and those with certain medical conditions. Patients with SCD – who are predominantly Black and commonly present for care due to pain treated with opioid medications – experience discrimination and bias in healthcare, but the ways this bias may manifest in the EMR are not well understood.

This cross-sectional study of 13,001,158 clinician notes across 1,400,389 adult patients compared the presence of negative and positive descriptors in notes about patients with SCD to notes about patients in four comparison groups: 1) Black patients without SCD; 2) patients with chronic pain without SCD; 3) patients with opioid use disorder (OUD) without SCD; and 4) non-Black patients without chronic pain, OUD, or SCD (“counterfactual” comparison group). Negative descriptors included categories of credibility (untruthful or poor historian), demeanor (difficult or aggressive), and conformity (noncompliant or refuse). Positive descriptors included good historian, cooperative, pleasant, and adherent. Descriptors were identified using previously validated natural language processing models. Multivariable logistic regression models accounting for clustering of notes by patient were used to determine the odds of a negative or positive descriptor in a clinician note when comparing patients with SCD to each comparison group. Models adjusted for age, gender, ethnicity, interpreter use, insurance, marital status, clinical department, and author type.

The most frequently used negative descriptors in notes about patients with SCD were refuse (5.0%) and poor historian (1.1%), with at least 1 negative descriptor appearing in 8.1% of notes. The most frequently used positive descriptors for patients with SCD were cooperative (6.5%) and pleasant (6.1%), with at least 1 positive descriptor in 12.0% of notes. Patients with SCD had higher odds of negative descriptors in notes relative to other Black patients (aOR 1.26, 95% CI 1.09-1.47) or the counterfactual comparison group (aOR 2.33, 95% CI 2.0-2.71) but lower odds relative to patients with chronic pain (aOR 0.71, 95% CI 0.60-0.84) or OUD (aOR 0.63, 95% CI 0.54-0.74). Patients with SCD had lower odds of positive descriptors in notes relative to all four comparison groups (Black: aOR 0.71, 95% CI 0.67-0.75; chronic pain: aOR 0.77, 95% CI 0.72-0.83; OUD: aOR 0.82, 95% CI 0.76-0.88; counterfactual: aOR 0.70, 95% CI 0.66-0.74).

Patients with SCD are described less positively than any comparison group and more negatively than Black patients without SCD or the non-Black comparison group. Because patients with SCD more often have negative descriptors in the EMR than other Black patients, this suggests that at least some SCD-related stigma may be attributable to pain and/or opioids. These results may inform bias interventions to reduce the stigmas faced by patients with SCD. PSYCHOTHERAPY UTILIZATION AMONG TRANSGENDER AND GENDER DIVERSE VETERANS IN VETERANS AFFAIRS (VA) AND VA PURCHASED CARE Mark Zocchi1; Rajinder (Sonia) Singh6,7; Hill L. Wolfe2; Varsha Vimalananda1,3; John Blosnich4; Joy L. Lee5,1; Julianne E. Brady1; Guneet Jasuja1. 1Center for Health Optimization and Implementation Research, VA Bedford Healthcare System, Bedford, MA; 2Department of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT; 3Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 4Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; 5Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA; 6Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System John L McClellan Memorial Veterans Hospital, Little Rock, AR; 7Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR. (Control ID #4271028)

The Department of Veterans Affairs (VA) is the largest integrated health care system and likely the largest provider for transgender and gender diverse (TGD) care in the US. VA offers in-person and tele-psychotherapy, in addition to VA-purchased care in the community for veterans who cannot readily access VA care. Little is known about patterns of psychotherapy use, including tele-psychotherapy among TGD veterans and even less is known in VA-purchased care. We examined psychotherapy use in VA and VA-purchased care among TGD veterans compared to a matched group of presumptive cisgender veterans.

A retrospective cohort of TGD veterans with a new diagnosis of gender dysphoria (n=8,047) between October 2020 and September 2023 was matched 1:1 to patients with no gender dysphoria diagnosis, a new diagnosis of depressive disorder (n=8,047) on age, race, sex marker (F, M), use of psychotherapy in the year prior to diagnosis, rurality, distance to nearest VA facility, VA health care market, calendar-quarter of diagnosis, and prior year comorbidity risk score. National VA administrative and VA-purchased care claims data were used to identify in-person and tele-psychotherapy visits in the VA and in VA-purchased care. Monthly utilization rates for one-year post-diagnosis were estimated using Poisson regression. Multivariable logistic regression examined predictors of psychotherapy (in-person or tele) and tele-psychotherapy (VA or VA-purchased) among TGD veterans.

Post-diagnosis, incidence of in-person psychotherapy (VA or VA-purchased) was 150 visits per 1,000 person-months for TGD veterans and 139 per 1,000 person-months for non-TGD veterans (Incidence Rate Ratio [IRR] = 1.1, 95% CI 1.0 – 1.2). Tele-psychotherapy use was significantly higher among TGD veterans compared to non-TGD veterans (114 vs 74 visits per 1,000 person-months, IRR = 1.5, 95% CI 1.4 – 1.7). For VA-purchased psychotherapy (in-person or tele), there was no significant difference in incidence between TGD and non-TGD veterans (42 vs 40 visits per 1,000 person-months). In adjusted models, for TGD veterans, younger age, higher risk scores, and living outside the Northeast, was associated with increased odds of using VA-purchased psychotherapy (in-person or tele). For tele-psychotherapy (VA or VA-purchased), younger age, higher comorbidity risk scores, and living in the South or West was associated with increased odds of using tele-psychotherapy among TGD veterans.

Psychotherapy utilization patterns differed significantly between TGD veterans and presumptive cisgender veterans, with higher rates of both in-person and tele-psychotherapy for TGD veterans; however, TGD and non-TGD veterans used VA-purchased care for psychotherapy at similar rates. Increased use of tele-psychotherapy was also evident among TGD veterans, underscoring the importance of supporting virtual care for TGD veterans. Further research is warranted to study variation in use of psychotherapy among TGD veterans. RACIAL AND ETHNIC DISPARITIES IN MEDICATION ADHERENCE AMONG MEDICARE ADVANTAGE ENROLLEES WITH DIABETES: DECOMPOSING WITHIN VS. BETWEEN-PLAN DISPARITIES Utibe R. Essien4; Eric Roberts2; Dominic A. Ruggiero3; Renuka Tipirneni1. 1Medicine, University of Michigan Medical School, Ann Arbor, MI; 2General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 3Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA; 4General Internal Medicine & Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA. (Control ID #4273283)

One in 5 Medicare enrollees has diabetes, which is associated with high prescription costs and racial/ethnic disparities. Medicare Advantage (MA), the managed care alternative to fee-for-service Medicare, provides coverage to >50% of Medicare enrollees, with higher proportions from minoritized racial/ethnic groups. We examined disparities in low- vs. high-cost diabetes medication adherence, assessing whether disparities came from within- vs. between-plan variation.

We used a 20% national sample of MA enrollees with diabetes and at least one diabetes medication fill in 2019 (N=595,296). We examined adherence to low-cost (metformin, insulin) and high-cost (GLP-1 receptor agonists, SGLT-2 inhibitors) diabetes medications. Adherence was measured in Part D claims as Proportion of Days Covered >=80%. For each medication, we estimated a multilevel model (beneficiaries nested within plans) to quantify the extent to which racial/ethnic disparities in adherence occurred within (reflecting differences across racial/ethnic groups within the same plan) vs. between plans (comparing adherence among plans ranked by quintile of adherence pooled across demographic groups, a proxy for quality of plans).

Across all plans, we found significant disparities in adherence to metformin (Black-White disparity: 9.4 percentage points [pp], Hispanic-White disparity: 2.2 pp), insulin (Black-White disparity: 9.0 pp, Hispanic-White disparity: 2.8 pp) and high-cost diabetes medications (combined GLP-1RA and SGLT-2i; Black-White disparity: 9.0 pp, Hispanic-White disparity: 8.5 pp). Within-plan disparities accounted for 98%, 93%, and 82% of the Black-White disparity in adherence to metformin, insulin, and high-cost diabetes medications, respectively, and for 92% and 71% of the Hispanic-White disparity in adherence to insulin and high-cost medications, respectively. Adherence for enrollees of all groups was higher in plans with higher overall quality. Yet, for high-cost medications, disparities were greater in the highest quintile compared to lowest quintile of plan quality (4.7 pp greater Black-White disparity, P<0.001; 7.1 pp greater Hispanic-White disparity, P<0.0001). Black-White (2.3 pp difference; P=0.002) and Hispanic-White (2.0 pp difference; P=0.0.01) disparities in insulin adherence were also larger in higher- compared to lower-quality plans.

We found wide variation in adherence to diabetes medications by race/ethnicity. Disparities appeared to result more from differences within rather than between plans, which may be influenced by factors (e.g., structural racism) impacting care for minorities across all MA plans. We also found greater Black-White disparities in adherence to insulin and high-cost diabetes medications in higher- compared to lower-quality plans. As benefits of enrolling in higher-quality plans were not equally realized across all groups, our findings underscore the importance of evaluating plan-level performance for specific racial, ethnic, and social groups. RACIAL AND ETHNIC DISPARITIES IN RECEIPT OF TREATMENT VERSUS HISTORY OF ARREST AMONG ADULTS WITH MENTAL ILLNESS, A NATIONAL STUDY Emily L. Lupez3; Stephanie Woolhandler1,2; David Himmelstein1,2; Alysse G. Wurcel3; Michael O. Mensah4; Danny McCormick5,2. 1City University of New York School of Urban Public Health at Hunter College, New York, NY; 2Harvard Medical School, Boston, MA; 3General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA; 4Psychiatry, Yale University School of Medicine, New Haven, CT; 5Internal Medicine, Cambridge Health Alliance, Cambridge, MA. (Control ID #4270888)

Mental illness (MI) increases the risk of criminal legal involvement; outpatient mental health treatment can reduce this risk. Black and Hispanic people experience higher rates of arrest and untreated MI than white people. Yet, little is known about racial and ethnic disparities in divergent experiences of receipt of treatment without history of arrest versus history of arrest without receipt of treatment among individuals with MI.

We analyzed adult respondents to the 2022 National Survey of Drug Use and Health (NSDUH) with any MI or serious mental illness (SMI) in the past 12 months. Our exposure was self-reported race and ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic). Using self-reported receipt of mental health treatment and history of arrest in the prior 12 months, we compared rates of the composite outcomes: (1) treatment without arrest; and (2) arrest without treatment. Using logistic regression, we estimated the likelihood of arrest without treatment vs. treatment without arrest among Black and Hispanic people compared with white people. Models were adjusted for age, sex, urbanicity, education, employment, and income. We conducted all analyses first with treatment defined as any treatment, and second with treatment defined as pharmacologic treatment.

Among people with any MI (N = 11,519), Hispanic people were younger; white people were more often rural residents and had higher educational attainment; and more Black people were unemployed and poor. Among adults with SMI (N = 3,290), education and employment patterns were similar across race/ethnicity. White people with MI were most likely to receive treatment without arrest (white: 54.1%; Black: 36.0% and Hispanic: 38.0%). Similar patterns were observed among respondents with SMI. Black people with MI were more likely than white people to have history of arrest without treatment rather than receipt of treatment without arrest (adjusted odds ratio (aOR) [95% CI]: any treatment, 3.0 [1.2-7.2]; pharmacologic treatment, 4.5 [2.4-8.5]). Among people with SMI, Black and white people had similar likelihoods of having a history of arrest without treatment, but Black people were more likely than white people to have a history of arrest without psychopharmacologic treatment (aOR, 4.5; 95% CI, 2.4-8.5). In adjusted analyses, no White:Hispanic disparities in outcomes were statistically significant.

Black people with MI or SMI were substantially more likely than white people to have a history of arrest without treatment, even after adjustment for other demographic and socioeconomic factors, implicating structural racism in access to care and policing. Study limitations include low arrest rates, likely reflecting the NSDUH’s exclusion of incarcerated individuals (including those in pre-trial detention). Improving community access to mental health treatment, especially for Black people, along with addressing systemic racism in policing and sentencing, might reduce incarceration rates. RECRUITING DISADVANTAGED POPULATIONS FOR RESEARCH: AN EHR-BASED APPROACH USING AREA DEPRIVATION INDEX Krishna Brucia1; Rebecca M. North4; Cynthia J. Coffman3; Kathryn N. Porter Starr5; Connie Bales5; Anna Hung2; Nia S. Mitchell5. 1Medicine, Tulane University School of Medicine, New Orleans, LA; 2Population Health Sciences, Duke University School of Medicine, Durham, NC; 3Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC; 4Duke Aging Center, Duke University School of Medicine, Durham, NC; 5Medicine, Duke University School of Medicine, Durham, NC. (Control ID #4269392)

Recruiting disadvantaged populations into research studies is critical to address health disparities. Using community-based methods, we initially failed to recruit older African American (AA) women who lived in public housing communities for a weight loss study. We adapted and used an electronic health record (EHR) with the area deprivation index (ADI) to recruit participants. ADI uses income, education, employment, and housing quality to quantify neighborhood disadvantage. ADI ranges from 1 to 100, with higher numbers indicating more disadvantaged neighborhoods. We evaluated the effectiveness of this method to recruit participants from disadvantaged neighborhoods for a 6-month study. Retention was also assessed.

At an academic medical center in the southern region, we used the EHR to send email invitations to African American women who met the following criteria: age ≥55 years; BMI ≥27 kg/m2; active in the EHR; and listed as “OK to contact for research.” To oversample from disadvantaged neighborhoods, half the invitations were sent to those who lived in neighborhoods with ADIs in the highest quintile (80-100). Invitation acceptance, consent, and retention were compared between two ADI categories: 1-79 and 80-100. Participation-to-prevalence ratios (PPR), which were calculated as the proportion of women in a specific study timepoint category divided by the proportion of women who received invitations within the same ADI category, was used to assess representation. PPR values below 0.8 or above 1.2 indicate under- or over-representation, respectively.

Compared to ADI 1-79, a lower proportion of acceptance, consent, and attendance at 3- and 6-month visits came from ADI 80-100. The PPRs for the acceptance and consent subgroups were all between 0.8 and 1.2, so the representation is comparable. The PPRs for both 3- and 6-month visits were 1.3-1.4 and 0.6-0.7 for ADI categories 1-79 and 80-100, respectively. Thus, at the follow up visits, participants from ADI 1-79 were overrepresented and from ADI 80-100 were underrepresented.

An EHR and ADI-based strategy was used to successfully recruit older African American women for a weight loss study. However, those from more disadvantaged neighborhoods were less likely to attend the follow up visits. To enhance recruitment and retention of individuals from disadvantaged neighborhoods, future studies should identify and address the barriers that lead them to decline study invitations, deny consent, and miss follow up visits. REGIONAL DISPARITIES AND TRENDS IN END-OF-LIFE CARE PREFERENCES FOR THYROID CANCER MORTALITY ACROSS U.S. CENSUS REGIONS 2018 TO 2022 Ayushi Garg1; Pranav Chalasani1; Sarah Eringaard2; Maryam B. Mufti2; Nour Aldaoud6; mekdes asfaw3; Aman Saleemi4; Darlene F. Nguyen1; Parshva Salvi5. 1Internal Medicine, Wayne State University School of Medicine, Detroit, MI; 2Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI; 3Internal medicine, Wayne State University, Detroit, MI; 4Internal Medicine, Wayne State University, Detroit, MI; 5Wayne State University School of Medicine, Detroit, MI; 6Internal Medicine Residency, Wayne State University School of Medicine, Detroit, MI. (Control ID #4273316)

Thyroid cancer mortality can be influenced by regional and urbanization disparities, impacting outcomes across different U.S. regions. The study aims to explore these trends in thyroid cancer mortality from 2018 to 2022 by examining changes in the preferred place of death—specifically at home, in a hospice facility, or in a medical facility—in different U.S. census regions. This analysis provides insight into the evolving dynamics of end-of-life care preferences and the implications for regional healthcare policies.

We conducted a retrospective, population-based observational study using the CDC WONDER database (2018–2022) to analyze thyroid cancer mortality across U.S. census regions. Place of death was categorized as home, hospice, or medical facility. Temporal trends and regional disparities were evaluated using descriptive statistics in Microsoft Excel.

From 2018 to 2022, there were a total of 2,985 thyroid cancer deaths recorded across the United States. The data reveals a significant shift in preferences for the place of death, with a notable increase in the proportion of deaths occurring at home, which accounted for 79% of all deaths (2,347 cases) during the study period. Specifically, in 2018, home deaths were 17.29% (351 cases), increasing to 19.19% (392 cases) in 2019, 26.40% (528 cases) in 2020, 27.32% (574 cases) in 2021, and finally, 22.78% (502 cases) in 2022. This upward trend demonstrates a growing preference for home-based care over time. Hospice care also showed an increasing trend, rising from 1.28% (26 cases) in 2018 to 2.11% (43 cases) in 2019, then to 0.60% (12 cases) in 2020, 1.52% (32 cases) in 2021, and 0.50% (11 cases) in 2022. This increase reflects a growing acceptance of hospice care as a preferred setting for end-of-life care. Despite these trends, significant regional disparities persist. In 2022, the South recorded the highest number of deaths in medical facilities with 259 cases (14.7%), compared to 79 cases (4.4%) in the Northeast, 10 cases (0.6%) in the Midwest, and 39 cases (2.2%) in the West.

The findings reveal a growing preference for home-based end-of-life care among thyroid cancer patients, with hospice care gaining gradual acceptance. However, regional disparities persist, with the South and Midwest relying more on hospital-based care compared to the Northeast and West, reflecting inequities in access to alternative care settings and resources. Addressing these gaps requires targeted efforts to expand home-based and hospice care in underserved regions. Collaboration among healthcare providers, policymakers, and community organizations is essential to ensure equitable, patient-centered end-of-life care. By improving access and aligning services with patient preferences, healthcare systems can enhance care quality and outcomes. REPORTING OF SOCIODEMOGRAPHIC AND CLINICAL CHARACTERISTICS IN RANDOMIZED CLINICAL TRIALS OF DEPRESCRIBING INTERVENTIONS FOR OLDER ADULTS Alexander Chaitoff1; Jeanne M. Wildisen3; Julie Lauffenburger2; Donovan Maust4; Katharina T. Jungo5. 1Internal Medicine, University of Michigan, Ann Arbor, MI; 2Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; 33. Institute of Primary Health Care (BIHAM), Bern, Switzerland; 4Psychiatry, University of Michigan, Ann Arbor, MI; 5Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA. (Control ID #4272983)

To generate generalizable recommendations for medication use that apply equally to all patients, randomized clinical trials (RCTs) need to reflect diverse populations. It is unknown if deprescribing RCTs are adequately recruiting all populations despite calls to ensure equity in deprescribing research. We sought to evaluate the reported sociodemographic and clinical characteristics of older adults across deprescribing RCTs.

We identified RCTs from a recently published systematic review on the effect of deprescribing in adults aged ≥65 years, which included published studies and grey literature indexed until April 2024. We included RCTs that were conducted in the United States. Trial participant characteristics were extracted by one author (JW) and verified by a second author (KTJ). We present the sociodemographic and clinical characteristics of each trial separately and report aggregate descriptive statistics, including what proportion of trials did not report these relevant characteristics. For RCTs that reported variables by study group, we calculated a weighted mean based on group sizes. For continuous variables, we report medians and interquartile ranges (IQRs) weighted by sample size.

There were 28 US-based deprescribing RCTs with sample sizes ranging from 11 to 3012 participants (median = 150, IQR = 45-552). On average, participants were 78 years old (IQR = 73-80), with 65% female (IQR = 51-66). An average of 22% of older adults included in the RCTs were non-White (IQR = 9-36). Only four trials (15%) reported ethnicity separately from race, and in these trials an average of 4% of trial participants were Hispanic (IQR = 4-7). 17 trials (61%) included participants with cognitive impairment. Few trials reported on other clinical characteristics: four trials (14%) reported participants’ number of medications; three (11%) on comorbidities; three (11%) on healthcare use (11%); and one (4%) on frailty. Other sociodemographic variables were reported by only a minority, including language (1 trial/4%), education (10 trials/36%), and income (1 trial/4%).

There was limited reporting of pertinent patient characteristics in deprescribing RCTs. This makes it harder to identify to whom trial results apply and to audit equity in deprescribing research. Additionally, older adults are a heterogeneous group, and based on prior work in other settings it is likely that the effects of deprescribing interventions are moderated by important sociodemographic and clinical factors, which are rarely reported. These findings emphasize the need for more comprehensive, age-appropriate, and standardized reporting of participant characteristics in deprescribing trials to ensure inclusivity and generalizability. SOUTH ASIAN AMERICAN HEALTHCARE AND ACCESS SURVEY (SAAHAS): PRELIMINARY RESULTS Mehak Sharma1; Lia Urban Spillane2; Arnab Sengupta2; Mohini Ranganathan2. 1University of Connecticut School of Medicine, Farmington, CT; 2Yale University School of Medicine, New Haven, CT. (Control ID #4272998)

Access to healthcare is fundamental to quality of life. Disparities in healthcare access need to be addressed to improve healthcare outcomes, especially amongst minority groups such as South Asian Americans (SAA). Despite steadily rising rates of mental illness in the US, and robust efforts to gather data in several communities, there is almost no literature on the prevalence of mental health (MH) problems or engagement with care amongst SAA. The existing literature often groups Asian Americans and Pacific Islanders (AAPI) collectively or focuses on South Asians elsewhere (in the UK and Canada) with minimal information about SAA within the US. To address this gap, we have developed a survey-based strategy to identify and characterize MH problems, barriers to MH access, and possible ways to address these gaps in the SAA community.

We developed a brief anonymous university IRB-approved REDCap survey that asks questions about the following: demographics, general medical and mental health care of respondents and their families, sources of their healthcare information and conversations, as well as desire for mental health information. The questions adhere to standards of survey healthcare projects with closed questions that include multiple choice or Likert scales as responses. The goal of this model is to increase data accuracy, decrease responder burden, and standardize answers across participants. We partnered with the National Alliance of Mental Illness (NAMI), which approved our IRB survey for dissemination on their website.

Preliminary data (N=74), demonstrates that while SAA individuals or their families endorse MH problems, 60% of SAA individuals do not receive MH care in the U.S. partly due to a lack of awareness and stigma (15% in SAA individuals/22% in family members). Moreover, 64% felt addressing the lack of information regarding MH and access to care would be helpful. Over 50% strongly agreed that increasing talks by experts, available information at doctor's offices, general access to MH providers with shared cultural identity, and guidance on how to obtain MH care in the U.S. would be helpful. Figure 1 provides a breakdown of the desire for MH information amongst SAA.

Our data suggests that MH problems do exist among SAA and there is an alarming lack of access to MH services. However, this community does express a desire to learn more about MH care so long as measures are taken to advocate for their access to culturally competent care and health resources. This preliminary data has empowered us to further explore the prevalence of MH problems amongst SAA to ultimately increase the existing literature that exists for this population. We are actively partnering with grassroots and nationwide SAA associations to collect a nationwide representative sample. We hope all of this data will help increase awareness about MH problems in the SAA population, identify their barriers to MH access, and promote actionable change. STATE LEADERSHIP ACADEMIES TO REDUCE TOBACCO USE PREVALENCE: FOUR CASE STUDIES OF EARLY STATE ADOPTERS OF TOBACCO TREATMENT AND POLICY Maya Vijayaraghavan3,2; Alanna Williams1; Catherine Bonniot3,2; Christine P. Cheng3,2; Brian Clark3,2; Jason Satterfield3; Jessica Safier3,2; Maria Pamatmat3,2; Steve A. Schroeder3,2. 1Internal Medicine, University of California San Francisco, San Francisco, CA; 2UCSF Smoking Cessation Leadership Center, University of California San Francisco, San Francisco, CA; 3Division of General Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4269814)

Despite a decline in tobacco use over the past five decades in the general population, there are an estimated 28.3 million Americans (11.5%) who are current cigarette smokers. About two-thirds of the US population currently smoking have a behavioral health condition (a mental health and/or substance use disorder), calling for renewed efforts to increase access to treatment for these populations.

Between 2010 and 2023, the Smoking Cessation Leadership Center (SCLC), in partnership with the Substance Abuse Mental Health Services Administration (SAMHSA), launched the Leadership Academies program. The Leadership Academies was a facilitated convening of state leaders in tobacco control, behavioral health, and public health who created action plans to reduce the high rates of tobacco use in behavioral health populations in their states. Using a multi-methods evaluation approach, including progress survey data and smoking prevalence estimates from the Behavioral Risk Factor Surveillance System, we describe short-term, intermediate, and long-term outcomes of the Leadership Academies, focusing on four case studies of states that engaged in unique models of collaboration.

SCLC convened 23 state Leadership Academies between 2010 and 2023 and facilitated collaborations among 2,773 organizations. State A engaged in a project to increase the availability of nicotine replacement therapy in residential drug treatment. State B worked with its Department of Mental Health to implement tobacco-free grounds in all its community mental health clinics. State C worked with its managed care organizations to increase access to tobacco treatment and tobacco-free grounds in any state-operated health facility. State D created a funding program with a request for applications to support state behavioral health facilities to adopt tobacco-free grounds and integrate tobacco treatment. The four states had a decline in smoking prevalence in the target populations. The median unadjusted decline in smoking prevalence among those with frequent poor mental health in the four states between baseline and five-year follow-up was 5.2%. The median unadjusted decline in smoking prevalence among those with heavy drinking in the four states between baseline and five-year follow-up was 6.2%.

State Leadership Academies presented several lessons: 1) reduction in tobacco use prevalence in states with high rates of smoking was achieved in large part due to interdisciplinary partnerships between tobacco control and behavioral health entities that had previously not collaborated; and 2) there was a strong need for leadership buy-in, funding and infrastructure to support projects that could be brought to scale to achieve population-level impact. The Leadership Academies model increased awareness of the need to make tobacco use central to behavioral health to reduce the large tobacco-related disparities in this population. STI AND HIV TESTING AMONG SEXUAL AND GENDER MINORITY SOUTH ASIAN AND INDO-CARIBBEAN PEOPLE IN THE UNITED STATES AND CANADA Debjyoti Datta1; Musaub Khan1,2; Viraj V. Patel1,2. 1Division of General Internal Medicine, Albert Einstein College of Medicine, New York, NY; 2Medicine, Montefiore Health System, Bronx, NY. (Control ID #4272995)

South Asian and Indo-Carribean (SA/IC) are a large and increasing population in the U.S. and Canada, however little is known about their sexual health needs as they are usually subsumed under a heterogenous Asian ethnicity. Additionally, almost no data exists about sexual health needs among SA/IC sexual and gender minority people in the US/Canada. Very little is known about the association of outness to family, family acceptance, religious belief and sexual behaviors with HIV and STI testing uptake of sexual and gender minorities of SA/IC origin. We conducted a web-based cross-sectional survey to assess HIV/STI testing uptake, access and its associations with sexual identity, gender identity, insurance status, religion, sexual behaviors, outness to family and family acceptance among sexually active SA/IC living in the US and Canada.

The survey was distributed through social media advertisements and six SA/IC LGBTQ+ community-based organizations’ social media pages across the U.S. and Canada. We examined HIV and STI testing as the primary outcomes and assessed associations of factors like sexual identity, gender identity, insurance status, religion, sexual behaviors, outness to family, and family acceptance with testing; conducted statistical tests including univariate, bivariate analysis and performed multivariable logistic regression modeling to evaluate associations of predictors to primary outcomes.

Among N=802 respondents, 50.1% were aged 18-24 years, 38.9% were 25-34 years, and 11% 35 years and older. Most (38.3%) of our respondents self-identified as cisgender-woman, 36.8% as non-cisgender individuals and 24.9% as cisgender man. While the respondents were predominantly (57.1%) covered by private insurance, followed by 35.3% covered by public insurance, only 7.7% were uninsured. In our study sample HIV testing rate was 58% and STI testing rate was 64%. HIV testing was associated with reporting Very good/Excellent self-rated health (AOR = 1.6, 95% CI 1.02,2.44; reference: Good/Fair/Poor Self Rated Health) while negatively impacted by cisgender women gender identity (AOR = 0.5, 95% CI 0.23,0.91; reference: cisgender man). STI testing likelihood rates were associated with having private insurance (AOR = 1.8, 95% CI 1.04,3.08; reference: covered by Public Insurance) while lower among non-cisgender identfied individuals (AOR = 0.4, 95% CI 1.15,0.78; reference: cisgender man gender identity). Sexual behaviors, outness to family, family acceptance, and religion were not associated with HIV and STI testing.

HIV and STI testing rates of this study sample were lower than the expected Healthy people 2030 objective of 72%. As the HIV and STI testing in this sample is suboptimal, there is a need of novel strategies directed especially for cisgender women and non-cisgender gender identities of SA/IC origin to increase HIV/STI testing uptake. THE ROLE OF TELEMEDICINE IN PRIMARY CARE ACCESS DISPARITIES AMONG TRADITIONAL MEDICARE BENEFICIARIES Ishani Ganguli1; Andrew L. Hicks2; Nicholas Daley1; Ateev Mehrotra5; David Cutler3; Meredith Rosenthal4. 1Division of General Medicine and Primary Care, Brigham and Women's Hospital, Chestnut Hill, MA; 2Health Care Policy, Harvard Medical School, Boston, MA; 3Economics, Harvard University, Cambridge, MA; 4Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, MA; 5Brown University School of Public Health, Providence, RI. (Control ID #4273121)

There are large sociodemographic disparities in access to primary care in the US. Widespread post-pandemic telemedicine adoption may mitigate disparities by providing more access points to primary care. Prior studies have shown mixed results on whether patients in racial-ethnic minority groups or in rural areas use more or less telemedicine than others, but have not examined how telemedicine contributes to primary care access for these groups.

We used 2019 and 2022 100% Traditional Medicare (TM) claims data for TM patients who were alive and continuously enrolled for the given year. In serial cross-sectional analyses, we examined use of primary care visits (in-person and virtual visits with physicians specializing in internal medicine, family medicine, pediatrics, general practice, geriatrics, or preventive medicine or with nurse practitioners or physician assistants). Minority race-ethnicity included Black, Hispanic, Asian, North American Native, and Other (RTI definition). Rural and urban residence were defined by Rural-Urban Commuting Area codes. We described primary care visits per patient-year and share with ≥1 primary care visit per year; we used Z tests for differences in disparities and chi-square tests for differences across visit modality groups.

We examined 73,452,716 patient-years. Patients had mean(SD) 3.0(3.8) primary care visits in both 2019 and 2022. In 2019, 0% of these visits were virtual; in 2022, 9% of these visits were virtual. In both 2019 and 2022, 65% of TM patients had ≥1 primary care visit – of those with any primary care visit in 2022, 79% had in-person visits only, 2% had virtual only, and 20% had both. In 2019, compared to non-Hispanic white patients, those in racial-ethnic minority groups had lower primary care visit rates and a smaller share had ≥1 primary care visit (53% vs 68% for white). Compared to patients in urban areas, those in rural areas had lower primary care visit rates and a smaller share had ≥1 primary care visit (56% vs 67% for urban). In 2022, a larger share of racial-ethnic minority patients with primary care accessed this care through virtual visits (24% vs 21% for white); in contrast, a smaller share of rural residents with primary care accessed this care through virtual visits (15% vs 22% for urban) (all p<0.001). In 2022, the racial-ethnic disparity in having ≥1 primary care visit grew to 50% vs 68% (p<0.001), but the rural-urban disparity did not change (56% vs 67%) (p=1.0).

Only two-thirds of TM patients saw primary care in both 2019 and 2022, with virtual visits replacing a share of previously in-person visits in 2022. Despite growth of telemedicine over this period, the racial-ethnic disparity widened and the rural-urban disparity persisted. Notably, those in racial or ethnic minority groups who did access primary care relied more on virtual visits than their white counterparts; but the opposite was true for rural residents, for whom connectivity issues may pose insurmountable barriers. TOWARDS HEALTH EQUITY FOR GEORGIA’S FORMERLY INCARCERATED PATIENTS: THE FOUNDATION OF A TRANSITIONS CLINIC IN ATLANTA Janhavi Dubhashi2; Mark Spencer1; Ariella Fogel1; Saria M. Hassan3; Abigail Clark4; Caroline Idehen5. 1General Internal Medicine, Emory University School of Medicine, Atlanta, GA; 2General Internal Medicine, Emory University, Atlanta, GA; 3Internal Medicine, Emory University, Atlanta, GA; 4Internal Medicine and Psychaitry, Emory University Woodruff Health Sciences Center, Atlanta, GA; 5Morehouse School of Medicine, Atlanta, GA. (Control ID #4273389)

In Georgia, where Medicaid has not yet been expanded, many people returning have difficulty obtaining medical insurance, limiting their options for access to comprehensive or timely healthcare. Atlanta has no formerly incarcerated transition program to link individuals to care. Through interviews with recently released individuals from the Georgia State prison system, we hoped to learn about what the re-entry experience is like in Georgia, including what barriers or facilitators to accessing healthcare may exist.

We aimed to better understand formerly incarcerated Georgians' experience shortly before, during, and after release to inform what clinical interventions and policy reforms might improve access to care in this population. Our qualitative study used semi-structured interviews of individuals over 18 who were previously incarcerated in a Georgia state prison and released less than two years ago. Recruitment was done through our research teams community advisory board, a group of eight community based organizations that work in the re-entry space. Our interview guide explored the following areas: healthcare quality and access while incarcerated, priorities during transition, and facilitators and barriers to healthcare on re-entry. This IRB approved study’s interviews were conducted over zoom. An inductive, iterative approach was used for our thematic analysis. At least two team members coded each transcript in forming our code book.

Four large themes arose regarding health during incarceration 1) negative impact on mental health 2) structural barriers from rules and regulations on healthcare access 3) perceptions of indifference of staff 4) limits of care available. The main themes described during the re-entry period included 1) lack of support in obtaining healthcare access and other resources 2) competing priorities of re-entry period 3) concerns regarding cost 4) facilitators of successful re-entry, including family support.

Overwhelmingly people did not feel that healthcare services in prison were adequate. Improvements can come most directly through state level legislation and external medical oversight. There is a significant need for care navigation that ideally begins prior to release. Facilitating a connection to a clinic with trusted providers and supporting through the special enrollment period for insurance when possible would improve access. Economic stress and marginalization forced many to deprioritize their own immediate physical and mental health needs in search of income and housing. Many reforms can address this through improved transitional housing programs, increased cash assistance on release, and state level elimination of many of the collateral consequences that continue to punish individuals long after release.State and local funding should consider covering care costs for a certain period of time post-release to remove cost barriers and reduce emergency room visits and hospitalizations. TRACKING HEMOGLOBIN A1C TRENDS IN TYPE 2 DIABETIC PATIENTS FROM 2018 TO 2022 ACROSS ETHNICITIES IN EPIC COSMOS, A NATIONAL ELECTRONIC HEALTH RECORD DATABASE Kathryn Tsai1,2; Ashley Tang1,2; Kristy Y. Lin1,2; Heidi Gaddey1,3. 1Family Medicine, Carle Foundation Hospital, Urbana, IL; 2Carle Illinois College of Medicine, Urbana, IL; 3Family Medicine, Christie Clinic, Champaign, IL. (Control ID #4273555)

Asian Americans develop type 2 diabetes mellitus (T2DM) at lower body mass indices (BMIs) and younger ages than general U.S. populations. The American Diabetes Association recommends diabetes screening at a lower BMI of 23 in Asian Americans, compared to 25 for the general population. Moreover, ethnic differences in hemoglobin A1C (HbA1C) values, due to variations in glycemic control, genetics, and hemoglobin structure, raise concerns about the reliability of current HbA1C cutoffs for diagnosing T2DM in this population. This would parallel the adjusted BMI screenings. This study tracks HbA1C levels of Asian Americans compared to other racial groups to investigate its correlations with existing literature and shed light on whether current diagnostic practices align with clinical reality. It leverages Epic Cosmos, an electronic health records dataset (EHR).

A retrospective cohort analysis was conducted with Cosmos for T2DM patients between 1/1/2021 and 12/31/2023. Patients with pregnancy or hereditary hemolytic anemias were excluded. Data was stratified by patient race (six identified groups). Additional stratifications included age of onset (<45 or ≥45 years), BMIs at time of new diagnosis of prediabetes and/or T2DM, and progression rates from nondiabetes to prediabetes or prediabetes to T2DM within one year. 95% confidence intervals and p-values from chi-squared tests were calculated.

Results showed that Asian Americans were diagnosed with T2DM at lower HbA1C levels (8.6% for those <45 years; 7.8% for those ≥45 years) and lower BMIs compared to other groups. Unexpectedly, progression from prediabetes to T2DM within one year was lowest among Asian Americans (6% vs 10.6%, p<0.001) compared to other groups. The difference in oral glucose tolerance testing (OGTT) and HbA1C in diagnosing T2DM in Asians was lowest compared to other ethnicities (2.5% vs 3.2%, p<0.05). Underdiagnosis of T2DM in Asians may contribute to prolonged periods of hyperglycemia, increasing the risk of long-term complications such as nephropathy (0.191%) and retinopathy (0.044%).

In our study, Asians diagnosed with T2DM had a lower average HbA1C compared to other races, aligning with previous literature demonstrating HbA1C’s low sensitivity for detecting T2DM in Asians. An HbA1C cutoff for T2DM of ≤ 6.5 may be too low, leading to underdiagnosis of T2DM in Asians, delaying appropriate management and increasing the risk of complications. Evaluating effects of specific variables, such as medication adherence or technical variation, is difficult in a retrospective EHR study. Future research can measure differences between Asian subgroups, evaluating long-term outcomes of diabetes management at lower HbA1C levels, and investigating alternative diagnostic tools or methods to address variability in HbA1C sensitivity across ethnicities. UNDERDIAGNOSIS OF ATRIAL FIBRILLATION AMONG NON-HISPANIC BLACK AMERICANS IN MARGINALIZED NEIGHBORHOODS: EVIDENCE FROM INSURANCE CLAIMS DATA Kano Amagai1; Alya Nadji3; Melissa Berkowitz1; Erica L. Dixon1; Atheendar Venkataramani2. 1Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; 2Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 3Independence Blue Cross, Philadelphia, PA. (Control ID #4267726)

Non-Hispanic Black (NHB) populations are consistently reported to have a lower prevalence of diagnosed atrial fibrillation (AF) compared to non-Hispanic White (NHW) populations, even though they have a higher prevalence of AF risk factors. Moreover, studies using ambulatory monitoring have demonstrated similar rates of detected AF across race/ethnicity. The discordant findings suggest that AF may be differentially underdiagnosed by race/ethnicity. Research suggests that underdiagnosis may also be more common in population facing adverse social determinants of health (SDoH). The extent to which both race/ethnicity and SDoH interact to affect AF diagnosis rates is not well-known. This study aims to describe disparities in AF diagnosis by race/ethnicity and a novel index of neighborhood-level SDoH.

We conducted a retrospective, cohort study using administrative claims data (2018-2021) for patients in the Philadelphia metro area who were members of Independence Blue Cross (IBX) for at least one month in 2018 and identified as either NHW or NHB. The primary outcome was ICD-10 code based AF diagnosis. SDoH was defined by the social barrier index (SBI), an IBX-created score that aggregates census tract-level SDoH measures: economic stability, education access and quality, health care access and quality, neighborhood and built environment, social and community context, health behaviors and outcomes. High SBI scores denote more disadvantaged areas. We ran a logistic regression model to estimate the association between AF diagnosis, race/ethnicity and SBI after adjusting for covariates including age, sex, length of insurance coverage, and frequency of primary care physician visit.

In our final sample of 504,876 members, the mean age was 48.34 (SD 17.93), 53% were female, 78% were NHW. We identified 28,529 members (5.1% of total) diagnosed with AF during the study period. 24,516 (5.6%) NHW members and 2,733 (4.1%) NHB members were diagnosed with AF. Racial differences in diagnosis rates were greatest in more marginalized neighborhoods. The relationship between SBI and whether or not a patient had an AF diagnosis differed by race/ethnicity. For every one unit increase in SBI, the odds of AF diagnosis changed by a factor of 1.06 (95%CI: 1.04,1.08) for NHW members; for NHB members, the SBI score was not associated with the odds of receiving an AF diagnosis (OR: 0.95, 95%CI: 0.91,1.00). These patterns were noted even among members who received regular primary care visits and members who were continuously covered by IBX during the study period.

Although AF is correlated with comorbidities that are more common in areas of high need and NHB have a higher prevalence of AF risk factors, NHB members were still less likely to be diagnosed with AF than NHW members in high SBI areas in Philadelphia. These findings demonstrate the need to develop tailored interventions to increase diagnosis among NHB populations particularly living in more disadvantaged neighborhoods. USE OF ANATOMIC INVENTORY FIELDS IN A TRANSGENDER AND GENDER DIVERSE (TGD) PATIENT COHORT Jennifer Siegel1; Meghan L. Rieu-Werden3; Suzanne Brodney4; Michael J. Barry1; Alex McDowell2. 1Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; 2Mongan Institute, Massachusetts General Hospital, Boston, MA; 3General Internal Medicine, Massachusetts General Hospital Department of Medicine, Boston, MA; 4General Internal Medicine, Massachusetts General Hospital, Boston, MA. (Control ID #4272189)

Transgender and gender diverse (TGD) patients face significant health inequities; collection of structured sexual orientation and gender identity (SOGI) data has been recommended to address disparities. Use of anatomic (or organ) inventories is also recommended to capture the presence or absence of specific organs, to ensure that patients are offered appropriate preventive care services such as cancer screening. Some Electronic Health Records (EHRs) offer structured anatomic inventory fields; the extent to which these fields are used by clinicians is currently unknown.

EHR used to capture data on patients self-identified as TGD or questioning who had visits to one of 6 hospitals affiliated with Mass General Brigham (MGB) between 1/2019 and 4/2024. Data was obtained regarding site(s) where patients received care as well as completeness of anatomic inventory fields. Chi-squared test performed to examine relationship between EHR field completion and receipt of care at TGD-focused practice

There were 10,566 unique adult patients who received care during the study period and self-reported their identity as TGD. Overall, the anatomic inventory fields in the EHR were completed for 286 (2.71%) patients. Among the 15.7% (n=1667) of patients with a visit to a TGD-focused practice, 10.92% had any anatomic inventory response; among those without any visit to a TGD-focused practice, 1.17% had any response. The relationship between completed anatomic inventory fields and a visit to any TGD-focused practice was significant: X2 (1, N =10,566 ) = 506.7122, p = <0.0001.

A small proportion of self-identified TGD or questioning patients had information entered into the anatomic inventory EHR fields; even smaller proportions had detailed information about specific organs that were present or absent. While it is notable that rates of anatomic inventory completeness were higher at clinical sites proficient in TGD health, rates of completion at these sites remained low. This finding may reflect lack of clinician familiarity with the concept of an organ inventory, challenges utilizing EHR fields, and/or overall clinician burnout with increasing EHR-based documentation demands. “DIFFERENT PERSPECTIVES CAN HELP”: LEADERS’ INSIGHTS FOR EQUITABLE SPONSORSHIP AND CAREER ADVANCEMENT IN ACADEMIC MEDICINE Colleen A. McGourty3; Rachel Schwartz2; Mia F. Williams1; Mitchell D. Feldman1. 1Internal Medicine, University of California San Francisco, San Francisco, CA; 2Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA; 3Internal Medicine, University of California San Francisco, San Francisco, CA. (Control ID #4271543)

Sponsorship describes actions in which an influential champion uses their position to actively advance a colleague’s career by helping them gain visibility, recognition, or positions. Studies suggest disparities exist in the provision of sponsorship to women and those historically underrepresented in medicine (UIM). This is problematic as effective sponsorship can mitigate inequities in career advancement and increase diversity in academic medicine. We aimed to characterize how leaders approach sponsorship with an equity lens, and what existing strategies and future interventions can support equitable sponsorship.

Leaders from the Department of Medicine at a large academic medical center were selected to provide insights into their sponsorship practices (n=14). A semi-structured interview guide was developed, informed by experts and a literature review of sponsorship. Three investigators conducted interviews from 2023-2024. Two investigators coded all transcripts, and coding discrepancies were resolved by consensus. An inductive thematic analysis approach was used to allow themes to emerge organically.

Three overarching themes emerged: 1) proactively sponsoring under-recognized groups; 2) training in equitable sponsorship; and 3) increasing transparency and standardization of sponsorship. Leaders felt that women and UIM faculty, as well as groups such as introverts, educators, and those less familiar to the leader need more sponsorship. Leaders advocated for interventions targeting these groups, such as awards for early-career UIM faculty scholarship. Others described successful demographic-based sponsorship committees in other departments that nominate women or UIMs for awards and advancements. Leaders agreed that transparency and standardization of sponsorship practices were important. They suggested 1) widely publicizing opportunities to reduce bias rather than reaching out to selected individuals; 2) compiling a database of sponsorship opportunities to increase awareness; and 3) forming selection committees with standardized processes for key positions and awards to diversify nominations. Leaders requested more research and education to support equitable sponsorship. Some suggested characterizing disparities in standardized sponsorship metrics for junior faculty (e.g. nominations for advancements). Others felt that department leaders may lack knowledge about sponsorship which could be addressed through optional training on best practices related to equitable sponsorship.

Interviews with department of medicine leaders yielded insights into their approaches to sponsorship relating to equity. Themes included enhancing data gathering and education on sponsorship best practices, proactively sponsoring under-represented groups, and increasing transparency and standardization of advancements and nominations. These themes may inform new interventions to support more equitable sponsorship practices in academic medicine. “SOME OTHER RACE:” IMPROVING RACE AND ETHNICITY MEASURES FOR HISPANIC OR LATINO INDIVIDUALS IN THE UNITED STATES Harita Shah1; Esbeidy Torres Hondal1; Pedro A. Serrano3; Kathleen R. Page2. 1Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 2Medicine, Johns Hopkins University, Baltimore, MD; 3Medical Social Sciences, Northwestern University, Evanston, IL. (Control ID #4268410)

Hispanic and Latino populations represent the largest and fastest-growing minorities in the United States (US), comprising approximately 19% of the US population. However, many Hispanic or Latino individuals have been poorly represented in standardized race measures. In March 2024, the U.S. Office of Management and Budget (OMB) updated the standard measures to combine race and ethnicity into one question. Many researchers have yet to adopt this change. More research is needed to understand how these Hispanic or Latino individuals self-identify race and how racial identities align or conflict with the updated OMB standard categories.

We explored race and ethnicity responses through a cross sectional study followed by a focused longitudinal study. First, we conducted cross-sectional surveys among Latino adults in Baltimore, MD and Chicago, IL from 2022-2023. We conducted chi squared analyses and multivariable regression to explore predictors of race responses, dichotomized into selection of a standard OMB race category vs. not. We furthermore sought to understand how Hispanic or Latino individuals self-identify race when given a write-in option. We conducted a baseline survey with the OMB separate race and ethnicity questions (standard from 1997-2024) and a 6-month follow-up survey with a write-in race question. A trained research assistant manually reviewed and coded each response, and we present these descriptive findings in a visual representation.

The cross sectional dataset included responses from 1705 Latino or HIspanic individuals. Most respondents did not identify a race within the standard OMB measure and either selected “Some other race" or did not answer (n=1362, 78.2%). Persons born outside the US were significantly more likely to choose “Some other race” or leave it blank compared to US born individuals, though rates were high for both groups (82.1% vs. 63.3%, p= 0.001). Among those who wrote in a “Some other race” response, the most common responses were "Latino,” ”Latina,” or “Latinx" (n= 295, 17.3%), Hispanic (n= 143, 8.4%), or a country-related answer (n=94, 5.4%). In multivariable regression, a high school education and English as a preferred language were significant predictors for choosing an OMB race category. Regarding the write-in race measure, 104 respondents completed the longitudinal survey and the evolution of responses is shown in Figure 1. Offering a write-in option markedly improved response rates from 47% (OMB measure) to 93%.

Based on our findings, combining race and ethnicity questions will better align with many Hispanic or Latino individuals’ identities and should result in more complete race data. When feasible, a write-in race question offers even more accurate and complete data. Latino populations are not monolithic. More research is needed to understand best practices for measuring race among specific Latino populations, particularly with respect to intersectional identities. Scientific Abstract - Hospital Medicine 30- AND 90-DAY REHOSPITALIZATION RATES IN PATIENTS WITH PULMONARY EMBOLISM COMPLICATED BY PULMONARY INFARCTION STRATIFIED BY COMORBIDITIES Gary Tan, Esther S. Kim, Ingit Parmar, Manila Jindal. Internal Medicine, Northwell Health, New Hyde Park, NY. (Control ID #4269914)

Pulmonary infarct (PI) is a complication seen in up to 30 percent of patients with pulmonary embolism (PE). PIs have been associated with increased risk of infection and post-pulmonary embolism syndrome. While PE is known for its mortality and morbidity related to cardiovascular compromise, the clinical implications and optimal management of PI remain unclear. Given the current gap in knowledge, identifying patients at risk for worse clinical outcomes may be beneficial to develop more targeted strategies for PI management. In this retrospective study, we identified patients with PI in the setting of PE who were rehospitalized within 30 and 90 days of PI diagnosis and stratified the cohort based on medical comorbidities. The goal of this study is to identify factors associated with increased risk of readmission in patients with PE and PI.

We performed a systemwide de-identified patient data search of all patients ages 18 and older who were admitted to a large academic health institution in New York between 2013 to 2023 and found to have PE with evidence of PI on CT chest imaging. We then conducted a retrospective chart review of electronic medical records to identify rates of rehospitalization within 30 and 90 days of initial admission. The chi-square test was used to compare rehospitalization rates according to medical comorbidities.

2974 patients were found to have PE and PI on chest CT imaging. Of those, 627 patients had imaging findings of either pulmonary infiltrates, consolidations, or pleural effusions. In these patients, composite rates of 30- and 90-day hospital readmission were 13.5% and 20.7% respectively. Patients with pulmonary disease had a higher 30-day readmission rate compared to those without (25.0% vs 12% p= 0.002). Both 30-day and 90-day readmission rates were higher in patients with heart failure (28.2% vs 12.6%, p=0.006 and 46.2% vs 19%, p=<0.001, respectively) and patients with diabetes (24.7% vs 11.9%, p=0.002 and 35.8% vs 18.5%, p=<0.001, respectively). Lastly, patients with cancer had higher 90-day readmission rates than those without (29.2% vs 19.2%, p=0.03). The presence of vascular disease or obesity was not associated with increased readmission rates.

Our results show that, among patients diagnosed with PE and PI, those who had pulmonary disease, heart failure, diabetes, and cancer had higher readmission rates. We selected patients with imaging findings of pulmonary infiltrates, consolidations, or effusions because this group was hypothesized to have the greatest risk for complications. This is the first retrospective review of a large patient data pool investigating readmission rates in patients with PE and PI. Our results underscore the risk of patients with certain comorbidities to repeated medical visits for various reasons that are not included in this study. Further studies investigating the reasons for readmission in this population may help elucidate complications related to PI and treatment strategies. ACETAMINOPHEN TREATMENT OF HOSPITALIZED PATIENTS WITH COMMUNITY ACQUIRED INFECTIONS: AN EXPLORATORY LANDSCAPE ANALYSIS Daniel Lang3; Raja Goyal3; Joel F. Baker1; Zachary Kirkland1; Bradd Kaplan1; Krystian Bonilla1; Wilhelmine Wiese-Rometsch2,1; Karen Hamad1; Robert A. Smith1. 1Clinical Sciences, Florida State University College of Medicine, Tallahassee, FL; 2Graduate Medical Education, Florida State University, Sarasota, FL; 3Medicine, Florida State University College of Medicine, Tallahassee, FL. (Control ID #4272251)

Older adults are vulnerable to community-acquired bloodstream infections (BSI), pneumonia (PNA), and urinary tract infections (UTI), which can lead to morbidity and mortality. Specific aim was to explore interactions among acetaminophen treatment (97% prevalence) versus demographics, extant chronic comorbidities, fever manifestation, clinical course and outcomes across sites of infection in adult patients aged at least 65 years.

Data were extracted under IRB exemption from EMRs of patients discharge with BSI, PNA or UTI diagnosis between September 2020 and August 2024. Dynamic host response was estimated using change (%) between first and last measures of putative biomarkers. Continuous data were summarized with mean [SD] compared with Student’s t-test. Discrete data were summarized as proportions compared with chi-square. A Bonferroni corrected p<0.017 was considered significant with confounders controlled including COVID-19.

Infection site among 15,265 patients included BSI (3114, 15%), PNA (8036, 39%), and UTI (9621, 46%). Age 80 [8] years and race distribution (Whites 93%, Blacks 3%, and other 4%) with females (40%, 45%, 59%). Fever at least 38C manifested among 22%, 12%, 10% with duration (h) 30 [70], 36 [84], 22 [55] while patients received at least one dose of acetaminophen accumulating (mg) to 2266 [1601], 1608 [1130], 1625 [1200] (p<.001). Hypertension (79%), anemia (30%), diabetes (29%), renal failure (28%), and liver disease (7%) were distributed isomorphically, but heterogeneous prevalence (%) of COPD was 23, 41, 20 (p<.001); heart failure 26, 36, 23 (p<.001); and neurological disorders 32, 22, 34 (p<.001). BSI were associated with highest mean ALT/SGPT at baseline (55 U/L) and greatest mean increase across hospital stay (119%). PNA and UTI evoked lower initial ALT/SGPT levels (44 U/L and 38 U/L, respectively) and smaller increases (65% and 17%, respectively). BSI exhibited highest mean AST/SGOT at baseline (73 U/L) and greatest visit delta (243%). PNA and UTI had lower baseline AST/SGOT levels (51 U/L and 45 U/L, respectively) with smaller increases (90% and 25%, respectively). BSI patients had highest creatinine level at baseline (1.95 mg/dL) but also largest decrease delta visit (-38%). PNA and UTI patients expressed lower initial creatinine serum levels (1.58 mg/dL) and smaller decreases (-29% and -30%, respectively). Hospital length of stay (HLOS) (d) was 6.87 [4.9], 6.3 [4.86], 5.6 [4.2].

Findings suggest BSI patients manifest a more severe inflammatory response compared to those with PNA or UTI. Evinced by higher baseline levels with greater escalation in ALT/SGPT and AST/SGOT. Longer hospital LOS and higher rate of ICU visits for BSI further substantiates these patients experience a more severe clinical course. Next steps include exploring the impact of acetaminophen timing and dosage to establish whether there are specific patient subgroups that may fare better or worse undergoing acetaminophen treatment. ANAGRELIDE IN THE MANAGEMENT OF ESSENTIAL THROMBOCYTHEMIA: A SYSTEMIC REVIEW AND META-ANALYSIS. Ernesto Calderon Martinez1; Barbara A. Abreu Lopez2; Joanne Arvelaez Pascucci3; Safiya Mohamed Ramzy4; Shivani Mehta5; Daniel Sami Sami6; Rishita Dave7; Insiya M. Rampurawala8; Lakshmi Sree Pugalenthi9; Dhanuddara Kandambige10. 1Internal medicine, The University of Texas Health Science Center at Houston, Houston, TX; 2Universidad de Carabobo Facultad de Ciencias Economicas y Sociales, Carabobo, Venezuela, Bolivarian Republic of; 3The University of Texas MD Anderson Cancer Center Children's Cancer Hospital, Houston, TX; 4International Medical University malaysia, Kuala Lumpur, Malaysia; 5Washington University of Health and Sciences, San Pedro, Belize, Belize; 6American University of the Caribbean School of Medicine BV, Cupecoy, Sint Maarten (Dutch part); 7University of Medicine & Health Sciences, Basseterre, Saint Kitts and Nevis; 8JSS Medical College, Mysore, Karnataka, India; 9Mercy Fitzgerald Hospital, Darby, PA; 10Kurskij gosudarstvennyj medicinskij universitet Ministerstva zdravoohranenia Rossijskoj Federacii, Kursk, Kurskaâ, Russian Federation. (Control ID #4232288)

Essential thrombocythemia (ET) is a myeloproliferative neoplasm commonly treated with hydroxyurea or pegylated interferon alpha, while anagrelide serves as a second-line option. Despite its thrombocyte-specific action, anagrelide’s comparative efficacy remains debated. This systematic review and meta-analysis aimed to compare anagrelide with first-line treatments, focusing on platelet reduction, thromboembolic events, and side effects.

A systematic search of PubMed, Cochrane, Web of Science, Scopus, EMBASE, and CINAHL databases up to October 6, 2024, was conducted following the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Randomized controlled trials and cohort studies comparing anagrelide and hydroxyurea were included, focusing on platelet count, thrombotic events, and bleeding complications. Analysis was performed using R version 3.4.3.

Six studies with 1,555 participants met the inclusion criteria, with 66% multinational, and the remaining from Japan and Australia/New Zealand. Anagrelide was associated with significantly lower platelet counts than hydroxyurea (MD -65.22; 95% CI -80.78 to -49.66; p < 0.01; I2 = 0%), but there was no significant difference in thrombohemorrhagic events (RR 1.34; 95% CI 1.10 to 1.62; p < 0.01; I2 = 12.5%). In single-arm analysis, JAK-positive patients showed a higher thrombotic proportion (23%; 95% CI 14%–35%) than JAK-negative patients (10%; 95% CI 8%–13%). Patients with hypertension or diabetes had higher platelet counts MD (430.70 and 345.10, respectively; p = 0.04). Adverse event rates varied, with high heterogeneity (RR 1.37; 95% CI 0.37–5.12; I2 = 94.9%).

Anagrelide is effective in platelet reduction for ET, comparable to hydroxyurea, yet higher bleeding risks require caution, especially in at-risk patients. Further studies are needed to confirm long-term safety, assess thrombotic outcomes, and refine dosing. ANGIODYSPLASIA VERSUS NON-ANGIODYSPLASIA GASTROINTESTINAL BLEED IN SCLERODERMA PATIENTS: EFFECT OF RACE AND GENDER Syed Mujtaba Baqir1; Kundan Jana1; Azka Naeem1; Omair A. Khan2; Carla Barberan Parraga1; Sarah Meribout1; Avleen Kaur3; Neha Sharma1; Linda A. Lee4. 1Internal Medicine, Maimonides Medical Center, Brooklyn, NY; 2Rheumatology, University of Nebraska Omaha, Omaha, NE; 3Gastroenterology, SUNY Upstate Medical University, Syracuse, NY; 4Gastroenterology, Long Island Jewish Medical Center, New Hyde Park, NY. (Control ID #4230853)

Systemic sclerosis (SSc) is a multiorgan, autoimmune disease of connective tissue with variable outcomes across race and gender. SSc patients are at risk of developing gastrointestinal bleed (GIB) and mucosal angiodysplasia is the most common cause.

We queried data from the National Inpatient Sample, 2012-2019. We identified patients (≥18 years) who had a discharge diagnosis of SSc via ICD-9 and ICD-10 codes. We further identified patients with an admitting diagnosis of GIB, dividing them into angiodysplasia (N=950) and non-angiodysplasia (N=1001) GI bleeds. We analyzed gender and racial differences in outcomes including mortality, mechanical ventilation, and endoscopic intervention.

Females and Caucasians constituted the majority overall. Survival from angiodysplasia GIB was only slightly better compared to non-angiodysplasia GIB (p-value <0.01). African Americans underwent less esophagogastroduodenoscopy (EGD) as compared to Caucasians (p-value 0.02). More patients with angiodysplasia GIB underwent EGD intervention (p-value < 0.01). Females in the angiodysplasia GIB group had lower mortality (p-value 0.04) compared to males. No difference in age and race was observed. In the overall GI bleed and angiodysplasia group, patients needing blood transfusion needed more EGD intervention (p-value <0.01).

Men had a higher mortality due to reasons unknown. Since our study did not reveal a significant difference in mortality related to GIB in African Americans despite less endoscopic intervention, further studies are needed to see if the higher mortality reported previously is due to other organ involvement. A RETROSPECTIVE ANALYSIS OF POST-HOSPITALIZATION OUTCOMES FOR PATIENTS ADMITTED WITH CHRONIC CONDITIONS Jessica Thayer1; Jesse Thompson2; A. Brianna Sheppard3; Nicole L. Stout4; Christopher McCartney2; Rebecca Reece2. 1General Internal Medicine, West Virginia University School of Medicine, Morgantown, WV; 2Department of Medicine, West Virginia University Health Sciences Center, Morgantown, WV; 3West Virginia Area Health Education Center Program, Charleston, WV; 4West Virginia University, Morgantown, WV. (Control ID #4273097)

Acute care use post-hospitalization is a costly issue for patients and hospitals. Multiple studies have evaluated the readmission risk for heart failure and chronic obstructive pulmonary disease but usually exclude the impact of comorbidities on post-hospitalization outcomes. Our study compared categories of acute care use following a chronic condition related hospitalization to investigate outcomes in patients with complex medical conditions.

We performed a retrospective review of hospital discharges from our health system between June 2023 to June 2024. Inclusion criteria included age >18 years, a chronic condition primary diagnosis, and a home discharge. We analyzed the first occurring discharge for each patient and collected demographic and clinical variables. We defined chronic conditions using the Chronic Condition Indicator Refined database and grouped them into organ-based categories. We separated patients into three cohorts of acute care use within 30 days: no return (NR), ER return only (ER), or readmission (RA). Descriptive statistics, including t-test, ANOVA, Wilcoxon, Kruskal-Wallis, chi squared and Fischer’s exact were performed where appropriate. Subsequent post-hoc pairwise comparisons were not corrected for. Statistical significance was defined as a p-value <0.05.

27,073 hospital encounters met our criteria. 80.5% of patients (n=21,807) had NR, 8.9% (n=2,402) ER, and 10.5% (n=2,864) RA. There was no significant difference in race or sex between the groups. Overall mortality for the cohort was 11.9% (n=3,233), with a difference in mortality for NR, ER, and RA cohorts (10.4%,9.6%,26.1%, <0.001). When compared to ER, patients in the RA cohort had a longer length of stay (5.0,4.0 days, <0.001), different proportion of primary diagnoses related to cancer (12.2%,8.7%, <0.001), and higher percentage in 10 of 20 comorbidities including cardiovascular (92.7%,88.4%, <0.001), dermatologic (8.1%,5.0%, <0.001), metabolic (87.3%,85.2%, <0.05), and pulmonary (48.4%,41.0%, <0.001). Compared to the RA cohort, the NR group had higher proportions of elective admissions (24.6%,16.6%, <0.001), higher proportion of neurologic and rheumatologic primary diagnoses and lower percentages in 15 of 20 comorbidities including dementia (5.7%,6.4%, <0.001), mood disorders (28.0%,31.1%, <0.001), gastrointestinal (51.3%,58.6%, <0.001), renal (31.7%,42.5%, <0.001), and pulmonary (7.4%,9.3%, <0.001).

Our study compared 30-day acute care usage patterns following a chronic condition related hospitalization. We found significant differences in mortality, proportionality of primary diagnoses, comorbidities, length of stay, and medications prescribed on discharge. This study is limited by a one-year review and may benefit from additional years to expand the acute care cohorts. We plan to expand this study further with additional variables focused on social deprivation, access to care, and post-hospitalization follow-up. ARRHYTHMIA AFTER AN ABLATION? AN ANALYSIS USING THE NATIONAL READMISSION DATABASE Vivek Varughese, Patryk Czyzewski, Chandler Richardson, Hata Mujadzic. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4273397)

Arrhythmias are electrical conductions in the heart that cause an irregular rate, rhythm, or a combination of both. Ranging from benign to life-threatening, most arrhythmia require intervention. Medication is usually first-line therapy, but despite treatment, many continue to have recurrence of arrhythmia. Since the 1980’s, radiofrequency ablation has become an effective treatment modality for certain types of arrythmia. Despite advances in catheter and mapping system technologies, a subset of patients previously treated with an ablation for atrial fibrillation (Afib) experience recurrence of arrythmia and require hospitalization. The objective of this retrospective study is to review readmission data to assess the number of readmissions, events causing readmissions, and chronic comorbidities in those readmitted with Afib following an ablation for afib.

The National Readmission Database was utilized to search for patients who underwent an ablation and were hospitalized in the 6 month follow up period. Data was stratified to search for causes of hospitalization and chronic comorbidities.

In total, 37,951 patients were identified to have an ablation for Afib. In the 6 month (180 day) follow up period, 23,456 readmission events were recorded in this patient group. Major readmission events were as follows: 3816 readmissions for heart failure 2312 readmissions for Afib 1338 readmissions for ventricular tachycardia 864 readmissions for sepsis 492 admissions for supraventricular tachycardia A total of 4142 readmissions events occurred for tachyarrhythmias (Afib, supraventricular tachycardias, and ventricular tachycardias). Of those, 2312 readmission events were for Afib. Of the 37,951 patients who underwent an ablation, 1428 (3.8%) patients were readmitted with recurrent Afib. Mean age was 69.71 and 54.8% were males. We analyzed the association between chronic comorbid conditions and readmission after ablation in the 1428 patients: Probit Multivariate Logistic Regression was used, regressing for age, sex and quarterly income. A two tailed p-value <0.05 was used to determine statistical significance. Uncontrolled hypertension had a significant association for recurrent Afib after ablation: OR: 1.20, 95 % CI (1.03 - 1.39). P value <0.017 Obesity had a significant association for recurrent Afib after ablation: OR: 1.22, 95% CI (1.05 - 1.40). P value <0.006 Uncontrolled Diabetes had no significant association with recurrent Afib after ablation.

Although effective, ablations are not curative for all patients. A total of 3.8% of patients who underwent an ablation were readmitted for Afib and accounted for 2312 readmission events, indicating some were hospitalized multiple times with recurrent afib. Uncontrolled hypertension and obesity were associated with readmission for Afib revealing the need for strict control of chronic conditions and continued monitoring for arrythmias. ASSOCIATION BETWEEN FACILITY AND SECTION-LEVEL CHARACTERISTICS AND BURNOUT IN VA HOSPITAL MEDICINE SECTIONS Elizabeth A. Schackmann1,2; Joel C. Boggan3; Jacqueline Ferguson4; Charlie Wray5; Robert E. Burke6; Kirstin Manges Piazza7; Hye Sun Kim8. 1Medicine, University of Washington, Boise, ID; 2Boise VA Medical Center, Boise, ID; 3Medicine, Duke Medicine, Durham, NC; 4Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, CA; 5Medicine, University of California San Francisco, San Francisco, CA; 6Medicine, Philadelphia VAMC, VA Medical Center Corporal Michael J Crescenz, Philadelphia, PA, US, hospital, Philadelphia, PA; 7CHERP, Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA; 8San Francisco VA Health Care System, San Francisco, CA. (Control ID #4270767)

Burnout among hospital medicine (HM) physicians is highly prevalent, with studies suggesting burnout may be lower in the Veterans Affairs system (VA) compared to non-VA settings. Little prior work has evaluated what specific facility or work processes are associated with burnout. We sought to evaluate these characteristics across 67 HM sections in the VA, where robust reporting on work practices and burnout is present.

We assessed self-reported burnout across VA HM sections using data from the VA All Employees’ Survey (AES), a national survey distributed in 2023 to all VA work units. Burnout was defined as an individual reporting at least one of three domains: high exhaustion, high depersonalization, and at least weekly frequency of reduced personal achievement. Respondents were aggregated to calculate “section-level prevalence of burnout.” Facility-level characteristics were described using VA administrative data sources, while hospital section characteristics were abstracted from a 2023 national survey of VA HM section chiefs (HM survey). The primary outcome was higher section-level burnout, defined as prevalence higher than the median. Descriptive statistics were used to analyze facility and section characteristics associated with burnout.

A total of 67 VA HM sections had complete AES and HM survey data. Among these, 29 sections (43.3%) reported burnout higher than the median (41.6%). Lower section burnout prevalence was associated with the following characteristics: working at the highest-complexity facilities (31.0% of sections with higher burnout vs. 52.6% of sections with lower burnout), academic affiliation (86.2% vs. 94.7%), the presence of trainees, including residents/fellows (75.9% vs. 89.5%) or medical students (82.8% vs. 92.1%), and having access to a broad array of clinical specialty services, such as neurology (34.5% vs. 55.3%). Conversely, sections with higher burnout had additional simultaneous clinical responsibilities outside general ward care, such as caring for ICU patients (34.5% vs. 28.9%) or performing inter-hospital transfers (93.1% vs. 78.9%). Additionally, higher burnout was more prevalent in facilities with physician staffing shortages (44.8% vs. 26.3%).

In a national sample of VA HM sections, hospitalists working in higher complexity facilities with greater clinical and educational resources reported lower prevalence of burnout. Many of these associated characteristics are non-modifiable, but VA leaders looking to decrease hospitalist burnout could choose to focus on potentially modifiable workload factors, such as reducing when hospitalists perform multiple high-complexity tasks (e.g. caring for ICU patients and performing inter-hospital transfers) while also caring for general wards patients. Addressing section-level characteristics, and bolstering opportunities for education and access to specialty services could improve the hospital medicine work environment and subsequently improve burnout among hospitalists. ASSOCIATION OF MELATONIN ADMINISTRATION WITH HOSPITAL LENGTH OF STAY IN PATIENTS WITH HEPATIC ENCEPHALOPATHY: A RETROSPECTIVE STUDY. Avneet Singh2; Alexander Garcia2; Tanay-Veer Gandhi1; Nicole Melchiorre1; Shrey Dalwadi1; Fariha Hasan2; Emily Serata1; Zehara Abidi3; Krystal Hunter2; Satyajeet Roy2. 1Student, Rowan University Cooper Medical School, Camden, NJ; 2Internal Medicine, Cooper University Health Care, Camden, NJ; 3Touro College of Osteopathic Medicine, Middletown, NY. (Control ID #4269190)

Hepatic encephalopathy (HE) is associated with high mortality rates in advanced liver disease patients. A common complication of HE is sleep-wake inversion often due to delayed increases in melatonin secretion at night. Melatonin may have a positive impact in hepatic encephalopathy given its antioxidant properties and role in the circadian rhythm. In this retrospective study we evaluate the impact of melatonin administration in patients with cirrhosis and HE, focusing on length of stay (LOS).

A Retrospective review of hospitalized patients aged 18 years and older with a diagnosis of HE between January of 2009 and November of 2021 was conducted. Eligible patients were grouped into those who received melatonin treatment (HEM) and those who did not (HENoM). We applied univariate analysis using independent t tests, Mann Whitney U tests and chi square tests. We ran a regression model where the outcome was LOS and the explanatory variables were demographic factors, comorbidities, lab values, and medications.

Among 164 patients, there were 19 (11.6%) patients in the HEM group and 145 (88.4%) in the HENoM group. There was no significant difference in the mean ages, sex and race distributions, alcohol use, and etiology of cirrhosis between the groups. Linear regression analysis showed that the LOS decreased as serum albumin increased (t = -2.43, p = 0.017). Although the in-hospital mortality of the patients in the HEM group was lower than the HENoM group, the difference was not statistically significant (5.3% vs 15.2%; P=0.479). The 30-day readmission rate was significantly higher in the HEM group compared to HENoM group (59.9% vs 26.2%; P=0.005). Lastly, the median LOS was lower in the HEM group compared to HENoM, but the difference was not statistically significant (4 (3-10) vs 5 (3-8) days; P=0.780).

In this retrospective review we report that hospitalized patients with hepatic encephalopathy who had melatonin administration did not have a statistically significant decrease in LOS and in hospital mortality when compared to HENoM. The insignificance in our findings can be partly due to the small sample size. Larger scale retrospective studies and clinical trials are needed to evaluate the benefits of melatonin administration in patients with hepatic encephalopathy. ASSOCIATION OF PHYSICAL THERAPIST CHARACTERISTICS WITH PT NON-TREATMENT IN HOSPITALIZED PATIENTS WITH MEDICAL ILLNESS Mahnoor Baig1; Daniel L. Young2; Marla Robinson3; Maylyn Martinez1. 1Medicine, University of Chicago Division of the Biological Sciences, Chicago, IL; 2Physical Therapy, University of Nevada Las Vegas, Las Vegas, NV; 3Inpatient Therapy Services Department, The University of Chicago, Chicago, IL. (Control ID #4269716)

Physical therapy (PT) is important for treatment and prevention of hospital-associated disability and functional decline, but PT consistency is difficult in hospital settings. Missing PT sessions, known as “PT non-treatment”, may compromise patients’ functional recovery and decrease therapist efficiency. Little is known about therapist-related factors influencing PT non-treatment. We aimed to assess associations between therapist experience and PT non-treatment.

We conducted a retrospective analysis of admissions to a tertiary academic hospital between 8/2018 - 3/2021. We included patients admitted to Hospital medicine services who were > 50 years old with a length of stay of 3-10 days and a mobility score indicating functional impairment at the time of admission. A priori, we established six categories for reasons for PT non-treatment: patient declined due to symptoms/condition, patient declined for non-medical reasons, patient unavailable, therapist deferred due to patient condition, patient does not need PT, and other. Logistic regression was used to assess associations between PT non-treatment and PT graduation year, acute care experience, and site-specific hospital experience. Linear regression was used to test for associations between total treatment time and therapist experience. The three experience variables were the only covariates in each model.

We reviewed 6753 PT notes from 44 physical therapists and 3368 admissions. Of all attempted sessions, 21.3% were not completed (non-treatment). The most common reasons for missed sessions were “therapist deferred due to patient condition” (32.9%) and “patient unavailable” (27.3%). Mean total treatment time was 24.2 minutes. Patients treated by therapists with more acute care experience had higher odds of PT non-treatment (OR=1.25, 95% CI: 1.07–1.46, p=0.005). Patients treated by therapists with more years of experience at the study hospital had lower odds of PT non-treatment (OR=0.82, 95% CI: 0.70–0.96, p=0.013) There was no association between total years of therapist experience and PT non-treatment. Patients treated by therapists with more total years of experience had longer sessions (β= +5.84, p < 0.001). Those treated by therapists with more acute care experience had shorter sessions (β= -1.12, p=0.028). There was no association between study hospital experience and session length.

Over 20% of scheduled PT sessions are not completed for hospitalized patients. More experience in one's current hospital was associated with lower odds of non-treatment while more acute care experience was associated with higher odds. Orienting new therapy staff to the hospital system and patient population may be a way to improve non-treatment. More studies are needed to further characterize these associations. CHLORHEXIDINE ACTIVATING AGENT WITH INTERMITTENT CATHETER: A NOVEL APPROACH TO CATHER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) PREVENTION Gerard Henry2; Edward Karpman3; Ased Ali4; Lynn Tong1; Anthony Stuart1; Carolyn L. Twomey5. 1Internal Medicine, Willis Knighton Bossier, Bossier City, LA; 2Urology, Willis Knighton Bossier, Bossier City, LA; 3Urology, A Division of Urological Surgeons of Northern California, Mountain View, CA; 4Urology, ConvaTec Inc, Bridgewater, NJ; 5Irrimax Corporation, Lawrenceville, GA. (Control ID #4244849)

Catheter-associated urinary tract infection (CAUTI) is a complication that can develop with urinary catheter placement. It is the most common healthcare-associated infection that can increase patient morbidity, mortality, length of stay, and cost to healthcare. While CAUTI’s are preventable and treatable, causative bacteria have become increasingly resistant to antibiotics. Despite the evolvement of Intermittent Catheter (IC) technology increasing the ease of placement while decreasing discomfort (with hydrophilic properties), there has been minimal research on different activating agents to further reduce CAUTI development. Our group recently showed that chlorhexidine gluconate (CHG) solutions significantly reduce pathogenic organisms on hydrophilic implant discs with potential to lowering penile prosthesis infection (PPI) rates. This study aimed to evaluate the antiseptic ability of CHG after inoculation of common UTI pathogens on sterile IC disks as an additional strategy for reducing CAUTI.

In-vitro microbiological studies done at Nelson Labs Bozeman compared outcomes of catheter activation agents between 0.05% CHG wash solution (IrriseptTM), 0.05% CHG lube (EndosgelTM), and sterile water. 3 different strains of bacteria were inoculated onto 2 different catheter surfaces, the Hydrophilic Cure CatheterTM and GentleCathTM intermittent urinary catheter. The bacterial strains tested included Bacteroides fragilis, Enterococcus faecalis, and Escherichia coli. The trials involved three 3x1 cm discs (carriers) of catheter material being activated in the agents for 2 minutes each, and then inoculated with 0.01 mL of approximately 109 CFU/mL suspension of bacteria. These contaminated carriers were then left at room temperature for 2-3 minutes to mimic real life self-catheterization and then neutralized. Following incubation, the bacterial growth was then collected and analyzed.

Both Cure CatheterTM and GentleCathTM demonstrated substantially reduced bacterial load when using CHG wash and lube. Sterile water had no effect on microbial colony count reduction. The most potent combination seen comprised of GentleCathTM catheter activated with CHG lube, resulting in a significant 3-log reduction in E. coli bacterial load.

Overall, bacterial load was noticeably reduced when using CHG activating agents. This 3-log reduction seen with E. coli and GentleCathTM highlights the potential of CHG activating agents used as an additional method for CAUTI prevention. Further studies are needed for validation clinically. CLINICAL OUTCOMES OF TREATED VS. UNTREATED ADULT HOSPITALIZED PATIENTS WITH NAAT-POSITIVE, TOXIN-NEGATIVE CLOSTRIDIOIDES DIFFICILE INFECTION August A. Culbert1,2; Jeffrey Shu1,2; Jeff D. Kovach3,2; Rebecca Schulte4,2; Kevin A. Brown5; Curtis J. Donskey6; Marya Zilberberg7; Abhishek Deshpande8,2. 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH; 2Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH; 3Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 4Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 5Public Health Ontario, Toronto, ON, Canada; 6Medicine, Cleveland VAMC, Cleveland, OH; 7EviMed Research Group LLC, Goshen, MA; 8Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4235931)

Clostridioides difficile infection (CDI) remains the leading cause of healthcare-associated diarrhea. While nucleic acid amplification testing (NAAT) is highly sensitive for detecting C. difficile, its use as a standalone test may lead to overdiagnosis. Current guidelines recommend combining NAAT with toxin enzyme immunoassay (toxin EIA) testing to distinguish colonization from active CDI, but the clinical management of NAAT-positive/toxin-negative patients remains controversial. Here, we investigated clinical outcomes of NAAT-positive/toxin-negative patients based on treatment decisions.

In this retrospective study, we analyzed adult inpatients with positive C. difficile NAAT results from 2018-2023 across 12 hospitals within a single U.S. health system. In NAAT-positive/toxin-negative patients, we compared those who received ≥2 days of CDI therapy to those who did not. Primary outcomes included 30-day hospital readmission, recurrent CDI, in-hospital mortality, and CDI-related complications (composite of ICU transfer, toxic megacolon, or colectomy). To minimize confounding, we constructed propensity scores using multivariable logistic regression incorporating demographics and clinical parameters. Inverse probability of treatment weighting (IPTW) was applied to evaluate the independent effect of treatment on outcomes. Results were reported as adjusted odds ratios (aOR) with confidence intervals.

Among 8,066 NAAT-positive patients, 5,403 (67%) were toxin-negative. In the toxin-negative group, 82% received CDI treatment, primarily with vancomycin (86%). Treated toxin-negative patients had higher baseline rates of immunosuppression, chemotherapy, and high-risk antibiotic exposure (p<0.001). After propensity score adjustment, treatment of toxin-negative patients was associated with increased odds of 30-day hospital readmission (aOR 1.25 [95% CI: 1.01-1.53], p=0.04), but showed no significant differences in ICU transfer, recurrent CDI, in-hospital mortality or composite CDI complications (Figure 1).

Treatment of NAAT-positive/toxin-negative patients was common but associated with increased hospital readmission risk without demonstrable clinical benefit. Consideration should be given to withholding CDI treatment in toxin-negative patients and reinforce the value of two-step diagnostic algorithms in clinical practice. CLINICIAN PERSPECTIVES ON ELECTRONIC HEALTH RECORD BEHAVIORAL ALERTS AND HOSPITAL WORKPLACE VIOLENCE PREVENTION: A MIXED METHODS STUDY AT 20 ORGANIZATIONS Zoe Kopp1; Himali Weerahandi2; Catherine Callister3; Russell Ledford4; Andrew D. Auerbach2; Marisha Burden5; Jaime Burke3; Khooshbu S. Dayton5; Angela Keniston6; Katie Raffel7. 1Department of General Internal Medicine, University of California San Francisco, San Francisco, CA; 2Medicine, University of California San Francisco, San Francisco, CA; 3Hospital Medicine, University of Colorado Denver School of Medicine, Aurora, CO; 4Hospital Medicine, Vanderbilt University, Nashville, TN; 5Medicine, University of Colorado Denver School of Medicine, Aurora, CO; 6Division of Hospital Medicine, University of Colorado, Aurora, CO; 7Medicine, University of Colorado System, Denver, CO. (Control ID #4271901)

The Occupational Safety and Health Administration (OSHA) requires healthcare organizations to provide staff with a patient’s history of behavioral incidents if there is the potential for violence, aggression, or abuse. Electronic health record behavioral alerts (EBAs) are a common method that healthcare organizations use to meet this requirement. Prior work on EBAs has focused primarily on emergency room settings. Few data exist to describe clinician experiences from inpatient settings, and even fewer to describe how EBAs are deployed across multiple healthcare institutions. To address this gap in knowledge, we applied a mixed methods approach to explore (1) how EBAs are applied across hospital workplace violence prevention programs and (2) inpatient clinician perspectives on EBAs as workplace violence prevention tools.

We used a mixed-methods approach consisting of virtual focus groups with an embedded brief structured survey. This design allowed us to systematically assess focus group participants’ familiarity and experiences of EBAs through the survey while also obtaining rich examples of EBAs use through dialogue shared in the focus groups. Participants were physicians, administrators and researchers from a national consortium of hospitals. We used rapid qualitative methods for data analysis. Our main outcomes were qualitative data from focus groups and quantitative data from the survey.

Twenty-eight individuals from 20 different organizations participated in focus groups, with 24 (86%) completing the survey. Data revealed 3 key themes. There was broad uncertainty in best practices for inpatient workplace violence prevention, and most (67%) survey respondents did not think EBAs substantially prevented workplace violence. There was also wide variation in EBA use across multiple domains, including how and why the alerts are placed, and how they are used by the end user. Finally, focus groups had mixed sentiments on the potential impacts of these alerts; among participants who responded to surveys, half (50%) noted that alerts caused deviations in care, and 21% indicated they witnessed instances where EBAs led to adverse patient outcomes. The majority (88%) of respondents also reported that patient demographic factors impacted whether an alert was placed.

Reports of uncertainty in best practices for deploying EBAs, along with perceptions of variability in implementation and potential biases in how alerts are used, raise concerns about alert effectiveness and their potential for worsening disparities. Standardized, evidence-based practices that safeguard healthcare workers without compromising patient care and equity are needed. COMPARISON OF OUTCOMES FOR HOSPITALIZED PATIENTS BETWEEN HOSPITALISTS AND PRIMARY CARE PHYSICIANS Peter McDonnell1; Karen Joynt Maddox1; Nathan Moore2. 1Internal Medicine, Washington University in St Louis School of Medicine, St. Louis, MO; 2Internal Medicine, Missouri Baptist Medical Center, St. Louis, MO. (Control ID #4271777)

The rise of hospitalists has been one of most significant changes to the practice of inpatient medicine over the past half century while primary care providers (PCPs) managing the inpatient care of their patients has declined. The hospitalist model has been studied extensively with most analyses showing hospitalists having a lower length of stay, but conflicting results regarding other outcomes. The complexity of our health care system has limited many prior studies to have to choose between comprehensive data at a single site, not including post-hospitalization outcomes, or broader data with limited outcomes such as not having actual cost of care. Studying the outcomes of hospitalized patients at the level of an accountable care organization (ACO) allows us to strike a balance of getting comprehensive data at several sites during and after the hospitalization including real costs.

We studied hospitalizations of a Midwest ACO with 34,000 beneficiaries between January 1 and December 31, 2019 at hospitals where patients were cared for by a mixture of hospitalists and PCPs. Each hospitalization was attributed to a physician based on the majority of admitting provider, discharging provider, and plurality note author. Classification of a physician as a hospitalist, PCP, or other was made by manual confirmation of the provider’s role. Hospitalizations attributed to neither a hospitalist nor a PCP were excluded. All outcomes were determined by what was billed to the ACO.

We studied a total of 3,044 medicine admissions to 6 hospitals from January 1 to December 31, 2019. Patients were cared by PCPs in 34% of admissions and hospitalists in 64% of admissions. Baseline patient characteristics were similar although PCP patients were slightly older, less likely to be dual Medicaid eligible, and had lower Charlson-Deyo-Comorbidity-Index scores on average. Hospitalization outcomes were similar between the two groups with no difference in mortality during or after the hospitalization, readmission, discharge destination, or utilization of home health in the multivariate analysis. Patients cared for by hospitalists had lower lengths of stay and were less likely to have an ICU stay during their admission, but were more likely to be transferred to another hospital. Patients cared for by PCPs had a lower cost of care 90 days after discharge and a lower total cost of care for the admission and post-admission period. Hospitalist admissions were also more likely to have a PCP visit within 30 days of discharge.

We found that PCPs and hospitalists had overall similar patient outcomes including no difference in mortality and readmission. Hospitalists did have a slightly lower average length of stay, which has been the most consistent finding in studies of hospitalist outcomes. PCPs had lower total costs of care for the admission and 90 days after discharge. With ongoing concerns regarding the cost of healthcare delivery there may be value in supporting traditional PCP models. DETERMINING RISK FACTORS FOR READMISSION POST-PCI Vivek Varughese, Chandler Richardson, Hata Mujadzic. Internal Medicine, Prisma Health Midlands, Columbia, SC. (Control ID #4272186)

Hospital readmission rates are an important metric for hospitals and providers as they are now tied to reimbursement rates. It is impossible to determine who will require readmission after discharge, but what if we could identify risk factors associated with higher readmission rates compared to the general population? If we could identify these risk factors, then we could better target our management on these high-value conditions to help prevent readmission.

We used the National Readmission Database (NRD) to look at patients >18 years old who underwent percutaneous coronary intervention (PCI) during a hospitalization in 2021 and had follow-up within 30 and 60 days after discharge. From this cohort, we determined how many required readmission within the first 30 days followed by the next 30 days (60-day readmission group) for either acute myocardial infarction (MI) or heart failure. These readmission rates were compared to the national average weighted mean readmission rates per the NRD. We then looked for the presence of comorbid conditions, specifically uncontrolled diabetes and uncontrolled hypertension, to determine if these conditions were related to a higher rate of readmission.

24,471 patients met inclusion criteria within the first 30 days of discharge after PCI with 9,291 being readmitted giving them a weighted mean readmission rate of 0.0008 compared to the national average. Of the 9,291 readmissions, there were 1,107 for acute MI and 860 for heart failure. We then looked for an association between readmission from either acute MI or heart failure and their association with uncontrolled hypertension or diabetes. Using a multivariate logistic regression we found odds ratios of 1.42 and 1.24 respectively between uncontrolled diabetes and hypertension to acute MI readmissions. The same analysis did not hold for heart failure readmissions as there was no significant association between heart failure readmissions and these comorbid conditions. When we expanded to a 60-day post-discharge window there was a total of 25,308 patients meeting inclusion criteria (including the 30-day group) who experienced 11,179 readmission events giving a weighted mean readmission rate of 0.0011 compared to the national average. There were a total of 1,245 acute MI admissions and 1,202 for heart failure. The association between our comorbid conditions and our causes for readmission remained similar with an odds ratio of 1.50 and 1.32 for diabetes and hypertension, while there remained no association between comorbid conditions and heart failure.

Patients who undergo PCI have a lower rate of readmission when compared to the national average readmisison rate for all conditions. There is a significant correlation between readmission for acute MI within 30 and 60-days in patient with uncontrolled hypertension or diabetes, however, there is no correlation between these comorbid condition leading to readmission from heart failure after PCI. DIFFERENCES IN MANAGEMENT AND OUTCOMES BETWEEN TRICUSPID VALVE ENDOCARDITIS PATIENTS WHO INJECT DRUGS VS TRICUSPID VALVE ENDOCARDITIS PATIENTS WHO DO NOT INJECT DRUGS Augustin Beall, Surabhi Atreja, Lina Du. Internal Medicine - Cardiology, University of California Davis, Davis, CA. (Control ID #4272649)

Patients who inject drugs (PWID) have higher incidence of tricuspid valve endocarditis (TVE) compared to those who do not inject (PWNID). Despite longer hospitalizations and higher recidivism, mortality rates are lower in PWID. Historically, PWID have not been given outpatient parenteral antibiotics (OPAT). However, recent studies have shown that OPAT in certain circumstances can reduce readmission rates, hospital stays and costs associated with TVE PWID.

Retrospective review of TVE PWID vs PWNID diagnosed by TTE/TEE at a west coast hospital between Jan 1, 2013 - May 1, 2023.

Of 36 TVE patients, 23 had a history of using either opioids, meth or both by various routes; 20 were PWID. Etiology of TVE for PWID vs PWNID: injection drugs (75% vs 0%); cardiac prosthetic/device-related (15% vs 18.3%); catheter/line-related (10% vs 31.3%); nonbacterial thrombotic endocarditis or structural anomaly (0% vs 31.3%); other, e.g., trauma, immunosuppression, abscess, other tissue infection, respiratory origin (15% vs 25%). Mean age was 34.7 years for PWID vs 48.35 for PWNID. Of 16 deceased patients, 12 were PWNID, half of whom died during their hospital stay. Mean length of stay for PWID was 28.3 days vs 20.4 days. 5 of 6 patients who left prematurely were PWID. 50% of PWID underwent surgery vs 12.5%, with an average wait time of 85.1 days for PWID and 39.3 for PWNID. Mean number of readmissions was 2.7 in PWID vs 4.8; however, the average number of endocarditis-related readmissions (ERR) was 17% higher in PWID. PWID also received outpatient antibiotics more often (45% vs 25%), including higher rates of parenteral antibiotics (25% vs 0%). While 3 of the 5 PWID that received parenteral antibiotics had ERR, the remaining 2 had zero readmissions. Notably, PWID also faced higher housing instability than PWNID (65% vs 12.5%).

Our findings align with prior studies showing lower mortality for TVE PWID, which may be due to that cohort's younger age. Our data also suggest that PWNID comprise a sicker population with greater comorbidity, which may also account for their lower rate of surgery. PWID had lower readmission rates, possibly indicating improvements in treatment and management. Alternatively, it could be due to readmission at other hospitals, or not enough time from discharge to develop complications. The rate of OPAT was higher for PWID, possibly reflecting a shift in treatment practices. However, those OPAT PWID, had a higher rate of ERR than the PWID cohort as a whole. Still, the ERR rate among PWID was greater among those who did not receive any outpatient antibiotics. Furthermore, the OPAT patients who were readmitted were also likely to have a history of housing instability among other potentially confounding factors. Future research with a larger sample size may clarify reasons for readmission, complications during the clinical course, considerations for provision of parenteral antibiotics, and circumstances predisposing patients to depart prematurely. DIRECT VERSUS INDIRECT ADMISSION TO INTENSIVE CARE FROM EMERGENCY DEPARTMENT: A NATURAL EXPERIMENT TO EXPLORE SEPSIS OUTCOMES IN OLDER ADULTS David Younkin1; Patricia Riano Rivero1; Lauren Forchette1; Luis Palma1; Joel F. Baker1; Karen Hamad2. 1Internal medicine, Sarasota Memorial Health Care System, Sarasota, FL; 2Medicine, Florida State University College of Medicine, Tallahassee, FL. (Control ID #4272146)

Sepsis disproportionately affects older adults. Timely recognition and management are crucial for improving outcomes. Patients with sepsis often require intensive care unit (ICU) admission for advanced organ support. However, there is debate regarding optimal pathway for admitting older adults with sepsis to ICU. This study aimed to compare ICU Day 1 (ICU_D1) acute physiology and hospital outcomes in older adults admitted directly vs. indirectly from the ED who underwent standard of practice care in a hospital with a Medicare Five-Star Quality Rating.

Patients at least 65 years old presenting to the ED between December 1, 2019 and August 31, 2024, who were subsequently admitted to ICU were studied. Data were extracted from EMRs under IRB exemption. Primary outcome was a composite of hospice discharge or hospital mortality within 28 days of ICU admission. Secondary outcomes were ICU Day 1 APACHE IV and Acute Physiology Scores (APS) along with contributing clinical traits. Continuous data were summarized with mean [SD] compared using ANOVA. Discrete data were summarized as proportions and compared with chi-square. Bonferroni corrected p<0.0125 was considered significant.

Patients respectively admitted directly (n=1111) vs. indirectly (n=360) were similarly aged 78 [8] and balanced with females (43%) and males (57%), Whites (91%), Blacks (4%) and other races (5%). Inter and intra-group isomorphic distribution of predominant comorbidities included hypertension (82% vs. 81%), neurological disorders (57% vs. 49%), deficiency anemias (45% vs. 46%), heart failure (41% vs. 43%), renal failure (36% vs. 34%), diabetes (40% vs. 36%), and chronic pulmonary disease (27% vs. 26%). COVID-19 (9% vs. 8%) impact was minimal. No sepsis level differences emerged in ICU_D1 variables so direct vs. indirect pathway contrasts are reported. APACHE IV score was 78 [30] vs. 80 [33], APS 56 [30] vs. 59 [32], MAP (mmHg) 72 [30] vs. 70 [30], urine output (mL) 1418 [1320] vs. 1343 [1244], WBC (10^3/uL) 15.8 [16.3] vs. 17.2 [15.1], creatinine (mg/dL) 1.92 [1.61] vs. 1.91 [1.37], serum glucose (mg/dL) 154 [86] vs. 149 [85], and pHa 7.33 [0.14] vs 7.32 [0.13]. Direct vs. indirect admits had shorter time to ICU arrival (8 vs. 28h) with similar ICU LOS (3.1 vs. 3.2d), hospital LOS (8.5 vs. 9.2d) and hospital LOS / MSDRG GMLOS Ratio 1.2 vs. 1.3. There was no intergroup difference in composite outcome 42% vs. 43%.

Elderly sepsis patients admitted to non-ICU units from ED and subsequently transferred to ICU within 72h experienced similar hospital and ICU LOS and composite outcome versus direct admission. Although apparently unaffected by admission strategy, patients who underwent indirect clinical pathways may exhibit novel predictors of very early risk for needing a higher level of care. Deep machine learning can help identify these predictors by characterizing their dynamic acute physiology before they decompensate. EARLY ONSET OF HOSPITAL-ACQUIRED ANEMIA IN CARDIAC TELEMETRY PATIENTS: PREVALENCE, BLOOD LOSS, AND THE PROTECTIVE ROLE OF ATRIAL FIBRILLATION Mesrop Aleksanyan1; Claudia Villa Celi1; Irene O. Pokuaa1; Joseph Fares2; Ekaterina Vypritskaya3. 1Internal Medicine, Capital Health, Trenton, NJ; 2Rowan University School of Osteopathic Medicine, Stratford, NJ; 3Internal Medicine Residency Program, Capital Health, Trenton, NJ. (Control ID #4270331)

Hospital-acquired anemia (HAA) is defined as having a normal hemoglobin (Hb) value upon admission but developing anemia during hospitalization. Koch et al. found an incidence rate ranging from approximately 25% when defined as the Hb value before discharge to 74% when using the nadir Hb value during hospitalization. Several factors can contribute to the development of HAA, such as frequent blood draws, blood contamination necessitating further blood draws, and existing medical conditions. However, a primary cause of declining Hb levels is blood loss from diagnostic procedures. Multiple studies show the range of blood drawn. However, most calculated the drawn blood during the whole hospitalization period. We think it is important to evaluate developing HAA during the first days of hospitalization. A multicenter analysis demonstrated that there is an association between higher Hb with reductions in length of stay, charges, and mortality in hospitalized heart failure patients. Given our resource constraints and the costs associated with preventable HAA, we undertook to identify HAA prevalence rate in the first 5 days and to evaluate any association between HAA and sex, race, and comorbidities.

We conducted a retrospective cohort study to evaluate HAA prevalence in the cardiac telemetry unit. We reviewed the electronic medical records at our center for patients above 18 years admitted between June 1, 2023 to Dec 31, 2023. Anemia was defined as Hb < 12 g/dl in women and < 13 g/dl in men.

Applying our criteria, we identified 218 patients. Our study showed that during the first 5 days, the prevalence of HAA is 50% with SD 0.5, and the mean blood drawn during the first 5 days is 68ml SD ± 21ml. The logistic regression analysis reveals a significant association between atrial fibrillation (AF) and HAA. When adjusted for sex and race, the odds ratio (OR) for AF was 0.535 (95% CI: 0.287, 0.997; p=0.049), indicating that patients with AF are about 47% less likely to develop HAA compared to those without AF, holding other factors constant. However, sex and race did not show significant associations with HAA in the adjusted model. In the unadjusted model, AF remained a significant predictor of HAA with an OR of 0.507 (95% CI: 0.278, 0.922; p=0.026), indicating that patients with AF are about 49% less likely to develop HAA. The overall model was statistically significant (LR chi2(1) = 5.06, p=0.0245) but with a low Pseudo R2 value of 0.0167, highlighting the need for additional factors to better explain the variation in HAA. The analysis shows a significant association between sex and HAA among Black individuals. Specifically, Black females have significantly higher odds (approximately 2.53 times) of developing HAA compared to Black males.

Our study revealed that the prevalence of HAA was 50% during the initial five days. AF is associated with a significantly reduced likelihood of developing HAA while sex and race show no significant associations in the analysis. ECHOCARDIOGRAPHY VERSUS CARDIAC MAGNETIC RESONANCE IMAGING FOR THE DIAGNOSIS OF LEFT VENTRICULAR THROMBUS: A SYSTEMATIC REVIEW AND META-ANALYSIS Ernesto Calderon Martinez1; Carla Isabella Miret Durazo2; Ajay Kumar3; Rafael Pinto-Colmenarez6; Palvi Mroke4; Zishan Rahman5; MANUEL QUIROZ FLORES8; Valentina Milani9; Ahmad a. Hammoud10; María Fernanda Trujillo Rodriguez7. 1Internal medicine, The University of Texas Health Science Center at Houston, Houston, TX; 2Faculty of Medecine, Universidad Xochicalco - Campus Tijuana, Tijuana, Mexico; 3Medicine, Isra University Faculty of Medicine and Allied Medical Sciences, Hyderabad, Sindh, Pakistan, Hyderabad , Sindh, Pakistan; 4Caribbean Medical University, Des Plaines, IL; 5Caribbean Medical University, Des Plaines, IL; 6Universidad de Carabobo Facultad de Ciencias de la Salud - Escuela de Medicina (Nucleo Carabobo), Valencia, Carabobo, Venezuela, Bolivarian Republic of; 7Universidad Nacional Autonoma de Mexico Facultad de Medicina, Mexico City, CDMX, Mexico; 8Stanford University School of Medicine, Stanford, CA; 9Universita degli Studi di Roma La Sapienza, Rome, Lazio, Italy; 10Ilia State University, Tbilisi, Tbilisi , Georgia. (Control ID #4271158)

Left Ventricular Thrombus (LVT) is a serious complication of myocardial infarction (MI) that increases morbidity and mortality due to systemic embolization and stroke. Early detection is essential for timely anticoagulation therapy. This meta-analysis compares the diagnostic accuracy of Cardiac Magnetic Resonance (CMR) with Transthoracic Echocardiogram (TTE) in detecting LVT.

A systematic review and meta-analysis was conducted following PRISMA guidelines. Databases searched included PubMed, Cochrane Central Register of Controlled Trials, ICTRP, CNKI, Scopus, LILACS, Clinical Trials, Web of Science, Google Scholar, EMBASE, and CINDAHL.

Fifteen studies with 3,098 participants met the inclusion criteria. CMR demonstrated higher sensitivity (74%, 95% CI: 0.58-0.85) and specificity (99%, 95% CI: 0.98-0.99) compared to TTE (sensitivity: 44%, 95% CI: 0.28-0.62; specificity: 98%, 95% CI: 0.95-0.99). CMR’s area under the curve was 0.99, while TTE’s was 0.867. Heterogeneity was significant for TTE (I^2 = 67.6%) but low for CMR (I^2 = 0.0%).

CMR shows superior diagnostic accuracy compared to TTE in detecting LVT, supporting its use as the preferred imaging modality, especially in high-risk patients. Future studies should evaluate the role of anticoagulation therapy and myocardial remodeling in LVT detection. EPIDEMIOLOGY AND OUTCOMES OF INFECTIVE ENDOCARDITIS IN A BROOKLYN COMMUNITY HOSPITAL: A COMPARISON OF PRE- AND POST-PANDEMIC ERAS May Thet Hmu Tun1; Khin Htet Htet Soe2; Khant Kaung Htet Lwin2; Desen Zeng4; Andrew W. Li4; May Yee Lin2; Sumitra Paudel2; Usha Rathi2; Parversh K. Rathi2; Yu Shia Lin3. 1Internal Medicine, Maimonides Medical Center, Brooklyn, NY; 2Maimonides Medical Center, New York, NY; 3Infectious disease, Maimonides Medical Center, New York, NY; 4SUNY Downstate Health Sciences University, New York, NY. (Control ID #4241511)

Infective endocarditis (IE) is a severe and often life-threatening infection that affects the heart valves,endocardium, or implanted cardiac devices.Although relatively uncommon,its impact is significant, with the incidence in the U.S. rising steadily from 10.2 cases per 100,000 people in 1990 to 14.4 per 100,000 in 2019.Despite improvements in treatment, the mortality rate for IE has also escalated from 0.63 per 100,000 in 1990 to 1.42 per 100,000 in 2019.Given the limited data available, this study explores the evolving nature of IE in the post-pandemic era offering new insights into this complex disease.

We conducted a retrospective cohort study on hospitalized patients aged >18 years with IE,diagnosed based on the 2023 Duke-ISCVID IE criteria,who received at least 72 hours of antibiotics following admission to Brooklyn Community Hospital.The study population was categorized into two groups:pre-pandemic(January 1st,2016,to December 31st,2019) and post-pandemic(January 1st,2021, to June 30th,2024).Patients who did not meet these criteria were excluded.

A total of 257 patients were included:146 in the pre-pandemic and 111 in the post-pandemic group.Over 60% of the patients were Caucasian, and more than 65% were aged over 60.In both groups, more than 70% of cases met the criteria for a definitive diagnosis of IE.Notably,60% of patients in the pre-pandemic group had a high Charlson Comorbidity Index 4, 5 (≥5 points).Common presenting symptoms included fever, shortness of breath, fatigue, and altered mental status, with a median duration of one week (<1–4 weeks).Additionally, over 80% of patients in both groups met the SIRS criteria upon admission.Blood cultures were positive in over 80% of cases,with Staphylococcus aureus being the most common pathogen (34% vs. 37% in the pre- and post-pandemic groups,respectively), followed by Enterococcus faecalis (13% vs. 19%) and viridans group streptococci (12% vs. 12%).Vegetations were detected in 87% of pre-pandemic and 92% in the post-pandemic cases, while native valve involvement was 68% and 71%, and the size of vegetation ≥1 cm was 48% and 42%, respectively.The post-pandemic group experienced a higher rate of complications, including acute kidney injury, respiratory failure, septic shock, and embolic stroke, and a longer median hospital stay (22 vs. 19 days, respectively).Valve replacement surgery was performed in 17% of the pre-pandemic and 13.5% of the post-pandemic group.However, the trends of ICU admission rate and in-hospital mortality were lower in the post-pandemic group (37% vs. 48% and 17% vs. 22%,respectively).

Despite a higher rate of complications in the post-pandemic group, in-hospital mortality was lower compared to the pre-pandemic group.This may be due to earlier microorganism detection through molecular techniques and the prompt initiation of targeted antimicrobial therapy.These findings underscore the importance of effective antibiotic stewardship programs in improving outcomes for IE. EPIDEMIOLOGY OF DIARRHEAL PATHOGENS IN HIGH-RISK PATIENT POPULATIONS: A MULTIHOSPITAL COHORT STUDY Jeffrey Shu1,2; Hannah Wang1,3; Anisha Misra1,3; Daniel D. Rhoads1,3; Amy S. Nowacki2; Jarrod E. Dalton2; Abhishek Deshpande4. 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; 2Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH; 3Pathology and Laboratory Medicine, Cleveland Clinic, Cleveland, OH; 4Medicine, Cleveland Clinic, Cleveland, OH. (Control ID #4218486)

Infectious diarrhea causes significant morbidity and mortality worldwide, with >500,000 hospitalizations annually in the United States. Traditional diagnostic methods are limited by poor sensitivity and narrow organism range, failing to identify causative agents in >90% of cases. Multiplex polymerase chain reaction gastrointestinal panels (GIPs) can simultaneously detect >20 bacteria, viruses, and parasites, offering more comprehensive pathogen identification compared to traditional methods. However, the epidemiology of infectious diarrhea in high-risk immunocompromised populations using these panels remains poorly characterized.

We conducted a retrospective cohort analysis of adults (age ≥18 years) tested with a GIP across 12 hospitals within a single health system (2019-2024). We analyzed the first GIP per patient, excluding Clostridioides difficile results due to changes to target reporting during the study period. We reported pathogen detection rates overall and by 10 high-risk conditions identified using ICD10 codes. Univariable logistic regression compared pathogen detection between patients with ≥1 condition (“high risk”) vs. those without (“immunocompetent”).

Among 17,964 patients, (median age 64 years, IQR 44-76), 11,114 (62%) had ≥1 high-risk condition. Organisms were detected in 2067 (19%) high-risk patients, with >1 organism in 251 (2.3%). The distribution included bacteria (11%), viruses (7.5%), and parasites (0.9%). Enteropathogenic Escherichia coli (EPEC) (5.7%) and norovirus (5.2%) were most common organisms across all high-risk groups. The third most common organism varied by condition, primarily Campylobacter spp. (1.8%) and Salmonella spp. (1.5%). High-risk patients were less likely to detect any organism (OR 0.46, 95% CI 0.43-0.49) vs. immunocompetent patients.

In this large multihospital study, 81% of GIP tests in high-risk patients identified no causative pathogen, with EPEC and norovirus being the most common among positive cases. The significantly lower positivity rate among high-risk patients suggests a lower clinical threshold for GIP testing in these populations. Our findings can help guide empiric therapy decisions and isolation practices in these vulnerable populations. EPTINEZUMAB FOR THE TREATMENT OF CHRONIC MIGRAINE AND MEDICATION OVERUSE HEADACHE: A SYSTEMATIC REVIEW Angie Carolina Alonso Ramírez2; Carla Isabella Miret Durazo3; Lisyareli Salazar Arriaga4; España De la Rosa Valdez5; Ricardo Alberto Leyva Ramírez6; Brenda Tatiana Camacho Ramírez7; Joceline Almeida Hidalgo8; Lusine Menejyan9; Ada Lizandra Motiño-Villanueva10; Ernesto Calderon Martinez1. 1Internal medicine, The University of Texas Health Science Center at Houston, Houston, TX; 2Pontificia Universidad Javeriana, Bogota, Colombia; 3Universidad Xochicalco - Campus Tijuana, Tijuana, Mexico; 4Universidad de Monterrey, San Pedro Garza Garcia, Nuevo León, Mexico; 5Universidad Autonoma de Nuevo Leon Facultad de Medicina, Monterrey, Nuevo León, Mexico; 6Universidad Autonoma de Baja California - Campus Tijuana, Tijuana, Baja California, Mexico; 7Universidad Industrial de Santander Escuela de Medicina, Bucaramanga, Santander, Colombia; 8Universidad Tecnica de Ambato, Ambato, Tungurahua, Ecuador; 9Yerevan State Medical University Named after Mkhitar Heratsi, Yerevan, Armenia; 10Universidad Catolica de Honduras Facultad de Ciencias de la Salud, Tegucigalpa, Francisco Morazán, Honduras. (Control ID #4233705)

Chronic migraine (CM) and medication overuse headache (MOH) have prevalence rates of up to 2.2% and 1-2%, respectively. Standard treatments often fail to address the underlying causes of CM and can contribute to MOH, increasing disability and healthcare costs. Eptinezumab, a monoclonal antibody targeting calcitonin gene-related peptide (CGRP), shows potential for reducing migraine frequency and reliance on acute medications.

Following PRISMA guidelines, this systematic review was registered on PROSPERO (CRD42024598740). Databases searched included PubMed, MEDLINE, Web of Science, Scopus, EMBASE, CNKI, CINAHL, and Cochrane. Eligible studies were randomized controlled trials, post hoc analyses, cohort, and case-control studies involving adult patients with CM and MOH treated with eptinezumab. Outcomes analyzed included monthly migraine days (MMD), headache severity, acute medication use, and quality of life.

Six studies with 670 participants met inclusion criteria. Eptinezumab significantly reduced MMD compared to placebo in two studies. Three studies reported reductions in headache frequency and acute headache medication (AHM) use, with a higher proportion of eptinezumab-treated patients achieving reductions in both monthly headache days (MHDs) and a MMD scores. Quality-of-life outcomes, including HIT-6 and MIDAS scores, showed marked improvement. Treatment-emergent adverse events (TEAEs) were common but generally mild; severe TEAEs were rare and dose-dependent, with no deaths reported.

Eptinezumab shows promise in reducing MMD, dependency on AHM, and disability in CM and MOH, emerging as a viable treatment option. Further research on long-term outcomes, diverse populations, and standardized measures is essential to confirm these findings. EXPLORING MEDICATION OVERDOSES AT A JAPANESE COMMUNITY HOSPITAL: A CROSS-SECTIONAL STUDY Riku Kojima1; Masaji Saijo2; Shadia Constantine3. 1primary center, Sapporo Tokushukai Byoin, Sapporo, Hokkaido Prefecture, Japan; 2Primary Center, Sapporo Tokushukai Byoin, Sapporo, Hokkaido, Japan; 3Primary Center, Sapporo Tokushukai Hospital, Sapporo, Hokkaido, Japan. (Control ID #4271830)

Japan is the only Asian country among the top 10 global consumers of benzodiazepines and Z-drugs (zolpidem, zopiclone, zaleplon, and eszopiclone). This high consumption is likely influenced by Japan’s aging population and the prevalence of anxiety and mental illness. Despite universal healthcare through the National Insurance system, Japan lacks centralized information systems to track drug "shopping," posing challenges in managing drug misuse. Our community hospital receives a significant number of patients with acute intoxications. However, consistent psychiatric support remains unavailable, creating gaps in care for these patients. This study aimed to identify the most frequent causes of drug overdose at our institution and compare findings with national trends to inform improvements in patient care.

We conducted a retrospective cross-sectional study of all patients presenting with suspected drug intoxications at our hospital between April 2023 and March 2024. Data collected included demographics, drug types, the nature of the intoxication (accidental or intentional), comorbidities, survival outcomes, and discharge recommendations.

Over the study period, we identified 125 patients with acute drug intoxication, with women comprising 79% of cases. The most commonly implicated prescription drugs were benzodiazepines (45%), followed by Z-drugs (24%; 30 cases). Over-the-counter (OTC) medications accounted for 25% (31 cases), with the most frequently involved compounds being caffeine (16 cases), codeine (13 cases), dextromethorphan (12 cases), diphenhydramine (11 cases), and ephedrine (10 cases).Japan's strict regulations on narcotics, coupled with the over-the-counter availability of codeine, has led to this situation. Age-specific trends emerged: younger patients (all under 42 years old) predominantly used OTC medications, whereas older patients more often consumed prescription drugs such as benzodiazepines and Z-drugs. Most intoxications were accidental, though intentional cases were also significant. Of the 125 cases, 59 required hospital admission, while 49 were classified as mild and discharged directly from the emergency room. Importantly, all patients survived.

Our findings align with national trends, highlighting benzodiazepines, Z-drugs, and OTC medications as key contributors to drug overdoses in Japan. Among OTC drugs, caffeine emerged as the most commonly involved compound in younger populations, while older patients were more likely to use benzodiazepines and Z-drugs. These insights underscore the need for enhanced monitoring systems and improved psychiatric support to better address the needs of patients at risk of drug overdose. We plan to discuss these findings with our hospital leadership to design systems of care that improve the care of these patients. GAPS IN SAFETY WITH OPIOID PRESCRIBING ON HOSPITAL DISCHARGE: A PROSPECTIVE, MULTICENTER COHORT STUDY Delia Motavalli1; Alok Kapoor2; Linnea Wilson1; Aaron Madow2; Dawn Swain2,3; Boateng Owusu2; Timothy Anderson4; Shoshana J. Herzig1,5. 1General Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2University of Massachusetts Chan Medical School, Worcester, MA; 3Northeastern University, Boston, MA; 4General Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; 5Harvard Medical School, Boston, MA. (Control ID #4272570)

Opioid prescribing carries risk of direct harm to patients (i.e., overdose, injury) in addition to downstream risks of misuse, dependence, and diversion. Amplifying these risks, opioids are over-prescribed on hospital discharge, and very few patients store their leftover opioids in secure locations or dispose of them properly. Prior studies examining the safety of discharge opioid prescribing have been either single-center or focused on surgical populations. In a multicenter cohort of surgical and non-surgical patients, our objective was to examine the incidence of opioid over-prescription and unsafe opioid storage, and evaluate the extent of discharge education provided to patients.

In this multi-center prospective cohort study, we enrolled surgical and non-surgical patients aged 55 and older who were discharged home with an opioid prescription from two academic hospital systems in New England between June 2020 and April 2024. Consented participants completed structured interviews with study pharmacists regarding their filling and use of opioid after hospitalization, opioid storage and disposal, and their recollection of opioid-related discharge education.

Of the 751 participants (median age 70 years, 49.1% female, 87.2% white), 695 participants (92.5%) reported filling their opioid prescription, and of these, 567 (83.0%) took at least some of the opioids. Pain being well controlled without opioids was the most common reason cited by those who did not fill (37/56, 66.1%) or use (96/116, 82.8%) the prescription. Among those who filled the prescription, more than 60% of participants reported having some opioids leftover one month after discharge, with an average 66.5% of total morphine milligram equivalents (MMEs) prescribed left unused. Only 33 (4.8%) of participants stored their prescription in a locked container. Some participants reported drinking alcohol (6.5%) or operating heavy machinery (8.5%) while using opioids. Participants often did not recall receiving information on safety, with 31.2% reporting that they received no discharge information on any of the six safety topics surveyed (therapy duration, storage, disposal, side effects, and risks of drinking alcohol or operating heavy machinery).

This study demonstrated evidence of opioid over-prescription and unsafe opioid storage on hospital discharge. Participants reported unsafe behaviors while under the influence of opioids, and discharge counseling regarding opioid safety was suboptimal. Future interventions to reduce opioid over-prescription and improve discharge education are necessary to promote patient and public health safety. HOSPITALIST EXPERIENCE AND PATIENT OUTCOMES: A RETROSPECTIVE STUDY OF PERFORMANCE METRICS AT AN ACADEMIC MEDICAL CENTER Mukul Sharda1; Balpreet Kaur1; Sanjay Bhandari2; Barbara Slawski1; Pinky Jha3. 1Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; 2General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI; 3medicine, Medical College of Wisconsin, Milwaukee, WI. (Control ID #4272415)

Hospitalists at Froedtert Hospital and the Medical College of Wisconsin manage over one-third of the inpatient population, influencing both patient outcomes and hospital efficiency. While hospitalist-driven care is increasingly recognized, the relationship between years of experience and measurable outcomes remains underexplored. This study evaluates whether hospitalist experience correlates with key performance metrics, including patient outcomes and operational efficiency.

We identified 59 hospitalists and queried their National Provider Identifiers (NPIs) in EPIC Clarity to retrieve all discharged patient encounters from the past year. These encounters were merged with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data for patients who completed surveys related to their encounters. Provider information included gender and years of experience at Froedtert Hospital. Patient information included gender, insurance status, length of stay (LOS), readmissions (72-hour and 30-day), inpatient mortality, EPIC risk score, and HCAHPS scores (patient satisfaction ratings). Descriptive statistics were calculated using means and standard deviations for continuous variables and counts and percentages for categorical variables. Mixed-effects regression models, with provider ID as a random effect, were used to assess outcomes such as LOS, readmissions, inpatient mortality, and patient satisfaction scores, adjusting for the nested structure of multiple patients per provider. Provider experience was modeled as both a continuous variable and binary variables (less than 2 years vs. 2 or more years; ≤5 years vs. >5 years).

The analysis included 515 patient charts with complete satisfaction data. The cohort comprised of 24 hospitalists with 5 years of experience. Hospitalists with more than 5 years of experience were associated with a statistically significant reduction in LOS (-0.67 days, 95% CI: -1.24 to -0.10). In contrast, no significant differences were observed for other key outcomes, including 72-hour readmission rates (97.67%), 30-day readmission rates (87.77%), inpatient mortality (79.42%), or high patient satisfaction scores (67.38% for scores of 9–10).

This study demonstrates that hospitalist experience is significantly associated with reduced length of stay for patients, however, their experience does not appear to influence other key outcomes, such as 72-hour and 30-day readmission rates, inpatient mortality, or patient satisfaction scores. Selection bias from survey completion, the single-institution setting, and the study's one-year duration may limit generalizability. Additional factors, including administrative responsibilities and unmeasured confounders such as burnout or team dynamics, may influence outcomes. Future multi-institutional research is needed to explore long-term trends and professional development needs. HOW DOES PHYSICIAN EXPERIENCE AFFECT QUALITY OF CARE, AS MEASURED BY LENGTH OF STAY Eric Bethea2; Alexandra Arges1; Mary Ann K. Hall3. 1Hospital Medicine, Emory University, Atlanta, GA; 2Department of Medicine, Emory University School of Medicine, Atlanta, GA; 3Department of Medicine, Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA. (Control ID #4272905)

Length of stay (LOS) has become one of the most cited measures of hospital quality and efficiency. Longer LOS is associated with higher costs, higher risk of hospital-related complications, and slower hospital bed turnover, which negatively affects both patients and the hospital system. Hospitalists and internal medicine physicians are an integral part in determining a patient’s readiness for discharge. Therefore, examining factors influencing LOS, including a practitioner’s experience, can help improve future outcomes. In our review, we ask the question, how does physician experience affect LOS?

The search methodology was designed based in part on methods used by Ajmi & Aase [BMJ Open Quality, 2021]. A test search followed by hand review of initial articles revealed high yield phrases used to capture and describe physician experience. These terms were used to create a search string combining all the common ways of describing physician experience connected by the Boolean operator “OR” and completed with “AND” “length of stay.” Using PubMed as our database, we searched the terms "physician age" OR "physician experience" OR "years of experience" OR "clinician experience" OR "consultant experience" OR "years in practice" OR "clinical experience" AND "length of stay." A total of 557 articles were found, but after reviewing, only 15 were relevant to our review. Articles that pertained to medicine specialties in both academic and non-academic settings were included; those pertaining to surgical specialties were removed.

Results were mixed and inconclusive. Some articles associated more years in practice with longer LOS and worse outcomes, such as mortality. Conversely, a few articles found that the first year as a hospitalist was associated with longer LOS than a hospitalist in their second year of practice. Other studies noted no differences in LOS by physician experience or demonstrated differences that were attenuated after controlling for patient characteristics or case complexity. Additionally, patients under the care of a teaching team had LOS that was over a half day longer than nonteaching teams. Hospitalists were found to have lower LOS than non-hospitalists.