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Hospital Medicine 2020 Scientific Abstract Virtual Competition

July 14 – 16, 2020 (Tuesday – Thursday)

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A COMPARISON OF DISCARD RATE IN HEPATITIS C DECEASED LIVER DONORS BETWEEN TWO ERAS. A SINGLE ORGAN PROCUREMENT ORGANIZATION EXPERIENCE. 1335099 Tej Sura Saint Louis University School of Medicine Jennifer Keller Mustafa Nazzal Gary Marklin A COMPARISON OF DISCARD RATE IN HEPATITIS C DECEASED LIVER DONORS BETWEEN TWO ERAS. A SINGLE ORGAN PROCUREMENT ORGANIZATION EXPERIENCE. Accept Background: Hepatitis C virus (HCV) is a leading cause for liver cirrhosis and one of the commonest indications for liver transplantation. The introduction of direct acting antiviral (DAA) medications have revolutionized the treatment for HCV. Prior to 2014, the treatment for HCV consisted of interferon and ribavirin which yielded a sustained virologic response (SVR) of around 55%. In comparison to interferon and ribavirin, DAA's have improved rates of SVR. Since 2014, DAA’s are increasingly being used in hepatitis C positive patients while on the transplant waiting list, leading to a smaller number of patients on the transplant list with hepatitis C. Decreased numbers of hepatitis C positive recipients raised concerns that the utilization of hepatitis C positive deceased liver donors would decline. This study was conducted to evaluate if discard rate of hepatitis C positive donor livers has changed with the introduction of DAA’s.Methods: A retrospective observational study using a local organ procurement organization (OPO) database was performed. The study time frame was from 2008 to 2017 and was divided into two eras: a time before widespread use of DAA’s (2008-2013) and a time where DAA’s were common practice (2014-2017). A total of 96 patients who had positive HCV antibody serology or nucleic acid amplification techniques were included. The organ discard rates in these two eras were compared using Chi-square analysis with statistical significance considered at a p-value of less than 0.05. Analysis was also performed by employing binary logistic regression to evaluate for differences between patient factors, such as age, hypertension, and alcohol use. A secondary analysis was performed to determine how these organs were used: locally or regionally shared.Results: There were 96 organ donors who tested positive for hepatitis C in the study time frame of which 75 livers were transplanted. In the pre-DAA era (2008 to 2013), a total of 47 organ donors tested positive for hepatitis C, of which 31.9% were discarded. In the post-DAA era (2014-2017), a total of 49 HCV positive organs were identified, of which 12.2% were discarded. The results showed that the discard rate was significantly higher in the pre-DAA era compared to the post-DAA era [p=0.026]. Secondary analysis shows that there was a trend to increased regional sharing of hepatitis C donor organs in the post-DAA era compared to the pre-DAA era; however this finding was not statistically significant [p=0.106].Conclusions: The decrease in discard rate of hepatitis C organs in the OPO is related to the introduction of highly efficacious DAA's. The results of the secondary analysis are likely related to center derived variation in utilizing HCV positive organs and wait list HCV management. Treating patients who would have been eligible for an HCV positive donor liver makes them no longer eligible, transitioning them to a different, and longer, wait list. Treatment results in an improvement in liver function, but does not reverse cirrhosis or the sequelae of portal hypertension - including ascites and encephalopathy. It is suggested that transplant centers abstain from treating HCV positive wait list patients so they can be transplanted with HCV positive donor organs, and to treat recipients with DAA's post-transplant. This will potentially allow patients to receive organ transplants sooner and at a lower MELD score, and reduce the discard rate of HCV positive organs.References: 1) Grassi A, Ballardini G. Post-liver transplant hepatitis C virus recurrence: an unresolved thorny problem. World J Gastroenterol. 2014;20(32):11095-115. 2) Vinaixa C, Rubin A, Aguilera V, Berenguer M. Recurrence of hepatitis C after liver transplantation. Ann Gastroenterol. 2013;26(4):304-13. 3) Hori T, Onishi Y, Kamei H, Kurata N, Ishigami M, Ishizu Y, et al. Fibrosing cholestatic hepatitis C in post-transplant adult recipients of liver transplantation. Ann Gastroenterol. 2016;29(4):454-9. 4) Coilly A, Samuel D. Pros and Cons: Usage of organs from donors infected with hepatitis C virus - Revision in the direct-acting antiviral era. J Hepatol. 2016;64(1):226-31. 5) Ahmad B, Ali S, Ali I, Azam S, Bashir S. Response rates of standard interferon therapy in chronic HCV patients of Khyber Pakhtunkhwa (KPK). Virol J. 2012;9:18. 6) Gayowski T, Singh N, Marino IR, Vargas H, Wagener M, Wannstedt C, et al. Hepatitis C virus genotypes in liver transplant recipients: impact on posttransplant recurrence, infections, response to interferon-alpha therapy and outcome. Transplantation. 1997;64(3):422-6. 7) Campos-Varela I, Lai JC, Verna EC, O'Leary JG, Todd Stravitz R, Forman LM, et al. Hepatitis C genotype influences post-liver transplant outcomes. Transplantation. 2015;99(4):835-40. 8) Asselah T, Marcellin P. Interferon free therapy with direct acting antivirals for HCV. Liver Int. 2013;33 Suppl 1:93-104. 9) Vigano M, Perno CF, Craxi A, AdHoc Working P. Treatment of Hepatitis C virus infection in Italy: A consensus report from an expert panel. Dig Liver Dis. 2017;49(7):731-41. 10) Belli LS, Berenguer M, Cortesi PA, Strazzabosco M, Rockenschaub SR, Martini S, et al. Delisting of liver transplant candidates with chronic hepatitis C after viral eradication: A European study. J Hepatol. 2016;65(3):524-31. 11) Axelrod DA, Schnitzler MA, Alhamad T, Gordon F, Bloom RD, Hess GP, et al. The impact of direct-acting antiviral agents on liver and kidney transplant costs and outcomes. Am J Transplant. 2018;18(10):2473-82. 12) Kim WR, Lake JR, Smith JM, Schladt DP, Skeans MA, Harper AM, et al. OPTN/SRTR 2016 Annual Data Report: Liver. Am J Transplant. 2018;18 Suppl 1:172-253. 13) Parikh ND, Hutton D, Marrero W, Sanghani K, Xu Y, Lavieri M. Projections in donor organs available for liver transplantation in the United States: 2014-2025. Liver Transplantation. 2015;21(6):855-63. 14) Suryaprasad AG, White JZ, Xu F, Eichler B-A, Hamilton J, Patel A, et al. Emerging Epidemic of Hepatitis C Virus Infections Among Young Nonurban Persons Who Inject Drugs in the United States, 2006–2012. Clinical Infectious Diseases. 2014;59(10):1411-9. 15) Tapper EBM, Afdhal, Nezam H. MD, Curry, Michael P. MD. Before or After Transplantation? A Review of the Cost Effectiveness of Treating Waitlisted Patients with Hepatitis C. Transplantation. 2017;101(5):933-7. 16) Chhatwal J, Samur S, Kues B, Ayer T, Roberts MS, Kanwal F, et al. Optimal timing of hepatitis C treatment for patients on the liver transplant waiting list. Hepatology. 2017;65(3):777-88. 17) Goldberg DS, Abt PL, Blumberg EA, Van Deerlin VM, Levine M, Reddy KR, et al. Trial of Transplantation of HCV-Infected Kidneys into Uninfected Recipients. N Engl J Med. 2017;376(24):2394-5. 18) Bari K, Luckett K, Kaiser T, Diwan T, Cuffy M, Schoech MR, et al. Hepatitis C transmission from seropositive, nonviremic donors to non-hepatitis C liver transplant recipients. Hepatology. 2018;67(5):1673-82. 19) Saberi B, Hamilton JP, Durand CM, Li Z, Philosophe B, Cameron AM, et al. Utilization of hepatitis C virus RNA-positive donor liver for transplant to hepatitis C virus RNA-negative recipient. Liver Transpl. 2018;24(1):140-3.

CATALYZING HOSPITAL MEDICINE LEADERSHIP DEVELOPMENT 1334865 Vivek Patel UT Southwestern Maryam Warsi Eugene Chu CATALYZING HOSPITAL MEDICINE LEADERSHIP DEVELOPMENT Oral Background: Large hospital medicine groups of 30 or more physicians comprise over 20% of practices (SHM 2018). Our academic hospital medicine service is comprised of 65 faculty members. We recognized a need for multiple levels of leadership beyond the immediate chief and director of clinical operations. Our team, like most hospital medicine groups, is comprised primarily of early career physicians who had minimal leadership training in residency (Fraser et al 2015).Purpose: In 2018, we implemented a shared governance practice model with 9 committees composed of 8-10 hospitalists and 1 chair, forming the foundation of the model. 1 of 3 medical directors guide each chair and the division chief guides the 3 medical directors. The majority of our chairs and directors are junior faculty with little leadership experience and no formal leadership training. We recognized the need for a quick infusion of leadership skills and knowledge. Accordingly, we conducted a one day leadership retreat to catalyze the leadership acumen of our foundational and emerging leaders.Description: Retreat content included an introduction to the concept of leadership, review of divisional and health systems finances, the essentials of supervision, problem-solving, high-performance teamwork, effective communication and influence, trust in leadership and wellness. Key points for the retreat included the general leadership principles of values-based leadership and achieving results through others. For finances, our administrative lead reviewed the 2019 fiscal year divisional and health system’s budget. Key points of supervision included a review of non-verbal communication tools , a SWAG (State, Wait, Ask, Gain) exercise and content on leading with authenticity. High performance teamwork domains reviewed included relationship building, leadership styles, role clarity, working and thinking processes and structured communication tools. A deeper dive into communication included differentiating spontaneous and planned communication, utilizing the PAR (Problem, Action, Results) tool, first impressions and rapport building. Another theme the retreat delved into deeply was trust. Each participant received a copy of The Speed of Trust. A session based in the principles outlined in the book was delivered, including behaviors of high trust persons, showing integrity, intent, capability and results, creating transparency and practicing accountability. We administered pre and post surveys to retreat attendees to determine if the retreat improved our leaders’ perceived comfort in the various leadership domains covered as well as whether they gained specific knowledge. The survey consisted of both questions examining confidence in different leadership skills and knowledge as well as a testing of knowledge points made during the retreat. We found that attendees had a low level of baseline knowledge and comfort in all domains of leadership covered in the retreat. All attendees experienced a significant increase in confidence in and knowledge about leadership. (Tables 1 & 2).Conclusions: All hospital medicine groups and perhaps large groups, in particular, need to develop leaders on multiple levels for both the successful functioning of the group as well as for succession planning. A one, day, intensive leadership retreat successfully catalyzed and cultivated the leadership skills and qualities of the foundational (committee chairs) and emerging (medical directors) leaders of the UTSW Division of Hospital Medicine at Parkland.References: Angood, P. & Birk, S. (2014). The value of physician leadership. Physician Exec, 40(3), 6-20. Bernd, D. L., CEO, & Sentara Healthcare. (2005). The Future Role of Hospitalists. The Hospitalist. 9. De Winter, J. C., & Dodou, D. (2010). Five-Point Likert Items: T test versus Mann-Whitney-Wilcoxon. Practical Assessment, Research & Evaluation, 15(11). Retrieved June 21, 2019. Fraser, T. N., Blumenthal, D. M., Bernard, K., & Iyasere, C. (2015). Assessment of leadership training needs of internal medicine residents at the Massachusetts General Hospital. Proceedings (Baylor University. Medical Center), 28(3), 317–320. doi:10.1080/08998280.2015.11929260 Frich, J. C., Brewster, A. L., Cherlin, E. J., & Bradley, E. H. (2015). Influence of a Hospital-Based, Internal Leadership Development Program on Leadership Effectiveness. Journal of Internal Medicine, 30(5). doi: 10.1007/s11606-014-3141-1 Goodall, A. H. (2011). Physician-leaders and hospital performance: Is there an association? Social Science & Medicine, 73(4), 535-539. doi: 10.1016/j.socscimed.2011.06.025 Kelly, Deirdre & Mc Erlean, Sarah & Neff, Karl. (2018). Outcomes of a Clinical Leadership Training Program Amongst Hospital Doctors. Irish medical journal. 111. Roytman M. M., Thomas S. M., & Jiang C. S. (2008). Practice Patterns of Hospitalists and Community Physicians. Journal of Hospital Medicine, 3(1), 35-41. doi:10.1002/jhm.270 White, H. L., & Glazier, R. H. (2011). Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC medicine, 9 (58), 656/674. doi:10.1186/1741-7015-9-58

NURSE-DOCTOR CO-TEACHING ON THE GENERAL MEDICINE SERVICE: CREATION, DESIGN AND IMPLEMENTATION OF INTERACTIVE CO-TEACHING SESSIONS TO MODEL COLLABORATION 1334979 Marina Zambrotta Brigham and Women's Hospital Patricia Aylward Christopher Roy Emily Piper-Vallillo Stephen Pelletier Helen Shields NURSE-DOCTOR CO-TEACHING ON THE GENERAL MEDICINE SERVICE: CREATION, DESIGN AND IMPLEMENTATION OF INTERACTIVE CO-TEACHING SESSIONS TO MODEL COLLABORATION Oral Background: High levels of interprofessional collaboration and communication have been shown to lead to better patient safety outcomes, improved patients’ satisfaction and quality of care, as well as higher job satisfaction for doctors and nurses alike. Yet, challenges to nurse-doctor collaborations exist. One way of improving interprofessional collaboration may be through structured co-teaching by nurses and doctors. However, nurse-doctor co-teaching remains an under-explored area of research.Purpose: We created, designed and implemented a first-of-its-kind Nurse-Doctor Co-Teaching initiative on the General Medicine Service. The goal was to model nurse-doctor collaboration through nurse and doctor design, practice and presentation of interactive teaching sessions to residents and nurses.Description: Ten nurses and ten hospitalists volunteered to co-teach as pairs. Each pair decided on a topic and prepared an interactive, 30-minute teaching presentation under the guidance of the project’s educational team. The team encouraged interactive methods to promote active learning. The teaching sessions were presented to a group of residents and nurses weekly in the fall of 2019. Final topics included: Arterial Blood Gases, Alcohol Withdrawal and CIWA, Hyponatremia, Interruptions on the Medical Ward, Opioid Withdrawal and COWS, C. Difficile Testing and Treatment, Telemetry, Catheter Associated Urinary Tract Infections, Testing and Treatment of H. pylori, and Venous Thromboembolism. Sessions were videotaped and placed on the hospital’s Video Library Education website. Both nurse and resident learners completed an IRB approved survey after each session to assess the efficacy of the educational content and interactive methods on a Likert scale ranging from Excellent (1) to 4 (Poor). We collected nine days of Pre-Co-Teaching and Post-Co-Teaching surveys from residents and nurses on the medical floor about their interactions with each other on daily rounds and analyzed these for any significant differences. Nurses’ comfort with asking residents about an order significantly improved in the Post-Teaching period (N=41 Nurses) compared to the Pre-Teaching period (N=41 Nurses) by 14 percentage points going from 85.4% to 100 % (p value=0.01). No other significant differences were noted. Overall ratings for each session are shown in Table 1 and are in the Excellent range between 1.00 to 1.43 on the Likert scale. No significant difference was noted for the overall rating among sessions. Spontaneous resident and nurse responses to the question “What did you like best?” are grouped according to the most frequent responses in Figure 1 and indicate that learners most liked: 1. Interactive methods, 2. Hearing both Nurse and Doctor Perspectives, 3. Use of Cases, 4. Collaboration, 5. Relevant, Important and/or Practical Information , 6. Interdisciplinary/Interprofessional sessions and 7. Brief or Short sessions.Conclusions: We implemented a Nurse-Doctor Co-Teaching series which received uniformly excellent overall ratings from nurse and resident learners. Learners particularly appreciated the interactive methods and the opportunity to hear both nurse and physician perspectives on common clinical situations. We found a significant improvement (p=0.01) in nurse comfort in communicating with a resident about an order following the co-teaching series, which may indicate better collaboration and communication among nurses and residents.References:

PASSPORT TO CLINICAL TEACHING: NEEDS ASSESSMENT AND PILOT PROGRAM CREATION TO DEVELOP OUTSTANDING TEACHING SKILLS IN EARLY CAREER HOSPITALISTS (ECH) 1334770 Elizabeth Murphy University of Chicago Medicine Kara White Matthew Cerasale Shannon Martin University of Chicago PASSPORT TO CLINICAL TEACHING: NEEDS ASSESSMENT AND PILOT PROGRAM CREATION TO DEVELOP OUTSTANDING TEACHING SKILLS IN EARLY CAREER HOSPITALISTS (ECH) Plenary Background: Across the field of Hospital Medicine, there is a “call to arms” to build robust faculty development programs(1). Medical education and clinical teaching are common career interests for early career hospitalists (ECH), defined as hospitalists ≤5 years since postgraduate training. ECH often pursue academic positions to explore an interest in medical education, but find themselves on uncovered services with few teaching opportunities and little time or incentive to build their teaching skills in systematic faculty development programs. One potential strategy to address both of these issues is a passport program. Passports, which have been implemented in UME and GME, ensure that expectations for program participation are met, while also promoting self-directed learning, but have not been widely described for the purposes of faculty development at the attending level.Purpose: The aim of our project is to build a medical education passport for ECH within our group based on pairing currently available education faculty development opportunities at our institution with the self-identified educational needs of these providers. Once implemented, the passport program will be used to stratify ECH for allocation of teaching service time.Description: Our academic Section of Hospital Medicine hired 27 new ECH in the summer of 2019. The expansion coincided with a significant increase in the number of direct care service lines, with virtually no increase in teaching service time, decreasing the proportional availability of teaching for our ECH. To identify the volume of providers interested in teaching and their experience, we surveyed the ECH. These individuals identified a strong interest in medical education with 16.7% being highly interested and 41.7% moderately interested in medical education, but they had limited confidence in their teaching abilities with only 8.3% reporting feeling highly prepared and 33.3% moderately prepared for clinical teaching. Based on this interest and confidence gap, the decision was made to develop a medical education passport. Medical education leaders within Hospital Medicine and throughout the institution were approached to identify faculty development, volunteer, and instructional opportunities that would be appropriate for ECH participation. These activities were divided into 8 separate categories based on intensity and expected skill development (Figure 1). Completion of these activities is being paired with faculty mentorship and semi-annual reviews to create a formal process. The “Passport to Clinical Teaching Program” is an opt-in two-year program open to all hospitalists. Participants formally commit to the program by the end of their first quarter of employment. Figure 2 provides an example of an expected schedule of activities for a Passport participant. Those who successfully complete the Passport Program will be eligible for prioritized scheduling on teaching services. The next step is creation of an online tracking tool for passport completion and pilot of the program. Ongoing data collection, teaching evaluations and tracking of career path development is necessary to determine passport effectiveness.Conclusions: The gap between hospitalist interest in medical education and self-perceived level of preparedness to teach is an opportunity for innovation. A passport to clinical teaching has the potential to justly distribute scarce teaching service time and provide crucial faculty development to early career hospitalists.References: 1) Myers JS, S. Ryan Greysen, MD, Faculty Development for Hospitalists: A Call to Arms. J. Hosp. Med 2018;6;429-430. doi:10.12788/jhm.2973

POST-POLIO SYNDROME: AN UNERADICTED DIAGNOSIS 1334709 Francesca Galbiati UPMC Presbyterian Jared Romeo POST-POLIO SYNDROME: AN UNERADICTED DIAGNOSIS Accept Case Presentation: An 84-year-old female with history of pediatric paralytic polio, heart failure with preserved EF, atrial fibrillation, coronary artery disease presented with progressive shortness of breath (SOB). Four months prior, she had presented to the emergency department with similar SOB and generalized weakness. At that time EKG, CT angiography chest and transthoracic echocardiogram were unremarkable. A follow up pharmacologic stress test was low risk for ischemia. One month prior, the patient presented with SOB, dull, retrosternal chest pain, and ongoing weakness. At that time right heart catheterization showed normal volume status and coronary angiography was normal. On her current presentation, she reported the additional symptom of dysphagia to solids and liquids that had apparently started 4 months previously. Her vital signs were unremarkable with oxygen saturation 98% on room air. A full neurologic exam revealed reflexes 1+ throughout, generalized decreased bulk and tone, strength 4/5 for left upper and lower extremities, and 4-/5 for right upper and lower extremities. Given her progressive dysphagia and SOB without clear etiology, a primary neurologic process was considered and vitamin B12, folate, syphilis, autoimmune panel, TSH, Lyme, and acetylcholine receptor antibodies were assessed and normal. Electromyography (EMG) finally showed an active and chronic process with intraspinal canal lower motor axon loss of the cervical and lumbosacral areas, suggestive of a primary motor neuron disease. Given the patient’s history of polio and the isolation of findings to lower motor neurons, her disease was most likely a post-polio syndrome (PPS) with mild respiratory involvement. She was discharged with low-intensity physical therapy and repeat EMG if any progression of symptoms occurred.Discussion: PPS is a clinical entity characterized by new weakness and pain secondary to lower motor neuron axon loss, with onset decades after acute paralytic polio. It affects 28.5% of patients with history of paralytic polio. Given the polio epidemic of the 1950s, PPS is expected to be quite frequent in the current geriatric population and remains an underrecognized cause of weakness. The most important risk factors of PPS are female sex, respiratory symptoms during acute polio infection, older age at diagnosis, higher severity of disease, rapid recovery from the acute polio. The pathophysiology of PPS is not fully understood; however, axonal loss appears confined to the neurons affected during the primary illness. PPS can be confused with other more common causes of generalized weakness and myalgias. It is crucial to consider the patient’s history when it includes polio, even if diagnosed during infancy. Once suspected, it is important to keep in mind that there is not a diagnostic test: EMG can guide the diagnosis, but it does not reliably distinguish patients with prior paralytic polio, those with new weakness, or other lower motor neuron diseases. PPS remains a clinical diagnosis. The management of PPS is highly dependent on patient-physician relationship as reassurance and trust become fundamental in dealing with it. Low-intensity physical therapy, weight loss, respiratory support and orthotic supports are recommended.Conclusions: Despite USA polio eradication in 1979, PPS may still occur given the significant lag-time to presentation. Also, familiarity with PPS should be enforced as the growing global trend against infant immunization risks the return of previously eradicated diseases.References: 1) Cashman, N.R., Maselli, R., Wollmann, R.L., Roos, R., Simon, R., Antel, J.P., 1987. Late Denervation in Patients with Antecedent Paralytic Poliomyelitis. N. Engl. J. Med. 317, 7–12. https://doi.org/10.1056/NEJM198707023170102 2) Ramlow, J., Alexander, M., LaPorte, R., Kaufmann, C., Kuller, L., 1992. Epidemiology of the Post-Polio Syndrome. Am. J. Epidemiol. 136, 769–786. https://doi.org/10.1093/aje/136.7.769 3) Pastuszak, Ż., Stępień, A., Tomczykiewicz, K., Piusińska-Macoch, R., Galbarczyk, D., Rolewska, A., 2017. Post-polio syndrome. Cases report and review of literature. Neurol. Neurochir. Pol. 51, 140–145. https://doi.org/10.1016/j.pjnns.2017.01.009 4) Klingman, J., 1988. Functional Recovery. Arch. Neurol. 45, 645. https://doi.org/10.1001/archneur.1988.00520300065020 5) Jubelt, B., Cashman, N., 1987. Neurological manifestations of the post-polio syndrome. Crit Rev Neurobiol. 3, 199–220. 6) Chan, K.M., Amirjani, N., Sumrain, M., Clarke, A., Strohschein, F.J., 2003. Randomized controlled trial of strength training in post-polio patients. Muscle Nerve 27, 332–338. https://doi.org/10.1002/mus.10327 7) Feldman, R., Soskolne, C., 1987. The use of nonfatiguing strengthening exercises in post-polio syndrome. Birth Defects Orig Artic Ser. 23, 335–41. 8) Waring, W., Maynard, F., Grady, W., Grady, R., Boyles, C., 1989. Influence of appropriate lower extremity orthotic management on ambulation, pain, and fatigue in a postpolio population. Arch Phys Med Rehabil. 70, 371–5.

THE PROGNOSTIC VALUE OF SEPSIS-3 CRITERIA: DO "BIG DATA" STUDIES SYSTEMATICALLY OVERESTIMATE IT? 1334750 Shrirang Gadrey University of Virginia Emily Richardson Alex Zimmet Department of Medicine, University of Virginia School of Medicine Vernon Forrester Samuel Oliver Alexander Lawson Garret Rhodes Russ Clay John Voss Cristopher Moore J. Randall Moorman Robert Andris THE PROGNOSTIC VALUE OF SEPSIS-3 CRITERIA: DO "BIG DATA" STUDIES SYSTEMATICALLY OVERESTIMATE IT? Oral Background: In 2016, the Sepsis-3 taskforce posited that acute organ failure is the defining feature of sepsis. Accordingly, they recommended that an acute rise in the Sequential Organ Failure Assessment (SOFA) score by 2 points over baseline should replace the Systemic Inflammatory Response Syndrome (SIRS) score as the sepsis criteria (1). As a justification, they reported that SOFA was a better predictor of outcomes than SIRS in a study of 1.3 million encounters (2). But, in such large cohorts, it is impossible to discriminate between acute and chronic organ failure. So, their study labelled as septic any patient with SOFA > 2, whether it was an acute rise or just a chronic baseline. The assumption was that eliminating the distinction between acute and chronic organ failure would not adversely affect the validity of results. This assumption is necessitated by a “big data” approach and is common to most studies of Sepsis-3. Yet, it has never been tested. We sought to study the impact of this assumption and compare an acute rise in SOFA to past sepsis criteria (SIRS) (3,4) and to the national early warning score (NEWS) which has been reported to work well in medical acute-care sepsis (5).Methods: We identified all inpatients treated for an infection on medical acute-care wards of a 600 bed academic medical center over one year (n = 1864). With rigorous chart reviews and queries to our data warehouse, we determined the pre-infection SOFA baseline, the acute rise in SOFA, SIRS, qSOFA and NEWS scores at the onset of infection (up to 2 days before and 1 day after initial antibiotic dose). Inter-rater reliability of chart reviews was measured with Krippendorff’s alpha. Figure 1 details this process. We compared the predictive validity of these criteria using measures of discrimination for outcomes (primary: mortality - 1.8%; secondary: ICU transfer or mortality - 8.3%) such as fold change in rates of outcome and area under receiver operating characteristic curve (AUROC).Results: Acute organ failure (SOFA rise by 2 over baseline) showed poor predictive validity for mortality. The fold change in outcome was not significantly higher than 1 (1.76; 95% CI: 0.89-3.96). And, when added to a baseline risk model (age, gender, race & Charlson comorbidity index), the rise in AUROC was minimal (0.67 for SOFA vs. 0.66 for baseline model; p - 0.74). But, when all SOFA points (acute or chronic) were analyzed, the performance improved (fold change in outcome – 5.29; 95% CI: 1.81-18.76; AUROC 0.70 for SOFA vs. 0.66 for baseline model, p – 0.04). Also, we found that the NEWS score (sepsis defined as NEWS ≥ 6) performed better than other criteria (fold change in outcome – 5.23; 95% CI: 2.12-23.9; AUROC 0.74). Figure 2 shows our results. Results were similar for the secondary composite outcome of ICU transfer or mortality.Conclusions: In our study, failure to distinguish between acute and chronic organ failure resulted in biased overestimates of the prognostic value of Sepsis-3. If the predictive validity of the SOFA score relies heavily on chronic organ failure, then its use as the operational definition for an acute syndrome like sepsis may not be as justifiable as was previously assumed. Also, the NEWS score, which does not rely solely on organ failure, predicted outcomes better than acute organ failure in our medical acute-care cohort. This raises fundamental questions about the conception that acute organ failure is the defining feature of sepsis. These findings suggest that a more rigorous scrutiny of the Sepsis-3 taskforce recommendations is warranted.References: 1. Singer, M. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315, 801–810 (2016). 2. Seymour, C. W. et al. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315, 762–774 (2016). 3. Bone, R. C. et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101, 1644–1655 (1992). 4. Levy, M. M. et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit. Care Med. 31, 1250–1256 (2003). 5. Churpek, M. M. et al. Quick Sepsis-related Organ Failure Assessment, Systemic Inflammatory Response Syndrome, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients outside the Intensive Care Unit. Am. J. Respir. Crit. Care Med. 195, 906–911 (2017).

"TICK"-TOCK: LYME CARDITIS AND A RHYTHM YOU CAN'T IGNORE 1334874 Mark Schleiss University of Minnesota Medical School Faith Myers University of Minnesota Medical School Pooja Mishra University of Minnesota TICK"-TOCK: LYME CARDITIS AND A RHYTHM YOU CAN'T IGNORE Accept Case Presentation: A 16 y/o male presented with an acute onset of palpitations, generalized chest pain, and rash (Figure 1). In light of recent camping exposure and targetoid lesions compatible with erythema chronicum migrans (ECM), Lyme disease was suspected. An EKG demonstrated 1st degree AV block with a PR interval of 384 msec. Echocardiogram and troponin were reassuring against pan-carditis. Lyme IgM and western blot returned positive. The patient was admitted for telemetry and IV ceftriaxone. There was complete resolution of erythema migrans within two days of treatment. During the first week of hospitalization, he was noted to have sinus pauses and possible 2:1 heart block on telemetry (Figure 2). Given his clinical stability and a reassuring stress test, expectant management was observed. The patient was treated with IV ceftriaxone for 10 days with continuous cardiac monitoring until sustained stabilization of the PR interval at Discussion: Lyme disease (LD) is the most common tick-borne illness in North America. Climate change has resulted in an increased prevalence of LD, even in hyper-endemic regions of the upper Midwestern US. Although an unusual manifestation of LD, hospitalists should be aware of the risk of carditis as a potential complication. Lyme carditis results from direct invasion of the spirochete into the myocardium with subsequent immune response causing inflammation. In contrast to the neutrophilic response exhibited in Lyme arthritis, lymphocytes and macrophages are primarily involved in Lyme carditis. AV nodal block is the most common manifestation of Lyme carditis. It is not entirely clear why the AV node is most commonly affected, but it is postulated that its anatomic location, histology and metabolic mechanisms may play a role. Autoimmune response may contribute to injury as well, with antibodies produced during initial exposure reacting to self-components. Current guidelines recommend that any patient with cardiac symptoms such as syncope, chest pain, or EKG changes be admitted for telemetry. The risk of untreated 1st degree AV block is progression to 3rd degree heart block, which can be fatal. Guidelines suggest management with IV ceftriaxone (first-line) for 10-14 days followed by oral antibiotics to complete a total antibiotic course of 14-21 days. In Lyme-endemic areas or in the setting of ECM with a compatible clinical presentation, empiric antibiotic treatment should be administered while definitive diagnostic studies are pending. Overall, Lyme carditis has a favorable prognosis. Temporary pacemaker placement is recommended if the PR interval fails to normalize within 14 days post-admission.Conclusions: In patients who present with signs and symptoms concerning for LD with cardiac symptoms, it is vital to consider EKG and hospitalization for continuous cardiac monitoring and intravenous antibiotics. With the rising incidence of Lyme disease in the Midwest, providers must maintain a high level of suspicion in order to promptly diagnose and treat Lyme carditis, as well as prevent unnecessary pacemaker placement in the pediatric population.References: Dumic, I., & Severnini, E. (2018). “Ticking Bomb”: The Impact of Climate Change on the Incidence of Lyme Disease. Canadian Journal of Infectious Diseases and Medical Microbiology, 2018, 1-10. doi:10.1155/2018/5719081 Lyme Disease Charts and Figures: Historical Data. (2019, November 22). Retrieved from https://www.cdc.gov/Lyme/stats/graphs.html Nadelman, R. B. (2003). Lyme disease and the heart. Frontiers in Bioscience, 8(6). doi:10.2741/1065 Wormser, G. P., Dattwyler, R. J., Shapiro, E. D., Halperin, J. J., Steere, A. C., Klempner, M. S., Nadelman, R. B. (2006). The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases, 43(9), 1089-1134. doi:10.1086/508667 Yeung, C., & Baranchuk, A. (2019). Diagnosis and Treatment of Lyme Carditis. Journal of the American College of Cardiology, 73(6), 717-726. doi:10.1016/j.jacc.2018.11.035

WHAT DO PATIENTS WANT? A QUALITATIVE ANALYSIS OF PATIENT, PROVIDER, AND ADMINISTRATIVE PERCEPTIONS AND EXPECTATIONS ABOUT PATIENTS' HOSPITAL STAYS 1335319 Angela Keniston University of Colorado, Division of Hospital Medicine Sansrita Nepal Kimberly Indovina Maria Frank Denver Health Hospital Authority. University of Colorado, SOM Sarah Stella Itziar Quinzanos-Alonso Lauren McBeth Susan Moore Marisha Burden University of Colorado School of Medicine WHAT DO PATIENTS WANT? A QUALITATIVE ANALYSIS OF PATIENT, PROVIDER, AND ADMINISTRATIVE PERCEPTIONS AND EXPECTATIONS ABOUT PATIENTS' HOSPITAL STAYS Oral Background: Patient experience is increasingly recognized as a measure of healthcare quality and patient-centered care. However, there is insufficient understanding of patient expectations during hospitalization, and of how these are perceived by physicians, nurses, and administrators. The best way to apply the HCAHPS ratings remain elusive due to variability in practice environments, patient and clinician diversity and bias. The scores do not tell the full story and there have been recent calls to modify HCAHPS to better reflect shifts in patient experience in the last decade. Patient feedback regarding care experiences can be utilized in novel ways to improve the care experience. In this study, we aimed to 1) explore concepts identified by patients as being important to them during hospitalization, 2) explore concepts believed by physicians, nurses, and administrators to be important to patients during hospitalization, and 3) identify gaps and similarities between patient and healthcare professional perceptions and expectations.Methods: We conducted a qualitative study at a university-affiliated, safety net hospital utilizing semi-structured interviews with hospitalized English- and Spanish-speaking patients and focus groups with physicians, nurses, and administrators. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed using inductive thematic analysis.Results: Forty-five patients were interviewed and six focus groups were conducted with 13 physicians, 10 nursing staff, 15 managers, and seven executives from March 22, 2016 to May 15, 2017 (Table 1). The most important findings of this study are: 1) patients value whole person care, defined as holistic treatment that includes emotional and social needs along with treatment of illness, clear communication with their care providers, attentiveness and responsiveness to their needs, and a hospital environment that is conducive to healing (Table 2); 2) a sub-group of patients expressed the feeling of a lack of worthiness and a reluctance to self-advocate; 3) while physicians, nurses, and administrators can articulate what patients find most important, patients’ experiences indicate that hospitals struggle to bridge the gap between understanding patient needs and actually meeting those needs.Conclusions: We found several critical themes among hospitalized patients, such as communication between care team members, not currently captured in standard patient experience assessments. We found that there is a disconnect between what patients and clinical staff believe patients need and want and what hospital policies and environments drive in the care environment. Certain vulnerable populations may be less inclined to self-advocate regarding their needs and additional measures may need to be taken to ensure needs are met.References: 1. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3:77-101. 2. Shippee ND, Shippee TP, Mobley PD, Fernstrom KM, Britt HR. Effect of a Whole-Person Model of Care on Patient Experience in Patients With Complex Chronic Illness in Late Life. Am J Hosp Palliat Care 2018;35:104-9. 3. Kash BA, McKahan M, Tomaszewski L, McMaughan D. The four Ps of patient experience: A new strategic framework informed by theory and practice. Health Mark Q 2018;35:313-25. 4. Boylan MR, Slover JD, Kelly J, Hutzler LH, Bosco JA. Are HCAHPS Scores Higher for Private vs Double-Occupancy Inpatient Rooms in Total Joint Arthroplasty Patients? J Arthroplasty 2019;34:408-11. 5. Wray CM, Farnan JM, Arora VM, Meltzer DO. A qualitative analysis of patients' experience with hospitalist service handovers. J Hosp Med 2016;11:675-81. 6. Buckley LM. What About Recovery. Jama 2019;321:1253-4. 7. Groene O. Patient centredness and quality improvement efforts in hospitals: rationale, measurement, implementation. International journal for quality in health care : journal of the International Society for Quality in Health Care 2011;23:531-7.

4 "IS YOUR PATIENT GOING TO DIE?: A NOVEL MORTALITY PREDICTIVE MODEL FOR TRANSFER PATIENTS AT AN ACADEMIC HEALTH CENTER" 1334368 Neetu Mahendraker Indiana University Academic Health Center Linda williams Mindy Flanagan Jose Azar "IS YOUR PATIENT GOING TO DIE?: A NOVEL MORTALITY PREDICTIVE MODEL FOR TRANSFER PATIENTS AT AN ACADEMIC HEALTH CENTER" Finalist Background: Assessing severity of illness using available electronic medical record (EMR) data on admission and predicting inpatient mortality is very challenging. Lacking standardized practices around end of life issues, hospitalists use their clinical judgment in making these crucial decisions. Prolonged discussions may be needed in medically complex patients to direct an optimal plan of care resulting in Intensive Care Unit (ICU) escalations, increased length of stay and can negatively impact patient satisfaction. Thus, there is a critical need to assist hospitalists in accurately identifying patients at high risk for mortality and guide patient-physician discussions around end of life issues. Previously reported mortality risk stratification models are either disease specific, limited to ICU patients or predict post-discharge mortality. In this project we used administrative data available within the first 24 hours of transfer to predict 30-day inpatient mortality at Indiana University (IU) Adult Academic Health Center (AHC). This is the first known study to include all disease categories and all levels of inpatient care as our focus is to assist hospitalists who provide general medical care to a diverse inpatient population.Methods: A total of 10,389 patients (18 years and older) transferred to IU-Adult AHC between 1/1/2016 and 12/31/2017 from other facilities were included. Administrative data was collected from the IU Health data warehouse and from the Indiana Health Information Exchange (IHIE), a resource that stores clinical and diagnostic data for patients across Indiana. 31 putative variables were selected based on a PubMed literature search using terms “early In-hospital mortality, Inter-hospital transfers” and by consideration of previously reported mortality prediction tools. We used a multiple logistic regression model in the full data set to identify 21 out of the 31 variables that were associated with 30-day inpatient mortality(pResults: TThe final model was strongly discriminative (C statistic = .91) and had a good fit (Hosmer‐Lemeshow goodness‐of‐fit test, p = .14). The positive predictive value for 30-day inpatient death was 64.79% and the AUC-ROC was 0.91; (95% confidence interval 0.89 - 0.92, p Conclusions: This novel model can accurately predict 30-day inpatient mortality using readily available EMR data within the first 24 hours of a hospital transfer and facilitate complex goals of care discussions with patients and families.References: 1)Predicting In-Hospital Mortality in Patients With Acute Myocardial Infarction. McNamara R, Kennedy K, Cohen D, Diercks D, Moscucci M, Ramee S, Wang T, Connolly T, Spertus J. J Am Coll Cardiol. 2016 Aug 9;68(6):626-635. doi: 10.1016/j.jacc.2016.05.049. 2)Development of Imminent Mortality Predictor for Advanced Cancer (IMPAC), a Tool to Predict Short-Term Mortality in Hospitalized Patients With Advanced Cancer. Adelson K, Lee D, Velji S, Ma J, Lipka SK, Rimar J, Longley P, Vega T, Perez-Irizarry J, Pinker E, Lilenbaum R. J Oncol Pract. 2018 Mar;14(3):e168-e175. doi: 10.1200/JOP.2017.023200. Epub 2017 Dec 5. 3)A predictive model to identify hospitalized cancer patients at risk for 30‐day mortality based on admission criteria via the electronic medical record Ramchandran,K. et al. Cancer. 2013 Jun 1;119(11):2074-80. doi: 10.1002/cncr.27974. Epub 2013 Mar 15. 4)Association of Hospitalist Years of Experience With Mortality in the Hospitalized Medicare Population. Goodwin JS et al. JAMA Intern Med. 2018 Feb 1;178(2):196-203. doi: 10.1001/jamainternmed.2017.7049.

7 CREATING AN ATYPICAL PATHOGEN ASSESSMENT PROTOCOL TO DECREASE LOW YIELD CULTURES IN PEDIATRICS 1334842 Jennifer Hall Phoenix Children's Hospital John Hartley VICKY KHOURY Sandra Gage Phoenix Children's Hospital University of Arizona - Phoenix, School of Medicine Jamie Librizzi Phoenix Children's Hospital CREATING AN ATYPICAL PATHOGEN ASSESSMENT PROTOCOL TO DECREASE LOW YIELD CULTURES IN PEDIATRICS Finalist Background: Skin, soft tissue, and joint infections are common in pediatric patients and can require invasive procedures to drain purulent fluid. Atypical pathogens (fungal and acid-fast bacilli [AFB]) are important but rare causes of these infections with reported case rates as low as 0.6-1.6 cases/100,000 a year. Despite the rarity of these infections, costly atypical cultures are often sent. Prior studies have shown the use of assessment tools decrease variability in care and aid in optimizing resource utilization. The objective of this study was to investigate the possibility of improving appropriate use of atypical cultures by (1) creating an Atypical Pathogen Assessment Protocol (APAP) and (2) validating its sensitivity in detecting atypical infections in pediatric patients over a 10 year period.Methods: Utilizing recent literature and local experience with pediatric atypical infection epidemiology, 6 risk factors were identified for a risk assessment tool: symptoms for 10 days or more, immunosuppression, immunodeficiency, malignancy, diabetes, or indwelling foreign body. This tool combined with gram stain results constituted a 2-tiered screening protocol (APAP: Figure). To test the sensitivity of APAP, we conducted a retrospective chart review of all patients at a single freestanding children’s hospital with positive atypical cultures over 10 years (2009-2018). APAP was retrospectively applied to patients with cultures from potentially infected fluid in normally sterile sites, such as bone, joint, or soft tissue aspirates. Patients were excluded if cultures were obtained from normally non-sterile sites (respiratory tract, GI tract lumen, skin swabs) or from solid tissue specimens.Results: 19,632 cultures were obtained and 1732 (8.8%) resulted positive for fungal or AFB species; 98 cultures met inclusion criteria (Table). Patient ages ranged from 12 days to 18 years (mean 8.6 years) and 52% were male. The 2-tiered risk assessment protocol was 100% sensitive in identifying patients with positive atypical cultures. All patients with tuberculosis, non-tubercular mycobacteria, Coccidioidomycosis, and non-Candida fungal infections were identified by the risk factors alone. Gram stain identified 4 additional cases positive for Candida, all of which had positive bacterial cultures and were treated with antibiotics; 1 patient was treated with antifungals. Three of the 4 cases grew only a single colony of Candida making the clinical significance of the gram stain findings questionable.Conclusions: APAP was 100% sensitive in identifying patients with positive atypical cultures in our study population over a 10 year period, and therefore offers promise in 2 areas: 1) To guide the proceduralist in the decision whether to order atypical cultures when draining potentially infected fluid, and 2) To decrease processing of low-yield fluid specimens in the microbiology lab when bacteria are seen on gram stains in patients without risk factors for atypical infections. Additional matched case control analysis is planned to evaluate specificity of APAP.References: 1. American Academy of Pediatrics. Nontuberculous mycobacteria. In: Red Book: 2018 Report of the Committee on Infectious Diseases, 31st ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Itasca, IL 2018. p.853. 2. Elston D. Nontuberculous mycobacterial skin infections: recognition and management. Am J Clin Dermatol 2009; 10:281. 3. Henry, M., Miller, A., Walsh, T. et al. Fungal Musculoskeletal Infections. Infect Dis Clin N Am 31 (2017) 353–368. 4. Rammaert, B., Gamaletsou, M.N., Zeller, V. et al. Dimorphic fungal osteoarticular infections. Eur J Clin Microbiol Infect Dis (2014) 33: 2131.

10 A COST BENEFIT ANALYSIS OF AN ACADEMIC HOSPITAL MEDICINE TRIAGIST PROGRAM 1335233 Jose Soto University of Texas Southwestern Nainesh Shah UT Southwestern Eugene Chu A COST BENEFIT ANALYSIS OF AN ACADEMIC HOSPITAL MEDICINE TRIAGIST PROGRAM Finalist Background: ED visits increased to 145.59 million in 2016 (CDC 2019), resulting in an increase in hospital admissions. Chen et al. showed a correlation between the overall ED census and likelihood of admission; while, Velasquez et al. found up to 28% of hospitalists reported having admitted patients when no admission criteria were met. They described the role of the hospital medicine triagist as a physician who fields admissions requests and navigates appropriate disposition. We performed a cost-benefit analysis to determine the value of our triagist program.Methods: We took the organizational perspective in performing the cost benefit analysis. Our hospital medicine triagist program consists of one hospitalist performing triage duties day (0700-1500), evening (1500-2200) and night (2200-0700). We calculated the gross annual cost of the program to include 2.0 FTE each for day and evening shift (182 annual shifts/FTE), and 2.3 FTE for the night shift (156 annual shifts/FTE). Average annual compensation/FTE is $230,000 + 20% benefit rate = $276,000. Net annual cost was calculated by multiplying gross annual cost by proportion of clinical productivity lost. Proportion of triagist clinical productivity was calculated by dividing mean total visits/24hrs of the 3 triagists by 18 visits/24hrs - the typical productivity of 3 admitters. We calculated the benefits of our triagist program to include hospital bed days saved and staffing saved for decreased census. For every called admission that was prevented, we attributed one hospital day in cost savings. At our hospital, a non-telemetry floor bed costs $700/day (charge of $2500/day) with an average reimbursement of $375/day for a net cost of $325/day. We calculated the decreased staffing needed for a smaller census by dividing census days saved by 14 (typical census of our rounding physicians). This fraction was multiplied by 2.0 FTE/rounder and then by $276,000/FTE to determine a net annual staffing cost savings. Data kept on the triagist spreadsheet from July 1, 2019 – October 31, 2019 was analyzed for (1) the number of calls fielded, (2) number of visits performed/shift and (3) number of admission requests discharged to home. We performed a sensitivity analysis to determine the breakeven point for our triagist program.Results: On average, our triagists field 61.8 calls, perform 4.5 visits and avert 1.92 admissions daily (Table 1). Costs Gross annual program cost: 6.3 FTE/year * $276,000/FTE/year = $1,738,800 Triagist clinical productivity: 4.5 visits/24 hrs / 18 visits/24 hrs = 0.25 (75% lost clinical productivity) Net Annual Program Cost: 0.75* $1,738,800 = $1,304,100 Benefits Hospital Utilization Benefits: 1.92 admissions avoided * 1 day aLOS = 1.92 bed days saved/24hrs * $325/bed day = $624 saved/day * 365 days/year = $227,760 in bed day costs saved/year FTE Savings Benefits: 1.92 admissions avoided * 1 day aLOS = 1.92 patient days saved/24hrs 1.92 patient days / 14 patients/rounder = 0.137 rounders saved * 2.0 FTE/rounder = 0.274 FTE saved/year * $276,000/FTE/year = $75,703 in FTE cost savings/year Net Annual Program Benefit: $227,760 + $75,703 = $303,463 Net Annual Cost-Benefit: $303,463 - $1,304,100 = (Table 2)Conclusions: By averting 1.92 admissions daily (3.1% of calls fielded) our triagist program results in an annual organizational loss of $1,000,637. To break even, our triagists need to avert 8.25 admissions/day. Other benefits of the triagist program may include increased productivity of other admitters and improving utilization of other services.References: 1. Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. https://www.cdc.gov/nchs/ahcd/web_tables.htm. Pdf, Accessed date 26 November 2019 2. Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. https://www.cdc.gov/nchs/ahcd/web_tables.htm. Pdf, Accessed date 26 November 2019 3. Chen W, Linthicum B, Argon NT, et al., The effects of emergency department crowding on triage and hospital admission decisions. Am J Emerg Med. 2019 Jun 26. pii: S0735-6757(19)30420-6. https://doi.org/10.1016/j.ajem.2019.06.039 4. Velasquez ST, Wang ES, White AA, Chadha J, Mader M, Leykum LK, Pugh J. Hospitalists as Triagists: Description of the Triagist Role across Academic Medical Centers. J Hosp Med. 2019 Oct 23;14:E1-E4 5. Rappleye, E. Becker’s Hospital Review, Hospital CFO Report, Financial Management: The Average cost per inpatient day across 50 states. May 19th 2015. https://www.beckershospitalreview.com/finance/average-cost-per-inpatient-day-across-50-states.html. Date accessed: November 26th 2019 6. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D $2520/day in Texas

13 WORKFORCE STRATEGIES: IMPLEMENTING A TRIAD LEADERSHIP MODEL 1334685 Johanna Baldassari Brigham and Women's Faulkner Hospital Erin O'Fallon Margaret Duggan Scott Schissel Cori Loescher WORKFORCE STRATEGIES: IMPLEMENTING A TRIAD LEADERSHIP MODEL Finalist Background: Joint leadership- modeled by physician-nurse dyad unit leaders has been a successful leadership structure at our organization for years. Advanced practice providers (APPs) have grown significantly in numbers over the past 10 years and have become critical members of our inpatient healthcare teams. They represent a stable and engaged workforce. In 2016, the nurse-physician dyad expanded to a nurse-physician-APP triad. This triad model utilizes interprofessional collaboration to achieve measurable goals, which are tracked and trended on unit-based quality dashboards.Purpose: This initiative expanded an existing, effective unit dyad leadership model to a triad model that included advanced practice providers.Description: The natural progression of APP inclusion at our hospital resulted in the creation of the first nurse-physician-APP triad leadership team. Senior leadership and physicians have actively created an environment where APPs are valued, trusted and opinions respected. As a result, APPs have become increasingly instrumental to daily hospital operations. The triad model was formally implemented in June 2017 and subsequently adopted by other inpatient units. The dissemination of the triad model has supported the continued professional development of APPs, enhanced APP and physician alignment with the nursing department, and advanced the strategic goals of the organization. One inpatient medical triad improved patient flow by increasing discharge before noon rates resulting in improved patient satisfaction and reduced ED overcrowding by 26%. The inpatient surgical triad implemented same day discharges for 120 of 161 planned total joint replacement (TJR) patients, reducing length of stay and associated costs with no readmissions. They then collaborated with the perioperative triad to pilot same day discharge for TJR patients directly from the post-operative care unit (PACU). 75% of the identified patients (n=120) have successfully been recovered and discharged from the PACU without subsequent operative related readmissions. Senior organizational leaders, including the CMO and CNO, use the larger dyad/triad forum to drive innovation and best practice and to collect first hand feedback on organizational challenges. Current work includes: sepsis quality indicators, reduction in HACs, increased participation in workplace safety, and creation of a culture of high reliability.Conclusions: The formalization and integration of the nurse-physician-advanced practice provider triad leadership model has successfully leveraged the existing knowledge, skill, and engagement of APP, nurse and physician leaders to advance patient outcomes.References: House, S., & Havens, D. (2017). Nurses’ and physicians’ perceptions of nurse-physician collaboration: A systematic review. The Journal of Nursing Administration, 47(3), 165–171. https://doi.org/10.1097/NNA.0000000000000460 Siedlecki, S., Hixson, E., (2015) "Relationships Between Nurses and Physicians Matter" OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 3. Retrieved from: http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No3-Sept-2015/Articles-Previous-Topics/Relationships-between-Nurses-and-Physicians-Matter.html#TJC Trandel, E. (2015). Advocating for Dyad Leadership at your organization? Use our slides. Advisory Board. Retrieved from: https://www.advisory.com/research/physician-executive-council/prescription-for-change/2015/03/dyad-leadership-slides

19 RED DAY FLAG: A VISUAL CONTROL THAT REDUCES HOSPITAL LENGTH OF STAY AND IMPROVES THE EFFICIENCY OF PATIENT CARE 1335326 Nila Radhakrishnan University of Florida LaKesha Fountain Frederick Southwick RED DAY FLAG: A VISUAL CONTROL THAT REDUCES HOSPITAL LENGTH OF STAY AND IMPROVES THE EFFICIENCY OF PATIENT CARE Finalist Background: The hospitalist service at this large Academic tertiary center has a length of stay index that is longer than expected. Despite improvements in multi-disciplinary rounds and co-locating patients on a geographical units, improvements in length of stay slowed. Interviews of hospitalist physicians indicate that there are frequent delays in procedures, imaging and consult recommendations. However, the hospitalists have no mechanism to alert administrators about these delays and they then expend extra time to work around these delays.Purpose: By creating an electronic red flag alert for each delay accompanied by a brief explanation and organizing an administrative rapid action team to quickly address these delays we predicted we could reduce delays and reduce the average length of hospital stay Specific Aims – 1. Create an electronic notification system within our EMR that could be activated by our hospitalist physicians and/or case managers. 2. Create an administrative team to intervene to shorten process delays. 3. Create a series of communication channels for each category of process delay to assure timely responses to patient delays. 4. Reduce process delays and reduce the average length of stay in the intervention group.Description: We created a visual control – Red Day Flag to notify an administrative team of a process delay. The red day flag can be entered by the physician, nurse or case manager involved in the care of the patient by going to the EPIC and clicking on the FYI icon (upper right-hand corner of the standard EPIC patient face page) and enter search for “Red Day”. The Red Day Flag is accompanied by a comment box where the cause of the delay can be entered. An administrative team then could download the report daily to take action on the delay. Additionally, specific areas (procedures, imaging) can also access the report in the EMR to develop internal processes to address delays.Conclusions: The study period was from 6/6/18 to 9/30/18. In the control group, there were 425 discharges with an ALOS of 5.53 and a LOS index of 1.09. In the intervention group, there were 479 discharges with an ALOS of 5.28 and a LOS of 1.06. While the LOS index only decreased by .03, it should be noted that the intervention group was able to admit and discharge an additional 50 patients compared to the control group for the same time frame. Additionally, we were able to categorize areas of systems delays such as MRI imaging, endoscopy and subspecialty consults. We were then able to work with key stakeholders to improve systems of care. This is the pilot stage of the study. Phase 2 is to expand the activation of the Red flag to more physicians so that we can have a larger number of patients in the intervention group. As a balancing measure, readmission rates were followed and actually decreased from 17.7 % to 15.2% for the entire ward where the intervention was piloted. In addition to improving systems and reducing delay, the visual control allowed the physicians and administrators to work together towards a common goal. Adding the Red flag did not add additional time to the physicians' work and the physician was able to focus on patient-centered care as opposed to calling and coordinating to intervene on a delay. This is especially important as we focus to reduce administrative burden, improve time at the bedside for both patient and physician satisfaction.References:

21 DIAGNOSTIC STEWARDSHIP INTERVENTIONS FOR CLOSTRIDIOIDES DIFFICILE INFECTION 1334862 Luke yeager University of New Mexico Mary Lacy DIAGNOSTIC STEWARDSHIP INTERVENTIONS FOR CLOSTRIDIOIDES DIFFICILE INFECTION Finalist Background: Our institution’s rate of hospital acquired Clostridioides difficile (C. diff) infection (CDI) is higher than expected based on documented severity of illness of our patients. The C. diff testing algorithm at our institution utilizes a multi-step approach. It begins with two tests (antigen EIA and toxin A/B EIA). If the results of these two tests are indeterminate, the algorithm then reflexes to a third test (NAAT-PCR). Non-toxin producing C. diff colonization can result in a positive C. diff test in the absence of active infection (Madden, Solomon). Up to 20% of hospitalized patients are asymptomatic carriers of C. diff (Mcfarland). Diagnostic stewardship interventions have been shown to reduce the rate of CDI (Schultz).Purpose: We employed a multi-pronged approach to reducing CDI rates in our hospital. This included efforts in antibiotic stewardship, diagnostic stewardship, and infection control. We aimed to employ diagnostic stewardship interventions to reduce the number of inpatient C. diff tests ordered at a tertiary academic medical center in the Southwest United States.Description: In this quality improvement project there were two interventions. The first intervention was a clinical decision-aid tool (“pilot”) that providers and nursing staff on selected units used prior to ordering a C. diff test. This tool recommended testing only if the following criteria were met: 1) the presence of 3 loose stools in the last 24 hours, 2) signs or symptoms associated with CDI (i.e. leukocytosis, abdominal pain, or cramping), 3) the absence of laxative administration within the last 48 hours, and 4) the absence of a processed C. diff test within the last 7 days. This tool only provided a recommendation and did not preclude testing if the provider disagreed with its recommendation. Providers and nurses were educated about the tool. Nursing was asked to complete the tool prior to sending specimen samples for testing. In the second intervention, a hospital wide hard-stop within the electronic medical record (EMR) was instituted. Providers ordering an inpatient C. diff test were blocked from placing the order if at least one of the two following restrictions were present: 1) laxative administration within the last 24 hours, or 2) C. diff test already processed within the last 7 days. If a provider had a high clinic suspicion for CDI, they could bypass the hard stop by paging pathology and discussing the case. The quality measure assessed before and after these interventions was number of C. diff tests ordered. CDI rates were also tracked as an institution. Prior to these interventions, 22.3 C. diff tests were ordered weekly across all inpatient services. After the pilot intervention was instituted the weekly average dropped to 18.4. After both interventions were instituted, the weekly average dropped to 15.6 C. diff tests ordered.Conclusions: Diagnostic stewardship interventions, such as EMR hard-stops and clinical nursing decision aids, may be effective at reducing the number of inpatient C. diff tests ordered. Early data at our institution support that this is contributing to reduction in rates of CDI in our institution.References: 1. Madden, Gregory R., et al. “Diagnostic Stewardship and the 2017 Update of the IDSA-SHEA Clinical Practice Guidelines for Clostridium Difficile Infection.” Diagnosis, vol. 5, no. 3, 2018, pp. 119–125., doi:10.1515/dx-2018-0012. 2. Solomon, D. A., and D. A. Milner. “ID Learning Unit: Understanding and Interpreting Testing for Clostridium Difficile.” Open Forum Infectious Diseases, vol. 1, no. 1, 2014, doi:10.1093/ofid/ofu007. 3. Mcfarland, Lynne V., et al. “Nosocomial Acquisition OfClostridium DifficileInfection.” New England Journal of Medicine, vol. 320, no. 4, 1989, pp. 204–210., doi:10.1056/nejm198901263200402. 4. Schultz, Katherine, et al. “Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium Difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm.” Journal of Clinical Microbiology, vol. 56, no. 9, 2018, doi:10.1128/jcm.00625-18.

24 OPTIMIZING OVERNIGHT CROSS-COVER COMMUNCIATION 1334393 Meera Udayakumar UNC Rex Health Bailey Beauclair Sandra Page Julia Woodson OPTIMIZING OVERNIGHT CROSS-COVER COMMUNCIATION Finalist Background: One of the challenges in hospital medicine is the care of patients overnight, when the primary team is unavailable, and care is being provided by those who are not as familiar with the patient. This is compounded by the high volume of pages at night. At UNC Rex Hospital, these factors resulted in delays responding to time sensitive issues.Purpose: To decrease the hospitalist response time at night and improve nurse satisfaction by developing a more efficient communication method.Description: The hospitalist team recorded all cross-cover messages over 14-night shifts. Each message was categorized as a clinical concern, new patient consult/admission, medication request, notification of abnormal test result or unnecessary. It was noted that the hospitalists received >100 messages in a 12-hour night shift. These messages occurred on average every 6 minutes and were not separated by class or priority. As a result, the hospitalists would respond to messages in the order received and not by acuity. This led to delays in responsiveness to time sensitive issues. The hospitalist team then collaborated with telecommunications and information technology (IT) to create a personalized build in the Vocera communications platform that allowed HIPAA compliant text messages to be identified by category and acuity. Nurses from four units (general medicine, oncology, neurology and observation) were asked to securely text through this platform at night. Nurses were trained on how to categorize texts as a clinical concern, new patient consult/admission, medication request or notification of abnormal test result. Nurses were also asked to classify texts as urgent, high or routine priority. Education was provided in the form of online modules and tip sheets. Nurse satisfaction with hospitalist response time was measured pre and post intervention. Response time was measured from the time a text was received to the time a response was sent. IT problems and safety events were also tracked. Hospitalist response time significantly decreased from over one hour at baseline to two minutes, while overall nurse satisfaction increased from 54% to 95%. There were no IT issues and no documented safety events related to the intervention. (Figures 1 and 2)Conclusions: This multidisciplinary collaboration and optimization of technology reduced delays in patient care and improved nursing satisfaction. Based on this success, the process was expanded hospital wide and is now the standard for hospitalist-nurse communication at night.References:

28 ANALYSIS OF INTERPROFESSIONAL DISCHARGE COMMUNICATION 1334957 Christina Brown Rush Medical College Aliyah Smith Ben Schnieders Carleton College Christopher Bruti ANALYSIS OF INTERPROFESSIONAL DISCHARGE COMMUNICATION Accept Background: The discharge process is complex and high-risk. Clear and accurate communication between the physician or Advanced Practice Provider (providers), nurse, and patient are essential to ensure a safe and effective transition of care. Upon literature review, there have not been studies looking at interprofessional communication during the discharge process. Also, our institution (a large tertiary academic medical center) does not have a formal communication plan at the time of discharge. This study focused on understanding the current discharge practice to identify barriers in communication that may impact the quality of discharge care.Methods: The study team analyzed communication on the general medical floors between provider, nurse, and patient at the time of discharge. This was done via a multifaceted approach. Nurses and providers on the primary general medicine floors were surveyed about their satisfaction with and barriers to communication in the current discharge process. The study team also observed the discharge process from a provider, nurse, and patient perspective, taking notes that were used for qualitative analysis. Providers and nursing staff were also interviewed about current discharge communication.Results: There were 97 responses to the survey with participation from attending physicians, Advanced Practice Providers, senior residents, interns, and nurses (22.61%, 2.06%, 19.59%, 8.25%, 48.45% respectively). Providers ranked satisfaction with discharge communication as 3.35/5.00 while nurses ranked it 2.67/5.00 (p=0.0003). When nurses were asked how they currently are notified of the discharge plan, 76.92% responded by discharge orders in the EMR while 94.87% preferred direct communication or a phone call with the provider. Qualitative analysis of the interviews with providers and nurses showed several themes including nursing staff unable to round with providers, ineffective phone calls between nurses and providers, and nurses feeling uninformed of the discharge plan.Conclusions: Currently there are gaps in interprofessional communication at the time of discharge providing a clear opportunity for improvement. In our current model, providers have patients assigned throughout the hospital which requires communication with several nurses on different floors and limits face to face interactions. This creates barriers to communicate the discharge plan effectively. From surveys, providers were more comfortable than nurses with the current communication system which involves updating patient information in the EMR with resulting After-Visit Summary. This limits 2-way communication between providers, nurses, and patients, reducing the ability to ask questions or clarifications. Our institution is working towards “geolocalizing” provider-patient assignments which could help eliminate some of these barriers. Following this implementation, the next step will be to introduce a standardized patient-centered discharge process (Figure 1) and checklist (Figure 2). This would include having the provider and nurse at the bedside to discuss the discharge plan together with the patient, ensuring open communication and likely a safer and more effective transition of care. Limitations of this study include single center and the assumption that the current communication model is leading to poor patient outcomes which we plan to study with the change in discharge communication.References:

34 DISCHARGE TODAY: THE EFFICACY OF A MULTIDISCIPLINARY ELECTRONIC DISCHARGE READINESS TOOL 1334785 Angela Keniston University of Colorado, Division of Hospital Medicine Lauren McBeth Jonathan Pell University of Colorado Hospital Kasey Bowden University of Colorado Division of Hospital Medicine Anna Metzger Nordhagen Nordhagen Amanda Anthony UCHealth Marisha Burden University of Colorado School of Medicine DISCHARGE TODAY: THE EFFICACY OF A MULTIDISCIPLINARY ELECTRONIC DISCHARGE READINESS TOOL Accept Background: Commonly used discharge communication workflows hinder timely and efficient discharge. Studies exploring the use of the electronic health record (EHR) for discharge planning have been limited to electronic reports constructed from EHR data elements, including barriers to discharge documented at admission, care management data, and discharge criteria or other targeted interventions such as improving discharge summaries for patients or medication reconciliation at discharge. To address these deficits, we developed an innovative EHR tool to facilitate communication in real-time between hospitalists and other clinicians about discharge readiness and barriers to discharge.Methods: This study is a prospective, single center, interrupted time series study designed to test the effects of the Discharge Today tool. All clinicians who were scheduled to be on service during the five-month pilot period were trained and asked to use the Discharge Today tool every day they are on service with all patients assigned to their team. Clinicians were asked to update patient discharge readiness status (Definite, Possible, No, In 24-48 hours) every morning when they first reviewed their patient, and anytime patient status changes throughout the day. Primary outcomes were: (1) time of day the clinician enters the discharge order, (2) time of day the patient leaves the hospital, and (3) average length of stay. Secondary outcomes are: (1) proportion of patients for whom a discharge order is entered before 11 am, (2) proportion of patients discharged before 11 am, and (3) clinical staff experience collected via REDCap survey.Results: During the pilot implementation period, 351 users, including physicians, advanced practice providers, residents and medical students, nurses, physical and occupational therapists, care managers and social workers, and pharmacists added the tool to their patient worklists. Sixty-five (88%) of the hospitalists who discharged a patient during the pilot period used the tool at least once. We found that 85% of patients discharged during the pilot period, March to July 2019, were assigned a discharge status. The most common barriers identified were medical improvement, placement, subspecialty consults, physical therapy, and social work or care management (Table 1). For patients assigned at least one discharge status during the pilot period, 26% had a discharge order in before 11:00 am compared to 23% of patients who did not have any discharge statuses assigned during the pilot period. In a survey conducted with hospital staff who utilized the Discharge Today tool, 83% of hospitalist providers and 94% of partner users, including nursing staff, care managers, social workers, physical therapists, and pharmacists, gave a positive rating.Conclusions: Our Discharge Today tool is a real-time communication tool that transmits from the primary team provider to virtually every hospital care team member (regardless of type) within the EHR. Created by hospitalists and other healthcare professionals who care for hospitalized patients and participate in discharge planning, this tool not only documents and communicates what tasks need to be completed before a patient can be discharged but also helps clinicians, nursing, and other staff to prioritize their work in real-time. Preliminary data suggests this tool is acceptable to clinical staff and useful for improving discharge timing.References: 1. Zoucha J, Hull M, Keniston A, et al. Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals. J Hosp Med 2018;13:816-22. 2. Patel H, Yirdaw E, Yu A, et al. Improving Early Discharge Using a Team-Based Structure for Discharge Multidisciplinary Rounds. Prof Case Manag 2019;24:83-9. 3. Tyler A, Boyer A, Martin S, Neiman J, Bakel LA, Brittan M. Development of a discharge readiness report within the electronic health record-A discharge planning tool. J Hosp Med 2014;9:533-9. 4. Sarzynski E, Hashmi H, Subramanian J, et al. Opportunities to improve clinical summaries for patients at hospital discharge. BMJ Qual Saf 2017;26:372-80. 5. Dean SM, Gilmore-Bykovskyi A, Buchanan J, Ehlenfeldt B, Kind AJ. Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record. Jt Comm J Qual Patient Saf 2016;42:555-AP11. 6. Horsky J, Drucker EA, Ramelson HZ. Higher accuracy of complex medication reconciliation through improved design of electronic tools. J Am Med Inform Assoc 2018;25:465-75. 7. Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge. J Am Med Inform Assoc 2011;18:309-13.

37 INTERPRETER PROVIDER COLLABORATION: WHAT PREVENTS EFFECTIVE COMMUNICATION WITH PATIENTS OF LIMITED ENGLISH PROFICIENCY? 1335342 Hannah Lee University of Minnesota Michael Shyne Hope Pogemiller INTERPRETER PROVIDER COLLABORATION: WHAT PREVENTS EFFECTIVE COMMUNICATION WITH PATIENTS OF LIMITED ENGLISH PROFICIENCY? Accept Background: When people with Limited English Proficiency (LEP) access the US healthcare system, a disparity is created, leading to worse outcomes and lower quality of care.1-5 In-person interpreters are essential in circumventing these disparities, yet pitfalls to collaboration between providers and interpreters persist.6-9 This study’s goal was to assess barriers and identify opportunities for intervention at our institution when working with inpatients with LEP on the pediatric and internal medicine wards.Methods: A mixed methodology consisting of a cross-sectional survey and thematic analysis of open-ended questions was used. Participants included residents, hospitalists, and advanced practice providers at our institution at both adult and pediatric hospitals, as well as interpreters identified on our state’s public interpreter registry. Providers and interpreters completed a 21-item (paper) and 19-item (electronic Qualtrics) survey, respectively. The primary outcome of interest was barriers to effective collaboration between interpreters and providers while working inpatient on the pediatric or internal medicine services. Descriptive statistics, t-tests, and qualitative analysis of themes were applied. Interpreters that did not have hospital experience with internal medicine or pediatrics services were excluded. The study received IRB exemption status.Results: 160 interpreters and 146 providers responded. As top barriers, interpreters ranked providers “talking in long sentences” (42.5%, 34.8-50.2) and “lack of punctuality” (46.2%, 38.5-54.0), whereas providers identified “not enough time” (59.7%, 51.0-68.3) and “lack of access” (54.8%, 46.1-63.6). Interpreters felt part of a cohesive team less often than providers (85.0% vs 97.9% p=0.0001). Providers remembered introducing encounters with brief summaries of the patient’s situation (pre-sessions) more often than interpreters did (49.0% vs 31.9% p=0.0024). Interpreters were more comfortable giving feedback to providers than vice versa (73.1% vs 59.6% p=0.0121). The most common themes identified as barriers on qualitative analysis were “access to interpreters” (35.2%) and “interpretation techniques” (23.2%). 87.0% of the "access” comments were concerns from providers, and 90.1% of the “techniques” comments were from interpreters regarding providers’ skills working with interpreters.Conclusions: Limitations of the study are that findings are based on self-report, leading to recall or social desirability bias. The main strength of this study is that it uniquely and equally assessed the viewpoints of both providers and interpreters on specific behaviors when working together in the inpatient hospital setting, revealing significant discordant perceptions of team cohesiveness and communication. Other improvement topics include addressing “provider technique” and “lack of access to interpreters”, while taking into consideration the specific workflow and environment of inpatient medicine. Necessary cultural change in the area of interpreter provider collaboration on the wards requires education and reinforcement. We plan to work with our institution’s staff interpreters to implement an educational intervention for providers, especially trainees, which will address identified areas of weaknesses in 1) team cohesiveness 2) pre-session completions and 3) active feedback amongst both parties.References: 1. Betancourt JR, Tan-McGrory A. Creating a safe, high-quality healthcare system for all:meeting the needs of limited English proficient populations; Comment on “Patient safety and healthcare quality: the case for language access.” Int J Heal Policy Manag. 2014. doi:10.15171/ijhpm.2014.21 2. Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014. 3. Silva MD, Genoff M, Zaballa A, et al. Interpreting at the End of Life: A Systematic Review of t he Impact of Interpreters on the Delivery of Palliative Care Services to Cancer Patients with Limited English Proficiency. J Pain Symptom Manage. 2016. doi:10.1016/j.jpainsymman.2015.10.011 4. Goenka PK. Lost in translation. Curr Opin Pediatr. 2016;28(5):659-666. doi:10.1097/MOP.0000000000000404 5. Tang AS, Kruger JF, Quan J, Fernandez A. From Admission to Discharge: Patterns of Interpreter Use among Resident Physicians Caring for Hospitalized Patients with Limited English Proficiency. J Health Care Poor Underserved. 2014. doi:10.1353/hpu.2014.0160 6. Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-262. doi:10.1007/s11606-008-0875-7 7. Hsieh E. Not Just ???Getting by???: Factors Influencing Providers??? Choice of Interpreters. J Gen Intern Med. 2015. doi:10.1007/s11606-014-3066-8 8. Li S, Gerwing J, Krystallidou D, Rowlands A, Cox A, Pype P. Interaction—A missing piece of the jigsaw in interpreter-mediated medical consultation models. Patient Educ Couns. 2017. doi:10.1016/j.pec.2017.04.021 9. Bischoff A, Hudelson P. Communicating With Foreign Language–Speaking Patients: Is Access to Professional Interpreters Enough? doi:10.1111/j.1708-8305.2009.00314.x

48 IMPROVING HEALTHCARE POLICY KNOWLEDGE AMONG INTERNAL MEDICINE RESIDENTS DURING MORNING REPORT 1335111 Jennifer Cowart Mayo Clinic Florida Haares Mirzan Jed Cowdell Mayo Clinic Jacksonville M. Caroline Burton Michael Maniaci Mayo Clinic Jaimie Grega Michele Lewis IMPROVING HEALTHCARE POLICY KNOWLEDGE AMONG INTERNAL MEDICINE RESIDENTS DURING MORNING REPORT Accept Background: Physician advocacy and knowledge of healthcare policy are vital elements of medical education and included within the ACGME Core Competency of Systems-Based Practice. The ability to advocate effectively has potential to impact healthcare regulations for both inpatient and outpatient practice. However, many GME programs do not incorporate these topics into their trainee education. To address this gap in our program, we introduced a resident curriculum on advocacy and healthcare policy. We administered surveys to determine knowledge and behaviors related to advocacy prior to the course, and to assess for changes following completion of the course.Methods: All internal medicine residents at a single academic institution were invited to complete anonymous pre- and post-course surveys. Residents were surveyed on belief in the importance of advocacy, knowledge of healthcare policy, and participation in advocacy activities, using a 1-to-5 point Likert scale from "strongly disagree" to "strongly agree". After the pre-survey, residents underwent a year-long curriculum of monthly lectures during morning conference on the US health insurance system, prescription drug pricing, social determinants of health, and legislative advocacy. Inpatient and outpatient topics were covered by an attending hospitalist with training in healthcare policy and advocacy. After completion of the lecture series, residents were re-administered the survey in June. Survey data was analyzed for changes pre- and post-course, as well as for differences by trainee gender and PGY level.Results: All 47 internal medicine residents were invited to complete both anonymous online surveys. The pre-survey had 21 respondents (44.7%): 12 PGY-1, 9 PGY-2/3; 12 male, 9 female. The post-survey had 27 respondents (57.4%): 15 PGY-1, 12 PGY-2/3; 9 male, 16 female. See figures 1 and 2 for pre- vs. post-survey results. There were no significant differences by gender. Before the course, PGY-2/3s were more likely to report familiarity with current healthcare news compared to PGY-1s [Median±SD; 2.0±0.8 vs 1.0±0.9, p=0.041]. After the course, PGY-2/3s were more likely to report ability to describe policy making compared to PGY-1s [4.0±0.4 vs 3.0±1.0, p=0.005].Conclusions: This study demonstrated the feasibility of administering a healthcare policy curriculum for internal medicine residents during scheduled conferences. Before the course, residents showed a discrepancy between having high levels of belief in the importance of physician advocacy, but low levels of both knowledge of healthcare policy and participation in advocacy. After the course, residents maintained high levels of belief in the importance of advocacy and showed increased levels of policy knowledge, but exhibited no change in behavior related to advocacy activities. This suggests that further interventions may be needed to promote resident participation in advocacy.References: 1. Armstrong, EC. Harnessing new technologies while preserving basic values. Fam Sys & Health. 2003;21(4):351-355. 2. Baribeau D, Ramji N, Slater M, Weyman K. An advocacy experience for medical students. Clin Teach. 2017 Feb;14(1):15-19. 3. Basu G, Pels RJ, Stark RL, Jain P, Bor DH, McCormick D. Training internal medicine residents in social medicine and research-based health advocacy: a novel, in-depth curriculum. Acad Med. 2017 Apr;92(4):515-520. 4. Bodenheimer T, Grumbach K. Understanding Health Policy: A Clinical Approach. 7th ed. New York: McGraw Hill; 2016. 5. Guralnick S, Ludwig S, Englander R. Domain of competence: systems-based practice. Acad Pediatr. 2014 Mar-Apr;14(2 Suppl):S70-S79. 6. Howell BA, Kristal RB, Whitmire LR, Gentry M, Rabin RL, Rosenbaum J. A systematic review of advocacy curricula in graduate medical education. J Gen Int Med. 2019 Nov;34(11):2592-2601. 7. Hubinette MM, Ajjawi R, Dharamsi S. Family physician preceptors’ conceptualizations of health advocacy: implications for medical education. Acad Med. 2014 Nov;89(11):1502-1509. 8. Sessums L, Dennis L, Liebow M, Moran W, Rich E, eds. Health Care Advocacy: A Guide for Busy Clinicians. New York: Springer; 2011. 9. Stafford S, Sedlak T, Fok MC, Wong RY. Evaluation of resident attitudes and self-reported competencies in health advocacy. BMC Med Educ. 2010 Nov 18;10:82.

51 DO ACTING INTERNS NEED RESIDENTS? A COMPARISON OF SKILL DEVELOPMENT ON RESIDENT VERSUS NON-RESIDENT TEAMS 1334940 Adam Gray University of Kentucky and Lexington VA John Ragsdale University of Kentucky College of Medicine DO ACTING INTERNS NEED RESIDENTS? A COMPARISON OF SKILL DEVELOPMENT ON RESIDENT VERSUS NON-RESIDENT TEAMS Accept Background: As acting interns (or sub-interns), fourth-year medical students are placed in the intern role to develop skills important for internship. At our institution, this has traditionally occurred on inpatient teaching teams that also include residents, interns, and third-year medical students. Because teaching teams are at times crowded with learners, our acting interns have often reported limited patient contacts. In addition, the demand for an internal medicine acting intern experience among fourth-year students was increasing. Also, with rapid expansion of our institution’s hospital medicine division the number of non-resident teams has significantly increased while resident teaching services have remained unchanged, leading many hospitalists desiring more teaching opportunities. For these reasons, we created a non-resident acting intern team composed of one attending and two acting interns. To determine whether similar goals were being achieved in this new model, we compared student comfort level with various intern skills between acting interns on resident and non-resident teams.Methods: A pre- and post-rotation assessment tool asked students to rate their comfort level with nine core intern skills: calling consults, documenting assessment and plan, choosing appropriate antibiotics, writing discharge summaries, performing cross-cover, writing admission orders, performing hand-off, evaluating new patients, and discussing plans with patients. All are skills formally expected in the curriculum. Students rated their comfort level with these skills on a five-point Likert scale with 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and 5=strongly agree. All students enrolled in the course were invited to participate in the surveys anonymously. Pre- and post- responses were paired with a unique identifier to determine the change in each skill for each student. Results from resident and non-resident teams were compared with a t-test.Results: We surveyed 58 students in the 2018-19 academic year. We excluded 14 surveys due to inability to pair pre- and post- responses or lacking an answer on the team type, leaving 35 (60.3%) paired surveys for analysis. Nine (25.7%) students were on the non-resident team and 26 (74.3%) the resident team. All intern skills improved after completion of the four-week acting internship. Non-resident teams had greater mean improvement in their comfort level with developing an assessment and plan (non-resident 1.33, resident 0.58; pConclusions: Acting interns on non-resident teams reported greater skill development in two skills and were no worse in any skill compared to acting interns on traditional resident teams. This study supports a non-resident team model as an effective option for acting interns. This model can help offload crowded teaching teams, add additional acting intern experiences, and add teaching opportunities for hospital medicine attendings. Review of narrative comments on student evaluations shows strong support for this model. Since this pilot, we have expanded to a second non-resident team for the 2019-20 academic year.References:

60 BACK TO THE BEDSIDE...OR NOT? 1335163 William Lippert Wake Forest School of Medicine Hal Atkinson Peter Lichstein Satyen Nichani Michigan Medicine, University of Michigan Stephen Chiang Alan Hall University of Kentucky John Ragsdale University of Kentucky College of Medicine Joseph Sweigart University of Kentucky BACK TO THE BEDSIDE...OR NOT? Accept Background: Historical studies suggest that bedside (BS) rounding is optimal for learners. More recent studies report variable results with BS rounding viewed unfavorably among learners. Nonetheless, some academic institutions are moving toward widespread adoption of BS rounding as the preferred rounding style. On the Internal Medicine (IM) inpatient teaching services at the University of Kentucky Medical Center (UK), University of Michigan Medical Center (UM), and Wake Forest Baptist Medical Center (WF), supervising attending physicians utilize different rounding styles on teaching teams. Linking teaching evaluations from residents to attendings’ self-reported rounding and personality styles may identify important associations.Methods: Attendings with ≥4 weeks of service on IM inpatient teaching services at UK, UM, or WF from July 2018-June 2019 were invited to participate. All institutions secured IRB approval. A 13-question survey was distributed via email with up to two reminders over a 6-week period. Attending survey responses were linked to their teaching evaluations from residents and de-identified by a neutral third-party. Evaluation scores were converted to a percentage of maximum score for each site. The data were dichotomized as predominately BS or “other” rounding, which included predominately hallway or conference room rounding. Aggregated scores for professionalism, autonomy, time management, and total composite teaching score were compared using student’s t-tests.Results: 65 out of 105 attendings completed the survey (response rate of 62.0%). 26 (40%) attendings primarily use BS rounding and 39 (60%) primarily use “other” rounding style. Most (54%) of the BS rounding group identified themselves as extroverts, whereas most (62%) of the “other” rounding group identified themselves as introverts. The BS rounding group was also more likely to have a formal role in student or resident education (53.8% vs. 36.0% in the “other” rounding group) and report that their rounding style preference was “best for patients” (50.0% vs. 33.3% in the “other” rounding group). However, none of these differences were statistically significant. Total composite teaching scores and professionalism scores were higher for those who predominately used the BS rounding strategy, but these were not statistically significant. Furthermore, resident autonomy and time management scores were higher for the “other” rounding group, but again these were not statistically significant.Conclusions: Attendings who predominantly use BS rounding are significantly more likely to consider themselves as extroverts and to report their preferred rounding style as being “best for patients.” Although this study was not able to measure acquired clinical skills or patient related outcomes of bedside rounding across 3 major academic institutions, these data demonstrate no clear difference between resident perceptions of educational effectiveness of attendings who predominantly use BS rounding versus those who use predominately “other” rounding styles. Therefore, resident perception of effectiveness should not be the prime motivator for widespread institution of BS rounding.References: 1. Rabinowitz R, Farnan J, Hulland O, Kearns L, Long M, Monash B, Bhansali P, Fromme HB. Rounds Today: A Qualitative Study of Internal Medicine and Pediatrics Resident Perceptions. J Grad Med Educ 2016;8(4):523-531. 2. Hulland O, Farnan J, Rabinowits R, Kearns L, Long M, Monash B, Bhansali P, Fromme HB. What‘s the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students. J Hosp Med 2017;12(11):892-897. 3. Shankel SW, Mazzaferri EL. Teaching the resident in internal medicine. Present practices and suggestions for the future. JAMA 1986;256(6):725-729. 4. Huff NG, Roy B, Estrada CA, Centor RM, Castiglioni A, Willett LL, Shewchuk RM, Cohen S. Teaching behaviors that define highest rated attending physicians: A study of the resident perspective. Medical Teacher 2014;36:991-996. 5. Shoeb M, Khanna R, Fang M, Sharpe B, Finn K, Ranji S, Monash B. Internal Medicine Rounding Practices and the Accreditation Council for Graduate Medical Education Core Competencies. Journal of Hospital Medicine 2014;9:239-243.

61 "UNDERSTANDING THE GAPS"- A QUALITATIVE STUDY ASCERTAINING THE EDUCATIONAL VALUE OF GERIATRIC CARE TRANSITIONS CONFERENCE CALLS FOR INTERNAL MEDICINE RESIDENTS 1334778 Roxana Naderi University of Colorado Tyson Oberndorfer Sarah Jordan Blythe Dollar Ethan Cumbler Christine Jones University of Colorado "UNDERSTANDING THE GAPS"- A QUALITATIVE STUDY ASCERTAINING THE EDUCATIONAL VALUE OF GERIATRIC CARE TRANSITIONS CONFERENCE CALLS FOR INTERNAL MEDICINE RESIDENTS Accept Background: Literature regarding resident education in transitions of care is limited, particularly in geriatric populations. The University of Colorado performed a pilot of a virtual multidisciplinary conference call between providers on the geriatric inpatient unit of the University of Colorado Hospital and its Seniors Clinic. Residents rotating on the Acute Care of the Elder (ACE) unit of the hospital were asked to participate in weekly conferences discussing patients recently hospitalized and discharged from the hospital, to address clinical concerns pertaining to the transition of care. Our goal was to understand resident perceptions of the educational value of these multidisciplinary conferences and to determine if these conference calls changed their practice or attitudes pertaining to transitions of care.Methods: We performed an IRB-approved qualitative study of internal medicine interns and residents who rotated on the ACE unit during 2018-2019. Structured interviews were recorded, transcribed verbatim, managed with ATLAS.ti software, and analyzed inductively using thematic analysis. Transcripts were reviewed and coded using a team-based iterative approach.Results: Of the 32 internal medicine residents and interns who were invited to participate, 11 agreed to an interview. Three major themes emerged during these interviews: 1) Increased awareness of social complexities, 2) Deconstructing silos across care settings, and 3) Recognizing the value of different disciplines during transitions. A quote that exemplifies these three themes is: “It’s easy to just move on after you’ve just discharged a patient, your part is done, but I do think it’s useful to be reminded that these transitions are real people on the other end getting the documentation. What you do echoes in time for that person over weeks or months, or maybe their lifetime.” A common thread unifying all three themes was a sentiment of dawning awareness of educational blind spots.Conclusions: This study highlights the benefit of multidisciplinary conference calls between inpatient and outpatient providers as a modality for residents to see the contribution of their care decisions in the broader spectrum of the patient’s experience at transition from the hospital. Educators can maximize the value of these multidisciplinary experiences by promoting reflective debriefs with residents to highlight the educational value of bringing to light previously unrecognized gaps in understanding about hospital discharge.References: 1. Bowen, J. L., Ilgen, J. S., Irby, D. M., ten Cate, O., & O’Brien, B. C. (2017). “You Have to Know the End of the Story”: Motivations to Follow Up After Transitions of Clinical Responsibility. Academic Medicine, 92, S48–S54. https://doi.org/10.1097/ACM.0000000000001919 2. Lee, J. I., Ganz-Lord, F., Tung, J., Bishop, T., DeJesus, C., Ocampo, C., … Scott, K. A. (2013). Bridging Care Transitions: Findings From a Resident-Staffed Early Postdischarge Program. Academic Medicine, 88(11), 1685–1688. https://doi.org/10.1097/ACM.0b013e3182a7cd55 3. Pavon, J. M., Pinheiro, S. O., & Buhr, G. T. (2018). Resident learning across the full range of core competencies through a transitions of care curriculum. Gerontology & Geriatrics Education, 39(2), 144–159. https://doi.org/10.1080/02701960.2016.1247066 4. Soones, T. N., O’Brien, B. C., & Julian, K. A. (2015). Internal Medicine Residents’ Perceptions of Team-Based Care and its Educational Value in the Continuity Clinic: A Qualitative Study. Journal of General Internal Medicine, 30(9), 1279–1285. https://doi.org/10.1007/s11606-015-3228-3

69 OLDER ADULTS ON INVOLUNTARY HOLD STATUS IN THE EMERGENCY DEPARTMENT 1334731 PATRICIA CHIPI Mayo Clinic Michael Maniaci Mayo Clinic Christian Lachner Tyler Vadeboncoeur David Hodge M. Caroline Burton OLDER ADULTS ON INVOLUNTARY HOLD STATUS IN THE EMERGENCY DEPARTMENT Accept Background: As the United States population ages the health care system is experiencing overall change and growth in the patient population as evidenced by the rising demand of psychiatric care in the emergency department. By the year 2029 “baby boomers” or older adults, those born between mid-1946 through mid-1964, will be 65 and older resulting in 20 percent of the total U.S. population to be greater than 65. This study aims to identify factors in the older adult that may contribute to involuntary hold status in the ED.Methods: This study is a retrospective review conducted at a suburban acute-care hospital ED of adult patients evaluated while on involuntary hold from January 1, 2014, through November 30, 2015. Data collected included age, date of birth, sex, race, marital status, housing, payer source, and tobacco use. Clinical data collected included ED length of stay, reason for involuntary hold, psychiatric disorder, suicide attempt, substance use disorder, serum alcohol level, urine drug testing, medical comorbidity, violence in the ED, 30-day ED readmission, and 30-day mortality. To compare the older adults (patients born in 1964 or before) to younger adults (born 1965 or after), categorical variables were evaluated using the Pearson χ2 test and the Fisher exact test and continuous variables were evaluated using the Wilcoxon rank sum test.Results: Two-hundred and fifty-one patients were included in the study. Of these, 90 (35.9 %) were classified as older adults with an average age of 60.6 years and 161 (64.1 %) were younger adults with average age of 32.9 years. The most common reason for involuntary hold in both cohorts was suicidal ideation. Medical comorbidities were more prevalent in older adults [60 (66.7%) vs. 64 (39.8%), P=Conclusions: Involuntary older adult patients have unique characteristics that may present challenges in their care and transfer of care to the inpatient psychiatric facility. When compared to younger adults, they are less likely to use drugs. However, the older adult often presents with medical comorbidities that require hospitalization and may exacerbate their underlying psychiatric illness. Increasing awareness of underlying comorbidities may assist in more readily identifying disposition and treatment plan.References: 1. Colby SL, Ortman JM. The Baby Boom Cohort in the United States: 2012-2060. U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau. https://www.census.gov/library/publications/2014/demo/p25-1141.html. Published 2014. 2. Hazlett SB, McCarthy ML, Londner MS, Onyike CU. Epidemiology of Adult Psychiatric Visits to U.S. Emergency Departments. 3. Pompeii L, Dement J, Schoenfisch A, et al. Perpetrator, worker and workplace characteristics associated with patient and visitor perpetrated violence (Type II) on hospital workers: A review of the Literature and existing occupational injury data. Journal of Safety Research. 2013;44:57-64.

80 THE PRESCRIBING CASCADE: APPROPRIATE USE OF BENZODIAZEPINES AMONG HOSPITALIZED GERIATRIC PATIENTS 1334687 Neshahthari Wijeyakuhan Indiana University School of Medicine Rachel Gruber Nicholas Rattray THE PRESCRIBING CASCADE: APPROPRIATE USE OF BENZODIAZEPINES AMONG HOSPITALIZED GERIATRIC PATIENTS Accept Background: Addressing the needs of the geriatric population is critical, as “baby boomers” comprise a larger proportion of hospitalized patients. Hospitalists increasingly care for these complex geriatric patients. The “BEERS Criteria” are evidence-based guidelines that encourage medication safety by describing potentially inappropriate and harmful medications (PIMS) among geriatric patients. BEERS guidelines recommend that with a few exceptions, benzodiazepines should be avoided in older adults as they can increase the risk of cognitive impairment, delirium, and/or falls. Despite these guidelines, little is known about the extent to which hospitalists adhere to these guidelines. This study is aimed to characterize patterns of hospitalist adherence to BEERS guidelines for prescribing and monitoring benzodiazepines for older adults.Methods: We conducted a retrospective chart review based on electronic health records from a large Midwest hospital. Subjects were admitted patients aged 70-85 years who were seen by a hospitalist over a one-year period (Jan-Dec 2017) and who had been prescribed a benzodiazepine while in the hospital. Two independent reviewers reviewed 351 patient charts where benzodiazepines were prescribed during hospitalization as per inpatient pharmacy records, including admission and progress notes. Key elements noted were the adequacy of documentation and the rationale for prescribing the benzodiazepine. “Adequate” charts were classified as those with proper documentation and a stated rationale for prescribing benzodiazepines in the note’s impression and plan. “Partial” documentation was defined as the inclusion of rationale and the prescription of benzodiazepines in the note but missing from the impression and plan. “Missing” was defined as no documentation or rationale found for prescribed benzodiazepines. Data was entered into REDCap, and analyzed with R. Student's t-test and chi-square tests to determine any association between the care team information, patient data, and if the prescription followed the guidelines (p-value of Results: Charts from 351 patients were analyzed, which included 641 separate notes. The patient sample was 57.8% female, and the mean age was 75.9 years. 40.7% were discharged home and 37.3% were discharged to rehab (see table 1). Based on the rationale provided in the notes, 28.2% of benzodiazepines were prescribed to address anxiety, which is inconsistent with the BEERS criteria. Based on the quality of progress note documentation for the 641 notes, 39% were adequate, 51.3% were partial and 9.7% had missing data. 95.5% of the documentation were provided by the day-team providers, which included MDs, APPs or both; 8.7% of encounters included residents (see table 2). Based on the p-value (Conclusions: Hospitalists in this medical center inappropriately prescribe benzodiazepines in older patients. This suggests a persistent need for continuous education for hospitalist on current guidelines on prescribing benzodiazepines to the geriatric population.References: 1. American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for Potentially Inappropriate Medication Use in Older Adults. (2019). Journal of the American Geriatrics Society, 67(4), 674-694. doi:10.1111/jgs.15767 2. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. (2015). Journal of the American Geriatrics Society, 63(11), 2227-2246. doi:10.1111/jgs.13702 3. Morse, R. J., & DuBeau, C. E. (2015). Update in geriatric medicine: Evidence published in 2014. Annals of Internal Medicine, 162(9), W102-W105. doi:10.7326/M15-0298 4. Wald, Huddleston, & Kramer, 2006) Wald, H., Huddleston, J., & Kramer, A. (2006). Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. Journal of Hospital Medicine, 1(1), 29-35. doi:10.1002/jhm.9 5. Sinvani, L., Carney, M., Kozikowski, A., Smilios, C., Patel, V., Qiu, G., . . . Pekmezaris, R. (2018). The role of geriatrician-hospitalists in the care of older adults: A retrospective cohort study. Archives of Gerontology and Geriatrics, 77, 31-37. doi:10.1016/j.archger.2018.03.006

87 CO-MA'AM-DER IN CHIEF: THE EXPERIENCE OF WOMEN IN LEADERSHIP IN HOSPITAL MEDICINE 1335199 Emily Gottenborg University of Colorado Amy Yu University of Colorado Kaitlin Jaros Lauren McBeth Marisha Burden University of Colorado School of Medicine CO-MA'AM-DER IN CHIEF: THE EXPERIENCE OF WOMEN IN LEADERSHIP IN HOSPITAL MEDICINE Accept Background: Since 2017, women have made up over 50% of medical school matriculates and nearly 50% of resident physicians in the United States. (1,2) However, only 35% of active physicians and 16% of department chairs are women – a number that has remained stagnant and demonstrates the underrepresentation of women in leadership positions in medicine. (3,4) This leaky pipeline contributes to the gender pay gap, lack of diversity in decision making roles, and inflexibility in workplace culture. (5) We sought to learn about the experiences of women in leadership positions in Hospital Medicine groups, in order to inform how best to advance future women leaders within our field.Methods: We are conducting a qualitative descriptive study using a content analysis approach. We used purposeful sampling to enroll female hospital medicine leaders from both community and academic programs represented in Society of Hospital Medicine Chapters nationally. To date, we have completed 12 interviews. A semi-structured interview guide was used to explore the following domains: leadership journey, challenges experienced, organizational benefits realized, and recommended interventions to support future female leaders. Interviews were audio-recorded, transcribed, and de-identified for data analysis purposes. A general inductive coding approach was used using ATLAS.ti software. At least three team members coded all transcripts and resolved discrepancies through group discussion.Results: Women in leadership positions within hospital medicine experience a shared set of challenges during their leadership trajectory. Themes with illustrative quotes include: 1) Imposter Syndrome, “I thought I was keeping the seat warm until someone more suitable came along;” 2) Battling Gender Stereotypes, “Trying to figure out the emotional balance that people want to see," and “When a woman’s emotions run high people will have a knee jerk reaction and say calm down… (but if you) throw the pendulum too far you are perceived as too stoic and not engaged;” 3) Sacrifice in Work-Life Integration, “The need to be present at home is considered a woman’s responsibility.” In contrast, the women also perceived bringing benefits to their organization, including relationship building, personal investment in team members, and group advocacy, “As women, we are more in tune with people… We want to nurture people and make sure their needs are met.” Actionable interventions to support future women in leadership offered by our interviewees, include: 1) Creating venues to share experiences and offer peer support; 2) Building infrastructure for female sponsorship, “Someone who is speaking for you and about you behind closed doors;” and 3) Re-building Workplace Culture, with a focus on flexibility, “You know our role is so blended…we are parents, we are females, we are physicians…and just not having to be so separate from it is important.”Conclusions: Interventions to further support women in hospital medicine on their leadership trajectory are necessary to seal the leaky pipeline in a field where 40% of providers are women. A robust program may include access to peer mentorship and female sponsorship, and a conscious effort to rebuild workplace culture with a focus on work-life integration.References: 1. Association of American Medical Colleges. 2017 Fall Applicant and Matriculant Data Tables. https://www.aamc.org/system/files/d/1/92-applicant_and_matriculant_data_tables.pdf. Accessed December 1, 2019. 2. Association of American Medical Colleges. ACGME Residents and Fellows by Sex and Specialty, 2017, Table 2.2. https://www.aamc.org/data-reports/workforce/interactive-data/acgme-residents-and-fellows-sex-and-specialty-2017. Accessed December 1, 2019. 3. Association of American Medical Colleges. Active Physicians by Sex and Specialty 2017, Table 1.3. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-sex-and-specialty-2017. Accessed December 1, 2019. 4. Association of American Medical Colleges. Table C: Department Chairs by Department, Sex, and Race/Ethnicity, 2017. https://www.aamc.org/system/files/reports/1/supplementaltablec.pdf. Accessed December 1, 2019. 5. Jena AB, Olenski AR, Blumenthal DM. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med. 2016;176(9):1294–1304. doi:https://doi.org/10.1001/jamainternmed.2016.3284

108 REGIONAL VARIATION IN OUTCOMES AND HEALTHCARE UTILIZATION IN EMERGENCY DEPARTMENT VISITS FOR SYNCOPE 1335509 Moeen Aboabdo Johns Hopkins University School of Medicine Noor Bazerbashi Waseem Khaliq Che Matthew Harris Shaker Eid Johns Hopkins University School of Medicine REGIONAL VARIATION IN OUTCOMES AND HEALTHCARE UTILIZATION IN EMERGENCY DEPARTMENT VISITS FOR SYNCOPE Accept Background: The approach to managing and admitting patients with syncope in an emergency setting lacks standardization. Our study aims to investigate how regional variation in management of emergency department (ED) patients presenting with syncope impacts outcomes and resource utilization in this patient population.Methods: We used the 2006 to 2014 Nationwide Emergency Department Sample to identify adults ≥ 18 years old with an ICD-9 principal diagnosis code (780.2) of syncope. Basic patient demographics, socio-economic and comorbidity characteristics were compared across pre-defined federal geographic regions in the US: Northeast, Midwest, South and West. ED service charges were adjusted for inflation using the Consumer Price Index with 2019 as the reference year. Multivariate logistic regression models were constructed to compare hospitalization rates and mortality among regions with the Northeast as the reference while accounting for possible confounders. Similarly, negative binomial regression models were constructed to compare ED service charges and inpatient length of hospital stay.Results: From 2006 to 2014, 9,132,176 adult syncope ED visits were included in the analysis. Syncope visits in the Northeast (n=1,831,889) accounted for 20.1% of all included visits; visits in the Midwest (n=2,060,940) accounted for 22.6%; visits in the South (n=3,527,814) accounted for 38.6% and visits in the West (n=1,711,533) accounted for 18.7%. Mean age was 56 years with 57.7% being female. The majority (65.2%) of the syncope visits were to hospital EDs without a trauma designation and 42.2% of the visits were evaluated and treated in metropolitan non-teaching hospitals. The Northeast region had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, AOR 0.58; 95% CI 0.52-0.65, p<0.001), the Midwest (17.2%, AOR 0.51; 95% CI 0.46-0.58, p<0.001) and the West (15.8%, AOR 0.45; 95% CI 0.39-0.51, p<0.001). The overall risk-adjusted Syncope hospitalization rate significantly declined over the study period from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (Ptrend <0.001). The Northeast region had the lowest risk-adjusted ED service charge per visit ($3,320) followed by the Midwest ($4,675, IRRadj 1.41; 95% CI 1.30-1.52, p<0.001), the West ($4,814, IRRadj 1.45; 95% CI 1.31-1.60, p<0.001) and the South ($4,969, IRRadj 1.50; 95% CI 1.38-1.62, p<0.001). Overall, ED service charges increased during the study period from $3,047/visit (95% CI $2,912-$3,182) in 2006 to $6,267/visit (95% CI $5,947-$6,586) in 2014 (Ptrend <0.001). Compared to the Northeast, all regions had significantly lower risk-adjusted inpatient length of hospital stay (all pConclusions: We found significant regional variability in hospitalization rates, mortality, ED service charges and inpatient length of hospital stay in ED patients presenting with syncope. Standardized practices for management of this patient population are needed to reduce variability and the impact of such variability on healthcare delivery optimization and allocation of expensive resources.References:

109 SMALL BOWEL OBSTRUCTION: WAIT AND WATCH OR ACT AND DISSECT. 1334359 Sravanthi Ennala Cleveland Clinic Alfredo T. Zacarias Jr Arvin Parvataneni Pramil Cheriyath Anastasius O. Peter SMALL BOWEL OBSTRUCTION: WAIT AND WATCH OR ACT AND DISSECT. Accept Background: Small bowel obstruction (SBO) is one of the most common diagnoses encountered in medical and surgical practice. It causes significant morbidity and mortality. Post-operative adhesions are the most common cause. Several studies done in the past reviewed if early operative management would be of benefit compared to conservative management. Some studies have shown that early surgical management might be beneficial in recovery and morbidity outcomes, compared to conservative management however not many studies commented on readmission rate. Our purpose of this research was to determine if a conservative approach, as opposed to surgical, is more effective in reducing recurrences, readmissions from surgery and complications from small bowel obstruction.Methods: Data from 200 patients admitted to the Pinnacle Health Hospital between 2006 -2011were obtained from database using retrospective chart review. Further analysis included in this study were (1) Patient demographics including age, gender and racial background (2) Risk factors including diabetes, hypertension, smoking, alcohol use and BMI, proton pump inhibitor use, past abdominal surgery and inflammatory bowel disease. (3) Post surgery complication rate (4) Number of readmissions within a year (5) Number of readmissions for surgery (6) Average days before first admission. To compare the difference between the conservative and surgical approach, the students’ t-test, chi-squared, Fisher's exact test, and univariate analysis were used. A p-value Results: Of 200 SBO cases, 86 were treated conservatively and 114 were treated surgically. The results showed that the length of stay with conservative management was 4.5 +/- 2.7 days versus 9.8 +/- 6.1 days in surgical management (p-value Conclusions: Surgically treated patients had a lower rate of recurrence, longer time interval before first recurrence compared to conservative approach. However, patients treated operatively had longer length of stay. It was also noted that patients with bowel obstruction managed conservatively were operated on readmission. There was no significant risk of complications seen in either approach in our study.References: 1) Seror D, Feigin E, Szold A, et al. How conservatively can postoperative small bowel obstruction be treated? Am J Surg 1993; 165:121. 2) Zielinski MD, Eiken PW, Bannon MP, et al. Small bowel obstruction-who needs an operation? A multivariate prediction model. World J Surg 2010; 34:910. 3) Diaz JJ Jr, Bokhari F, Mowery NT, et al. Guidelines for management of small bowel obstruction. J Trauma 2008; 64:1651. 4) Oyasiji T, Angelo S, Kyriakides TC, Helton SW. Small bowel obstruction: outcome and cost implications of admitting service. Am Surg 2010; 76:687. 5) Cox MR, Gunn IF, Eastman MC, et al. The safety and duration of non-operative treatment for adhesive small bowel obstruction. Aust N Z J Surg 1993; 63:367. 6) Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction: conservative vs. surgical management. Dis Colon Rectum 2005; 48:1140. 7) Bizer LS, Liebling RW, Delany HM, Gliedman ML. Small bowel obstruction: the role of nonoperative treatment in simple intestinal obstruction and predictive criteria for strangulation obstruction. Surgery 1981; 89:407.

137 A COMPARISON OF ECART TO MEWS SCORE IN PREVENTING ADVERSE OUTCOMES 1334372 Clio Musurakis Amita Health Saint Francis Hospital Randa Sharag Eldin John Chul Won Chung Guillermo Rodriguez-Nava Gauri Pethe Nur un nissa Nabil Sumit Sohal Chris Costas Solab Chitrakar A COMPARISON OF ECART TO MEWS SCORE IN PREVENTING ADVERSE OUTCOMES Accept Background: The healthcare system needs tools that can predict which patients are at risk of deterioration, before adverse outcomes such as cardiac arrest or even death occur. Many of these patients will show signs of significant physiological deterioration in the 24 hours prior to ICU transfer or cardiac arrest [1-4]. Different scores have been developed to predict these adverse outcomes [6,7], two of them being eCART and MEWS which will be compared in this study.Methods: The study was conducted in Saint Francis Hospital of Evanston, Illinois. Data was collected from November 22nd 2018 to August 17th 2019 and all rapid responses during this time period were reviewed. We excluded patients that had rapid response (RRT) called but had a code status of DNR/DNI. The primary outcome was set as cardiac arrest, ICU transfer or death within 24 hours of activation of RRT. Patients were divided into two categories: ones that had adverse outcome after RRT versus ones that didn’t have an adverse outcome and remained on the general medical floor after 24 hours of RRT activation. Two early warning scores were compared in this study, MEWS and eCART, and comparison was done with calculation of accuracy of each of these scores in predicting adverse outcome (cardiac arrest, ICU transfer or death within 24 hours). Statistical analysis was done using PSPP software (GNU PSPP Statistical Analysis Software Release 1.2.0). MEWS more than 4 and 5 [5] versus eCART more than 94 or 97 (as established in our institution) were set as intermediate and high risk groups respectively.Results: 144 patients that had RRT called from January 22nd 2019 to August 17th 2019 were included. 10 were excluded due to DNR/DNI status. 84 patients had an adverse outcome within 24 hours after RRT. Mean hospital stay was 245.23 hours for the adverse outcome group versus 206.18 hours for the group that had no adverse outcome. More patients were discharged to home in the latter group. AUC for eCART was 0.62 (95% CI 0.540 - 0.710) and AUC for MEWS was 0.74 (95% CI 0.670 - 0.810). Specificity for an eCART value of 60, which was considered high risk in the study conducted by Churpek et al [7], was 48%. In their study they found a specificity of 95% which is a significant difference from our study. Specificity was 76% for an eCART value of 94 versus 84% for a MEWS score of 4. Specificity was 82% for an eCART value of 97 versus 90% for a MEWS score of 5. Sensitivity was 36% for an eCART value of 94 and 24% for a value of 97. It was 31% for a MEWS score of 4 and 21% for a score of 5. eCART value of 60 had a sensitivity of 68%. There was a significant decrease in the number of RRTs after eCART was available. There were 90 RRTs called from January 22nd 2019 to July 31st 2019 (post eCART era) and 158 RRTs called from January 22nd 2018 to July 31st 2018 (pre eCART era).Conclusions: MEWS score calculated at the time of RRT had higher accuracy in predicting adverse outcomes within 24 hours of RRT activation than eCART score. Due to the contradiction in findings as compared to prior studies [7,8,9] more research is needed to compare these two scores. Fewer RRTs occured since the implementation of eCART in our hospital and this is likely because we have real time access to patients’ eCART scores, even before RRT or adverse outcomes occur. This could lead to more interventions being done prior to a patient's deterioration when eCART values are generally high for a patient and could in fact mean that eCART is better than MEWS score in preventing rather than predicting adverse outcomes.References: 1) Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98(6):1388–92 2) Smith AF, Wood J. Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation. 1998;37(3):133–7. 3) Galhotra S, DeVita MA, Simmons RL, Dew MA, Members of the Medical Emergency Response Improvement Team C. Mature rapid response system and potentially avoidable cardiopulmonary arrests in hospital. Qual Saf Health Care. 2007;16(4):260–5. 10.1136/qshc.2007.022210 4) Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K, et al. A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom—the ACADEMIA study. Resuscitation. 2004;62(3):275–82. 10.1016/j.resuscitation.2004.05.016 5) Kipnis P, Turk BJ, Wulf DA, LaGuardia JC, Liu V, Churpek MM, Romero-Brufau S, Escobar GJ, Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU. J Biomed Inform. 2016 Dec;64:10-19 6) Won Young Kim, Yu Jung Shin, Jin Mi Lee, Jin Won Huh, Younsuck Koh, Chae-Man Lim, Sang Bum Hong. Modified Early Warning Score Changes Prior to Cardiac Arrest in General Wards. PLoS One. 2015; 10(6): e0130523. 7) Churpek MM, Wendlandt B, Zadravecz FJ, Adhikari R, Winslow C, Edelson DP. Association between intensive care unit transfer delay and hospital mortality: A multicenter investigation. J Hosp Med. 2016 Nov;11(11):757-762 8) Malcolm Greena, Harvey Lander, Ashley Snyder, Paul Hudsona, Matthew Churpek, Dana Edelson. Comparison of the Between the Flags calling criteria to the MEWS, NEWS and the electronic Cardiac Arrest Risk Triage (eCART) score for the identification of deteriorating ward patients. Resuscitation 2018; 123 :86-91 9) Kipnis P, Turk BJ, Wulf DA, LaGuardia JC, Liu V, Churpek MM, Romero-Brufau S, Escobar GJ. Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU.J Biomed Inform. 2016;64:10-19.

148 RACIAL AND ETHNIC DISPARITIES IN 7-DAY READMISSIONS FROM A HOSPITAL MEDICINE SERVICE 1334670 Aksharananda Rambachan UCSF Yumiko Abe-Jones Yalda Shahram RACIAL AND ETHNIC DISPARITIES IN 7-DAY READMISSIONS FROM A HOSPITAL MEDICINE SERVICE Accept Background: Health care equity, one of the six domains of high-quality health care as defined by the Institute of Medicine, will only be achieved when health care outcomes do not vary based on patient social characteristics, such as gender, race, ethnicity, geographic location, and socioeconomic status. Readmission is a significant outcome for patients and health systems, and 30-day readmission has been associated with racial disparities. However, less is known about disparities in 7-day readmissions across race and ethnicity. Previous studies have demonstrated that 7-day readmissions reflect a similar patient mix to 30-day readmissions, but that 7-day readmissions may be a better measure of hospital care. Readmissions beyond 7 days may be driven by factors beyond a hospital’s control. In the realm of health equity, studying 7-day, as opposed to 30-day readmissions, may better capture modifiable factors, diagnostic error, clinical decision making, and implicit bias from the provider.Methods: Using electronic health databases, we identified all adults discharged from the hospital medicine service between July 2016 and June 2019 from a 600-bed urban academic teaching hospital. Given the primary outcome of readmission, we excluded patients who died during hospitalization, were under observation status, or were transferred to a psychiatric facility. The primary predictor was self-reported race/ethnicity, categorized as White, Black, Hispanic, Asian, or Other/Unknown. The primary outcome was 7-day readmission back to the discharging hospital. Multivariable logistic regression was used to assess for factors associated with 7-day readmission adjusted for patient demographics (age, gender, Limited English Proficiency (LEP status), housing status, payor status), hospitalization and health system factors (including length of stay, intensive care unit management, teaching vs. hospitalist service, discharge disposition), and medical comorbidity index.Results: We identified a total of 18,808 patients in this dataset. A total of 1,297 (6.9%) of patients were readmitted within 7 days. We found a statistically significant association between race/ethnicity and 7-day readmission. Black patients (8.9%) and Asian patients (7.2%) had a higher 7-day readmission rate compared to White patients (6.4%). Using multivariable logistic regression, controlling for confounding variables, the Odds Ratio for 7-day readmission for Black patients was 1.35 (95% CI 1.15-1.59, p Conclusions: Black and Asian patients experienced higher rates of 7-day readmission than White patients, confirmed on adjusted analysis. Racial disparities in 7-day readmissions from hospital medicine services have not been previously characterized, but these findings align with known racial disparities in 30-day readmissions. Because 7-day readmissions may be more modifiable and impacted by factors like clinician bias, these results require further investigation into causal pathways and the development of tools to mitigate bias.References:

166 THE EFFECT OF FLUID STATUS ON OUTCOMES IN SEPSIS: THE EF SOS STUDY. 1334772 Michael Yoo Kaiser Permanente Santa Rosa Medical Center Shiyun Zhu Yun Lu John Greene Helen Hammer Colin Iberti Siamack Nemazie Martin Ananias Caitlin McCarthy Robert O'Malley Karlyn Young Karolin Reed Robert Martinez Kaiser Permanente Santa Rosa Family Medicine Residency Kawai Cheung Vincent Liu THE EFFECT OF FLUID STATUS ON OUTCOMES IN SEPSIS: THE EF SOS STUDY. Accept Background: Sepsis is a leading cause of hospital death and readmission (1-2). Prior work has suggested that early, adequate intravenous fluid (IVF) administration during sepsis care is associated with lower mortality, even among those at risk for fluid overload (including patients with chronic kidney disease [CKD] or heart failure [HF]) (3). At the same time, emerging evidence suggests that excess fluid accumulation may be harmful (4-10), with many concerned about positive fluid balance in sepsis contributing to adverse post-sepsis sequelae. Understanding the impact of fluid balance on sepsis readmission could offer a tangible approach to reducing adverse outcomes. However, a critical gap exists in understanding fluid practice for sepsis outside of the intensive care unit (ICU). While Tang et al showed that nearly 80% of sepsis patients do not require ICU care (11), there is little evidence available to guide practice. We therefore undertook this study to evaluate whether positive fluid balance among non-critically ill sepsis patients was associated with readmission, including readmission for HF.Methods: We conducted a retrospective cohort study of adult sepsis patients from 2012-2017 in an integrated health system. We identified patients admitted through the emergency department who met Sepsis-3 criteria within 6 hours of presentation. We excluded patients who spent any time in the ICU, died during hospitalization, had length of stay (LOS) > 7 days, end-stage renal disease, acute liver failure, or hypoalbuminemia. Our exposure of interest was net fluid balance (I/O), measured at daily intervals and characterized as positive vs negative at discharge. Our primary outcome was 30-day all-cause readmission. Our secondary outcomes were 30-day readmission by category (HF, infection, other) and mortality after living discharge. We used multivariable competing risk survival analysis (12-13) and Kaplan Meier survival analysis.Results: Our study included 57,032 sepsis patients admitted to a non-ICU setting who survived to discharge. Table 1 describes baseline characteristics comparing negative (28.2%) vs positive (71.8%) I/O. Negative I/O patients were older with increased comorbidity, pre-existing HF/CKD, acute physiology, IVF volume administration, and diuretic use. Overall, 8,719 patients (15.3%) were readmitted and 3,639 patients (6.4%) died during 30-day post-discharge follow-up. There was no difference in readmission risk between positive vs negative I/O after adjusting for age, sex, race, body mass index, history of CKD/HF, diuretic use, COPS2 (14-15), LAPS2 (14-15), and LOS (HR 1.00, 95% CI, 0.95-1.05). No association was detected between readmission risk and I/O using I/O as continuous, SPLINE, and quadratic function transformations. Table 2 shows adjusted readmission risk by category, with positive I/O associated with lower HF-related readmission risk. Finally, positive I/O was associated with higher adjusted 30-day mortality (HR 1.23, 95% CI, 1.15-1.31, pConclusions: In this large, multicenter study of non-critically ill sepsis patients, there was no association between positive fluid balance at time of sepsis discharge and readmission risk. Patients with negative fluid balance were older and had higher comorbid disease burden, with increased diuretic use. As a result, the current approach may be vulnerable to residual confounding, and other causal inference or interventional approaches are warranted.References: 1. Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90-2. 2. Mayr FB, Talisa VB, Balakumar V, Chang CH, Fine M, Yende S. Proportion and Cost of Unplanned 30-Day Readmissions After Sepsis Compared With Other Medical Conditions. JAMA. 2017;317(5):530-531. 3. Liu VX, Morehouse JW, Marelich GP, et al. Multicenter Implementation of a Treatment Bundle for Patients with Sepsis and Intermediate Lactate Values. AJRCCM. 2016;193(11):1264-1270. 4. Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235-2244. 5. Acheampong A, Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis. Critical Care. 2015;19:251. 6. Sadaka F, Juarez M, Naydenov S, O’Brien J. Fluid resuscitation in septic shock: the effect of increasing fluid balance on mortality. J Intensive Care Med. 2014;29(4):213–7. 7. Kelm DJ, Perrin JT, Cartin-Ceba R, et al. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock. 2015 Jan;43(1):68-73 8. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564–75. 9. Latham H, Bengtson CD, Satterwhite L, Stites M, Simpson SQ. Stroke volume guided resuscitation in severe sepsis and septic shock decreases time on pressors and ICU stay. University of Kansas Medical Center, Kansas City, United States. ISICEM, March 2017. 10. Latham H, Bengtson CD, Satterwhite L, Stites M, Simpson SQ. Stroke volume guided resuscitation in severe sepsis and septic shock decreases need for mechanical ventilation. University of Kansas Medical Center, Kansas City, United States. ISICEM, March 2017. 11. Tang Y, Choi J, Kim D, et al. Clinical predictors of adverse outcome in severe sepsis patients with lactate 2-4 mM admitted to the hospital. QJM. 2015;108(4):279-87. 12. Fine J, Gray R. Proportional hazard model for the sub-distribution of competing risks. J Amer Stat Assoc 1999;94:496–509. 13. Gardiner JC. 2016. Competing Risks Analyses: Overview of Regression Models SAS Global Forum 2016 Proceedings. Paper 8620-2016. 14. Escobar GJ, Greene JD, Scheirer P, Gardner MN, Draper D, Kipnis P. Risk-adjusting hospital inpatient mortality using automated inpatient, outpatient, and laboratory databases. Med Care 2008;46:232-239. 15. Escobar GJ, LaGuardia JC, Turk BJ, Ragins A, Kipnis P, Draper D. Early detection of impending physiologic deterioration among patients who are not in intensive care: development of predictive models using data from an automated electronic medical record. J Hosp Med 2012;7:388–395.

168 AWARENESS OF PERIPHERAL INTRAVENOUS CATHETERS AMONG NURSES, PHYSICIANS, AND TRAINEES: A SURVEY-BASED STUDY 1335206 Tessa Adzemovic Michigan Medicine Vineet Chopra University of Michigan Medicine and VA Ann Arbor Health System Sushant Govindan Dilshan Dhillon Joanna Kukla Muhammad Nabeel Sarah Ottum Megan O'Malley Alexander Zheutlin Matthew Gross Nejla Harba Blake Duffy Madison Miller University of Michigan Alison Baskin University of Michigan Melinda Song Smita Kohli Henry Ford Hospital Scott Kaatz Henry Ford Hospital Lakshmi Swaminathan AWARENESS OF PERIPHERAL INTRAVENOUS CATHETERS AMONG NURSES, PHYSICIANS, AND TRAINEES: A SURVEY-BASED STUDY Accept Background: Peripheral intravenous catheters (PIVs) are the most frequently used invasive devices in hospitalized patients. Although they are considered to pose a low risk of adverse events, complications associated with peripheral IVs such as phlebitis, bloodstream infection, and extravasation are not uncommon. Recent evidence suggests that all-cause mortality does not differ between peripheral catheter bloodstream infection and those that originate from central venous catheters. In order to reduce risk of complications from PIVs, awareness of presence and early removal are necessary. However, how often nurses, physicians and trainees are aware of PIV presence is unknown.Methods: We conducted a multicenter, prospective observational study to assess awareness of PIV presence in clinicians caring for hospitalized, non-critically ill patients in four Michigan hospitals. Between May 2018 and February 2019, we performed face-to-face interviews with patients to determine whether they had a PIV and where it was located in the patient’s body (e.g., left vs. right arm). After surveying patients, we interviewed care providers (e.g., nurses, attending physicians and trainees including medical students and residents) and asked them “Does your patient have a PIV? If so, where is it located?” Care providers were defined as attendings, senior residents, interns, medical students and bedside nurses responsible for patient care. To ensure generalizability, we included patients from a broad range of subspecialties including internal medicine, cardiology, gastroenterology, hematology and oncology services. We hypothesized that nurses would have greater awareness of PIV presence and location than physicians. Differences in awareness by provider type was assessed via chi-square tests; pResults: A total of 1,682 patients and 4,961 providers across four Michigan hospitals were interviewed and included in this study. Of 1,682 patients, 1,420 had a PIV in place at the time of interview. Among patients who had a PIV in place (n=1,420), bedside nurses were aware of PIV presence 97% of the time, students were aware 88% of the time, house-staff 87% of the time, and attendings 86% of the time. However, when no PIV was present (n=262), awareness varied substantially with many responding a PIV was in place when in fact, it was not. Among patients with no PIV, nurse awareness of lack of PIV presence was 60%, students 31%, house-staff 18%, and attendings 13%. Attendings were significantly less likely to correctly identify the location than house-staff (13.5% vs 36.8%, pConclusions: In this multicenter study of almost 5,000 clinicians, we found that bedside nurses were most aware of the presence and location of a peripheral IV catheter. In contrast, few physicians were able to identify absence of a PIV, suggesting an element of conjecture in responses. Given the ubiquity of these devices and concerns related to safety, strategies to improve physician awareness of PIV presence appear necessary.References:

170 USE OF PULMONARY EMBOLISM RULE-OUT CRITERIA AND AGE-ADJUSTED D-DIMER FOR PATIENTS WITH SUSPECTED PULMONARY EMBOLISM 1335351 Ricardo Cedeno-Mendoza Rutgers New Jersey Medical School/Trinitas Regional Medical Center Raul Angel Garcia Manthan Pandya Trinitas regional Medical Center Aakash Rajwani Mohamed Talaat Michael Brescia D'angelo John USE OF PULMONARY EMBOLISM RULE-OUT CRITERIA AND AGE-ADJUSTED D-DIMER FOR PATIENTS WITH SUSPECTED PULMONARY EMBOLISM Accept Background: Pulmonary embolism (PE), refers to obstruction of the pulmonary artery or one of its branches by material (thrombus, tumor, air or fat) that originated elsewhere in the body. Wells criteria must be part of the clinical assessment for PE. With these criteria, we can classify patients as high probability (>6 pts), moderate (2 to 6 pts), or low (<2 pts) for PE. Pulmonary embolism rule-out criteria (PERC) rule, is used for patients previously classified as low probability for PE as per Wells Criteria, and includes age 95%, no hemoptysis, no estrogen use, no prior DVT or PE, no unilateral swelling, no surgery/trauma requiring hospitalization in the previous 4 weeks. Patients that fulfill all criteria, have a low likelihood of PE and no further testing is recommended. By the other hand, the rest of the patients may need further testing (i.e. D dimer). It is unknown in our institution how many patients as per Wells criteria were low, intermediate or high probability for Pulmonary embolism in the ED, and furthermore in the low risk group, how many patients meet all 8 PERC rule criteria in order to avoid the use of CT pulmonary angiogram as a diagnostic method.Methods: Prospective study of the patients that underwent CTPA to rule out PE, in the ED in Trinitas Regional Medical Center, Elizabeth-New Jersey from January 2019 to June 2019. Patients were classified as per Wells Criteria in low, intermediate and high risk for PE. In the low risk group, PERC rule was applied to assess which patients needed further work up for PE and who did not, however this did not preclude to order CTPA if considered by ED physicians. Age-adjusted D-dimer was used for low and intermediate risk patients. Negative predictive value of PERC rule/age-adjusted D-dimer was calculated as well.Results: A total of 444 patients were analyzed. Of these, 45.7% (N = 203) were excluded due to incomplete documentation. Average age was 50.12 + 17.78 years, with a female predominance of 59.75% (n=144).Ninety one were considered low risk, of which, 80.22% (n=73) were PERC rule positive (+).From the PERC rule negative (-) patients, only 1 had PE. For PERC +, age adjusted D-Dimer was applied.From those, 60.27 % (n=44) had elevated age adjusted D- Dimer (> 250 ng/ml).CTPA in this group showed PE in 6.82% (n=3).Together, PERC - and PERC + with a normal age-adjusted D-dimer, only 2.13% (n = 1) had PE in CTPA.Negative Predictive Value (NPV) was 97.87% (95% CI, 89.28% to 99.61%).In patients PERC - and PERC + with normal age-adjusted D-dimer, CTPA could be avoided in 51.65%. On the other hand, one hundred ten patients were classified as intermediate risk, with a 69.09% (n=76) having an elevated age-adjusted D- Dimer.CTPA was positive for PE in 10.53% (n=8) in elevated age-adjusted D-dimer patients vs 2.94% (n=1) in normal age-adjusted D-dimer.NPV was 97.06% (95% CI, 83.58% to 99.53%).In the intermediate risk group, patients with a normal age-adjusted D-dimer, CTPA could be avoided in 30.91% of the cases.Conclusions: Applying clinical decision rules are effective means of reducing costly diagnostics. The PERC Rule and Wells Criteria are validated clinical decision rules that decrease radiation exposure, improve ED through put and mitigate advanced imaging consumption. It is important to educate the clinical staff at Community hospitals on the nuances of D-dimer assays so that the proper clinical application can be applied.References: 1. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism in the United States: evidence of overdiagnosis. Arch Intern Med 2011; 171:831. 2. Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med 2003; 163:1711. 3. COON WW, WILLIS PW. Deep venous thrombosis and pulmonary embolism: prediction, prevention and treatment. Am J Cardiol 1959; 4:611. 4. Freund Y, Cachanado M, Aubry A, et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department PatientsThe PROPER Randomized Clinical Trial. JAMA. 2018;319(6):559–566. doi:10.1001/jama.2017.21904

173 PREVALENCE AND NATURE OF DIAGNOSTIC ERROR IN HOSPITALIZED PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS 1334395 Craig Gunderson Yale University School of Medicine Victor Bilan Jurgen Holleck Phillip Nickerson Benjamin Cherry Philip Chui lori Bastian Alyssa Grimshaw Yale University, Cushing/Whitney Medical Library Benjamin Rodwin PREVALENCE AND NATURE OF DIAGNOSTIC ERROR IN HOSPITALIZED PATIENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS Accept Background: Diagnostic error is commonly defined as a missed or delayed diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of diagnostic errors in hospitalized patients.Methods: A systematic literature search was conducted using MEDLINE, Embase, Web of Science, and the Cochrane library from database inception through July 9, 2019. We included all studies of hospitalized adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias using the Joanna Briggs Institute Checklist for Prevalence Studies. Diagnostic error rates were pooled using a random-effects model. Between-study heterogeneity was estimated using the I² statistic. Subgroup analysis and meta-regression were performed using study level variables including geographic location, exclusion criteria, definitions of adverse event and diagnostic error, and study risk of bias. Statistical analysis was performed using metaprop, metareg and metafunnel commands in Stata/MP, version 15.1 (StataCorp, College Station, Texas).Results: Twenty-two studies including 80,026 patients and 760 diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5-1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%), pulmonary embolism (n=13, 9.6%), aortic aneurysm (n=5, 3.7%), congestive heart failure (n=5, 3.7%), urinary tract infection (n=5, 3.7%), and gastrointestinal perforation (n=5, 3.7%). In the United States, these estimates correspond to approximately 249,900 diagnostic errors yearly.Conclusions: Based on physician review, at least 0.7% of admissions involve a diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. This is fundamental information for patients and physicians who are interested in improving the diagnostic process.References:

174 NALOXONE AVAILABILITY IN NEW MEXICO 1335089 Anastasiya (Stacy) Haponyuk University of New Mexico School of Medicine Eileen Barrett University of New Mexico Tyler Dejong Bethany Gutfrucht Department of Family and Community Medicine, University of New Mexico NALOXONE AVAILABILITY IN NEW MEXICO Accept Background: New Mexico has a long-standing history of implementing harm reduction strategies for the prevention of opioid overdose. Most recently, on June 14, 2019, SB221 added language to the New Mexico Pain Relief Act requiring health care providers prescribing opioid analgesics for 5 days or longer to co-prescribe an opioid antagonist along with written information on how to administer the opioid antagonist. At least one study has identified difficulty for patients filling their opioid antagonist prescription, and patients needing to go to multiple pharmacies may not receive their prescriptions. The purpose of this research was to identify the same-day availability of opioid antagonists by surveying the pharmacies in major New Mexico cities.Methods: To examine barriers from the patient perspective, we performed an audit (“secret shopper”) study of pharmacies in Albuquerque, posing as callers wishing to obtain naloxone. The GoodRX website was used to identify 94 pharmacies in Albuquerque and 106 pharmacies in New Mexican cities outside of Albuquerque, dispensing opioid antagonists. Each location was called during working hours, at least 2 hours prior to closing. We inquired whether naloxone would be available for pick up the same day. If Naloxone was not available for same-day pick up, we asked when it would be available next. Responses were recorded and analyzed from 183 pharmacies. 17 locations were eliminated from analysis because the phone system was down or the pharmacy was permanently closed.Results: Of the pharmacies reached, 84.7% (155/183) reported they have opioid antagonists available for pick up on the same day. Of the 15.3% (28) pharmacies that did not have same day availability, (17) 60.7% reported availability in 1-2 days, (1) 3.6% pharmacies had availability in 3-4 days, (1) 3.6% of pharmacies had availability in 1 week, and (9) 32.1% pharmacies were unsure of next availability. Of the major cities surveyed in NM, Albuquerque (71.8%), Farmington (87.5%), Rio Rancho (90%), and Las Cruces (93.7%) had the lowest rates of same-day Naloxone availability. Santa Fe, Roswell, Los Lunas, Hobbs, Carlsbad, Taos, Alamogordo, Silver City, Edgewood, Gallup, Espanola, Ruidoso, Belen, and Las Vegas, had 100% same-day availability of Naloxone in all the pharmacies surveyed.Conclusions: The availability of opioid antagonists in New Mexican pharmacies has not been previously studied, and initial results suggest unpredictable same-day availability. Many patients have misgiving about opioid antagonists, and it places a burden on patients to go to multiple pharmacies or take multiple trips to fill this medications It is somewhat reassuring that most pharmacies without same day naloxone availability would have this within several days, but this delay may reduce the likelihood patients will get fill prescriptions. Opportunities to increase availability exist. Given that hospitalists commonly prescribe opioid antagonists, the topic of Naloxone availability requires further study. Further research may focus on examining the effects on patients when opioid antagonist prescriptions are delayed or unavailable, why there is variability in opioid antagonist availability between different cities, and the reasons for uncertainty when opioid antagonists will be available.References: 1. http://www.drugpolicy.org/harm-reduction-new-mexico 2. https://nmhealth.org/publication/view/presentation/2225/ 3. Katzman JA, Bhatt S, Duensing K, Martinez D, Swift R. New Mexico Naloxone Legislation: Targeting those Most in Need. Journal of Drug Abuse. 2017;03(04). doi:10.21767/2471-853x.100067. 4. https://www.nmlegis.gov/Sessions/19%20Regular/final/SB0221.pdf 5. Guadamuz, JS, et al. Availability and Cost of Naloxone Nasal Spray at Pharmacies in Philadelphia, Pennsylvania.JAMA Network Open. 2019;2(6):e195388. doi:10.1001/jamanetworkopen.2019.5388 6. Mueller, S, et alAttitudes Toward Naloxone Prescribing in Clinical Settings: A Qualitative Study of Patients Prescribed High Dose Opioids for Chronic Non-Cancer Pain. J Gen Intern Med. 2017 Mar; 32(3): 277–283.

191 HOW SALTY ARE YOUR FLUIDS? 1334584 Alan Hall University of Kentucky Carlos Ayus Michael Moritz HOW SALTY ARE YOUR FLUIDS? Accept Background: Hypotonic fluids have been historically used for maintenance intravenous fluids (mIVF) in acutely ill children (1). In 2018, the American Academy of Pediatrics released a Clinical Practice Guideline (AAP CPG) recommending that patients 28 days to 18 years receive maintenance isotonic fluids in order to prevent hyponatremia (2). Several published surveys have assessed mIVF prescribing practices in children with higher rates of hypotonic fluids selected (3-7). No published survey has focused on pediatric hospitalists and no survey has been published since the release of the AAP CPG. The goal of this survey was to assess mIVF prescribing practices among pediatric hospitalists after the release of this guideline.Methods: A survey was distributed to the LISTSERV® for the AAP Section on Hospital Medicine asking their primary maintenance fluid choice for children younger than 28 days, 28 days to 1 year, and 1 year to 18 years of age. Respondents were also asked their mIVF choice in four clinical scenarios associated with elevated anti-diuretic hormone (ADH) in either a 27-day-old neonate, a 6-month-old infant, or a 13-year-old adolescent. The survey was developed iteratively using a previously published survey as a guide (6).Results: There were 402 total responses (10.1% response rate). Isotonic solutions were preferred by respondents in older children compared to younger age groups, at 87.8% for the 1-18 years age group compared to 66.3% for the 28 days to 1-year age group and 10.6% for the younger than 28 days age group (all p values Conclusions: Based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH.References: 1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823-832. 2. Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018;142(6): e20183083. 3. Way C, Dhamrait R, Wade A, Walker I. Perioperative fluid therapy in children: a survey of current prescribing practice. Br J Anaesth. 2016;97(3):371–9. 4. Davies P, Hall T, Ali T, Lakhoo K. Intravenous postoperative fluid prescriptions for children: a survey of practice. BMC Surg. 2008;8:10. 5. Keijzers G, McGrath M, Bell C. Survey of paediatric intravenous fluid prescription: Are we safe in what we know and what we do? Emergency Medicine Australasia. 2012;24(1):86-97. 6. Freeman MA, Ayus JC, Moritz ML. Maintenance intravenous fluid prescribing practices among paediatric residents. Acta Paediatr. 2012;101(10):e465–e468. 7. Lee JM, Jung Y, Lee SE, et al. Intravenous fluid prescription practices among pediatric residents in Korea. Korean J Pediatr. 2013;56(7):282–85.

198 SCHEDULE-BASED FAMILY-CENTERED ROUNDS: A QUALITY IMPROVEMENT INITIATIVE TO IMPROVE ROUNDS EFFICIENCY AND NURSING PRESENCE 1334580 Marie Wang Marie Wang R. Marissa Hutauruk Shanna Perales Jenina Chang Joseph Kim Amit Singh Stanford University School of Medicine/Lucile Packard Children's Hospital Stanford SCHEDULE-BASED FAMILY-CENTERED ROUNDS: A QUALITY IMPROVEMENT INITIATIVE TO IMPROVE ROUNDS EFFICIENCY AND NURSING PRESENCE Accept Background: Family-centered rounds on our pediatric hospital medicine teaching service, which cares for patients in multiple units throughout the hospital, are often prolonged with unpredictable progression. This contributes to inconsistent nursing participation, inefficiencies in patient care, and variable end times. Through the implementation of scheduled-based rounding, our aims were to: 1) start 90% of rounds encounters within 30 minutes of the scheduled rounding time, 2) increase nursing presence on rounds to >90%, and 3) increase the percentage of rounds completed by 11:20am to 80% by November 2019.Methods: This initiative started in November 2018 and was focused on the primary pediatric hospital medicine service at a university-affiliated children’s hospital. Our multidisciplinary team, which included attendings, residents, nurses, case management, clinical informatics, interpreter services, and patient and family-centered care representatives, focused on the following key drivers: a shared mental model surrounding team member roles and daily rounding plan, senior resident ownership of the schedule, and enhanced family education. Interventions included: 1) customization and regular improvements of a semi-automated scheduling tool within the electronic medical record; 2) daily schedule management by the senior resident and resident data transparency; 3) real-time rounds notification to nurses via secure text messaging systems; 4) routine e-mail reminders to senior residents upon start of service weeks; 5) interpreter workflow modification to support scheduled rounding times; 6) weekly in-person meetings with the service team and key stakeholders to identify issues in real-time; and 7) family notification of rounding time and enhanced family education on the rounding process. Data were collected daily during rounds by a case manager or an attending physician.Results: As of November 2019, 94% of rounds occurred within 30 minutes of scheduled rounding time, nursing presence increased from 76% to 93% and the percentage of rounds completed by 11:20 am increased from 19% to 74% (Figure 1). After the implementation of scheduled rounds, the percent of residents who were “somewhat” or “extremely satisfied” with rounds increased from 25% to 75% (pConclusions: A multi-faceted scheduled-based rounding intervention which focuses on shared expectations, enhanced communication between team members, resident ownership and family education can improve efficiency and nursing presence during family-centered rounds.References:

202 HOSPITALISTS' EDUCATIONAL NEEDS IN QUALITY IMPROVEMENT AND PATIENT SAFETY VARY BY EXPERIENCE 1335423 Kathleen Abalos Medstar Georgetown University Hospital Anneliese Schleyer UW Medicine/Harborview Medical Center Matthew Cerasale Sarah Baron Montefiore Medical Center Padmaja Pavuluri Children's National Hospital Nishant Tripathi Chiara Mandel HOSPITALISTS' EDUCATIONAL NEEDS IN QUALITY IMPROVEMENT AND PATIENT SAFETY VARY BY EXPERIENCE Accept Background: The Society of Hospital Medicine (SHM) is the academic professional home for more than 16,000 hospitalists around the world [1]. The SHM Quality Improvement (QI) Special Interest Group (SIG), which currently has 813 members including residents and medical students, known as QI enthusiasts, uses an online platform, Hospital Medicine Exchange (HMX), to share project ideas, receive help to overcome barriers, spread QI/Patient Safety (PS) resources, hone QI skills, and interact with colleagues throughout the hospitalist QI/PS community. We performed a survey of members of the SHM HMX community to identify and describe the educational needs and preferences of QI enthusiasts. We further aimed to compare the educational needs of early career QI enthusiasts with those with more experience.Methods: The SHM QI SIG Initiatives subgroup created an 18-item survey in a web-based platform licensed through SHM and distributed it to members of SHM QI SIG and the SHM Open Forum via a post on the HMX platform to elicit information about members’ current involvement and experience in QI/PS and the types of resources and training that they seek. The project received an exemption from the Montefiore Health System Institutional Review Board. Reminders were sent 2 and 4 weeks after the initial post. We compared the educational needs of early career QI/PS enthusiasts (5 years or less of QI/PS experience) and those of more experienced QI/PS enthusiasts (more than 5 years of QI/PS) using Fisher’s Exact Test.Results: A total of 72 SHM HMX members responded to the survey. Respondents expressed an interest in a variety of topics, with the most frequent educational needs being medication safety (35%), length of stay (32%), transitions of care (31%), communication (31%), and readmissions (25%) (Figure 1). Among the respondents, 39% (28) reported having 0-5 years of experience in QI/PS and 37% (27) reported having more than 5 years of experience; 24% (17) did not answer the question regarding their years of QI/PS experience and were excluded from this analysis. Early career QI enthusiasts sought more support with manuscript writing and publication (68% vs 26%, p=0.003) and career development (64% vs 26%, p = 0.007) than their more experienced counterparts; they were also more interested in receiving training at regional meetings (71% vs. 37%, p=0.02) and were less likely to utilize the HMX community on a weekly to monthly basis (57% vs. 85%, p=0.04). Both groups expressed a substantial need for educational content on data analysis, a preference for online resources, and an interest in in-person training. Time was the most common barrier to completing QI/PS training. Cost was more of a barrier for those with less QI/PS experience, but the difference was not statistically significant (46% vs. 26%, p=0.2) (Figure 2).Conclusions: QI/PS enthusiasts at all stages of their career pursue a variety of educational opportunities to develop their QI/PS expertise. Early career QI enthusiasts, in our sample population are more likely to seek support in manuscript writing/publication and career development, are more interested in receiving training at regional meetings, and were less frequent utilizers of the HMX community. Knowledge of target areas of interest by experience will help guide the SHM QI SIG in developing new educational resources and innovative ways to deliver this content. Hospitalist leaders may also benefit as they mentor members of their hospital medicine groups.References: 1. Society of Hospital Medicine. Secondary Society of Hospital Medicine. https://www.hospitalmedicine.org/about/history-mission/

205 IMPROVING PATIENT NAVIGATION AND TIME TO HEMATOPOIETIC STEM CELL TRANSPLANT 1335003 Monica Arnell Baylor College of Medicine Rhonda Williams Cecilia Cai Molly Horstman Sarvari Yellapragada Lindsay Vaclavik, MD IMPROVING PATIENT NAVIGATION AND TIME TO HEMATOPOIETIC STEM CELL TRANSPLANT Accept Background: Hematopoietic stem cell transplantation (HSCT) can be a life-saving and curative therapy in hematological malignancies. Pre-transplant evaluation for HSCT is a multidisciplinary process that can be complicated, time-consuming, and expensive for patients to navigate. The process requires coordination between several medical subspecialties including pulmonary, cardiology, and mental health, in addition to social workers and patients’ families. There is often a narrow window between achieving disease control and preserving performance status in order to receive a transplant. Thus, timely completion of pretransplant evaluation can be vital, as it can affect transplant outcomes and patient mortality. Within the VA medical system, there are three national centers for HSCT, which requires additional multi-center coordination. Our goal was to evaluate the HSCT evaluation process at our VA Medical Center to determine which elements required the most time and effort. We planned to reduce time to transplant in days by 25% for HSCT candidates over two years, from March 2018 to March 2020.Methods: We reviewed data for 49 patients who underwent evaluation for HSCT from 2009-2019. We recorded the time from initiation of transplant evaluation to its completion. We also included time required to obtain studies such as pulmonary function tests (PFT) and transthoracic echocardiogram, as well as dental, mental health, and psychosocial consultant evaluation. A process map (attached) and fishbone diagram revealed several barriers and time-consuming steps. We used Lean Six Sigma principles to learn that the lack of a formal clinic and navigation process were a main source of waste and inefficiency. The interventions performed during the first PDSA cycle included a formal HSCT consult order and clinic appointment, a Telemedicine clinic appointment with national transplant centers, and the hiring of additional mid-level providers to help coordinate evaluation. The second PDSA cycle included an order set for both required lab workup and consult orders, reviewing with subspecialty departments such as cardiology and pulmonary to ensure the most effective means to obtain TTEs and PFTs, respectively, and a printed handout for patients. We used XmR statistical process control charts to evaluate the effect of these interventions. IRB was obtained per institutional protocol.Results: Our baseline process analysis revealed that the psychosocial evaluation, mental health referral, and dental referral took the longest time during HSCT evaluation. After the first PDSA cycle, the average time to HSCT referral improved from 101.9 days to 94.5 days. Patients had improved time from referral placement to completion of dental evaluation, PFTs, and mental health evaluation (XmR chart for dental consult attached). Data collection from the second PDSA cycle is ongoing.Conclusions: Referral for HSCT requires a complex decision-making process with hematology expertise, multidisciplinary evaluation, and interfacility care coordination. At our medical center, the implementation of a formal HSCT evaluation order set, dedicated clinic, and patient education helped reduce dependency on providers for consistent follow-up. Areas for future improvement include a potential formal social work consult and a weekly HSCT team coordinator meeting. There was a tremendous effort on behalf of caregivers to improve patient navigation through this difficult process, which was greatly appreciated.References:

208 THE HOSPITALIST MODEL AND ONCOLOGY: ATTITUDES AND OPPORTUNITIES 1334348 Kathleen Atlas Memorial Sloan Kettering Cancer Center Barbara Egan Caroline Novak Robert Sidlow THE HOSPITALIST MODEL AND ONCOLOGY: ATTITUDES AND OPPORTUNITIES Accept Background: Hospitalists, rather than primary oncologists, are increasingly caring for hospitalized patients with cancer. High medical acuity, complex psycho-social issues, rapidly evolving cancer treatments, advanced care planning, and end-of-life care make management of this patient population especially challenging. The impact of the oncology hospitalist model of care delivery on clinical quality and oncologists’ work satisfaction is unknown.Methods: A 28-item survey assessing oncologists’ experience with, and attitudes toward, the oncology hospitalist model was distributed to all medical oncologists practicing at Memorial Sloan Kettering Cancer Center, a single tertiary cancer center with an established hospitalist program. Quantitative and qualitative data were collected.Results: 102 surveys were received (50% response rate). Only 30% of oncologists agreed that “caring for hospitalized patients is an efficient use of my time.” A majority (81%) reported having a positive experience with hospitalists caring for their patients and felt that hospitalists exhibit a high degree of professionalism (95%). Most agreed that hospitalists communicate appropriately (71%), can diagnose and manage toxicities of cancer therapy (73%), engage in conversation about code status appropriately (71%), provide valuable teaching (96%), and allowed oncologists to pursue other interests (85%). Differences were noted between oncologists who identified as solid tumor specialists compared with those who identified as hematologic malignancy specialists. With regard the statement: “Hospitalists can provide care to hospitalized cancer patients that is equivalent to oncologists,” responses differed between solid tumor oncologists (66% agreed) and hematologic oncologists (29% agreed, p=0.0008). Hematologic oncologists were also significantly more likely to value inpatient service time. Free text responses emphasized the need for close communication between treating oncologist and hospitalist, including during the overnight hours.Conclusions: Oncologists at a tertiary cancer center had positive experiences with hospitalists and agreed that hospitalists provide quality care for their patients. The degree of confidence in hospitalists’ ability to manage common inpatient oncologic scenarios varied between hematologic and solid tumor oncologists; solid tumor oncologists had more confidence in their hospitalist colleagues than did hematologic oncologists.References:

210 FALSELY ELEVATED GLUCOSE LEVEL, IMPLICATION FOR PATIENT CARE AND INPATIENT GLYCEMIC CONTROL METRICS 1335152 Oluwatoyin Balogun Jacobi Medical Center Rita louard Ann Levine Sarah Baron Montefiore Medical Center FALSELY ELEVATED GLUCOSE LEVEL, IMPLICATION FOR PATIENT CARE AND INPATIENT GLYCEMIC CONTROL METRICS Accept Background: With increasing evidence on the impact of hyperglycemia on patient outcomes, hospitals are beginning to move towards using inpatient glucose control as metrics of performance (1-3). However, efforts to improve inpatient glycemic control should assure validity and reliability of laboratory values (4) as these measurements can potentially affect these metrics and how the metrics guide patient care.Methods: This project was carried out in a large urban medical center as a part of a larger quality improvement project aimed at improving glycemic control for hospitalized adults. Three months of laboratory data for all glucose values > 1000mg/dl on a Basic Metabolic Panel (BMP) was extracted from the electronic medical record. This was done to identify targets for improvement in glycemic control for these patients at risk of developing diabetes-associated complications. Chart review was performed to extract relevant clinical data including laboratory and medication data. Three criteria for a likely falsely elevated glucose were created by team consensus: 1. glucose level > 1000 mg/dl on BMP; 2. a subsequent value of glucose by BMP 6.4 recorded in the EMR. Fisher’s exact testing was used for this comparison.Results: Eighty-three instances of glucose level >1000 mg/dl over 3 months were included representing 67 unique patients. Out of these, 26 events (36%) met the criteria as a likely falsely elevated glucose. Eighteen of the events (69%) were based on phlebotomy testing that occurred during concomitant administration of dextrose-containing IVF. Of the 44 elevated glucose events with a documented elevated A1C, only 2 meet criteria for falsely elevated glucose event (5%). Results from Fischer’s exact test showed that likely falsely elevated glucose events were less likely to occur (i.e. did not meet criteria) in patients with an elevated A1C (pConclusions: As hospitals embark on more and more efforts to improve glycemic control in their admitted population, this study demonstrated that some of the highest glucose values in the hospital may, in fact, be falsely elevated glucose values. Additional studies are needed to look into why this might occur and how to prevent it.References: 1.Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB; Management of diabetes and hyperglycemia in hospitals American Diabetes Association Diabetes in Hospitals Writing Committee. 2. Badawi O1, Yeung SY, Rosenfeld BA. Evaluation of glycemic control metrics for intensive care unit populations. Am J Med Qual. 2009 Jul-Aug;24(4):310-20. 3. Cook CB1, Elias B, Kongable GL, Potter DJ, Shepherd KM, McMahon D.Diabetes and hyperglycemia quality improvement efforts in hospitals in the United States: current status, practice variation, and barriers to implementation. Endocr Pract. 2010 Mar-Apr;16(2):219-30 4. Barry H. Ginsberg, M.D., Ph.D. Factors Affecting Blood Glucose Monitoring: Sources of Errors in Measurement. J Diabetes Sci Technol. 2009 Jul 1;3(4):903-13

219 IDENTIFYING AND ADDRESSING OPPORTUNITIES TO IMPROVE PATIENT FALL PREVENTION 1334511 Wendy Chen Mercy Hospital and Medical Center Matthew Cerasale IDENTIFYING AND ADDRESSING OPPORTUNITIES TO IMPROVE PATIENT FALL PREVENTION Accept Background: Fall for hospitalized patients can cause significant injury and have devastating long term consequences for patients with 33% resulting in injury, 4-6% causing serious injury (1). Information is available regarding risk factors for falls and specific patient or nursing centric interventions to prevent falls, but there is little known about the physician perspective in falls and their direct role in post-fall assessments and secondary fall prevention. The perspective of a physician trainee is even less well known, but potentially even more important as they provide care for a large proportion of patients at most hospitals and especially during off-house. The aim of this study is to evaluate Internal Medicine residents baseline knowledge of fall risk factors, appropriate assessment practices, and opportunities for secondary fall prevention.Methods: The project was conducted within an Internal Medicine residency program based in an urban, community hospital. Falls were identified as a safety priority at the hospital level, where ongoing fall tracking was being carefully completed, as well as concurrent nursing education on best practices for falls. To perform a current state assessment internal medicine residents were asked to complete a survey to evaluate their understanding of fall risk factors, post-fall evaluation, and fall prevention practices. The survey was designed as free responses with an a priori design for aggregation of terms into specific categories within each question, and it was delivered during noon lecture at the end of academic year (AY) 2019 for all residents and in orientation for new interns of AY2020. A didactic lecture focused on best practices and internal protocols for fall prevention and post-falls assessment, with a focus on medication review, was delivered after completion of the survey. A follow-up survey was completed for all available residents at a subsequent noon conference. Pre-intervention surveys responses were compared between PGY-1s and PGY2-3s and cumulative pre- and post-intervention surveys were also compared.Results: A total of 46 residents completed the pre-intervention survey, 18 (39%) PGY-1s and 28 (61%) PGY2-3s. There were no significant differences in identification of risk factors, post-falls assessment protocol elements, identification of fall prevention orders within the admission order set, or additional resources for secondary fall prevention between the two groups, aside from post-fall communication (PGY-1 33% vs PGY2-3 7%, p=0.04). Post-intervention (Table 1), residents were significant more likely to know to complete a medication evaluation (7% vs 41 %, p=0.003). Residents were also significantly more likely to acknowledge physical fall-risk patient identifiers, “yellow items” (22 % vs 65%, p=0.002), identify chair alarms as a prevention resource (2% vs 41%, p=Conclusions: Fall assessment and secondary prevention opportunities are not well known to Internal Medicine residents at the study institution. A focused educational sessions was able to significantly improve residents’ knowledge in multiple domains of post-fall evaluations and secondary prevention strategies, but did not alter the overall hospital fall rate.References: Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med. 2004;19(7):732–739. doi:10.1111/j.1525-1497.2004.30387.x

224 COMBATING THE OPIOID EPIDEMIC THROUGH A NALOXONE BEST PRACTICE ALERT AND OTHER QUALITY IMPROVEMENT INTERVENTIONS WITHIN AN ACADEMIC HOSPITAL 1335210 Stephanie Eldred University of Colorado Hospital Tyler Anstett University of Colorado School of Medicine Caitlin Dietsche Abraham Wick Christine Johnston COMBATING THE OPIOID EPIDEMIC THROUGH A NALOXONE BEST PRACTICE ALERT AND OTHER QUALITY IMPROVEMENT INTERVENTIONS WITHIN AN ACADEMIC HOSPITAL Accept Background: Drug overdose deaths involving opioids are on the rise in the setting of the current opioid epidemic in the United States (US).1 In 2017 there were ~46.6 drug overdose deaths a day in the US involving prescription opioids.1 Naloxone is a proven and effective opioid antagonist that is FDA approved for use in the setting of CNS depression or respiratory depression from opioid overdose.3 Despite this known benefit, in the US in 2018 for every 69 high-dose opioid prescriptions written, only one concurrent naloxone prescription was written.2 Similarly, we found that between January 2018 to January 2019, only 2% of patients at high risk for an opioid overdose discharged from our academic institution were being prescribed naloxone. This project aimed to increase prescriptions for naloxone using quality improvement principles which included assessment of provider attitudes, provider education and an electronic health record (EHR) alert.Methods: The population studied included any patient discharged from our academic institution who met criteria for naloxone. Criteria were defined as: opioid prescription without active naloxone prescription + MME>/=90 or history of an opioid overdose or history of an opioid use disorder. Interventions included provider education and institution of a best practice alert (BPA) within the EHR triggering providers to order naloxone when patients met criteria. A retrospective analysis was completed using data collected through the EHR system to analyze the effects of these interventions. Additional data regarding provider attitudes towards naloxone and the BPA was also obtained through surveys. This project is pending IRB approval.Results: A survey of providers suggested that only 16.7% of those surveyed were aware that naloxone is indicated when prescribing opioids at a dose of > 50MME. Following implementation of the BPA, the rate of prescriptions for naloxone to those patients at high risk for overdose increased to 57.6% compared to 2% prior to the BPA (91 orders placed out of 158 BPA triggers). 76% of these prescriptions sent to the hospital pharmacy were filled by patients. Providers were surveyed after implementation of the BPA and 90% felt that they were prescribing more naloxone to high-risk patients since its release. Additionally, 80% of providers felt that the BPA was extremely helpful in improving their rate of naloxone prescriptions for high-risk patients.Conclusions: Deaths related to opioid overdoses are prevalent throughout the United States despite attempts to combat the current opioid epidemic. Prescription medications play a role in these deaths. Healthcare systems can institute interventions to help reduce opioid overdose deaths through the prescription of naloxone. Implementation of an EHR-based BPA at an academic institution can increase the rate at which naloxone is being prescribed for those at risk for opioid overdoses.References: 1. Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2018). Drug and Opioid-Involved Overdose Deaths - United States, 2013-2017. MMWR. Morbidity and mortality weekly report, 67(5152), 1419–1427. doi:10.15585/mmwr.mm675152e1 2. Guy, G. P., Jr, Haegerich, T. M., Evans, M. E., Losby, J. L., Young, R., & Jones, C. M. (2019). Vital Signs: Pharmacy-Based Naloxone Dispensing - United States, 2012-2018. MMWR. Morbidity and mortality weekly report, 68(31), 679–686. doi:10.15585/mmwr.mm6831e1 3. Kerensky, T., & Walley, A. Y. (2017). Opioid overdose prevention and naloxone rescue kits: what we know and what we don't know. Addiction science & clinical practice, 12(1), 4. doi:10.1186/s13722-016-0068-3

226 REDUCING THE HOSPITAL READMISSION RATE OF HEART FAILURE 1334774 Matthew Fallon Creighton University School of Medicine Abhishek Thandra Aravdeep Jhand Venkata Andukuri REDUCING THE HOSPITAL READMISSION RATE OF HEART FAILURE Accept Background: Heart failure (HF) is a major cause of hospital readmissions and healthcare costs. HF patients have the highest rate of unexpected readmission of all diseases tracked by the Centers for Medicare and Medicaid Services (CMS), at 21.2% (1). HF prevalence is also projected to increase 46% from 2012 to 2030, with total costs rising from $30.7 billion to $69.7 billion by 2030 (2). A readmission also increases the risk of both additional hospitalizations and mortality, particularly within one month of discharge (3). Research into improving care of patients during hospitalization and the first month after discharge could reduce both 30-day HF readmissions and mortality.Methods: A mixed-methods model incorporating qualitative and quantitative designs was performed. Data was collected on grounded theory using a sample of HF cases at a single hospital for the goal of facility and system quality improvement. The EMRs of all patients readmitted for HF exacerbation within 30 days of a previous HF admission from January through December 2018 were reviewed. From December 2018 through January 2019, all patients admitted with HF were offered to be interviewed by medical students during their hospital stay in an in-depth individual standardized open-ended interview format to learn more about how they understood and managed their HF and the barriers affecting their care.Results: Chart review: There were 80 30-day readmissions for HF. 45% of readmissions occurred within one week of discharge. 47 of patients (59%) received follow-up with the cardiology clinic or their primary care physician within 7 days of discharge. Another 20 patients (25%) received follow-up in 8-30 days, but 13 patients (16%) were not scheduled for a follow-up appointment. 21 of the 80 patients were discharged on the weekend. Of these 21, follow-up appointments within 7 days were not made for 13, or 62% of all HF patients discharged on the weekend. Interview: 40 patients consented to interview. 22.5% of patients reported having run out of their HF medications at least once. 72.5% of patients reported having a scale at home, but only 27.5% reported measuring their weight daily. 25% of patients were not aware of any relation between their diet and HF, 22.5% reported not monitoring the amount of salt in their diet, and 40% reported not following any fluid restriction recommendations. Few patients reported being able to follow their medication and lifestyle recommendations, as depicted below.Conclusions: Early follow-up has been shown to reduce rates of readmission and mortality (4, 5, 6). In this study, the low rate of early follow-ups for patients discharged on the weekend made it one of the most common factors contributing to readmissions, behind only sepsis, as depicted below. Many outpatient clinics are closed on weekends, so optimizing communication with outpatient clinics throughout the week would close the gap for these patients who require early follow-up appointments. The interview and chart review data showed similar rates of compliance. The interview elicited reasons for noncompliance, including: medication cost, transportation difficulties, underestimating the importance of diet and weight, or not understanding recommendations. Early and regular patient follow up allows for discussion and monitoring of lifestyle changes, optimizing medications, and ensuring access to care. The low rates of patient-reported understanding and compliance with recommendations as well as the high rate of one-week readmission are both areas meriting further study.References: (1) Schwartz, J., Strait, K.M., Keshawarz, A., Vellanky, S.S., Reilly, E.M., Curtis, J.P., … & Suter, L.G. (2014). CMS Hospital Quality Chartbook 2014. Centers of Medicare and Medicaid Services. (2) Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., … & Muntner, P. (2017). Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association. Circulation, 135(10), e146–e603. (3) Solomon, S.D., Dobson, J., Pocock, S., Skali, H., McMurray, J.J., Granger, C.B., … & Pfeffer, M.A. (2007) Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation, 116(13), 1482-1487. doi: 10.1161/CIRCULATIONAHA.107.696906 (4) Bradley, E.H., Curry, L., Horwitz, L.I., Sipsma, H., Wang, Y., Walsh, M.N., Goldmann, D., White, N., Piña, I.L., & Krumholz, H.M. (2013). Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes, 6, 444–450. doi: 10.1161/CIRCOUTCOMES.111.00010 (5) Hernandez, A.F., Greiner, M.A., Fonarow, G.C., Hammill, B.G., Heidenreich, P.A., Yancy, C.W., Peterson, E.D., & Curtis, L.H. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA, 303, 1716–1722. doi:10.1001/jama.2010.533 (6) Lee, K.K., Yang, J., Hernandez, A.F., Steimle, A.E., Go, A.S. (2016). Post-discharge follow-up characteristics associated with 30-day readmission after heart failure hospitalization. Med Care, 54, 365–372. doi: 10.1097/MLR.0000000000000492.

230 REDUCING OVERUSE OF ANTIBIOTIC AT DISCHARGE (ROAD) HOME 1334627 Daniel Giesler University of Michigan Adamo Brancaccio Daraoun Mashrah Jennifer Horowitz Linda Bashaw Twisha Patel David Ratz Tejal Gandhi Valerie Vaughn University of Michigan and VA Ann Arbor Healthcare System REDUCING OVERUSE OF ANTIBIOTIC AT DISCHARGE (ROAD) HOME Accept Background: Antibiotics prescribed at hospital discharge account for over half of antibiotic exposure related to hospitalization and contribute to antibiotic-related harm. We hypothesized that an antibiotic timeout to reconsider antibiotic necessity, selection, and duration prior to discharge could reduce antibiotic overuse. Thus, we conducted a 6 month prospective, controlled pilot study to determine feasibility and acceptability of an antibiotic timeout at discharge.Methods: Between 5/1/2019 and 10/31/2019, we conducted a prospective, non-randomized pilot of a pharmacist-facilitated antibiotic timeout prior to discharge. Both clinical pharmacists and hospitalists received education and a pocket card which outlined institutional guidelines for appropriate antibiotic selection and duration. Patients on the hospital medicine service who were anticipated to be discharged on oral antibiotics and did not meet exclusion criteria (e.g. complicated infection) were eligible for a 4-question antibiotic timeout. The timeout focused on discontinuing unnecessary antibiotics, narrowing broad-spectrum antibiotics, reducing duration, and improving documentation. To facilitate communication, the timeout occurred in person between clinical pharmacists and hospitalists during rounds. In the event of a patient being discharged on antibiotics, the pharmacist was notified via pager and contacted the hospitalist to perform a timeout if not completed previously. Patients on general medicine (resident covered) services who had similar infections served as the control group. Mixed-methods (observations, interviews, surveys) were used to determine our primary outcome of feasibility. Logistic regression was used to look at secondary outcomes of slope/level change post-intervention in adjusted rates of antibiotic use at discharge compared to the control group.Results: Antibiotic data were available on 425 patients and timeout data were available on 288 patients discharged from the hospital medicine service (Table 1). The majority (52%) of timeouts occurred during rounds (Figure 1) with changes made in 51 (18%) patients. The median time to complete a timeout was 5 minutes per pharmacist and 2 minutes per hospitalist. Eighty-five percent of hospitalists agreed/strongly agreed the intervention was useful. Qualitative feedback from pharmacists led us to simplify exclusion criteria. We also found that, due to the perceived value of this intervention, pharmacists often conducted timeouts in the control group. Adjusted rates of antibiotic prescribing at discharge decreased post-intervention, but were not significantly different when compared to changes in prescribing over time in the control group. In the timeout group, antibiotic duration was appropriately documented in 77% of discharge summaries (improved from 57% in 2018; PConclusions: This pilot study demonstrated an antibiotic timeout prior to discharge is feasible, acceptable, and changed prescribing in 18% of patients. Intervention feasibility improved after simplifying exclusion criteria. The high acceptability of the intervention may have led to substantial contamination, limiting the ability of our pilot to demonstrate an effect on prescribing compared to controls. Next steps include expanding the intervention to other services and evaluating the intervention’s effect on antibiotic overuse at discharge.References:

236 ANATOMY OF GENERAL MEDICINE ROUNDS 1335366 David Harmon Oregon Health & Science University Kellie Littlefield Rebecca Harrison Stephanie Halvorson ANATOMY OF GENERAL MEDICINE ROUNDS Accept Background: At our institution, no current standard exists for teaching rounds’ structure or content, which is largely at the discretion of the attending physician. The purpose of this study was to illustrate the "anatomy" of inpatient rounds as a needs assessment for future process improvement efforts.Methods: We performed a descriptive cross-sectional study of general medicine inpatient teaching rounds at a single academic center over a four-month period (Dec., 2018 to Mar., 2019). Five internal medicine teams were observed by trained volunteers during teaching rounds on acute care units. Volunteers accompanied rounds and recorded data including the encounter type (new presentation, follow-up, discharge), unit location, location of rounds (bedside, hallway, team workroom), identity of the "presenter" (student, intern, resident), presentation duration, time spent in the patient’s room, total encounter duration, and travel time between encounters. Also recorded were activities that are locally considered best practice, including RN participation, review of EMR data, placement of orders, explicit teaching by the attending physician or resident, updating a patient-centric whiteboard. Physician interruptions were also tabulated. No patient data were recorded. We performed frequency analyses on activities observed during rounds.Results: 1631 unique patient encounters were observed. The majority of encounters were follow-up visits (91%). Presentations occurred predominantly in the hallway outside the patient room (84%), and less frequently in team workrooms (8%) or inside patient rooms (7%). Interns were the most frequent presenters (48%) followed by residents (28%) and students (25%). The median and average presentation times were 5 and 7 minutes, respectively, and ranged from 0 to 47 minutes. The median and average encounter durations were 13 and 14 minutes, respectively, and ranged from 1 to 70 minutes. The median and average time spent in the patient’s room were 6 and 7 minutes, respectively, and ranged from 0 to 38 minutes. The frequency of other encounter activities included delivery of explicit teaching to the team by the attending physician or resident (62%), nurse participation (55%), review of EMR data (51%), placement of orders in the EMR (34%), and updating of a patient-centered board (29%). Physician interruptions occurred in 24% of encounters. The median and average travel time between encounters was 2 minutes and ranged from 0 to 7 minutes.Conclusions: Although internal medicine attending rounds have long been a cornerstone of hospital-based patient care and medical education, few studies have directly observed their structure or content. These data describe the current state of our institution’s teaching rounds, whose average encounter lasts fewer than 15 minutes, include presentations that typically occur outside patient rooms, involve multiple presenters, usually incorporate overt teaching, often include nurse participation and review of EMR data, and less frequently contain electronic order placement or the updating of patients’ whiteboards. The relatively low frequencies of several ‘best practices’ provide an opportunity to better define what, in fact, constitute best practices and understand barriers to their actualization. Future work will include refining expectations and role descriptions for team members and analyzing factors that may promote adherence to updated best practices.References:

238 INCIDENTALOPATHY: AN UNINTENDED EPIDEMIC IN HOSPITAL MEDICINE 1335415 Niraj Madhani, MD University of Texas Southwestern (UTSW) Anita Hegde Preetha Nair, MD Bryan Block, MD Lindsay Ripley, MD Eugene Chu INCIDENTALOPATHY: AN UNINTENDED EPIDEMIC IN HOSPITAL MEDICINE Accept Background: The use of imaging is highly prevalent in hospitalized patients with about two images performed on every hospitalized patient (Levin et al). While imaging is utilized for specific indications, incidental findings are common with 45.0% of chest CTs resulting in incidentalomas (O’Sullivan et al). Lack of appropriate follow up to incidental findings (IFs) leads to delays in diagnosis and treatment. Previous literature on incidental findings has focused on masses or “incidentalomas.” Incidental findings as a whole, including masses, anatomic abnormalities (AA), medical conditions (MC), and foreign bodies (FB), is an unstudied medical phenomenon. We sought to categorize and determine the prevalence of IFs as well as to characterize the provider’s assessment and plan for those findings.Methods: We reviewed a random sample of 153 patients from the 3,782 patients discharged between January 1 and June 30, 2018 from the Hospital Medicine service at Parkland Memorial Hospital, a 869 bed, academic safety net hospital in Dallas, TX. All x-ray (XR), computed tomography (CT), ultrasound (US), including echocardiogram, magnetic resonance (MR), and nuclear medicine (NM) studies ordered in the emergency department and during hospitalization were included. We assessed studies for type, reason, main findings, and IFs. We defined IFs as any finding found in the radiologists’ “Impressions” not related to the reason for imaging exam or the patient’s principal diagnosis and categorized them into masses, AAs, MCs or FBs. Progress notes one day after the imaging result date and discharge summaries were assessed for documentation of the IF. Follow up was assessed post-discharge and for one year after discharge. Patient adherence to follow up plans was also captured. Any progression or complications from IFs were assessed.Results: We found a total of 246 IFs out of 550 total radiologic studies with an average of 1.6 IFs per patient. Each patient had an average of 3.6 imaging studies. XR was the most common (1.63/patient) with an IF prevalence of 35.0% while CT was the second most common (0.82/patient) with an IF prevalence of 74.5%. While only 2% of imaging was MR, it had an IF prevalence of 50.0%. Anatomic abnormalities were the most prevalent (42.8% of IFs on CT, 53.4% on XR, 54.5% on US), followed by medical conditions (33.3% on CT, 40.9% on XR, 34.5% on US) and masses (22.2% on CT, 4.5% on XR, 10.9% on US). One incidental foreign body was seen. (Table 1) 20.6% of patients with masses had the IF noted on the next progress note and 23.5% had plans in the discharge summary (Table 2). Of the non-mass IFs, 16.4% of patients had the IF noted on the next day progress note and 14.5% had plans in the discharge summary. Nine of the patients showed progression of an IF on subsequent follow up, none of which were felt to be preventable. There were no deaths related to missed IFs.Conclusions: Incidental radiographic findings are common in hospitalized patients. The majority of IFs were not specifically addressed in the discharge plan or in follow up. However, the clinical relevance of many of the IFs is unclear and the “signal to noise” ratio may be diminished. Risk stratifying IFs may help to increase the signal to noise ratio and call notice to IFs that are high risk and require close and reliable follow up.References: Levin DC, Parker L & Rao VM. (2017). Recent Trends in Imaging Use in Hospital Settings: Implications for Future Planning. Journal of the American College of Radiology, 14, 331-336. doi:10.1016/j.jacr.2016.08.025, 10.1016/j.jacr.2016.08.025 O'Sullivan JW, Muntinga T, Grigg S & Ioannidis JPA. (2018). Prevalence and outcomes of incidental imaging findings: umbrella review. BMJ, 361, k2387. doi:10.1136/bmj.k2387, 10.1136/bmj.k2387

242 AVOIDING INSULIN DOSING ERRORS WITH CORRECTIONAL INSULIN IN HOSPITALIZED PATIENTS: FORMULA-BASED VS TABLE-BASED ORDERS 1335033 Patricia Hwang Emory University Hospital Midtown Ethan Molitch-Hou University of Chicago Erika Brechtelsbauer Dhaval Desai Rodolfo Galindo Haritha Katakam Maureen Hinds Karen Robinson Hasan Shabbir Ram Jagannathan Mary Clark Ingrid Pinzon Shanza Ashraf AVOIDING INSULIN DOSING ERRORS WITH CORRECTIONAL INSULIN IN HOSPITALIZED PATIENTS: FORMULA-BASED VS TABLE-BASED ORDERS Accept Background: Correctional insulin is frequently used in the hospital to optimize blood glucose levels before meals or even before bedtime. Dosages are not set and are instead scaled to the blood glucose level obtained just prior to administration. Insulin is considered a high-risk medication as dosing errors can potentially lead to serious adverse events such as hypoglycemia. In our hospital system, one of the hospitals already utilized a table-based order set in which the dosages were predetermined based on blood glucose ranges. Three of the hospitals used a formula-based order set in which nurses calculated the dosage based off the measured glucose level. Current guidelines recommend using a table-based dosing scheme in order to avoid medication errors. We thus created a new order set for our electronic medical record to change insulin dosing to table-based orders which was implemented system-wide.Methods: Data was collected for all hospitalized patients > 18 years of age who received at least one dose of correctional insulin and were admitted to at least one of the four hospitals in the healthcare system between 08/26/2018 and 08/25/2019. The expected calculated dosage of insulin was based on the ordered formula or table and compared with the actual dosage administered to the patient. Dosing errors were defined as 1) over-treatment (if the dose given was higher than the ordered dose), 2) correct dose (if both doses matched), and 3) under-treatment (if the dose given was lower than the ordered dose). Errors which were recorded as a greater than 10 unit difference were eliminated from analysis as a manual review of these error types showed that it comprised only a small portion of total errors. Other errors that were excluded include orders which were incorrectly executed, encounters which occurred mid-transition, and errors in glucose measurement input at the time of administration.Results: In a system consisting of four hospitals, 88,556 corrective insulin doses were evaluated in the pre-intervention group compared with 98,109 doses in the post-intervention group for correct dosing. Hospital 1 already had table-based dosing in both the pre and post intervention groups and had unchanged measurements with 93.2% vs. 93.5% correct dosing in the pre and post intervention groups, respectively. With a transition from formula-based to table-based dosing, Hospital 2 showed an improvement from 87.9% to 93.9% (p Conclusions: Changing from formula-based orders to table-based orders reduced the error rate of correctional insulin administration. It eliminated the need for performing calculations during busy shifts which could lead to increased errors. There was not a major impact on hypo or hyperglycemia from this change and more is needed to maintain glucose levels than just correctional insulin alone.References:

246 CLINICAL AND ECONOMIC IMPACT OF MEDICATION RECONCILIATION BY DESIGNATED WARD-PHARMACISTS IN THE HOSPITALIST MANAGED ACUTE MEDICAL UNIT 1334586 Hye Won Kim Seoul National University Bundang Hospital, South Korea Bogeum Park Anna Baek Yoonhee Kim Yewon Suh Jeongwha Lee Eunsook Lee Juyeun Lee Euni Lee Jong-chan Lee Hee Sun Park Eun Sun Kim Yejee Lim Nak-Hyun Kim Jung Hun Ohn CLINICAL AND ECONOMIC IMPACT OF MEDICATION RECONCILIATION BY DESIGNATED WARD-PHARMACISTS IN THE HOSPITALIST MANAGED ACUTE MEDICAL UNIT Accept Background: Acutely-ill and multimorbid patients are frequently exposed to unintended medication errors after admission and their impacts on patient safety are profound. Designated ward-pharmacists as team members of our Hospital Medicine Center reconcile medications of hospitalized patients by identifying discrepancies in patients' current medications and the medication used in acute care in emergency departments or before admission. The purpose of this study was to evaluate the clinical and economic impact of medication reconciliation by designated ward-pharmacist in the hospitalist managed acute medical unit at a tertiary hospital in Korea.Methods: In this retrospective observational study, intervention records were compared before (April to August 2018) and after (April to August 2019) the implementation of medication reconciliation by designated ward-pharmacists. The pharmacist's interventions were evaluated by the frequencies of interventions, types of interventions and hospitalists’ acceptance rate. Clinical impact of interventions was estimated by the length of stay and the 30-day readmission rate. The Cost avoidance was calculated by taking into account the cost of potential one-day extension of hospitalization without a pharmacist intervention and the clinical significance of the intervention categorized into five levels (potentially lethal, serious, significant, minor, no error).Results: After the designated pharmacist-led medication reconciliation service, frequencies of the intervention was significantly increased from 3.9% (n=59/1327 patients) to 22.1% (n=537/1378 patients) (pConclusions: We showed that implementation of designated ward-pharmacists-led medication reconciliation can improve the numbers and extent of the intervention and potentially significant medication errors were accepted by hospitalists. Successful performance of medication reconciliation can have positive clinical and economic impact in the hospitalist managed acute medical unit.References:

249 IMPLEMENTATION OF STATE HOUSE BILL 451 REQUIREMENTS TO CHANGE INPATIENT DISCHARGE OPIOID PRESCRIBING PRACTICES 1334949 Ginny Kwong Halifax Health Ralph Jacob Halifax Health/Healthien, Inc. Emma Robertson Blackmore IMPLEMENTATION OF STATE HOUSE BILL 451 REQUIREMENTS TO CHANGE INPATIENT DISCHARGE OPIOID PRESCRIBING PRACTICES Accept Background: In an effort to combat the national opioid crisis, our state legislation passed House Bill 451 effective July 1, 2019. It addresses medication overprescribing to decrease morbidity and mortality from opioid misuse, abuse, and overdose. The law has several requirements including discussion of non-opioid treatment alternatives, review of the Prescription Monitoring Drug Program (PDMP) database and providing an Alternatives to Opioid educational pamphlet prior to prescribing, ordering, dispensing or administrating a schedule 2 controlled substance. When discharging inpatients, a 3 day supply of opioids recommended with up to 7 days permissible with documentation of acute pain exception. Here, we describe the development and implementation of processes to meet the state House Bill 451 requirements and examine changes in discharge prescriptions within an urban community-based hospital.Methods: Institutional Oversight: A multidisciplinary AMPS (Assessing and Managing Pain Safely) committee comprising of medical, informatics, quality, and educational leadership was established to address opioid stewardship and data review. Education to Prescribers: Information was disseminated via email to medical staff and residents from the Chief Medical Officer (CMO) over three consecutive months (July through October). Education was grated each month, from overview to detailed requirements concerning safe and responsible opioid prescribing and adherence to the law. In-person education was also provided during a medical staff meeting. Leveraging Informatics: In November, feedback showed that accessing, reviewing and documenting the PDMP prior to each prescription was cumbersome. There was also variation in attestation of patient education and discussion and provision of the pamphlet. Consequently, documentation tools were designed and direct access to the PDMP and educational materials were embedded into the electronic health record. Point of care decision support for opioid prescribing was leveraged in the the hospital electronic opioid ordering system. Prescription Monitoring: Quarterly reports of all inpatient discharge prescriptions were generated by Pharmacy Informatics. Outliers, defined as opioid prescriptions for >7 days or > 42 tablets (or equivalent), were extracted and reviewed by the committee.Results: In the 3 months prior to July, an average of 14% of opioid prescriptions were considered outliers. This decrease to 13% in July and for the next two months, was 8% (z=3.04,pConclusions: Changing prescribing patterns due to required counseling of non-opioid alternatives treatments of acute pain meaningfully impacted prescribing behavior practices. Patient's shared decision making with informed understanding of non-opioid alternatives and potential adverse effects of opioid use significantly decreased the quantity of prescribed opioids for all hospitalized patients at discharge.References: www.flhealthsource.gov/hb-451 Rudd RA. Seth P, David G, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December 2016 Martin L, Laderman M, Hyatt J. Krueger J. Addressing the Opioid Crisis in the United States. IHI Innovation Report. Cambridge, Massachusettes: Institute for Healthcare Improvement: April 2016

250 REDEFINING, REDESIGNING, AND REFINING THE PATIENT GOWN 1334544 Christy Lucas UPMC Children's Hospital of Pittsburgh Nicholas Noverati Thomas Jefferson University Cheryl Dellasega Franklyn Luke REDEFINING, REDESIGNING, AND REFINING THE PATIENT GOWN Accept Background: Patients feel "uncomfortable, vulnerable, and exposed” in their gowns while providers are distressed at seeing and caring for their fellow human beings clad in sub-human “threadbare,” “ugly” garments. The purpose of this study was to create a patient gown based on design suggestions by patients and providers (physicians and nurses) and to refine the novel design through clinical use and feedback from users.Methods: Semi-structured 1:1 standardized interviews were previously conducted with 10 patients, 10 nurses, and 10 physicians at a large academic medical center to understand the attitudes surrounding the patient gown and receive input on a “patient-guided, provider approved” inpatient garment. Stemming from this work, a novel inpatient attire called “U MATTER” was developed and showcased at the Hospital Medicine 2019 “Shark Tank,” garnering feedback from hospital management and executives. Over the last 6 months, U MATTER has undergone several quality improvement (QI) cycles with input from the president of the health system, vice president of linens services, the hospital linens vendor, a professional seamstress, radiology, and health physicists.Results: Recurring participant suggestions for patient gown redesign can be found in Table 1. Among patients interviewed, the top three suggestions for patient gown improvements were: modesty, separates/option for pants, and color. The top three suggestions from nurses were color options, separates/option for pants, and softer fabric. The top three suggestions from physicians were separates/option for pants, color options, and ease of access. Keeping these results in mind, U MATTER was design to include: a faux collar with an access point for central lines/ports; a petal sleeve enabling patient independence in donning/doffing the gown; double-backed construction; a snap-line down the front of the gown to improve exam access and minimize exposure; and a soft, pineapple print jersey fabric. After undergoing QI cycles, several changes were made to the evidence-based design. First, the fabric was changed from jersey to cotton-polyester blend to be able to withstand laundering at 170F. Additionally, the snap line was removed from the front of the gown after an x-ray revealed significant artifact (Image 1). MRI confirmed compatibility of the garment. Thus, an alternative snap-free front-closure with a double-backed rear flap resulted. In looking forward to mass-production, the gown pattern was reduced from 10 pieces to 4, and the number of snaps was halved. The faux collar was eliminated as it was found to be a potential hindrance, and the opening did not sit at a level conducive to its intended purpose of port access. Finally, the pant was modified from a closed drawstring-waist to an open drawstring-waist with Velcro closure to enable ease of donning/doffing and accommodate catheterization.Conclusions: In progressing through the QI cycles, the patient and provider suggestions drove this evidence-based refinement of the design, which will undergo pilot-testing in January 2020 at an outpatient radiology center. For one month, we will ask patients and providers to provide feedback on the latest design using a brief survey inventory that checks for ease of use, comfort, impact on morale, and pragmatics. The current U MATTER design has the option of a single colorful gown and/or quirky pajamas and is compatible with mass-production, hospital-laundering, and multimodal imaging in design and construction.References: Edvardsson D. Balancing between being a person and being a patient – A qualitative study of wearing patient clothing. Int J Nurs Stud. 2009;46(1):4-11. doi:10.1016/j.ijnurstu.2008.08.008. Gordon L and Guttmann S. A user-centered approach to the redesign of the patient hospital gown. Fashion Practice. 2013;5(1):137-51. doi:10.2752/175693813X13559997788961. McDonald E, Dounaevskaia V, and Lee T. Inpatient attire: an opportunity to improve the patient experience. JAMA Intern Med. 2014;174(11):1865-66. doi:10.1001/jamainternmed.2014.4513. Topo P and Iltanen-Tahkavuori S. Scripting patienthood with patient clothing. Soc Sci Med. 2010;70(11):1682-1689. doi:10.1016/j.socscimed.2010.01.050.

260 THE $2.4 MILLION DOLLAR REMINDER: REDUCING MEDICARE 1 DAY WRITE-OFFS DUE TO INAPPROPRIATE ADMISSION ORDERS 1335216 Olufolarin Oke Stanford Health Care Lisa Shieh Benjamin Leung Jason Hom David Svec Michaela Sullivan THE $2.4 MILLION DOLLAR REMINDER: REDUCING MEDICARE 1 DAY WRITE-OFFS DUE TO INAPPROPRIATE ADMISSION ORDERS Accept Background: The designation of a patient as outpatient versus inpatient status at time of discharge affects how hospitals bill Medicare for services because the center for Medicaid and Medicare services (CMS) reimburses hospitals at a higher rate for inpatient when compared to outpatient designation(1). Since the fiscal year of 2014, one of the major benchmarks for outpatient status as defined by CMS was that the expected patient stay was less than 48 hours with a few exceptions such as certain procedures listed by CMS(1). To discourage hospitals from designating patients as inpatient when not appropriate, CMS established the recovery audit program in 2003 to identify and correct past improper payments to hospitals(1) . At Stanford hospital, case managers are supposed to review each patient’s designation prior to discharge for compliance with CMS criteria for inpatient stay. When this safety net fails, Stanford hospital does not bill Medicare for patients who erroneously designated as inpatient. These write-offs as they are called leads to a significant loss of income to Stanford hospital on a yearly basis.Methods: A best practice alert (BPA) intervention was developed and could fire upon signing of discharge order for Medicare patients who have the designation of inpatient but have stayed less than two midnights provided they were in an acute level of care. Upon firing, the primary team would be asked to confer with the case manager who also gets a message to review the patient’s designation as inpatient. All patients that were admitted between July 18, 2019 and October 2019 at Stanford hospital were randomized to the intervention arm (BPA fires) or control (BPA is silent). Chart review was then conducted and information regarding patient’s designation either as inpatient vs outpatient at time of discharge, case manager notes regarding whether inpatient designation was appropriate and BPA override reason in cases where a patient was not converted from inpatient to outpatient was documented. Estimated number of write offs was calculated in the intervention arm using the number of patients that were not converted from inpatient to observation as a surrogate followed by deduction of those who met criteria for inpatient stay after case manager review. Similar calculation was done for the control arm but since not all patients were reviewed by case manager because of lack of BPA reminder, the number of patients who would have met criteria for inpatient stay was estimated using the intervention arm as a surrogate.Results: There were 88 patients in this study; 40 in the control arm and 48 in the intervention arm. In the intervention arm, 40 were converted to outpatient status after case manager review of the patient’s designation. 7 out of the 8 patients who were not converted were deemed to have met criteria for inpatient stay by our case manager leading to an estimated Medicare write off of 1. There were 40 patients in the control arm of which 23 were designated as inpatient at time of discharge for an estimated number of write offs of 17.Conclusions: Using a best practice alert to remind the primary team and case manager to review patient’s designation to ensure appropriate classification as inpatient or outpatient, we were to reduce the estimated number of write offs from 17 to 1 which amounts to 2.4 million dollars in potential savings to Stanford hospital.References: 1. Locke, C., et al., Changes to inpatient versus outpatient hospitalization: Medicare's 2-midnight rule. J Hosp Med, 2015. 10(3): p. 194-201.

278 RETROSPECTIVE ANALYSIS OF INPATIENT REHABILITATION DENIALS: EXAMINING INCREASES IN LENGTH OF STAY FOR MEDICALLY STABLE PATIENTS AWAITING INSURANCE AUTHORIZATIONS 1334452 Corie Tewari Emory Decatur Hospital RETROSPECTIVE ANALYSIS OF INPATIENT REHABILITATION DENIALS: EXAMINING INCREASES IN LENGTH OF STAY FOR MEDICALLY STABLE PATIENTS AWAITING INSURANCE AUTHORIZATIONS Accept Background: The insurance authorization process for Inpatient Rehab Facility (IRF) and Skilled Nursing Facility placement is lengthy. It takes several days for insurance companies to make decisions regarding patient disposition. This creates increased length of stay (LOS) for otherwise medically stable patients. Several factors contribute to delays and include the lack of weekend authorization staff to process referral paperwork. Delays in authorization and disposition cause medically stable patients to remain unnecessarily in acute-care hospital beds, and increase costs when lower levels of care can be utilized. The purpose of this study is to examine LOS increase caused by insurance authorization delays on medically stable patients otherwise ready for discharge. This study seeks to investigate if authorization time mandates would be helpful to facilitate patient disposition.Methods: Data was collected from 6/30/14 to 6/30/19 in patients denied insurance authorization to IRFs. The sample includes 198 IRF-denied candidates that had to find alternative dispositions. 22 were excluded because medical reasons caused delays. 7 patients were excluded because alternative dispositions were chosen. 11 were excluded because identifying information was unavailable. Total sample: 158 patients. Information obtained through E-rehab data was verified through individual patient chart review. The LOS extension was determined by the date patients deemed medically stable for discharge had referrals submitted for IRFs minus the date insurance-authorized dispositions were determined.Results: Of 158 patients denied IRF authorization, the average LOS increase beyond when patients were medically stable for discharge was 5 days. The majority of patients with IRF denials were Medicare Advantage patients (81%), with the highest average increase in LOS attributed to Aetna MA (7 days). Humana MA represented 30% of the MCA patients (5 days of increased LOS). The shortest LOS extension occurred in Cigna private insured patients (3 days).Conclusions: The authorization process for insurers/payers to determine dispositions for medically stable patients creates unnecessary delays in discharge. The average LOS increase per patient awaiting then receiving an alternate disposition after IRF denial is 5 days beyond when they are medically stable for discharge. The majority of LOS extension is due to the authorization process, denial, and seeking an alternative disposition for the patient. Some of LOS extension occurred because weekend authorization staff was lacking by insurance companies. Information is needed to determine if denial appeal processes (peer-to-peer) affects LOS. Limitations include inability to track whether information wasn’t received by payers/insurers and if this contributed to delays. Increased LOS in medically stable patients contributes to patient dissatisfaction, and further risk of hospital-associated illnesses. A mandate or policy could be incorporated to reduce the time which insurers make authorization decisions.References: 1) National Health Expenditure Data, CMS.gov, February 2019 2) How Allina Saved $13 Million By Optimizing Length of Stay, Health Catalyst, 2017 3) State Health Reform: Waivers, Single-Payer, and the Need for Alternative Pathways, Annals of Internal Medicine, J Maroulis, JD, MAS and TK Mackey, MAS, PhD, August 2019 4) Single-Payer Reform – “Medicare for All,” S Woolhandler, MD, MPH and DU Himmelstein, MD, May 2019 5) Legislation: Bill Would Streamline Medicare Advantage Prior Authorizations, J Parker, April 2019

280 CHRONICLING CALORIES: THE CASE OF IMPROVING THE MISSED-DOCUMENTATION OF MALNUTRITION 1334668 Yasaswi Vengalasetti University of Central Florida Jason Hom Mirvaldy Joseph David Svec Meagan Moyer Stanford Health Care Beatriz Astavapranee Lisa Shieh CHRONICLING CALORIES: THE CASE OF IMPROVING THE MISSED-DOCUMENTATION OF MALNUTRITION Accept Background: Anywhere from 20-50% of all hospitalized adult patients are impacted by malnourishment on admission. Although malnutrition has a worldwide impact on patient outcomes, it is frequently under documented. This proves detrimental to patient outcomes as the average length of stay is 1.5 times greater than those not affected by malnutrition. This is further exemplified through the three times greater mortality rate at one year from discharge of malnourished patients. Malnutrition can complicate patient outcomes by increasing length of stay, infection rates, readmission rates, as well as treatment costs. By improving documentation for malnutrition, we have the potential to improve patient outcomes. Malnutrition can be a predictor for many other outcomes, and by documenting the predictor early we have an opportunity to act upon potential complications and improve patient outcomes. At Stanford Hospital, Malnutrition was frequently the number one queried item in the medicine division of the hospital. Malnutrition was queried an average of 18-20 times over the past few years, which is quite high for internal medicine. Given that malnutrition is a complex diagnosis requiring multifaceted care, we have implemented a novel solution of the group note to improve documentation. We believe that integrating the available expertise of our care extended the care team like the registered dieticians into a team note, will allow our physicians to make the diagnosis more confidently, more frequently, and more efficiently. By reducing the number of missed malnutrition diagnoses we should be able to reduce our query rate.Methods: We created an intervention that improves nutritional assessment and captures malnutrition-based diagnoses in an inpatient setting. The study was conducted at the inpatient medicine setting of a tertiary academic medical center. A survey was conducted to understand the comfort and confidence of physicians in diagnosing malnutrition. A macros was set up within a physician’s note that autopopulates from dietician’s note (group note). We combine the results of this group note with that of the physician survey. This measures the physician’s comfort in diagnosing malnutrition and utilizing the dietician in making the diagnosis. We use a test of proportion to compare and contrast the query rate before and after the intervention.Results: Our group note improves malnutrition documentation. Malnutrition was frequently the number one queried at high average of 18-20 times over the past few years. There has been a 55% drop in the number of malnutrition queries for August (8) and September (9) compared to the numbers from three (3) previous months: July (18), June (18), May (17). More than 92% of those surveyed (60% of the new interns) reported using the new progress note template (group note). More than 86% of responders indicated average or below average comfort in distinguishing between the various malnutrition categoriesConclusions: Physicians can partner with dieticians to make the malnutrition diagnosis. With more data in the following months, we will likely be able to show significance for the group note intervention. The wide-spread adoption of the group note can streamline our documentation process. Our intervention is replicable within other divisions and can become a scalable solution improving malnutrition diagnosis at other hospitals.References: 1. K. Funk, C. Ayton. Improving Malnutrition Documentation Enhances Reimbursement. J Am Diet Assoc. 1995;95(4):468-475. 2. Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization , length of stay , readmission and 3-year mortality q. Clin Nutr. 2012;31(3):345-350. doi:10.1016/j.clnu.2011.11.001 3. Raja R, Lim A V, Lim YP, Lim G, Chan SP, Vu CKF. Malnutrition screening in hospitalised patients and its implication on reimbursement. 2004:176-181. 4. Malone A, Hamilton C. The Academy of Nutrition and Dietetics / The American Society for Parenteral and Enteral Nutrition Consensus Malnutrition Characteristics : Application in Practice. 2013. doi:10.1177/0884533613508435 5. Giannopoulos GA, Merriman LR, Rumsey A, Zwiebel DS. Malnutrition Coding 101 : Financial Impact and More Relating CCs and MCCs to Malnutrition Documentation. 2013. doi:10.1177/0884533613508788

286 PREDICTING OBSERVATION STATUS PATIENTS LIKELY TO STAY LESS THAN 24 HOURS USING A MACHINE-LEARNING-BASED TRIAGE TOOL 1334658 Trushar Dungarani Johns Hopkins Medicine Scott Levin Jeremiah Hinson Matthew Toerper Anthony DeAngelo Eric Hamrock StoCastic PREDICTING OBSERVATION STATUS PATIENTS LIKELY TO STAY LESS THAN 24 HOURS USING A MACHINE-LEARNING-BASED TRIAGE TOOL Accept Background: Observation status was designed to reduce health care costs for patients in need of short hospital stays. CMS suggests that observation care should typically require less than 24 hours, and only rarely last more than 48 hours. However, studies suggest that length of stay for observation patients is often longer than CMS guidance.[1,2] An observation unit filled with patients who are long stay (>24hours) are mismatched for the competency of a high turnover observation unit. Correctly identifying short-stay observation status patients at the time of emergency department (ED) disposition decision should reduce hospital denials and improve operations by reducing internal transfers, avoidable handoffs (physician/nursing), ED boarding time and inappropriate utilization of environmental services.Methods: Our ED is currently using a machine-learning-based clinical decision support (CDS) tool for triage. The tool predicts patient’s risk of critical care, emergency procedure, and hospitalization using routinely available ER triage data: complaints, vital signs, demographics, and past medical history.[4, 5] Risk is translated to triage level recommendations that may be accepted or overridden by the triage nurse. We aim to use this same tool with collaboration of our physicians to predict the likelihood of hospitalization less than 24 hours. We performed a retrospective observational study and applied this CDS tool to a cohort of adult ED patients triaged at a community-based hospital between January 1, 2018 and September 1, 2019. Those hospitalized were eligible to receive the decision support. The major outcome was predicting the likelihood of a patient being in the hospital < 30 hours from arrival (6 hours ED LOS + 24-hour hospitalization). Performance measures, AUC, sensitivity, specificity all evaluate out-of-sample using 5-fold cross-validation. In this new workflow, upon decision to hospitalize, our hospitalist would still have the ability to change the patient status from ER to Observation or Inpatient. If meeting short-stay criteria, a CDS message would be displayed in the Electronic Health Record to place the patient in both observation status and in our observation unit. Our provider has final discretion on this decision.Results: Applying our model to a cohort of 101,426 adult ED patients triaged at Howard County General Hospital, ultimately 30,459 (30%) were hospitalized and eligible to receive the decision support as seen in Figure 1. Of those hospitalized, 15,536 (51%) were short-stays. The AUC for predicting short stay patients at ED triage was 0.82. Selecting a 78% risk of short-stay threshold, an estimated 7,443 (24%) of hospitalized patients would receive a viewable warning that the patient is likely short-stay. This would represent and estimated 38% sensitivity and 80% specificity in accurately identifying short-stay patients.Conclusions: By utilizing a clinical decision tool that identifies patients who will stay in the hospital less than 24 hours, we are able to correctly identify short stay observation patients as well as preferentially place these patients in an observation unit designed for high turnover. More than 40% of all nurse case manager job postings are now for status determination work, shifting duties from patient care and quality improvement.[3] This tool shows potential for improved predictive performance over the resource intensive use involved to make this decision more accurate and cost effective.References: 1. Hockenberry JM, Mutter R, Barrett M, Parlato J, Ross MA. Factors associated with prolonged observation services stays and the impact of long stays on patient cost. Health Serv Res. 2014;49(3):893–909. 2. Sheehy, AM, Graf, B, Gangireddy, S, Hoffman, R, Ehlenbach, M, Heidke, M, Heidkle C, Fields, S, Liegel, B. Jacobs, EA. Hospitalized but not Admitted: Characteristics of Patients with “Observation Status” at an Academic Medical Center. JAMA Intern Med. Nov. 25, 2013; 173(21): 1991-1998. 3. Reynolds J. Another look at roles and functions: has hospital case management lost its way? Prof Case Manag. 2013;18(5):246-254. doi: 10.1097/NCM.0b013e31829c8aa8. 4. Levin S, Toerper M, Hamrock E, Hinson J, Barnes S, Gardner H, Dugas A, Linton B, Kirsch T, Kelen G. Machine Learning-Based Triage More Accurately Differentiates Patients with Respect to Clinical Outcomes Compared to the Emergency Severity Index. Ann Emerg Med. 71(5):565-574, 2018. PMID 28888332 5. Dugas A, Kirsch T, Toerper M, Korley F, Yenokyan G, France D, Hager D, Levin S. An Electronic Emergency Triage System Improves Patient Distribution. J Emerg Med. 50(6):910-918, 2016. PMID 27133736.

288 RATE OF MEDICATION DISCREPANCIES IN DISCHARGE DOCUMENTATION 1335603 Taylor Roberts UT Southwestern Medical Center Nimish Shah Brian Duffy Timothy Brown Emmanuel Johnson Nainesh Shah UT Southwestern RATE OF MEDICATION DISCREPANCIES IN DISCHARGE DOCUMENTATION Accept Background: The hospital discharge process is challenging and opportune for human error. Medication discrepancies continue to be a patient-safety problem, exacerbated with the multiple sources of discharge medication documentation. Medication discrepancies may lead to medication errors and may contribute to adverse drug events with potential subsequent healthcare utilization and cost. Discharge medications can be listed within discharge summaries (DS), patient discharge instructions (DI), or the electronically-generated discharge medication list (eDML) given to the patient in the after visit summary (AVS). Within the electronic health record (EHR) at our institution, each of these document types can contain unique discharge medication lists, creating opportunities for discrepancies. Clinicians have routinely used EHR developed links to import medication lists into DS and DI. The rates of medication documentation discrepancies at our academic institution is unknown.Methods: This retrospective study was conducted at an academic tertiary care county hospital. We performed a randomized chart review of 239 discharge encounters with an equal number of encounters from medicine, surgery, cardiology, and ob-gyn services. Discharge encounters between January 1 and March 30, 2017 were studied. We compared medication names, number of medications, dosages, and signatures among the DS, DI, and eDML for each encounter. In April 2017, the EHR governance committee disabled many commonly used links being used to import discharge medications lists. Post-intervention, a similar retrospective randomized chart review of 240 discharge encounters was conducted. Encounters from the same services were studied between July 1 and September 30, 2017.Results: Prior to the intervention, at the county hospital, 57% of DS contained a medication list, and 28% of these lists had errors. Post-intervention, these rates fell to 34% and 26%, respectively (Table 1). Prior to the intervention, 43% of DI contained a medication list, and 53% of these lists had errors at Parkland. Post-intervention, these rates fell to 25 % and 38%, respectively (Table 2). The 2 largest categories of discrepancies for both DS and DI lists were: difference in total number of medications listed and difference in medication sig.Conclusions: No prior studies have described discrepancies between discharge medication lists generated in the EHR for the adult hospitalized population. We demonstrate that these discrepancies are prevalent within our institution, and that modifying EHR functions may reduce absolute discharge documentation errors. Patients receiving multiple lists that contain varying number of medications or different medication sigs has a high risk for leading to adverse drug events, increased costs, and increased healthcare utilization. In this study, we show the rate of discrepancies and one approach to decrease the absolute number of discrepancies by modifying EHR functionality.References:

290 HOSPITAL MEDICINE PHYSICIAN ELECTRONIC HEALTH RECORDS UTILIZATION: EFFICIENCY, VARIATION, AND OPPORTUNITIES 1335189 Joseph Vento UT Southwestern Nainesh Shah UT Southwestern Maryam Warsi Brett Moran Anita Hegde Eugene Chu HOSPITAL MEDICINE PHYSICIAN ELECTRONIC HEALTH RECORDS UTILIZATION: EFFICIENCY, VARIATION, AND OPPORTUNITIES Accept Background: Physicians increasingly utilize electronic health records (EHR) to deliver healthcare, and the EHR has been identified as leading source of physician burnout and frustration [Shanafelt et al]. Studies report up to 52.6% of hospitalists exhibit symptoms of burnout [Roberts et al]. However, there is no data to inform how hospital medicine physicians spend their time in EHRs. We sought to understand how hospital medicine physicians partition their time within the EHR as well as the variability among physicians.Methods: We conducted a retrospective cohort study of 44 full time equivalent, day-shift hospital medicine physicians performing direct patient care at our hospital, which uses Epic EHR. We obtained each hospitalist's Epic activity logs for six non-consecutive months between March 2017 and March 2019. Practitioners who were responsible for admitting patients, consulting, moonlighting, or on teaching team with residents for more than 10% of their total shifts within the study periods were excluded from analysis. If a provider worked a number of different shift types within the same month, only hospitalists who conducted daytime, direct care, rounding shifts for 80% or more of a given month were included. Physicians on rounding shifts have on average 14 patient encounters each day. We ranked physicians by total time spent interacting with the EHR and divided them into quartiles. Descriptive analysis was performed using SAS statistical software.Results: We found that hospital medicine physicians at our institution spend a mean of 4.3 hours (± 66.9 minutes) a day in the EHR with a range of 2.2 hours/day to 7.4 hours/day in the EHR. Physicians in the top quartile spent a mean of 3.0 hours ± 31.3 minutes/day in the EHR while physicians in the bottom quartile spent a mean of 5.7 hours ± 57.6 minutes/day in the EHR, with nearly twice as much time in note writing and clinical review. Physicians in the top quartile spend 56 minutes, on average, writing notes while physicians in the bottom quartile take nearly 50 minutes longer, on average, to complete their notes (Figure 1). Physicians spent the most time in the EHR writing notes (mean 86.6 ± 39.9 minutes) and in clinical review (49.0 ± 18.6 minutes), followed by time writing orders (32.8 ± 10.0 minutes) and navigating patient lists (23.8 ± 7.6 minutes) (Figure 1). Physician time in the EHR showed a bimodal distribution with a sharp peak at 0800 and a second, flatter peak between 1300 and 1600 (Figure 2). On average, physicians spend 18.8 (Q1) to 41.4 (Q4) minutes in the EHR between 1800 and 0000 (“pajama time”).Conclusions: For the same tasks, there is large intragroup variation amongst hospital medicine physicians in EHR usage and efficiency. Hospitalists spend a significant amount of “pajama time” in the EHR, potentially contributing to burnout. It is not clear whether those who spend less time in the EHR do so at the cost of quality. EHR customization and EHR proficiency have been suggested to prevent burnout [Dastagir et al]. Physicians who are able to minimize time in the EHR and maintain high quality clinical review, documentation, and patient care may be able to share their EHR practices to optimize the value of time spent in the EHR for others and minimize burnout associated with the EHR.References: Dastagir, M.T., et al., Advanced proficiency EHR training: effect on physicians' EHR efficiency, EHR satisfaction and job satisfaction. AMIA ... Annual Symposium proceedings. AMIA Symposium, 2012. 2012: p. 136-143. Roberts, D.L., et al., A national comparison of burnout and work-life balance among internal medicine hospitalists and outpatient general internists. J Hosp Med, 2014. 9(3): p. 176-81. Shanafelt, T.D., et al., Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clinic Proceedings, 2016. 91(7): p. 836-848.

302 EFFECT OF A TRANSITION TO EHR-BASED DAILY SIGN-OUT ON HOSPITALIST PERCEPTIONS OF HANDOFF 1334897 Maggie Jones UCSF Department of Hospital Medicine Stephanie Conner UCSF David Arboleda Sarah Apgar University of California, San Francisco Molly Kantor EFFECT OF A TRANSITION TO EHR-BASED DAILY SIGN-OUT ON HOSPITALIST PERCEPTIONS OF HANDOFF Accept Background: Handoff is defined as the transfer of information and accountability between providers. In hospital medicine, handoffs occur between day, swing and night providers, risking gaps in communication that can lead to errors and uncertainty in management. Communication deficiencies are identified as a root cause in 70% of sentinel safety events. Optimal implementation of structured handoff on a direct-care hospitalist service is not well described. We hypothesized that the implementation of a standardized IPASS-based daily handoff embedded within our electronic medical record (EMR) would improve hospitalist satisfaction with the handoff process, reduce perceived time spent on handoff and maintain perceived handoff safety.Methods: At our 600 bed, tertiary care urban teaching hospital, daily handoff within the 90-person hospitalist group was historically performed using a semi-structured free-text email exchanged by day, swing and night providers. A standardized handoff tool using IPASS structure was developed using available fields in our EMR. These included Illness Severity, Patient Summary, Action List/To-Dos and Situational Awareness/Contingencies as well as space to record cross-cover events. A user guide was developed by a volunteer task force of hospitalists using an iterative process until consensus was reached. The new handoff process was introduced to hospitalists through email and faculty meetings. On-site support was available for troubleshooting during roll-out. A survey was sent to daytime and cross-cover (swing and night) hospitalists to assess satisfaction, perception of time spent on preparing handoff, and perceived safety of the handoff process prior to the implementation of the EMR-based handoff and again four months after implementation.Results: Of the 90-person hospitalist group, 72 worked relevant shifts during the study period and 100% implemented the change during the first shift worked after roll-out. Response rates were 57% (41/72) to the first survey and 56% (40/72) to the second survey. Survey results were analyzed using unpaired t-tests. Average satisfaction with daily handoff as rated from 1 (completely dissatisfied) to 10 (completely satisfied) increased significantly from 6.73 to 8.67 (PConclusions: In this intervention, we aimed to assess the impact of a transition from free-text, email-based handoff to a standardized, IPASS structured, EMR-based handoff tool. The transition led to a statistically significant improvement in hospitalist satisfaction with daily handoff overall and a reduction in time spent preparing handoff. In addition, there were significant improvement in hospitalists’ perceptions of efficiency, the ability to promote safe cross-cover care, and work-life balance. Hospitalist groups could consider similar interventions to improve providers’ experience with these daily care transitions.References:

316 CUMULATIVE LAXATION RESPONSE WITH METHYLNALTREXONE: IMPLICATIONS FOR HOSPITALIZED PATIENTS WITH ADVANCED ILLNESS AND OPIOID-INDUCED CONSTIPATION 1335278 Neal Slatkin Salix Pharmaceuticals David Farchadi Loma Linda University Medical Center Nancy Stambler Robert Israel Michael Matus CUMULATIVE LAXATION RESPONSE WITH METHYLNALTREXONE: IMPLICATIONS FOR HOSPITALIZED PATIENTS WITH ADVANCED ILLNESS AND OPIOID-INDUCED CONSTIPATION Accept Background: Hospitalized patients with advanced illness often encounter constipation when receiving treatment for pain. Methylnaltrexone (MNTX, Relistor®) is a peripherally acting μ-opioid receptor antagonist used to treat opioid-induced constipation (OIC), which does not affect opioid central analgesia. This post hoc analysis evaluated cumulative laxation response rates in adults with advanced illness and laxative refractory OIC who had varying levels of baseline functional status.Methods: Data were pooled from 2 randomized, double-blind, placebo-controlled studies of laxative-treated patients with advanced illness. Both studies received appropriate Institutional Review Board approval. Patients received subcutaneous (SC) MNTX 0.15 mg/kg or placebo (study 302) or SC MNTX 8 mg (38–Results: The pooled analysis included 364 patients (MNTX=179; placebo=185). The median age was 66 years in each group. Approximately 52% were women; 94% were white. The primary diagnosis was cancer (63.4%), followed by cardiovascular disorders (11.3%) and pulmonary disease (7.4%), among others. Median baseline opioid morphine equivalent (mg/day) was greater in patients receiving MNTX (156 mg, range 0–4427 mg) vs placebo (130 mg, range, 0–10,160). MNTX treatment significantly improved RFL response 4 hours after the first dose, cumulative second dose, and cumulative third dose, each PConclusions: In a diverse population of laxative-treated advanced-illness patients with OIC, MNTX significantly improved RFL responses 4 hours after the first dose compared with placebo; the cumulative response continued after the second and third doses and was maintained regardless of baseline ECOG/WHO status, indicating that MNTX efficacy was not impacted by varying degrees of functional performance status. Opioid analgesia was maintained, and side effects were generally reflective of effective laxation. These findings have implications for hospitalized advanced-illness patients with OIC.References:

320 SELF-REPORTED PENICILLIN ALLERGY: PREVALENCE AND CHARACTERISTICS AMONG ADULTS ADMITTED TO A COMMUNITY HOSPITAL IN SOUTH BRONX 1334890 Mayurapriya Velusamy Lincoln Medical and Mental Health Center Jung Yun Lincoln Medical Center Maksim Shmargun Svyatoslav Polishchuk Syeda Fatima Ali Leela Kantamneni Wendy Moh Marcia Gossai Moiz Kasubhai Addi Feinstein David Erstein Vidya Menon Gregory Hoge SELF-REPORTED PENICILLIN ALLERGY: PREVALENCE AND CHARACTERISTICS AMONG ADULTS ADMITTED TO A COMMUNITY HOSPITAL IN SOUTH BRONX Accept Background: Self-reported penicillin (PCN) allergy affects 7-10% of the community population and affects almost 20% of hospitalized patients nationally [1,2]. Mislabeling of side effects (gastrointestinal symptoms) or coincidental events (headache) as a true allergic reaction (IgE-mediated type I hypersensitivity) contributes largely to statistics. In recent studies, the rate of positive skin test results to PCN in self-reported PCN allergic patients is only 1% to 8%. Unverified PCN allergy in hospitalized patients is associated with longer hospital stays and increased rates of serious drug-resistant infections [3]. Patients with self-reported PCN allergy frequently receive suboptimal antibiotic therapy, which is associated with higher health care costs and increased morbidity. The Choosing Wisely campaign of the American Board of Internal Medicine Foundation recommended in 2014 that clinicians do not overuse non-beta lactam antibiotics in patients with a history of PCN allergy, without an appropriate evaluation [4]. The aim of study was to assess the prevalence and characteristics of self-reported PCN allergy among adult inpatients admitted to Lincoln Medical Center.Methods: Retrospective analysis from January 2016 - June 2019 of all adult inpatients with self-reported PCN allergy was performed. Patient characteristics included clinical history consistent with a true PCN allergy, mislabeled side effects, coincidental effects, coexistent asthma and allergies, and admitting diagnosis. Use of alternate antibiotics among patients admitted with infections and prevalence of infections due to methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant enterococcus (VRE) were also examined.Results: The prevalence of self-reported PCN allergy among all admitted inpatients was 4.2%. Our cohort included 2,742 patients with selfreported PCN allergy, of which 995 (36%) were males and 1,747 (64%) were females. 376 (14%) patients had true PCN allergy, while 1,799 (65%) patients had other adverse symptoms not consistent with a true PCN allergy and 567 (21%) patients had no documented allergy symptoms. 31 patients had mislabeling of side effects (nausea/vomiting), while 16 had coincidental effects like dizziness and headache. 679 (25%) patients had a history of asthma, while 761 (28%) patients had other co-existent allergies. Of the 422 (1%) patients admitted for infection, 160 (38%) patients had respiratory tract infections, 119 (28%) patients had skin and soft tissue infections, and 69 (16%) patients had genitourinary infections. 344 (81%) patients required alternate classes of antibiotics – vancomycin (120 patients; 35%), carbapenem (42 patients; 0.2%) and quinolone (238 patients; 69%) – for management of infections during their hospital stay. Among these individuals, 117 (34%) patients received suboptimal therapy, and 32 (9%) patients in the cohort had MRSA infection while 12 (3%) patients had VRE infection.Conclusions: Routine performance of PCN allergy testing for patients with self-reported PCN allergy will lead to a greater proportion of patients safely receiving penicillin [5]. This will decrease costs of care, enhance patient safety, improve outcomes of care, and reduce emergence of multidrug-resistant infections.References: (1) Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010;126477-522. (2) Solensky R, Khan DA, Bernstein IL, Bloomberg GR, Castells MC, Mendelson LM, et al. Drug allergy: an updated parameter. Ann Allergy Asthma Immunol 2010;105259-73. (3) Salkind AR, Cuddy PG, Foxworth JW. Is this patient allergic to penicillin? An evidence-based analysis of the likelihood of penicillin allergy. JAMA 2001;2852498-505. (4) Blumenthal KG, Wickner PG, Hurwitz S, Pricco N. Tackling inpatient penicillin allergies: assessing tools for antimicrobial stewardship. J Allergy Clin Immunol 2017;140154-61. (5) Lang DM, Castells MC, Khan DA, Macy EM, Murphy AW. Penicillin Allergy Testing Should Be Performed Routinely in Patients with Self-Reported Penicillin Allergy. J Allergy Clin Immunol Pract. 2017;5(2):333-334. doi: 10.1016/j.jaip.2016.12.010.

326 A TIME AND MOTION (T&M) PILOT STUDY OF NEBULIZED COPD THERAPY IN US INPATIENT AND LONG-TERM CARE (LTC) SETTINGS 1334646 Brooks Kuhn UC Davis School of Medicine Grace Leung Grant Maclaine Hemal Shah Bryan Nichols Erwin De Cock A TIME AND MOTION (T&M) PILOT STUDY OF NEBULIZED COPD THERAPY IN US INPATIENT AND LONG-TERM CARE (LTC) SETTINGS Accept Background: Hospitals and LTC facilities devote substantial staff time to treating COPD patients requiring intense care. Standard of care (SoC) treatment includes nebulized short-acting beta agonists and muscarinic antagonists (SABA, SAMA, or SABA+SAMA). There is a lack of quantitative data on HCP time dedicated to nebulizations. Workflow mapping confirmed the suitability of T&M methodology to accurately quantify HCP time. The goal of this pilot study was to quantify HCP time and costs associated with nebulized COPD therapy in US inpatient and LTC settings, and to estimate potential efficiencies that could result from newer therapies with less frequent dosing regimens.Methods: One HCP from each setting completed a survey to describe center characteristics, COPD treatment, and nebulization workflow focused on SABA (albuterol; ALB) and SABA+SAMA (ipratropium bromide and albuterol sulfate; IP/ALB). A Case Report Form (CRF) was built to reflect nebulization workflow. IRB approval for 20 observations was obtained at each site. Staff received training, collected data using stopwatches, and recorded data in the CRF. Time was translated to costs using publicly available salary data and local purchase prices for materials.Results: Inpatient observations included 3 ALB and 17 IP/ALB (2 initial and 18 subsequent nebulizations); LTC observations included 5 ALB and 15 IP/ALB (8 patients were cognitively impaired, 12 not). At the inpatient site, all tasks were performed by a respiratory therapist (RT) and at the LTC site by a nurse (RN). Average process time was 16.13 minutes in inpatient (95% CI: 14.48-17.77) and 21.02 minutes in LTC (95% CI: 18.80-23.23), of which 50% and 67% respectively were nebulization time (see Figure 1). At the LTC site, confidence intervals suggest a difference by cognitive impairment status: mean 24.06 minutes (95% CI: 21.29-26.84) if cognitively impaired vs. 18.98 minutes (95% CI: 16.12-21.84) if not impaired. Process time weighted by cognitive impairment status (71% of COPD patients are reportedly impaired and 29% not) is 22.59 minutes. Time/cost modelling compares an estimated frequency of nebulized SoC per day (current dosing) with once-daily dosing. In the inpatient setting, an observed 4.8 nebulizations per day of IP/ALB (weighted by COPD exacerbation severity) and an average LOS of 5.4 days amounts to 7.8 hours of nebulization time per admission. A once-daily nebulized drug would amount to 2.3 hours of nebulization time per admission, a 70% reduction in time. In the LTC setting, current dosing of 2.6 nebulized SoC per day amounts to 32.2 hours of nebulization time per month, while a once-daily nebulized drug would require 13.8 hours, a 57% reduction. In both settings, nebulization materials (one tubing set and one mask/mouthpiece) are stored after nebulization and typically replaced every 9 uses. Applying RT/RN salary data to time spent, average cost of HCP time and materials per nebulization is $8.33 in the inpatient setting and $13.82 in the LTC setting (see Figure 2). Cost modelling in the inpatient setting yields $243 per admission with current dosing versus $72 with once-daily dosing (70% reduction); in the LTC setting, $1,180 per month with current dosing versus $506 with once-daily dosing (57% reduction).Conclusions: The nebulization process for COPD patients consumes quantifiable HCP time and associated costs. A switch from ALB or IP/ALB to a drug with once-daily nebulization could generate sizable time savings, depending on setting of care and individual site characteristics.References:

328 TUMOR LYSIS SYNDROME: AN UNDER-RECOGNIZED ONCOLOGIC EMERGENCY IN PROSTATE CANCER 1334782 Dawood Findakly Creighton University School of Medicine Jue Wang University of Arizona Cancer Center at SJHMC TUMOR LYSIS SYNDROME: AN UNDER-RECOGNIZED ONCOLOGIC EMERGENCY IN PROSTATE CANCER Accept Background: Tumor lysis syndrome (TLS) is a major life-threatening oncological emergency where accelerated damage of rapidly proliferating tumor cells results in critical metabolic derangements including hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia potentially leading to acute kidney injury (AKI) and multi-organ failure. TLS has been well documented in hematologic malignancies but is extremely rare in solid neoplasms, particularly in prostate cancer. In this article, we investigate the clinical characteristics and outcomes of TLS in the available literature and our practice relevant to patients with prostate cancer.Methods: We conducted a systematic review with a comprehensive literature search for published cases of TLS in prostate cancer. Statistical analysis of the pooled data from the literature search and cases identified at our institution were described.Results: We recognized 18 publications where TLS occurred in the setting of prostate cancer out of which 12 were treatment-related TLS and 6 happened spontaneously. Also, we identified four cases of spontaneous TLS diagnosed in our institutional database. The final cohort was consistent with a total of 22 prostate cancer patients with TLS. The median age of patients was 68 years and the median prostate-specific antigen was 374. The majority of cases were prostate adenocarcinoma (except one with prostate rhabdomyosarcoma, two cases with small cell prostate carcinoma, and four cases didn’t report the prostate cancer pathology type). TLS occurred as a consequence of cancer therapy in 55% of patients while 45% occurred spontaneously. Chemotherapy was associated with 27% of cases, hormonal therapy was complicated with TLS in 14% of cases, radiation therapy complicated 9% of cases. There was one reported case that developed TLS after treatment with methylprednisolone for pembrolizumab induced acute liver injury (5%). All patients had elevated LDH with other biochemical variables such as uric acid, potassium, phosphorus, and creatinine and all patients received aggressive supportive therapy. Metastasis is documented to the bone in 86.4% and viscera in 59.1% of TLS cases. Fifty percent of cases undergone hemodialysis. Rasburicase used in 55% of cases together with supportive therapy or in combination with hemodialysis and 14% of cases received allopurinol. The mortality rate was 75% among 12 cases of treatment-related TLS. The mortality rate was 30% in the ten patients with spontaneous TLS. No reported mortality in the 4 cases recognized and managed in our hospital.Conclusions: This review highlights the life-threatening nature of TLS, a previously under-recognized complication of prostate cancer. The true incidence of TLS in solid tumors, particularly prostate cancer cases, still need attention as TLS can mimic AKI with metabolic abnormalities in its presentation. Currently, there is insufficient evidence to recommend one particular treatment over others when TLS is suspected. Physicians should be alerted to monitor for TLS. This review provides the most current information regarding the clinical features and outcome of TLS in prostate cancer for the development of optimal management strategies for this rare, but potentially fatal complication.References:

332 SAVING STICKS: ASSESSING PREVALENCE, PROVIDER AWARENESS AND NURSE PERCEPTIONS ABOUT FINGERSTICK BLOOD GLUCOSE TESTING IN HOSPITALIZED PATIENTS 1335007 Anne Linker Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai Jared Dashevsky Icahn School of Medicine at Mount Sinai Madeline Floodstrand Alyssa Gontzes Samir Kamat Caroline Liu Grenye O'Malley SAVING STICKS: ASSESSING PREVALENCE, PROVIDER AWARENESS AND NURSE PERCEPTIONS ABOUT FINGERSTICK BLOOD GLUCOSE TESTING IN HOSPITALIZED PATIENTS Accept Background: Fingerstick blood glucose (FSBG) testing allows inpatient providers to adjust insulin in real time to protect patients from significant hypo- or hyperglycemia. Admitted diabetic patients are often placed on sliding scale insulin with four times per day FSBG testing, regardless of home insulin use. FSBG test materials cost $9 per use (1). We estimate that over $500,000 is spent annually on FSBG supplies for the hospital medicine teaching service (HMTS). In patients who are low risk for inadequate glycemic control, FSBG monitoring may add to nursing workload, cause patient discomfort, and waste resources without improving quality of care. We performed a study to better define the issue, and assess opportunity to reduce FSBG testing in patients with well-controlled type 2 diabetes.Methods: Our student-run team conducted a multi-faceted needs assessment of the HMTS at an urban academic 1,100-bed tertiary care center, including a point prevalence study of hospitalized patients, a provider awareness study, and a nurse perceptions survey. The point prevalence study assessed the number of patients on the HMTS receiving FSBG monitoring, defined as an order for four times per day FSBG tests for any patient, regardless of diabetes history. Patients with active FSBG orders were identified through the EMR. The cross-sectional survey of interns, residents, and hospitalist attendings assessed awareness of FSBG orders, similar to Saint et al’s Foley catheter study (2). Each provider was given a copy of his/her patient list and was asked to identify patients prescribed FSBG in the last 24 hours, without looking at the EMR. Participants were observed to ensure that the EMR was not accessed. The nurse perceptions survey was a multiple-choice five question survey assessing common practice and perceived workload attributed to FSBG testing.Results: 55 of 103 total patients were receiving FSBG during the point prevalence study. The cross-sectional awareness survey was administered to 31 respondents (12 interns, 12 residents, 7 hospitalists). Only 10% (3/31) correctly identified all patients who had FSBG orders. By training level, 8% (1/12) of interns, 8% (1/12) of residents, and 14% (1/7) of attendings correctly identified all patients on FSBG. Among interns, 42% overestimated and 42% underestimated the percentage of patients on FSBG. Among residents, 33% overestimated and 50% underestimated the percentage of patients on FSBG. 70% of attendings underestimated the percentage of patients on FSBG (Figure 1). The mean percentage of patients receiving FSBG testing who were correctly identified was 66%. The nurse perception survey was administered to 28 nurses with 100% completion. 67.9% reported that it takes 4- 6-minutes to administer a FSBG test, and 17.9% reported it takes 7-10 minutes (Figure 2). 60.7% reported that fewer than 50% of patients getting FSBG testing are given insulin in response to test results.Conclusions: Our student-run study demonstrates that FSBG testing is common, that provider awareness of FSBG monitoring is low, and that nurses require 4-10 minutes per fingerstick. In aggregate, FSBG is costly. Residents and attendings were more likely to underestimate the number of patients on FSBG, perhaps because such tasks are often delegated to junior team members. As such, FSBG testing represents a potential quality gap. Our work will inform quality improvement interventions to decrease fingersticks that are not changing care, maximize providers’ time and hospital resources and improve patient experience.References: Healthcare Bluebook. https://healthcarebluebook.com. Accessed November 1, 2019. Saint S, Wiese J, Amory JK, Bernstein ML, Patel UD, Zemencuk JK, Bernstein SJ, Lipsky BA, Hofer TP. Are physicians aware of which of their patients have indwelling urinary catheters?. The American Journal of Medicine. 2000 Oct 15;109(6):476-80.

341 RETROSPECTIVE ANALYSIS OF CLINICAL UTILITY OF RENAL ULTRASOUND IN HOSPITALIZED PATIENTS DIAGNOSED WITH ACUTE KIDNEY INJURY 1334752 Rajat Thawani OHSU Syed Atif Mustafa Varun Tej Gonuguntla Shaurya Sharma Maimonides Medical Center Susan Lin Jason Kim Sanwal Mehta Suhali Kundu Shiran Porat Iqra Aftab Meer Deen Lawrence Wolf RETROSPECTIVE ANALYSIS OF CLINICAL UTILITY OF RENAL ULTRASOUND IN HOSPITALIZED PATIENTS DIAGNOSED WITH ACUTE KIDNEY INJURY Accept Background: Acute kidney injury (AKI) is common in adult hospitalized patients, with the incidence being reported as high as 7.2%. While evaluation of the cause of AKI is often necessary, in hospitalized patients the causes of AKI are more likely to be pre-renal or intrinsic. Previous studies have found that decreased renal perfusion, medications, radiographic contrast media, and sepsis are responsible for AKI in the majority of hospitalized patients. We performed a retrospective analysis of patients who underwent renal sonography for the indication of AKI, and assessed the proportion of those patients who had a scan suggestive of hydronephrosis, as well as those who underwent an intervention to treat hydronephrosis.Methods: In our retrospective observational study, we conducted a chart review of all adult patients in a large urban community teaching hospital in 2017 who underwent renal sonography after admission with the indication of elevated BUN/Creatinine documented in the electronic health record. We excluded patients who were diagnosed with AKI at admission and any patient with relevant missing information. We collected the baseline characteristics for our patients, including comorbidities, labs at admission, and peak creatinine. We then analyzed the renal ultrasound report and any intervention performed based on that report.Results: There were 625 patients in the study, with a mean age of 75.2 +/- 15.0, of which 255 (41%) were female. 312 (50%) of the patients had baseline CKD (Stage I to V). Renal ultrasound reports showed only 45 (7.2%) had hydronephrosis, whereas most of them had increased echogenicity (87.8%). Other important findings included cortical thickening (21.4%) and atrophy (5%). Only 4 (0.16%) subsequently underwent any urologic or interventional radiology procedure to address the hydronephrosis.Conclusions: In this study, only 4 out of 625 patients who underwent renal sonography for hospital acquired AKI had a positive result requiring an intervention. The utility of renal imaging in patients with hospital acquired AKI admitted to a medicine service appears to be limited, and should be investigated more thoroughly by a prospective randomized trial. Meanwhile, hospitals should study ordering patterns of renal sonography and consider implementing high value measures for appropriate ordering of this test.References:

342 THEHOSPITALIZEDPATIENT.COM: EMPOWERING PATIENTS WITH ONLINE KNOWLEDGE AND RESOURCES 1335363 Diana Childers University of California, San Diego THEHOSPITALIZEDPATIENT.COM: EMPOWERING PATIENTS WITH ONLINE KNOWLEDGE AND RESOURCES Accept Background: With 81% of Americans having access to smartphones (1) and 58% using the internet for health related questions (2), there is a need for online resources to prepare patients and families for common experiences in the inpatient setting. The creation of Web based sites for patients and caregivers, such as TheHospitalizedPatient.com, attempts to fill this gap and empower patients, friends and families to understand common aspects of inpatient care and ultimately prepare for discharge.Purpose: TheHospitalizedPatient.com was created to empower patients, friends and families with information and expectations during their hospital stay. The site attempts to address common inpatient scenarios and guide patients to get the most out of their hospital stay prior to discharge. To evaluate the feasibility for use of a website in the inpatient setting, 10 English speaking patients were interviewed regarding their use of smartphones, tablets or computers during their hospital stay.Description: TheHospitalizedPatient.com is a website broken down into 5 key areas: 1) “Top 5” gives 5 pieces of advice for patients and care givers. 2) “Who’s Who,” explains the role of different care providers. 3) “Why Do We Do ‘that?’” goes through common hospital scenarios such as DVT prophylaxis and daily labs. 4) “Tips for Family” gives information on how friends and families can help out their loved ones who are hospitalized. 5) “Preparing for Discharge” explains common discharge scenarios and has links to additional resources. As options after discharge can be overwhelming, this page includes links to resources such as alcohol and drug treatment centers and groups, local nursing facilities and other housing options. To evaluate the feasibility of use, 10 English speaking patients were asked about their ability to use a smartphone, tablet or computer while hospitalized, if their friends or family used a smartphone, tablet or computer during the hospitalization, and if they used their devices for medical information while hospitalized. Of the 10 respondents, 7 used a smart phone while in house, none used a computer. Five reported their family used a smartphone during the hospital stay. All 10 reported that they or their friend or family member used the internet to look up medical information during their hospital stay. Anecdotally, most searched for information regarding their diagnosis, although this was not part of the questionnaire.Conclusions: Trends in America are clearly moving towards an internet based system of information acquisition and exchange. Use of a website is ideal to address common questions and concerns for patients, friends and families. Web based sites, can be easily modified to fit an individual intuition, and duplicated with modifications for another. This is the 2020 version of caring for TheHospitalizedPatient (.com!).References: 1. Pew Research Center, Internet & Technology. Internet/Broadband Fact Sheet. June 12, 2019. 2. Pew Research Center, Internet & Technology. Internet adoption becomes nearly universal among some groups, but others lag behind. May 30, 2013.

360 MICROAGGRESSION RESPONSE TRAINING WORKSHOP FOR INTERNAL MEDICINE RESIDENTS 1335185 Herrick Fisher Brigham and Women's Hospital Paula Chatterjee Jo Shapiro Joel Katz Maria Yialamas MICROAGGRESSION RESPONSE TRAINING WORKSHOP FOR INTERNAL MEDICINE RESIDENTS Accept Background: Microaggressions, defined as verbal or non-verbal communications that convey hostility, invalidation or insult based on an individual’s marginalized status in society, are ubiquitous and harmful in health care and medical training. They occur between and among patients, families, and interprofessional providers of all levels. Prior work has shown that microaggressions can pollute the clinical learning environment by increasing depression and anxiety, lowering self-esteem, impeding productivity and problem-solving, and creating a hostile work environment. Microaggressions are difficult to respond to, especially for medical trainees who are trying to maintain a therapeutic alliance, balance principles of medical ethics, and negotiate professional hierarchies.Purpose: To provide internal medicine residents with practical training on how to recognize and respond to microaggressions from patients and other clinical care team members.Description: We developed a Microaggression Response Toolkit based on a literature review and in consultation with a resident working group that describes various strategies individuals can adopt when they experience a microaggression as a target or as a witness (Figure 1). We designed a fifty-minute interactive workshop for internal medicine residents based on the Toolkit with the goals of: identifying microaggressions using case scenarios; describing the impact of microaggressions on provider wellbeing and the learning environment; and practicing various response strategies. Case scenarios used in the workshop were developed from examples in published works and from resident-reported microaggressions in our hospital. The workshop was led by a PGY3 resident (HF), and participants had access to the toolkit in print and electronically after the workshop. The workshop was delivered three times to approximately 85 residents (15 to 40 residents per session) of mixed post-graduate years (PGY1-PGY3) during April and May 2019, with brief and optional electronic pre- and post-surveys. Response rates varied between workshops, with a total of 55 responses to the pre-workshop (65% response rate, N = 85) and 37 responses to the post-workshop surveys (44% response rate). On the pre-survey, 75% of residents agreed or strongly agreed that training on microaggressions should be part of the residency curriculum (rated as 4 or 5 on a 1-5 Likert scale). In comparing pre- and post-survey responses, we found that residents reported increased comfort with identifying microaggressions (mean 4.1 post-survey vs 3.1 pre-survey), improved understanding of the impact of microaggressions (mean 4.3 post-survey vs 3.6 pre-survey), and increased confidence in responding to microaggressions (mean 3.7 post-survey vs 2.5 pre-survey). On the post-survey, 97% of residents agreed or strongly agreed that the workshop was a worthwhile use of their time (rated as 4 or 5 on a 1-5 Likert scale).Conclusions: Participation in this brief, practical workshop using a Microaggression Response Toolkit was associated with improvements in residents’ self-reported comfort in identifying microaggressions, understanding of their impacts, and confidence in responding to them. Participants found the workshop valuable and wanted such training in the residency curriculum. Future work is needed to determine the durability of these benefits and whether reported comfort with addressing microaggressions translates into real-world experiences.References: Cowan AN. Inappropriate Behavior by Patients and Their Families—Call It Out. JAMA Intern Med. 2018;178(11):1441. Ganote C, Cheung F, Souza T. Microresistance as a Means of Personal Survival and Cultural Change. In: Louisville, KY; 2016:3-7. Lucey CR, Navarro R, King TE. Lessons From an Educational Never Event. JAMA Internal Medicine. 2017;177(10):1415. Sue DW, Alsaidi S, Awad MN, Glaeser E, Calle CZ, Mendez N. Disarming racial microaggressions: Microintervention strategies for targets, White allies, and bystanders. American Psychologist. 2019;74(1):128-142. Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. JAMA Surg. 2019;154(9):868. Wheeler DJ, Zapata J, Davis D, Chou C. Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner. Medical Teacher. October 2018:1-6.

361 POCUS FACULTY PROGRAM DESCRIPTION AND ONE-YEAR EVALUATION 1334606 Michael Janjigian Bellevue Hospital Anne Dembitzer Caroline Srisarajivakul-Klein Khemraj Hardower Deborah Cooke Sondra Zabar Harald Sauthoff POCUS FACULTY PROGRAM DESCRIPTION AND ONE-YEAR EVALUATION Accept Background: Point-of-care ultrasound (POCUS), when integrated with a physical examination, increases accuracy of diagnosis and decreases procedural complications.Purpose: We developed the Integrated Sonographic Competency at NYU (I-ScaN) to train hospitalists in POCUS.Description: The program begins with an intensive 2-day course consisting of lectures, clip reviews, and hands-on training on humans models covering views of the heart, lungs/pleura, abdomen and leg vasculature. Following is a year-long program designed to facilitate retention and improve upon the skills which includes: - hands-on teaching sessions led by local experts - monthly conferences with the course director (HS) - creation of an online portfolio of clips in accordance with standards set by the Society of Hospital Medicine. Graphic displays program features and sequence of assessments - Knowledge test assessing image acquisition, interpretation and integration - Hands-on test on a standardized patient without pathology - Confidence survey of image acquisition and application - Satisfaction survey of program elements - Barriers survey to assess challenges Results: Knowledge test: 2-day vs 1-year (fig 1; 82 and 78%, NS) Hand-on test: 2-day vs 1-year (fig 2; 74 and 74% well done, NS) Confidence survey: 2-day vs 1-year (fig 3; 2.9 and 2.8, NS) Performance on the 1-year knowledge test correlated highly with results on the 1-year hands-on test (fig 4; r=0.8, p<0.001). 19 participants uploaded a total of 2,787 clips. After excluding the 2 outliers, the correlation between the number of clip uploads and 1-year hands-on results was excellent (fig 5; r=0.71, p=0.002). A passing score of 80% was identified at approximately 125 clip uploads (see dotted line). Confidence was not correlative with hands-on performance after the 2-day course but was correlative after 1-year (fig 6a&b; r=0.59, p=0.01). Barriers: Participants felt the portable ultrasound device was less of a barrier for use compared to cart-based machines, though acknowledged not saving clips even when using a handheld probe. Lack of time was listed as the most common barrier.Conclusions: Performance on the 1-year hands-on and knowledge tests did not decay suggesting the program methodology is effective at promoting knowledge and skill retention. Number of clip uploads correlated highly to results of the 1-year hands-on test, with approximately 125 clip uploads corresponding to a passing score on the hands-on test. Performance at 1-year on the hands-on and knowledge tests correlated highly. Confidence correlated with results of the hands-on test only at the 1-year mark, revealing that participants developed awareness of their abilities. Time was reported as the principal barrier both to overall use of POCUS as well as to uploading and labeling of clips.References:

365 ULTRASOUND TRAINING OF HOSPITALISTS BY RESIDENTS--SHIFTS IN CULTURE 1334438 William Novak University of Rochester Jennifer Readlynn University of Rochester School of Medicine Chris Jacob University of Rochester Medical Center Valerie Lang University of Rochester ULTRASOUND TRAINING OF HOSPITALISTS BY RESIDENTS--SHIFTS IN CULTURE Accept Background: We have markedly expanded Point-of-Care Ultrasound (PoCUS) education within our Internal Medicine residency program through multifaceted instructional interventions. But despite an increasing number of trainees familiar with PoCUS, there remains insufficient real-time clinical use and supervision due to a lack of formal PoCUS training and experience among attending faculty. Traditional PoCUS faculty development programs have largely used a multi-day block or “bolus” course approach which is resource-intensive, inefficient, and disruptive to clinical schedules. Moreover, retention of PoCUS skills quickly wanes without subsequent skills reinforcement. Our focused, “drip” method is a dramatic shift from most approaches to faculty PoCUS training.Purpose: The primary goal of our innovation is to increase the number of hospitalist faculty with core skills in PoCUS by implementing more efficient and effective faculty development methods.Description: Our faculty development program is guided by a theoretical framework for the acquisition of expert performance. We aim to increase training efficiency and skills retention by: (1) focusing on six core POCUS views with the greatest relevance; and (2) building on prior conceptual and theoretical work in medical education, including scaffolding learning in small “chunks”, providing opportunity for deliberate practice with direct observation and feedback, and utilizing quizzes for test-enhanced learning. We instituted nine recurrent hands-on noon hour training sessions for teaching hospitalists spread over a one year period. Pre-session video work replaced didactics using a “flipped classroom” model. Residents that had completed a POCUS elective rotation served as the hands-on POCUS instructors for teaching faculty across eight standardized patient stations during each session.Conclusions: Our supportive, low stakes faculty development setting has enabled hospitalists to overcome initial perceived barriers to learning POCUS and has provided a solid foundation of core POCUS skillsets for faculty. Our work has resulted in the development of novel assessment tools, including: (1) a direct observation tool to assess imaging acquisition skills; and (2) on-line quizzes utilizing clinical vignettes and hand-held POCUS videos to assess image interpretation and clinical decision-making skills. Assessment results illustrate excellent faculty skill acquisition through the program. Additionally, we have detailed a steady increase in the integration of point-of-care ultrasound into our clinical teaching services through sequential faculty and resident surveys, rotation evaluations, ultrasound machine logs, and intermittent “diary” sampling of resident teams. Given the faculty development program’s successes, we plan to continue the series and assessment for new faculty during the next academic year.References: 1. Liao SF, Chen PJ, Chao CH, Lee CH. Top-cited publications on point-of-care ultrasound: The evolution of research trends. Amer J Emerg Med. 2018;36:1429-1438. 2. Moore CL, Copel JA. Point-of-Care Ultrasonography. NEJM. 2012;364:749-57. 3. Soni NJ, Schnobrich D, Mathews BK et al. Point-of-Care Ultrasound for Hospitalists: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019; Online Only doi: 10.12788/jhm.3079. 4. Ma IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, Otremba M, Willemot P, Blouw M. Internal medicine point-of-care ultrasound curriculum: consensus recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) group. JGIM. 2017;32:1052-1057. 5. Kimura BJ, Yogo N, O’Connell CW, Phan JN, Showalter BK, Wolfson T. Cardiopulmonary limited ultrasound examination for “quick-look” bedside application. Am J Cardiol. 2011;108:586-90. 6. Mathews BK, Reierson K, Vuong K, Mehta A, Miller P, Koenig S, Narasimhan M. The design and evaluation of the comprehensive hospitalist assessment and mentorship with portfolios (CHAMP) ultrasound program. J Hosp Med. 2018;13:544-550. 7. EDE Bootcamp. Brantford, Ontario, CA. https://emergdoc.com/bootcamp-ede-student/. 8. Kimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Retention of ultrasound skills and training in “Point-of-Care” Cardiac Ultrasound. J Am Soc Echocardiagr. 2016;29:992-997. 9. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychological Review. 1993;100(3):363. 10. McGaghie WC, Siddall VJ, Mazmanian PE, Myers J. Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: effectiveness of continuing medical education: American College of Chest Physicians evidence-based educational guidelines. Chest. 2009;135:62S-68S. 11. Larsen DP, Butler AC, Roediger III, HL. Test—enhanced learning in medical education. Med Educ. 2008;42:959-966. 12. Moulaert V, Verwignen MGM, Rikers R, Scherpbier AJJA. The effects of deliberate practice in undergraduate medical education. Medical Education. 2004;38:1044-1052. 13. Kerfoot BP, Fu Y, Baker H, Connelly D, Ritchey ML, Genega EM. Online spaced education generates transfer and improves long-term retention of diagnostic skills: A randomized controlled trial. J Am Coll Surg. 2010;211:331-337.

382 PATIENT SAFETY IN ACTION: IMPROVING THE QUALITY OF RESIDENT EVENT REPORTING 1334589 Monica Arnell Baylor College of Medicine Rosemary Pfaff Baylor College of Medicine Cecilia Cai Nathan Nowalk Lindsay Vaclavik Molly Horstman Kristen Staggers Xiaofan Huang PATIENT SAFETY IN ACTION: IMPROVING THE QUALITY OF RESIDENT EVENT REPORTING Accept Background: Event reporting has been the cornerstone of patient safety culture since the IOM report “To Err is Human” was published. Over the past 20 years, the medical literature has focused on improving the overall rates, but not the quality, of reporting. To inform change, event reports must have a standard quality of content for use in hospital patient safety efforts.Purpose: The purpose of this study is to test the impact of a practical and measurable intervention to improve the structure and content of event reports submitted by physician trainees.Description: The study involved a one-hour didactic session for Internal Medicine residents delivered during protected educational time. The teaching module was developed with a multidisciplinary team of patient safety leaders. The session included the following: 1. Pre-course survey and event report (10 minutes): We collected data on respondents’ reporting habits and experience. Additionally, residents read a fictitious patient safety event of a narcotic overdose and were asked to write an event report. 2. Interactive case-based course (40 minutes): We included education on the value of event reporting, what happens to reports, and what constitutes a good or bad report. We also walked through a framework for event reporting using a safety event that involved a delay of antibiotic administration. 3. Post-course survey and event report (10 minutes): Residents applied their knowledge by writing a post-course event report for a case involving patient misidentification. The primary measure of the study was the quality of event reporting practices using a comparison of pre- and post-course event reports. Reports were scored using a novel 10-point rubric based on the I-SAFEST model, which was adapted by our team using additional patient safety guidelines. The rubric included items such as event description, staff involved, and action items. The event reports were graded by two independent reviewers and results were analyzed using paired T-tests. Secondary measures of our study were assessed by survey and included event reporting knowledge and attitudes.Conclusions: Data from 41 surveys, including 20 pre- and 21 post-course submissions, were collected from 35% PGY1, 35% PGY2, and 30% PGY3 level residents. Respondents encountered an average of 2.8 events per month and reported these events 25% of the time. The major barriers to reporting included the time required (85%) and the difficulty of using current reporting interfaces (50%). Residents’ ability to correctly identify the key components of the event improved from an average total score of 4.65 to 7.6 (p<0.001) out of a total 10 possible points after the course. The areas of greatest improvement included patient information (p<0.001), staff involved (p<0.001), and the follow-up initiated by the team (p=0.002). Inter-rater agreement on total score was 95.1% with kappa= 0.943 for 41 surveys. In order to learn from our mistakes, the quality of event reporting is critical to support patient safety officers’ review. As information from real-world event reporting is protected and often submitted anonymously, simulated cases are necessary to assess the quality of reporting by providers. Preliminary data shows that residents were able to apply these concepts to the practice of event reporting. Our next step is to offer this session to all internal medicine residents at our institution, and we ultimately aim to teach this module to our medical students as well.References: 1. Kohn LT, Corrigan JM, Donaldson MS. To err is human. Institute of Medicine. 1999. 2. Macrae C. The problem with incident reporting. BMJ Quality and Safety. 2016;25:71–75. 3. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care’s ability to quantify and accurately measure harm reduction. Journal of Patient Safety. 2010;6:247–50. 4. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. BMJ Quality and Safety. 2002;11:15–18. 5. Keefer P, Helms L, Warrier K, et al. SAFEST: Use of a rubric to teach safety reporting to pediatric house officers. Pediatric Quality and Safety. 2017;2:6;e045. 6. VHA National Patient Safety Improvement Handbook. VHA Handbook 1050.01. Published 03/04/2011, Washington, DC. https://psnet.ahrq.gov/resources/resource/1103/VHA-National-Patient-Safety-Improvement-Handbook?q=patient+safety+handbook. 7. Patient Safety Primer: Reporting Patient Safety Events. AHRQ Patient Safety Network. Updated 01/2019. https://psnet.ahrq.gov/primers/primer/13/Reporting-Patient-Safety-Events?q=ncps+event+reporting.

383 REDUCING CATHETER ASSOCCIATED URINARY TRACT INFECTIONS VIA INDICATION BASED ORDERING PAIRED WITH NURSE-DRIVEN REMOVAL PROTOCOL FOR INDWELLING URINARY CATHETERS 1335241 John Bell UC San Diego Health Ian Jenkins Brian Clay UC San Diego Health REDUCING CATHETER ASSOCCIATED URINARY TRACT INFECTIONS VIA INDICATION BASED ORDERING PAIRED WITH NURSE-DRIVEN REMOVAL PROTOCOL FOR INDWELLING URINARY CATHETERS Accept Background: Catheter associated urinary tract infections (CAUTI) are one of the most common hospital acquired infections and cost on average $13,793 per case according to the AHRQ. Many quality and safety organizations including the Society of Hospital Medicine recommend reducing the prevalence of indwelling urinary catheters (IUC) as a means to reduce the incidence of CAUTIs.Purpose: We sought to reduce IUC usage and as a result reduce CAUTI in our health system using indication-based ordering combined with a nurse-driven removal protocol.Description: A multidisciplinary team with representatives from hospital medicine, urology, critical care, nursing and informatics developed two tools aimed at reducing overall IUC usage. We created a new indication based urinary management order-set. This order-set required providers to first identify the reason for urine management, then pointed them to appropriate means. For appropriate indications external collection devices or in-and-out catheterizations were prioritized, and IUC usage was limited to appropriate indications based on a combination of guidelines and consensus of the involved stakeholders. We recommended external collection devices for perineal wound healing, incontinence, urine collection, and end of life comfort. The allowed indications for IUC were brief perioperative care, urine output measurement in a critically ill patient, gross hematuria, urology/gynecology/pelvic procedure, unstable spine/pelvis, failure of external urinary collection device, or urinary retention (with the caveat that in-and-out catheterization is preferred). Providers were also allowed to select “other” as an indication for an IUC but had to specify their reason. Once appropriate indications for IUC had been determined, then stakeholders determined by consensus which indications were amenable for utilizing a nurse-driven removal protocol and which indications required a physician order for catheter removal. The only indications that the nurse-driven removal protocol did not apply to and required a physician order to remove were gross hematuria and urology/gynecology/pelvic procedure. The order-set was placed into use in December of 2018. We supported the initiative with physician and nurse training sessions, fliers, nurse champion outreach, and feedback, but efforts were not intensive. Institution-wide IUC days fell from an average of 9143 IUC days in the 5 quarters prior to implementation to an average of 8082 IUC days per quarter after implementation. The average standardized utilization ratio (SUR; observed over expected utilization) fell from 0.83 before implementation to 0.61 following implementation. Our institutional CAUTI rate fell from an average of 11 CAUTIs per quarter in the 5 quarters prior to implementation to an average of 6 CAUTIs per quarter afterwards. The average standardized infection ratio (SIR; observed over expected CAUTIs) fell from 0.85 prior to implementation to 0.45 following implementation.Conclusions: The combination of indication-based ordering for urine collection management along with the institution of a nurse-driven removal protocol was associated with fewer IUC days and an improved IUC SUR and CAUTI rate/SIR. Our approach may be useful to other institutions attempting to reduce IUC use and complication rates.References: https://www.ahrq.gov/hai/pfp/haccost2017-results.html

385 TWO YEAR IMPLENTATION OF A CODE LEADER SIGN OFF PROCESS 1334315 Jed Cowdell Mayo Clinic Jacksonville Christopher Trautman Andree Koop Myra Irvin Ricardo Pagan Dana Herrigel Michele Lewis Tyler Vadeboncoeur TWO YEAR IMPLENTATION OF A CODE LEADER SIGN OFF PROCESS Accept Background: Hospital based providers are often tasked with leading cardiopulmonary arrest resuscitations known as code blues. This responsibility can be stress provoking and poorly executed without appropriate training resulting in poor patient outcomes. At our academic medical center, internal medicine residents on their inpatient hospital based rotations are responsible for this assignment. The process of ensuring providers are prepared for this responsibility is poorly defined.Purpose: Implementation of a standardized written and simulation-based code leader examination to ensure hospital based medical resident competence for leading code blue scenarios while also improving their perceived level of preparedness for this task.Description: Following a year-long code training course in the simulation center, categorical internal medicine residents were assigned to 1 of 4 sessions to complete a written and simulated examination. The written component consisted of 20 code blue-related questions. The simulated component consisted of 2 code blue scenarios, 1 shockable and 1 non-shockable rhythm case. A score of 80.0% or better on each component was required to pass. All categorical medical residents participated and were given direct feedback following their simulated experience. A post-intervention survey was sent to each participant and based on responses demonstrating an improvement in mean scores for perceived preparedness 64% to 73% (p-value 0.098) to be code leader, this course was repeated the following year which again demonstrated an improved post-intervention perceived preparedness response 48% to 75% (p-value 0.0048).Conclusions: Implementation of a standardized written and simulation-based code leader examination after a year-long course provided a formal process to evaluate internal medicine residents, give feedback prior to promotion to code leader, and increase the level of provider preparedness for this role. This concept could be applied to any hospitalist program responsible for leading codes and looking for a more standardized approach to ensuring competency and comfort for this task.References: 1. Stefan MS, Belforti RK, Langlois G, Rothberg MB. A simulation-based program to train medical residents to lead and perform advanced cardiovascular life support. Hosp Pract (1995). 2011;39(4):63-69. 2. Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;35(7):1668-1672. 3. Price JW, Applegarth O, Vu M, Price JR. Code Blue Emergencies: A Team Task Analysis and Educational Initiative. Can Med Educ J. 2012;3(1):e4-e20. 4. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med. 2006;21(3):251-256. 5. Mickelsen S, McNeil R, Parikh P, Persoff J. Reduced resident "code blue" experience in the era of quality improvement: new challenges in physician training. Acad Med. 2011;86(6):726-730. 6. Wayne DB, Siddall VJ, Butter J, et al. A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills. Acad Med. 2006;81(10 Suppl):S9-S12. 7. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56-61. 8. Wayne DB, Butter J, Siddall VJ, et al. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med. 2005;17(3):210-216. 9. Barsuk JH, Cohen ER, Wayne DB, Siddall VJ, McGaghie WC. Developing a Simulation-Based Mastery Learning Curriculum: Lessons From 11 Years of Advanced Cardiac Life Support. Simul Healthc. 2016;11(1):52-59. 10. Cooper S. Developing leaders for advanced life support: evaluation of a training programme. Resuscitation. 2001;49(1):33-38. 11. Rodgers DL, Bhanji F, McKee BR. Written evaluation is not a predictor for skills performance in an Advanced Cardiovascular Life Support course. Resuscitation. 2010;81(4):453-456. 12. Rodgers DL, Securro S, Jr., Pauley RD. The effect of high-fidelity simulation on educational outcomes in an advanced cardiovascular life support course. Simul Healthc. 2009;4(4):200-206. 13. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. 14. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451. 15. Honarmand K, Mepham C, Ainsworth C, Khalid Z. Adherence to Advanced Cardiovascular Life Support (ACLS) Guidelines During In-Hospital Cardiac Arrest Is Associated With Improved Outcomes. Resuscitation. 2018;129:76-81.

388 A CALL TO ACTION: IMPROVING THE IMPROVEMENT CONFERENCE 1334329 Yingkei Hui St Vincent Hospital Indianapolis Lannie J Cation Stephen C Swinney A CALL TO ACTION: IMPROVING THE IMPROVEMENT CONFERENCE Accept Background: Morbidity and Mortality Conference (MMC) has been recognized as a valuable educational resource in training programs to improve patient safety. Traditional MMCs are often poorly defined in terms of format, goals, and outcomes, leading to ineffective reflection, discussion and action. Increasing evidence suggests that a structured and transparent approach to MMCs results in measurable gains in staff satisfaction and participation, education and quality of patient care. In August 2018, our residency program appointed an MMC Faculty Champion (FC) to redesign our monthly MMCs presented by PGY-3 residents. MMC FC reviewed the literature and met with healthcare leaders to develop a new guideline.Purpose: Under the new guideline, case selection and preparation processes start 4-6 weeks prior to the presentation. Collaboration with Risk Management (RM) and Quality & Patient Safety (QPS) departments plays a key role in eliminating bias and information gaps during the process of RCA. Progress reports on Patient Safety and Quality Improvement (PSQI) projects generated from prior MMC are presented at the beginning of each conference. A standardized case presentation format features a combination of A3 problem-solving methodology and fishbone diagrams based on the Joint Commission RCA types, focusing on topic learning and system improvement opportunity. A collaborative and non-judgmental approach was adopted for a 20-minute, multidisciplinary discussion following the case presentation. Core attendees include Medical Specialists, Intensivist, Supportive teams, Nursing team, ED Care Coordinators, RM, QPS, Clinical Informatics and Pharmacy. The numerous projects generated have prompted us to establish an MMC Process Improvement Team to more effectively generate and conduct PSQI projects in addressing preventable patient safety events at the hospital and system level. We have identified more than 25 proposed system improvement interventions within 9 months. Our MMC is ACCME accredited.Description: To assess the effectiveness of our MMC changes, we conducted a survey with 47 faculty and resident responses. Forty two out of 47 (89.13%) reported that the new M&M format has significantly improved this teaching conference, 47/47 (100%) agreed that the multidisciplinary discussion sessions were valuable, 43/47 (91.39%) reported better understanding in system improvement processes as a result of MMC, 42/47 (89.36%) expressed better understanding of RCA process, 45/47 (95.74%) pointed out that the follow up recaps and take home messages were useful, Even more importantly, 42/47 (89.36%) reported seeing positive changes in patient care processes. Changes include better participation and communication, increased awareness of easily missed events and improved EMR functionality. Additional comments include appreciation of the more organized nature of MMC, residents are better-prepared, excellent team effort and a culture shifted away from individual blame/shame.Conclusions: In summary, we present a program innovation that dramatically transformed our routine MMC into a conference of educational value and system improvement. The significant progress we made demonstrated the importance of collective effort in the structure-process-system-outcome chain. Our conferences provide platforms and opportunities for participants to improve quality of patient care in a safe and nurturing environment. Programs looking to improve their own MMCs might benefit from our experience.References: - M L Bechtold, S Scott, K C Dellsperger, L W Hall, K Nelson, K R Cox; Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasized patient safety, Postgrad Med Journal, 18 April 2008 - Draft Practice Guide for Mortality and Morbidity Meetings - Scottish Mortality and Morbidity Program, Healthcare Improvement Scotland 2016, November 2016 - Daniel S. J. Pang, Frédérik Rousseau-Blass and Jessica M. Pang, Morbidity and Mortality Conferences: A mini Review and Illustrated Application in Veterinary Medicine, Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada, Frontiers in Veterinary Science, 06 March 2018 - Dan Schwarz et al., Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement, BMJ Qual Saf 2011;20:1082e1088. doi:10.1136/bmjqs-2011-000273

389 MEDICAL STUDENTS PREVENTING MEDICAL ERRORS: A STUDENT-LED APPROACH TO PATIENT SAFETY IN PRE-CLINICAL CURRICULUM 1335494 Lauren Bayliss University of Texas Rio Grande Valley Sahar Panjwani University of Texas Rio Grande Valley School of Medicine Daniel Nwosuocha Nelson Gonzalez Ayleen Godreau MEDICAL STUDENTS PREVENTING MEDICAL ERRORS: A STUDENT-LED APPROACH TO PATIENT SAFETY IN PRE-CLINICAL CURRICULUM Accept Background: Preventable medical errors are currently the third leading cause of death in the United States following heart disease and cancer (1). Because of this, patient safety has become an important concern for healthcare systems due to the high costs associated with medical errors as well as the impact on reputation and mortality and morbidity statistics. However, formal education on patient safety and preventable medical errors is often not implemented in the pre-clinical years of medical education and medical students do not learn about these until their third year of medical school.Purpose: Incorporation of patient safety curriculum prior to clinical years may yield favorable results in clerkships and residency as these students will be adequately informed about the importance of patient safety. This study was designed to assess the effectiveness of earlier exposure and education during pre-clinical years and its impact on interest and knowledge about patient safety.Description: A patient safety training was conducted for interested first and second-year medical students and responses were assessed through a pre-test and multiple post-tests, which were administered immediately after the training, at 3-months post-training, and at 6-months post-training. The survey assessed student knowledge on aspects of patient safety, identifying the correct course of action in different scenarios concerning patient safety, and a Likert scale assessing if the training influenced students’ desire to learn about patient safety. As part of the training, alongside presentations on patient safety, students were able to discuss real case scenarios and learn about clinical best practices in an interactive segment with physicians. RStudio was used to perform summary statistics on the categorical variables and chi-square tests to compare the scores between the pre- and post- tests.Conclusions: Seventeen students completed the immediate post-test survey out of twenty-three participants. At this time, the data from the three-month and six-month follow-up are unavailable as that time period has not been met yet. Data showed improvement in students considering themselves to be well-versed in different aspects of patient safety (11.8% to 41.2%) in the pre- and post-training surveys. There was no change in responses between the surveys asking if students felt that the school’s curriculum adequately educated them on patient safety during preclinical years (23.5% to 23.5%). While there were no significant findings, the general trend of improvement in students who considered themselves to be knowledgeable about patient safety prior to the training to after is promising as it does show the effectiveness of the patient safety training. Additionally, there is only a small percentage of students who felt that the school’s curriculum educated them on patient safety, indicating a need to incorporate more patient safety into pre-clinical year curriculum that can be made mandatory for all students to attend. Patient safety is especially important when entering clerkship years and residency as the majority of medical errors occur while patients are in the hospital and students should be prepared to address any issues they see. The lack of significant findings can most likely be attributed to small sample size, which will improve as more of these training sessions are conducted and additional data is collected. The surveys for the 3 and 6-months timepoints will also yield important data to further this analysis.References: Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. Bmj, 353, i2139

396 IMPACT OF EDUCATIONAL MEDICATION CARDS ON PATIENT SATISFACTION SCORES ON AN INPATIENT TELEMETRY UNIT 1334355 Svetlana Akbasheva North Shore University Hospital Tina Glowatz Nicole Ellerbe Lily Yung Northwell Health - North Shore University Hospital IMPACT OF EDUCATIONAL MEDICATION CARDS ON PATIENT SATISFACTION SCORES ON AN INPATIENT TELEMETRY UNIT Accept Background: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is an instrument used to evaluate patient experience and satisfaction during patients’ hospital stay. One of the areas assessed by the survey is education about medications. The survey asks patients how often they were educated about the purpose and possible side effects of any new medications they received, and whether they understood the purpose for taking their medications upon discharge.Purpose: The aim of this quality improvement initiative was to assess whether the use of medication cards to facilitate patient education would improve HCAHPS scores on an inpatient telemetry unit. By improving patients’ understanding of medications, particularly in a heart failure designated specialty floor where numerous new medications are introduced, it may help enforce compliance and decrease the rate of readmissions.Description: Beginning in January 2019, medication cards for 29 commonly initiated drug classes describing medication brand and generic names, indications, common side effects, and potential serious side effects became available on the inpatient telemetry unit. Pharmacy and nursing personnel distributed the medication cards to patients who were initiated on any new medications and anyone who was thought to have potential benefit from medication education. Patient education using the cards was documented in the electronic medical record, and data was collected on the number of medication cards distributed weekly and the percentage of patients who were discharged with at least one medication card. HCAHPS survey scores were monitored to assess the impact of the quality improvement project on patient responses to questions regarding medication education during their hospital stay. From January to July 2019, over 1,000 medication cards were distributed. Twenty-nine percent of all discharges had documented receipt of at least one medication card during their hospitalization. In an anonymous nursing survey distributed in May 2019, 94 percent of nurses on the unit agreed that providing patients with medication cards was easy to incorporate into their daily workflow. HCAHPS scores for all medication related questions improved from 2018 baseline. Overall communication about medications improved from the 12th to 45th percentile. Scores for staff describing what patients’ new medicine was for increased from the 13th to 57th percentile, describing medicine side effects increased from the 13th to the 38th percentile, and patient understanding of the purpose of taking their medications on discharge from the 57th to the 66th percentile. During this time period, the telemetry unit saw a downtrend in readmissions from 142 readmissions down to 112 (January to June 2018 compared to January to June 2019). Readmissions for heart failure averaged 10% compared to the hospital average of 20%.Conclusions: Medication cards appear to be a simple and effective tool that can be incorporated into the daily nursing and pharmacist workflow to ensure that patients are educated about new medications prior to discharge and improve patient satisfaction as indicated by the HCAHPS survey. The downtrend in readmissions since initiation of medication cards suggests the positive impact made by improving patient experience and understanding of their medications.References:

397 META QUALITY IMPROVEMENT: HOW THE QI INITIATIVE SPECIAL INTEREST GROUP USES QI TOOLS 1335037 Sarah Baron Montefiore Medical Center Matthew Cerasale Kathleen Abalos Medstar Georgetown University Hospital Anneliese Schleyer UW Medicine/Harborview Medical Center Nishant Tripathi Chiara Mandel Padmaja Pavuluri Children's National Hospital META QUALITY IMPROVEMENT: HOW THE QI INITIATIVE SPECIAL INTEREST GROUP USES QI TOOLS Accept Background: The Society of Hospital Medicine (SHM)’s Quality Improvement Special Interest Group’s (QI SIG) mission is “to create and maintain a community that promotes quality improvement by connecting quality improvement enthusiasts to each other and the resources necessary to develop and hone quality improvement skills.” The QI Initiative subgroup of QI SIG was charged with improving support for QI enthusiasts within SHM, especially those with advanced QI experience and skills. As leaders in QI methodologies, the subgroup applied its expertise to use by turning its mission and initiative into a Quality Improvement (QI) project itself.Purpose: The purpose of this QI project was to identify opportunities for enhanced support available from SHM and SHM QI SIG for QI enthusiasts with previous experience and skills.Description: The QI SIG Initiatives subgroup was launched in May 2019 and used the QI SIG A3 template, from the HMX (Hospital Medicine Exchange online platform) SIG Library on (Figure 1), as the primary project guidance tool. This allowed the information to be easily shared amongst subgroup members and the QI SIG community at-large and on HMX. The subgroup's initial efforts were to better understand the background and current state of QI support efforts within SHM, i.e. describe the problem. This was accomplished by informal interviews with SHM Hospital Quality and Patient Safety (HQPS) committee members and SHM staff, as well as reviewing content in The Hospitalist, HM19, and the Journal of Hospital Medicine. Based on these data, we determined there was insufficient information about the QI enthusiasts’ true needs to launch a high yield intervention. Thus, the subgroup identified three project aims: 1) Identify QI related roles that hospitalists fill within their institution/healthcare system/at-large 2) Describe QI educational needs within a population of self-identified QI enthusiast hospitalists and 3) Design an educational project to directly address these needs. To accomplish the first two aims, we created and administered a survey for SHM QI enthusiasts via the HMX. As of November 26, 2019, 72 QI enthusiasts have answered the survey. Preliminary analysis of the survey demonstrated that nearly half of the respondents (35/72, 49%) were junior faculty Internists from large hospitals affiliated with large health systems and/or academic centers. For the needs assessment, respondents desired a number of resources including focus on QI methodologies, manuscript preparation, and peer-to-peer mentorship models. When asked about barriers to getting training that they need, time was a significant contributor for nearly two-thirds of respondents. After a more detailed analysis is completed, stratifying for different respondent types and needs, the information will be shared with both the HQPS committee and the SIG’s liaison to the SHM Board. With all the appropriate stakeholders updated, the intervention planning will begin.Conclusions: Applying QI methodology improved our ability to coordinate and accomplish our project aims. SHM's QI content experts were willing to participate in a needs assessment survey. Once our problem description and analysis are complete, the subgroup anticipates designing interventions to address respondents' educational needs.References:

400 IMPROVING CARE FOR HOSPITALIZED PATIENTS WITH OPIOID USE DISORDER 1334769 Dana Clifton Duke University Hospital Noel Ivey Duke University Hospital Shavone Hamilton Noppon Setji Duke University IMPROVING CARE FOR HOSPITALIZED PATIENTS WITH OPIOID USE DISORDER Accept Background: The opioid epidemic, well-recognized as a national emergency, is a wake-up call to physicians. Medication-assisted treatment (MAT) for opioid use disorder (OUD) has been shown to be safe, cost-effective, and reduce mortality; however, MAT use remains low (1-4). More recently, the hospital setting has been seen as a potential starting point for treatment for substance use disorders, with studies showing success with inpatient diagnosis, management and linkage to care post-discharge(5-8). These programs often involve psychiatry or addiction medicine specialists; however, this is not possible in all hospital-based settings. With the increasing demand for hospitalists to initiate medication for OUD(9), there is a need for development of practical and sustainable models for hospitalists to address the burgeoning opioid epidemic.Purpose: Project COMET (Caring for patients with Opioid Misuse through Evidence-based Treatment) is a comprehensive, multi-disciplinary program to improve care for patients hospitalized with OUD. Our objectives include increasing access to and initiation of medication for OUD during hospitalization, as well as increasing referrals to the community for ongoing MAT following discharge.Description: We collected preliminary data on patients hospitalized at a large, academic hospital for an acute medical issue who had a history of intravenous drug use and determined an annual estimated volume of 216 patients. We utilized this data to propose implementation of a program to treat hospitalized patients with OUD. Using this information, we successfully secured health system funding. We utilized a multidisciplinary, collaborative approach to prepare for and launch our hospital-based program. Hospital medicine physicians obtained their DEA-X license and participated in orientation to the program. We had key stakeholder involvement from pharmacy, nursing, acute pain service and infectious disease teams. We launched Project COMET on July 1, 2019. We have a hybrid model, consisting of a primary general medicine service of patients with OUD and also see consultation requests. In the first 4 months of the launch, we have seen 87 individual patients, far exceeding our initial projections. The full-time hospitalists and social worker currently evaluate and treat hospitalized patients with OUD. Our social worker creates partnerships with community organizations to facilitate post-discharge care for each patient. We have successfully discharged patients earlier than anticipated in their hospital stay. Selected patients considered lower risk were discharged home to continue IV antibiotics; others were discharged to a skilled nursing facility to receive IV antibiotics and concomitant MAT; some required no further IV antimicrobials and were discharged to continue MAT in community settings.Conclusions: We have created an innovative, multidisciplinary program to improve care for patients hospitalized with OUD. We continue to refine and improve our program based on data collected and analyzed, as well as experience from those working as part of the program. Project COMET can serve as an example to hospitals and hospitalist providers at other institutions who are interested in implementation of similar services.References: 1. Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies--tackling the opioid-overdose epidemic. N Engl J Med. 2014;370(22):2063-2066. 2. Degenhardt L, Randall D, Hall W, Law M, Butler T, Burns L. Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: risk factors and lives saved. Drug Alcohol Depend. 2009;105(1-2):9-15. 3. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550. 4. Schwartz RP, Gryczynski J, O'Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health. 2013;103(5):917-922. 5. Trowbridge P, Weinstein ZM, Kerensky T, et al. Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1-5. 6. Englander H, Dobbertin K, Lind BK, et al. Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis. J Gen Intern Med. 2019;34(12):2796-2803. 7. Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-1376. 8. Wakeman SE, Metlay JP, Chang Y, Herman GE, Rigotti NA. Inpatient Addiction Consultation for Hospitalized Patients Increases Post-Discharge Abstinence and Reduces Addiction Severity. J Gen Intern Med. 2017;32(8):909-916. 9. Lagisetty P, Bohnert A. Web Exclusives. Annals for Hospitalists Inpatient Notes - The Opioid Epidemic-What's a Hospitalist to Do? Ann Intern Med. 2017;167(2):HO2-HO3.

401 RISK ASSESSMENT TOOL FOR HOSPITALIZED PATIENTS WITH OPIOID USE DISORDER REQUIRING PARENTERAL ANTIMICROBIAL THERAPY 1335082 Noel Ivey Duke University Hospital Dana Clifton Duke University Hospital Kristen Dicks Shavone Hamilton Noppon Setji Duke University RISK ASSESSMENT TOOL FOR HOSPITALIZED PATIENTS WITH OPIOID USE DISORDER REQUIRING PARENTERAL ANTIMICROBIAL THERAPY Accept Background: The opioid epidemic is a well-recognized, national public health emergency. Patients admitted to the hospital with complications of opioid use disorder (OUD) often have complex infections which frequently require lengthy courses of intravenous (IV) antimicrobial therapy (1). Many in the medical community have valid concerns about patient safety and risk of central line misuse in these situations; consequently, many patients remain hospitalized for the duration of their antibiotics courses, leading to high costs and dissatisfied patients (1). We developed criteria to determine if certain hospitalized patients with OUD could be safely discharged with outpatient parenteral antimicrobial therapy (OPAT).Purpose: Project COMET (Caring for patients with Opioid Misuse through Evidence-based Treatment) is a comprehensive, multi-disciplinary program that seeks to improve care of hospitalized patients with opioid use disorder (OUD). Within the framework of this program, we sought to identify criteria which would support earlier discharge from the hospital with OPAT.Description: We launched Project COMET July 1, 2019 after obtaining funding from our health system and meeting with various key stakeholders, including Infectious Disease (ID). In collaboration with our ID colleagues and after reviewing relevant literature (2-4), we created a list of criteria for discharge home with IV antibiotics to be administered via a Peripherally Inserted Central Catheter (PICC) line under the supervision of a home health agency. These criteria included 1) stable living conditions; 2) supportive caregiver; 3) active engagement with providers while hospitalized; 4) readiness to change and stop substance use as determined by social worker; 5) no evidence of ongoing or suspected drug use during current hospitalization; 6) no transportation barriers to outpatient appointments; 7) willingness to sign a contract with home health providers for safe PICC use; 8) providers feel that patient will be safe with home IV antibiotics. Using these criteria, we have discharged seven patients home with OPAT in the four months since we started our project. Six of these patients have completed therapy with one still receiving OPAT. Among these seven patients, we have had no readmissions and there have been no concerns documented for antimicrobial treatment failure or PICC misuse. There is documentation of several missed antibiotic doses, one missed ID follow-up appointment, and one Emergency Room visit during the treatment period. These findings are consistent with other published literature showing high rates of OPAT completion, even in higher-risk populations (2, 5). In our cohort, a total of 184 hospital days were saved due to earlier discharge.Conclusions: A collaborative approach is necessary for optimal care of hospitalized patients with OUD. Many patients with OUD are hospitalized with complex infections requiring lengthy courses of IV antibiotics. A risk assessment tool with eight simple criteria can identify patients who will likely be successful with OPAT with home health and outpatient ID supervision. We hope other institutions can use these criteria to identify patients who may be able to be discharged home earlier, leading to length of stay reductions. This can translate into significant cost savings and improved patient satisfaction. More research is needed to determine the longer-term outcomes of this approach.References: 1. Fanucchi L, Walsh S, Thornton A, et al. Do Persons With Opioid Use Disorder and Injection-Related Infections Really Need Prolonged Hospitalizations to Complete Intravenous Antibiotic Therapy? Open Forum Infect Dis. 2018 Nov; 5(Suppl 1): S44. Published online 2018 Nov 26. doi: 10.1093/ofid/ofy209.105 2. Suzuki J, Johnson J, Montgomery M, et al. Outpatient Parenteral Antimicrobial Therapy Among People Who Inject Drugs: A Review of the Literature. Open Forum Infect Dis. 2018 Sep; 5(9): ofy194. 3. Eaton EF, Mathews RE, Lane PS, et al. A 9-Point Risk Assessment for Patients Who Inject Drugs and Require Intravenous Antibiotics: Focusing Inpatient Resources on Patients at Greatest Risk of Ongoing Drug Use. Clin Infect Dis. 2C019 Mar 5; 68(6):1041-1043. doi: 10.1093/cid/ciy722. 4. Englander H, Mahoney S, Brandt K, et al. Tools to Support Hospital-Based Addiction Care: CoreComponents, Values, and Activities of the Improving Addiction Care Team. J Addict Med. 2019;13(2):85-89. 5. Dobson PM, Loewenthal MR, Schneider K, Lai K. Comparing injecting drug users with others receiving outpatient parenteral antibiotic therapy. Open Forum Infect Dis. 2017; 4:ofx183.

410 USE OF AN EHR TEMPLATE IMPROVES DISCHARGE COMMUNICATION BETWEEN PROVIDERS OF CHILDREN WITH COMPLEX MEDICAL CONDITIONS 1334820 Alexandra Kauffman Phoenix Children's Hospital Charity Adusei-Baah Children’s National Hospital Kyler Black Rotem Fishel Ben-Kenan Phoenix Children's Hospital Sophie Loeb Adrienne Marler Phoenix Children's Hospital Courtney Smith Phoenix Children's Hospital Alexandra Thompson Phoenix Children's Hospital Sandra Gage Phoenix Children's Hospital University of Arizona - Phoenix, School of Medicine Lauren Washatka USE OF AN EHR TEMPLATE IMPROVES DISCHARGE COMMUNICATION BETWEEN PROVIDERS OF CHILDREN WITH COMPLEX MEDICAL CONDITIONS Accept Background: Communication between inpatient (IPP) and outpatient providers (OPP) at discharge is essential for continuity of care. However, studies show that communication is often inconsistent, leading to interruptions in care and patient safety events, especially for patients requiring complex management. The discharge summary (DS) serves as the primary mode of communication between IPP and OPP, but survey of local OPP admitting to our large university affiliated, free-standing children’s hospital indicated that this document was lacking clear instructions for OPP management following discharge.Purpose: Improve OPP post-discharge instruction clarity and completeness within hospital DS for children with medical complexity (CMC) by 50% within 12 months.Description: Improvement team was formed which included a variety of IPP and OPP. Baseline satisfaction and performance measures were obtained via chart review and survey of providers of CMC treated and discharged between 03/01/2019 to 11/21/2019. CMC were defined by the COE4CCN consensus definition for children with medical complexity. Key interventions to improve clarity of DS information and instructions for OPP were implemented. These included modifications of the DS format sent to OPP, education of residents about the importance of the inclusion of relevant information in the DS, creation of a DS EHR tool (dot phrase: Table) to highlight OPP key information and instructions, and education of attending physicians about the EHR tool. Ongoing education for residents working on the complex care unit was performed each month. Interventions resulted in an increase in the inclusion of clear provider instructions in the DS from 33.3% to 75.6% (Figure) which exceeded our goal. Pre and post OPP surveys showed an increase in the perception of clear provider instructions from 38% to 71%.Conclusions: Clear communication is essential for transition of care of CMC between IPP and OPP. Modification of the DS format and introduction of an EHR tool were key interventions in improving inclusion of clear OPP instructions. OPP perceptions of improvement mirrored chart review findings. However, given frequent changes in discharging providers of CMC, frequent reeducation regarding dot phrase use was required. Further interventions are needed to embed this change in the system.References: Coleman, E. A. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555. Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. Jama, 297(8), 831-841. Robelia, P. M., Kashiwagi, D. T., Jenkins, S. M., Newman, J. S., & Sorita, A. (2017). Information Transfer and the Hospital Discharge Summary: National Primary Care Provider Perspectives of Challenges and Opportunities. The Journal of the American Board of Family Medicine, 30(6), 758-765. Simon, T. D., Haaland, W., Hawley, K., Lambka, K., & Mangione-Smith, R. (2018). Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0. Academic pediatrics.

423 USE BEST PRACTICE ALERTS TO PREVENT NSAID INDUCED NEPHROTOXICITY 1334623 Katie Rizzolo University of Colorado Elizabeth Herrle Wendy Craig USE BEST PRACTICE ALERTS TO PREVENT NSAID INDUCED NEPHROTOXICITY Accept Background: Acute Kidney Injury (AKI) is a common hospital problem which may lead to increased mortality, hospital costs, and increased length of stay (1). A leading cause of renal dysfunction in the inpatient population is drug nephrotoxicity. Several studies show that physician prescribers often do not take renal function into account with new or existing prescriptions, often leading to inappropriate dosing of renally cleared medications up to 50% of the time (2).Purpose: Nephrotoxic alerts aimed at informing prescribing providers of acute kidney injury or baseline renal dysfunction have shown statistically significant improvement in changing prescriber habits (3). In particular, interruptive alerts informing providers of the development of AKI or CKD in patients can have a positive impact on careful use of nephrotoxic agents (4,5,6). A clinical decision support system specifically designed for non-steroidal anti inflammatory drugs (NSAID) ordering in the setting of all renal dysfunction, including CKD and AKI, has not been evaluated. We evaluated the use of a best practice alert (BPA) in NSAID ordering for patients with all cause renal dysfunction to determine impact on provider practice and incidence of AKI.Description: The intervention was an interruptive alert in the EMR designed to alert the provider to renal dysfunction. We conducted a pre- post-study of this intervention in patients with documented pre-NSAID creatinine clearance less than 50 mL/min who received an NSAID order during hospitalization. Patients were adults (age >18) admitted to a large tertiary care hospital healthcare system. The phase 1 intervention (1/16/18-7/11/19) was a Best Practice Alert (BPA) triggered at the time of order entry when NSAID was ordered on a patient with a creatinine clearance <50 mL/min. Follow-up phase 2 intervention (7/12/19-10/31/19) was an update to the initial BPA including a display of the individual patient’s current creatinine clearance rather than creatinine alone and a change in override reason from “Risk assessed, order appropriate” to “Override contraindication”, as well as addition of “will remove order” button (Figure 1). We compared patient and provider characteristics between the three study periods, and compared the percentage of BPAs that were overridden by the provider between phases 1 and 2 of the BPA. Over 1,000 unique patients received a BPA in phase 1 after removal of duplicate BPA fires. 33% of orders were removed in total. In phase 2, the rate of removal was further increased (results ongoing). There was no difference between patients’ characteristics such as age and creatinine clearance. Overall, those patients with a CKD or HD flag had a higher rate of removal compared with acknowledgement. Duplicate orders were Home Meds had a lower rate of removal compared with acknowledgement.Conclusions: Clinical Support Systems including Best Practice Alerts (BPAs) have been shown to be helpful in judicious use of nephrotoxic medicines for patients with renal dysfunction. Clinical support systems requiring an override may be more likely to affect provider management. Thus, Clinical Support Systems in the setting of NSAID ordering with renal dysfunction may be helpful in certain ordering provider and clinical patient populations.References: 1. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 2005;16:3365–70. 2. McCoy AB, Waitman LR, Gadd CS, Danciu I, Smith JP, Lewis JB, Schildcrout JS, Peterson JF: A computerized provider order entry intervention for medication safety during acute kidney injury: A quality improvement report. Am J Kidney Dis. 2010; 56: 832–841. 3. Tawadrous D, Sharioff S, Haynes RB, Iansavichus A, Jain A, Garg A. Use of Clinical Decision Support Systems for Kidney-Related Drug Prescribing: A systematic review. AJKD. 2011 4. Pou P, Gonzalez IA, Garcia AI, Garcia- Fernandez N. Improvement of drug prescribing in acute kidney injury with a nephrotoxic drug alert system. European Journal of Hospital Pharmacy.2019 (1): 33-38. 5. Chertow GM, Lee J, Kuperman GJ, Burdick E, Horsky J, Seger DL, Lee R, Mekala A, Song J, Komaroff AL, Bates DW: Guided medication dosing for inpatients with renal insufficiency. JAMA. 2001; 286: 2839–2844. 6. Galanter WL, Didomenico RJ, Polikaitis A: A trial of automated decision support alerts for contraindicated medications using computerized physician order entry. J Am Med Inform Assoc. 2005; 12: 269–274.

425 IMPROVING RESIDENT DISCHARGE SUMMARIES 1335604 Andrew Russell Tulane University School of Medicine Kalyani Kumar Taylor Cravanas David Jensen IMPROVING RESIDENT DISCHARGE SUMMARIES Accept Background: A discharge summary serves as a crucial means of communication between inpatient and outpatient providers. Appropriate transitions of care rely on updates to patient problems, diagnostics, treatment history, and discharge plans. Many studies have identified lacking components in discharge summaries that may lead to poor medical management. In an effort to improve patient transitions of care, many healthcare institutions have surveyed their general practitioners in order to identify the key components of a high-quality discharge summary. A literature review nets over thirty items as potentially important, far more than the mere six outlined by the Joint Commission on the Accreditation of Healthcare Organizations. The most consistently identified items include discharge diagnoses, management plans/follow-up information, discharge medications, and diagnostics. Several interventions for improving discharge summaries by medical residents have been studied. These include didactic curricula, interactive workshops, or combinations of both. While these interventions have demonstrated significant improvement in the quality of discharge summaries, they used different tools and thus cannot be compared to one another. These tools were developed based on Joint Commission standards, consensus recommendations from other guideline-forming healthcare entities, and previously published or newly attained results from physician surveys.Purpose: To identify which components of discharge summaries are most valued by primary care providers among the Tulane Internal Medicine network and develop an intervention to improve resident discharge communication to those providers.Description: The first stage of the project involved surveying primary care attending physicians among two of the three healthcare networks associated with the Tulane University Department of Medicine, including Tulane Internal Medicine residents themselves, who also serve in primary care roles. The next step was to develop an evaluation tool based on these survey results as well as a review of the literature. An intervention was developed to improve resident discharge summaries using this tool as a guide and conducted over a five-week period. Pre- and post-intervention discharge summaries are currently being evaluated with the tool to assess for significant differences.Conclusions: The initial surveys identified the two most important components of discharge summaries as: 1) a brief narrative with a reason for admission, and 2) an accurate discharge medication list. The next most highly emphasized components consisted of: 1) a hospital course by problem, 2) a list of follow-up appointments, 3) outpatient issues to be addressed, 4) tests pending at discharge, and 5) procedures performed while inpatient. This was consistent with a literature review. Overall, the surveys rated the resident discharge summaries as fair to good. An evaluation tool was created weighting the two highest-ranked components greater than the following five components. The intervention involved reviewing the results of the surveys with the residents, discussing the evaluation tool, and having residents practice using the tool to evaluate sample discharge summaries with a partner. Whether this workshop will improve the quality of resident discharge summaries has yet to be seen once the pre- and post-intervention evaluations are complete.References: 1) Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007 Feb 28;297(8):831-41. 2) Gandara E, Moniz T, Ungar J, Lee J, Chan-Macrae M, O'Malley T, Schnipper JL. Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals. J Hosp Med. 2009 Oct;4(8):E28-33. doi: 10.1002/jhm.474. 3) Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-8. 4) Were MC, Li X, Kesterson J, Cadwallader J, Asirwa C, Khan B, Rosenman MB. Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. J Gen Intern Med. 2009 Sep;24(9):1002-6. doi: 10.1007/s11606-009-1057-y. Epub 2009 Jul 3. 5) Alderton M, Callen J. Are general practitioners satisfied with electronic discharge summaries? Health Inf Manag. 2007;36(1):7-12. 6) Greer RC, Liu Y, Crews DC, Jaar BG, Rabb H, Boulware LE. Hospital discharge communications during care transitions for patients with acute kidney injury: a cross-sectional study. BMC Health Serv Res. 2016 Aug 30;16:449. doi: 10.1186/s12913-016-1697-7. 7) Legault K, Ostro J, Khalid Z, Wasi P, You JJ. Quality of discharge summaries prepared by first year internal medicine residents. BMC Med Educ. 2012 Aug 15;12:77. doi: 10.1186/1472-6920-12-77. 8) Perren A, Previsdomini M, Cerutti B, Soldini D, Donghi D, Marone C. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care. 2009 Jun;18(3):205-8. doi: 10.1136/qshc.2007.024588. 9) Grimes T, Delaney T, Duggan C, Kelly JG, Graham IM. Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care. Ir J Med Sci. 2008 Jun;177(2):93-7. doi: 10.1007/s11845-008-0142-2. Epub 2008 Apr 15. 10) Caleres G, Bondesson Å, Midlöv P, Modig S. Elderly at risk in care transitions When discharge summaries are poorly transferred and used -a descriptive study. BMC Health Serv Res. 2018 Oct 11;18(1):770. doi: 10.1186/s12913-018-3581-0. 11) Uitvlugt EB, Siegert CE, Janssen MJ, Nijpels G, Karapinar-Çarkit F. Completeness of medication-related information in discharge letters and post-discharge general practitioner overviews. Int J Clin Pharm. 2015 Dec;37(6):1206-12. doi: 10.1007/s11096-015-0187-z. Epub 2015 Sep 4. 12) Ooi CE, Rofe O, Vienet M, Elliott RA. Improving communication of medication changes using a pharmacist-prepared discharge medication management summary. Int J Clin Pharm. 2017 Apr;39(2):394-402. doi: 10.1007/s11096-017-0435-5. Epub 2017 Mar 11. 13) Monfort AS, Curatolo N, Begue T, Rieutord A, Roy S. Medication at discharge in an orthopaedic surgical ward: quality of information transmission and implementation of a medication reconciliation form. Int J Clin Pharm. 2016 Aug;38(4):838-47. doi: 10.1007/s11096-016-0292-7. Epub 2016 Apr 2. 14) Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003 Aug;18(8):646-51. 15) O'Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, Landler MP, Baker DW. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med. 2009 Apr;4(4):219-25. doi: 10.1002/jhm.425. 16) Mehta RL, Baxendale B, Roth K, Caswell V, Le Jeune I, Hawkins J, Zedan H, Avery AJ. Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study. BMC Health Serv Res. 2017 Sep 5;17(1):624. doi: 10.1186/s12913-017-2579-3. 17) Lehnbom EC, Raban MZ, Walter SR, Richardson K, Westbrook JI. Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries. Health Inf Manag. 2014;43(3):4-12. 18) Wimsett J, Harper A, Jones P. Review article: Components of a good quality discharge summary: a systematic review. Emerg Med Australas. 2014 Oct;26(5):430-8. doi: 10.1111/1742-6723.12285. Epub 2014 Sep 3. 19) Kind AJH, Smith MA. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Source: Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug. 20) Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program. Acad Med. 2006 Oct;81(10 Suppl):S5-8. 21) Coit MH, Katz JT, McMahon GT. The effect of workload reduction on the quality of residents' discharge summaries. J Gen Intern Med. 2011 Jan;26(1):28-32. doi: 10.1007/s11606-010-1465-z. Epub 2010 Aug 10. 22) Hommos MS, Kuperman EF, Kamath A, Kreiter CD. The Development and Evaluation of a Novel Instrument Assessing Residents' DischargeSummaries. Acad Med. 2017 Apr;92(4):550-555. doi: 10.1097/ACM.0000000000001450. 23) Talwalkar JS, Ouellette JR, Alston S, Buller GK, Cottrell D, Genese T, Vaezy A. A structured workshop to improve the quality of resident discharge summaries. J Grad Med Educ. 2012 Mar;4(1):87-91. doi: 10.4300/JGME-D-10-00249.1. 24) Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, Weiss KB, Williams MV; American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. J Gen Intern Med. 2009 Aug;24(8):971-6. doi: 10.1007/s11606-009-0969-x. Epub 2009 Apr 3. 25) Axon RN, Penney FT, Kyle TR, Zapka J, Marsden J, Zhao Y, Mauldin PD, Moran WP. A hospital discharge summary quality improvement program featuring individual and team-based feedback and academic detailing. Am J Med Sci. 2014 Jun;347(6):472-7. doi: 10.1097/MAJ.0000000000000171. 26) Rao P, Andrei A, Fried A, Gonzalez D, Shine D. Assessing quality and efficiency of discharge summaries. Am J Med Qual. 2005 Nov-Dec;20(6):337-43. 27) Black M, Colford CM. Transitions of Care: Improving the Quality of Discharge Summaries Completed By Internal Medicine Residents. MedEdPORTAL. 2017 Aug 7;13:10613. doi: 10.15766/mep_2374-8265.10613.

440 STAYING FIT: INTEGRATED EMR TOOL TO TRACK INTERDISCIPLINARY TEAM ROUNDING 1335493 Constance Chace University of California, San Diego David Ries Daniel Bouland Sarah Horman Paula Aragon, RN STAYING FIT: INTEGRATED EMR TOOL TO TRACK INTERDISCIPLINARY TEAM ROUNDING Accept Background: As inpatient medical care has increased in complexity and fragmentation, rounding has become siloed away from patients and by discipline, resulting in disjointed and inefficient care models. In response, hospitalist groups across the country have been implementing unit-based rounding programs to centralize communication and align work-flow of health care team members. At UC San Diego Health, the Division of Hospital Medicine rolled out FIT (Focused Interdisciplinary Team) Rounding in 2017 across seven diverse patient care units. Since implementation, we have been working to maintain standardization of rounding behavior and track the impact of FIT on care quality and efficiency.Purpose: We aimed to design a user-friendly electronic medical record (EMR) embedded tool to track elements of rounds discussion and quality measures in real-time. Data from this flowsheet can be leveraged for three purposes: 1) remotely assess FIT rounding fidelity across multiple units, 2) evaluate the direct impact of FIT on patient flow elements, and 3) track direct impact on quality metrics.Description: We created a flowsheet in the EMR (figure 1) to document elements of FIT rounds discussion that were determined to be most valuable. With simple drop-down lists, the user identifies: 1) whether or not FIT rounds had been done that day, 2) whether or not rounds were done at the patient’s bedside, 3) which team members were present, 4) whether or not the expected discharge date had been discussed, 5) which lines and tubes were removed, and 6) whether or not the level of care had been downgraded. If FIT rounding was not done at bedside, a drop down list would appear providing options for why bedside rounding did not occur (patient was on contact/droplet/airborne precautions, patient was non-English speaking, patient was not present in the room, patient was gone for testing/treatment, patient deferred, team deferred). If the expected discharge date was discussed, a calendar would appear facilitating the selection of the expected discharge date. The FIT Rounds Interdisciplinary Leadership team appointed the rounds coordinator to use a computer station on wheels and populate the flowsheet fields during rounds. The flowsheet was piloted on an oncology/palliative care unit. According to user feedback, the FIT Flowsheet is easy to use, does not distract from FIT rounds, and empowers the clinical nurse leader to ask about quality metrics on rounds and ensure that they are routinely addressed. With this tool, we can remotely track fidelity elements of FIT rounding, such as patient and team member involvement, across multiple units simultaneously. Additionally, quality outcomes, such as Foley utilization and central line removal, can be directly linked to our rounding program. The tool itself may also increase adherence to discussion check lists. Preliminary data shows improved level of care utilization and a trend toward shortened length of stay since implementation of the flowsheet.Conclusions: A simple, click-based flowsheet in the EMR to document key elements of interdisciplinary rounding discussion empowers rounds coordinators and facilitates rounding fidelity. The data collected by this tool can also be used to inform staff re-education efforts and assess the impact of multidisciplinary rounding on quality care metrics. As we continue to transform inpatient healthcare delivery for improved efficiency and quality, harnessing the EMR to track and sustain innovations will be critical in driving value-based care.References: 1) O’Leary, K.J., Johnson, J.K., Manojlovich, M. et al. Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems. BMC Health Serv Res 19, 293 (2019) doi:10.1186/s12913-019-4116-z. 2) O'Leary KJ, Sehgal NL, Terrell G, Williams MV. Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement. J Hosp Med. 2012;7(1):48–54. 3) Singh S, Tarima S, Rana V, et al. Impact of localizing general medical teams to a single nursing unit. J Hosp Med. 2012;7(7):551–6.

442 CPRS INPATIENT DASHBOARD - A NOVEL ELECTRONIC HEALTH RECORD COMPANION 1335579 Christopher Grondin Michigan Medicine/Ann Arbor VA Christina Arens Gabriel Solomon CPRS INPATIENT DASHBOARD - A NOVEL ELECTRONIC HEALTH RECORD COMPANION Accept Background: The Department of Veterans Affairs (VA) originally released the Computerized Patient Record System (CPRS) in 1997. While revolutionary for its time, there has been limited substantial update in the last twenty years. Customization opportunities and ease of acquiring data are limited compared with newer, widely adopted electronic health record (EHR) systems.Purpose: To develop an inpatient dashboard tool for CPRS that improves satisfaction, decreases time at the computer, standardizes inpatient notes, & improves safety measures.Description: An inpatient electronic dashboard hub was created that draws data directly from the Veterans Health Information Systems and Technology Architecture (VistA) Integration Adapter (VIA), which allows it to pull data from every VA in the nation. Through this central dashboard is displayed patient identifiers/code status, intake/output, & vitals that are updated every 8 minutes as well as on demand. Selecting a patient’s name from the dashboard launches a patient-specific view that shows all of the above as well as brings in an integrated note writing tool. Also in this patient-specific view you can access labs, studies, microbiology, and a medication administration record. When the daily progress note is finished, this can be conveniently copied and pasted into CPRS in an organized format. This tool was launched on the Ann Arbor VA’s general medicine services January 2019. After the residents completed their inpatient month, an electronic survey was provided to give feedback on the tool. From January 2019 through September 2019, 43 residents responded that had used the dashboard. 88% of respondents favored the dashboard to CPRS, 10% were neutral, and 2% preferred CPRS. 93% found the tool reduced daily work stress while 7% were neutral. 73% found that the tool saved time for rounds, 22% were neutral, and 5% felt the tool increased time for rounds. 65% reported that they were more aware of which patients had deep vein thrombosis prophylaxis and Foley catheters and, for the other 35%, awareness did not change. Of the respondents, 12% found errors or omissions with the tool daily, 64% found errors or omissions a few times throughout their month, and 24% never found errors or omissions. Commonly cited ‘errors’ were slow loading times, printing errors, and duplication of data.Conclusions: Residents greatly prefer the dashboard application to native CPRS. This tool generally made utilizing the computer more efficient, decreased daily work stress/burnout, increased awareness of safety measures (DVT prophylaxis, Foley catheter use), and standardized inpatient notes. Throughout the test period most users found an error or omission, which highlights the importance of rapid plan/do/check/act cycles to continuously improve new initiatives based on feedback. This dashboard tool for CPRS has great potential to improve the user experience and patient safety for the care of veterans across the VA system.References:

445 IMPLEMENTING A MOBILE APPROACH TO PATIENT CARE TO IMPROVE PROVIDER SATISFACTION 1335139 Ginny Kwong Halifax Health IMPLEMENTING A MOBILE APPROACH TO PATIENT CARE TO IMPROVE PROVIDER SATISFACTION Accept Background: When used optimally, technology should serve as a tool for clinicians, not an obstacle. Yet according to a recent study by the Mayo Clinic, Electronic Health Records (EHR) score in the bottom nineth percentile of technologies when evaluated for usability. This lack of usability can lead to increased documenting times, workflow bottlenecks, and physician burnout. Providers must divide their attention between patients and the EHR, compromising patient-physician relationships leading to dissatisfaction.Purpose: Having the largest Emergency Department in the state, our health system is constantly searching for new ways to improve efficiency and enhance operational processes. The decision to implement MEDITECH Expanse EHR gave physicians the opportunity for an unparalleled level of mobility, and opened the door for improved ED throughput, admission and discharge processes, and more meaningful hospital patient interactions.Description: By equipping physicians with tablets for rounding and documentation, the action empowered them to work more efficiently, unencumbered by traditional desktops. Providers no longer need to leave the bedside to quickly recall patient medical histories, access chart information, order tests or medications, discharge patient with medication reconciliation and new prescriptions, or start documentation in the EHR. Strategies in change management and physician adoption of new hospital workflow leveraging mobiity implemented and shared. Physician experiences with merging new mobiity workflow and patient care revealed ability to cut down on their administrative burdens, increase RVU, and enhance patient experience utilizing tablet as visual tool for education.Conclusions: By implementing a more mobile approach to care, organization improved ED throughput, expedited their discharge processes, and decreased their average LOS by half a day. Over 80 percent of hospitalists are now using tablets to view charts while rounding and placing orders. Hospital plans to expand its mobility rollout to other specialties after success with ED and hospitalist physicians' positive experience with merging EHR mobility with patient care. Preliminary data through KLAS (Healthcare IT research) Arch Collaborative using standardized surveys and benchmarking revealed providers are more satisfied with utilizing mobility with tablet technology rather than traditional desktop when using EHR. Quality patient care is delivered optimally with merging the best transformation of people, process, and technology.References: https://www.mayoclnicproceeding.org/article/S0025-6196(19)30836-5/fulltext Beresford, L. Electronic Health Records Key Driver of Physician Burnout The Hospitalists. 2015 Dec R. Gardner, E. Cooper. Physician stress and burnout: the impact of health information technology. Journal of the American Medical Informatics Association, Vol 26, Issue 2, February 2019, pages 106-114

459 TOWARDS A LEAN DISCHARGE: UTILIZING VISUAL MANAGEMENT TO IMPROVE CARE COORDINATION ON A GENERAL MEDICINE UNIT 1334937 Anne Linker Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai Lauren Ritter Shria Raghunathan Jamie Ruhmshottel Mount Sinai Hospital Michael Herscher Tao Xu TOWARDS A LEAN DISCHARGE: UTILIZING VISUAL MANAGEMENT TO IMPROVE CARE COORDINATION ON A GENERAL MEDICINE UNIT Accept Background: Hospitals emphasize early discharge to improve throughput. Interdisciplinary team members often report feeling rushed in the 24 hours before discharge, which may increase the likelihood of discharge errors and burnout for the team.Purpose: To identify obstacles preventing timely completion of discharge activities, improve reliability of the discharge process, improve staff experience, and decrease avoidable days.Description: This project was conducted on one 25-bed medicine unit at an urban tertiary-care 1,100-bed academic teaching hospital. Physician teams were not geographically organized. Unit-based staff included case managers (CM), social workers (SW), nurses (RN), pharmacists, and physical therapists. The team of interdisciplinary staff used continuous improvement tools and activities to understand current state discharge processes, including cross-functional process mapping, information flow mapping, observations, interdisciplinary work groups and data collection. They identified that there was no standard method to track patient progression towards discharge, resulting in functional silos and redundant communication and work by the interdisciplinary team. A pilot was designed to test a shared visual management system during daily interdisciplinary rounds (IDR) to improve operational stability by creating a shared mental model of patient status, which would assist staff in prioritizing work. Each patient’s status was categorized across four phases: Red (acutely ill), Orange (forecasting medical readiness in the next 24-48 hours), Yellow (medically ready but pending needs, such as home services or insurance authorization), and Green (ready for discharge). The Yellow phase was used as a proxy for avoidable days. Each day, the physician presented the patient status at IDR. The unit team reached consensus on the phase designation, and the unit nurse manager recorded the phase on the visual management whiteboard. Iterations included adding a column to the whiteboard for remaining barriers to discharge to allow for closed loop communication. 256 patients were tracked, of whom 140 were discharged from the unit. Preliminary measures to assess impact included lead time (time before discharge) for implement discharge plan order (IDP), length of stay (LOS), avoidable days, and qualitative impact on process predictability. We did not find a significant difference between pre- and post-intervention periods for IDP lead time or LOS. A linear regression trend showed a decrease in Yellow days (R^2=0.3, Figure 1). Discharges before noon increased by 3% (Figure 2). A qualitative survey was distributed to 26 RNs (100% completed) and showed improvements in predictability, clarity about discharge timing, and ability to prioritize daily work (96%, 100% and 100%, respectively). During informal interviews, nurse managers reporting using the board for general unit planning, even outside of IDR. CM reported increased confidence in prompting teams for discharge tasks.Conclusions: The use of a jointly created interdisciplinary visual management system on a non-geographic unit to identify patient status led to a perceived improvement in discharge planning and higher predictability of workflow, with trends suggesting an improvement in hospital level metrics. A sustainability plan was developed and the visual manager has transitioned to standard practice. The positive nature of included metrics indicates progress towards consistency and standardization in discharge processes.References:

461 HOSPITALISTS AS LEADERS: DEVELOPMENT OF A CAPACITY MANAGEMENT PHYSICIAN TEAM PARTNERED WITH CARE MANAGEMENT TO IMPROVE THROUGHPUT AND HOSPITAL CAPACITY 1335179 Meghaan Hawes Harborview Medical Center, University of Washington Maralyssa Bann Leslie Enzian Nicholas Johnson Thuan Ong Azmera Telahun Anneliese Schleyer UW Medicine/Harborview Medical Center HOSPITALISTS AS LEADERS: DEVELOPMENT OF A CAPACITY MANAGEMENT PHYSICIAN TEAM PARTNERED WITH CARE MANAGEMENT TO IMPROVE THROUGHPUT AND HOSPITAL CAPACITY Accept Background: Harborview Medical Center (HMC) is a 413-bed academic safety net hospital in Seattle, WA, and a level one trauma center for five states. Over the past seven years, HMC has observed increasingly long length of stay (LOS) resulting in a critically high patient census and limited capacity. To improve LOS, a Care Management department was restructured to include continuity of care nurses, social workers, utilization management and other key members of the discharge team. Physicians were not traditionally actively involved.Purpose: To integrate physicians into care management at HMC, a Capacity Management Physician (CMP) program was formed. Five clinically active faculty physicians were recruited from across the care continuum: Primary Care, Emergency Medicine/Critical Care, Hospital Medicine, Post-Acute Care and Respite.Description: In partnership with Care Management, CMPs help provide throughput optimization for all services in the hospital. Each CMP rotates through the role every five weeks. During designated weeks, CMPs round with medical and surgical teams daily to mitigate barriers to discharge and identify treatments that can be expedited. They participate in multidisciplinary census/safety huddles and weekly LOS meetings and provide as-needed consultation for patients with high clinical complexity and challenging discharge barriers. Additionally, CMPs meet monthly for didactics in topics such as post-acute care, respite, public health and community programs for the homeless as well as utilization management, revenue cycle, regulatory requirements, and risk management. They convene with leaders of innovative care programs from across HMC and the community. They also share case-based lessons and develop collective best practices. These efforts provide support to frontline hospital clinicians and aim to optimize patient throughput and advocate for systemic changes that enhance safe, appropriate patient care. In the first eight months, CMPs have attended over 450 discharge huddles and were actively involved in >550 patient hospitalizations. Through participation in rounds, CMPs have identified 85 types of barriers to efficient throughput including practice variation, knowledge gaps about available system resources, and patient factors. CMPs have identified opportunities to standardize practices for specific populations including patients with foot wounds and those requiring prolonged antibiotics that have led to dedicated quality improvement efforts.Conclusions: The CMP program is a novel initiative that engages clinically active physicians in care management. Bringing together hospitalists with colleagues who practice in other care settings promotes shared expertise allowing CMPs to provide comprehensive advocacy for patients and teams. Together, they help to achieve targeted hospital initiatives such as decreased LOS while maintaining patient-centered, high-quality care.References:

464 STREAMLING THE SKILLED NURSING FACILITY REHABILITATION APPLICATION PROCESS TO REDUCED LENGTH OF STAY FOR AN INPATIENT ORTHOPEDIC UNIT 1334474 Jenny Shen University of Rochester Medical Center Strong Memorial Hospital STREAMLING THE SKILLED NURSING FACILITY REHABILITATION APPLICATION PROCESS TO REDUCED LENGTH OF STAY FOR AN INPATIENT ORTHOPEDIC UNIT Accept Background: Length of stay (LOS) is an important quality indicator and has significant financial implications and impact on hospital throughput. Geriatric Fracture Center (GFC) is a co-management program between Hospital Medicine and Orthopedic for patients who are age 60 and above with fragility fracture. Delays in skilled nursing facility (SNF) rehabilitation placement are a major contributor to prolonged length of stay, especially for GFC where patients’ mobility and functional abilities are significantly impacted. Nearly all patients in GFC require surgery and subsequent rehabilitation. The traditional SNF rehabilitation placement process includes multiple steps: (1) identification of the need for rehabilitation, (2) decision to pursue placement, (3) provision of the application paperwork by a social worker to the patient and family, (4) submission of paperwork to the placement office and various facilities, and (5) awaiting a bed offer from a facility.Purpose: The purpose of the pilot study was to test viability as well as effect on LOS of early initiation of the SNF rehab placement process via pre-prepared, conveniently available, and user-friendly paperwork folders.Description: A pilot study was implemented in collaboration between Hospital Medicine, Orthopedics, and Social Work. SNF rehabilitation placement paperwork was assembled into folders and placed in the orthopedic resident work room in emergency department (ED) as well as the orthopedic unit where majority of GFC patients were admitted. Orthopedic residents were provided with a talking script and instructed to provide these folders to patients’ families at the time of consenting for urgent surgery if they predicted SNF rehabilitation placement afterward would be necessary. Nursing and other providers on the unit could also provide the folders to patients and families. We performed a chart review to track the intervals of time from (1) hospital admission to provision of the folder to the patient and family, (2) provision of the folder to submission of completed paperwork to the placement office, and (3) return of the completed paperwork to bed offer from facilities and discharge. Total LOS was tracked. Data from the pilot intervention were compared to the traditional placement process where social workers initiate the process. Average LOS was 8.2 days for the traditional process, 6.3 days when folders were provided through the pilot process in the ED and 6.8 days when received after arrival to the unit (Figure 1).Conclusions: Initiating the SNF rehabilitation placement process earlier in the admission during the surgical consent process was associated with a quicker turnaround time and decreased LOS. The user-friendly folder allowed non-social workers to initiate the process whenever opportunities arise and streamlined the process.References:

469 HOW TO GET PAID FOR ACCEPTING THOSE TRANSFERS FROM OTHER HOSPITALS 1334661 John Bell UC San Diego Health Joseph Avalos UC San Diego Health Sonny McGowan HOW TO GET PAID FOR ACCEPTING THOSE TRANSFERS FROM OTHER HOSPITALS Accept Background: At academic institutions and other referral centers the process of accepting transfers from other hospitals has been a challenging and potentially laborious process to coordinate smoothly. It was also one that was not previously reimbursable. However, beginning in 2017 Medicare and other insurance companies began reimbursing Non-Face-to-Face Prolonged services procedural codes. These new codes allowed providers to bill for time spent reviewing records and coordinating care with other physicians either before or after a patient encounter if the total time spent doing this was at least 30 minutes.Purpose: To use these new Non Face-to-Face prolonged services codes to be reimbursed for the time spent accepting some of the transfers from other hospitals when that work was documented in the medical record.Description: At our institution accepting transfers from other hospitals involves communication with a transfer center to find out the gist of the transfer request and to determine who at the other facility to call. Then, the hospitalist briefly reviews any records about the patient already available in our electronic medical record. They then call the requesting physician to gather pertinent information about the patient’s stay at the other facility. If the reason for transfer is a procedure, many times the hospitalist also will contact the proceduralist to see if the request is reasonable. Finally, after the hospitalist has informed the requesting physician that they are willing to accept the transfer request, the hospitalist then completes an outside hospital transfer accept note in the hospital encounter that was created by the transfer center. This note briefly summarizes all of the previous conversations to allow the hospital medicine team that is on-call when the accepted patient arrives to quickly understand the patient’s course at the sending hospital, the reason for transfer, and the first steps to take when the patient arrives. After discussions with our institution's billing and compliance office. We had the CPT codes for Non-Face-to-Face Prolonged Service charges (99358 and 99359) added to the ones we could submit from within an inpatient encounter. We then added an optional section to our outside hospital accepted transfer note template that included the required language for the Non-Face-to-Face prolonged service code to use when accepting a transfer took longer than 30 minutes and educated our hospitalists about how to use this new code. We obtained data on the number of Non-Face-to-Face Prolonged Services charges that our hospitalist submitted in the first 12 months of use and the number of those submitted charges that were paid. We collected on 80.3% of the Non-Face-to-Face Charges we submitted for an average return per charge paid of $95.33 and an average return per charge submitted of $75.25. The collection rate on the charges for the division of hospital medicine was roughly the same as the institution as a whole (81%) with the vast majority of the other claims coming from the outpatient setting.Conclusions: Thus, for little extra work above what we were already doing in accepting transfers from other hospitals, hospitalists at our institution were able to submit Non-Face-to-Face prolonged service charges and get paid for their work. Our approach to generating this net new revenue stream utilizing the notes that we already use in accepting patients in transfer from other hospitals may be useful to other hospital medicine groups who have similar opportunities to capitalize on this workflow.References:

470 THE AMBULATORY MEDICAL EMERGENCY TEAM: A NOVEL ROLE FOR HOSPITALISTS 1334883 Michael Conway University of Colorado Christopher Smith University of Colorado Denver Linda Staubli Kasey Bowden University of Colorado Division of Hospital Medicine Jason Brainard Angela Keniston University of Colorado, Division of Hospital Medicine Laurie Kirkley Lauren McBeth Justin Oeth Trudy Orona Jennifer Rodgers Marisha Burden University of Colorado School of Medicine THE AMBULATORY MEDICAL EMERGENCY TEAM: A NOVEL ROLE FOR HOSPITALISTS Accept Background: While rapid response teams are well established for inpatient emergencies, outpatient emergency response on large medical campuses is much more variable. At our institution, this need for outpatient emergency response is particularly acute. As a tertiary referral center, cancer treatment center, and the largest transplant center in the state, our clinics provide 1.4 million visits per year to a large amount of medically complex patients. These clinic buildings are connected with our inpatient units and emergency department (ED) via walkways. While the clinics previously called 911 for emergencies, this system was burdened by multiple major inefficiencies. Delays in patient care arose from the need to wait for an ambulance to arrive on campus, find parking and the appropriate clinic, and then transport the patient outside and around campus to the ED. Although the ambulance ride was short, the ambulance companies’ bills to patients were high, averaging about $1500. The high volume of calls from our clinics also placed significant stress on our city’s emergency response system, with 911 operators and ambulance crews managing around 300 calls per year from campus.Purpose: The Ambulatory Medical Emergency Team (AMET) was created to replace 911 response to acutely ill patients in clinics and common areas on campus.Description: The AMET was rapidly developed and implemented over a period of about a month in August 2019 by a multidisciplinary group that included hospital medicine, the emergency department, the resuscitation committee, security, hospital operators, nursing educators, and hospital and outpatient leadership. The team is composed of a hospital medicine provider (advanced practice provider, attending physician, or senior resident) and an ED nurse. The team is activated via a call to our campus operators. Once on site, the AMET provides rapid assessment, intervention, and transportation to the appropriate level of care, typically the ED. Averaging 2-3 activations per day, the team has responded to a wide variety of calls, with the most common chief complaints relating to new vital sign abnormalities or syncope/pre-syncope. The AMET nurse carries a jump bag with a number of rapidly acting interventions such as IV fluids, epinephrine for anaphylaxis, oral glucose, and naloxone. While most patients are transported to the ED, in some cases we are able to consult with the outpatient provider and avoid a potentially unnecessary ED visit. The team has provided a significant reduction in response time over 911, with a review of surveillance footage finding an average time from 911 response to ED evaluation of 28 minutes, compared with 10 minutes for the AMET. In a particularly notable case, the AMET was called for a patient bleeding due to placenta previa who was found in a public bathroom. The patient was rushed to the obstetric emergency department and underwent c-section within 25 minutes of the initial call.Conclusions: The AMET has achieved a significant reduction in 911 calls from campus, saving patients money and decreasing stress on community resources. The team exemplifies a novel way for hospitalists to improve patient care and reduce healthcare costs.References:

472 A MODEL FOR HOSPITALISTS TO PROVIDE ADVANCED CARE IN THE HOME 1335080 Patrick Kneeland DispatchHealth/University of Colorado Anschutz Medical Campus A MODEL FOR HOSPITALISTS TO PROVIDE ADVANCED CARE IN THE HOME Accept Background: “Hospital at Home” (HaH) models of care have existed for over 20 years in the U.S. Recent demand for healthcare value and advances in relevant technologies have driven renewed attention to HaH models, including from the Center for Medicare and Medicaid Services (CMS), and have spawned several pilots within the U.S. Where studied, these models have had desirable impacts on readmission rates, care-acquired adverse events, patient satisfaction, and cost. Despite this, adoption and scaling of these models remains difficult due to a number of factors: complex logistics, cumbersome supply chain management, coordinating the appropriate clinical workforce, and lack of a workable payment model.Purpose: To create and deploy a sustainable and scalable model for hospitalists to provide safe and high-quality advanced care in patients’ homes.Description: DispatchHealth has built an in-home medical practice model in more than 15 U.S. cities utilizing mobile teams of emergency physicians, advanced practice providers, and emergency medical technicians. While these teams provide a broad range of diagnostic and therapeutic services, 6% of patients require escalation to the Emergency Department (ED), and 75% of those are admitted to the hospital. Our innovation, called AdvancedCare, leverages existing DispatchHealth practice infrastructures to support enhanced in-home care capabilities. Within a city with a DispatchHealth presence, we built a clinical team consisting of hospitalist physicians, hospitalist-trained APPs, an operations leader, and a nurse navigator. That team designed standardized clinical work-flows and built processes for managing complex logistics (such as deploying just-in-time imaging, IV medications, and oxygen). We developed evidence-based risk stratification protocols around 6 core clinical conditions: COPD, CHF, pneumonia, cellulitis, complicated UTI, and electrolyte abnormalities. We paired risk assessments with MCG criteria to demonstrate level-of-care necessity. The care model consists of twice-daily nursing visits and once-daily hospitalist visits during the acute illness, followed by a 14-day period of post-acute remote nursing oversight. Beginning in mid-November 2019, we aligned with a single payer partner for a deliberately measured roll-out. While we projected a patient volume of 2 patients in the first 30 days, we on-boarded 3 patients in the first 12 days of service. 1 additional patient was evaluated but fell outside of risk stratification parameters. Conditions treated to date are COPD with pneumonia, COPD exacerbation, and hyponatremia. All 3 patients have successfully transitioned out of the acute illness phase. Tracked metrics include length of stay, patient satisfaction, care-associated adverse events, ED escalations, readmissions, and cost of care. Average length of the acute phase for the first 3 patients was 3.3 days. Anecdotal satisfaction from patients and caregivers has been highly positive and the measured net promoter score (NPS) +100. Since launch, we have partnered with an additional payer to begin patient care in December 2019.Conclusions: While providing advanced levels of care inside patients’ homes has shown promise, models to do so have proven difficult to adopt and scale. Hospitalists are uniquely positioned to design, lead, and provide advanced care in the home. Our model is unique in that it leverages an existing mobile in-home practice infrastructure to identify and treat appropriate patients.References: 1. Leff B, Burton L, Guido S, et al. Home hospital program: a pilot study. J Am Geriatr Soc. 1999 Jun;47(6):697-702. 2. Danielsson P, Leff B. Hospital at Home and Emergence of the Home Hospitalist. J. Hosp. Med 2019;6;382-384. 3. Physician-Focused Payment Model Technical Advisory Committee. Report to the Secretary of Health and Human Services. Comments and Recommendation on “HaH-Plus (Hospital at Home Plus) Provider-Focused Payment Model. https://aspe.hhs.gov/system/files/pdf/255906/MtSinaiHAHReport-Secretary.pdf. Accessed November 10, 2019. 4.The Secretary of Health and Human Services. Response to the Report to the Secretary of Health and Human Services. Comments and Recommendation on “HaH-Plus (Hospital at Home Plus) Provider-Focused Payment Model. https://downloads.cms.gov/files/cmmi/ptachhssecresponse-oct17-may18.pdf. Accessed November 10, 2019. 5. Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005 Dec 6;143(11):798-808. 6.Caplan GA, Sulaiman NS, Mangin DA, et al. A meta-analysis of "hospital in the home". Med J Aust. 2012 Nov 5;197(9):512-9. 7.Federman AD, Soones T, DeCherrie LV, et al. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med. 2018;178(8):1033-1040.

475 DROP THE CHARGE! CREATION OF A BILLING BEST PRACTICES COMMITTEE 1334831 Li-Kheng Ngov University of Colorado Lisa Fosnot University of Colorado School of Medicine Philip Vatterott Dimitriy Levin Lauren McBeth Leah Lleras Marisha Burden University of Colorado School of Medicine DROP THE CHARGE! CREATION OF A BILLING BEST PRACTICES COMMITTEE Accept Background: For academic hospital medicine groups to thrive and be partners with their hospital systems, physicians must document and bill appropriately as a means of demonstrating their clinical value. Yet, many major academic hospital medicine groups may be unaware or receive little training for this very important skill set. Based on data from the Society of Hospital Medicine’s State of Hospital Medicine Report from 2018, for groups with 30 or more full time equivalent positions, the responsibility of selecting the correct current procedural terminology (CPT) code lands on the provider 80.3% of the time.Purpose: Our division created a Billing Best Practices Committee to educate faculty on billing practices to accurately reflect our group’s clinical productivity and to mitigate potential lost revenue.Description: In 2018, we assembled a team and created a framework to ensure that our faculty receive training in clinical documentation and billing. The committee consists of our Division Head, Director of Clinical Operations, Division Administrator, and three other highly clinical faculty. Our mission was to develop a billing curriculum to teach new faculty and audit billing practices of current faculty to minimize lost revenue. After reviewing the billing data for our division, we identified two performance measures to improve upon: rates of missing charges and changed CPT codes. The hospital’s billing department flagged providers with missing charges and changed CPT codes after a secondary review. Changed CPT codes are defined as down charges or up charges based on Centers for Medicare and Medicaid Services documentation requirements. Missing charges means that the provider did not bill for the clinical encounter. Our first aim was to develop a billing curriculum to teach new hires. Starting in academic year 2019, all 14 of our new physician hires received training on billing best practices, including a review of inpatient CPT codes, time-based billing, and billing based on the components of history, physical exam, and medical decision making. New faculty attend three one-hour courses in their first year to reinforce this training and to review their own billing audits. We then tracked the rates of missing charges and changed CPT codes of new hires compared to the rest of the faculty over the year. The rate of missing charges for new hires was 1.96% compared to the remaining faculty at 6.15%. The rate of changed CPT codes was comparable between the two groups with new hires at 5% and remaining faculty at 4.3%. The committee’s secondary goal was to identify established physicians with the highest rates of missing charges and provide feedback on how to improve their compliance rates. This feedback included incorporating billing as part of their daily routine after writing notes and adding a “dropped charges” column to their patient list in the electronic medical record which alerts physicians if they have billed for the day. After this intervention, there was an improvement in this cohort’s rate of missing charges from 51.5% to 9.16%.Conclusions: Academic hospitalist groups have a mission to provide high quality patient care while advancing education and innovation. One way to demonstrate value within a healthcare system is to appropriately capture productivity for direct patient care. By creating a standardized billing curriculum for new hires and providing continuous feedback, physicians are held accountable to patients and themselves to ensure appropriate and timely billing for the comprehensive services they provide.References:

476 AIMING FOR VALUE: INNOVATIONS IN HOSPITAL BASED COPD CARE 1334654 Valerie Press University of Chicago Amelia Waltman Sharon Feehan Jennifer Austin University of Chicago Medicine Shwetha Devanagondi Stephanie Chia Vineet Arora University of Chicago Steven White AIMING FOR VALUE: INNOVATIONS IN HOSPITAL BASED COPD CARE Accept Background: COPD is the third leading cause of death and hospital readmissions. Inpatient care for patients with COPD exacerbations varies widely across the US which can lead to patients failing to receive recommended evaluation, treatment, education, and follow-up to reduce the likelihood of recurrent exacerbations and unnecessary acute care utilization. In an effort to innovate and address this care variation, the Centers for Medicare and Medicaid (CMS) offered a voluntary Bundled Payment Care Initiative to hospitals that aims to reward high value care and reduce unnecessary and preventable readmissions. We extended our existing COPD readmissions reduction program initially focused on 30-day readmissions to extend through 90-days post readmissions. Our inter-professional team aimed to provide evidence-based, high quality care, to patients hospitalized with acute exacerbations of COPD to reduce care variation, improve the transition of care process, and reduce acute care utilization. Specifically, we provided COPD-specific expert care in the hospital and the clinic across 90 days, including Advanced Nurse Practionner evaluations, pharmacy based education and medication management, and nursing phone calls.Purpose: From October 2015 through September 2018 we sought to reduce 90-day all-cause readmissions in an effort to maintain average 90-day patient episode costs below target. Due to fluctuations in staffing, we also sought to determine whether the program running fully (APN and pharmacy coverage inpatient and outpatient), partially (APN and pharmacy coverage inpatient only), or not at all (no APN or pharmacy coverage) impacted readmission rates and/or our reconciliation price-target price. The primary outcome was reconciliation price-target price. Our process measures included: BPCI patients identified and seen by program while hospitalized, outpatient visits scheduled and completed, and acute care utilization (ED and hospital readmissions).Description: Our program targeted all patients admitted with COPD exacerbations. They received APN and pharmacy COPD specific care and education while hospitalized, prior to discharge. After discharge the patients were called by our patient experience nurse within 48 hours after discharge and then were seen by our APN and PharmD providers at 1 week, 30 days, and 60 days after discharge. Our team consists of 1-2 Advanced Practice Nurses, a PharmD and team of pharmacy students, a patient experience RN, as well as hospital leadership.Conclusions: We found that readmission rates went down at 30, 60, and 90 days , though our sample size was underpowered to show statistically significant differences compared to our pre-program comparison year (2013-2104). Overall, our median costs were below target every quarter except one. However, we found significant fluctuations in costs/savings that were correlated with staffing levels. When the program was fully staffed, the program met or exceeded the target in all but one quarter, and the one quarter where there was a loss, it was minimal. However, when there was no APN coverage (and therefore, no pharmacy coverage), the losses increased 10 times the worst quarter with full coverage. Therefore, the program not only appears to improve readmission rates but also reflects positive value in terms of savings when it is running fully compared to when it was not running fully or at all.References: Medicare the USC for, Boulevard MS 7500 S, Baltimore, Baltimore M 21244 7500 SB, Usa M 21244. Bundled Payments for Care Improvement (BPCI) Initiative: General Information | Center for Medicare & Medicaid Innovation. https://innovation.cms.gov/initiatives/bundled-payments/. Accessed April 15, 2019 Joynt KE, Jha AK. Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program. JAMA. 2013;309(4):342-343. doi:10.1001/jama.2012.94856 Shah T, Press VG, Huisingh-Scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. CHEST. 2016;150(4):916-926. doi:10.1016/j.chest.2016.05.002 Bhatt SP, Wells JM, Iyer AS, et al. Results of a Medicare Bundled Payments for Care Improvement Initiative for Chronic Obstructive Pulmonary Disease Readmissions. Ann Am Thorac Soc. 2017;14(5):643-648. doi:10.1513/AnnalsATS.201610-775BC

477 ADVANCED APPROACH TO THROUGHPUT: ADVANCED PRACTICE CLINICIAN AND PHYSICIAN COLLABORATION IN EARLY DISCHARGE OF A HIGH VOLUME HOSPITALIST SERVICE 1335605 Christopher Waybright TeamHealth Sarah Puim Grand Strand Medical Center Dipali Sahoo Grand Strand Medical Center Andrew Glover Jon Pangia ADVANCED APPROACH TO THROUGHPUT: ADVANCED PRACTICE CLINICIAN AND PHYSICIAN COLLABORATION IN EARLY DISCHARGE OF A HIGH VOLUME HOSPITALIST SERVICE Accept Background: The timing of discharges of admitted patients has a significant impact on hospital efficiency and throughput. Earlier discharges are associated with improved boarding times, admissions arriving to inpatient units earlier in the day, and decreased length of stay. Discharges that occur later in the day creates a bottleneck effect, causing emergency room congestion, overcrowding, and higher inpatient mortality.Purpose: This project was developed to address a high volume hospitalist service challenged with meeting early discharge goals. This study implemented a targeted initiative developed to improve throughput by increasing the rate of early discharges before 9 am and 11 am.Description: Our model implemented an Advanced Practice Clinician (APC) and Physician team to standardize the discharge process of patients on the inpatient hospitalist service in an acute community-based academic medical center. Goals of this innovative staffing plan were to improve the percentage of discharges before 9am and 11am while allowing physicians to be freed up to see critical patients in the morning and APCs to feel engaged and valued. A sign-out method was established to notify a designated APC of potential discharges the day prior to expected discharge, including potential barriers to discharge. On the day of discharge, the APC reviewed the chart and examined the patient. If the APC determined the patient was clinically appropriate for discharge, the APC would notify the physician, discuss the discharge treatment plan, and complete the discharge paperwork. The patient was then evaluated by the APC-Physician team for final instruction and plan of care review prior to discharge. A retrospective analysis was performed to evaluate the percent of patients discharged prior to 9 am and 11 am. The data was obtained over a 6 month period before and after the intervention. Discharge goals of 25% for discharges prior to 9am and 40% for discharges prior to 11am were established.Conclusions: Prior to the staffing model change, the hospitalist group averaged 28.83% of discharge orders placed before 11am. After the change, the discharge orders before 11am rose to above goal at 43.2% and continues to be successful. This study continues to be at an early stage and represents preliminary data that was gathered to ensure that our intervention is yielding positive improvement to discharge rates. Data analysis is ongoing to obtain the rate of discharges prior to 9am, which are expected to also be above goal for this time period. Preliminary data has shown significant improvement to discharge rates by implementation of our discharge initiative. Future goals will analyze length of stay to ensure that our early discharge intervention does not compromise length of stay. The collaboration of APC and Physician initiative has resulted in profound improvements in the percent of early discharge rates. This was accomplished by shifting the role of an APC to develop a team-based approach to discharge planning. Although still in early stages, this study has demonstrated a successful plan, which improves hospital throughput by overcoming challenges with efficient and successful early discharge of patients. "This project was undertaken as a Quality Improvement Initiative at Grand Strand Medical Center, and as such was not formally supervised by the IRB per their policies."References:

480 INPATIENT ADULT EATING DISORDER TREATMENT 1334697 Katherine Stewart University of Rochester Medical Center Jennifer Zagursky Adam Bracken University of Rochester Taylor Starr INPATIENT ADULT EATING DISORDER TREATMENT Accept Background: Approximately 20 million females and 10 million males in the United States have a clinically significant eating disorder at some point in their lifetime. In Western New York, comprising the three largest cities of Buffalo, Rochester and Syracuse, there are about 29,000 persons with eating disorders. Unfortunately , treatment for these medically fragile patients is limited, especially in the adult population. Most efforts have been towards adolescents. Currently, throughout the country, patients can be treated as an outpatient, partial hospitalization or residential. If a patient becomes medically unstable, the only option to date has been ICU level treatments for specialized eating disorder management.Purpose: And adult eating disorder program has been developed to care for adult patients with active eating disorders who are too medically ill to be treated on an outpatient basis . The goal is for medical stabilization, initiation of treatment for the eating disorder and coordination of resources to establish a successful transition of care to lower level treatment (residential, partial, outpatient).Description: The adult eating disorder program is a multidisciplinary collaboration initiated in 2018, with cohorting of patients on one inpatient medical unit. The current adolescent medicine protocol at the Golisano Children's Hospital was used as a basis and was modified to treat the adult population, which included modification from a 17-day to a 14-day protocol. Initiation required intensive education for nurses, social workers, registered dietitians and providers to this patient population and the protocol. Patients are referred to the inpatient treatment by outside providers, with referrals from the thirty counties that are covered under the Western New York Comprehensive Care Center for Eating Disorders. Once admitted, these patients are enrolled in the protocol, which includes screening for medical complications of an eating disorders. It also involves strict monitoring of intake/output, daily blinded weights, monitoring orthostatic vital signs, electrolytes with replacement as needed, activity monitoring, bowel maintenance , meal planning and support, monitoring for food avoidance or diversionary tactics and education. Given the early nature of the program, rounding is with both the Adult Hospital Medicine team and Adolescent Medicine. All patients are screened by the Prime Team (Proactive Integration of Mental Healthcare in Medicine) to detect psychiatric co-morbitidies and to provide consultation, as necessary. As the protocol progresses, family members/support persons are folded into education with onsite and then 4-hour day passes for demonstrating/practicing of acquired skills.Conclusions: This program is the first of its kind in the country, and it provides care and treatment for some of the most vulnerable and sick patients. To date, approximately fifty patients , male and female, ages 19 - 60 have been through the program. In addition to providing optimal care, this latest year has also some unmasked questions and issues that previously were not well recognized. These included ethical and legal issues, such as decision-making capacity and lack thereof; refusal of care and how that impacts treatment; need to modify the protocol per patient, depending on their medical stability and support system; as well as the need to educate people not directly involved in patient care, such as environmental service workers, to avoid making unintended, inappropriate comments to the patient.References: Cuerda C, Vasiloglou MF and Arhip L. Nutritional Management of Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa. Journal of Clinical Medicine 2019 July 8(7): 1042. Smink FR, van Hoeken D., Hoek HN. Epidemiology of eating disorders: Incidence, Prevalence and Mortality Rates. Currrnt Psychiatry Report 2012 Aug:14(4) 406-14.

482 RATIONALIZING USE OF ROUTINE LAB TESTS THROUGH COST TRANSPARENCY 1334391 Meera Udayakumar UNC Rex Health Joshua Barclay Julia Woodson RATIONALIZING USE OF ROUTINE LAB TESTS THROUGH COST TRANSPARENCY Accept Background: While multiple organizations have recommended reducing unnecessary and repetitive lab tests in hospitalized patients, this has not resulted in a widespread change in behavior. There is agreement that unwarranted labs increase costs, but data around specific lab costs have not been readily available. At baseline, there were 125,586 labs ordered by the UNC Rex Hospitalist team per year at an annual cost of $767,712.Purpose: To reduce lab test utilization across the hospitalist team by sharing lab utilization data and providing cost transparency.Description: In April 2019, the hospitalist team was shown data on individual lab ordering practices (number of labs per patient per day) and the associated cost (cost of labs per patient per day). This data was made transparent across the hospitalist team and pushed out on a biweekly basis by email. The team was provided education on the cost of specific labs as well as the total cost of labs per year. The team then set a goal to reduce their total cost of labs by 5%. The total monthly cost of labs decreased by 16% from $71,087 (January-March 2019) to $59,856 (April-August 2019) (figure 1), as the number of labs per patient per day decreased. When corrected for the census, the average cost of labs per patient per day decreased from $10.46 (January-March 2019) to $9.15 (April-August 2019), which is a 12.5% reduction (figure 2).Conclusions: This intervention of simply providing data on utilization and cost quickly resulted in a behavioral change, thereby reducing lab test utilization and associated costs. One of the challenges in hospital medicine, however, is that patients are often cared for by multiple specialists at once. The next phase of this project involves applying the same intervention to other specialties while sustaining the behavioral change for the hospitalist team.References:

486 MIND THE GAP: EUGLYCEMIC DIABETIC KETOACIDOSIS WITH EMPAGLIFLOZIN USE 1335422 Jonathan Chang Tulane University School of Medicine Ugochukwu Ezema Tulane Christine Bojanowski Angela Hamilton MIND THE GAP: EUGLYCEMIC DIABETIC KETOACIDOSIS WITH EMPAGLIFLOZIN USE Finalist Case Presentation: A 64-year-old man with type 2 diabetes mellitus presented with three days of severe epigastric abdominal pain, vomiting, polyuria, and subjective dyspnea. Following the onset of illness, he stopped taking his home medications including insulin glargine and empagliflozin. Temperature was 97.5°F, heart rate 112 beats per minute, blood pressure 130/81 mmHg, respiratory rate 23 breaths per minute, and oxygen saturation 95% on room air. He was alert and oriented but appeared restless with labored breathing. Crackles were auscultated in the right lower lung field. Epigastric tenderness was present without rebound or guarding. Complete blood count was normal. Serum bicarbonate was 8 mg/dL with an anion gap of 28 mEq/L, and blood glucose was 157 mg/dL. Arterial blood gas showed pH 7.10, pCO2 22 mmHg, and pO2 112 mmHg. Serum osmolality was grossly elevated at 363 mOsm/kg. Lipase was 751 IU/L. Urinalysis showed ketones and serum β-hydroxybutyrate was 11.9 mmol/L. Ethanol, volatile alcohols, and urine toxicology were negative. CT of the abdomen revealed edema and fat stranding of the pancreas, consistent with acute pancreatitis. The patient was diagnosed with euglycemic diabetic ketoacidosis and started on a continuous insulin infusion as well as intravenous fluids containing 10% dextrose. The acidemia and anion gap gradually resolved. Pancreatitis improved with supportive care and opioid analgesia. Empagliflozin was discontinued.Discussion: The sodium-glucose linked transporter 2 (SGLT-2) inhibitors, including empagliflozin, canagliflozin, and dapagliflozin, promote glycosuria by inhibiting glucose resorption in the proximal renal tubule. However, these medications have been associated with euglycemic diabetic ketoacidosis (DKA), prompting the US Food and Drug Administration to issue a warning in 2015. Euglycemic DKA with SGLT-2 inhibitors is thought to result from persistent glycosuria despite ongoing insulin deficiency, poor cellular glucose uptake, and ketogenesis. With full-dose empagliflozin, urinary glucose losses reach 50-100 g/day, which represents 200-400 kcal/day of nutritional content. Decreased plasma glucose removes the stimulus for insulin secretion, promoting lipolysis, fatty acid oxidation, and ketogenesis. SGLT-2 inhibitors also independently increase glucagon secretion by pancreatic alpha cells, further favoring ketoacid production. Euglycemic DKA should remain a consideration in normoglycemic patients with a compatible history, high anion gap metabolic acidosis, and positive ketones. As in all cases of DKA, these patients require aggressive volume resuscitation, electrolyte repletion, and continuous insulin infusion to inhibit ketogenesis. Dextrose-containing fluids are often necessary from the outset to prevent hypoglycemia. Once the ketoacidosis resolves and the patient tolerates oral intake, insulin is switched to the subcutaneous route.Conclusions: SGLT-2 inhibitors are commonly prescribed in type 2 diabetes, and off-label use in type 1 diabetes is widespread. As such, internists, intensivists, and emergency physicians will likely encounter increasing incidence of euglycemic DKA. Primary care providers and endocrinologists should also educate their patients to use home ketone testing as an early indicator of DKA when experiencing malaise or gastrointestinal symptoms, regardless of blood glucose level.References: Bonora BM et al. Sodium-glucose co-transporter-2 inhibitors and diabetic ketoacidosis: an updated review of the literature. Diabetes Obes Metab 2018;20:25-33. Burke KR et al. SGLT2 inhibitors: a systematic review of diabetic ketoacidosis and related risk factors in the primary literature. Pharmacotherapy 2017;37(2):187-194. Ferrannini E et al. Metabolic response to sodium-glucose cotransporter 2 inhibition in type 2 diabetic patients. J Clin Invest 2013;124(2):499-508. Peters AL et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care 2015;38:1687-1693. Rosenstock J, Ferrannini E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care 2015;38:1638-1642.

489 AYE-DUNNO! ADENOVIRUS IN RENAL TRANSPLANT PATIENT. A CLINICAL MYSTERY. 1334848 Virginia Ferreira NYU Langone Health Benjamin Verplanke AYE-DUNNO! ADENOVIRUS IN RENAL TRANSPLANT PATIENT. A CLINICAL MYSTERY. Finalist Case Presentation: A 32-year-old South Asian woman with history of IgA nephropathy complicated by end stage renal disease status post renal transplant (CMV/EBV positive), latent tuberculosis infection, C. Diff colitis, and recurrent urinary tract infections presented with two days of fevers and diarrhea. One week prior to admission she was seen at a local ED for dysuria and was empirically treated with cefpodoxime for presumed UTI. Two days following completion of cefpodoxime, she began to experience profuse non-bloody diarrhea accompanied by fevers, chills, dysuria, myalgias and arthralgias. During her admission, she had fevers up to 101.3°F with diaphoresis. Laboratory tests were notable for serum creatinine 1.5 (from baseline 1.0), and no leukocytosis, neutrophilia or bandemia. Her urinalysis showed cloudy urine with large blood, small protein, large leukocyte esterase, greater than 100 red blood cells (RBCs), greater than 100 white blood cells (WBCs) and few bacteria. Infectious work-up including blood, urine, and stool cultures were all negative, as were whole-body CT scans, colonoscopy, and gallium scan. She was treated with vancomycin and piperacillin-tazobactam. She was eventually found to have an adenovirus viral load of 219,000 despite negative viral cultures. She was treated with Brincidofovir which resulted in cessation of her fevers, diarrhea and viremia.Discussion: Adenovirus in solid organ transplant is very rare and deadly. Though adenovirus most commonly causes respiratory illness, it can also cause gastroenteritis, cystitis, conjunctivitis and less often neurological disease. Adenovirus has severe consequences, specifically in patients with compromised immune systems. Currently, the only FDA approved treatment for disseminated adenovirus is Cidofovir, a highly nephrotoxic medication. Until recently, the only treatment for patients with renal impairment and/or transplanted kidneys was supportive care. Brincidofovir, an investigational, lipophilic formulation of cidofovir without its nephrotoxic properties is currently showing great promise at clearing adenovirus in this special patient population.Conclusions: Disseminated adenovirus in solid organ transplant recipients is an uncommon and deadly condition. It can mimic other infections like influenza, C. Diff infection or gastroenteritis. Clinicians should remain vigilant for this disease, particularly in immunocompromised patients with persistent fevers, diarrhea and negative infectious work-ups. Clinicians should also remain vigilant for novel therapies that are showing great promise in decreasing mortality.References: 1. Centers for Disease Control [Adenovirus]. (n.d.). Retrieved from https://www.cdc.gov/adenovirus/hcp/clinical-overview.html. 2. Echavarría, M. (2008). Adenoviruses in immunocompromised hosts. Clinical microbiology reviews, 21(4), 704-715. 3. Florescu, D. F. (2017). The evaluation of critically ill transplant patients with infectious diarrhea. Current opinion in critical care, 23(5), 364-371. 4. Majorant, D., Qiu, F., Kalil, A. C., Wilson, N., & Florescu, D. F. (2018). Adenovirus—A Deadly Disease in the Solid Organ Transplant Population: Risk Factors and Outcomes. In Transplantation proceedings (Vol. 50, No. 10, pp. 3769-3774). Elsevier. 5. National Institute of Health, United States National Library of Medicine [Open label study of intravenous Brincidofovir in adult transplant recipients with adenovirus viremia (identifier number NCT03532035)]. (n.d.). Retrieved June 23, 2019, from https://clinicaltrials.gov/ct2/show/NCT03532035. 6. Bowman, L., Baliga, R., & Mayer, C. (2018, June). Brincidofovir for Disseminated Adenovirus in Kidney and Kidney-Pancreas Transplant Recipients: Report of a Case Series. American Journal of Transplantation, 18 (534-535) .

491 A CASE OF EGPA PRESENTING AS CHRONIC ASTHMA WITH HEMOPTYSIS 1334971 Jared Geibig USC Internal Medicine Residency Program Sonia Lin Richard Castriotta University of Southern California Keck School of Medicine Tobias Dong A CASE OF EGPA PRESENTING AS CHRONIC ASTHMA WITH HEMOPTYSIS Finalist Case Presentation: A 25 year-old woman with severe persistent asthma, chronic self-resolving episodes of hemoptysis, history of miscarriage, and iron deficiency anemia secondary to heavy menses presented with sub-acute worsening shortness of breath and hemoptysis despite adherence to home inhalers. Patient had multiple prior hospitalizations requiring intubation for asthma exacerbations, complicated by hemoptysis. Upon presentation, she was found to be afebrile, normotensive, tachycardic to 130 bpm, tachypneic to 23, and saturating 95% on room air. Exam was notable for bilateral crackles at the lung bases. Labs were significant for microcytic anemia and UA with > 50 RBCs. EKG showed sinus rhythm. CTPA was negative for pulmonary embolism and demonstrated diffuse ground-glass opacifications with a new consolidation of the left lung (figure 1). She was started on CAP coverage and treatment for an asthma exacerbation. Given the findings of hematuria, an autoimmune workup was initiated, and she was found to have positive P-ANCA titers with normal IgE and complement levels, suggestive of vasculitis. She then underwent a renal biopsy demonstrating fibrocellular crescent glomeruli (figure 2) and immune complex deposits in the mesangium supporting the diagnosis of eosinophilic granulomatosis with polyangitis (EGPA). She was started on rituximab and steroid therapy and discharged home with plans for follow up with rheumatology and pulmonology.Discussion: This case highlights several of the salient features of a patient with EGPA vasculitis. This disease process has been found to present in a sequential set of phases often beginning in the second to third decades of life, starting with a prodromal phase, followed by an eosinophilic phase, and finally a vasculitic phase. It has been established that these patients often initially develop asthma and allergic rhinitis during the prodromal phase, during which the classic laboratory markers of eosinophilia and ANCA positivity may be absent. In addition this phase of the disease can precede the vasculitis phase of disease by as much as ten years. In the eosinophilic phase, asthma symptoms are persistent and the patient develops peripheral eosinophilia. Finally, in the vasculitic phase, multi-organ damage often to the skin, lungs, heart, and kidneys occurs as a result of small and medium vessel involvement. Thus, for hospitalists who manage patients with asthma exacerbations, it is crucial to consider when an alternative diagnosis might be present. In this case, our patient presented with several symptoms and findings in her history that were incongruent with a simple asthma exacerbation. These symptoms include the history of recurrent hemoptysis, severe persistent respiratory symptoms despite medication compliance, and hematuria. The history of miscarriage should also have raised concern as there have been previous studies noting increased rates of miscarriage in patients with EGPA. At the time of presentation our patient would be classified in the vasculitis stage as evidence of necrotizing vasculitis had taken place.Conclusions: EGPA is a systemic vasculitis that can affect multiple organs of the body; however, it is also a disease process that typically presents in a sequential set of phases that if not considered, can lead to a delay in diagnosis and treatment. For the hospitalist, this case highlights the importance of being mindful of and identifying risk factors of other disease processes, in this instance a vasculitis, that may present as a case of asthma exacerbation.References: Gioffredi, Andrea, et al. "Eosinophilic granulomatosis with polyangiitis: an overview." Frontiers in immunology 5 (2014): 549. Pagnoux, Christian, et al. "Pregnancies in systemic necrotizing vasculitides: report on 12 women and their 20 pregnancies." Rheumatology 50.5 (2010): 953-961.

492 METASTATIC COCCIDIOIDES OSTEOMYELITIS IN PATIENT WITH UNCONTROLLED DIABETES 1334771 David Goldstein Natividad Family Medicine Residency Brittany Chamberlain Marie Schow METASTATIC COCCIDIOIDES OSTEOMYELITIS IN PATIENT WITH UNCONTROLLED DIABETES Finalist Case Presentation: An 82-year-old, Samoan male with history of poorly controlled diabetes, hypertension, COPD, and pulmonary coccidioidomycosis on fluconazole therapy (400 mg/day) was referred to the hospital by his primary doctor for treatment of a left ankle ulcer and cellulitis that had not responded to ten days of outpatient amoxicillin-clavulanate therapy. He had no constitutional symptoms or leukocytosis at the time of admission, but ESR was elevated at 117 mm/hr. MRI indicated severe osteomyelitis involving the entire left talus. He was started on broad-spectrum antibiotics, and underwent a wound exploration and debridement with vacuum-assisted closure. Wound cultures grew Coccidioides immitus. Antibacterial therapy was discontinued, and fluconazole was changed to posaconazole. Vacuum-assisted closure was discontinued in favor of daily wet-to-dry dressing changes, and the patient was discharged to acute rehabilitation.Discussion: Coccidioidomycosis, commonly known as valley fever, is endemic to the southwestern United States, Mexico and Central/South America. The incidence is on the rise in California, especially in concentrated endemic areas along the central coast. The most common manifestations involve self-limited constitutional or respiratory symptoms. Extrapulmonary disease can manifest as meningo-encephalitis, skin and soft tissue infection, or osteoarticular infection. Persons with diabetes or immune compromise, pregnant women, and Black or Filipino patients are at increased risk for severe pulmonary and disseminated disease. In this case, the patient's first manifestation of coccidioidomycosis was pneumonia 20 months earlier. The pulmonary infection was successfully treated with fluconazole, but maintenance therapy failed to prevent a metastatic infection. Osteoarticular infections have been shown to be more successfully treated with itraconazole, and posaconazole is a newer azole, which may be used to treat coccidioidomycosis refractory to other azoles. The hospitalist should consider the possibility of failed cocciodiomycosis treatment, especially for patients with risk factors for disseminated disease. In patients with open wounds, used dressings must be handled with extreme caution, as materials contaminated with Coccidioides arthroconidia are a transmission hazard.Conclusions: Especially in endemic areas, coccidioidomycosis is an important consideration when evaluating atypical presentations of skin infections. The hospitalist may easily mistake it for a more common, conventional, bacterial infections, potentially both delaying effective therapy and exposing patients to unnecessary parenteral antibiotics and hospital days. The hospitalist should be vigilant to consider and rule out primary or metastatic Coccidioides osteoarticular infections early in the clinical evaluation process.References:

496 LET THEM EAT (URINAL) CAKE? 1335368 Kierstin Kennedy UAB Hospital Janelle James Jill Neely Marisa Pasquale William Rushton KeAndrea Titer LET THEM EAT (URINAL) CAKE? Finalist Case Presentation: A 31 year old female with a history of polysubstance abuse was brought to the Emergency Department by family after they noted confusion, weakness, hallucinations, ataxia, vision loss, and bizarre behaviors for 2 weeks along with the patient emitting a pungent odor. Physical exam was notable for a strong odor permeating from her skin, global weakness, confusion, excoriations to the chest and neck, and mydriasis. Ancillary studies demonstrated hypomagnesemia, hypokalemia and microcytic anemia. MRI brain showed cytotoxic lesions of the corpus callosum. After further history, the patient’s family reported that she had been "eating toilet bowl cleaners" for several months. Aggressive fluid hydration, dextrose therapy, 72 hours of n-acetylcysteine, and TPN was started; however, on hospital day 4 the patient was no longer following commands and a repeat MRI brain revealed worsening leukoencephalopathy. EEG monitoring did not demonstrate epileptic seizures. A urine paradichlorobenzene concentration ultimately returned at 1000mg/L (ref: Discussion: Paradichlorobenzene (PDCB), an aromatic hydrocarbon, is a common ingredient in mothballs and urinal deodorizer cakes. PDCB can be absorbed via inhalation, ingestion, or dermal exposure, and is stored in adipose tissue due to its high lipophilicity. PDCB is further metabolized by the CYP450 systems to an inactive metabolite. Both neurotoxicity and withdrawal symptoms have been described in case reports. Other clinical manifestations include hemolytic anemia, acute hepatitis, dermatitis, renal failure, and pulmonary granulomatosis. Neurotoxicity after PDCB exposure may manifest as psychomotor slowing, dysarthria, ataxia, amnesia, vision loss, peripheral neuropathy, cognitive decline, and coma. Of note, a "coasting" phenomenon has also been documented presumably due to the lipophilic nature of PDCB causing it to be slowly released from adipose tissues, which may prolong clinical improvement after cessation of initial exposure. This is particularly notable when starvation is present, as faster mobilization of fat reserves occurs – suggesting that both acute and chronic toxicities can occur. Another case report hypothesized that abrupt withdrawal from PDCB can also manifest with severe neurologic decline with catatonia and MRI findings of demyelination and axonal loss. Management of neurotoxicity secondary to PDCB exposure is limited. All case reports note some degree of cognitive decline although time courses for symptom manifestations and clinical improvement were variable. Most patients had complete resolution of symptoms within 3 to 6 months, while for some patients symptoms persisted. It remains unclear if time to recovery and severity of neurotoxicity depends upon duration of exposure or total body burden of PDCB. Reducing agents such as n-acetylcysteine, dextrose to prevent adipose tissue mobilization, and lipid therapy to bind up PDCB have been theorized but no current high level evidence supports their use.Conclusions: With the increased incidence of creative drug use, physicians should be adept in identifying PDCB toxicity. Exposure to high concentrations of PDCB can cause a variety of symptoms, most notably neurotoxicity. The time courses for symptom manifestation and clinical improvement can be variable. There are no known proven effective antidotes for PDCB neurotoxicity. The goal of treatment is reduction of exposure along with supportive care.References: Kim, Hong K.. "Camphor and Moth Repellents."Goldfrank's Toxicologic Emergencies, 11e Eds. Lewis S. Nelson, et al. New York, NY: McGraw-Hill, Dubey D et al. Para-dichlorobenzene toxicity –a review of potential neurotoxic manifestations. Ther Adv Neurol Disord. 2014;7(3):177-187 Tardiolo et al. Overview on the effects of n-acetylcysteine in neurodegenerative diseases. Molecules. 2018;23(12): 3305 Chong et al. Mothball withdrawal encephalopathy –case report and review of paradichlorobenzene toxicity. 2006;27(4):63-67.

499 PUFF PUFF PATH TO LUNG INURY: A CASE OF LIPOID PNEUMONIA DUE TO E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY. 1334768 Nikki Kimura Northwell Health Derek Ou Juan Carlos Arrieta Manile Dastagir Gregory Hughes St. John's University College of Pharmacy and Health Sciences Eileen Kim Matthew Lee PUFF PUFF PATH TO LUNG INURY: A CASE OF LIPOID PNEUMONIA DUE TO E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY. Finalist Case Presentation: A 33-year-old woman presented to the hospital following seven days of persistent fever and non-productive cough despite a course of azithromycin prescribed by her primary care physician. She denied shortness of breath, chest pain, palpitations or lower extremity swelling. She reported no sick contacts or travel in the last six months. She endorsed use of vaping tetrahydrocannabinol (THC) oil for three years but denied use of tobacco or other illicit drugs. On presentation, she was afebrile but her SpO2 was 85% on room air. Lung exam demonstrated bibasilar crackles. Laboratory results were notable for a WBC of 6.5k/uL, thrombocytosis to 480k/uL, elevated ESR (111mm/hr) and CRP (26 mg/dL). Infectious workup was negative, including HIV. Rheumatologic workup was only revealing for elevated ANA (1:320) and low C4 (10 mg/dL). CTA was negative for pulmonary embolism but demonstrated diffuse bilateral groundglass opacities. The patient was initially started on intravenous antibiotics for community-acquired pneumonia, but suspicion was raised for e-cigarette or vaping product use-associated lung injury (EVALI). A bronchoscopy and transbronchial biopsy were performed and cytology on bronchoalveolar lavage fluid was remarkable for alveolar macrophages and chronic inflammatory cells with no organisms detected. Microscopy of alveolar parenchyma showed increased intra-alveolar histiocytes with intracellular lipid and focal reactive type II pneumocytes (Figure 1). This biopsy was consistent with lipoid pneumonia secondary to EVALI. She was started on methylprednisolone and transitioned to a prednisone taper. Despite high oxygen requirements, the patient remained largely asymptomatic throughout the hospital course and was discharged on a prolonged prednisone taper. She was seen in the pulmonology clinic two weeks after discharge and reported feeling well. A follow up CT chest obtained two months after discharge showed resolution of ground glass opacities.Discussion: Lipoid pneumonia secondary to EVALI is a diagnosis recently in the spotlight as of fall 2019. Prior to EVALI, exogenous lipoid pneumonia was a relatively uncommon diagnosis in healthy adults and was generally caused by aspiration or inhalation of fatty substances such as oil-based laxatives or oily nasal drops. This patient’s presentation was similar to other EVALI patients whose presentations have included respiratory symptoms and constitutional symptoms 95% and 85% of the time, respectively. Bronchoalveolar lavage revealed lipid-laden macrophages, a finding consistent with EVALI as pulmonary macrophages cannot metabolize oil and it is simply released back into the alveoli upon cell death. Although the treatment of EVALI is unknown, the use of corticosteroids, antibiotics, antivirals, or antifungals can be considered based on clinical suspicion. These medications should be used in accordance with published guidelines in the instances of concurrent infections such as community-acquired pneumonia or influenza. Though severity of illness varies, 96% of reported patients diagnosed with EVALI were hospitalized and 47% were admitted to the intensive care unit.Conclusions: E-cigarette or vaping product use-associated lung injury is a relatively new and therefore likely unfamiliar phenomenon. As the vast majority of cases are encountered in the hospital setting, hospital medicine professionals are in an important position to detect and manage this patient population.References: 1. Smoking and Tobacco Use; Electronic Cigarettes. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. Published October 31, 2019. Accessed November 1, 2019. 2. Hadda V, Khilnani GC. Lipoid pneumonia: an overview. Expert Rev Respir Med. 2010;4(6):799-807. 3. Siegel DA. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep. 2019;68. 4. Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report. N Engl J Med. 2019;0(0): 5. Lauque D, Dongay G, Levade T, et al. Bronchoalveolar Lavage in Liquid Paraffin Pneumonitis. CHEST. 1990;98(5):1149-1155.

503 A CASE DEMONSTRATING THE YING AND YANG OF INHALED CORTICOSTEROIDS IN ASTHMA 1335147 Jellyana Peraza Montefiore Medical Center Rachel Levy Shitij Arora A CASE DEMONSTRATING THE YING AND YANG OF INHALED CORTICOSTEROIDS IN ASTHMA Finalist Case Presentation: A 78-year-old woman with severe persistent asthma on a maximum dose of inhaled corticosteroids (ICS) was admitted for lethargy and skin nodules on her thighs. She had three hospital admissions in the past two months for reported pneumonia. She was found to have fever, left basilar crackles, and multiple violaceous, firm, tender subcutaneous nodules on the abdomen and lower extremities. She had no leukocytosis, and blood cultures were negative. CT chest revealed a mass-like consolidation in the right lower lobe. Punch biopsies of the skin nodules initially revealed a suppurative process with lymphoplasmacytic cell infiltrate; gram and PAS stains failed to show any organism. The course of her admission was complicated by severe headache and worsening lethargy. Brain MRI revealed ring-enhancing lesions suggestive of abscesses. CSF cultures were negative. Further review of the skin pathology demonstrated few gram-positive filamentous organisms. The patient received TMP-SMX, Meropenem, and Linezolid for empiric coverage of actinomycetes, with interval resolution of lung and skin nodules, but worsening of mental status and brain lesions. She underwent craniotomy for evacuation of intracerebral abscess. Brain tissue grew Nocardia farcinica, which subsequently was isolated from all the sampled tissues. The patient's mental status and functional capacity markedly improved, and she was discharged with a nine-month course of oral TMP-SMX and Linezolid. Follow-up neuroimaging revealed resolution of the abscesses.Discussion: Disseminated nocardiosis is defined as involvement of two noncontiguous sites and is associated with a mortality rate as high as 64%. Lung seems to be the organ most frequently involved. The majority of cases of pulmonary or disseminated disease occur in people with deficient cell-mediated immunity, such as lymphoma, transplantation, chronic glucocorticoid therapy, and AIDS. To date, only several cases have been reported in patients with exposure to ICS as the only identifiable risk factor. ICS act by suppressing inflammation in asthma, and it is not surprising that the counter-effect would be increased susceptibility to infections. Alveolar macrophages are the resident phagocytes, which, along with T-cells, coordinate an immune response to clear the pathogen. However, Nocardia has enhanced resistance against intracellular killing. Therefore, clearance of such organisms relies heavily on the T-cell cytotoxic response, with a critical dependence on IL-12/IFN-gamma axis. Steroids, including ICS, have an effect on aforesaid pathways by inhibiting transcription of pro-inflammatory cytokines and by pro-apoptotic effects on T-cells. In a single center observational study, it was noted that the mean time to diagnosis of disseminated nocardiosis was 42 days. A high clinical suspicion is vital for an early diagnosis and appropriate treatment in patients who present with lung involvement or signs of non-resolving pneumonia. Our case illustrates the importance of considering ICS use, especially at maximum recommended dosage, as a risk factor for Nocardia infection.Conclusions: ICS have an inhibitory effect on the T-cells involved in the production of cellular immunity. Hence, they can cause sufficient immunosuppression to predispose a patient to disseminated infections with intracellular organisms, such as Nocardia.References:

506 A FISHY CASE: SALMONELLOSIS MANIFESTING AS EMPYEMA 1334354 Dipesh Solanky University of California, San Diego Ian Drobish Milli Desai Jennifer Quartarolo Brian Kwan University of California, San Diego; VA San Diego Healthcare System A FISHY CASE: SALMONELLOSIS MANIFESTING AS EMPYEMA Finalist Case Presentation: A 66-year-old man with uncontrolled type 2 diabetes mellitus (hemoglobin A1c = 18.1%) presented with one month of worsening pleuritic chest pain, productive cough and 10-pound weight loss. He denied any gastrointestinal (GI) symptoms, including diarrhea or abdominal pain. He worked as a clinical nursing assistant. Patient denied any recent international travel, animal exposures or raw food ingestion. His medications included insulin glargine, sliding scale insulin, metformin, aspirin, atorvastatin and lisinopril. Vital signs were notable for respiratory rate of 18 to 22 and oxygen saturation greater than 95% on room air. On examination, he appeared cachectic with temporal wasting. Breath sounds were markedly decreased in the left lower and middle lobes of his lung. Abdomen was benign. Laboratory studies revealed a white blood cell count of 16,900/mm^3 with 30% bandemia and a lactate of 3.3 mmol/L (0.5 - 2.0 mmol/L). Serum glucose was 277 mg/dL. CT Chest demonstrated a left lower lobe consolidation with multiple, loculated pleural fluid collections. CT Abdomen was negative for intra-abdominal infection. Transesophageal echocardiography was negative for vegetations. A chest tube was placed to drain the largest left loculated pleural effusion. Blood, sputum and pleural fluid cultures grew Salmonella Enteritidis, consistent with pneumonia complicated by empyema. The patient was initially treated with vancomycin, metronidazole, ceftriaxone and azithromycin and narrowed to ceftriaxone per susceptibilities. He underwent successful thoracic decortication of the empyema and completed 5 weeks of ceftriaxone post-procedure with resolution of symptoms.Discussion: This case illustrates an adult with systemic, nontyphoid Salmonella infection complicated by pneumonia and empyema and the lack of a preceding GI illness. Salmonella infection is classified into typhoid and nontyphoid (NTS) subtypes. Infection with NTS is typically a self-limited gastroenteritis resulting from fecal-oral transmission from contaminated water and food. Approximately 1.2 million cases and 450 deaths are attributed each year to NTS in the United States. About 5% of infections progress to bacteremia, which can lead to extraintestinal focal infections (EFIs) including endarteritis, septic arthritis, osteomyelitis, and pneumonia/empyema--especially in immunocompromised hosts. Additional risk factors for EFIs include age greater than 60, diabetes mellitus, hypertension and chronic lung disease. Long-standing diabetes is thought to increase the risk for NTS infection through reduced gastric acidity and impaired gut motility from associated enteric neuropathy. Initial management involves parenteral antibiotic therapy against Gram negative enteric bacteria and source control of any focal infections. Prompt recognition of uncontrolled diabetes mellitus as a risk factor for complicated NTS infection and improving glycemic control in these patients may be critical to effective management for this high-risk population.Conclusions: Salmonella bacteremia with pneumonia and empyema is a rare manifestation of nontyphoid Salmonella infection, and can present without GI symptoms. Treatment involves prompt initiation of parenteral antibiotic therapy and achieving adequate source control of the infection. Further, it is critical to recognize uncontrolled diabetes mellitus as a predisposing risk factor for systemic nontyphoid Salmonella infection, with or without extraintestinal manifestations.References: “Information for Healthcare Professionals | Salmonella | CDC.” Centers for Disease Control and Prevention, U.S. Department of Health & Human Services, https://www.cdc.gov/salmonella/general/technical.html. Acheson D, Hohmann EL. Nontyphoidal Salmonellosis. Clinical Infectious Diseases 2001;32:263-9. Chen PL, Chang CM, Wu CJ, et al. Extraintestinal focal infections in adults with nontyphoid Salmonella bacteraemia: predisposing factors and clinical outcome. Journal of Internal Medicine 2007;261:91-100. Telzak EE, Zweig Greenberg MS, Budnick LD, Singh T, Blum S. Diabetes Mellitus—A Newly Described Risk Factor for Infection from Salmonella enteritidis. The Journal of Infectious Diseases 1991;164:538-41. Ramos JM, García-Corbeira P, Aguado JM, Alés JM, Soriano F. Classifying extraintestinal non-typhoid Salmonella infections. QJM: An International Journal of Medicine 1996;89:123-6. Shimoni Z, Pitlik S, Leibovici L, et al. Nontyphoid Salmonella Bacteremia: Age-Related Differences in Clinical Presentation, Bacteriology, and Outcome. Clinical Infectious Diseases 1999;28:822-7.

509 CALL THE BUTCHER: A PIG-TAIL CATHETER WAS NOT ON THE MENU 1335502 Darius Byramji UNC Robert Gardner Zachary Pettigrew UNC Health Alana Painter Ashley Sutton UNC CALL THE BUTCHER: A PIG-TAIL CATHETER WAS NOT ON THE MENU Finalist Case Presentation: A 12-year-old healthy female presented for three weeks of abdominal pain, loose non-bloody stools accompanied by night sweats and an eight-pound weight loss. Initial exam was only significant for diffuse abdominal pain. An abdominal X-ray demonstrated a unique appearing paravertebral stripe which prompted a follow up MRI abdomen/pelvis. MRI imaging revealed a 5.8 cm left paravertebral mass at T10-T12 with a radiographic differential including neuroblastoma, ganglioneuroblastoma, or lymphoma (Image 1). Subsequent vertebral mass biopsy showed histiocytic infiltrate with negative AFB stain and no malignancy on flow cytometry. The patient was discharged home with close oncology follow up. Three days later she returned with new left sided chest pain, dyspnea, and an unrelenting fever. New symptoms raised concern for a diagnosis other than malignancy, including infectious and rheumatologic. On exam the patient was ill appearing, febrile (103°F) with rigors. Lung exam had decreased breath sounds with dullness to percussion at the left lung base. There was no cardiac murmur, skin rash, or lymphadenopathy. There was tenderness to the lower thoracic vertebra but no lower extremity weakness or paresthesia. Laboratory evaluation was significant for negative blood cultures, HIV Ab and quantiferon TB test. Lung ultrasound showed complex left pleural collection prompting VATS and pig-tail catheter placement. Pleural rind culture grew non-typhoid Salmonella. Fecal Salmonella PCR was negative. MRI dedicated to the thoracic spine for ongoing fever showed T10-12 vertebral osteomyelitis with adjacent paraspinal abscess and resolving left lung empyema (Image 2). The patient responded well to a four-week course of ceftriaxone antimicrobial treatment followed by two weeks of oral cefdinir.Discussion: We present a case of non-typhoid Salmonella gastroenteritis with hematogenous spread to the spine and pleural space in a healthy adolescent. Further history revealed the family ate meat from a local butcher prior to onset of symptoms and had self-resolved diarrhea. It is unclear if the pleural space infection was due to the primary infectious process or related to a communicating tract following needle biopsy with spread from the paraspinal infection. Salmonella is a common enteric pathogen, however, invasive multisite infection affecting either the bones or pleural space is rare in immunocompetent hosts. Pulmonary Salmonella infection is almost exclusively reported to be found in individuals with malignancy, tuberculosis or other immunocompromised states. Vague symptoms and imaging concerning for malignancy, likely resulted in anchoring bias that delayed further evaluation of infectious etiologies for her fevers.Conclusions: This unique case of multisite salmonellosis, involving the pleural space and the vertebra, highlights the importance of maintaining a broad differential in pediatric patients with fever and contributes to a growing caseload of immunocompetent children with invasive Salmonella disease.References:

514 A CHALLENGING DIAGNOSIS OF BRAIN TUBERCULOMA 1334489 fatemeh Abbasi Capital health Regional Medical center Muhammet Ozer Babak JAMASSIAN Marc S. Whitman A CHALLENGING DIAGNOSIS OF BRAIN TUBERCULOMA Accept Case Presentation: A 79-year-old African American male patient with a past medical history of prostate cancer presented with progressive weakness, headache, and confusion. Free and total PSA levels were within normal limits. Brain MRI showed a 4.1x3.3x4.1 cm left frontal lesion at the surface of the left lateral ventricle with vasogenic edema and midline shift. The stereotactic biopsy of the lesion was inconclusive with showing the possibility of a non-caseating granuloma. This result was similar to the right para-adrenal mass that was biopsied a year ago. The pathologic diagnosis was in favor of sarcoidosis and metastatic prostate cancer ruled out. The patient was immigrated from Liberia and denied any constitutional symptoms. Quantiferon gold test was positive. Chest CT showed pleural calcifications without evidence of active tuberculosis(TB). Acid-Fast Basili (AFB) smear of blood was negative. Bone marrow AFB culture was negative. Rheumatologic and infectious workup of blood serum and cerebrospinal fluid were unremarkable. Stereotactic brain biopsy was inconclusive with showing astrocytosis. He subsequently, underwent left-sided frontal open brain biopsy which was compatible with granulomatous inflammation. Fungus tissue culture, sputum and blood cultures were negative. He was empirically started on anti-TB medications and dexamethasone treatment. We were unable to have significant clinical improvement two weeks after anti-TB treatment. Considering the possible diagnosis of neurosarcoidosis, we started him on intravenous methylprednisolone 1 g daily treatment for 3 days and tapered within 6 weeks. Later on, the culture of the brain biopsy showed acid-fast bacilli. We diagnosed him with tuberculoma of the brain. After a month control CT of head showed near resolution of the mid-line shift and decrease in the left frontal and bilateral parietal lobes edema.Discussion: Central Nervous System (CNS) tuberculoma accounts for almost 1% of all tuberculosis (TB) presentations. The incidence of brain tuberculoma is increasing in developed countries due to AIDS and immigration from TB endemic countries. Symptoms and radiologic findings of CNS TB can be nonspecific and leading to misdiagnosis or mistreatment. We describe a case of brain tuberculoma in a patient who was thought to have a neuro-sarcoidosis due to non-caseating granuloma. Brain Tuberculoma can present with a seizure, intracranial hypertension or focal neurologic symptoms. A definitive diagnosis can be made with AFB in the pathologic specimen. In our case diagnosis was challenging between neurosarcoidosis and TB due to inconclusive results of stereotactic brain biopsy and clinical presentation. We proceed to open brain biopsy. It revealed non-caseating granuloma.Conclusions: Diagnosing brain tuberculoma can be challenging due to atypical presentation and inconclusive pathological results. Considering the catastrophic course of brain tuberculoma, physicians should consider empiric anti-TB treatment in high-risk patients.References:

529 A CASE OF STERNOCLAVICULAR JOINT SEPTIC ARTHRITIS IN THE SETTING OF UNSTERILE INSULIN INJECTIONS: A RARE CLINICAL ENTITY 1335484 Ahmed Ahmed EVMS Sami Tahhan Jennifer Knips A CASE OF STERNOCLAVICULAR JOINT SEPTIC ARTHRITIS IN THE SETTING OF UNSTERILE INSULIN INJECTIONS: A RARE CLINICAL ENTITY Accept Case Presentation: Septic arthritis (SA) of the sternoclavicular joint (SCJ) is a rare clinical entity with just over 200 cases reported in the past 45 years. We report an interesting case of SCJ septic arthritis in a patient with type one diabetes. A 47-year-old African American male with a medical history significant for poorly controlled diabetes presented to the hospital with complaints of left-sided chest pain localized to the sternal end of the clavicular bone with radiation to the neck and limitation of movement of the ipsilateral shoulder for one-week duration. He denied any history of direct trauma, intravenous drug use, recent central venous catheterizations, or infections. Chest x-ray showed non-specific findings. Additional imaging with CT and MRI of the chest revealed inflammatory changes suggestive of SCJ SA. Culture data from blood and joint aspirate were positive for Methicillin Sensitive Staphylococcus Aureus (MSSA). SCJ arthrotomy with drainage was performed and the patient was given four weeks of antibiotics. Further history from the family indicated that the patient, at times was not very sterile with his insulin injection technique. The patient also acknowledged that he is right-handed and uses his left upper arm as the preferred site for his daily injections.Discussion: The SCJ is an unusual site of SA. It is responsible for 0.5–1.0 % of all joint infections. Patients usually present in a subacute fashion. Localized SCJ pain with ipsilateral referred neck and/or shoulder pain are the most common presenting symptoms. Exam is often limited to occasional localized swelling, tenderness, and redness. Leukocytosis, positive blood, and joint aspirate cultures are invariably present in most patients. Initial plain radiographs are usually normal. Advanced imaging with CT and MRI is superior and can reveal inflammatory changes suggestive of SA. Based on a literature review of 180 cases, Staphylococcus aureus is the most common isolated pathogen (present in 49% of patients). Various predisposing factors have been identified with the following frequencies in SCJ patients: Intravenous drug use in 36% of patients, distant site infection in 25% of patients, diabetes mellitus in 13% of patients, trauma in 12% of patients, and infected central venous line in 9% of patients.Conclusions: The association between diabetes and this rare clinical entity is not entirely clear. Hyperglycemia-induced immunosuppression is thought to play a role. We propose that subcutaneous insulin delivery with poor skin hygiene can increase the risk of infection through a mechanism similar to that of intravenous drug users and infected central line catheters. We suspect bacterial contaminants injected into the upper extremity pass back along the course of the subclavian vein, ultimately seeding and propagating to the SCJ given their intimate anatomical association. This case highlights the importance of a comprehensive history to assess risk factors.References:

542 DRESS IN DISGUISE. AN UNUSUAL CASE OF MYOSITIS 1334906 Zohair Ali Northwell Health Internal Medicine Residency Program Prachi Mehta Edward Vuong Ava-Dawn Gabbidon DRESS IN DISGUISE. AN UNUSUAL CASE OF MYOSITIS Accept Case Presentation: A 60 year old man with a prior history of cutaneous sarcoidosis was admitted to the hospital with fatigue, myalgias, fever, and hypotension. His physical exam revealed a maculopapular erythematous rash on his trunk and bilateral lower extremities. Of note, three weeks prior to his presentation, he was treated with a ten day course of Clindamycin for presumed strep throat. His symptoms persisted, and he was then prescribed a five day course of Azithromycin for “walking pneumonia”. Initial labs were notable for mild transaminitis and a lactate of 5.4. In addition, he had a CK level as high as 5650 and eosinophilia as high as 19.2%. He underwent an infectious work up that was all negative and included a CT angiogram of the chest and abdomen/pelvis, viral panel, and blood and urine cultures. He was treated with norepinephrine and empiric vancomycin and piperacillin/tazobactam for possible toxic shock syndrome. Eventually, he improved and was discharged home. About a week after discharge, he was re-admitted to the hospital with the same presentation and a newly developing dysphagia. Again he required pressor support and was treated with broad spectrum antibiotics. This time his eosinophilia peaked to 31% and his CK level was greater than 50,000. He received an extensive infectious workup, rheumatologic/autoimmune work up, and evaluation for adrenal insufficiency, which were all unremarkable. He underwent an upper endoscopy with no identified cause for his dysphagia. Due to sinus bradycardia and his history of sarcoidosis, a cardiac MRI was obtained which was negative. A MRI of his femur, for his myalgias and CK level, was done which showed myositis. He was treated with high dose methylprednisolone then transitioned to oral prednisone. All of his symptoms resolved, and he was discharged on prednisone daily.Discussion: Taking into account this patient's clinical picture and extensive unremarkable work up, drug rash with eosinophilia and systemic systems (DRESS) likely went unnoticed. DRESS can occur anywhere from 2-8 weeks after the exposure to an offending agent. It is most commonly associated with anti-epileptic agents and antimicrobial agents, however, there is no comprehensive list of all known offending agents. In this scenario, the patient was exposed to azithromycin and clindamycin weeks prior to his initial presentation, both of which have been associated with DRESS in some literature. Interestingly, DRESS can have a relapsing form within days to weeks of the initial presentation despite cessation of the causative agent. This patient illustrated the key features of DRESS. Of note, the most common organ involved in DRESS is the liver. However, what was particularly profound was this patient's rhabdomyolysis and muscle involvement. This is a rare finding that can be seen in DRESS. Unfortunately, no muscle biopsy was performed. A validated scoring system, the RegiSCAR criteria indicated that for this patient DRESS is a “probable diagnosis”.Conclusions: Signs consistent with septic shock should be treated empirically given its high mortality rate. However, once infection has been ruled out, it is crucial to recognize that DRESS can present similarly to sepsis with a relapsing form that may go unnoticed due to the fact that it can occur despite cessation of the culprit agent. Additionally, even though it is rare, myositis can be one of the manifestations of DRESS. Ideally, a muscle biopsy would have solidified the diagnosis, but the RegiSCAR criteria can be utilized as a surrogate to guide management and treatment.References: Choudhary, S., McLeod, M., Torchia, D., & Romanelli, P. (2013). Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome. The Journal of clinical and aesthetic dermatology, 6(6), 31–37. Shao-Hsuan, Hsu, Che-Wan, Y., Yi-Chun, H., Yung-Tsu, C., Jau-Yu, L., Cher-Wei, L., Yu-Pin, C., Chia-Yu, C. (2018). Fever, eosinophilia, and abnormal liver function are early signs suggestive of DRESS: A comparative study between DRESS and MPE. Dermatologic Sinica, 36(1), 25-29. Bauer, KA, Brimhall, A., Chang, T. (2011). Drug reaction with eosinophilia and systemic symptoms (DRESS) associated with azithromycin in acute Epstein-Barr virus infection. Pediatric Dermatology, 28(6), 741-743. Miller Quidley, A, Bookstaver, P., Gainey, A., Gainey, M. (2012). Fatal clindamycin-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome. Pharmacotherapy, 32(12), 387-392.

546 DARTH VAPER: A NOVEL EVALI FORCE 1334361 Nhan Vuong UC San Diego Health Sarah Horman Nhan Vuong Maryann Ally UCSD Supraja Thota DARTH VAPER: A NOVEL EVALI FORCE Accept Case Presentation: A 37-year-old male auto-mechanic, with a history of tobacco use, presented with acute right-sided pleuritic chest pain. He was diagnosed with musculoskeletal pain and discharged from the ED. Several days later he returned with dyspnea, dry cough, fever and diaphoresis. He revealed that he recently tried vaping marijuana (THC) oil. Vital signs were temperature of 101.9 F, HR 111 bpm, BP 131/80, RR 38/min, and 91% oxygen saturation on room air. He appeared acutely ill and had poor diaphragmatic excursion and diminished breath sounds. Laboratory studies were significant for WBC 9.7/mm3 (69% segs, 16% lymphs, 14% monos), creatinine 1.28 mg/dL, BNP 58 pg/mL, procalcitonin 0.15 ng/mL, D-dimer 192 ng/mL, troponin T gen 5 Discussion: Our patient presented with severe right-sided chest pain which was initially misdiagnosed as musculoskeletal pain but turned out to be EVALI. He is just one of the hundreds of cases that comprise a national outbreak that began to accelerate in July 2019. At the time of this submission, 1,080 cases of e-cigarette associated lung injury have been reported across 48 states with 18 confirmed deaths. CDC and state health departments are currently collecting epidemiologic data. The specific chemical causing this outbreak is thus far unknown. Epidemiology, clinical features, pathophysiology, treatment and prognosis are not well-established. Based on information from a handful of cases series and CDC updates, general trends have been identified. Most patients are young and healthy. All report a history of e-cigarette use with either THC or a tobacco-containing product. Patients can present with acute to subacute onset of fever, cough, dyspnea, nausea, vomiting, and/or diarrhea. Typical chest imaging shows bilateral pulmonary infiltrates. Infectious workup is almost always negative. A recent case series described the finding of foamy macrophages and pneumocyte vacuolization in lung biopsies from patients with a confirmed diagnosis, but uniform histologic criteria was not defined.Conclusions: EVALI should be suspected when there is a history of e-cigarette use within 90 days of symptom onset, imaging shows lung injury, infectious work up is negative and an alternative diagnosis is unlikely. Our patient is just one of the many who are a part of a national outbreak of EVALI. In the context of this novel public health crisis, Hospitalists have a central role in recognizing this diagnostic entity, reporting cases for ongoing study, counseling patients on the perils of e-cigarette and vaping exposure, and discouraging use of these products to those not yet affected by this illness.References: Centers for Disease Control and Prevention. (2019 Oct). Outbreak of lung injury associated with using e-cigarette use, or vaping. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin - preliminary report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614.

547 FLAWED FLOW: A CASE OF THALAMIC DEMENTIA SECONDARY TO A DURAL ARTERIOVENOUS FISTULA 1334340 Jonathan McIntyre University of California San Diego Robertino Garcia Cortes William Frederick Maryann Ally UCSD FLAWED FLOW: A CASE OF THALAMIC DEMENTIA SECONDARY TO A DURAL ARTERIOVENOUS FISTULA Accept Case Presentation: We present a 68 year-old man, with a history of benign prostatic hypertrophy, who presented with several months of progressive personality changes and mild gait changes. His wife noticed he had become more introverted, and his gait had become more ataxic with prolonged ambulation. He also started having subtle memory problems. On physical, vital signs were normal. His neurologic exam was notable for mild decreased speech fluency, saccadic intrusions, and short-stepped gait. CBC and electrolytes were normal. HIV, RPR, Coccidioides, Cryptococcus, and Histoplasma antigens were negative. MRI brain revealed bilateral thalamic masses. Neurology and Neurosurgery were consulted and recommended MR spectroscopy, MRA and MRV brain. This imaging revealed dural arteriovenous fistula (dAVF) with persistent venous congestion involving the thalami. Subsequent cerebral angiogram showed dAVF in the branches of the vein of Galen. Attempted percutaneous closure was unsuccessful, so he underwent supracerebral craniotomy for resection of his dAVF. In follow-up, our patient was noted to be more engaged and conversant with others.Discussion: The majority of intracranial dAVF are idiopathic. Modes of presentation include intracranial hemorrhage (ICH) and non-hemorrhagic neurological deficits (NHNDs), both attributed to cortical venous hypertension. One manifestation of NHND is progressive dementia resulting from venous hypertension in the bilateral thalami. dAVF-induced thalamic dementia occurs most often in men in their fifth to seventh decade of life. Presenting findings include deficits in memory, executive function, attention, ataxia, and aphasia that develop over weeks to months. MRI of the brain invariably demonstrates T2/FLAIR hyperintensities indicating thalamic edema. Endovascular or surgical treatment of dAVF is performed to disconnect cortical venous drainage, the portion of the dAVF responsible for dementia. Improvement in neurologic symptoms is seen within days of treatment, and full neurologic recovery is achieved over months.Conclusions: This case demonstrates the importance for hospitalists to expand their differential diagnoses to include intracranial dural arteriovenous fistulas when faced with a patient with dementia and neurologic deficits. A thorough history, physical exam, and intracranial imaging were essential to diagnosing this patient correctly, allowing him to receive appropriate treatment that improved his symptoms and quality of life.References: Gandhi D, Chen J, Pearl M, et al. Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment. Am J Neuroradiol June 2012, 33 (6) 1007-1013. Gupta AK and Periakaruppan. Intracranial dural arteriovenous fistulas: a review. Indian J Radiol Imaging. 2009 Feb; 19(1): 43–48. Holekamp T, Mollman M, Murphy R, et al. Dural arteriovenous fistula-induced thalamic dementia: report of 4 cases. J Neurosurg. 2016 Jun;124(6):1752-65. Kaye L, Renati S, Corliss B, et al. Complex dural arteriovenous fistula masquerading as pseudotumor cerebri. Neurology Apr 2017; 88 (16 Supplement).

548 TAILORING THE MANAGEMENT OF TALAROMYCOSIS (PENICILLIOSIS) 1335370 Nouf Almaghlouth Mountain View Regional Medical Center Josh Hall Obiefuna Okoli Laura Cashin TAILORING THE MANAGEMENT OF TALAROMYCOSIS (PENICILLIOSIS) Accept Case Presentation: Talaromycosis (formerly known as Penicilliosis) is a rare fungal disease that predominantly affects immunocompromised patients, such as those with HIV and low CD4 cell counts, from endemic regions (e.g., Southeast Asia). There have been a limited number of cases reported worldwide, with a travel-related exposure. We present a case of an immunocompetent patient residing in the southern part of the United States. The patient is a 63-year-old female with a medical history of type two diabetes mellitus and hypertension, who is originally from Thailand, but has lived in the United States since the 1970s. She initially presented at our hospital in June 2018 with dyspnea, persistent high-grade fevers, malaise, and weight loss over the preceding 4-5 months. Physical examination showed mild pallor, skin lesions and cervical lymphadenopathy. Computed tomography (CT) of the chest with contrast showed mediastinal lymphadenopathy and traces of bilateral pleural effusion. She underwent extensive workup to rule out neoplasm. Cervical lymph node biopsy had features consistent with benign reactive lymphoid hyperplasia with sinus histiocytosis or a cortical T-cell hyperplasia, but was negative for malignancy. Aspergillosis, coccidioidomycosis, histoplasmosis and HIV testing were all negative. Immunoglobulin panel and IgG subtype were within normal levels. She was treated empirically with a combination of intravenous (IV) piperacillin-tazobactam and vancomycin, and later de-escalated to oral levofloxacin, with the addition of fluconazole. She improved over the course of her hospitalization, antibiotics were discontinued, and she was discharged. Over the next several months, she was hospitalized almost monthly with a similar presentation of dyspnea, persistent high-grade fever, malaise and generalized weakness. During one such spell in early January 2019, review of bronchoscopy sample taken in June 2018 was found to be positive for Talaromyces (Penicillium) marneffei. Treatment was initiated with itraconazole; the patient responded immediately to the medication and she was sent home on itraconazole. By the end of January, she presented to the hospital this time with severe neck stiffness, right sub-mandibular swelling and fever as high as 102°F. At that point, itraconazole was discontinued and she was started on treatment with liposomal amphotericin B. She responded well to treatment and was discharged home on IV liposomal amphotericin B to complete two weeks of therapy, after which she was treated with itraconazole for a of 6-month period. She continues to follow up in clinic and has not had recurrence of the symptoms.Discussion: This case is the first to be reported in the southern part of the United States and illustrates a very rare fungal infection occurring in an immune-competent individual living in a non-endemic area. It is unclear whether the patient contracted the disease during recent travel-related exposure or had a latent infection with an almost 40-year period between probable exposure and onset of clinical infection.Conclusions: An understanding of the importance of early recognition of this infection is critical to clinicians, in order to appropriately diagnose, treat, and prevent serious complications related to Talaromycosis.References:

561 HODGKIN HEART: THE FIRST REPORTED CASE OF AN ANTEMORTEM PRESENTATION OF INTRACARDIAC HODGKIN LYMPHOMA 1335127 Alheli Arce Gastelum Creighton University Internal Medicine Department Abedel Rahman Anani Paul Millner Charles Joseph Altfillisch HODGKIN HEART: THE FIRST REPORTED CASE OF AN ANTEMORTEM PRESENTATION OF INTRACARDIAC HODGKIN LYMPHOMA Accept Case Presentation: Our patient was a 70-year-old male with a past medical history of HTN, HLD, COPD, and CAD status-post CABG. He originally presented with hypotension, new onset weakness, dyspnea, orthopnea and bilateral lower extremity pitting edema. As part of his work-up, a CT scan of the abdomen and pelvis was ordered, which revealed an 8-cm mass involving the majority of the right atrium, a 2.2 cm necrotic right pericardiophrenic lymph node and a 2.3 cm enhancing nodule from the right kidney. Additional labs revealed elevated liver function tests. Further workup involved a TEE which noted a right atrial mass. This mass was not present on a TEE done just a few months prior. A repeat CT confirmed a 10.8 cm right atrial mass that extended through the anterior atrial wall into the anterior mediastinum and pericardium as well as a small right-sided pleural effusion. Biopsies were obtained of both the atrial and renal masses. The renal mass was determined to be a renal oncocytoma that is to be treated in an outpatient clinic via cryoablation. Pathology of the atrial mass proved to be classic Hodgkin lymphoma, nodular sclerosis subtype, CD15 and CD30 positive. Bone marrow biopsy showed normal marrow with multilineage hematopoiesis and no cytogenic evidence of abnormal clone of cells, which was consistent with analysis of the pleural effusion. This enabled us to determine that the atrial mass was not a result of metastasis but rather an original presentation of classic Hodgkin lymphoma. The physical exam findings of bilateral lower extremity edema and low-normal baseline blood pressure, as well as lab evidence of elevated liver enzymes were the result of mass involvement of the right atrium with possibly impaired venous return and thus low cardiac output. The lymphoma was treated with adriamycin, bleomycin, vinblastine, dacarbazine chemotherapy.Discussion: Primary cardiac neoplasms are relatively rare with a prevalence of 0.001-0.03%. Metastatic involvement of the heart is more than 20 times as common as primary lesions. Myxomas are the most common primary cardiac tumor, accounting for nearly 50% of cardiac neoplasms. Furthermore, myxomas usually involve the left side of the heart as right-sided myxomas account for (only) 8.6% to 20% of all cardiac myxomas. Primary cardiac lymphomas are rare neoplasms involving the heart and pericardium, predominantly in immunocompromised patients, with Non-Hodgkin lymphomas as the predominant type. Diagnosis of cardiac lymphomas is challenging as many of the presenting symptoms often mimic other cardiac conditions. In our study, we report a rare case of nodular sclerosing Hodgkin’s lymphoma in an elderly male presenting with a right atrial mass with mediastinal extension. Although few postmortem studies reported the rare involvement of the heart by Hodgkin’s lymphoma, to our knowledge, this is the first reported case of Hodgkin lymphoma with antemortem presentation of an intracardiac mass.Conclusions: Primary cardiac tumors are rare, with the incidence ranging from 0.0017% to 0.33%. Most primary cardiac tumors are benign, making up 58–77% of all primary cardiac tumors. Malignant tumors of the heart are less common and comprise 24–42% of all primary cardiac tumors. The incidence of cardiac involvement in metastatic lymphoma ranges from 7.5 to 9.3% in one case series. In contrast, the incidence of primary cardiac lymphoma is exceedingly rare, ranging from 0.04% to 1.8% of all primary cardiac tumors. With such a rare condition and vague presentation, a broad and thorough workup is imperative.References: Petersen, C. D., Robinson, W. A., & Kurnick, J. E. (1976). Involvement of the heart and pericardium in the malignant lymphomas. The American Journal of the Medical Sciences, 272(2), 161–166. doi: 10.1097/00000441-197609000-00005 Ceresoli, G. L., Ferreri, A. S. J. M., Bucci, E., Ripa, C., Ponzoni, M., & Villa, E. (1997). Primary cardiac lymphoma in immunocompetent patients. Cancer, 80(8), 1497–1506. doi: 10.1002/(sici)1097-0142(19971015)80:83.0.co;2-0 Bolanos, A. J., Dibu, G., Burke, F. W., Klodell, C. T., Li, Y., Rand, K. H., & Lucas, A. R. (2015, October 29). A rare case of classical Hodgkin's lymphoma in the setting of a newly diagnosed left atrial myxoma. Retrieved November 27, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636710/. Grantomo, J., Pratita, J., Rachmat, J., & Saraswati, M. (2018, October 23). A rare case of primary cardiac lymphoma and the role of early surgical debulking: a case report. Retrieved November 27, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/31020192. Mani, H., & Jaffe, E. S. (2009, June). Hodgkin lymphoma: an update on its biology with new insights into classification. Retrieved November 27, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806063/. Manjunath, G., Prakash, S. N. N., Krishnappa, S. B., Rao, P. A. S., & Anandaswamy, V. G. (2018, December 31). Right atrial mass-not always a myxoma!! Retrieved November 27, 2019, from https://www.sciencedirect.com/science/article/pii/S2468600X18301683. Mauricio, Rina, Mgbako, Adam, Moreira, Andre, … Albert. (2016, December 22). Complete Resolution of Tumor Burden of Primary Cardiac Non-Hodgkin's Lymphoma. Retrieved November 27, 2019, from https://www.hindawi.com/journals/cric/2016/2124975/.

562 EVALI: A National Outbreak 1334458 Bhavna Verma Long Island Community Hospital Amit Mandal Samuel Arcieri Alexander Belkin Long Island Community Hospital Wazhma Hossaini Anil Mattoo EVALI: A National Outbreak Accept Case Presentation: There has been an increasing number of cases of e-cigarette, or vaping, product use associated lung injury (EVALI) in the United States; however, much is still unknown about the disease. Thus far, most cases have occurred in individuals under the age of 35 with a history of tetrahydrocannabinol (THC) vaping. A 32 year-old Caucasian female with a past medical history of migraines, GERD, and obesity presented to the emergency department with two days of shortness of breath associated with fever, chills, and a nonproductive cough. She denied tobacco use or occupational exposures but reported excessive vaping with illicit THC oil. On exam, she was tachycardic, tachypneic, febrile (101 degrees Fahrenheit) and had an oxygen saturation of 93% on room air; lung exam revealed fine crackles bilaterally with an expiratory wheeze. Laboratory results included white blood cell count of 20.99, erythrocyte sedimentation rate (ESR) greater than 120, C-reactive protein (CRP) 288.0, brain natriuretic peptide 689, and negative troponin. A chest CT with angiography was negative for pulmonary embolism but showed diffuse pulmonary edema; a bedside echocardiogram did not show evidence of heart failure. An arterial blood gas revealed PaO2/FiO2 ratio of 173. The patient was admitted for acute respiratory distress syndrome (ARDS); her respiratory status shortly deteriorated and she was placed on mechanical ventilation and started on systemic steroids and antibiotics. Further testing including sputum and blood cultures and influenza swab were negative. Due to minimal improvement over the subsequent days, she was transferred to a tertiary care center for potential extracorporeal membrane oxygenation (ECMO). At the center, she did not require ECMO as her respiratory status improved. However, her course was complicated by multiple cerebral vascular accidents with subsequent deficits to visual tracking. She remains hospitalized with planned transfer to a rehabilitation facility.Discussion: EVALIs are increasingly prevalent in 2019; most patients are in their twenties or thirties with a history of vaping products containing illicit THC. While the pathogenesis is not clear, a number of poorly-understood chemicals associated with illicit THC-containing products are believed to be the cause. EVALI patients typically present with respiratory and constitutional symptoms while exam findings include hypoxia, tachypnea, and diffuse bilateral rales and rhonchi. Laboratory findings include leukocytosis and elevated inflammatory markers, such as ESR and CRP, without a clear infectious etiology. Radiographic studies usually reveal diffuse bilateral ground glass opacities. There are no formal diagnostic criteria for EVALI and it is mostly a diagnosis of exclusion. Optimal treatment for EVALI is unknown; management includes adequate ventilation and possibly systemic steroids. Given the novelty of EVALI, the prognosis for patients is not well documented. As of October 2019, there were 1604 cases reported to the CDC, 34 of which resulted in mortality.Conclusions: Physicians should keep EVALI high on their differential for patients who present with respiratory complaints in the setting of a history of vaping illicit substances.References: Korfei M. The underestimated danger of E-cigarettes - also in the absence of nicotine. Respir Res. 2018;19(1):159. Published 2018 Aug 29. doi:10.1186/s12931-018-0870-4 Layden JE et al. Pulmonary illness related to E-cigarette use in Illinois and Wisconsin – Preliminary report

568 A CASE OF MALIGNANT BREAST CANCER MASQUERADING AS LOCALIZED SCLERODERMA 1334594 Meera Babu Allegheny General Hospital Maryam Tetlay Kevin Taffe A CASE OF MALIGNANT BREAST CANCER MASQUERADING AS LOCALIZED SCLERODERMA Accept Case Presentation: This patient was a 44-year-old female with a past medical history of localized scleroderma (morphea) of the breast diagnosed by punch biopsy. She presented to the emergency department with right upper quadrant pain and nausea. At that time, a CT scan showed a heterogeneous liver without a definitive underlying mass. Her workup revealed drug induced liver injury possibly from a vitamin supplementation containing clinoptilolite zeolite and phosphatyidyl choline by her chiropractor. Although there is no definitive evidence of hepatotoxicity from these agents, they were discontinued. She received supportive care and was discharged with outpatient gastroenterology follow up. On outpatient follow up, her liver function tests were noted to be worsening despite stopping the vitamin. She was then readmitted and had repeat imaging with MRI of the abdomen. It showed severe acute hepatitis without evidence of intra-or-extrahepatic bile duct dilation or solid intrahepatic lesion. There was also a right pleural effusion and incompletely visualized right cutaneous breast thickening with edema. A thoracentesis was performed and revealed an exudative fluid concerning for malignancy. Initially, a source could not be found despite increased CA125 and a negative pelvic ultrasound. Subsequently, the patient’s mental status declined, and she was transferred to the intensive care unit for acute liver failure (ALF). Ultimately, a liver biopsy was done and showed carcinomatous infiltrate of the liver, most likely from primary breast carcinoma. The specimen also stained positively for HER2-neu. The patient’s family decided to change her care to comfort measures only, and she passed away several days later. Of note, this patient had a recent negative mammogram, but a core biopsy was never done.Discussion: Morphea is an inflammatory disease leading to sclerotic changes in the skin. Although systemic sclerosis (SS) is associated with an increase in malignancy, there is limited data linking morphea with cancer. There have been studies showing a temporal clustering of SS with breast cancer diagnosis. Consequently, the authors recommended that women diagnosed with SS should have annual mammograms starting at age 40. This case report suggests that similar recommendations should be made for patients with morphea of the breast tissue since it could be a precursor to breast cancer. Moreover, this case illustrates the importance of considering malignancy as the cause of ALF in a breast morphea patient. Ultimately, these patients may benefit from an oncological workup while admitted as an inpatient.Conclusions: Our case report suggests that morphea of the breast tissue could be a precursor to the disease. There is not any published data at present regarding prevalence of breast cancer in patients with morphea, and more studies are needed to establish this relation. Until we have more data, our case report suggests that there might be an association between morphea and breast cancer. Therefore, if a patient with a history of breast morphea presents with ALF, a diagnosis of metastasized breast malignancy should be considered as a cause.References: Boozalis E, Shah AA, Wigley F, Kang S, Kwatra SG. Morphea and systemic sclerosis are associated with an increased risk for melanoma and nonmelanoma skin cancer. Journal Of The American Academy Of Dermatology. 2019;80(5):1449-1451. doi:10.1016/j.jaad.2018.10.022. Igusa T, Hummers LK, Visvanathan K, et al. Autoantibodies and scleroderma phenotype define subgroups at high-risk and low-risk for cancer. Annals Of The Rheumatic Diseases. 2018;77(8):1179-1186. doi:10.1136/annrheumdis-2018-212999. Olesen AB, Svaerke C, Farkas DK, Sørensen HT. Systemic sclerosis and the risk of cancer: a nationwide population-based cohort study. The British Journal Of Dermatology. 2010;163(4):800-806. doi:10.1111/j.1365-2133.2010.09861.x. Scope, A., Sadetzki, S., Sidi, Y., Barzilai, A., Trau, H., [2] Kaufman , B., Ehrenfeld , M. (2006). Breast cancer and scleroderma. Skin Med, 1, 18–24. Retrieved https://www.ncbi.nlm.nih.gov/pubmed/16522978, Breast cancer and scleroderma. Shah, A. A., & Casciola-Rosen, L. (2015, November). Cancer and scleroderma: a paraneoplastic disease with implications for malignancy screening. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26352736.

569 GIANT PROLACTINOMA: STRANGE TUMOR, STRANGE BEHAVIOR 1335019 Alicia Baca University of New Mexico/ Department of Internal Medicine/ Division of Hospital Medicine Amanda Lechel University of New Mexico Hospital Deepti Rao GIANT PROLACTINOMA: STRANGE TUMOR, STRANGE BEHAVIOR Accept Case Presentation: A 32 year old male presented with worsening headaches over several weeks. He had multiple previous visits to medical and psychiatric facilities often leaving against medical advice (AMA). On his last hospital visit, a large brain mass was discovered on imaging. However, he left AMA before work-up was complete. He was later brought to the emergency department by family with concerns that he had not been himself for several months and exhibited worsening impulsive and erratic behavior. He was unable to perform his job as a mechanic, had crashed his car multiple times, was involved in several altercations and had a gun pulled on him for walking into unknown homes. On admission, the patient was minimally cooperative. Physical exam revealed slight right eye ptosis with no other neurological deficits. Labs were unremarkable with the exception of prolactin level >10,000, TSH 1.49, FT4 0.6 and testosterone 33. The toxicology screen was positive for cannabinoids. CT and MRI imaging of the head showed a large (54.4mm x 34.5mm) sellar/suprasellar mass with superior extension resulting in mass effect, compression of the 3rd ventricle and early obstructive hydrocephalus. During his work-up, the patient became anxious and wanted to leave AMA. He was rambling, restless and impulsive and deemed to be a danger to himself and others. He was placed on a medical hold and later found to be non-decisional by Psychiatry. He was also evaluated by Neurosurgery, Ophthalmology and Endocrine. Surgical intervention was not warranted and medical management was initiated with high dose steroids, cabergoline, levothyroxine, quetiapine and valproic acid. Throughout his hospitalization, he continued to display impulsive and dangerous behavior, threatening to leave and attempting to do so. This led to a prolonged hospitalization as the team could not ensure a safe and appropriate discharge. After a few weeks of treatment, his behavior, judgement and insight improved enabling a safe discharge home. After 3 months of treatment, his tumor size decreased, hydrocephalus resolved, prolactin and testosterone levels nearly normalized and symptoms improved.Discussion: While prolactinoma is the most common pituitary adenoma in adults, giant prolactinoma is relatively rare. It accounts for 1-5% of prolactinomas and is defined by size >40mm in diameter. Typical presentation includes headache, vision changes and amenorrhea in women and hypogonadism and erectile dysfunction in men.Conclusions: There are few reports of giant prolactinoma presenting with behavioral or psychiatric symptoms. This case seeks to add to the current body of literature and to inform Hospitalists of this unusual presentation of a rarely occurring pituitary tumor. It also highlights the unique safety challenges that may accompany this condition and emphasizes the need for early safety interventions and a collaborative approach to care.References: Shimon I. Giant Prolactinomas. Neuroendocrinology. 2018;109(1):51–56. doi:10.1159/000495184 Moraes AB, Silva CM, Vieira Neto L, et al. Giant prolactinomas: the therapeutic approach. Clin Endocrinol 2013;79:447–56. Sabatine M. Pocket medicine: The Massachusetts General Hospital handbook of internal medicine 6th edition. Philadelphia: Wolters Kluwer; 2017. 7-1 p. Arshad MF, Arambewela M, Debono M. Atypical giant prolactinoma with frontal lobe manifestations. BMJ Case Reports. April 2018. doi:10.1136/bcr-2018-226982. Chanson P, Maiter D. Prolactinoma. 2017 Jan 6 [accessed 2019 Oct 29]. https://www.sciencedirect.com/science/article/pii/B9780128041697000167 [NIDDK] National Institute of Diabetes and Digestive and Kidney Diseases. Prolactinoma. 2019 Sep 1 [accessed 2019 Oct 29]. https://www.niddk.nih.gov/health-information/endocrine-diseases/prolactinoma

591 MYOCLONUS AND DROWSINESS IN A PATIENT WITH ACUTE OSTEOMYELITIS 1335400 Jonathan Chang Tulane University School of Medicine Kaitlyn Arbour Marjorie Bateman Brett Wilkinson MYOCLONUS AND DROWSINESS IN A PATIENT WITH ACUTE OSTEOMYELITIS Accept Case Presentation: A 48-year-old man presented with 3 days of confusion, excessive drowsiness, and upper extremity twitching. He denied any fever, headache, or neck stiffness. History was notable for kidney transplant on chronic immunosuppression. Three weeks prior, the patient was started on a course of cefepime for pseudomonal osteomyelitis of the tibia. Vital signs were normal. The patient was hypersomnolent and offered no response to voice. He had intermittent myoclonic jerks in both arms and hyperreflexia in the lower extremities. There was no nuchal rigidity or jolt accentuation. Serum creatinine was 2.9 mg/dL (estimated GFR 29 mL/min/1.73m2), elevated from a baseline of 1.2 mg/dL. Blood cultures were negative. Cerebrospinal fluid showed white blood cells of 46/μL with 62% lymphocytes, red blood cells of 8/μL, glucose of 74 mg/dL, protein of 70 mg/dL, and no organisms on Gram stain. CT scan of the head was unremarkable. EEG demonstrated diffuse slowing and rare triphasic waveforms, but no epileptiform activity. Despite the addition of broad-spectrum antibiotics for meningitis and cessation of potentially neurotoxic medications such as gabapentin, baclofen, and tacrolimus, mentation failed to improve. The patient became nonverbal by hospital day five. Cefepime was then switched to ciprofloxacin. Within 24 hours, the patient became fully alert and oriented, with normal conversational ability and resolution of the myoclonus. He was discharged to a skilled nursing facility.Discussion: Cefepime, a fourth-generation cephalosporin with broad activity against Gram-positive and Gram-negative bacteria including Pseudomonas aeruginosa, is associated with neurotoxicity in up to 15% of ICU patients. Given its ubiquity in the inpatient setting, cefepime’s potentially severe neurologic effects should be acknowledged by internists and intensivists alike. Common manifestations include decreased consciousness, confusion, and seizures, with median onset at 4 days after initiation. Myoclonus occurs in 40% of cases. EEG abnormalities are nonspecific but include triphasic waves, focal sharp waves, and non-convulsive status epilepticus. Effects may be attributable to cefepime’s concentration-dependent gamma-aminobutyric acid (GABA) antagonism, which blocks the central nervous system’s main inhibitory neurotransmitter pathway and lowers the seizure threshold. The kidneys excrete 85% of cefepime in the unmetabolized form, making renal failure the strongest risk factor for developing neurotoxicity. Serum drug concentrations greater than 20 mg/L have been associated with a five-fold risk increase, but laboratory assays for cefepime monitoring are not widely available. In 90% of cases, discontinuing cefepime leads to reversal of neurologic symptoms within 1-3 days. In the setting of unexplained encephalopathy, providers should consider switching cefepime to an acceptable alternative while awaiting additional workup. Severe cases may benefit from hemodialysis. Importantly, cefepime neurotoxicity will likely become more widely recognized in the near future, as some physicians now favor vancomycin/cefepime over vancomycin/piperacillin-tazobactam for empiric sepsis treatment due to the latter’s association with acute kidney injury.Conclusions: Patients with renal failure are at highest risk for cefepime-induced neurotoxicity Manifestations include decreased consciousness, confusion, myoclonus, and seizures. Discontinuing cefepime typically leads to resolution of symptoms.References: Fugate JE et al. Cefepime neurotoxicity in the intensive care unit: a cause of severe, underappreciated encephalopathy. Crit Care 2013 Nov 7;17(6):R264. PMID:24200036. Payne LE et al. Cefepime-induced neurotoxicity: a systematic review. Crit Care 2017 Nov 14;21(1):276. PMID:29137682. Lindsay H, Gruner S, Brackett J. Cefepime-induced neurotoxicity despite dose adjustment for renal disease: a brief report and review of the literature. J Pediatric Infect Dis Soc 2017 Jun 1;6(2):199-201. PMID:27147713. Huwyler T et al. Cefepime plasma concentrations and clinical toxicity: a retrospective cohort study. Clin Microbiol Infect 2017 Jul;23(7):454-459. PMID:28111294. Navalkele B et al. Risk of acute kidney injury in patients on concomitant vancomycin and piperacillin-tazobactam compared to those on vancomycin and cefepime. Clin Infect Dis 2017 Jan 15;64(2):116-123. PMID:27986669.

610 AN URBAN CASE OF CHROMOBLASTOMYCOSIS 1335219 victor canela Methodist Health System Carley Legan AN URBAN CASE OF CHROMOBLASTOMYCOSIS Accept Case Presentation: A 91-year-old healthy Taiwanese female presented with a worsening skin lesion on her right forearm. Initially, she had mild skin breakdown, which progressed to redness, swelling and increased warmth to the touch. The patient noted some purple spots in her lower extremities, especially around her right knee. The female patient denied any swollen lymph nodes, fever, chills, night sweats or weight loss. In addition, the patient stated her cheeks developed redness but attributed this to her high blood pressure. Per family, it was unknown the exact chronicity of the rash as she usually wore long sleeves and pants. The patient, originally from Taiwan, immigrated to the United States in 1995. The patient’s home medications included hydrochlorothiazide, meloxicam for arthritis and hydrocodone/acetaminophen as needed. On exam, the patient was afebrile and had normal vital signs. Present, there was a large fungated/crusted lesion in the right forearm with a scabbed area and surrounding redness without signs of infection noted. The lesion was mildly warm to touch. On her lower extremities there were non-blanching purple macules, the largest, around her right knee and right thigh. No clavicular or inguinal swollen nodes were noted. The Initial CBC workup was unrevealing. PT, PTT, SPEP and UPEP were negative. ANCA and cryoglobulins were negative. A skin biopsy of the thigh showed non-specific purpura. The nodular erythematous area on her arm was biopsied with findings consistent with Fonsecaea species. The infectious disease team was consulted and the patient started on Itraconazole twice a day. About a week later, she was discharged with close clinic follow up and inflammatory markers routinely monitored. Two months later when evaluated for follow up, the patient’s rash was persistent but moderate improvement was noted.Discussion: Chromoblastomycosis is a chronic granulomatous disease caused by transcutaneous inoculation of fungal spores. It is caused by the Fonsecaea and Cladophialophora species found in tropical and subtropical regions of developing countries in Asia, Africa and Latin America. Chromoblastomycosis is considered an occupational disease and it primarily affects immunocompetent individuals. The available data suggests that the incidence of this condition in the United States is 1:8,625,000 patients. Treatment for chromoblastomycosis can be challenging as it includes surgical excision to systemic antifungals such as Itraconazole and even laser therapy in severe cases. Long term assessment with histology is needed up to two years to confirm cure. Inadequate treatment can result in fibrosis, chronic lymphedema, secondary infection or malignancy.Conclusions: Chromoblastomycosis is a common infection in tropical and subtropical regions; it is rare that these cases are reported in the United States. Workers from developing countries are at risk of exposure to contaminated soil or plants. Diagnosis is made by identification of muriform cells from clinical samples. Treatment for chromoblastomycosis ranges from surgical removal to systemic itraconazole.References: Chromoblastomycosis Flavio Queiroz-Telles, Sybren de Hoog, Daniel Wagner C. L. Santos, Claudio Guedes Salgado, Vania Aparecida Vicente, Alexandro Bonifaz, Emmanuel Roilides, Liyan Xi, Conceição de Maria Pedrozo e Silva Azevedo, Moises Batista da Silva, Zoe Dorothea Pana, Arnaldo Lopes Colombo, Thomas J. Walsh Clinical Microbiology Reviews Nov 2016, 30 (1) 233-276; DOI: 10.1128/CMR.00032-16 December 2019 Chromoblastomycosis. Uptodate.com Author:Flavio Queiroz-Telles, MD, PhD December 2019

615 HIDING BEHIND DIABETIC KETOACIDOSIS! 1334912 Anjana Chandrasekhara Pillai UPMC kiran kuriakose UPMC Mckeesport Thomas Powell HIDING BEHIND DIABETIC KETOACIDOSIS! Accept Case Presentation: 36-year-old male with past medical history of end stage renal disease (ESRD) on PD for 5 years, was admitted with chief complaints of abdominal pain, vomiting and diarrhea for 3 days. Examination revealed diffuse abdominal tenderness, without any rebound tenderness or guarding. PD catheter site was in place with no surrounding tenderness, or erythema. Laboratory markers revealed blood glucose of 593, metabolic acidosis with high anion gap, and WBCs of 12.4. CT abdomen without contrast showed small amount of ascites, otherwise unremarkable. Patients was managed with insulin drip and fluid therapy under the impression of diabetic ketoacidosis. Two days later, purulent discharge was noticed from the catheter site. Accordingly, empiric intraperitoneal antibiotics therapy was started. Peritoneal fluid analysis was performed, which showed WBC less than 5. However, antibiotics were discontinued and the PD catheter was removed due to concern of infection. HD was initiated through a temporary catheter. In a few days, his pain improved and he was discharged in good condition. Following discharge, he had 3 episodes of re-admission with similar complaints. CT scans were repeated for 3 times which showed ascites and minimal small bowel inflammatory changes. On further reviewing the CT scans, subtle peritoneal thickening was observed. The bowel loops were fixed in the same position on multiple CT scans over four months, which was consistent with loculation, a key feature of Encapsulating Peritoneal Sclerosis.Discussion: Encapsulating peritoneal sclerosis (EPS) is an uncommon, but devastating complication after long-term peritoneal dialysis (PD). EPS is characterized by slowly progressive peritoneal fibrosis, leading to encasement of the bowel, which may result in bowel obstruction and ultrafiltration failure.In order to diagnose EPS, specific EPS scoring system can be used. Treatment of EPS includes tamoxifen, sirolimus, steroids and/or enterolysis.Conclusions: EPS incurs high morbidity and mortality. The clinical findings of EPS can be vague, with subtle radiologic findings. This case highlights the importance of suspecting EPS as a potential cause of recurrent ascites and abdominal pain in a patient on chronic PD.Our patient was initiated on tamoxifen and tapering course of steroids on discharge.References: Saurabh Bansal,Beth Piraino et al, Incidence of Encapsulating, Peritoneal Sclerosis at a Single U.S.University Center: Advances in Peritoneal Dialysis, Vol. 26, 2010;75-80. Lo WK, Kawanishi H. Encapsulating peritoneal sclerosis—medical and surgical treatment. Perit Dial Int 2009;29(Suppl 2):S211–14..

616 NEUROBORRELIOSIS WITH A DIFFERENCE! 1335138 Anjana Chandrasekhara Pillai UPMC kiran kuriakose UPMC Mckeesport Frempong-Manso Emmanuel NEUROBORRELIOSIS WITH A DIFFERENCE! Accept Case Presentation: 54 year old Caucasian male admitted with complaints of intractable radicular low back pain, headache, nausea and vomiting for a week. 4 weeks ago, he had an annular rash, which was treated as cellulitis from urgent care, with cephalexin for 7 days. His vitals were normal, physical examination revealed bilateral positive SLR, otherwise neurological exam was negative. Labs revealed Na- 133, K- 3.2, normal ESR and CRP. He was initiated on opioids for pain management and Orthopedics was consulted, who suggested MRI of the whole spine. MRI revealed no nerve root impingment, unremarkable terminal cord and cauda equina. 3 days after admission he developed bilateral facial nerve palsy. On further history taking, patient gave history of Lyme disease diagnosis for the neighbours dog and on reevaluating the rash picture from phone records, it was suggestive of Erythema Migrans. Subsequently, his lyme screen came back highly positive 5.79(>1.1), IgM and IgG Lyme negative. CSF revealed lymphocytes 67, monocytes- 15, protein – 189, glucose- 48, CSF lyme PCR -negative. Meanwhile patients pain did not improve on opioids, considering the differential of neuroborreliosis , we started him on Ceftriaxone 2 g m i/v daily and patients intractable back pain improved in a week and discharged from the hospital after 10 days.Discussion: In 1922 Garin and Bujadoux described tick bite associated meningoradiculitis and later in 1941, a more detailed description was added by Dr. Alfred Bannwarth, a German neurologist. Bannwarth syndrome is characterized by painful radiculopathy, facial nerve palsy and CSF lymphocytic pleocytosis., which was the triad our patient had. Bannwarth syndrome typically manifests with zoster like segmental pain, which respond poorly to common pain relieving drugs and only 25-50% will have a history of preceeding Erythema Migrans.Our patients back pain improved on initiating Ceftriaxone, but not on opioids.Conclusions: Garin - Bujadoux Bannwarth syndrome is an infrequent manifestation of neuroinvasive Lyme disease in USA. It is caused by Borrelia burgdorferi sensuo lato(Bbsl) complex. Considering the clinical spectrum of Bannwarth syndrome from ascending paralysis to transient psychosis, it is prudent to understand this variant of neuroborreliosis. Early recognition and treatment can reduce the neurological complications.References: References 1.An Unusual Cluster of Neuroinvasive Lyme Disease Cases Presenting With Bannwarth Syndrome in the Midwest United StatesAditya Shah, John C O’Horo, [...], and Elitza S Theel 2.Course and Outcome of Early European Lyme Neuroborreliosis (Bannwarth Syndrome): Clinical and Laboratory FindingsKatarina Ogrinc, Lara Lusa, Stanka Lotrič-Furlan, Petra Bogovič, Daša Stupica, Tjaša Cerar, Eva Ružić-Sabljić, Franc Strl.

623 THE HYPERGLYCEMIC DANCE 1335042 Michelle Chen Montefiore Medical Center Ginger Wey Lauren Shapiro THE HYPERGLYCEMIC DANCE Accept Case Presentation: A 62-year-old man with history of end-stage renal disease and poorly controlled type 2 diabetes mellitus presents to the hospital after a fall due to unsteady gait and was noted to have facial movements similar to tardive dyskinesia, whole body chorea, and hyperkinesis of torso and bilateral extremities. On admission, he had an elevated serum osmolarity to 311 Osm/L and glucose to 500 mg/dL. The magnetic resonance imaging (MRI) of the brain showed T2 hyperintense signal abnormality in the bilateral lentiform nuclei with vague associated restricted diffusion concerning for diabetic striatopathy and most likely secondary to prolonged hyperglycemia. The hyperkinetic movements persisted after glycemic control. Treatment with risperidone 0.5 mg twice a day led to improvement of the choreiform movements.Discussion: Hospitalists frequently see patients with diabetes mellitus and associated complications in the inpatient setting. Diabetic striatopathy is a rare neurologic complication that occurs in the context of non-ketotic hyperglycemia and may be the first manifestation of uncontrolled type 2 diabetes mellitus. The diagnosis is based on clinical and imaging findings, characterized by abnormalities of the basal ganglia on brain MRI with associated hyperkinesis. The basal ganglia inhibit unwanted movements and removal of this inhibition results in unsuppressed excitatory output leading to hyperkinesis, specifically chorea. Similar movement disorders from this loss of inhibition are Huntingtons disease, dystonia, and hemiballismus. Most published cases of diabetic striatopathy report hemichorea as the clinical presentation with putamen involvement on MRI. While there have been multiple case reports describing this syndrome, the pathophysiology of this rare neurologic sequelae has not fully been elucidated. The theories of pathophysiology are based on the effects to the lentiform nucleus within the basal ganglia. One theory is due to lack of flow there is depletion of inhibitory gamma-aminobutyric acid (GABA). Another theory is hyperviscosity secondary to hyperglycemia resulting in a regional blood-brain barrier disruption. Why this affects the basal ganglionic vessels specifically is unknown. In some cases, resolution of the chorea can be achieved with glycemic control although therapy targeting hyperkinesis, such as haloperidol and risperidone, may be needed in refractory cases.Conclusions: This case vignette illustrates a rare complication that can occur in decompensated diabetic patients that are not able to achieve glycemic control.References: Presentation of striatal hyperintensity on T1-weighted MRI in patients with hemiballism-hemichorea caused by non-ketotic hyperglycemia: report of seven new cases and a review of literature. Lin JJ, Lin GY, Shih C, Shen WC. J Neurol. 2001 Sep; 248(9):750-5. Non-ketotic hyperglycaemic chorea: a SPECT study. Chang MH, Li JY, Lee SR, Men CY. J Neurol Neurosurg Psychiatry. 1996 Apr; 60(4):428-30. Chorea associated with non-ketotic hyperglycemia and hyperintensity basal ganglia lesion on T1-weighted brain MRI study: a meta-analysis of 53 cases including four present cases. Seung-Hun Oh, Kyung-Yul Lee, Joo-Hyuk Im, Myung-Sik Lee. J Neurol Sciences. 2002 Aug; 200(1-2):57-62

628 KIKUCHI-FUJIMOTO'S DISEASE AND SLE 1334434 Woo Young Kim Westchester Medical Center - New York Medical College Ronald Cho New York Medical College, Westchester Medical Center Aditi Sen Nicole Zagelbaum Rugved Pattarkine Fouzia Shakil KIKUCHI-FUJIMOTO'S DISEASE AND SLE Accept Case Presentation: A 32 year-old African American man with a history of Kikuchi-Fujimoto’s Disease (KFD), presented with 2 weeks of fever, cervical lymphadenopathy and cough. Laboratory tests showed pancytopenia, elevated ESR, positive double stranded DNA and ANA titer. Complement 3 and 4 levels were low. His fever persisted despite broad spectrum antibiotics. Computed tomography (CT) showed multiple lymph node enlargements in cervical and retroperitoneal areas and cavitary lung nodules. Tuberculosis was ruled out with three negative acid-fact bacilli (AFB) staining, culture and interferon-gamma release assay. Hematoxylin and eosin stain of axillary lymph node showed paracortical, well circumscribed necrotic lesions with abundant nuclear debris, expanded sinusoids and histiocytic proliferation with focally preserved lymph node architecture composed of monocytoid looking polyclonal (polyclonality by immunohistochemistry and by flow cytometry) B and T cells. No intermixed neutrophils or hematoxylin bodies are identified. Immunostains highlight CD68 (histiocytes), BCL6 (germinal center), PAX5 (B cells), CD20 (B cells), CD3 (T cells), CD30 (occasional immunoblots), S-100 (Rare Langerhans cells) and BCL2 (negative germinal center), whereas BCL1, EBER, GMS, AFB, BCL- 1, CAM5.2, AE1/AE3 are negative. This immuno-histologic pattern is consistent with histiocytic necrotizing lymphadenitis (KFD) especially with absence of hematoxylin bodies. SLE was also suspected because 7 out of 11 criteria were met (malar rash, oral ulcer, ANA+, arthritis, dsDNA+/antiSmith+, proteinuria, pancytopenia). Decreased levels of C3 and C4 with increased ESR were highly supportive of acute lupus flare. Methylprednisolone 30 mg IV twice a day was started for lupus flare and oral hydroxychloroquine was continued. A week after treatment, WBCs normalized and hemoglobin and platelets increased to normal range. He improved clinically with complete resolution of cough and fever. The patient was discharged with tapering regimen of high dose oral steroid with hydroxychloroquine. Outpatient follow up with rheumatology and pulmonary was recommended.Discussion: KFD typically affects young women less than 40 years old in East Asia, but it has been reported in other races.[1] Patients with KFD present with fever and tender cervical lymphadenopathy. Other symptoms are myalgia, arthralgia, weight loss, and hepatosplenomegaly. Diagnosis can be made with excisional lymph node biopsy showing necrosis with histiocytic infiltrates.[2] 13% to 25% of KFD are associated with SLE.[3,4] Etiology is unknown, but it has been suggested that increased apoptotic pathways in KFD could accelerate the formation of autoantibodies and may subsequently cause SLE flare.[8] Characteristic morphology and histopathology of necrosis with histiocytic infiltrates in the resected lymph nodes can distinguish KFD from lupus lymphadenitis. Distinguishing SLE from KFD or even lymphoma will be critical to decide on appropriate treatment.Conclusions: Kikuchi-Fujimoto Disease (KFD) is a self-limited disease associated with cervical lymphadenopathy and fever.[2] Herein, we report a young African American male with Kikuchi-Fujimoto disease who later presented with SLE manifestations. KFD is a rare disease. If SLE manifestations are also present, then it may be challenging to make an accurate diagnosis. Therefore, physicians need to consider KFD and SLE when a patient with fever and lymphadenopathy shows SLE manifestations.References: 1. Kikuchi M. Lymphadenitis showing focal reticulum cell hyperplasia with nuclear debris and phagocytes: a clinicopathological study. Acta Hematol Jpn. 1972;35:379-80. 2. Bosch X, Guilabert A, Miquel R, Campo E. Enigmatic Kikuchi-Fujimoto disease: a comprehensive review. Am J Clin Pathol 2004;122:141-52. 3. Dumas G, Prendki V, Haroche J, Amoura Z, Cacoub P, Galicier L, et al. Kikuchi-Fujimoto disease: retrospective study of 91 cases and review of the literature. Medicine (Baltimore) 2014;93:372-82. 4. Komagamine T, Nagashima T, Kojima M, Kokubun N, Nakamura T, Hashimoto K, et al. Recurrent aseptic meningitis in association with Kikuchi-Fujimoto disease: case report and literature review. BMC Neurol 2012;12:112. 5. Song JY, Lee J, Park DW, Sohn JW, Suh SI, Kim IS, et al. Clinical outcome and predictive factors of recurrence among patients with Kikuchi's disease. Int J Infect Dis 2009;13:322-6. 6. Sopena B, Rivera A, Vazquez-Trinanes C, Fluiters E, Gonzalez-Carrero J, del Pozo M, et al. Autoimmune manifestations of Kikuchi disease. Semin Arthritis Rheum 2012;41:900-6. 7. Sopena B, Rivera A, Chamorro A, Freire M, Alende V, Seco E, et al. Clinical association between Kikuchis disease and systemic lupus erythematosus: A systematic literature review. Semin Arthritis Rheum 2017;47:46-52. 8. Hedia G, Jamel A, Maher A, Hanadi A, Agnes H, Nidhameddine K. Kikuchi-Fujimoto disease associated with systemic lupus erythematosus. J Clin Rheumatol 2005;11:341-2. 9. Medeiros LJ, Kaynor B, Harris NL. Lupus lymphadenitis: report of a case with immunohistologic studies on frozen sections. Hum Pathol 1989;20:295-9. 10. Cramer J, Schmiedel S, Alegre NG, Schafer H, Burchard GD, Merz H. Necrotizing lymphadenitis: Kikuchi--Fujimoto disease alias lupus lymphadenitis? Lupus 2010;19:89-92. 11. Rao GS, Vohra D, Kuruvilla M. Is Kikuchi-Fujimoto disease a manifestation of systemic lupus erythematosus? Int J Dermatol 2006;45:454-6. 12. Kampitak T. Fatal Kikuchi-Fujimoto disease associated with SLE and hemophagocytic syndrome: a case report. Clin Rheumatol 2008;27:1073-5. 13. Behdadnia A, Allameh SF, Gharabaghi MA, Najafizadeh SR, Roudsari AT, Ghajar A, et al. Systemic Kikuchi-Fujimoto disease bordering lupus lymphadenitis: A fresh look? Intractable Rare Dis Res 1. Kikuchi M. Lymphadenitis showing focal reticulum cell hyperplasia with nuclear debris and phagocytes: a clinicopathological study. Acta Hematol Jpn. 1972;35:379-80. 2. Bosch X, Guilabert A, Miquel R, Campo E. Enigmatic Kikuchi-Fujimoto disease: a comprehensive review. Am J Clin Pathol 2004;122:141-52. 3. Dumas G, Prendki V, Haroche J, Amoura Z, Cacoub P, Galicier L, et al. Kikuchi-Fujimoto disease: retrospective study of 91 cases and review of the literature. Medicine (Baltimore) 2014;93:372-82. 4. Komagamine T, Nagashima T, Kojima M, Kokubun N, Nakamura T, Hashimoto K, et al. Recurrent aseptic meningitis in association with Kikuchi-Fujimoto disease: case report and literature review. BMC Neurol 2012;12:112. 5. Song JY, Lee J, Park DW, Sohn JW, Suh SI, Kim IS, et al. Clinical outcome and predictive factors of recurrence among patients with Kikuchi's disease. Int J Infect Dis 2009;13:322-6. 6. Sopena B, Rivera A, Vazquez-Trinanes C, Fluiters E, Gonzalez-Carrero J, del Pozo M, et al. Autoimmune manifestations of Kikuchi disease. Semin Arthritis Rheum 2012;41:900-6. 7. Sopena B, Rivera A, Chamorro A, Freire M, Alende V, Seco E, et al. Clinical association between Kikuchis disease and systemic lupus erythematosus: A systematic literature review. Semin Arthritis Rheum 2017;47:46-52. 8. Hedia G, Jamel A, Maher A, Hanadi A, Agnes H, Nidhameddine K. Kikuchi-Fujimoto disease associated with systemic lupus erythematosus. J Clin Rheumatol 2005;11:341-2. 9. Medeiros LJ, Kaynor B, Harris NL. Lupus lymphadenitis: report of a case with immunohistologic studies on frozen sections. Hum Pathol 1989;20:295-9. 10. Cramer J, Schmiedel S, Alegre NG, Schafer H, Burchard GD, Merz H. Necrotizing lymphadenitis: Kikuchi--Fujimoto disease alias lupus lymphadenitis? Lupus 2010;19:89-92. 11. Rao GS, Vohra D, Kuruvilla M. Is Kikuchi-Fujimoto disease a manifestation of systemic lupus erythematosus? Int J Dermatol 2006;45:454-6. 12. Kampitak T. Fatal Kikuchi-Fujimoto disease associated with SLE and hemophagocytic syndrome: a case report. Clin Rheumatol 2008;27:1073-5. 13. Behdadnia A, Allameh SF, Gharabaghi MA, Najafizadeh SR, Roudsari AT, Ghajar A, et al. Systemic Kikuchi-Fujimoto disease bordering lupus lymphadenitis: A fresh look? Intractable Rare Dis Res 2016;5:301-5.

640 A DIFFUSE DESQUAMATIVE RASH FOLLOWING CORONARY ARTERY BYPASS GRAFTING 1335386 Kaitlin Markoja Medstar Georgetown University Hospital Ryan Commins MedStar Georgetown University Medical Center Heather Hopkins Wen Chen Cherinne Arundel A DIFFUSE DESQUAMATIVE RASH FOLLOWING CORONARY ARTERY BYPASS GRAFTING Accept Case Presentation: A 74-year-old man with coronary artery disease, sick sinus syndrome with biventricular PPM/ICD, HFrEF (EF 45%), and diabetes. He presented to the hospital with five days of worsening substernal chest pain and troponin elevation concerning for a NSTEMI. Urgent left heart catheterization showed multivessel disease and he subsequently underwent three vessel CABG. His post-operative course was complicated by acute hypoxic respiratory failure secondary to multidrug resistant Enterobacter cloacae pneumonia requiring intubation and acute renal failure requiring initiation of hemodialysis. Amidst these complications, he developed a rapidly progressive, painful, full body desquamative skin rash. His skin exam was notable for diffuse erythema, shallow erosions and ulcers, and superficial desquamation that spared the palms, soles, and mucosal surfaces. Nikolsky sign was positive. Skin biopsy showed subcorneal splitting of the epidermis without evidence of bacterial or neutrophilic invasion. A diagnosis of Staph Scalded Skin Syndrome (SSSS) was made based on the biopsy and clinical history. The patient was treated with IV vancomycin and clindamycin with improvement of the rash and crusting over two weeks.Discussion: SSSS is caused by infection with exfoliative exotoxin producing strains of Staphylococcus aureus. Hematogenous spread of the exotoxin from the initial focus of S. aureus infection cleave desmoglein-1, a protein responsible for keratinocyte adhesion in the upper layers of the epidermis. Staph scalded skin syndrome is a rare disease in adults, with an estimated incidence of less than 1:1,000,000. It typically occurs in immunocompromised patients, patients with renal impairment, and diabetics. Sites of infection are often not evident for patients with SSSS as seen in our patient who only had Staph aureus in the nares upon discharge. Cultures should be taken from sites with purulence or as in our case from common sites of S. aureus colonization such as the nares. It is important to distinguish SSSS from other etiologies of blistering and desquamative rashes, particularly Stevens Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) and pemphigus foliaceus. SJS/TEN is often drug-induced and requires prompt discontinuation of the causative drug. SJS/TEN may respond to immunosuppressive therapy while antibiotics are the cornerstone of treatment for SSSS. SJS/TEN typically involves the mucosa, while SSSS is mucosa-sparing, as in our patient. Histopathology of SJS/TEN shows full thickness necrosis of the epidermis, while SSSS characteristically shows subcorneal splitting of the epidermis. Pemphigus foliaceus is an autoimmune skin disorder in which autoantibodies bind to desmoglein-1, leading to separation of the upper layers of the epidermis. Most cases of Pemphigus foliaceus are idiopathic but may also be precipitated by drugs such as angiotensin-converting enzyme inhibitors. Pemphigus foliaceus is indistinguishable from SSSS on skin biopsy, but typically presents on the face and scalp with rare extension to the whole body.Conclusions: Staph scalded skin syndrome is a rare disease entity among adults that typically impacts patients with renal dysfunction or other immune compromise. It can be distinguished from other causes of a desquamative skin rash by physical exam and histopathology. Accurate diagnosis is imperative, given the dichotomy in treatment approach between Staph Scalded Skin Syndrome and other causes of desquamative rash, such as Toxic Epidermal Necrolysis.References:

641 A LUNG MASS THAT VANISHES 1334946 David Crawford Baylor College of Medicine Yufan Wu Frederick Peng Daniel Musher A LUNG MASS THAT VANISHES Accept Case Presentation: A 73 year-old man with type 2 diabetes mellitus (hemoglobin A1c 7.5), hypertension, hyperlipidemia, chronic renal failure stage 3a, and a distant 10 pack year smoking history presented with 2 weeks of substernal chest tightness and dyspnea on exertion. He was hemodynamically stable without tachypnea at rest. Examination revealed a grade 2/6 holosystolic murmur at the apex, fine rales over the right lower lung, and 1+ bilateral lower extremity edema. The creatinine was 2.18 mg/dL (baseline creatinine 1.50 mg/dL) and the brain natriuretic peptide level (BNP) was 849 ng/L. Chest X-ray (CXR) demonstrated a large density in the right lower lung field region with mild pulmonary vascular congestion (Figure 1). Lateral CXR suggested location of the density to be in the right middle lobe region. CT Thorax (Figure 2) revealed ground glass opacities in the right perihilar region and an elliptical 7x3 cm fluid collection with a tail that clearly showed it to be located in the right major fissure. Transthoracic echocardiogram (TTE) showed an ejection fraction 60-64% with mitral and tricuspid regurgitation. Left ventricular relaxation was impaired with elevated left ventricular filling pressure. The patient was treated with oral furosemide 20mg daily. Repeat CXR after 3 days showed resolution of the right lung density. Patient was discharged on hospital day 3 with plans for further evaluation of heart function.Discussion: “Vanishing tumor syndrome” is a well-described but uncommon finding wherein a volume-overloaded patient presents with what appears to be a lung mass but is actually a loculated interlobar pleural effusion, usually in the right minor fissure. The finding most strongly indicative of an intrapleural collection is the way it tails off into a fissure. The diagnosis is confirmed when the “tumor” disappears with correction of volume status. These lesions occur with adhesions and obliteration of the pleural space secondary to earlier pleuritis, thus restricting the free movement of fluid. The location of this patient's loculated effusion in the right major fissure is uncommon in presentations of vanishing tumor syndrome. This case provides an example of a patient without a known history of congestive heart failure (CHF) who presented with a radiologic finding suggesting a lung mass. The case highlights the importance of harnessing physical examination and laboratory findings to refine the differential diagnosis and guide management, which allowed us to arrive at a diagnosis before undergoing a lengthy and expensive oncologic workup. As with more typical pleural effusions in CHF, this “potential mass” resolved with medical management.Conclusions: In evaluating a patient with a newly recognized radiologic finding suggesting a lung mass in the setting of symptoms consistent with CHF, careful attention should be taken in assessing for physical exam and lab findings of volume overload. Remembering to keep a loculated pleural effusion on the differential for a patient with a presentation similar to this case can be crucial in avoiding the physical, financial, and emotional cost to the patient of an oncologic workup.References: 1. Antonio FA, Edavalath M, Pappachan JM. Vanishing Tumor of the Lung. Oman Med J. 2015;30(3):223. doi:10.5001/omj.2015.47A 2. Ardic I, Yarlioglues M, Celik A, Kaya MG. Vanishing or Phantom Tumor of the Lung. Tex Heart Inst J. 2010;37(6):730-731. 3. Buch KP, Morehead RS. Multiple Left-Sided Vanishing Tumors. Chest. 2000;118(5):1486-1489. doi:10.1378/chest.118.5.1486 4. Higgins JA, Juergens JL, Bruwer AJ. Loculated Interlobar Pleural Effusion Due to Congestive Heart Failure. AMA Archives of Internal Medicine. 1955;96(2):180. doi:10.1001/archinte.1955.00250130054008. 5. Kabnick EM, Sobo S, Cooper C, Alexander LL. Vanishing Lung Tumor. J Natl Med Assoc. 1985;77(3):229-230. 6. Lozo M, Lozo Vukovac E, Ivancevic Z, Pletikosic I. Phantom Tumor of the Lung: Localized Interlobar Effusion in Congestive Heart Failure. Case Reports in Cardiology. 2014;2014:1-3. doi:10.1155/2014/207294

659 RARE PICTURE OF REACTIVE ARTHRITIS CAUSED BY CLOSTRIDIUM DIFFICILE INFECTION IN A PATIENT WITH INFLAMMATORY BOWEL DISEASE 1334600 Anh Do Henry Ford Hospital Joshua Thomas Bright Thilagar Henry Ford Health System RARE PICTURE OF REACTIVE ARTHRITIS CAUSED BY CLOSTRIDIUM DIFFICILE INFECTION IN A PATIENT WITH INFLAMMATORY BOWEL DISEASE Accept Case Presentation: A 21-year-old male with past medical history of Crohn's disease on monthly infliximab infusion initially presented to the emergency department with a 5-day history of joint pain. He first noted left-sided pain that was only relieved by heat, but it progressed to left hip and groin pain made worse with movement. The patient was discharged with pain medication. He presented to the emergency department again a day later with worsening of symptoms. He was empirically started on intravenous vancomycin and piperacillin/tazobactam before admitting. Upon admission, vital signs were significant for tachycardia (110 beats/minute) but was otherwise afebrile and stable. White blood cell count was elevated at 20 g/dL. Initial concern was for septic arthritis, reactive arthritis (ReA) or inflammatory bowel disease (IBD) induced arthritis. Further investigation revealed no eye pain, eye redness, abdominal pain, tenesmus, blood in the stool, new rashes, or mucosal ulcers. The patient admitted to having increased diarrhea compared to baseline. He also denied any recent bug or tick bites. Physical examination revealed mild swelling bilaterally of wrists. Left hip pain was induced on any active movement and passive internal and external rotation. There was no joint warmth, redness or effusion. Initial pertinent negative laboratory studies included antinuclear antibody, rheumatoid factor, human leukocyte antigen-B subtype 27 (HLA-B27), iron study, blood culture, urinalysis, HIV, chlamydia and Neisseria RNA. Inflammatory markers included C-reactive protein of 89.2 mg/L and erythrocyte sedimentation rate of 7 mm/h. Bilateral hip and sacroiliac joint x-ray did not show any abnormality. Because there was no obvious evidence of infection, intravenous antibiotics were discontinued after 2 days with only minimal improvement of symptoms. Eventually, the stool sample returned positive for Clostridium difficile infection (CDI). Oral vancomycin was promptly initiated. The patient’s symptoms improved significantly over the next 2 days. Joint pain as well as wrist swelling was completely resolved and he was able to walk without pain. He was discharged home to complete a 10-day course of oral vancomycin.Discussion: ReA is an acute inflammatory arthropathy following an infectious process such as gastrointestinal infections. The organisms that are often times responsible for ReA are Salmonella, Shigella or Chlamydia and less common in CDI. This case illustrated the potential cause of ReA from community-acquired CDI. Although community-acquired CDI are rare, patients with IBD have an increased risk for CDI, especially since those patients are often on glucocorticoids and biologics that can suppress the immune system. Patients with IBD most frequently complain of diarrhea; testing for CDI is recommended and must be a part of the differential diagnosis. The exact pathogenesis through which ReA occurs is not clear, but the systemic absorption of C. difficile toxin results in antibody production which could be the pathogenesis for ReA. It has been shown that ReA is commonly seen in young males with positive HLA-B27. The patient in focus represents a case of ReA where HLA-B27 was negative.Conclusions: CDI is a rare cause of ReA. The many overlapping symptoms between other causes of acute arthritis in addition to the rarity of CDI-induced ReA poses a considerable diagnostic challenge. Clinicians should always consider CDI as one of the differentials in patients with diarrhea and appropriate risk factors.References: 1. Hellmann DB, Imboden Jr. JB. Reactive Arthritis. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.sladenlibrary.hfhs.org:2048/content.aspx?bookid=2683§ionid=225053007. Accessed September 27, 2019. 2. Chun, P., Kim, Y. J., Han, Y. M., & Kim, Y. M. (2011). A case of reactive arthritis after Salmonella enteritis in a 12-year-old boy. Korean Journal of Pediatrics. doi: 10.3345/kjp.2011.54.7.313 3. Burakoff, R., (2019). Decker: Medicine. Hamilton, Ontario & Philadelphia, PA. Decker Intellectual Properties. ISSN 2292-597X. STAT!Ref Online Electronic Medical Library. http://online.statref.com/document/umHD8XWc7ToP9PvpxuNVgj!! 4. Essenmacher, A. C., Khurram, N., & Bismack, G. T. (2016). A case of reactive arthritis due to Clostridium difficile colitis. Journal of Community Hospital Internal Medicine Perspectives, 6:1, doi: 10.3402/jchimp.v6.30151

662 LYMPHOMA BURNS THE BEANS 1334843 Madison Dressler University of Kentucky College of Medicine Kristen Fletcher Lexington VA Health Care Will Ford LYMPHOMA BURNS THE BEANS Accept Case Presentation: 73 year old male with solitary kidney due to prior renal cell carcinoma and splenic marginal zone lymphoma currently treated with chlorambucil presented to the emergency department with acute kidney injury. He complained of red “kool-aid” urine and lower extremity rash. The rash was non-blanching, erythematous, papular and present on his ankles and extended circumferentially to his knees. He denied other symptoms including fever, arthralgia, neuropathy, or flank pain. On presentation, his creatinine was elevated to 7.5 (base-line 1.1), potassium was 6.0, and phosphorus was 7.7. Uric acid was 10, but decreased from prior. His LDH and total bilirubin levels were normal. His WBC was 4.5, Hgb 8.2, and platelets were 71, all stable. Urinalysis revealed large blood and nephrotic-range proteinuria. Renal ultrasound demonstrated mild hydronephrosis of his solitary kidney; computed tomography confirmed unilateral obstruction secondary to bulky lymphadenopathy. Urologic intervention improved but did not resolve renal dysfunction. Given purpura, proteinuria, and persistent kidney injury, further workup was pursued, which demonstrated low C3 and C4 levels, a positive rheumatoid factor and IgM predominance on SPEP. A skin biopsy revealed a resolving leukocytoclastic vasculitis. He was diagnosed with mixed cryoglobulinemia secondary to lymphoma and started on rituximab with resolution of kidney injury and rash.Discussion: Acute kidney injury in the setting of a lymphoproliferative disorder increases mortality, delays cancer therapy, and provides a unique differential diagnosis. As in non-cancer AKI, the most common etiology is pre-renal etiology. Here, we discuss a framework describing the remainder of AKI in hematologic malignancy. Consider four categories of AKI related to the cancer itself: direct renal infiltration, obstructive uropathy from tumor burden or bulky lymphadenopathy, malignancy associated glomerular diseases, and malignancy-associated vasculitides. Treatment-induced acute kidney injury differentials should include: chemoradiotherapy toxicity (including tumor lysis syndrome) and acute tubular necrosis from sepsis. Imaging with ultrasound or CT may be helpful; however, history, physical exam, and urine sediment evaluation are crucial. This case highlights malignancy-associated vasculitis as an etiology to consider in AKI in a patient with hematologic malignancy, particularly with purpura. Diagnosis of mixed cryoglobulinemia is based on the presence of cryoglobulins in the blood coupled with the clinical presentation. Mixed cryoglobulinemias are most notoriously associated with HCV infection (~80%) but are also associated with lymphoproliferative disorders, autoimmune disease, and other infections. Purpura is the most suggestive feature (90% of cases) but arthralgias, peripheral neuropathy, and glomerulonephritis are also suggestive. Supportive laboratory features include hypocomplementemia (specifically C4), a positive rheumatoid factor, and hypergammaglobulinemia.Conclusions: Acute kidney injury in patients with hematologic malignancy presents a targeted differential diagnosis for the hospitalist, which includes kidney injury related to the cancer itself or the unique treatments thereof. Cryoglobulinemic vasculitis should be considered in patients with underlying leukemia/lymphoma presenting with renal dysfunction and purpura.References: Khalil, et al. “Acute kidney injury in lymphoma: a single centre experience.” Int J Nephrol. 2014;2014:272961. Luciano and Brewster. “Kidney involvement in leukemia and lymphoma.” Adv Chronic Kidney Dis. 2014 Jan;21(1):27-35. Muchtar, et al. “How I treat cryoglobulinemia.” Blood. 2017 Jan 19;129(3):289-298. Terrier and Cacoub. “Cryoglobulinemia vasculitis: an update.” Curr Opin Rheumatol. 2013 Jan;25(1):10-8.

663 POSTERIOR NUTCRACKER SYNDROME: A CASE OF RARE DISEASE OR ANCHORING BIAS? 1334593 Rebecca Dryer Emory University School of Medicine Kaitlin Sandor Michael Andrew Yu Samuel Huxley Emory University School of Medicine Ndubuisi Ahuruonye Tracey Henry Emory University School of Medicine POSTERIOR NUTCRACKER SYNDROME: A CASE OF RARE DISEASE OR ANCHORING BIAS? Accept Case Presentation: A 67-year-old male with a past medical history significant for hypertension and a prior cerebrovascular accident presented with subjective 9/10 left-sided abdominal pain, systolic blood pressure >200, and tachycardia. Upon presentation, the patient experienced several episodes of asymptomatic supraventricular tachycardia. Blood work subsequently drawn showed no elevated troponins. After the second episode of supraventricular tarchycardia, a CT dissection protocol was initiated that showed no dissection. However, it uncovered a hyperechoic region of the left kidney, suggesting a renal infarct versus renal congestion. It also demonstrated a retroaortic left accessory renal vein that was potentially compressed between the aorta and the vertebral column. Additionally, the patient’s creatinine was 1.6, increased from his baseline of 1-1.2, and a urinalysis was notable for hematuria and proteinuria. The patient was admitted to medicine for further work up of his acute kidney injury and possible renal infarct. A subsequent doppler ultrasound showed patent venous flow through the left main renal vein despite suspected compression of the accessory vein. Imaging was reviewed by vascular surgery who recommended no emergent surgical intervention. The patient was stabilized, with his blood pressure controlled, pain managed, and creatinine normalized with IV fluids. The CT dissection imaging was reviewed in greater scrutiny with both medical and radiology staff, and it was recognized that the patient had two left-sided ureters and a 4x4mm nonobstructing urolith near the uretovesicular junction. His management was adjusted, and he was discharged on tramadol for pain management and instructions to hydrate well.Discussion: This patient’s presentation of left flank pain, hematuria and proteinuria, and severe hypertension, with a CT read suggesting renal infarct and a compressed retroaortic renal vein, was consistent with renal infarct secondary to posterior nutcracker syndrome. However, posterior nutcracker syndrome is exceedingly rare and a diagnosis of exclusion. Our patient's CT illustrated a likely compressed accessory renal vein, but it also showed a hyperechoic region of the left kidney that did not correspond to the area that was associated with the renal vein in question, according to one of the reads. Due to this discrepancy and the unusual presentation of our patient, we sought diagnostic clarity in the form of an integrative team and were eventually able to visualize the urolith.Conclusions: We have demonstrated a case of a patient with a retroaortic accessory renal vein and a clinical picture consistent with posterior nutcracker syndrome who was ultimately found to have a kidney stone. This emphasizes the need to incorporate a broad differential to avoid anchoring bias when presented with a possible rare diagnosis, as well as the utility of interdisciplinary review of potentially rare radiological findings.References:

666 A RASH DIAGNOSIS 1334323 Philicia Duncan The Ohio State University Wexner Medical Center A RASH DIAGNOSIS Accept Case Presentation: A 48 year-old woman with a history of ulcerative colitis presented to the hospital with a rash and diffuse myalgia of one-week duration. The skin rash was painful and mildly pruritic. She had no fever, abdominal pain, diarrhea, or arthralgia. Physical exam revealed papules on the conjunctivae of her right eye and non-tender, indurated, papulo-nodular plaques with some lesions bearing central necrosis on her scalp, torso, and extremities. Laboratory examination revealed normal white blood cell count, renal, and liver function tests. C-reactive protein and erythrocyte sedimentation rate were 90.9 mg/L and 50 mm/hr, respectively. Anti-nuclear antibody test was negative. Infectious serology including blood culture, HIV 1 and 2 antibodies, fungitell assay, Rickettsia antibodies, and Blastomyces urinary antigen were negative. A swab for bacterial culture and sensitivity from one of the skin lesions was negative. Dermatology was consulted and performed a skin biopsy of a nodule on her right forearm. This revealed a neutrophilic infiltrate without evidence of vasculitis. Histopathologic findings were consistent with acute febrile neutrophilic dermatosis (Sweet’s syndrome). She was started on prednisone 60 mg daily and the appearance of her skin lesions improved. She was discharged home to complete a 14-day prednisone taper.Discussion: While other cutaneous extra-intestinal manifestations of inflammatory bowel disease (IBD) are frequently observed, Sweet's Syndrome (SS) is rare and seen in less than 1% of patients with IBD (3). Because this dermatosis is usually responsive to treatment, being able to recognize and diagnose SS may dramatically alter a patient’s clinical course. Moreover, SS is associated with malignancy in 20% of cases (4) where many previously undiagnosed patients present with SS as a paraneoplastic syndrome (2). In three-quarter of patients, the rash is accompanied with systemic symptoms such as fever, myalgia, leukocytosis, or GI manifestations of IBD (5). The diagnosis of SS requires the presence of two major criteria and at least 2 of 4 minor criteria. The major criteria include eruption of painful plaques or nodules with the characteristic finding of neutrophilic dermal infiltrate without vasculitis on histopathology (1). Characteristic lesions are painful, erythematous nodules or papules without ulceration that appear on the upper extremities, face, and neck (6). Extra-cutaneous lesions do occur with oral lesions being associated with malignancy (2). Though lesions may recur, treatment with systemic corticosteroids is largely effective.Conclusions: Hospitalists commonly encounter patients with rash. Sweet's Syndrome is an uncommon inflammatory disorder that is associated with IBD, malignancy, infections, and drugs. Prompt recognition of SS should lead to an investigation for an underlying disease, when warranted, and initiation of corticosteroid therapy which often results in dramatic improvement of symptoms within days of initiation.References: 1. Cohen PR, Kurzrock R. Sweet’s syndrome revisited: a review of disease concepts. Int J Dermatol 2003 Oct;42(10):761-78. 2. Fett DL, Gibson LE, Daniel Su WP. Sweet’s Syndrome: Systemic Signs and Symptoms and Associated Disorders. Mayo Clin Proc 1995 Mar;70(3):234-40. 3. Levine JS, Burakoff R. Extraintestinal Manifestations of Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2011 Apr;7(4):235-41. 4. Marzano AV, Ishak RS, Saibeni S, et al. Autoinflammatory Skin Disorders in Inflammatory Bowel Diseases, Pyoderma Gangrenosum and Sweet’s Syndrome: a Comprehensive Review and Disease Classification Criteria. Clin Rev Allergy Immunol 2013 Oct;45(2):202-10. 5. Travis S, Innes N, Davies MG, et al. Sweet’s syndrome: an unusual cutaneous feature of Crohn’s diseae or ulcerative colitis. Eur J Gastroenterol Hepatol 1997 Jul;9(7):715-20. 6. Ytting H, Vind I, Bang D, Munkholm P. Sweet’s Syndrome – An Extraintestinal Manifestation in Inflammatory Bowel Disease. Digestion 2005;72(2-3):195-200.

668 WHAT COULD IT B: FATIGUE, FEVERS AND NIGHT SWEATS IN AN IMMUNOSUPPRESSED PATIENT 1334740 Kaitlyn Dykes Georgetown University Hospital Michael Owens Georgetown University School of Medicine Yiannis Dimopoulos Michael Serzan Stephen Fox WHAT COULD IT B: FATIGUE, FEVERS AND NIGHT SWEATS IN AN IMMUNOSUPPRESSED PATIENT Accept Case Presentation: A 60-year-old male presented with one week of new onset fevers and fatigue. Past medical history included primary sclerosing cholangitis, orthotopic liver transplant 12 years ago and Epstein-Barr virus (EBV) negative post transplant lymphoproliferative disease (PTLD) with partial response to single-agent Rituximab treatment one-year prior. The patient reported debilitating fatigue, daily low-grade fevers, night sweats, non-productive cough, headache, anorexia and epigastric pain for one week. He had no outdoor exposure, travel or sick contacts. Physical exam elicited palpable splenomegaly however no lymphadenopathy, jaundice or rash. Labs were notable for acute pancytopenia and CT scan showed splenomegaly with hypoattenuating lesions as well as intrabdominal lymphadenopathy (Image 1). The patient was treated with fluid resuscitation and empiric antibiotics. He had a negative infectious work up including EBV testing. Flow cytometry was significant for 9% lymphocytes including polyclonal B-Cells. A core biopsy of a mediastinal lymph node had effacement of normal lymph node architecture by sheets of large atypical lymphocytes and sclerosis (Image 2). Immunohistochemical analysis confirmed the B-cell lineage of these cells (+CD20) with a high proliferation index (+Ki67) and negative EBV. The patient was diagnosed with EBV negative diffuse large B-cell lymphoma (DLBCL), an aggressive disease requiring prompt initiation of chemotherapy.Discussion: This case presentation was initially concerning for recurrent PTLD or transformation to high-grade lymphoma verses acute infection in an immunocompromised host. PTLD is the most common malignancy after solid organ transplant, complicating 1.5% of cases.1, 2 PTLD is caused by aberrant lymphoproliferation in the setting of chronic immunosuppression and decreased cancer immune surveillance.1, 2, 3 It includes a wide spectrum of heterogeneous diseases that can progress into high-grade lymphomas.1 PTLD has a biphasic presentation including EBV positive PTLD 0-3 years post transplant and EBV negative PTLD 7-10 years post transplant.3, 4 It is essential that hospitalists consider the diagnosis of PTLD in the differential of transplant patients presenting with B symptoms, lymphadenopathy or signs of graft dysfunction.5 This patient had indolent PTLD with sudden extreme fatigue, worsening lymphadenopathy and pancytopenia, which represented transformation to DLBCL. Hospitalists are essential to the care of solid organ transplant and hematologic malignancy patients with acute decompensations and can ensure a comprehensive evaluation including infectious disease testing, PET scan, flow cytometry and excisional lymph biopsy.5 Hospitalists may also be able to help prevent PTLD, as regular evaluation and treatment for EBV may be protective in post transplant patients.3, 5Conclusions: This case emphasized important learning objectives in hospital medicine such as: to include hematologic malignancy early in the differential diagnosis and work up in post-transplant patients; identify immunosuppression as a risk factor for hematologic malignancy; recognize the biphasic presentation of PTLD and association with EBV; and to learn possible preventative measures for PTLD.References: 1. Crombie, J. L., LaCasce, A. S., Epstein Barr Virus Associated B-Cell Lymphomas and Iatrogenic Lymphoproliferative Disorders. Front.Oncol. 2019; 9: 109. 2. Mahale, P., Engels, E. A., Lynch, C. F., Morton, L. M., Cancer risk following post-transplant lymphoproliferative disorders in solid organ transplant recipients. Br.J.Haematol. 2019; 186: 347-351. 3. Allen, U. D., Preiksaitis, J. K., AST Infectious Diseases Community of Practice, Post-transplant lymphoproliferative disorders, Epstein-Barr virus infection, and disease in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin.Transplant. 2019; 33: e13652. 4. Yu, F., Huang, Y., Wang, Y., Yu, Z., Li, X., Dong, J., Very late onset post-transplant diffuse large B cell lymphoma in a liver transplant recipient with hepatitis B: A case report. Medicine (Baltimore). 2018; 97: e13063. 5. Malyszko, J., Post-transplant lymphoproliferative disorder: risk factors and management. Nephrol.Dial.Transplant. 2019.

678 AMIODARONE: A TOUGH PILL TO SWALLOW! 1334426 Yuanchen Wang Internal Medicine Residency Lindsay Euers Leena Samuel Christopher Force AMIODARONE: A TOUGH PILL TO SWALLOW! Accept Case Presentation: A 73-year-old female with coronary artery disease, biventricular systolic heart failure requiring implantable cardiac defibrillator (ICD), paroxysmal atrial fibrillation (A-fib) treated with amiodarone for 2 years presented with abdominal pain, nausea, loss of appetite for 1 month. She also reported a recent ICD discharge. Initial vital signs were remarkable for a blood pressure of 215/91. On physical exam she appeared comfortable. She had a nontender thyroid without enlargement or nodules. There was no proptosis. On abdominal exam there was mild diffuse tenderness. Laboratory evaluation revealed elevated troponin at 0.342 ng/mL(5.2 ng/dL. She underwent plasmapheresis as a bridge to thyroidectomy. After surgery, fT4 normalized, and her abdominal symptoms resolved. Final surgical pathology revealed follicular epithelial degeneration, foamy histiocytes, and mild lymphocytic inflammation, consistent with AIT.Discussion: AIT is a life-threatening disorder that can present with cardiac arrhythmias or heart failure exacerbation. The prevalence ranges from 2-10%, with fewer cases in Iodine sufficient areas. AIT is due to disruption of thyroid hormone synthesis or direct damage to thyroid cells. Diagnosis is made when TSH is suppressed and fT3, fT4 increased, although in rare cases fT3 can be normal. Type 1 is due to increased synthesis of thyroid hormone and is treated with thionamides or radioablation. Type 2 is caused by increased hormone release from destructive thyroiditis and responds to glucocorticoids. When the type is unclear as in this case, patients are treated as both. AIT can occur at almost any time during amiodarone therapy. Signs and symptoms range from asymptomatic presentation discovered on routine labs to typical hyperthyroid symptoms such as palpitations and heat intolerance. Classic symptoms of thyrotoxicosis may be absent due to antiadrenergic action of amiodarone and its impairment of conversion of T4 to T3. Besides the arrhythmia, her symptoms of abdominal pain and nausea were atypical. In cases like this, surgery is indicated if medical therapy is unsuccessful. Plasmapheresis can remove cytokines, antibodies and thyroid hormones from plasma, resulting in improvement in thyrotoxicosis within 3 days, however it is a temporizing measure. There is no immediate benefit to discontinuing amiodarone given the long half-life.Conclusions: The hospitalist role of taking a comprehensive medical history including medication reconciliation is of utmost importance. The question of whether a certain drug is causing the patient’s presenting symptoms can be difficult to tease out. This case serves as a reminder to keep medication side effects on the differential.References: 1. Martino, E. et al. Environmental iodine intake and thyroid dysfunction during chronic amiodarone therapy. Ann. Intern. Med. 101, 28–34 (1984). 2. Kotwal A, Clark J, Lyden M, McKenzie T, Thompson G, Stan MN. Thyroidectomy for Amiodarone-Induced Thyrotoxicosis: Mayo Clinic Experience. J Endocr Soc. 2018;2(11):1226–1235. Published 2018 Sep 6. doi:10.1210/js.2018-00259 3. Cohen-Lehman J, Dahl P, Danzi S, Klein I. Effects of amiodarone therapy on thyroid function. Nat Rev Endocrinol. 2010;6(1):34-41. 4. Martino E, Bartalena L, Bogazzi F, Braverman LE. The effects of amiodarone on the thyroid. Endocr Rev. 2001;22(2):240‐254. 5. Elnaggar MN, Jbeili K, Nik-Hussin N, Kozhippally M, Pappachan JM. Amiodarone-induced thyroid dysfunction:a clinical update. Exp Clin Endocrinol Diabetes (2018) 126:333–41. 10.1055/a-0577-7574 6. Vyas AA, Vyas P, Fillipon NL, Vijayakrishnan R, Trivedi N. Successful treatment of thyroid storm with plasmapheresis in a patient with methimazole-induced agranulocytosis. Endocr Pract. 2010;16(4):673-6.

679 A CASE OF HOSPITAL ACQUIRED LEGIONELLA PNEUMONIA 1335066 Darrel Gachette NYU Langone Health Chino Aneke-Nash David Rehe Ian Fagan Bellevue Hospital / NYU A CASE OF HOSPITAL ACQUIRED LEGIONELLA PNEUMONIA Accept Case Presentation: The patient is a 60-year-old male with chronic mixed systolic and diastolic heart failure, Chronic Obstructive Pulmonary Disease (COPD), and Obstructive Sleep Apnea (OSA) who was admitted to general medicine due to a 4-week history of progressive dyspnea and lower extremity edema, concerning for a heart failure exacerbation. Eight days into his hospital course, the patient developed worsening dyspnea, tachypnea and a productive cough with bloody sputum. On exam, he was febrile to 102F; his neurologic and psychiatric exams were notable for hypervigilance, and visual hallucinations concerning for delirium. Labs were notable for a WBC to 15.36 with a neutrophilic predominance and hyponatremia with a serum sodium of 120mmol/L. Chest X-ray was notable for an increasing left apical hazy opacity consistent with left upper lobe pneumonia. Blood cultures were drawn and patient was started on empiric antibiotic therapy with Vancomycin and Cefepime. Over the subsequent 5 days, the patient continued to decline with worsening hyperactive delirium and paranoid delusions despite broad spectrum antibiotics. In addition, he developed acute kidney injury with peak BUN and creatinine of 119 and 8.3, respectively. On hospital day 15 a urine antigen test for legionella resulted positive, and he was started on a 10-day course of levofloxacin. Over the subsequent week, his encephalopathy, renal failure, hyponatremia and leukocytosis all resolved. Infection control in the hospital investigated and determined this to be a case of hospital acquired legionella infection.Discussion: Hospital acquired legionella infections make up 4-8% of all legionella pneumonia cases and carry a mortality rate of up to 30-50%, due in part to delayed diagnosis and treatment. Infection with legionella pneumonia is most commonly acquired as a result of inhalation of aerosolized water droplets from contaminated aerosolized water sources and is associated with a rapidly progressive pneumonia with severe extrapulmonary manifestations including encephalopathy, renal failure, and hyponatremia. Risk factors for this infection include male gender, cigarette smoking, and poorly managed comorbid health conditions. Per 2019 Infectious Disease Society of America (IDSA) guidelines for Community Acquired Pneumonia (CAP), patients who meet criteria for severe infection should have urine and sputum legionella testing as part of their diagnostic workup. Of note, despite the high mortality rate associated with hospital acquired legionella pneumonia, this clinical entity is not mentioned in 2016 IDSA guidelines for Hospital Acquired Pneumonia (HAP). This omission may contribute to delay in recognition of this pathogen by hospitalists when patients develop a syndrome consistent with HAP. In this case of hospital acquired pneumonia complicated by delirium, renal failure, and hyponatremia, early clinical suspicion for legionella infection may have led to an expedited diagnosis.Conclusions: Due to the high mortality associated with legionella infection, it should be considered on the differential diagnosis for hospital acquired pneumonia, especially if there are atypical or extrapulmonary manifestations. In these cases, urine and sputum legionella testing should be sent.References:

689 MULTISYSTEMIC MANIFESTATIONS OF HEPATIC ANGIOSARCOMA 1334503 Brandon Fields Keck School of Medicine of University of Southern California George Matcuk Doan Lai Andrew Lee Sami Dwabe Courtney Hanlon University of Southern California Natalie Demirjian Keck School of Medicine of University of Southern California Seth Politano MULTISYSTEMIC MANIFESTATIONS OF HEPATIC ANGIOSARCOMA Accept Case Presentation: A 76-year-old Chinese woman with history of cryptogenic cirrhosis (MELD-Na 25) presented to our hospital with 1 week of worsening jaundice, abdominal distension, and right upper quadrant pain. Cirrhosis was diagnosed by imaging on admission 2 months previously and presumed to be secondary to Hepatitis C infection due to antibody positivity. CT of the abdomen and pelvis at that time also demonstrated multiple small hyperattenuating liver masses. Subsequent multiphase CT of the liver demonstrated arterially enhancing lesions with persistent enhancement on portal and delayed phases. This was interpreted as progressive centripetal fill-in suggestive of hemangiomas. On examination, she was afebrile, diffusely icteric, and had mild abdominal distention. Initial labs revealed a total bilirubin of 17.5, with a direct component of 11.2. Hemoglobin was 10.1, decreased from 15.7 on prior admission. Follow-up CT was also interpreted as hemangiomas, although the lesions had markedly increased in size. A dominant left-hepatic lobe lesion again demonstrated avid circumferential enhancement with poor late-phase washout. Infection was ruled out as a cause of decompensation. Hepatitis C RNA PCR was not detected. During this admission, patient’s hemoglobin and platelets began to steadily decline. Blood smear showed immature forms and was also suggestive of a thrombotic microangiopathy. Bedside bone marrow biopsy was a dry tap. Liver biopsy ultimately yielded a diagnosis of hepatic angiosarcoma. However, two days later, patient rapidly decompensated. Hemoglobin decreased from 9.4 to 6.1, and platelets decreased from 111,000 to 63,000. Repeat blood smear showed evidence of a worsening microangiopathic process. Subsequent imaging showed an expansile perihepatic hematoma along the biopsy site. Total bilirubin continued to rise and was last measured at 42.6 on hospital day 17. On hospital day 18, she developed mucosal bleeding from the ears and mouth, which somewhat improved following administration of cryoprecipitate. Patient was made hospice care and went home with family.Discussion: Angiosarcoma is a rare tumor representing less than less than 1% of all soft-tissue sarcomas and only 2% of all primary hepatic neoplasms. It is a rare but known cause of cirrhosis due to necrosis of hepatocytes secondary to massive tumor infiltration of hepatic sinusoids. As in our patient, it may present with a variety of clinical syndromes, including Kasabach-Merritt Syndrome (consumptive thrombocytopenia), myelofibrosis, and microangiopathic hemolytic anemia. On imaging, hepatic angiosarcoma can appear as multiple nodules (as in this case), a dominant mass, or a diffuse infiltrative lesion with variable enhancement patterns that can mimic hemangiomas, hepatocellular carcinoma, or metastases. Outcomes today remain poor regardless of whether patients present initially with localized or metastatic tumor burden, with a relapse rates as high as 40% reported in patients treated with primary surgical resection.Conclusions: This case illustrates the need for a high index of suspicion when presented with a case of hepatic angiosarcoma, which may often be metastatic on presentation given its vascular origins and aggressive clinical course. Diagnosis of primary hepatic angiosarcoma is especially challenging given its predilection for early metastasis and frequent multisystemic involvement on presentation. Though imaging can be suggestive of malignancy, biopsy remains the gold standard for diagnosis.References: 1. Schuetze SM. Imaging and response in soft tissue sarcomas. Hematology/oncology clinics of North America 2005;19:471-87, vi. 2. Read WL, Williams F. Metastatic Angiosarcoma with Kasabach-Merritt Syndrome Responsive to Gemcitabine and Vinorelbine after Failure of Liposomal Doxorubicin and Paclitaxel: A Case Report. Case reports in oncology 2016;9:177-81. 3. Mazharuddin S, Podduturi V, Guileyardo JM, Cooper B. Hepatic angiosarcoma associated with disseminated intravascular coagulation. Proceedings (Baylor University Medical Center) 2015;28:54-6. 4. Averbukh LD, Mavilia MG, Einstein MM. Hepatic Angiosarcoma: A Challenging Diagnosis. Cureus 2018;10:e3283. 5. Hu S, Bueso-Ramos CE, Verstovsek S, et al. Metastatic splenic angiosarcoma presenting with thrombocytopenia and bone marrow fibrosis mimicking idiopathic thrombocytopenic purpura and primary myelofibrosis: a diagnostic challenge. Clinical lymphoma, myeloma & leukemia 2013;13:629-33.

690 ACUTE EPSTEIN-BARR VIRUS INFECTION RESEMBLING ACUTE LEUKEMIA: A CASE REPORT 1334828 Dawood Findakly Creighton University School of Medicine Nathan Delafield ACUTE EPSTEIN-BARR VIRUS INFECTION RESEMBLING ACUTE LEUKEMIA: A CASE REPORT Accept Case Presentation: A 29-year-old woman presented to the emergency department for a 5-day history of persistent fever, sore throat, diffuse myalgias, and epigastric abdominal pain. The patient was recently diagnosed and treated for pelvic inflammatory disease after unprotected intercourse with a new sexual partner. On examination, she was tachycardic, hypotensive, afebrile and was noted to have scleral icterus and mild hepatosplenomegaly. Lab studies revealed a WBC 5.0 ^3/µL with 32% blasts, platelets of 94K. Further lab testing revealed a mixed hyperbilirubinemia with T.bili 4.1, ALT 521 U/L, AST 424 U/L, Alk Phos 210 U/L. HIV Ag/Ab and HCV RNA were negative. The abdominal US confirmed hepatosplenomegaly without biliary abnormality. Peripheral smear displayed atypical lymphocytes and blast cells, no Auer rods were seen. Hematology was consulted for possible acute leukemia, and promptly recommended flow cytometry and consideration of bone marrow biopsy. Flow cytometry revealed slightly abnormal antigen expression in granulocytes without an increase in blasts and no evidence of a B-cell or T-cell lymphoproliferative disorder. A Monospot was eventually obtained and was positive, consistent with EBV Infectious Mononucleosis. Bone marrow biopsy was deferred and the blasts, thrombocytopenia, and hyperbilirubinemia with transaminitis were attributed to Infectious Mononucleosis. The patient was discharged from the hospital with routine outpatient follow-up.Discussion: Epstein-Barr virus (EBV) is a herpesvirus that primarily infects B cells and typically becomes latent in the human B lymphocytes for their entire lifetime. In immunocompetent hosts, humoral and cellular immunity usually controls the primary infection without incident. Occasionally, this condition advances into infectious mononucleosis and can resemble or cause acute leukemia, lymphoma, and many other hematologic emergencies. EBV pathogenesis to lymphoma and leukemia has been attributed to its chronic active phase that stimulates cellular proliferation and increases the risk of pathologic transformation.Conclusions: EBV infection is a self-limited infection that primarily infects B cells. It can transform B cells into proliferating blasts, mimicking acute leukemia and other lymphoproliferative disorders. A multidisciplinary team and broad differential are critical to providing timely, comprehensive care to patients that present with these concerning clinical features.References:

691 INTRAVASCULAR LEIOMYOMATOSIS: AN UNPRECEDENTED MOLECULAR ANALYSIS 1335228 Dawood Findakly Creighton University School of Medicine Jue Wang University of Arizona Cancer Center at SJHMC INTRAVASCULAR LEIOMYOMATOSIS: AN UNPRECEDENTED MOLECULAR ANALYSIS Accept Case Presentation: A 43-year-old woman was admitted to the hospital for increasing lower extremity swelling and dyspnea on exertion. Past medical history is pertinent for hypertension, obesity, and stroke. A few months prior, she had a hysterectomy for leiomyomata. Physical examination was within normal limits except for jugular venous distension and irregular heart rate and rhythm. Transthoracic echo revealed reduced ejection fraction of 20-25% and a 4.0 x 3.5 cm globular mass, almost filling the entire right atrium. CT scan of the chest, abdomen, and pelvis reported on extensive IVC thrombus extending contiguously from the right mid external iliac vein and the left common iliac vein through the IVC and into the right atrium, in addition to a lobulated 12 cm pelvic cystic mass. The patient underwent successful right atrial, IVC, and bilateral iliac tumor thrombus resection and the patient was later discharged. Subsequent thrombus pathology described angioleiomyoma, and pelvic mass histopathology reported benign leiomyoma. One year later, the patient noticed the recurrence of the dyspnea on exertion and lower extremity swelling. Workup revealed new pulmonary nodules on chest CT scan which led to the diagnosis of benign metastasizing leiomyoma (BML). Transjugular IVC mass biopsy performed, and pathology was consistent with intravascular leiomyomatosis (IVL) with ER+/PR+ on immunohistochemical stains. Preoperative TTE showed 15-20% LVEF for which, the patient deemed a poor candidate for surgery and thus, hormonal treatment with leuprolide and letrozole started. While on this treatment, her abdominal mass and lung nodules were considered stable by RECIST 1.1 criteria (9.2% decrease in total tumor burden size), and she has had no new symptoms for the last 2 years. Genetic testing showed amplification of JUN, cyclin-dependent kinase 4 (CDK4), and MCL1, and loss of SUFU, AT-rich interaction domain 1A (AR1D1A), RB transcriptional corepressor 1 (RB1), and Hepatocyte nuclear factor 1-alpha (HNF1A).Discussion: BML is a rare condition, first described in 1939. It is usually diagnosed several years after hysterectomy for uterine leiomyoma. IVL is a rare, classically benign uterine smooth muscle cell tumor that extends into the venous system. IVL arises from the tunica media of the veins and could potentially cause an intraluminal thrombus which may extend to the right heart through the pelvic veins and IVC. Treatment of pulmonary BML depends on the extent of the disease, the expression of estrogen and progesterone receptors in the tumor which makes them responsive to hormonal manipulation, and the age of the patient, it may include hysterectomy with oophorectomy, debulking surgery and/or the use of GnRH agonists, aromatase inhibitors, selective estrogen receptor modulators, or chemotherapy to decrease tumor burden in conditions that are unamenable for surgery.Conclusions: This unique case represents a novel approach to the study of BML, supporting that genetic studies could be useful in providing a further understanding of this tumor's mechanism of metastasis. Here, we discussed the molecular profiling results of intravascular leiomyomatosis, which showed amplification of CDK4, JUN, and MCL1 loss, besides, we identified amplification of AR1D1A, RB1, SUFU, and HNF1A loss. These findings may suggest molecular evidence of the malignant behavior of a previously thought benign entity.References:

692 ISOLATED THROMBOCYTOSIS: A RARE PRESENTATION OF CHRONIC MYELOID LEUKEMIA 1334833 Dawood Findakly Creighton University School of Medicine Waqas Arslan ISOLATED THROMBOCYTOSIS: A RARE PRESENTATION OF CHRONIC MYELOID LEUKEMIA Accept Case Presentation: A 21-year-old woman was referred to the hematology clinic for further workup for thrombocytosis which was found upon evaluation for vasovagal syncope. The patient was asymptomatic with no pertinent past medical or family history. Upon presentation, the patient was vitally stable and physical examination was normal. Labs were relevant for a white blood cell count of 6.6 x10^3/µL, with 56% neutrophils, 33% lymphocytes, 7% monocytes, and 1% basophils, 0.2% eosinophils, Hemoglobin of 13.4 x10^3/µL, Platelets of 764 K/µL and minimally elevated ESR at 39 mm/hr. The patient was commenced on daily low-dose aspirin. Meanwhile, the thrombocytosis workup for myeloproliferative disorders (MPD) with peripheral blood JAK2 Exon 12,14, CALR (Calreticulin) and MPL genes were unmutated. CT scan of the abdomen and pelvis was performed and was unremarkable. Initial peripheral blood fluorescence in-situ hybridization (FISH) for BCR‐ABL1 was negative. As platelet count continued to rise, the patient had a bone marrow biopsy which revealed a translocation t(9;22) BCR/ABL1 consistent with chronic myeloid leukemia (CML). The patient was then started on a second-generation tyrosine kinase inhibitor Dasatinib. The patient achieved complete cytogenetic and molecular remission and the patient was referred for stem cell transplant evaluation.Discussion: The annual incidence of CML in the United States is about 4800 cases. CML usually presents with marked leukocytosis, but rarely presents with an isolated, marked thrombocytosis. Thrombocytosis could be reactive or it may be paraneoplastic where it is triggered by an altered immune response to myeloproliferative syndromes including polycythemia vera, CML or as an essential thrombocytosis (ET). With the success of tyrosine kinase inhibitor (TKI) therapy, the all-cause annual mortality rate was reduced to 2% despite the increasing prevalence of CML with time.Conclusions: BCR/ABL negative or atypical CML is a rare hematologic malignancy. It should be high on the differential diagnosis for cases of significant thrombocytosis, even when it is accompanied by slight leukocytosis. It has a very poor prognosis with a median overall survival of 24 months. These patients should undergo genetic testing for the BCR/ABL gene in order to confirm the diagnosis and tailor therapy.References:

705 "THE POOR MAN'S METHADONE:" AN INCREASINGLY COMMON, UNCOMMON CAUSE OF PANCREATITIS 1334639 John George University of Florida College of Medicine Bahram Dideban Nila Radhakrishnan University of Florida "THE POOR MAN'S METHADONE:" AN INCREASINGLY COMMON, UNCOMMON CAUSE OF PANCREATITIS Accept Case Presentation: A 37 year-old woman with a past medical history of depression and chronic knee pain presented with complaints of two day duration non-radiating 8/10 epigastric and lower abdominal pain associated with nausea and vomiting. Vitals sings were normal. Abdomen was soft, non-distended with generalized tenderness, but without masses, rebound, or guarding. Lipase was 843. Urine drug screen was positive for opiates and morphine, but patient had received morphine in the ER. CT abdomen showed uncomplicated pancreatitis. EKG showed prolonged QTc of 534. Initially, no clear cause could be found for the pancreatitis. LFT and lipids were normal. Patient denied alcohol use, family history, or scorpion strings. Interestingly, the patient revealed that she was consuming three 72 count bottles of loperamide per day. She had been on opiates for chronic knee pain; but after starting a job that required frequent random drug screening, she started consuming large quantities of loperamide. Just prior to admission she had attempted to wean herself off loperamide, however, developed symptoms of nausea, vomiting, diarrhea, tachycardia, jitteriness, myalgias, and worsening knee pain. The patient was admitted under observation to the hospitalist service. She progressed well and had symptomatic improvement with bowel rest, IV hydration, and supportive care. Repeat Labs were unremarkable. Addiction medicine was consulted. Ultimately, the patient was discharged home with oral acetaminophen and ibuprofen with addiction medicine follow-up.Discussion: Hospitalists frequently encounter pancreatitis, and sometimes cannot find a clear etiology. Here we present a rarer but possibly under-identified cause: loperamide abuse. With more stringent regulations to combat the opioid epidemic, many patients have turned to illicit drugs or abusing over-the-counter medications.(1) Loperamide (marketed as Imodium) has become one of these medications of abuse.(2,3) Popularized as the “Poor Man’s Methadone,” Loperamide acts on mu receptors. (2-9) In recommended doses only trace amounts cross the blood-brain barrier, with the primary effect being gastrointestinal.(2,3,5-7,9) When consumed in high enough doses, however, a sufficient amount of Imodium is absorbed to act on central opiate receptors to prevent withdrawal symptoms and produce a euphoric effect.(2,5,6,9) Loperamide is readily available OTC and not detected on drug screens, making it an attractive option for patients who may be subject to drug screening.(2,7) This also makes it difficult for hospitalists to identify as a medication of abuse. Loperamide at toxic levels has been documented to cause pancreatitis, fatal cardiac arrhythmias (Torsades de Pointes), and respiratory suppression.(5,7,10-14) This patient presented with acute pancreatitis and had findings of QTc prolongation. Unfortunately, like the patient presented here, patients attempting to discontinue use are at risk for developing opiate withdrawal symptoms.(2,6,15) Unlike prior cases reported, our patient presented with multiple adverse effects from loperamide abuse.Conclusions: As we confront the opiate epidemic, we need to recognize new substances of abuse that can adversely affect our patients. Loperamide, with its potential for abuse and life threatening toxicity, has unfortunately emerged as one. Hospitalists should be aware of the side effects of loperamide abuse including pancreatitis and QTc prolongation.References: 1. CDC guidelines: https://www.cdc.gov/drugoverdose/prescribing/guideline.html 2. MacDonald R, Heiner J, Villarreal J, Strote J. Loperamide dependence and abuse. BMJ Case Rep. 2015 May 2;2015. 3. Daniulaityte R, Carlson R, Falck R, Cameron D, Perera S, Chen L, Sheth A. "I just wanted to tell you that loperamide WILL WORK": a web-based study of extra-medical use of loperamide. Drug Alcohol Depend. 2013 Jun 1;130(1-3):241-4. 4. McGinley, Laurie. "FDA wants to curb abuse of Imodium, 'the poor man's methadone.'" The Washington Post, January 30, 2018 5. Salama A, Levin Y, Jha P, Alweis R. Ventricular fibrillation due to overdose of loperamide, the "poor man's methadone". J Community Hosp Intern Med Perspect. 2017 Sep 19;7(4):222-226 6. Stanciu CN, Gnanasegaram SA. Loperamide, the "Poor Man's Methadone": Brief Review. J Psychoactive Drugs. 2017 Jan-Mar;49(1):18-21 7. Dierksen J, Gonsoulin M, Walterscheid JP. Poor Man's Methadone: A Case Report of Loperamide Toxicity. Am J Forensic Med Pathol. 2015 Dec;36(4):268-70 8. Mackerer CR, Clay GA, Dajani EZ. Loperamide binding to opiate receptor sites of brain and myenteric plexus. J Pharmacol Exp Ther. 1976 Oct;199(1):131-40. 9. Lee VR, Vera A, Alexander A, Ruck B, Nelson LS, Wax P, Campleman S, Brent J, Calello DP. Loperamide misuse to avoid opioid withdrawal and to achieve a euphoric effect: high doses and high risk. Clin Toxicol (Phila). 2019 Mar;57(3):175 10. Vidarsdottir H, Vidarsdottir H, Moller PH, Bjornsson ES. Loperamide-induced acute pancreatitis. Case Rep Gastrointest Med. 2013;2013: 517414 11. Labgaa I, Uldry E, Doerig C, Schmidt S, Demartines N, Halkic N. Loperamide-induced recurrent acute pancreatitis. Clin Res Hepatol Gastroenterol. 2016;40(1): e13-4 12. Upadhyay A, Bodar V, Malekzadegan M, et al. Loperamide Induced Life Threatening Ventricular Arrhythmia. Case Rep Cardiol. 2016;2016: 5040176 13. Katz KD, Cannon RD, Cook MD, et al. Loperamide-Induced Torsades de Pointes: A Case Series. J Emerg Med. 2017;53(3): 339-344 14. Eggleston W, Clark KH, Marraffa JM. Loperamide Abuse Associated With Cardiac Dysrhythmia and Death. Ann Emerg Med. 2017 Jan;69(1):83-86. 15. Wolfrum LA, Nordmeyer AS, Racine CW, Nichols SD. Loperamide-Associated Opioid Use Disorder and Proposal of an Alternative Treatment with Buprenorphine. J Addict Med. 2019 May/Jun;13(3):245-247.

711 UNLUCKY CATCH: UNLIKELY CELLULITIS 1334301 Catherine Glatz University of Rochester Medical Center Meghan Train Asad Arastu UNLUCKY CATCH: UNLIKELY CELLULITIS Accept Case Presentation: A 43- year- old healthy man presented to the emergency department with chills, arm pain, swelling, and redness after sustaining a puncture wound from a dead catfish. Vital signs included temperature 38.2 C, HR 116, BP 87/55. He had left medial wrist and forearm erythema, swelling and induration surrounding a small puncture wound as well as decreased wrist range of motion. Lab work was notable for WBC 14.1 with 2% bands. Due to a penicillin allergy he was started on broad- spectrum antibiotics with vancomycin, ciprofloxacin, and doxycycline. Within several hours there was marked lymphangitic spread and Clindamycin was added. CT scan of the arm showed no retained foreign body or deep fascia infection. Initial blood culture was positive for Plesiomonas shigelloides. Ultimately, given clinical improvement and repeat negative blood cultures, he was discharged on oral Ciprofloxacin to complete a 14- day course.Discussion: Health care providers frequently encounter cellulitis, which accounts for over 537,000 hospitalizations and $3.74 billion in healthcare costs yearly. It is critical to obtain a thorough history in order to identify potential complications and effectively manage care. In this case, the mechanism of injury significantly altered the antibiotic selection. Catfish are the number one cause of a fish-related injury in the USA. Freshwater catfish have dorsal and pectoral barbs containing venomous glands. When threatened, the barb can penetrate and release venom leading to local inflammation, erythema, and tissue necrosis. Envenomation may result in systemic symptoms including tachycardia, hypotension, nausea, emesis, and dizziness. Many organisms are found on catfish but rarely Plesiomonas shigelloides, a facultatively anaerobic, oxidase-positive, gram-negative rod. When ingested via contaminated water or raw food, Plesiomonas typically leads to gastrointestinal symptoms. There are few case reports of Plesiomonas bacteremia. These are typically seen in immunocompromised hosts and thought to be due to bacterial translocation across the bowel wall.Conclusions: Due to the mechanism of injury, antibiotic coverage for our patient’s cellulitis had to include gram-negative bacteria found in freshwater as well as gram-positive bacteria. Evaluation for retained foreign body and prompt removal is necessary. Complications of catfish envenomation include pain, tissue necrosis, and limb amputation. The unusual mechanism of injury also led to bacteremia with an organism that is usually only found in the gastrointestinal tract and has led to illness in immunocompromised hosts. This presentation of cellulitis from an unusual cause demonstrates the importance of a thorough history in making an effective management plan. As in this case, the typical antibiotic coverage for cellulitis was not sufficient and required the addition of gram-negative coverage.References: Ajmal, Nadeem, et al. “Catfish Spine Envenomation: A Case of Delayed Presentation.” Wilderness & Environmental Medicine, vol. 14, no. 2, 2003, pp. 101–105. Blomkalns, Andra L., and Edward J. Otten. “Catfish Spine Envenomation: a Case Report and Literature Review.” Wilderness & Environmental Medicine, vol. 10, no. 4, 1999, pp. 242–246. Huang, Gary, et al. “Catfish Spine Envenomation and Bacterial Abscess with Proteus and Morganella: a Case Report.” Journal of Medical Case Reports, vol. 7, no. 1, 2013. Janda, J.M., S.L. Abbott, and C.J. McIver, Plesiomonas shigelloides Revisited. Clin Microbiol Rev, 2016. 29(2): p. 349-74. Lee, A.C., et al., Plesiomonas shigelloides septicemia: case report and literature review. Pediatric Hematology Oncology, 1996. 13(3): p. 265-9. Peterson, R. A., Polgreen, L. A., Cavanaugh, J. E., & Polgreen, P. M. (2017). Increasing Incidence, Cost, and Seasonality in Patients Hospitalized for Cellulitis. Open forum infectious diseases, 4(1), ofx008-ofx008. doi:10.1093/ofid/ofx008 Rolston, K.V., et al., Spectrum of Aeromonas and Plesiomonas infections in patients with cancer and AIDS. Experientia, 1991. 47(5): p. 437-9. Wong, T.Y., et al., Plesiomonas shigelloides infection in Hong Kong: retrospective study of 167 laboratory-confirmed cases. Hong Kong Med J, 2000. 6(4): p. 375-80. Woo, P.C., S.K. Lau, and K.Y. Yuen, Biliary tract disease as a risk factor for Plesiomonas shigelloides bacteraemia: a nine-year experience in a Hong Kong hospital and review of the literature. New Microbiol, 2005. 28(1): p. 45-55. Young, A.Z., D. Neujahr, and L. Estok, Case report. Epididymo-orchitis and bacteremia caused by Plesiomonas shigelloides in an HIV-infected patient. AIDS Read, 2001. 11(12): p. 617-9.

730 ORTHOSTATIC HYPOTENSION: UNCOMMON TOXICITY OF AN UNCOMMON MEDICATION 1335327 Ishaan Gupta Johns Hopkins University School of Medicine Sonal Gandhi Amteshwar Singh Johns Hopkins University School of Medicine ORTHOSTATIC HYPOTENSION: UNCOMMON TOXICITY OF AN UNCOMMON MEDICATION Accept Case Presentation: 64-year-old man with history of schizoaffective disorder, hypertension, cigarette smoker (quit recently) was admitted to the hospital with acute onset recurrent falls in the last 2 weeks. Medications include buspirone 10mg, amlodipine 2.5 mg, metoprolol 50 mg, clozapine 450 mg. He had hypotension on presentation, which improved with fluids. Symptomatic orthostatic hypotension persisted even after stopping his antihypertensives. We ruled out adrenal insufficiency, neurodegenerative diseases and cardiac causes of orthostatic hypotension. Salt tablets, compression stockings, midodrine and fludrocortisone were ineffective. Attention turned to medication reconciliation: He was found to have toxic clozapine levels (1,486 ng/mL) despite stable dosing for 20 years. Clozapine was tapered safely which led to resolution of orthostasis.Discussion: Clozapine (strong dopaminergic, serotonergic, noradrenergic, and anticholinergic agent) is an effective but underutilized antipsychotic for resistant schizophrenia in US. Clozapine REMS program is effective in 30-60% patients. Tobacco smoking tends to decrease the levels by inducing CYP1A2; by corollary - smoking cessation may led to elevated blood levels. Clozapine can also cause orthostatic hypotension in about 9% of patients during initial 4-6 weeks (Patel 2019). Clozapine toxicity (target levels 350-450 ng/ml ) can cause arrhythmias, myocarditis (0.2-3%), cardiomyopathy (Conclusions: 1. Clozapine is a very effective for treatment of resistant schizophrenia. 2. The utilization of clozapine is expected to increase . 3. As hospitalists, we are providing care to patients with mental health disease. It is imperative we identify the safety profile and interactions of Clozapine. 4. Smoking cessation can increase the levels of clozapine to toxic levels.References: 1. Goren, JL et al. (June 2016). The business case for expanded clozapine utilization. Psychiatric Services. 2. Kane, JM. (March 2016). The role of clozapine in treatment-resistant schizophrenia. JAMA Psychiatry. 3. FDA Clozapine Drug Insert 4. Citrome (2016). A Guide to the Management of Clozapine- Related Tolerability and Safety Concerns. Clin Schizop & Related Psychoses 5. De Berardis (2017). Safety of antipsychotics for the treatment of schizophrenia: a focus on the adverse effects of clozapine Ther Adv in Drug Safety

736 WHAT HIDES IN THE CHEST MAY WRACK YOUR BRAIN 1335500 Lauren Haggerty UC San Diego Health Milla Kviatkovsky UCSD WHAT HIDES IN THE CHEST MAY WRACK YOUR BRAIN Accept Case Presentation: A 76 year old male with a history of hypertension and hyperlipidemia presented with acute onset ascending weakness, perioral tingling, and loss of temperature sensation. The patient’s profound weakness progressed over the course of a few days, with subsequent diplopia, hallucinations, and confusion. He received the influenza vaccine a few weeks prior, and traveled to Paris and Wyoming within the last six months. Review of systems was positive for a chronic, intermittent cough and negative for all other infectious symptoms. Initial blood pressure was 159/94 mmHg. All other vitals were within normal limits. He was alert but could not answer questions appropriately. Neurological exam was notable for left sided facial droop, 4/5 strength in the right arm, 3/5 strength in the left arm, 2/5 strength in the hips and knees bilaterally, and hyporeflexia in all extremities. Initial labs were notable for elevated AST and ALT only. CSF analysis revealed a lymphocytic pleocytosis (WBC 41, protein >600, glucose 69). MRI head and spine and EEG were unrevealing. Initial differential diagnosis included Guillain-Barré syndrome, viral encephalitis, and autoimmune encephalitis. Acyclovir, vancomycin, ampicillin, and ceftriaxone were empirically started started and subsequently discontinued after infectious workup was unrevealing. Patient’s weakness progressed, though altered mentation improved and diplopia resolved. He developed symptomatic bradycardia along with rapid oscillations in blood pressure (80s/40s to 180s/90s mmHg), along with an AKI secondary to urinary retention. Neurology was consulted, who recommended empiric IVIG therapy for suspected Guillain-Barré syndrome or autoimmune encephalitis. After a five day course of IVIG, the patient demonstrated a modest improvement in strength. Considering unrevealing work up, a CT chest was performed to evaluate for occult malignancy out of concern for paraneoplastic syndrome. To our surprise, it revealed hilar lymphadenopathy which then directed our suspicion towards a rare diagnosis of neurosarcoidosis (Figure 1). He underwent biopsy of lymph nodes via endobronchial ultrasound, but biopsy results were nondiagnostic. Serum ACE was normal. Given the high clinical suspicion for neurosarcoidosis, high dose steroids were started with subsequent improvement in strength, sensation, and mentation.Discussion: Neurosarcoidosis occurs in 10-15% of patients with sarcoidosis, and can be difficult to diagnose. Patients present with a variety of neurological symptoms including peripheral neuropathies, encephalopathy, cranial neuropathies, and dysautonomia with changes in heart rate and blood pressure. MRI brain can reveal meningeal or parenchymal enhancement, but is only present in 40% of cases. CSF studies show a lymphocytic pleocytosis and elevated total protein. Biopsy is not necessary to confirm diagnosis. Corticosteroids are the mainstay of treatment. This case highlights the utility of Chest CT when evaluating patients who present with an unusual constellation of neurologic symptoms and a negative infectious workup. Various pulmonary and mediastinal findings are associated with neurologic disease (Figure 1), and can guide further workup.Conclusions: Neurosarcoidosis is a rare cause of encephalopathy, weakness, and other neurologic symptoms. Consider a CT chest if preliminary work up with MRI, lumbar puncture, EEG, and infectious studies are unrevealing.References: Ibitoye RT, Wilkins A, Scolding NJ. Neurosarcoidosis: a clinical approach to diagnosis and management. J Neurol. 2017;264(5):1023-1028. Vinas FC, Rengachary S. Diagnosis and management of neurosarcoidosis. J Clin Neurosci. 2001;8(6):505-13.

742 A CASE OF PARANEOPLASTIC ENCEPHALITIS MASQUERADING AS ALCOHOL INTOXICATION 1334705 William Harkin UCSD Farid Abushamat Shaun Giancaterino William Frederick III Harshal Mehdi A CASE OF PARANEOPLASTIC ENCEPHALITIS MASQUERADING AS ALCOHOL INTOXICATION Accept Case Presentation: A 61-year-old female with history of alcoholism presented with confusion and hallucinations. Three days prior to admission, the patient fell while intoxicated. She typically drank 1-2 bottles of wine daily. She endorsed dizziness and blurry vision since the fall as well as visual hallucinations and paranoid delusions. On examination, she was unable to appropriately answer questions and had fluctuating level of consciousness. Initial head CT was concerning for temporal lobe encephalitis. MRI demonstrated right temporal and frontal T2 hyperintensities concerning for limbic encephalitis. An EEG showed focal slowing and lateralized periodic discharges (LPDs) over the right hemisphere. The patient was treated with IV Acyclovir for presumed HSV encephalitis but did not improve. Lumbar puncture and CSF PCR infectious panel showed no evidence of infection including HSV. She then developed left upper extremity myoclonic jerks concerning for epilepsia partialis continua and was started on levetiracetam and clonazepam. Autoimmune and paraneoplastic encephalitis remained on the differential. Several autoimmune/paraneoplastic panels were sent, and a search for malignancy began. CT of the chest, abdomen and pelvis revealed right upper lobe lung and right adrenal lesions. She was then treated empirically for paraneoplastic encephalitis with IVIG for 3 days with drastic improvement in symptoms. Biopsies showed adenocarcinoma of the lung, confirming the diagnosis of paraneoplastic encephalitis.Discussion: Paraneoplastic encephalitis is an immune-mediated process whereby, in the setting of malignancy, auto-antibodies are produced which attack the central nervous system. This form of encephalitis often affects the limbic system, though it can also involve the brainstem or cause widespread inflammation of the CNS. In paraneoplastic limbic encephalitis (PLE), the affected structures include the amygdala, hippocampus, cingulate gyrus, and limbic cortex. PLE can manifest as acute or sub-acute behavioral changes, short-term memory problems, seizures, and cognitive dysfunction. As seen in this case, MRI often shows T2 hyperintensities localizing to the medial temporal lobes. EEGs can demonstrate focal or generalized slowing with epileptiform activity in the temporal lobes. While numerous malignancies are associated with PLE, the most common is small cell lung cancer, although non-SCLC is a frequent cause as well. As we experienced, in a significant portion of PLE, a specific auto-antibody is never detected. The best treatment for PLE is typically identification and treatment of the primary tumor with initiation of immunotherapy (IVIG, PLEX, rituximab, cyclophosphamide).Conclusions: It is prudent to consider a paraneoplastic syndrome as a potential cause of encephalitis once more common etiologies have been ruled out. In many cases of PLE, a specific antibody is never detected. Early treatment of the neoplasm with joint immunotherapy is crucial to slowing the progression of PLE.References:

747 PRETTY IN PURPLE: IS IT JUST SKIN-DEEP? 1334798 Kevin He Beth Israel Deaconess Medical Center Ken He University of Washington Paul Cornia PRETTY IN PURPLE: IS IT JUST SKIN-DEEP? Accept Case Presentation: A 48-year-old man with a history of gastroesophageal reflux disease and obstructive sleep apnea presented with one week of pain, warmth, and rash over the right foot accompanied by episodic fever and headaches. He was a landscaper. Six weeks ago, he fell from a ladder with resultant right nondisplaced medial malleolar and comminuted talar fractures. The fractures were managed non-surgically with resolution of swelling and bruising 2 weeks ago. On presentation, he was well appearing with temperature 100.8 F, HR 88, RR 18, BP 102/95. Cardiopulmonary and abdominal exams were normal; trace lower extremity edema was present and pedal pulses were normal. Faint erythema was present over the right ankle and dorsomedial foot along with non-tender, non-palpable, non-blanching purpura over the dorsum of the foot and scattered petechiae over the right lateral leg. Labs were notable for WBC 6, hemoglobin 13.7, platelets 118, creatinine 1.3, total bilirubin 0.8, AST 78, ALT 106, ALP 117, INR 1.2, PTT 41, CRP 7, ESR 14, and normal urinalysis. He was initially treated for cellulitis with subsequent workup for possible vasculitis. Punch biopsies were performed without evidence of vasculitis. During the hospitalization, the patient noted that the foot rash faded with leg elevation and worsened with dependency. Repeat examination revealed a dusky, purpuric rash when sitting that faded to pink upon leg elevation above heart level. Venous duplex ultrasound revealed an acute deep venous thrombosis (DVT) isolated to the right posterior tibial vein. Anticoagulation (rivaroxaban) was initiated and he was discharged. Symptoms resolved within one month, and he completed a four-month course. A hypercoagulable workup was negative.Discussion: We present a case of isolated distal DVT presenting as unilateral, non-palpable purpura. Purpura is a dermatological manifestation of localized red blood cell extravasation, typically through vascular congestion, capillary damage, or coagulopathy—a milieu similar to one conducive to thrombosis. The distribution of purpura in this patient is compatible with vascular congestion of the plantar veins draining into the thrombosed posterior tibial vein, resulting in dependency. Recent ankle fracture and reduced mobility likely provoked the DVT. There are two other reported cases of DVT presenting as purpura; a femoral DVT in a cirrhotic with chronic thrombocytopenia and a recurrent popliteal DVT in a patient with history of thrombosis in the same vein. Atypical features of the purpura without compelling systemic abnormalities helped narrow the diagnosis. However, suspicion should still be maintained for systemic conditions that produce purpura in the setting of a hypercoagulable state, such as thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. Currently, consensus guidelines are lacking for anticoagulation of isolated distal DVTs, though studies show reductions in proximal venous extension, pulmonary embolism, and recurrent DVT. Our patient was anticoagulated given symptoms and low bleeding risk. Because atypical presentation of common pathology remains a diagnostic challenge, we share our experience to better inform clinicians.Conclusions: We present a case of isolated distal DVT masquerading as unilateral purpura. This is the third case reported in the literature, and the first in a distal vein. Recognition of unilateral dynamic vascular changes helped refine the diagnosis in this case.References: Dhakal P, Gundabolu K, Bhatt VR. An Algorithmic Approach to Management of Venous Thromboembolism. Clin Appl Thromb Hemost. 2017;23(6):511-517. doi:10.1177/1076029616652727. Franco L, Giustozzi M, Agnelli G, Becattini C. Anticoagulation in patients with isolated distal deep vein thrombosis: a meta-analysis. J Thromb Haemost. 2017;15(6):1142-1154. doi:10.1111/jth.13677. Freed JA, Hale AJ. Unilateral purpura resulting from deep vein thrombosis. Am J Hematol. 2019;94(5):622-623. doi:10.1002/ajh.25266. Lim MS, Ariyarajah A, Oldmeadow C, Hall A, Enjeti AK. A Systematic Review and Meta-analysis Comparing Anticoagulation versus No Anticoagulation and Shorter versus Longer duration of Anticoagulation for Treatment of Isolated Distal Deep Vein Thrombosis. Semin Thromb Hemost. 2017;43(8):836-848. doi:10.1055/s-0037-1604085. Mikoshiba Y, Uhara H, Okuyama R, Mikoshiba Y, Saiki M. Unilateral pigmented purpuric dermatosis associated with deep thrombosis. Int J Dermatol. 2014;53(2):e87-8. doi:10.1111/j.1365-4632.2012.05492.x. Righini M, Galanaud J-P, Guenneguez H, et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. Lancet Haematol. 2016;3(12):e556-e562. doi:10.1016/S2352-3026(16)30131-4.

764 ESOPHAGEAL PERFORATION LEADING TO EPIDURAL ABSCESS 1334462 Sayyada Hyder University of Kentucky College of Medicine Gordon Lents Karolina Viquez ESOPHAGEAL PERFORATION LEADING TO EPIDURAL ABSCESS Accept Case Presentation: Epidural-Esophageal fistula is an uncommon adverse event after esophageal perforation. The presenting symptoms may mimic other more common conditions, which may lead to incorrect diagnosis. We present a patient with esophageal perforation of unknown etiology, complicated by spinal epidural abscess. 52-year-old female with a history of liver cirrhosis secondary to hepatitis C, endometrial carcinoma with metastasis to lung for which she received radiation therapy, hypertension and diabetes mellitus presented to the hospital with cough, fever and shortness of breath. Computer tomography scan (CT) showed a loculated effusion and a thoracostomy tube was placed. Microbiology cultures from the chest tube showed infection with GDS, Klebsiella, Eubacterium, VSE. She received vancomycin and unasyn, and the thoracostomy was removed. Subsequently, the patient developed acute back pain that prompted to get a magnetic resonance imaging (MRI) showing destruction of the endplates at T2-T3, a paravertebral and epidural abscess as well as an esophageal leak at the same level. Barium esophagogram revealed a 3.5 cm contained leak of the mid-upper esophagus. Antibiotic therapy with cefepime was started. Since the esophageal leak was contained and patient did not have any neurologic complaints at the time, the decision was made for no surgical intervention. An esophageal/endoluminal wound vac (WV) and PEG tube was placed as well, in an attempt to seal the leak and bypass the defect.Discussion: Esophageal fistula presenting as epidural abscess has been reported to be a rare complication of esophageal dilation, stent placement/removal, endoscopy and radiation. Management of epidural abscess depends on the severity and presence of neurologic symptoms. Certain patients can be conservatively treated with medical management alone, where antibiotics are the mainstem treatment . Clinical suspicion and early medical therapy or surgical management with indicated are the most important factors to have in mind when managing these patients.Conclusions: Our case highlights the existence of esophageal fistulas, complicated by epidural abscess which is an uncommon complication, but in the presence of back pain and neurological symptoms, a CT scan or MRI should be pursued in order to have a prompt diagnosis and start early treatment strategies with the aim to reduce complications and improve clinical outcomes.References: 1. Darouiche R. Spinal Epidural Abscess. N Engl J Med. 2006; 355(19):2012-20. 2. Boulis N, Armstrong W, Chandler W, Orringer M. Epidural Abscess: A Delayed Complication of Esophageal Stenting for Benign Stricture. The Annals of Thoracic Surgery. 1999;68(2):568–70. 3. Abelson J, Murphy J, Loo B, et al. Esophageal tolerance to high-dose stereotactic ablative radiotherapy. Disease of the esophagus. 2012;25(7):623-9.

780 A SEVERE CASE OF TICK BORNE DISEASE 1334333 Hanish Jain SUNY Upstate Medical University Rahul Mahapatra SUNY Upstate University Hospital A SEVERE CASE OF TICK BORNE DISEASE Accept Case Presentation: An 81-year old healthy male from Upstate New York without significant past medical history presented as a transfer from an outside hospital with a 5-6 day history of fevers, malaise, vague abdominal pain, and worsening confusion. There was no travel outside of the local area in the previous six months. The patient was an avid golfer but reported no recent tick bites. Blood smear testing on the day of admission returned positive for babesiosis with a parasite index of 13 percent. A DNA PCR sequencing confirmed the species to be Babesia microti. He was started on oral atovaquone, azithromycin, and doxycycline in the setting of a high rate of co-infection among Ixodes scapularis ticks for both Borrelia burgdorferi and Babesia microti. Within the next three hours, he developed massive hematemesis, respiratory failure, and oliguric renal failure. He was subsequently intubated and transferred to MICU. Clindamycin was added to the antiparasitic regimen. A repeat blood parasite index level returned at 25 percent and the patient was urgently started on an exchange transfusion. He was also started on piperacillin-tazobactam therapy for broad coverage in the setting of septic shock and multi-organ dysfunction. Following 48 hours of antiparasitic therapy and exchange transfusion, his parasitemia level dropped to 0.7%. He was slowly weaned off vasopressor therapy, DIC resolved with improved fibrinogen levels, was extubated in 72 hours and creatinine levels returned to baseline over course of seven days.Discussion: Babesia infections range from asymptomatic to severe and sometimes are fatal. The severity of infection depends on the Babesia species and the immune status of the host. B. microti is the predominant species that infects humans in the United States. The incubation period of B. microti infection following a tick bite typically is one to four weeks. Severe babesiosis often occurs in older and/or immunocompromised patients and is associated with parasitemia greater than four percent. Severe babesiosis may also lead to complications, including persistent or relapsing disease. The most common complication is acute respiratory distress syndrome requiring intensive care. Shock, intravascular hemolytic anemia, multi-organ dysfunction are also observed.Conclusions: Babesiosis is a tick-borne disease which shares the Lyme disease tick vector. Prompt microbiological smear examination along with a parasitemia index guides further therapy. In severe cases with parasitemia index greater than four percent; exchange transfusion should be carried out at the earliest for preventing fatality and improving patient outcomes along with co-administration of antibiotic therapy. A clinic follow up should be advocated to check for relapse.References:

781 SUSPICIOUS FOR SOMETHING PERNICIOUS 1334915 Jonathan Albert Jamito Mount Sinai West-Morningside Krystle Hernandez Mount Sinai Morningside Ana Belen Arevalo Molina Mount Sinai Morningside - West / Icahn School of Meidicne David Weininger Cohen Kirtipal Bhatia Shivani Handa Yasmin Herrera SUSPICIOUS FOR SOMETHING PERNICIOUS Accept Case Presentation: A 52-year-old African American male with a past medical history of gastric ulcer presented to the emergency department with progressively worsening exertional dyspnea and fatigue over the past two months. Physical examination was significant for a heart rate of 105 bpm and icteric sclera. Pinprick and vibratory sensations over bilateral lower extremity were normal. Initial laboratory analysis revealed a hemoglobin of 3.9 g/dl, platelet count of 54 X 103/ml, and white blood cell count of 5.8 X 103/ml, with a mean corpuscular volume (MCV) of 110 fL. Peripheral smear revealed schistocytosis, teardrop cells, and anisopoikilocytosis. No hypersegmented neutrophils were seen. PT/INR and aPTT were normal. Total bilirubin was 2.8 mg/dl with a direct component of 0.9 mg/dl, lactate dehydrogenase (LDH) was 6,975 IU/L and haptoglobin levels (Discussion: Our patient presented with symptomatic anemia, thrombocytopenia, schistocytes, elevated LDH, low haptoglobin, and indirect hyperbilirubinemia concerning for microangiopathic hemolytic anemia (MAHA). However, ADAMTS13 levels, coagulation profile, and fibrinogen levels were normal, ruling out disseminated intravascular coagulopathy (DIC) and thrombotic thrombocytopenic purpura (TTP). The patient’s inadequate bone marrow response, signified by a low reticulocyte count, along with the low vitamin B12 levels and elevated MMA, confirmed vitamin B12 deficiency as the cause for his anemia. Intramedullary hemolysis resulting in pseudo-thrombotic microangiopathy may occur in 2.5 percent of patients with severe vitamin B12 deficiency and can mimic TTP. Pernicious anemia is the most common cause of severe B12 deficiency. It occurs due to an autoimmune response against the gastric mucosa, resulting in the formation of autoantibodies to intrinsic factor secreted by parietal cells. Lifelong treatment with parenteral or oral B12 supplementation is indicated, and initiation of treatment results in a marked improvement in markers of hemolysis and cell counts.Conclusions: Intramedullary hemolysis is an uncommon presentation of severe vitamin B12 deficiency. Due to the starkly differing management strategies, differentiation between MAHA and vitamin B12 deficiency is of utmost importance. Therefore, physicians should always include B12 deficiency as a differential for a patient presenting with features of MAHA and an inadequate bone marrow response.References:

787 EMERGEN-C! TREATMENT OF A PATIENT WITH METHEMOGLOBINEMIA WITH VITAMIN C 1334377 Guillermo Jimenez University of Colorado Neel Gakhar Adrienne Mann EMERGEN-C! TREATMENT OF A PATIENT WITH METHEMOGLOBINEMIA WITH VITAMIN C Accept Case Presentation: Our patient was a 46-year-old man who presented with two days of malaise, headache, fever and productive cough. He denied chest pain, shortness of breath, exposure to sick contacts or recent travel. He has a past medical history of Celiac disease with associated dermatitis herpetiformis treated with dapsone and betamethasone cream for several years. Two weeks prior to presentation, the dapsone dose was increased due to ongoing dermatitis. Physical Exam The patient was tachycardic with a heart rate of 110 and febrile with a temperature of 101.2. His oxygen saturation was mid to high 80s on 6-10 litres/minute of oxygen by high flow nasal canula. He was in mild distress, but able to speak in complete sentences. His cardiac exam was normal. Pulmonary exam was notable for reduced breath sounds and ronchi in the right lower lobe. Perioral and auricular cyanosis was noted. Laboratory Work and imaging His white blood cell count was 18.4 x 10^3/uL, Hemoglobin concentration was 13.5 g/dL, and the MCV was 103.5 fL. Total bilirubin was 3 mg/dL. A right lower lobe opacification was seen on his chest XR. Blood cultures revealed no growth. Pulmonary CT angiography revealed the absence of a pulmonary embolus. Diagnosis The patient was treated for sepsis secondary to lobar pneumonia. Despite antibiotics and supplementary oxygenation via nasal canula, oxygen saturation remained 80-90%. The hypoxia was out of proportion to the pulmonary infiltrate, prompting additional investigation including evaluation of methemoglobin level which was elevated at 15.2%Discussion: This patient was diagnosed with acquired methemoglobinemia due to dapsone. Methemoglobinemia can be a challenging diagnosis to uncover given its rare incidence in the population and nonspecific presentation. Methylene blue (MB) and ascorbic acid are the standard treatments for this disease. We elected to use ascorbic acid, as MB can induce hemolysis in patients with G6PD deficiency.Conclusions: In this case, the discovery of methemoglobinemia was made by investigating his persistent hypoxia. Accepting the current diagnosis of pneumonia would have ended the diagnostic process. This is known as premature closure, a cognitive bias. We employed type 2 clinical reasoning, a slow and deliberate analysis, to ask ourselves why this patient was not improving despite treatment. Repetition of type 2 clinical reasoning ultimately results in better ability for physicians to use type 1 reasoning, which is quicker, more intuitive and relies on recognition of patterns.References:

794 SYSTEMIC AA AMYLOIDOSIS PRESENTING WITH GASTROINTESTINAL BLEEDING - A CASE REPORT WITH DIAGNOSTIC CHALLENGES 1334835 Juliana Kan Singapore General Hospital, Singapore Cherie Gan Raden De Guzman Kevin Teh Yuyang Tan SYSTEMIC AA AMYLOIDOSIS PRESENTING WITH GASTROINTESTINAL BLEEDING - A CASE REPORT WITH DIAGNOSTIC CHALLENGES Accept Case Presentation: Patient is a 76 year-old male with a significant background of ischemic heart disease with reduced ejection fraction, pyloric and duodenal ulcers, and chronic kidney disease attributed to chronic glomerulonephritis (not biopsy-proven). He presented with hematemesis and melena. Esophagogastroduodenoscopy revealed multiple gastric ulcers that were negative for Helicobacter pylori. Histology from the gastric biopsy showed amyloid deposits on Congo Red stain. Laboratory results revealed progressive chronic kidney disease with estimated glomerular filtration rate deteriorating from normal to 6ml/min over 2 years. On admission, patient had fluid overload and symptomatic uremia requiring initiation of hemodialysis. During his stay, there were episodes of recurrent bradycardia and paroxysmal atrial fibrillation, triggering concerns of cardiac amyloidosis. Stress echocardiogram was unable to confirm cardiac involvement due to pre-existing poor cardiac function, and cardiac magnetic resonance imaging was not performed due to his poor renal function and resultant risk of nephrogenic systemic fibrosis. Investigations for recurrent hypoglycaemia revealed severe hypothyroidism and adrenal insufficiency. Despite adequate replacement of levothyroxine and hydrocortisone, episodes of postural hypotension raised the suspicion for autonomic neuropathy. Abdominal fat pad biopsy was negative for amyloidosis and patient declined bone marrow testing. Subsequent repeat gastric biopsy sent for mass spectrophotometry confirmed AA (secondary) amyloidosis.Discussion: This case demonstrates the varied presentation and multi-systemic involvement of AA amyloidosis. Patient presented with gastrointestinal bleeding, rapidly progressive renal failure, multiple endocrinopathies, with possible autonomic neuropathy and cardiac involvement. It also highlights the challenges in diagnosis of cardiac amyloidosis in patients with pre-exiting heart disease and poor renal function. There was difficulty in initially determining the type of amyloidosis, mainly AL (primary) amyloidosis versus AA (secondary) amyloidosis. Management would differ between giving a bortezomib-based regimen versus control of the underlying inflammatory disease. AL amyloidosis was not strongly considered as there was no evidence of plasma cell dyscrasia in the myeloma studies and absence of lymphoplasmacytic infiltrates in the gastric biopsy sample. Hence, there was no strong indication to give systemic bortezomib-based treatment. Moreover, the demonstration of loss of affinity for Congo Red after incubation of gastric tissue sections with potassium permanganate classically supported a secondary type of amyloidosis. The diagnosis of AA amyloidosis was confirmed by mass spectrophotometry of a subsequent gastric tissue sample.Conclusions: Physicians need to be aware of the multi-systemic involvement of amyloidosis, evaluate for relevant organ involvement, and coordinate care between multiple healthcare disciplines. Characterizing the type of amyloidosis is crucial to guide appropriate management and the mainstay of diagnosis is via tissue biopsy. This case demonstrates that abdominal fat pad biopsy can be falsely negative in systemic amyloidosis, and alternative biopsy sites from clinically involved organs should be sought if suspicion remains high. Limitations for evaluation of cardiac amyloidosis needs to be acknowledged in the presence of pre-existing poor heart and renal function.References:

803 CHEST PAIN AFTER CHEST PAIN: A RARE COMPLICATION OF PULMONARY EMBOLISM 1334591 Rachel Han University of Texas Long School of Medicine at San Antonio Gregory Kendall Kanapa Kornsawad CHEST PAIN AFTER CHEST PAIN: A RARE COMPLICATION OF PULMONARY EMBOLISM Accept Case Presentation: A 57-year old man was found down at home one day prior to admission. Three days prior, he experienced intermittent “stabbing” chest pain and dizziness. Past medical history was significant only for multiple sclerosis treated with Copaxone. On admission, he was afebrile, heart rate 113bpm, blood pressure 104/71 mmHg, respiratory rate 19 breaths per minute, and oxygen saturation 96% on room air. Physical exam was unremarkable. Laboratory work up was significant for white blood cell count of 24,020 cells/mcL and troponin of 0.094 ng/ml. EKG showed slight ST elevation in aVR and V1-V2 with ST depression in lateral leads and he was taken for left heart catheterization which revealed nonobstructive coronary artery disease. Working diagnosis then became Type II NSTEMI in the setting of suspected sepsis of unknown source and he was started on broad spectrum antibiotics. Despite initial treatment, he continued to have severe chest pain and tachycardia. Repeat EKG was obtained and now significant for S1QT3T3 concerning for PE (Fig-1A). CTPE revealed a large saddle pulmonary embolus with extension into the segmental and subsegmental branches of the bilateral pulmonary arteries and signs of right ventricle strain (Fig-1B). He was diagnosed with a sub-massive PE with associated Type II NSTEMI. A heparin drip was started, and IR was consulted for catheter directed thrombolysis. Following thrombolysis, he was then transitioned to treatment dose Lovenox. The following day, the patient continued to have severe chest pain with tachycardia. EKG was without acute changes and repeat chest CT showed a pericardial effusion which was further evaluated with a transthoracic echocardiogram (Fig-2). He was diagnosed with pericarditis and started on NSAIDs and Colchicine. Treatment was changed to Prednisone after continued chest pain which relieved his symptoms. He was discharged on Apixaban, Colchicine, and Prednisone taper.Discussion: Post-cardiac injury syndromes such as Dressler syndrome occur following myocardial infarction and cardiac surgery and the mechanism of these injuries is thought to be an autoimmune phenomenon. Although not well reported, there have been cases of patients presenting with pericarditis following pulmonary embolism. The mechanism is likely due to the anatomical vicinity of injury from a pulmonary embolism and hypersensitivity [1]. One single center retrospective study reported that 3.48% of 402 cases of pulmonary embolism developed pericarditis over a 13-year period [2], implying that this complication may be more common than expected. In our case, the patient continued to have uncontrolled chest pain after undergoing thrombolysis and starting on anticoagulation. Once cardiac ischemia had been ruled out, repeat imaging with a new pericardial effusion led us to consider pericarditis. Once treated as such, his symptoms resolved.Conclusions: This case demonstrates that PE-related events and symptoms need to be recognized early as delayed diagnosis may worsen outcomes. After initial diagnosis and treatment, complications such as pericarditis should be considered.References: [1] Nakata, A., Aburadani, I., Kontani, K., & Hirota, S. (2017). Acute Pericarditis Following Acute Pulmonary Thromboembolism. International Heart Journal, 58(6), 1028–1033. doi: 10.1536/ihj.17-035 [2] Jerjes-Sanchez C, Ramirez-Rivera A, Ibarra-Perez C. The Dressler syndrome after pulmonary embolism. Am J Cardiol 1996; 78: 343-5.

821 ACUTE, SYMPTOMATIC HYPONATREMIA FOLLOWING ZOLEDRONIC ACID INFUSION 1335464 Saniya Kishnani UC San Diego School of Medicine Masihullah Barat Meghan Sebasky University of California San Diego Gina Woods ACUTE, SYMPTOMATIC HYPONATREMIA FOLLOWING ZOLEDRONIC ACID INFUSION Accept Case Presentation: A 67-year-old woman with a history of osteoporosis, GERD, diverticulitis, and osteoarthritis presented to the emergency department with altered mental status and a witnessed tonic-clonic seizure one day after receiving zoledronic acid (ZA) for treatment of osteoporosis. The seizure was refractory to medical management and she required intubation for airway protection. Labs were notable for hyponatremia (120 mg/dL), hypocalcemia (7.9 mg/dL), hypokalemia (3.3 mEq/L), and later hypomagnesemia and hypophosphatemia during admission. CT and MRI head, EEG, and lumbar puncture were normal. Chart review revealed the patient had normal labs four days prior to ZA infusion (Na 140 mg/dL, Ca 9.7 mg/dL). The patient’s acute hyponatremia was corrected with hypertonic saline, followed by normal saline. Hypocalcemia was managed with calcitriol and calcium carbonate, and magnesium and phosphorus were aggressively repleted. Other causes of hyponatremia, specifically SIADH, were ruled out with 24-hour urine studies, morning cortisol, and other studies. Previous reports show acquired Fanconi syndrome following ZA use, which would have explained the patient’s hypophosphatemia, but 24-hour urine electrolytes were inconsistent and additional diagnostic criteria were not met. On hospital day 3, the patient developed rhabdomyolysis with peak creatinine kinase (CPK) of 19,875 U/L; this was attributed to electrolyte abnormalities rather than her seizure as the CPK rose suddenly three days later. She was resuscitated with fluids to prevent kidney injury. At discharge (hospital day 7), the patient’s electrolytes were within normal range, and CPK was trending down. She was alert and oriented with no neurologic abnormalities.Discussion: ZA is an aminobisphosphonate that accumulates at sites of high bone turnover where it is internalized by osteoclasts and decreases bone resorption by inhibiting farnesyl pyrophosphate synthase and preventing protein prenylation. ZA is a common treatment for osteoporosis, bone metastases from solid tumors, and hypercalcemia of malignancy; infusions are typically well-tolerated. The most common side effects are pyrexia, myalgias, influenza like symptoms, headache, and arthralgias with a peak onset after 1 day and average duration of 3 days. Other reported adverse events include renal failure, atrial fibrillation, osteonecrosis of the jaw, and hypocalcemia. There is one case report of a patient who experienced diarrhea and hyponatremia after ZA; the hyponatremia in this case was attributed to gastrointestinal fluid losses. According to the World Health Organization’s Causality Scale, ZA was the likely cause of this patient’s electrolyte abnormalities given the temporal relationship of the infusion and patient’s presentation. This was further supported by ruling out other common causes of hyponatremia. However, the direct mechanism by which the ZA infusion caused the hyponatremia remains unclear.Conclusions: We present the case of a patient with acute, symptomatic hyponatremia caused by ZA through an unclear mechanism which has not been previously described in the literature. This case illustrates the importance of taking a thorough history at the time of hospital admission including a careful review of all medications, including recent outpatient infusions. It also highlights the side effect profile of a medication that hospitalists may prescribe, particularly to treat hypercalcemia of malignancy.References: Kuchay MS, Farooqui KJ, Mithal A. Acute severe diarrhoea and hyponatremia after zoledronic acid infusion: an acute phase reaction. Clin Cases Miner Bone Metab. 2017;14(1):101–104. doi:10.11138/ccmbm/2017.14.1.101

831 AN INSPIRING DIAGNOSIS 1335612 Zhenya Krapivinsky UCSF Michael Peluso AN INSPIRING DIAGNOSIS Accept Case Presentation: A 69 year old woman presented to our hospital with 5 days of fever, diarrhea, abdominal pain & debilitating leg pain. Her only known medical problem was hyperlipidemia, for which she had recently increased her statin dose. 6 weeks prior to admission, she visited her hometown in Jiangxi, China. There, she drank tap water, ate home-cooked food, and was exposed to dogs, chickens, mice, and mosquitoes. On presentation, patient was febrile to 38.7°C, tachycardic and normotensive. She had profuse diarrhea. Her abdomen and thighs were tender and she was unable to walk due to the severity of her leg pain. Labs showed anemia (Hb 10.9), thrombocytopenia (Plts 134), and elevated creatinine kinase (412 U/L). Following admission, the rhabdomyolysis (CK 412→ 2805) and thrombocytopenia (platelet 105 → 49) worsened. Abdominal CT revealed severe mesenteric inflammation and enlarged mesenteric lymph nodes. She developed elevated transaminases and progressive renal failure (Cr 0.5→2.4). Peripheral smear showed no hemolysis. Urine studies were consistent with acute tubulointerstitial inflammation. Initial differential was broad and important consideration was given to patient’s travel history. Leptospirosis, which is endemic to China’s Juangxi Province, fit our patient’s clinical picture. Myalgia, mild rhabdomyolysis, thrombocytopenia & renal failure are common in severe disease. Our patient’s GI symptoms, mesenteric inflammation, and long incubation period, however, were highly atypical. Testing for malaria, rickettsia, dengue, salmonella, viral hepatitis, HIV, TB, CMV, and EBV was negative. Despite atypical features, due to suspicion for Leptospirosis, IV Ceftriaxone and oral doxycycline were started on hospital day 3. Over the next 5 days, her fever resolved, and labs improved renal function normalized. She was discharged to complete 7 days of doxycycline for presumed leptospirosis. The diagnosis was later confirmed when a Leptospira IgM returned positive.Discussion: Although rare in the U.S., Leptospirosis is a globally widespread zoonosis. Transmission takes place via the urine or feces of infected animals, and humans become infected by ingesting contaminated food or water. Common features include fever, myalgia, rhabdomyolysis, thrombocytopenia and renal failure in severe disease. The typical incubation period is 1-3 weeks, but incubations up to 1 month have been reported. GI manifestations are rare, but pancreatitis and cholecystitis have been described. We report an atypical case of Leptospirosis presenting with diarrhea, mesenteric inflammation, and renal failure 6 weeks following travel to an endemic region. In this case, antibiotics were initially deferred while infectious diarrhea causing hemolytic uremic syndrome was excluded. We also considered statin-induced myopathy and other cosmopolitan infections endemic to Jiangxi, where the WHO reports sporadic malaria, typhoid, and recent outbreaks of scrub typhus. Ultimately, Leptospirosis was felt to be the unifying diagnosis, despite atypical features, due to relevant exposure, fever with multiorgan involvement, renal failure and thrombocytopenia.Conclusions: Our patient presented with typical findings of severe Leptospirosis but with several uncommon features including a long incubation period and prominent diarrhea. In an increasingly interconnected world, it is imperative that clinicians develop illness scripts for global infectious diseases, especially those that carry a high mortality if untreated.References:

838 YOU BETTER KEEP IT COMPACT! 1335467 kiran kuriakose UPMC Mckeesport Francis Ergina Anjana Chandrasekhara Pillai UPMC YOU BETTER KEEP IT COMPACT! Accept Case Presentation: 24-year-old male with no significant past medical history came to the emergency department (ED) after he was found unconscious at home. He had agonal respirations, which was reversed by Narcan at the scene and the patient was combative in the ED.He was tachycardic with heart rate of 120, saturation maintained at 92% on 15 L of oxygen. Physical examination was unremarkable except for bilateral decreased air entry. His initial blood gas showed a pH of 7.13, PCO2 56, bicarbonate 18, creatinine was 2.5, lactate was 11.6, CPK 13,532, troponin 2.1. Urine drug screen was positive for cocaine and marijuana. Chest x-ray showed patchy pneumonia entire Left lung and right lower lobe which was confirmed by CT chest. Patient was admitted to the ICU, for acute respiratory failure and possible aspiration pneumonia and was treated with vancomycin and Zosyn for 4 days, narrowed down to Augmentin for the next 3 days. Meanwhile patient's lactate, CPK, creatinine was trending down on adequate hydration and chest x-ray 2 days later, showed interval improvement of pneumonia. On the second day, patient was complaining of sensory motor weakness of right lower extremity,clinical examination showed a sciatic nerve distribution pattern . His troponin trended up from 2.1 to 8.9 ng/ml . Serial EKGs demonstrated sinus tachycardia, however no ischemic changes. Patient was initiated on aspirin and Plavix and IV heparin, however when UDS came back positive for cocaine, heparin was discontinued considering the possibility of type 2 NSTEMI. Echo cardiogram was obtained, which showed normal ejection fraction, but the presence of non-compaction cardiomyopathy. Due to the high risk of arrhythmias and sudden cardiac death associated with non-compaction cardiomyopathy patient was discharged on life vest. The plan is to get a cardiac MRI as outpatient to consider ICD placement.Discussion: Left ventricular noncompaction (LVNC) was described by Grant in 1926 describes a ventricular wall anatomy characterized by prominent left ventricular (LV) trabeculae, a thin compacted layer, and deep intertrabecular recesses. Clinical presentation can occur at any age, range from asymptomatic to end-stage heart failure, or be associated with lethal arrhythmias, sudden cardiac death, or thromboembolic events.The American Heart Association’s new guidelines on ICD implantation, permit the primary prophylactic implantation of an ICD in patients with NCCM. Long-term oral anticoagulation is indicated in particular for patients with atrial fibrillation, impaired left ventricular function, or demonstrated intracardiac thrombi.Conclusions: Our patient here was fortunate enough to get an echocardiogram and the condition was diagnosed early enough, as the risk of sudden cardiac death is high with noncompaction cardiomyopathy. Patient's neuromuscular weakness gradually improved with physical therapy. Because the disease can run in families, the affected patients’ relatives should undergo screening and it is advisable for patients to be examined by a neurologist in order to rule out any accompanying neuromuscular disturbances.References: Left Ventricular Noncompaction, A Distinct Genetic Cardiomyopathy? Eloisa Arbustini, Valentina Favalli, Nupoor Narula, Alessandra Serio and Maurizia Grasso Left ventricular non-compaction cardiomyopathy Dr Jeffrey A, Towbin MD , Angela Lorts MD , John Lynn Jefferies MD

840 DERMATOMYOSITIS: A DIFFICULT DIAGNOSIS TO SWALLOW 1335492 Kevin Kwak UC San Diego DERMATOMYOSITIS: A DIFFICULT DIAGNOSIS TO SWALLOW Accept Case Presentation: The patient is a 77-year-old woman who presented with a two-day history of progressively worsening oropharyngeal dysphagia, dysphonia and left upper extremity weakness. She was discharged from the hospital three days prior for a three-month history of a pruritic rash. During the previous hospitalization, she was noted to have facial erythema, Shawl and V signs, and Gottron’s papules. She was evaluated by dermatology and underwent a skin biopsy with a preliminary pathology consistent with dermatomyositis. She had also mentioned that she was experiencing some dysphagia, which she attributed to oral mucosal ulcerations, and generalized myalgias and fatigue, which she attributed to a recent prolonged hospitalization. Despite these subjective findings as well as elevated creatine phosphokinase and C-reactive protein levels, she was discharged only on topical steroids with a presumed diagnosis of amyopathic dermatitis. After discharge the patient experienced worsening of her rash, and had profound worsening of her dysphagia, being unable to swallow both liquids and solids, prompting her to return to the hospital. During her second hospitalization, she was noted to have 3/5 left upper extremity strength, as well as pharyngeal collapse and glottic gap on laryngoscopy. She was evaluated by dermatology and rheumatology, both of whom had agreed upon a formal diagnosis of dermatomyositis. She was initiated on systemic steroids with significant improvement in her symptoms.Discussion: Dysphagia and rashes are common symptoms that are encountered by hospitalists. Dermatomyositis is a type of idiopathic inflammatory myopathy and can present with a wide range of symptoms, most notably proximal muscle weakness, cutaneous findings, interstitial lung disease, dysphagia, and polyarthritis. A diagnosis is usually made using the EULAR/ACR classification criteria in conjunction with physical examination findings. Treatment for dermatomyositis involves high dose systemic glucocorticoid therapy followed by a slow taper, and likely an addition of a glucocorticoid sparing agent. There is a subset of individuals that are diagnosed with amyopathic dermatomyositis when only cutaneous manifestations are present. These patients can, at times, be treated with topical steroids, photoprotection and anti-pruritic agents, but most also need and benefit from systemic steroids.Conclusions: This patient’s elevated muscle enzymes and inflammatory marker, in addition to presence of dysphagia and generalized myalgia should likely have prompted evaluation by rheumatology to help distinguish dermatomyositis versus amyopathic dermatomyositis. Although it is impossible to predict, given the patient’s significant response to systemic steroids, treating the patient with steroids during and after her first hospitalization may have prevented her readmission.References:

843 BONE MARROW SARCOIDOSIS PRESENTING AS SEVERE THROMBOCYTOPENIA? - A CHALLENGING DIAGNOSIS 1335574 Lokesh Lahoti Robert Wood Johnson University Hospital Neeraj Hotchandani Payal Parikh Rutgers, Robert Wood Johnson Medical School Jessica Kunadia Rutgers Robert Wood Johnson University Hospital BONE MARROW SARCOIDOSIS PRESENTING AS SEVERE THROMBOCYTOPENIA? - A CHALLENGING DIAGNOSIS Accept Case Presentation: A 32-year old female with complicated past medical history of intravenous drug use, mitral valve endocarditis status/post repair, and recent diagnosis of Immune thrombocytopenia (ITP) was transferred from another hospital for management of severe thrombocytopenia refractory to Intravenous Immunoglobulin (IVIG) and steroids. She had initially presented with intermittent high-grade fevers and fatigue without associated arthralgia or dyspnea. She was found to have labs significant for pancytopenia with white blood cell count of 3000/microliter, hemoglobin of 8 gram/deciliter and platelets of 4000/microliter (prior admission labs 3 months with similar labs except for platelets of 174 thousand), reticulocyte proliferative index 1.30, unremarkable hemolysis labs. Of note, prior to the current admission, she recently had a bone marrow (BM) biopsy to work up her thrombocytopenic episodes, which was significant for non-caseating granulomatous inflammation. Her vital signs on arrival were stable. Her physical exam was notable for lungs with bibasilar crackles, generalized abdominal tenderness more prominent on left side and petechiae on all extremities. Imaging of her chest, abdomen and pelvis was unremarkable except for noted hepatosplenomegaly. Peripheral smear was negative for schistocytes. As per Hematology recommendations, patient was started on solumedrol 60 mg twice daily and given a second dose of IVIG. Patient’s platelets increased to 18,000 but did not sustain. Extensive infectious evaluation was negative, including parasite work-up and blood cultures. Trans-thoracic echocardiogram was negative for vegetations. Due to suspicion for connective tissue disorder (CTD) based on prior BM biopsy, rheumatology was consulted. Extensive rheumatologic workup was notable for elevated RF (320) and angiotensin converting enzyme (ACE) 94 along with low C3 (51) and C4 (7) complements and vitamin D25 (14). All other workup including immunofixation, other CTD antibodies and ANCA panel were negative. There was a high concern for BM sarcoidosis after review of the BM biopsy in the setting of low vitamin D25, elevated ACE level and negative workup for other diseases. With no significant increase in platelets with IVIG and steroids, patient was started on Rituximab resulting in favorable response. After a multi-interdisciplinary discussion, it was noted that the patient likely has secondary ITP from underlying bone marrow sarcoidosis.Discussion: Severe thrombocytopenia is a rare presentation of sarcoidosis. Three possible mechanisms are generally stated to cause thrombocytopenia in sarcoidosis – 1) sequestration in spleen 2) bone marrow involvement 3) autoantibody production [2,3]. All three mechanisms are likely contributing to the patient’s severe thrombocytopenia, which is why secondary ITP was considered in this patient. ITP secondary to sarcoidosis is treated similar to primary ITP [1].Conclusions: Sarcoidosis is a disease known to commonly affect the pulmonary and musculoskeletal system. Bone marrow involvement with severe thrombocytopenia is an uncommon presentation of sarcoidosis, making it difficult to recognize in the inpatient setting. In a patient with refractory thrombocytopenia, rheumatologic diseases such as sarcoidosis should always be considered as a possible underlying etiology. This case highlights both the difficulty and importance in identifying bone marrow involvement of sarcoidosis in order to provide appropriate management.References: 1) Arnold, Donald; Cuker, Adam. "Immune Thrombocytopenia." UpToDate, 2019. 2) King, Talmadge; Flaherty, Keving. "Extrapulmonary Manifestations of Sarcodosis". UpToDate, 2018. 3) Kayar, Yusuf. “Sarcoidosis Presenting with Severe Thrombocytopenia.” International Journal of Respiratory and Pulmonary Medicine, vol. 3, no. 3, 2016, doi:10.23937/2378-3516/1410056. 4) Mahévas M, Le Page L, Salle V, Lescure FX, Smail A, et al. (2006) Thrombocytopenia in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 23: 229-235.

871 NO BRIDGES OVER THIS TROUBLED WATER: A CASE OF SNAKEBITES AND CREEK BITES 1334873 Lorenzo Di Francesco Emory University Minh Hang Atlanta VA Samuel Maidman NYU Grossman School of Medicine NO BRIDGES OVER THIS TROUBLED WATER: A CASE OF SNAKEBITES AND CREEK BITES Accept Case Presentation: Mr. A is a 53-year-old male who presented with a painful thigh. The patient was released from prison one week prior and had been living under a bridge next to a creek ever since. On the day of admission, Mr. A decided to bathed himself in the creek. As he was wading through water up to his knees, he felt a sharp pain on his left thigh and immediately suspected he was bitten by a snake. Upon exiting, he slipped on wet rocks, resulting in numerous extremity abrasions. Shortly thereafter, his left medial thigh became red, swollen and extremely painful, prompting him to call 911. Upon presentation, Mr. A was hypotensive, tachycardic, but afebrile. His left thigh was erythematous and swollen, and he had a notable left dorsal foot erythematous pustule. Admission laboratories revealed acute thrombocytopenia, an elevated INR, transaminitis with an elevated alkaline phosphatase, and mild rhabdomyolysis. The emergency department suspected snake envenomation, and the patient was initiated on CroFab, in addition to broad-spectrum antibiotics. Upon transfer to the medicine service, admission blood cultures grew Plesiomonas shigelloides, and a skin scraping from the left foot pustule obtained the following day grew Aeromonas hydrophila. Work-up of Mr. A’s liver injury and coagulopathy revealed elevated Factor VIII levels and hepatitis B-related cirrhosis with portal hypertension. His hospitalization was complicated by progressive skin and soft tissue infections of the left foot and right finger that required surgical debridement and grew methicillin-susceptible S. Aureus. Mr. A slowly improved on antibiotic therapy and was discharged after 16 days.Discussion: Chronic liver disease (CLD) complicated by a skin and soft tissue infection (SSTI) is commonly encountered by hospitalists. Differentiating this condition from snakebite envenomation is challenging yet important as treatments for each are vastly different. Following a typical Crotalinae (pit viper) snakebite, fang marks should be evident and accompanied by adjacent pain, swelling, and ecchymosis. Envenomation can also result in shock, acute disseminated intravascular coagulopathy, and rhabdomyolysis. In this case, nearly all of these findings were present. However, the patient never visualized the snake, and there were no clear bite marks on his thigh. Furthermore, clinical evidence of hepatitis B-related cirrhosis and an elevated Factor VIII level suggested a most likely diagnosis of CLD with an associated coagulopathy complicated by a severe SSTI from freshwater aquatic bacteria. CLD patients are at an increased risk for developing rapidly progressive SSTIs, especially following inoculation from traumatic aquatic injury. While snakebite envenomation can certainly occur and suspicion necessitates a thorough evaluation, CLD patients should always be covered with broad-spectrum antibiotics when presenting with skin and soft tissue complaints following freshwater environment exposure.Conclusions: Aquatic environments can be hazardous. Snakebite envenomation can result in a presentation similar to CLD, and a thorough work-up is necessary to ensure accurate diagnosis and treatment. Atypical bacteria also thrive in these habitats, and hospitalists should utilize broad-spectrum antibiotics accordingly, especially in CLD patients who are at high risk for life-threatening SSTIs.References:

880 WHEN A LEAK DOWNSTAIRS CAUSES A FLOOD UPSTAIRS, A CASE OF PANCREATICOPLEURAL FISTULA LEADING TO NECROTIZING PNEUMONIA 1335116 Olivia Karcis University of Massachusetts Medical School Brooke McNeilly Irma Hashmi Majid Yazdani WHEN A LEAK DOWNSTAIRS CAUSES A FLOOD UPSTAIRS, A CASE OF PANCREATICOPLEURAL FISTULA LEADING TO NECROTIZING PNEUMONIA Accept Case Presentation: Pancreaticopleural fistula is a rare and serious complication of acute and chronic pancreatitis. This phenomenon develops due to a leak from an incompletely formed or disrupted pseudocyst, though it can also result from direct pancreatic duct leak. Although few case reports identify pancreaticopleural fistula causing recurrent pleural effusion and empyema, we describe the unique case of pancreaticopleural fistula causing necrotizing pneumonia, a finding never before reported in the literature.Discussion: A 47-year old man presented for subacute, intermittent, severe left-sided pleuritic chest pain. Past medical history was significant for chronic alcoholic pancreatitis, complicated by pancreatic pseudocyst formation and chronic splenic vein thrombosis. Notably, three months prior to presentation, the patient had undergone cystgastrostomy for complicated pancreatic pseudocyst. On presentation, laboratory values were significant for leukocytosis 16.7 cells/L, lipase 16 U/L, and normal liver function tests. Initial computed tomography (CT) chest showed necrotizing consolidation in the left lower lung lobe. Additionally, a left-sided subphrenic collection extended from the pancreatic tail to the splenic hilum. The patient was initiated on intravenous antibiotics for necrotizing pneumonia. Diagnostic thoracentesis revealed growth of Streptococcus constellatus, a gut bacterium, amylase 17,347 U/L, protein 5.2 g/dL, and LDH >12,000 U/L. Interval imaging with CT abdomen and pelvis demonstrated a thick-walled fluid collection from the pancreatic tail tracking directly to the pleural space, confirming a pancreaticopleural fistula. The patient underwent endoscopic retrograde cholangiopancreatography, which revealed a large distal pancreatic duct leak, repaired with plastic stent. The patient was discharged home with octreotide and recommendation to follow up with gastroenterology and transplant surgery for continued monitoring of the pancreatic duct leak.Conclusions: Extremely rare and deceiving in their presentation, pancreaticopleural fistulas often present with large-volume effusion that can progress to empyema. To the best of our ability, our case is the first reported case of pancreaticopleural fistula leading to necrotizing pneumonia. Magnetic resonance cholangiopancreatography is the best modality to diagnose a fistulous tract and guide therapeutic management. Additionally, pleural fluid amylase should be obtained to support the diagnosis of pancreaticopleural fistula. Treatment is with stent placement for pancreatic duct leak. Few case reports also cite the use of octreotide in management of the fistula, with surgical intervention reserved for those refractory to conservative management. In our case, the presence of a gut bacterium in the pleural space, along with the patient’s history, triggered further investigation of necrotizing pneumonia. To prevent such complications, a high index of suspicion is required in patients with complicated pancreatitis, in particular those presenting with pulmonary complaints and a recent history of pancreatic pseudocyst formation requiring cystgastrostomy.References:

883 PERSISTENT HYPOXIA IN SICKLE CELL VASO-OCCLUSIVE CRISIS SECONDARY TO INTRA-PULMONARY SHUNTING 1335599 Shourik Dutta University of Virginia Rahul Mehta University of Virginia Jess Greenwald Matthew Hagerman Samuel Konkol Emily Richardson Rohan Mehta Evan Harmon Nidhi Mehta Braulio Cuesta PERSISTENT HYPOXIA IN SICKLE CELL VASO-OCCLUSIVE CRISIS SECONDARY TO INTRA-PULMONARY SHUNTING Accept Case Presentation: A 29 year-old woman with sickle cell disease (SCD) on hydroxyurea and L-glutamine, and mild intermittent asthma presented to our institution with right lower extremity and back pain suggestive of a vaso-occlusive crisis. She did not report fever, cough or dyspnea. Vital signs revealed a heart rate of 91/min, blood pressure of 126/86 mmHg, temperature of 36.9 ° C, oxygen saturation (SO2) of 91% on ambient air and a respiratory rate of 15/min. She appeared in mild distress due to pain with anicteric sclerae and dry mucous membranes. There was no JVD; cardiac examination was remarkable for normal S1 and S2 with no murmur. Chest was clear to auscultation bilaterally and right lower extremity was tender to palpation. Laboratory data included hemoglobin of 8.8 gm/dL, WBC count of 8,900 cells/mm3, total bilirubin of 2.1 mg/dL and normal liver enzymes. She received 3 L saline; ketorolac and hydromorphone infusion was initiated. By hospital day (HD) two, her lower extremity pain had resolved. She developed a sharp, midsternal, non-pleuritic chest pain on HD 3, with no associated cough, dyspnea or fever. There was no tachypnea, and SO2 was 87% on room air. Her cardiopulmonary examination was unchanged. Chest radiograph revealed no infiltrate and an electrocardiogram was unremarkable. She had developed a similar episode of chest discomfort associated with hypoxia approximately a month prior, which was evaluated with CT pulmonary angiogram with no pulmonary embolism or consolidation. As her current presentation was inconsistent with acute chest syndrome (ACS) or pulmonary embolism, and due to an elevated BNP (997 pg/ml), contrasted transthoracic echocardiogram (TTE) was obtained. TTE revealed normal LV systolic and diastolic function, normal RV function, trivial tricuspid regurgitation and detection of contrast in the left atrium 5 cardiac cycles after contrast appearance in the right atrium, characteristic of intra-pulmonary shunting. FEV1/FVC was 81% and FEF 25-75% notably 66% on PFT. Budesonide-formoterol by inhaler was initiated with modest improvement in hypoxia.Discussion: SCD affects approximately 100, 000 Americans and encompasses several clinical syndromes, including vaso-occlusive pain events and stroke. Many patients with SCD develop hypoxia, attributable usually to ACS or pulmonary embolism or pulmonary hypertension. A significant number of patients with hypoxia of unclear etiology are diagnosed with intra-pulmonary right-to-left shunting by bubble-echocardiogram. 1,2 The magnitude of this shunting may exacerbate during vaso-occlusive crisis, 3 and may represent an important mechanism of progressive hypoxia.Conclusions: In SCD patients presenting with hypoxia, intra-pulmonary shunting should be considered in the differential, especially when the etiology of hypoxia remains unclear.References: 1. Hambley BC, Rahman RA, O'Riordan MA, et al. Right‐to‐left shunts are unexpectedly common in adults in adults with Hb SS. Blood. 2016; 128: 3659. 2. Desai PC, Kendel N, Huang Y, et al. Hypoxia in sickle cell disease due to right to left shunting. Am Jo Hematol. 2019 Feb; 94(2): E53-E55. 3. Mekontso Dessap A, Leon R, Habibi A, et al. Pulmonary hypertension and Cor Pulmonale during severe acute chest syndrome in sickle cell disease. Am J Resp Crit Care Med. 2008; 177( 6): 646‐ 653.

894 I CAN'T HEAR YOU, YOU SAID I HAVE WHAT? 1334616 Zackquill Morgan Dallas Methodist Health System Leslie Cler Methodist Dallas Medical Center Leigh Hunter I CAN'T HEAR YOU, YOU SAID I HAVE WHAT? Accept Case Presentation: A 46 year old African American woman presented with one week of worsening hearing loss along with 3 days of vision changes, confusion, visual hallucinations, and difficulty ambulating. She had history of invasive ductal cell carcinoma status-post mastectomy and chemotherapy. Additional history included hemorrhoids for which she underwent hemorrhoidectomy due to excessive bleeding while on chemotherapy. Vital signs were within normal limits other than tachycardia with heart rate to 110 beats per minute. The initial physical examination was notable for a reasonably well-nourished appearing woman although her BMI had dropped from 27 to 22 within the previous 18 months. She spoke very loudly and complained of difficulty hearing questions or reading written questions. Responses were inappropriate at times, which could have been attributable to misunderstanding questions asked. She was alert, intermittently oriented, and also complained of visual hallucinations. Neurologic examination was notable for end-gaze horizontal nystagmus, dysmetria as measured with finger-to-nose exam, decreased visual acuity and decreased hearing bilaterally. Laboratory evaluation was significant for WBC count 14.4 x 10^3uL, AST 106 U/L, and ALT 15 U/L. The patient was initiated on broad spectrum antibiotics for suspicion of meningitis. CT of brain and MRI of brain were normal. Lumbar puncture was performed and showed grossly normal CSF studies with negative cultures and PCR studies. Wernicke encephalopathy was suspected, and intravenous thiamine supplementation was initiated with subsequent improvement of auditory and visual disturbances, confusion and ataxia. Serum thiamine level returned undetectable and she later admitted to significantly more alcohol intake than the “occasional use” reported at admission.Discussion: Wernicke encephalopathy is a condition of thiamine deficiency commonly affecting those with alcohol use disorder or gastric bypass history. Though traditionally associated with encephalopathy, ophthalmoplegia, and ataxia, it can rarely be associated with auditory deficits as well. Wernicke encephalopathy should be suspected in any patient presenting with altered mentation and alcohol intake history, but also in those with auditory deficits. Recovery of deficits is possible with prompt diagnosis and treatment, and mortality from untreated disease is high.Conclusions: Wernicke encephalopathy classically presents with the triad of encephalopathy, oculomotor dysfunction, and ataxia, but only one-third of patients have the full triad. Other less common findings include vestibular dysfunction, peripheral neuropathy, hypothermia, protein calorie malnutrition, and rarely hearing loss. It is imperative that hospitalists consider this entity in the differential diagnosis even when classic findings are not present in order to provide prompt treatment, prevent morbidity, although residual deficits are common.References:

895 A CASE OF AUTOIMMUNE ENCEPHALITIS PRESENTING AS REFRACTORY EPILEPSY 1334493 Christy Morrissey NYU Langone Health Amit Jhaveri Michael Janjigian Bellevue Hospital A CASE OF AUTOIMMUNE ENCEPHALITIS PRESENTING AS REFRACTORY EPILEPSY Accept Case Presentation: A 60 year-old female with no significant past medical history was brought in as a level 2 trauma after being involved in a motor vehicle accident. The non-contrast head CT demonstrated bilateral frontal brain lesions, prompting a brain MRI which revealed a non-enhancing T2/FLAIR hyperintense lesion in the anterior frontal lobes and crossing the genu of the corpus callosum. The patient was noted to have persistent episodes of right upper and lower extremity shaking with right gaze deviation with an awake though impaired sensorium. She was transferred to the medicine service and placed on video EEG which showed focal seizures originating in the right and left temporal lobes. The patient was noted to have focal seizures every 3-20 minutes while on 5 anti-epileptic drugs (AED). Further history from the patient’s husband indicated that the patient had developed irritability with poor impulse control and hyperphagia with associated weight gain. Workup included a lumbar puncture (LP) and brain biopsy, both unremarkable. The patient continued to have refractory seizures during this period with worsening mental status despite continual AED. Given concern for an inflammatory etiology the patient was started on dexamethasone and IVIG and a repeat LP was obtained which was positive for oligoclonal bands and anti-GAD65 antibodies. This made for a presumed diagnosis of autoimmune encephalitis. The patient was seizure free after 5 days of treatment with IVIG, dexamethasone and up-titration of AED.Discussion: The International League Against Epilepsy published in 2017 a revised classification of seizure types. Seizures are first divided into onset: generalized, focal or unknown; subcategories for motor or non-motor and then for focal onset, retained or impaired awareness 1. With the new nomenclature, our patient was experiencing focal impaired awareness seizures with motor onset, previously known as complex partial seizures. Since the patient was having multiple unprovoked seizures while on 5 AED, she was also experiencing refractory epilepsy (RE). RE is defined as disabling seizures that continue despite appropriate trials of two AED, either alone or in combination 2. Most seizures in autoimmune encephalitis are AED resistant 3. Immunotherapy (steroids, IVIG, plasma exchange) and tumor treatment are causal treatments in autoimmune encephalitis, while AED are only for symptomatic treatment 3. Autoimmune encephalitis is being increasingly recognized as an etiology for acute onset and chronic epilepsy, accounting for more than 20% of adult epilepsy of unknown etiology 4,5. Autoimmune encephalitis should be considered early as a cause of refractory epilepsy to avoid an unnecessary brain biopsy.Conclusions: It is imperative that autoimmune encephalitis be considered when a patient presents with RE. Early identification of autoimmune encephalitis can prevent the patient from undergoing unnecessary procedures. If the diagnosis of autoimmune encephalitis is made and a primary malignancy is not identified, the patient should be started immediately on immunotherapy. The hospitalist should be aware of the revised seizure nomenclature.References: 1. Fisher, R. S., Cross, J. H., French, J. A., Higurashi, N. , Hirsch, E. , Jansen, F. E., Lagae, L. , Moshé, S. L., Peltola, J. , Roulet Perez, E. , Scheffer, I. E. and Zuberi, S. M. (2017), Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia, 58: 522-530. doi:10.1111/epi.13670 2. Engel J., Jr (2014). Approaches to refractory epilepsy. Annals of Indian Academy of Neurology, 17(Suppl 1), S12–S17. doi:10.4103/0972-2327.128644 3. de Bruijn, M., van Sonderen, A., van Coevorden-Hameete, M. H., Bastiaansen, A., Schreurs, M., Rouhl, R., … Titulaer, M. J. (2019). Evaluation of seizure treatment in anti-LGI1, anti-NMDAR, and anti-GABABR encephalitis. Neurology, 92(19), e2185–e2196. doi:10.1212/WNL.0000000000007475 4. Spatola M, Dalmau J. Seizures and risk of epilepsy in autoimmune and other inflammatory encephalitis. Curr Opin Neurol 2017;30:345–53. 5. Dubey D, Alqallaf A, Hays R, Freeman M, Chen K, Ding K, et al. Neurological autoantibody prevalence in epilepsy of unknown etiology. JAMA Neurol 2017;74:397–402.

899 SUBNORMAL THYROID MAKES THE HEART SKIP A BEAT 1334942 Lauren Bayliss University of Texas Rio Grande Valley Supraja Thunuguntla Rizwan Mohammed Juan Cortinas Galvan David Diaz Voss Varela Jose Campo Maldonado University of Texas Rio Grande Valley School of Medicine SUBNORMAL THYROID MAKES THE HEART SKIP A BEAT Accept Case Presentation: A 72-year-old Hispanic male with an unconfirmed history of alcohol-related cirrhosis presented to the hospital for rectal bleeding and dark stool for two days. Vitals included a heart rate of 90-120 bpm, blood pressure 90-140 over 50-60 mm Hg. A left thyroid nodule was appreciated on physical exam. His pertinent labs included TSH, free T3 and T4 levels that were 0.033mU/L (low), 3.33mU/L and 1.33mU/L (both within normal limits) respectively. A TSH done 3 days later was low (0.024). Thyroid peroxidase antibody and TSH receptor antibody were negative. EKG on admission revealed new-onset atrial fibrillation (AF) with a ventricular response of 99. Neck ultrasound confirmed the physical exam finding of a calcified nodule on left inferior lobe of thyroid corresponding to a cold nodule on radioactive uptake scan. Ultrasound of the abdomen documented coarsened liver echotexture/chronic liver disease with no free fluid. Echocardiogram revealed mild left atrial dilation with normal EF and diastolic dysfunction. Rate control was achieved with a diltiazem bolus during episodes of RVR. Metoprolol was used to treat AF and the adrenergic effects of subclinical hyperthyroidism. Low dose methimazole therapy was considered, though with caution due to his high risk of liver dysfunction. However, the patient ultimately refused. Anticoagulation was delayed due to his increased risk of bleeding (HASBLED - 4). The patient was later discharged with apixaban after an unremarkable EGD and colonoscopy and was advised to follow up for a possible biopsy of a hypoactive thyroid nodule and follow up to evaluate alternative options to treat subclinical hyperthyroidism.Discussion: Subclinical hyperthyroidism is defined by normal T3 and T4 with subnormal TSH (< 0.5 mU/L). While overt hyperthyroidism is often misconstrued as the presence of clinical symptoms, its definition is biochemical- hyperthyroidism (HT) with elevated T3, T4 (or both) and a subnormal TSH concentration. The risk of atrial fibrillation is documented to be higher in patients with TSH levels below 0.1 mU/L. Although the effect of T3 on chronotropy and inotropy is well-known, the cause of atrial fibrillation in an individual with normal free T3 remains unclear. Causes of subclinical hyperthyroidism such as herbal supplements with iodine, biotin, Grave’s or Hashimoto’s Disease, and autonomous adenoma were considered but excluded during our evaluation; male sex and increasing age (>61 years) were two risk factors for AF present on this patient. Restoration of thyroid function, in this case, may eventually reverse his abnormal cardiovascular hemodynamics and improve his overall outcome. The benefits can be even larger if anticoagulation can be discontinued in patients with a higher risk of bleeding such as this patient.Conclusions: Subclinical hyperthyroidism is associated with a higher prevalence of atrial fibrillation as exemplified by the case above. It highlights the importance of thorough work-up for causes of atrial fibrillation. It serves as a reminder to consider reversible causes of atrial fibrillation, which could change the risk-benefit assessment for anticoagulation when the underlying cause of AF can be corrected.References: 1. Baumgartner, Christine et al. “Thyroid Function Within the Normal Range, Subclinical Hypothyroidism, and the Risk of Atrial Fibrillation.” Circulation vol. 136,22 (2017): 2100-2116. doi:10.1161/CIRCULATIONAHA.117.028753 2. Auer, Johann, et al. “Subclinical Hyperthyroidism as a Risk Factor for Atrial Fibrillation.” American Heart Journal, vol. 142, no. 5, 2001, pp. 838–842., doi:10.1067/mhj.2001.119370. 3. Krahn, A. D. “How Useful Is Thyroid Function Testing in Patients with Recent-Onset Atrial Fibrillation? The Canadian Registry of Atrial Fibrillation Investigators.” Archives of Internal Medicine, vol. 156, no. 19, 1996, pp. 2221–2224., doi:10.1001/archinte.156.19.2221. 4. Sawin, Clark T., et al. “Low Serum Thyrotropin Concentrations as a Risk Factor for Atrial Fibrillation in Older Persons.” New England Journal of Medicine, vol. 331, no. 19, Oct. 1994, pp. 1249–1252., doi:10.1056/nejm199411103311901.

913 NOT YOUR USUAL BELL'S PALSY 1334986 Preetha Nair UT Southwestern NOT YOUR USUAL BELL'S PALSY Accept Case Presentation: A thirty-one-year-old man presented to the ED complaining of right-sided facial droop of one-day duration. He also complained of left-sided facial numbness and tingling, right lower extremity shooting pain for one week, night sweats, 50-60 pound weight loss, fatigue for a few months. He denied vision changes, headache, focal weakness elsewhere on his body. He had left-sided facial droop a month ago which fully recovered on prednisone and acyclovir. He was diagnosed with pulmonary embolism two months prior to the presentation but was not on anticoagulation. Vital signs were stable on admission. Physical exam revealed right-sided facial droop, the neurological exam was otherwise unremarkable. CT brain and CT Angiogram brain were normal, CT Angiogram chest revealed multiple chronic or partially treated linear filling defects in pulmonary artery branches supplying right lower lobe with bulky lymphadenopathy and splenomegaly. MRI brain was unremarkable, and MRI lumbar spine revealed degenerative changes at L4-L5 and L5-S1 with disc extrusions and nerve impingement. Labs revealed elevated calcium of 11.3, ACE level normal at 60, SPEP without M component, 25-hydroxy vitamin D reduced to 9.7, CRP elevated to 0.9, ESR elevated to 36, 1,25 dihydroxy vitamin D normal at 41, T-Spot TB test was negative, ANA was negative. His recurrent Bell’s palsy, hypercalcemia, bulky lymphadenopathy was concerning for sarcoidosis. The patient subsequently underwent cervical lymph node biopsy which revealed noncaseating granulomatous inflammation suggestive of sarcoidosis, negative for malignant cells, AFB and GMS stains were negative. He was discharged on rivaroxaban for his pulmonary embolism and a slow prednisone taper.Discussion: Neurologic complications occur in approximately 5-10% of patients with sarcoidosis. Facial nerve palsy can develop in 25-50% of patients with neurosarcoidosis. The onset of neurosarcoidosis is most often in the fourth or fifth decade of life and neuropathy is rarely the presenting feature of sarcoidosis. Our case was unique since the patient was relatively young and had no other classic symptoms of sarcoidosis. His workup ruled out life-threatening diseases like stroke or malignancy. Infectious etiologies were felt to be less likely with no fever, skin lesions, normal white blood cell count. Although noncaseating granuloma is a non-specific finding which could be seen as a reaction to drugs, infection, tumor antigens, foreign bodies, these etiologies were ruled out in our patient. The constellation of facial nerve palsy, weight loss, bulky lymphadenopathy, elevated inflammatory markers, hypercalcemia, splenomegaly prompted a suspicion for sarcoidosis and a lymph node biopsy confirmed the diagnosis. The association between venous thromboembolism and sarcoidosis has also been reported recently. Swigris et al found PE in 2.5% of US decedents with sarcoidosis, regardless of gender, race or age. The mechanisms responsible for thromboembolism are not clear and may be influenced by several factors including inflammation, compression of pulmonary arteries by enlarged mediastinal lymph nodes or other comorbid conditions predisposing to thromboembolism.Conclusions: Sarcoidosis should be considered in patients presenting with recurrent Bell’s palsy. Sarcoidosis is often a clinical diagnosis and proper workup should be done to exclude other possibilities. There is also an increased risk of thromboembolism in patients with sarcoidosis.References: 1. Stern B.J, Krumholz A., Johns C., Scott P., Nissim J. Sarcoidosis and its neurological manifestations Arch Neurol 1985 ; 42 : 909-917 2. Joseph F.G., Scolding N.J. Neurosarcoidosis: a study of 30 new cases J Neurol Neurosur Psychiatry 2009 ; 80 : 297-304 3. Pawate S, Moses H, Sriram S. Presentations and outcomes of neurosarcoidosis: a study of 54 cases. QJM. 2009;102(7):449–60. 4. Swigris, JJ, Olson, AL, Huie, TJ et al. Increased risk of pulmonary embolism among US decedents with sarcoidosis from 1988 to 2007. Chest. 2011; 140: 1261–1266

921 SEVERE ANEMIA WITH HIGH OUTPUT HEART FAILURE: AN UNUSUAL INITIAL PRESENTATION OF CROHN'S DISEASE 1334839 Rabin Neupane Medstar Washington Hospital Center Shiva Shankar Vangimalla Nidhi Malhotra SEVERE ANEMIA WITH HIGH OUTPUT HEART FAILURE: AN UNUSUAL INITIAL PRESENTATION OF CROHN'S DISEASE Accept Case Presentation: Inflammatory bowel disease (IBD) is a chronic disease affecting the gastrointestinal (GI) tract consisting of Crohn’s disease (CD) and ulcerative colitis (UC). Patients typically have GI symptoms such as abdominal pain, rectal bleeding, and weight loss. However, the extra-intestinal presentation of IBD is not an uncommon occurrence. Here, we describe a case of a young male patient who presented with severe symptomatic anemia with heart failure, later diagnosed to have CD. Our patient was a 47-year-old Hispanic male with no prior medical history who presented with fatigue, shortness of breath, and lower extremity swelling for 3 weeks. His vitals were stable on admission. Physical examination revealed volume overload and warm extremities. Initial labs were pertinent for severe anemia with hemoglobin 2.3 gm/dl, mean corpuscular volume 63.9 fL and mildly elevated INR 1.3. Iron panel revealed iron deficiency anemia with iron level 16mcg/dl, iron saturation 4%, and ferritin 5.1ng/ml. Further evaluation of the anemia was unrevealing for any overt bleeding, hemolysis, hematuria, or internal bleeding. Echocardiogram revealed low ejection fraction (EF) of 25% with global hypokinesis of the left ventricle. With a presumptive diagnosis of acute systolic heart failure likely from severe anemia, he was promptly treated with transfusion of blood products and diuretics. Further workup with cardiac magnetic resonance imaging (MRI) and cardiac computed tomography angiogram (CTA) was unrevealing. Esophagogastroduodenoscopy (EGD) revealed mild antral gastropathy. However, a colonoscopy revealed diffuse erythema and erosions with pseudo-polyps from the cecum to the descending colon with normal mucosa in the rectum and sigmoid colon. Magnetic resonance enterography (MRE) did not show any fistulas or strictures. Colonic biopsies demonstrated chronic active colitis concerning for CD. His CRP and fecal calprotectin was elevated at 17.7 mg/ml and 1250 respectively. He was started on Prednisone (1mg/kg/day) with plans for initiation of appropriate therapy. Repeat ECHO after correction of anemia showed an improved EF of 35%. His clinical condition improved and he was discharged with a plan for outpatient follow up.Discussion: It has been noted that about 25% of the IBD symptoms are extra-intestinal involving major organs such as liver, kidney, heart, eyes, muscles, and blood. Among them, more than one-third of the patients present with anemia with a hemoglobin of less than 12g/dl. Anemia in IBD is secondary to a combination of iron-deficiency, chronic inflammation, vitamin deficiencies, metabolic disturbances, and drug therapies. Cardiovascular manifestations usually include myocarditis, pericarditis, VTE and rarely, heart failure. Heart failure is proposed secondary to cardiac re-modelling and myocardial fibrosis secondary to underlying inflammatory state. However, our patient had severe anemia causing high output HF as the first and only presentation of his CD. He did not have any active GI symptoms. In the light of his improved cardiac function with correction of anemia and complete negative workup for other cardiac etiologies, his acute systolic heart failure was attributed to his severe anemia.Conclusions: It is important to focus on the extra-intestinal manifestation of CD as this could be the only presenting symptom in some patients.References: 1. Kilcoyne A, Kaplan JL, Gee MS. Inflammatory bowel disease imaging: Current practice and future directions. World J Gastroenterol. 2016;22(3):917–932. doi:10.3748/wjg.v22.i3.917 2. Calvo P, Pablo L. Managing IBD outside the gut: ocular manifestations. Dig Dis. 2013;31(2):229-32. doi: 10.1159/000353375. Epub 2013 Sep 6. Review. PubMed PMID: 24030231. 3. Kaitha S, Bashir M, Ali T. Iron deficiency anemia in inflammatory bowel disease. World J Gastrointest Pathophysiol. 2015;6(3):62–72. doi:10.4291/wjgp.v6.i3.62 4. Gomollón F, Gisbert JP. Anemia and inflammatory bowel diseases. World J Gastroenterol. 2009;15(37):4659–4665. doi:10.3748/wjg.15.4659 5. Filmann N, Rey J, Schneeweiss S, Ardizzone S, Bager P, Bergamaschi G, Koutroubakis I, Lindgren S, Morena Fde L, Moum B, Vavricka SR, Schröder O, Herrmann E, Blumenstein I. Prevalence of anemia in inflammatory bowel diseases in european countries: a systematic review and individual patient data meta-analysis. Inflamm Bowel Dis. 2014 May;20(5):936-45. doi: 10.1097/01.MIB.0000442728.74340.fd. Review. PubMed PMID: 24572205. 6. Bunu DM, Timofte CE, Ciocoiu M, et al. Cardiovascular Manifestations of Inflammatory Bowel Disease: Pathogenesis, Diagnosis, and Preventive Strategies. Gastroenterol Res Pract. 2019;2019:3012509. Published 2019 Jan 13. doi:10.1155/2019/3012509

922 A CASE OF ABDOMINAL COCOON POST RENAL TRANSPLANT 1334575 Tu Nguyen Cedars Sinai Medical Center Lawrence Ku Anshu Abhat A CASE OF ABDOMINAL COCOON POST RENAL TRANSPLANT Accept Case Presentation: A 38-year-old woman with ESRD from lupus nephritis and deceased-donor kidney transplant 6 months ago, chronic Hepatitis B, and prior tuberculosis, presented with 2 months of abdominal pain. She endorsed progressive epigastric pain, bilious emesis after meals, abdominal bloating, intermittent diarrhea, and weight loss of 30 lbs in 6 months, only tolerating a liquid diet. She had been on PD for 11 years prior to transplant. She was treated for pulmonary tuberculosis 14 years ago in South Africa for 8 months. Physical exam revealed a distended, tympanic, mildly tender abdomen; no tenderness over the transplant site; normal bowel sounds; and a small, firm peri-umbilical nodule. Abdominal CT showed a large amount of ascites and severe luminal narrowing of the small bowel, consistent with high-grade small bowel obstruction. Differential diagnosis included TB peritonitis, post-transplant lymphoproliferative disorders (PTLD), and EPS. Ascitic fluid showed 1120 WBC with 71% lymphocytes and 29% monocytes, and a SAAG of 0.8, not consistent with PTLD. Sputum and ascites MTB PCR were negative, making TB peritonitis unlikely. Peritoneal biopsy to definitively diagnose EPS and rule out TB peritonitis was deferred given high risk of adhesion and worsening obstruction, as well as concern for inadequate healing due to poor nutritional status. She was started on empiric treatment for EPS with tamoxifen and mycophenolic acid; nutritional optimization with TPN, and a diet of clear liquids as tolerated.Discussion: EPS is a rare complication of peritoneal dialysis, with incidence of 0.7 to 13.6 per 1000 patient-years in PD. Although its pathogenesis is uncertain, the “two-hit hypothesis” theorizes that a peritoneal membrane injury from longstanding PD followed by a “second hit” leads to its development. This patient had multiple “second hit” risk factors for EPS, including long duration on PD, renal transplantation, and the use of beta-blockers and calcineurin inhibitors. Other risk factors include severe recurrent peritonitis, PD with high dialysate glucose, ultrafiltration failure, and increased solute transport. Early EPS is nonspecific, presenting with anorexia, nausea, diarrhea, and intermittent abdominal pain. Late EPS has features of ileus, peritoneal adhesions, and intermittent obstruction. EPS is diagnosed by laparotomy demonstrating a thickened, brown peritoneum enclosing the intestinal contents, although rarely done due to risks. EPS is associated with significant morbidity and high mortality of 50% at 2 years.Conclusions: Encapsulating peritoneal sclerosis (EPS), also known as abdominal cocoon, is a rare complication of peritoneal dialysis (PD). EPS is characterized by intraperitoneal inflammation and fibrosis, causing encasement of bowel loops and a clinical syndrome of bowel obstruction. EPS should be considered in patients with a history of PD presenting with symptoms of ileus and bowel obstruction.References: 1. Burkart MD. Encapsulating peritoneal sclerosis in peritoneal dialysis patients. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. www.uptodate.com (Accessed on August 20, 2019.) 2. Johnson, David W., et al. “Encapsulating Peritoneal Sclerosis: Incidence, Predictors, and Outcomes.” Kidney International, vol. 77, no. 10, 2010, pp. 904–912., doi:10.1038/ki.2010.16

934 EBV, CLINDAMYCIN AND RECURRENT ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS: A RARE CASE OF CLINICAL QUANDARY 1334514 Obinna Ofoche Mount Sinai Beth Israel Svetlana Chernyavsky EBV, CLINDAMYCIN AND RECURRENT ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS: A RARE CASE OF CLINICAL QUANDARY Accept Case Presentation: The patient is a 30 year American Born, Middle Eastern male with PMH Acute Generalized Exanthematous Pustulsosis (AGEP) that comes into hospital with high fevers and diffuse pruritic rash. In January of 2019, the patient, while being treated for pharyngitis, developed a pruritic, pustular rash, after treatment with amoxicillin/clavulanic acid. He was diagnosed with AGEP, the medication was discontinued and his sore throat and rash resolved. In late March 2019, the patient was admitted for presumed streptococcal pharyngitis infection and was treated alternatively with IV clindamycin, in-hospital, and he was discharged on oral Clindamycin. He presented again in early April with facial swelling and redness that developed on his face, arms, trunk and legs. The patient noted only the aforementioned allergy to penicillin. He took no medications nor did he use any drugs or alcohol. He was a former smoker (quit the previous year). He was heterosexual and had no recent travel. In the emergency department, his vitals were noted as such: Tmax was 101.6 F. Exam on admission was noted for diffuse erythematous maculopapular morbilliform rash. Labs were remarkable for a WBC of 18.7. It was suspected that this was a repeat presentation of his AGEP. With 12 hours, the quality of the patient’s rash changed to pustules on the patient’s face arms, and trunk. Patient’s fever came up to 103.2 and his WBC increased to 23.9. Measles PCR was negative as was Rapid Strep Test and Throat Culture. Patient had no antibody titers to Measles, Mumps or Rubella. This was thought to be a new presentation of AGEP due to clindamycin. He was started on oral steroids. By the 4th day of admission, the rash came to resolve. He was discharged with a 7 day course of topical and oral steroids. It was found later that the patient not only had positive EBV VCA IGG Antibodies and Nuclear Antigen Antibodies, He was noted to have Viral DNA PCR positive for EBV DNA. EBV IgM VCA was negative.Discussion: AGEP is rare condition entailing diffuse pustular rash on that can encompass the face, extremities, and trunk often associated with edematous erythema, high fevers, and elevated neutrophils. This is due to apoptosis of the keratinocytes in the epidermis, recruitment of Neutrophils to the skin surface and pustule formation. Risk factors include, exposure pristinamycin, penicillins, quinolones, and others drugs. Most other cases of AGEP are viral in nature or idiopathic. Recurrent AGEP is only rarely documented in the medical literature. In the patient, positive EBV VCA IgG and Nuclear antigen Antibodies with negative VCA IgM seem to indicate that primary diagnosis on his first admission in March was Epstein-Bar Virus infection. The presence EBV DNA (detected through PCR) can be elevated in the presence of infectious mononucleosis early in the disease course pointing to a likely reactivation event. It is possible that our case patient is the victim of a “second hit”; with virally mediated dysregulation of T-cell Activity followed by exposure to a novel antibiotic.Conclusions: In this case, we have patient that has rare presentation to the hospital with a recurrent AGEP in patient with exposure to clindamycin and EBV. Diagnostic uncertainty as made it difficult to label the exact insult leading to disease presentation. It is possible that the patient was the victim of combination of factors leading to dysregulated T-cell activity within the epidermis. Further research is need into precise mechanism of drug induced/virally mediated cytotoxic response on the skin.References: Bauer, CC et al. "Serum Epstein-Barr virus DNA load in primary Epstein-Barr virus infection." Journal of Medical Virology (2005 Jan): 54-58. "Epstein-Barr Virus and Infectious Mononucleosis: Laboratory Testing." 10 May 2018. Centers for Diease Control and Prevention. 30 April 2019 . Feldmeyer, Laurence, Kristine Heidemeyer and Nikhil Yawalkar. "Acute Generalized Exanthematous Pustulosis: Pathogenesis, Genetic Background, Clinical Variants and Therapy." International Journal of Molecular Sciences (2016 Aug): 1214. Ofuji, Satoshi and Osamu Yamamoto. "Acute generalized exanthematous pustulosis associated with a human parvovirus B19 infection." The Journal of Dermatology (2007 Jan 16): 121-123 . Ropars, Nolwenn, et. all. "Acute generalized exanthematous pustulosis associated with primary Epstein-Barr virus infection." Journal of the American Academy of Dermatology: Case Reports (2015 Jan): 9–11. Roujeau, JC et al. "Acute generalized exanthematous pustulosis. Analysis of 63 cases." Archives of Dermatology (JAMA Dermatology) (1991 Sep): 1333-1338. Sidoroff, A, et al. "Risk factors for acute generalized exanthematous pustulosis (AGEP)-results of a multinational case-control study (EuroSCAR)." British Journal of Dermatology (2007 Nov): 989-96. Thienvibul, Chitprapassorn, Vasanop Vachiramon and Kumutnart Chanprapaph . "Five-Year Retrospective Review of Acute Generalized Exanthematous Pustulosis." Dermatology Research and Practice (2015 Dec 10). Valeyrie-Allanore, Laurence, Grace Obeid and Jean Revuz. "Drug Reactions." Bolognia, Jean L., Julie V. Schaffer and Lorenzo Cerroni. Dermatology. Elsevier, 2018. 348-375. Vouloumanou, Evridiki, Rafailidis Petros and Matthew Falagas. "Current diagnosis and management of infectious mononucleosis." Current Opinion in Hematology (2012): 14–20. Weinberg, Jason B. "Epstein-Barr Virus." Kliegman, Robert M. and et. al. Nelson Textbook of Pediatrics,. Philadelphia: Elsevier, 2020. 1715-1718.

944 A DRUG RASH... AFTER ALL THESE ADMISSIONS ? 1334790 Srujana Pachigolla Carilion Clinic Roanoke Memorial hospital Adegbenga Bankole Virginia Tech Carilion School of Medicine Atchuyta Pachigolla A DRUG RASH... AFTER ALL THESE ADMISSIONS ? Accept Case Presentation: A 45-year-old woman presented to Emergency Department (ED) with a 1-weeks history of a sore throat, sinus congestion and dry cough. She was diagnosed with an upper respiratory tract infection and treated with amoxicillin/clavulanic acid. After 3 doses, she developed a high-grade fever and pink confluent pruritic maculopapular rash on arms and legs that progressed to her entire body. She returned to the ED and was diagnosed with a drug induced rash. She was treated with prednisone and the antibiotic was stopped. She returned to the ED with worsening rash, fever and hypotension. Her physical examination confirmed bilateral lower zone pulmonary crackles. Her laboratory tests showed leukocytosis, eosinophilia, acute kidney injury and lactic acidemia (Table 1). Computerized tomography scan confirmed diffuse lymphadenopathy, mild lung base consolidations and paranasal sinusitis. She was admitted for septic shock and treated with broad spectrum antibiotics. A skin rash biopsy confirmed leukocytoclastic vasculitis and a lymph node biopsy showed atypical lymphocytic proliferation and excluded malignancy. Infectious disease, Rheumatology, and Nephrology were consulted and entertained a diagnosis of Epstein–Barr virus (EBV) infection. She was treated pulse dose steroids, followed by high dose oral steroids, and she discharged on steroid taper with outpatient follow up. Drug reaction with eosinophilia and systemic symptoms (DRESS) is excluded as symptom onset was immediate rather than delayed. Renal biopsy performed during the hospitalization resulted after her discharge and showed eosinophilic interstitial inflammatory infiltrates. She had two further hospitalizations with similar symptoms that again responded to steroids. Hematology was consulted and a bone marrow biopsy excluded malignancy. Churg-Strauss syndrome is ruled out given the absence of necrotizing granulomatous vasculitis in skin or renal biopsy and negative PR3, MPO antibodies. A diagnosis of Hypereosinophilic Syndrome (HES) was made. She was treated with azathioprine on her last admission and has had no further hospitalizations. She is currently being treated outpatient with Benralizumab (Fasenra).Discussion: Hypereosinophilic syndrome (HES) can be peripheral hypereosinophilia (HE) or tissue HE that is associated with HE-related organ damage. Peripheral HE is defined as an elevated absolute eosinophil count (AEC) >1.5 x 109 /L on two occasions more than 1 month apart. Tissue HE is defined bone marrow eosinophils greater than 20% and/or tissue infiltration by eosinophils or deposition of eosinophil granule proteins. Reactive or secondary HE is associated with allergies, infections, autoimmune and neoplasms disease and needs to be excluded to make a diagnosis of primary HES. High dose steroids is the first line therapy for acute HES and in steroid responsive patients, the AEC decreases within 24 hours. Steroid sparing agents including hydroxyurea, imatinib, cyclophosphamide, azathioprine, rituximab and methotrexate can be considered depending on the subtype of HES. Recently several biologic/monoclonal Ab treatments are available and are promising for people with HES.Conclusions: HES is associated with wide spectrum of organ dysfunction and hence evaluation of patients with HES requires complex testing and multidisciplinary approach. Early suspicion for and recognition of HES is crucial for hospitalists as involvement of subspecialists is essential in the management of HES and prevents readmission.References: 1.Polliana Mihaela Leru. Eosinophilic disorders: evaluation of current classification and diagnostic criteria, proposal of a practical diagnostic algorithm.Clin Transl Allergy. 2019 Jul 25;9:36. doi: 10.1186/s13601-019-0277-4.PMID:31367340 2. Kahn JE, Groh M, Lefevre G. (A critical appraisal of) Classification of hypereosinophilic disorders. Front Med. 2017;4:216. doi: 10.3389/fmed.2017.00216. 3. Hocqueloux L, Guinard J, Buret J, et al. Do penicillins really increase the frequency of a rash when given during Epstein-Barr Virus primary infection? Clin Infect Dis 2013; 57:1661. 4.Thompson DF, Ramos CL. Antibiotic-Induced Rash in Patients With Infectious Mononucleosis. Ann Pharmacother. 2017;51(2):154. Epub 2016 Oct 1 5. Kuang FL, Klion AD. Biologic Agents for the Treatment of Hypereosinophilic Syndromes. J Allergy Clin Immunol Pract. 2017 Nov - Dec;5(6):1502-1509. doi: 10.1016/j.jaip.2017.08.001.

959 AN UNUSUAL CAUSE OF CAVITARY LUNG LESION: POLYANGIITIS OVERLAP SYNDROME 1335437 Jessica Kunadia Rutgers Robert Wood Johnson University Hospital Manank Patel Rutgers Robert Wood Johnson Medical School Michael Makar Sarah Orfanos Jared Radbel AN UNUSUAL CAUSE OF CAVITARY LUNG LESION: POLYANGIITIS OVERLAP SYNDROME Accept Case Presentation: A 23-year-old male with intermittent controlled asthma, presented to the emergency department for recurrent hemoptysis and night sweats of two months duration. The patient also complained of loss of sensation in his left thumb, index and middle fingers and bilateral lower extremity rash of two days duration. On examination, lung fields were clear to auscultation bilaterally with normal percussion. Neurologic examination was remarkable for decreased tactile sensation in left hand of ulnar distribution. Skin examination was remarkable for palpable purpuric lesions bilaterally on the lower extremities. Chest X-ray revealed a large cavitary lesion with air fluid level in the right upper lobe. Computed tomography of the chest further defined the cavitary lesion size as 11.5cm*7cm with significant fluid and irregular walls with extensive pleural contact. Laboratory results were remarkable for white blood count of 19 thousand/ul with 42% eosinophils (7.960 thousand/uI). Autoimmune work-up revealed positive proteinase 3 anti-neutrophil cytoplasmic antibody (c-ANCA PR3+). A punch biopsy of the purpuric rash performed before initiation of steroids revealed leukocytoclastic vasculitis with a large number of eosinophils in capillaries and post-capillary venules. After multidisciplinary discussions involving pulmonary, rheumatology, and infectious disease consultants, a diagnosis of polyangiitis overlap syndrome was made. Patient was treated with pulse dose steroids with clinical improvement and was discharged with maintenance therapy of Rituximab.Discussion: A cavitary lung lesion has a wide differential and includes infection, septic emboli, malignancy, and non-infectious granulomas. Less common etiologies include sarcoidosis, pulmonary infarct and cryptogenic organizing pneumonia. Given this broad differential, it is important to determine the underlying etiology and treat it appropriately. In our case, patient had several features that pointed towards the diagnosis of vasculitis, in particular small vessel vasculitis. The diagnosis of the underlying vasculitis was challenging as patient had features overlapping granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (EGPA). After discussion with the consultants, our patient was diagnosed with polyangiitis overlap syndrome, given his history of asthma, peripheral and tissue eosinophilia which are more associated with EGPA and presence of PR3 positive C-ANCA and cavitary lesions which are more consistent with GPA. Of the 15 cases of GPA- EGPA polyangiitis overlap syndrome reported in literature, 4 cases described nodular lesions on chest CT, 9 cases reported ground glass opacities and 2 cases reported cavitary lesions. Therefore, Polyangiitis overlap syndrome needs to be considered as a part of differential diagnosis while evaluating patients with cavitary lung lesion. Our patient was appropriately treated with methylprednisolone 1mg/kg for 3 days inducing a decrease in peripheral and tissue eosinophils. Patient’s symptoms improved and he was discharged on Rituximab for immunosuppression. During post hospitalization follow up, he was noted to have significant reduction in size of his cavitary lesion.Conclusions: Cavitary lung lesions are a common presentation of several disease entities and vasculitis needs to be considered as a part of differential diagnosis. It is also important to identify the type of vasculitis as treatment differs significantly.References: 1. Leavitt RY, Fauci AS. Polyangiitis overlap syndrome. Classification and prospective clinical experience. Am J Med. 1986 Jul;81(1):79–85. 2. Quan MV, Frankel SK, Maleki-Fischbach M, Tan LD. A rare case report of polyangiitis overlap syndrome: granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis. BMC Pulm Med. 2018 Nov 29;18(1):181. 3. Uematsu H, Takata S, Sueishi K, Inoue H. Polyangiitis overlap syndrome of granulomatosis with polyangiitis (Wegener’s granulomatosis) and eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). BMJ Case Rep. 2014 Feb 27;2014. 4. Surendran S, Gundappa C, Gandhi A, Kurien AA, Fernando E. An overlap of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant Saudi Arab. 2017 Jun;28(3):639–44.

974 ITS NOT ALWAYS A DRUG RASH! OR IS IT? A CASE OF BEHÇET'S SYNDROME MASQUERADING AS A DRUG RASH 1334314 Anusha Pinjala Creighton University Sima Maraqa Alheli Arce Gastelum Creighton University Internal Medicine Department Joshua Samec Timea Bor ITS NOT ALWAYS A DRUG RASH! OR IS IT? A CASE OF BEHÇET'S SYNDROME MASQUERADING AS A DRUG RASH Accept Case Presentation: A 61-year-old Caucasian man with a past medical history of HTN, coronary artery disease, obstructive sleep apnea, osteoarthritis of the right knee, chronic pain syndrome on an opioid contract and major depressive disorder was transferred to our hospital for a rash suspicious for Steven Johnson Syndrome. He underwent right knee revision arthroplasty two months prior to the presentation. He was prescribed celecoxib for post-operative pain. Within two days he developed pink eyes and painful ulcerations of his mouth and lips. His rash was presumed to be an adverse reaction to celecoxib, and hence it was discontinued. He was then treated with a 10-day prednisone taper and an antihistamine. Two weeks later, he was admitted to a local hospital with cellulitis of the right knee at the surgical incision site that was treated with IV vancomycin. He then developed ulcerations on his buttocks and groin. Vancomycin was stopped and the patient was transitioned to oral levofloxacin and rifampin prior to being transferred to our facility. Upon arrival, his vital signs were stable. On exam, he had ulcerations on the tongue and oral mucosa, a desquamating rash with erythema and edema involving the perianal skin, gluteal cleft, and groin. Labs were significant for normal white cell count, normocytic anemia, elevated ESR (73 mm/hr) and CRP (92.9 mg/L), negative procalcitonin, and negative blood cultures. The right knee synovial fluid culture was negative as well. Dermatology was consulted in which they diagnosed the patient with Behçet's disease. He was treated with IV methylprednisolone for three days and then transitioned to an oral prednisone taper in addition to wound care and pain control.Discussion: Behçet’s disease is an autoimmune vasculitis that is most common along the ancient Silk Road. It is very rare in the United States with the incidence of 0.12-0.33 per 100,000 people. There has been a positive correlation between HLA-5, HLA-B27, and HLA—B51. The pathophysiology involves vasculitis of arteries and veins of all sizes. The most common clinical manifestations include relapsing and remitting mucocutaneous ulcerations that involve the oral cavity and groin, vitritis, and uveitis. Other less common manifestations include arthralgias, arthritis, skin aphthosis, and erythema nodosum. Neurologic, pulmonary, cardiac, and gastrointestinal involvement is rarely seen. Diagnosis is clinical. ISG and ICBD criteria can be used to aid in diagnosis. The disease itself is mostly self-limiting with the exception of eye lesions which can lead to blindness if untreated. In our patient, the diagnosis was not straight forward as he was exposed to multiple medications (celecoxib and vancomycin) all of which can cause a rash. Steven Johnson syndrome and red man syndrome were initially considered. Since he remained hemodynamically stable, presented with the classic anatomic location of the rash, and his history of similar but less severe lesions in the past led us to the diagnosis. Treatment involves systemic steroids, colchicine, methotrexate, cyclophosphamide, cyclosporine, and azathioprine. In severe refractory cases, TNF alpha inhibitors are also recommended.Conclusions: Rash is not a frequent admitting diagnosis encountered by hospitalists. Behçet’s disease is usually low on the differential diagnosis due to its lower incidence. Although a desquamating rash can be seen in various conditions, a prior history of orogenital lesions and the location of the rash can help differentiate Behçet’s from other diagnoses.References: 1.Greco, Antonio, et al. "Behçet's disease: new insights into pathophysiology, clinical features and treatment options." Autoimmunity reviews 17.6 (2018): 567-575. 2.Scherrer, Maria Antonieta Rios, Vanessa Barreto Rocha, and Lucas Campos Garcia. "Behçet's disease: review with emphasis on dermatological aspects." Anais brasileiros de dermatologia 92.4 (2017): 452-464. 3. Davatchi, Fereydoun. "Behcet's disease." International journal of rheumatic diseases 17.4 (2014): 355.

979 LEFT VENTRICULAR PSEUDOANEURYSM - A RARE BUT LIFE-THREATENING COMPLICATION OF ACUTE MYOCARDIAL INFARCTION 1334977 Todd Prol Morristown Medical Center Joseph Petro Nisha Giyanani Jason Salamon LEFT VENTRICULAR PSEUDOANEURYSM - A RARE BUT LIFE-THREATENING COMPLICATION OF ACUTE MYOCARDIAL INFARCTION Accept Case Presentation: A 77-year-old caucasian man with a known history of hypertension, hyperlipidemia and tobacco abuse initially presented to the hospital with chest pain for five days. He was diagnosed with an anterior wall ST elevation myocardial infarction (STEMI). He underwent cardiac catheterization with drug-eluting stent placement to the left anterior descending coronary artery. Subsequent transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction of 45%, and a large left ventricular (LV) thrombus. The patient was anticoagulated, medically optimized and discharged home. He returned one month later with recurrent chest pain prompting a repeat TTE, which demonstrated resolution of the LV thrombus with a new pericardial effusion and pseudoaneurysm. The patient underwent urgent cardiothoracic surgery with patching of the LV rupture with pericardium and his immediate postoperative course was uncomplicated. A repeat TTE immediately post-op revealed no LV thrombus. He was discharged home not on anticoagulation. Follow up TTE 3 weeks later demonstrated recurrent LV thrombus. Follow up TTE at 6 weeks demonstrated resolution of LV thrombus with residual LV apical dyskinesis and no pericardial effusion.Discussion: LV pseudoaneurysm is a rare, but serious complication of acute myocardial infarction that occurs more commonly with late presentation of STEMIs. Due to modern medical management and prompt attention to STEMIs, this phenomena occurs only in approximately 0.3% of patients who have suffered an MI. Despite its low incidence, it should remain high on the differential diagnosis for patients presenting with chest pain or dyspnea after a MI, due to its high mortality rate. A timely and accurate diagnosis is the difference between life and death for the patient. Untreated cases have a 30-45% risk of complete rupture; medical management alone carries a near 50% mortality. TTE remains the mainstay for diagnosis, with echo contrast available to assist in visualization. Once a diagnosis is definitively made, urgent surgical repair is indicated as definitive, often lifesaving therapy.Conclusions: Given its life threatening nature, a cardiac pseudoaneurysm must be identified and corrected rapidly. It typically occurs 3-5 days post myocardial infarction and the index of suspicion must be high in patients with the appropriate clinical history. Due to modern interventions, patients spend more of their recovery time on the general medial floor under the care of a hospitalist, highlighting the need for awareness of such a condition. Being alert and acting quickly with regards to a pseudoaneurysm can save a life.References: Alapati L, Chitwood WR, Cahill J, Mehra S, Movahed A (2014) Left ventricular pseudoaneurysm: A case report and review of the literature WJCC 2: 90-93 Frances C, Romero A, Grady D. Left ventricular pseudoaneurysms. J Am Coll Cardiol. 1998;32(3):557–561. Vlodavar, Z, Coe, JI, and Edwards, JE. True and false left ventricular aneurysm (Propensity of the latter to rupture) . Circulation. 1975; 51: 567–572 Zoffoli G, Mangino D, Venturini A, Terrini A, Asta A, Zanchettin C, et al. Diagnosing left ventricular aneurysm from pseudo-aneurysm: A case report and a review in literature. J Cardiothorac Surg. 2009;4:11. Yeo TC, Malouf JF, Oh JK, Seward JB (1998) Clinical profile and outcome in 52 patients with cardiacpseudoaneurysm. Ann Intern Med 128:299–305.

982 A TROPICALLY LOCAL RASH 1335311 Nila Radhakrishnan University of Florida Bhagwan Dass Kiran Lukose Department of Medicine, University of Florida Amardeep Singh Mohamad Taha A TROPICALLY LOCAL RASH Accept Case Presentation: A 28-year-old male with no significant past medical history presented with acute onset of left arm numbness, paresthesia, itching, and rash. The patient works as a roofer, where he occasionally walks barefoot, and reported an injury to his left hand about 2 weeks prior to presentation. The injured area was covered with blisters, associated with visible linear redness (serpiginous) extending from the blister site at the base of the hand up to the arm that migrated overnight. A similar linear rash was noted in the left plantar foot with surrounding redness (Figure 1). Patient denied having any constitutional or respiratory symptoms. On presentation, blood pressure was 106/62mmHg, heart rate 72 beats/minute, temperature 98.4oF, respiratory rate 16/minute, and oxygen saturation of 100% on room air. Laboratory findings showed white blood cells 15.3x109/L, 15% eosinophils, hemoglobin 15.7mg/dL, platelets 380x109/L, C-reactive protein 28.9mg/dL, erythrocyte sedimentation rate 32mm/hour. The patient was diagnosed with a hookworm-related cutaneous larva migrans (HrCLM). The patient was treated with a single dose of Ivermectin and the symptoms improved within a few days.Discussion: HrCLM is the most frequent travel-associated skin disease of tropical origin caused by the penetration of the skin by a cat, dog, or other mammal nematode larvae. Although frequently seen in tropical countries, this tropical dermatosis is not sufficiently well known by clinicians in western countries, and this can delay diagnosis and effective treatment by up to 22 months. The incubation period of HrCLM is usually several days. The striking symptom of HrCLM is pruritus localized at the site of the eruption and the characteristic sign is creeping dermatitis. The most frequent anatomic locations are the feet (in more than 50% of individuals), followed by the buttocks and thighs. HrCLM can present in a self-limited disseminated form called Löffler syndrome. HrCLM is a clinical diagnosis based on history of exposure to contaminated soil and associated with a characteristics serpiginous skin lesion. Blood tests are not necessary for diagnosis and are not currently recommended. Eosinophilia is reported in 20% in tropical travelers. Skin biopsy can be pursued in difficult presentations and may reveal nematode larvae in the follicular canal. The treatment of choice is a single-dose of ivermectin 200µg/kg. Ivermectin affects nematode motility, feeding and reproduction acting via ligand-gated chloride channels. Our case demonstrates a classic HrCLM clinical presentation with excellent response to treatment, but a unique absence of risk factors, in which traditional geographic distribution and disease exposure (i.e. contaminated soil) were lacking.Conclusions: HrCLM is a clinical diagnosis, and it is predominantly tropical disease that is rarely seen in this part of the world. Clinicians need to keep this differential diagnosis in mind as it responds very well to the treatment, if diagnosed promptly. A single dose of Ivermectin is sufficient for treatment.References: 1. Podder I, Chandra S, Gharami RC. Loeffler's Syndrome Following Cutaneous Larva Migrans: An Uncommon Sequel. Indian J Dermatol. 2016; 61: p.190 2. Schuster A, Lesshafft H, Reichert F, Talhari S, de Oliveira SG, Ignatius R, Feldmeier H. Hookworm-related cutaneous larva migrans in northern Brazil: resolution of clinical pathology after a single dose of ivermectin. Clin Infect Dis. 2013; 57: p.1155. 3. Laing R, Gillan V, Devaney E. Ivermectin –old drug, new tricks? Trends Parasitol. 2017; 33:463-472.

986 CEFEPIME NEUROTOXICITY IN A PATIENT WITH RECURRENT ACUTE MYELOGENOUS LEUKEMIA 1334309 Eric Ray Maine Medical Center Lesley Gordon Gilles Fraser CEFEPIME NEUROTOXICITY IN A PATIENT WITH RECURRENT ACUTE MYELOGENOUS LEUKEMIA Accept Case Presentation: A 53-year-old woman with thrice-recurrent AML presented to the emergency department with a few days of sinus pressure then neck soreness, mild headache, fatigue, and finally low-grade fever. She had a donor lymphocyte infusion 18 days prior but no signs/symptoms of graft-versus host disease. Her initial exam was non-focal and lacked meningeal signs or encephalopathy, yet she was tachycardic, febrile, and drowsy. Empiric broad-spectrum coverage with cefepime was started, and lumbar puncture (LP) deferred given her reassuring exam. She had a normal WBC count, lactate, urinalysis, and CXR. Vancomycin was added for staphylococcus epidermidis in 1 of 2 blood cultures. After 48 hours, she developed marked confusion and word-finding difficulty, and her WBC of 5,500 had 8% blasts on smear. A sinus CT, brain MRI, and LP with extensive infectious/paraneoplastic workup were negative. Acyclovir was started, however her fevers and encephalopathy progressed with complete disorientation, expressive aphasia, and asterixis. On hospital day 5 an EEG showed diffuse toxic-metabolic encephalopathy with 2-3 Hz triphasic morphology. The cefepime, as a possible contributor, was changed to piperacillin-tazobactam and her neurologic symptoms started to improve within 24 hours. At 48 hours, her neurologic symptoms were resolved with ongoing fevers attributed to recurrence of AML.Discussion: Cefepime has been commonly used since 1996 for a range of infections, however the reversible neurologic syndromes this antibiotic can cause are becoming increasingly recognized. This renally-excreted GABA-antagonist has an estimated 1:480 incidence of neurotoxicity which can manifest as encephalopathy, myoclonus, aphasia, and even nonconvulsive status epilepticus which was recognized in a 2012 statement by the FDA. The largest risk factor for these adverse reactions is renal impairment, which is present in 70-87% of cases and can increase blood brain barrier penetrance of the drug from 10% to 45%. Preexisting brain injuries and elevated serum concentrations are other risk factors; however, some patients have no risk factors at all. Additionally, the neurological symptoms can be difficult to recognize in patients who undoubtedly already have several acute conditions. This patient did have mild renal impairment with creatinine clearance at 55, however recurrent AML was likely contributory to decreased permeability of her blood brain barrier.Conclusions: This case not only shows the benefit in identifying cefepime neurotoxicity but also the difficulty of doing so. Drug serum trough levels may be helpful but are not well studied, and an EEG may have non-specific findings. Cefepime should be utilized when clinically appropriate, but efforts should be made for improved accuracy of dosing according to creatinine clearance, conscious monitoring of renal function of patients on cefepime, and increased recognition of the syndrome which should prompt antibiotic discontinuation.References: Appa, Ayesha A., et al. "Characterizing cefepime neurotoxicity: a systematic review." Open forum infectious diseases. Vol. 4. No. 4. US: Oxford University Press, 2017. Bow, E. J., et al. "A randomized, open-label, multicenter comparative study of the efficacy and safety of piperacillin-tazobactam and cefepime for the empirical treatment of febrile neutropenic episodes in patients with hematologic malignancies." Clinical infectious diseases 43.4 (2006): 447-459. Food and Drug Administration. FDA Drug Safety Communication: Cefepime and risk of seizure in patients not receiving dosage adjustments for kidney impairment. 12 Jun 2012. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-cefepime-and-risk-seizure-patients-not-receiving-dosage-adjustments Fugate, Jennifer E., et al. "Cefepime neurotoxicity in the intensive care unit: a cause of severe, underappreciated encephalopathy." Critical Care 17.6 (2013): R264. Huwyler, Tibor, et al. "Cefepime plasma concentrations and clinical toxicity: a retrospective cohort study." Clinical Microbiology and Infection 23.7 (2017): 454-459. Li, Han-Tao, et al. "Clinical, Electroencephalographic Features and Prognostic Factors of Cefepime-Induced Neurotoxicity: A Retrospective Study." Neurocritical care (2019): 1-9. Payne, Lauren E., et al. "Cefepime-induced neurotoxicity: a systematic review." Critical Care 21.1 (2017): 276. Pettit, Natasha N., et al. "Cefepime-Induced Encephalopathy, Single-Center Incidence, Complexities in Diagnosis." Open forum infectious diseases. Vol. 4. No. 4. US: Oxford University Press, 2017. Tamune, Hidetaka, et al. "Cefepime‐induced encephalopathy: Neural mass modeling of triphasic wave‐like generalized periodic discharges with a high negative component (Tri‐HNC)." Psychiatry and clinical neurosciences 73.1 (2019): 34-42.

990 "OUT OF THE WINDOW" - PNEUMOCYSTIS PNEUMONIA 18 MONTHS AFTER A RENAL TRANSPLANT 1334799 David Rhee NYU Langone Health Benjamin Verplanke "OUT OF THE WINDOW" - PNEUMOCYSTIS PNEUMONIA 18 MONTHS AFTER A RENAL TRANSPLANT Accept Case Presentation: A 63-year-old man with significant history of deceased donor transplant (18 months prior to presentation), hypertension, diabetes mellitus, who presented with two weeks of fevers and malaise. His other symptoms included drenching night sweats, shortness of breath, and diffuse pleuritic chest pain, however he denied cough. A recent exposure was a renovation of a room with water damage and mold. His transplant history was notable for basiliximab induction complicated by donor and recipient low-level cytomegalovirus (CMV) viremia, pancytopenia, and tacrolimus toxicity, but these were resolved prior to his admission. He completed 6 months of post-transplant atovaquone for PJP prophylaxis. For the past year, his kidney function has been stable but suboptimal with CKD stage IV and nephrotic range proteinuria. His medications have remained unchanged: monthly belatacept infusions, mycophenolate mofetil 500mg twice a day, and prednisone 5mg daily. His admission labs were notable for a white blood cell count of 3.7x 10^3/uL and creatinine of 2.43 mg/dl (baseline). Chest computed tomography revealed mixed airspace-interstitial infiltrates with diffuse ground-glass opacities and bronchiectasis (Fig. 1). He was started on empiric coverage of bacterial vs. fungal pneumonia with vancomycin, piperacillin-tazobactam, azithromycin, and voriconazole. Because of his persistent hypoxemia, a bronchoscopy was performed and returned positive for Pneumocystis pneumonia (PJP). He was started on sulfamethoxazole-trimethoprim and steroids by hospital day 4. Unfortunately, his hypoxia worsened and he required intubation for acute respiratory distress syndrome (ARDS). There were empiric trials of micafungin, meropenem, acyclovir, doxycycline, primaquine, and clindamycin. A repeat bronchoscopy was unrevealing and his ARDS worsened. After 3 weeks of intubation without clinical improvement, the family declined tracheostomy and the patient was palliatively extubated and expired.Discussion: PJP is a morbid infection predominantly associated with AIDS, hematologic malignancies, chronic high dose steroids or immunosuppressive medications, and transplant (hematopoietic cell and solid organ). In solid organ transplantations (SOT), the risk of PJP is highest in the first 6 months after transplantation.[1] However, PJP outside of the 6-month window is being increasingly recognized and has been associated with CMV viremia, lymphopenia, and immunosuppressive treatment failures[2,3] - all present in our patient.Conclusions: There are no clear guidelines for life-long PJP prophylaxis in renal transplant recipients, but various professional societies recommend anywhere between 4 to 12 months.[4] Emerging data will need to both shape recommendations for extending prophylaxis in risk-stratified SOT recipients and raise the index of suspicion for prompt PJP treatment.References: 1. Gerrard JG. Pneumocystis carinii pneumonia in HIV-negative immunocompromised adults. Med J Aust. 1995;162(5):233-5. 2. Radisic M, et al. Risk Factors for Pneumocystis carinii pneumonia in kidney transplant recipients: a case-control study. Transpl Infect Dis. 2003;5(2)84-93. 3. Hosseini-Moghaddam SM, et al. A Multicenter Case-control Study of the Effect of Acute Rejection and Cytomegalovirus Infection on Pneumocystis Pneumonia in Solid Organ Transplant Recipients. Clin Infect Dis. 2019;68(8):1320-1326. 4. Fishman JA, et al. Pneumocystis jiroveci in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33(9):e13587.

995 A CASE OF RELAPSING POLYCHONDRITIS? I'M ALL EARS 1334303 Kandice Roberts Washington University School of Medicine Seth Knight Jagriti Chadha A CASE OF RELAPSING POLYCHONDRITIS? I'M ALL EARS Accept Case Presentation: A 71-year-old man presented with 2 months of progressive diffuse weakness and myalgias to the point of not being able to ambulate without a cane. He noticed lumps on his left forearm during that time, which improved spontaneously. He also endorsed photophobia, right eye swelling, and pain worsened by extraocular movement. He had left ear swelling and pain worsened by contact on presentation. Additionally, he had constant aching of the throat with negative strep and flu tests. He denied joint pain, stiffness and swelling, fevers, and cough. He had history of multiple emergency department visits during the 2 months prior to presentation. On presentation, vital signs were within normal limits. He had minimal conjunctival congestion and some eyelid erythema and swelling. His left upper auricle was erythematous, swollen, and tender to palpation. Fundoscopy showed retinal hemorrhages and cotton wool spots in the right eye. Flexible laryngoscopy showed mild erythema throughout the glottis. C-reactive protein was 10.5 mg/dL (normal 0-0.9 mg/dL), erythrocyte sedimentation rate was 114 mm/hr (normal 0-11 mm/hr), and rheumatoid factor was 26 IU/mL (normal Discussion: Relapsing polychondritis can involve nearly every organ system. The most common presenting feature is ear inflammation, which appears in up to 90% of patients (Kent, et al). Ocular manifestations occur in up to 60% of patients during the course of disease. Greater than 50% of patients develop laryngotracheal disease. Skin findings occur in only 25% of patients. Symptoms may also involve the nose, joints, heart, kidneys, nervous system, and gastrointestinal tract. McAdam or Damiani criteria can be used to establish a diagnosis of relapsing polychondritis. McAdam criteria require the presence of at least three of the following symptoms, plus compatible histology: bilateral auricular chondritis, nonerosive, seronegative inflammatory polyarthritis, nasal chondritis, eye inflammation, chondritis of the respiratory tract, and cochlear and/or vestibular dysfunction. According to Damiani criteria, a diagnosis is confirmed if at least three of McAdam’s criteria are met, two McAdam’s criteria are met with positive histology, or chondritis is present in at least 2 anatomic locations with a response to steroids or dapsone.Conclusions: The hospitalist should be aware of the symptoms of relapsing polychondritis. Prompt diagnosis and treatment with corticosteroids will provide rapid relief of symptoms and prevent progression to life threatening organ compromise, including irreversible lung, heart, and kidney inflammation.References: Kent, Peter D., Clement J. Michet, and Harvinder S. Luthra. "Relapsing Polychondritis." Current Opinion in Rheumatology 16.1 (2004): 56-61. Web.

996 WHAT ABOUT THE SPLEEN? AN UNUSUAL PRESENTATION OF ADULT IGA VASCULITIS WITH MASSIVE SPLENOMEGALY 1334572 Kelli Robertson University of Colorado Internal Medicine Residency Program James Welle Andy Berry WHAT ABOUT THE SPLEEN? AN UNUSUAL PRESENTATION OF ADULT IGA VASCULITIS WITH MASSIVE SPLENOMEGALY Accept Case Presentation: A 50-year-old man without significant medical history presented with two months of purpura over his lower extremities and abdomen, ankle pain, and two days of severe abdominal pain associated with vomiting and melena. His symptoms started following a respiratory infection. On presentation, he was afebrile with normal vital signs. Physical exam was notable for a tender abdomen and non-blanchable purpura of his lower extremities to the thighs and across his abdomen. Laboratory testing demonstrated chronic lymphopenia (WBC 2.4x109 cells/L), microcytic anemia (hemoglobin of 12 g/dL, MCV 78.3 fL), and normal platelets. His serum creatinine was 1.1 mg/dL and urinalysis was negative for blood and protein. Complements were normal. Inflammatory markers were elevated (CRP of 45 mg/L and ESR of 43 mm/hr). Blood cultures were negative. CT abdomen demonstrated a 23 cm spleen and duodenal thickening without lymphadenopathy. No splenic vein thrombosis was visualized. HIV, HBV, HCV, EBV, ANA, RF, and anti-CCP were negative. cANCA was slightly positive (titer 1:80) but with negative PR3 and MPO. SPEP and UPEP were without significant abnormalities. Punch biopsy demonstrated leukocytoclastic vasculitis and immunofluorescence showed IgA deposition. EGD revealed large, circumferential patches of ulcerated, friable mucosa in the duodenum. Histology was consistent with acute inflammation and immunohistochemical stains for CMV and HSV were negative. Given a negative infectious workup, the patient started oral prednisone for presumed IgA vasculitis with rapid symptom improvement. Splenomegaly persisted after discharge prompting a peripheral smear which was concerning for hairy cell leukemia. He was referred for bone marrow biopsy, which did not reveal underlying malignancy by histology, cytogenetics, or flow cytometry. Given concern for isolated splenic lymphoma, a PET scan was obtained, but no splenic uptake was seen. He remains asymptomatic after weaning steroids and serial imaging demonstrates improvement in his splenomegaly to 17 cm.Discussion: IgA vasculitis (IgAV) classically presents with palpable purpura, abdominal pain, arthralgias, and renal disease. Our patient lacked renal disease, which occurs in approximately one third of adult cases (1). He had massive splenomegaly which has not been described as a feature of adult-onset IgAV. The differential diagnosis for massive splenomegaly is limited, including lymphoma, leukemia, myelofibrosis, beta-thalassemia, malaria, leishmaniasis, sarcoidosis, and some HIV-associated infections (2). Given the association between malignancy and IgAV, our patient underwent a thorough investigation for neoplastic causes which was negative. Although the differential for massive splenomegaly is narrow, there are cases where the etiology remains idiopathic. Splenectomy studies to evaluate etiology in such cases ultimately diagnosed most with neoplastic disease, however up to 33% of cases remained idiopathic (3). Such cases require surveillance and discussion of splenectomy with the patient.Conclusions: Purpura, arthritis, and abdominal pain should drive suspicion for malignancy-related vasculitis and initiate specialty consultation for diagnosis and management. This unusual case with splenomegaly hints at underlying neoplasm, however the etiology remains idiopathic. Given the interval decrease in spleen size, the patient has opted to be followed with serial splenic imaging rather than diagnostic splenectomy.References: 1. Pillebout E, Thervet E, Hill G, Alberti C, Vanhille P, Nochy D. Henoch-Schönlein Purpura in Adults: Outcome and Prognostic Factors. J Am Soc Nephrol. May 2002;13(5):1271-1278. 2. Luo, E, Levitt, L. Resident grand rounds: Massive splenomegaly. Hosp Physician. 2008;31-38. 3. Carr JA, Shurafa M, Velanovich V. Surgical Indications in Idiopathic Splenomegaly. Arch Surg. 2002;137(1):64-68.

999 DARK AND STORMY: A CASE OF PARAVALVULAR LEAK MANIFESTING AS HEMOLYTIC ANEMIA 1334970 Michael Root UCSF Irina (Era) Kryzhanovskaya UCSF DARK AND STORMY: A CASE OF PARAVALVULAR LEAK MANIFESTING AS HEMOLYTIC ANEMIA Accept Case Presentation: 81 year-old man with a history of atrial fibrillation on Warfarin and bioprosthetic aortic and mitral valves presented with dark urine and shortness of breath. He described progressive shortness of breath and reduced exercise tolerance, unable to walk upstairs to his apartment. His urine had become “the color of eggplant”. On exam, he had an elevated JVP, new lower extremity edema, and a holosystolic murmur. Initial laboratory evaluation revealed large hemoglobin on urinalysis without RBCs, hemoglobin 9.5 (baseline 11.2), platelets 230, creatinine 1.28 (baseline 0.93), total bilirubin 2.2. Additional testing revealed reticulocytosis, schistocytes 2-5/HPF on smear, haptoglobin < 6 mg/dL, and LDH 1722. Direct Coombs test was weakly positive. The patient underwent a transesophageal echocardiogram (TEE) showing several mobile echo-densities on the aortic cusps, moderate paravalvular mitral leak, pulsatile aneurysmal segment near the aortic valve, and severe tricuspid regurgitation. He was started on antibiotics for possible endocarditis and transferred to Cardiology for management of the paravalvular leak (PVL). He underwent aortic and mitral valve replacement, occlusion of the aortic cavitary lesion, and tricuspid valve repair. Intraoperative findings included inflammatory changes along prior suture lines without vegetations. Postoperatively, blood cultures remained negative and antibiotics were stopped. His hemoglobin stabilized at 8.6 and bilirubin, LDH, and recticulocyte count returned to normal. The patient was discharged and was asymptomatic a month later in clinic.Discussion: Anemia is commonly encountered in the hospital. This patient presented with dark urine and heart failure, prompting consideration of entities where these findings overlap. His hemoglobinuria rather than true hematuria and schistocytes on peripheral smear warranted urgent evaluation for hemolysis. The undetectable haptoglobin and elevated LDH and plasma free hemoglobin were diagnostic: a haptoglobin of < 25 mg/dL has a sensitivity of 83% and specificity of 96% for hemolytic anemia.1 Clinically significant hemolysis after cardiac valve replacement is a known but rare occurrence, estimated to be < 1% of cases.2 It is more commonly seen with mechanical valves or due to either PVLs or valve degradation, both of which likely contributed in this case.2 In order to evaluate prosthetic valves, a TEE is often needed to fully evaluate the mitral position. In this case, the TEE characterized the severity of the PVL and better visualized the damaged aortic valve. Ultimately, management of PVLs include leak closure or valve replacement. 3 In addition to following hemoglobin, LDH, and haptoglobin, monitoring the bone marrow response via reticulocyte count is critical in patients with hemolysis. Patients with an appropriate peripheral reticulocytosis, especially with acute on chronic hemolysis, often require folate and iron supplementation.Conclusions: This case of a patient with bioprosthetic valve replacements and symptomatic hemolytic anemia illustrates the importance of evaluating mechanical causes for hemolysis. After repair of the mitral PVL and aortic valve replacement, the patient’s laboratory markers of hemolysis and symptoms of heart failure resolved. While clinically significant anemia from valve replacement is rare, the advent of new cardiac devices and techniques makes it likely that more inpatient and outpatient providers will encounter this in their practice.References: 1. Marchand A, Galen RS, Van Lente F. The Predictive Value of Serum Haptoglobin in Hemolytic Disease. JAMA. 1980;243:1909-1911 2. Alkhouli M, Farooq A, Go RS, Balla S, Berzingi C. Cardiac prosthesis-related hemolytic anemia. Clinical Cardiology. 2019;42:692-700. 3. Ali AM, Kayani AM, Ali M, Hussain AB. Haemolytic Anemia due to Paravalvular Leak Following Mitral and Aortic Valves Replacement. J Cardiovasc Dis Diagn. 2018;6:308.

1000 RAPID PLASMA REAGIN IN THE DANGER ZONE: A CASE OF THE PROZONE EFFECT IN SECONDARY SYPHILIS 1334383 Bari Rosenberg Duke University Health System Lavanya Dharmarajan Yoo Mee Shin Emory University Hospital Midtown RAPID PLASMA REAGIN IN THE DANGER ZONE: A CASE OF THE PROZONE EFFECT IN SECONDARY SYPHILIS Accept Case Presentation: A 34-year old male with a history of acquired immunodeficiency syndrome (CD4 count 268 cells/µL, viral load 31 copies/mL) and Kaposi’s sarcoma presented with two days of diarrhea, abdominal pain, and a new rash on his hands. He had unprotected sexual intercourse with a new partner a few days prior to admission. On presentation, he was febrile and tachycardic. Physical exam revealed a hyperpigmented rash on his palms and soles bilaterally and condyloma lata on rectal exam. Initial laboratory workup revealed an alanine aminotransferase of 467 unit/L, aspartate aminotransferase of 259 unit/L, alkaline phosphatase of 1255 unit/L, and a total bilirubin of 0.3 mg/dL. A rapid plasma reagin was non-reactive. Gonorrhea and chlamydia screening from the rectum was positive. Secondary syphilis was suspected due to his pathognomonic presentation despite the unreactive rapid plasma reagin. The patient’s rapid plasma reagin sample was re-run after dilution which was reactive with a titer of 1:32. The patient was treated for secondary syphilis with one dose of 2.4 million units of benzathine penicillin intramuscularly. His diarrhea was thought to be secondary to proctitis from Gonorrhea/Chlamydia, however, due to the severity of symptoms, he was treated empirically with a course of doxycycline for lymphogranuloma venereum. His symptoms improved, and liver enzymes began to downtrend. Outpatient follow up showed near normalization of liver enzymes.Discussion: Secondary syphilis occurs in approximately twenty-five percent of individuals with untreated primary syphilis. Manifestations of secondary syphilis are varied, and can include the classic palmar and solar rash, a diffuse body rash, condyloma lata, glomerulonephritis, hepatitis, central nervous system involvement in addition to constitutional symptoms such as fever, malaise, lymphadenopathy, arthralgias, and weight loss. Syphilitic hepatitis, as seen in this case, typically presents with a disproportionally elevated alkaline phosphatase level, with normal to mildly elevated transaminase and bilirubin levels. Liver enzymes normalize after treatment for syphilis. False negative results can occur due to an antibody-antigen mismatch called the prozone phenomenon. Agglutination reactions rely on an antibody to antigen ratio within the zone of equivalence, or optimal ratio. The prozone refers to an excessively high antibody to antigen ratio, while the post zone refers to a low antibody to antigen ratio. Both can lead to false negative results, as a visible precipitant will not form properly.Conclusions: This case demonstrates that when the clinical suspicion for syphilis is high, it is prudent to have the laboratory dilute the sample in an attempt to bring the antibody to antigen ratio into the zone of equivalence if the initial rapid plasma reagin is non-reactive.References: Baughn RE, Musher DM. Secondary syphilitic lesions. ClinMicrobiol Rev. 2005;18(1):205-16. Brown DL. Diagnosis and Management of Syphillis. American Family Physician. 2003;68(2):283-290. doi:15554481. Sidana R, Mangala HC, Murugesh SB, Ravindra K. Prozone phenomenon in secondary syphilis. Indian J Sex Transm Dis AIDS. 2011;32(1):47-9. Young MF, Sanowski RA, Manne RA. Syphilitic hepatitis. J ClinGastroenterol 1992;15:174 doi:10.1097/00004836-199209000-00028

1003 A NOT-SO-BENIGN MECKEL'S DIVERTICULUM 1335094 Max Ruge Rush Medical Center Ira Miller Michael Ralls Erica Park Richard Dwyer Rush University Medical Center A NOT-SO-BENIGN MECKEL'S DIVERTICULUM Accept Case Presentation: A 71-year-old man with a history of Meckel’s diverticulum diagnosed by CT scan 10 months prior, diverticulitis, colonic polyps, intestinal hernias, iron deficiency anemia, and hypothyroidism presented to the ED with intermittent episodes of diffuse abdominal pain over the preceding 10 months with increasing frequency starting 3 days prior to arrival. Family history was significant for a sister with colon cancer diagnosed in her 30s. Routine colonoscopy 4 years prior revealed 13 polyps, which were removed. He had previously declined surgical intervention for his Meckel’s diverticulum, electing instead for conservative surveillance. Presenting vitals were stable, and labs were significant for his chronic anemia. CT abdomen demonstrated a partial small bowel obstruction within his known Meckel’s diverticulum. He was promptly taken to the OR for an uncomplicated exploratory laparotomy and ileal small bowel resection. Post-operative surgical pathology taken 15-20 cm from the ileocecal valve revealed high grade neuroendocrine carcinoma and moderately differentiated adenocarcinoma within the Meckel’s diverticulum that was also invasive to adjacent bowel. He was referred to oncology, and subsequently began chemotherapy.Discussion: A neuroendocrine tumor (NET) is a rare and frequently asymptomatic neoplasm of neuroendocrine cells. Given the numerous primary site locations and the wide range of secretory granules produced by these cells, tumors often present obscurely, making symptomatic diagnosis challenging. NETs are most common in the gastrointestinal tract (41.8%) and the lungs (27.4%) due to the high density of neuroendocrine cells within these sites. NETs have been reported along the entire GI tract from esophagus to anus although most commonly in the small intestine (29.0%) and rectum (27.4%). Symptoms vary considerably based on primary tumor location. Our patient’s tumor developed within his Meckel’s diverticulum, which has been reported in less than 200 cases. Although only 0.48% of NETs develop within a Meckel’s diverticulum, they are the most common neoplasm of a Meckel’s diverticulum. While the mechanism is unclear, some Meckel’s diverticuli contain a high density of parietal cells that is thought to provide an alkalotic environment favorable for NET development. The most common presentation of Meckel’s diverticulum NETs is obstruction, as seen with this patient. Although NETs are often thought to be relatively benign, 58.3% of small intestinal NETs are non-localized at diagnosis with a five-year survival of 60.5%. These indications do not solely represent benign tumors. The risk of lethal malignancy further emphasizes the importance of resecting a symptomatic Meckel’s diverticulum.Conclusions: NETs can develop within a Meckel’s diverticulum, particularly those with an alkalotic environment. Given that small intestinal NETs are often non-localized at the time of diagnosis with a five-year survival of 60.5%, this case further emphasizes the importance of resecting a symptomatic Meckel’s diverticulum.References: Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer. 2003 Feb 15;97(4):934-59. Modlin IM, Shapiro MD, Kidd M. An analysis of rare carcinoid tumors: clarifying these clinical conundrums. World J Surg. 2005 Jan;29(1):92-101. Review. Srisajjakul S, Prapaisilp P, Bangchokdee S. Many faces of Meckel's diverticulum and its complications. Jpn J Radiol. 2016 May;34(5):313-20. Review.

1008 A CROWNED DIAGNOSIS 1335553 Faye Sajjadi Jersey City Medical Center Valentin Marian A CROWNED DIAGNOSIS Accept Case Presentation: A 66-year-old female with a history of Cerebrovascular accident, diabetes, hypertension, chronic kidney disease, and osteoarthritis, presents to the hospital for worsening acute neck pain which had woken her up in the night a week prior. She had had minimal to no relief with Tylenol or Flexeril and her neck pain had continued to intensify radiating to the shoulder girdle, leading to marked immobility. Upon evaluation, she exhibited decreased range of motion in the cervical spine with significant limitations in rotation, and no evidence of meningeal irritation. Labs showed elevated erythrocyte sedimentation rate (ESR) >140 mm/hr (0.0-20.0) and C-Reactive Protein of 22.8 mg/dL (0.0-0.9), with no leukocytosis. CT of the cervical spine showed chondrocalcinosis of the transverse ligament of the atlas (Fig.1). Given her sudden onset severe cervical pain with stiffness, imaging, and elevated inflammatory markers with no evidence of infectious etiology, Crowned Dens Syndrome (CDS) was suspected. She was treated with methylprednisolone 40 mg followed by 20 mg the nest day in addition to Colchicine 1.2 mg once and 0.6mg daily for prophylaxis. The next day she reported dramatic improvement in her pain and range of motion, which further supported the suspected diagnosis. In outpatient clinic, her labs had normalized and she had complete resolution of her symptoms. Two weeks later a 73-year-old female with a history of coronary artery disease, heart failure recently on diuretics, hypertension, and osteoarthritis presented with sudden onset shoulder pain and fevers. On day two of admission, she woke up with severe neck pain and stiffness with no signs of meningeal irritation, which prompted further workup. She was found to have an elevated ESR >140 mm/hr (0.0-20.0) and CT cervical spine revealed retro-dental ligamental calcification (Fig.2). She was started on NSAIDs and methylprednisolone with improvement in her symptoms followed by Oral prednisone for 5 days on discharge.Discussion: Crowned dens syndrome is a rare form of calcium pyrophosphate dihydrate deposition disease. It is characterized by acute onset severe neck pain resulting in restricted neck rotation, which is associated with calcification deposited in the transverse and alar ligaments surrounding the odontoid process 1. The predilection for crystal deposition in and around the dens leads to the hallmark “crown-like” pattern seen on imaging2. In the acute form, there is an inflammatory response with elevated acute phase reactants with or without fever, oftentimes provoking clinicians to pursue workup for meningitis or Inflammatory arthritis. Females are more commonly affected, and risk factors include older age, osteoarthritis, CKD, and diuretics2.Conclusions: According to a study by Sayed Ali, et al, there have been 35 reported cases of Crowned Dens Syndrome, however the exact incidence remains unknown, with recent literature proposing that CDS may be more common than previously documented1. Patients respond well to corticosteroids, colchicine, and NSAIDs, therefore CDS is often treated symptomatically without formal diagnosis. It is important to consider Crowned Dens Syndrome in elderly patients who present with sudden onset neck pain accompanied by restricted motion, radiologic evidence of CPPD deposition surrounding the dens, and elevated inflammatory markers in the absence of infectious etiology. In doing so, extensive workup such as intrusive lumbar punctures, an extended hospital stay and incorrect treatment can be avoided.References: 1) Goto, S., Umehara, J., Aizawa, T., and Kokubun, S. Crowned dens syndrome. J Bone Joint Surg Am. 2007; 89: 2732–2736 2) Ali S, Hoch M, Dadhania V, Khurana JS. CPPD crowned dens syndrome with clivus destruction: a case report. J Radiol Case Rep. 2011;5(8):30–37. doi:10.3941/jrcr.v5i8.802. 3) Rho, Y.H., Zhu, Y., Zhang, Y., Reginato, A.M., and Choi, H.K. Risk factors for pseudogout in the general population. Rheumatology (Oxford). 2012; 51: 2070–2074

1014 BREAST CANCER METASTASIS MASQUERADING AS A PRIMARY GYNECOLOGICAL/ COLONIC MALIGNANCY: A RARE DIAGNOSTIC CONUMDRUM 1334969 Humaira Sarfraz Houston Methodist Hospital Diana Chen Ibrahim Muhsen MARTINA OGBONNA BREAST CANCER METASTASIS MASQUERADING AS A PRIMARY GYNECOLOGICAL/ COLONIC MALIGNANCY: A RARE DIAGNOSTIC CONUMDRUM Accept Case Presentation: 60 year old female who presented with generalized abdominal pain and distension. Associated featured included unintentional weight loss of 20 lbs, fatigue, nausea, vomiting. She denied melena, hematochezia, diarrhea or pelvic bleeding. Her past medical history was significant for Estrogen Receptor (ER) positive, Progesterone Receptor (PR) positive, human epidermal factor 2 (HER2) negative, stage 1 right breast lobular cancer for which she underwent bilateral mastectomy the same year. The left breast was removed pre-emptively and she took Tamoxifen for five years. Physical exam revealed stable vital signs, distended abdomen, generalized tenderness with positive fluid thrill. Initial CT scan of the abdomen and pelvis showed a moderate sized right sided pleural effusion, large ascites in the abdomen, an enlarged uterus with multiple fibroids with fluid filling the endometrium with enhancement. She underwent thoracentesis and paracentesis which were consistent with an exudative process suspicious for malignancy versus tuberculosis (TB); workup for both of these was negative. Elevated tumor markers CEA, CA 27-29, CA15-3 and CA125 were noted. Her CBC was remarkable for normocytic anemia. Later, she was evaluated by the gynecological oncology team due to the concern for a primary uterine malignancy. Subsequently MRI abdomen/ pelvis was done to evaluate for her primary malignancy, this revealed distal descending colon narrowing concerning for a colonic mass along with peritoneal carcinomatosis. No endometrial mass was noted. Subsequently, the patient underwent flexible sigmoidoscopy which showed an infiltrating, circumferential partially obstructing mass in the rectosigmoid colon. Biopsy results were consistent with invasive lobular cancer with a primary breast cancer. The patient was also evaluated by gastroenterology for any possible intervention with diverting colostomy or stenting for her colonic mass but given her metastatic disease and higher risk versus benefit of surgery, conservative management was recommended. The teams discussed the the non-curable nature of disease with the family. The patient was subsequently started on letrozole and abemciclib and discharged to skilled nursing facility with scheduled frequent paracentesis.Discussion: The most frequent sites of metastasis from breast cancer include liver, lung, brain and bones. Involvement of GI tract secondary to a primary breast malignancy is rare and the most common histopathological diagnosis is Invasive lobular carcinoma. The mechanism of cancer dissemination is thought to be primarily hematogenous; others include lymphatic and peritoneal. Since the spectrum of clinical presentation of metastatic breast cancer to colon is very wide and maybe non-specific, this poses a significant diagnostic challenge. The prognosis of metastatic breast cancer to gastrointestinal tract is dismal with very few patients surviving beyond 2 years. As per statistics from National Institute of Health, in 2015, 71.6% women had a screening mammogram while 63.4% of women got colonoscopy within the screening age group indicating that while women are getting the mammogram, there still exists an 8.2% difference between the colonoscopy and mammogram rate.Conclusions: This case demonstrates the importance of considering metastatic breast cancer as a differential when a patient presents with non-specific abdominal complaints in the context of a previously treated primary breast malignancy.References: 1. Matsuda I, Matsubara N, Aoyama N, Hamanaka M, Yamagishi D, Kuno T, et al. Metastatic lobular carcinoma, of the breast masquerading as a primary rectal cancer. World J Surg Oncol 2012; 10:231 10.1186/1477-7819-10-231. 2. Galanopoulos M, Gkeros F, Liatsos C, Pontas C, Papaefthymiou A, Viazis N, et al. Secondary metastatic lesions to colon and rectum. Ann Gastroenterol 2018; 31:282–7. 10.20524/aog.2018.0244. 3. Balakrishnan B, Shaik S, Burman-Solovyeva I. An unusual clinical presentation of gastrointestinal metastasis from invasive lobular carcinoma of breast. J Investig Med High Impact Case Rep 2016; 4:2324709616639723 10.1177/2324709616639723. 4. Albero-González R, Gimeno-Beltrán J, Vázquez de las Heras I, et al. Lobular breast carcinoma with colonic metastases: A synchronous diagnosis in a 4-day period. Human Pathology: Case Reports. 2017; 7:27–30.

1029 MOLDY DRAINS: A RARE CASE OF SFP (SECONDARY FUNGAL PERITONITIS), NOT SBP 1334326 Vijairam Selvaraj Miriam Hospital Karina Verma Jaclyn McKenna MOLDY DRAINS: A RARE CASE OF SFP (SECONDARY FUNGAL PERITONITIS), NOT SBP Accept Case Presentation: We present a 68-year-old woman who was in her usual state of health until July 2019 who presented with abdominal pain, back pain along with unintentional weight loss. Imaging revealed a mass in her pancreatic body which was confirmed with EUS and biopsy as invasive pancreatic adenocarcinoma. In late August, she presented with jaundice and worsening abdominal pain and was diagnosed to have extensive intrahepatic biliary dilatation. ERCP was attempted, although this was unsuccessful and she eventually had a percutaneous biliary drain placed. In early September, she was started on gemcitabine and abraxane for her pancreatic adenocarcinoma. A few days later, she was noted to have a perihepatic biloma when her initial drain was dislodged and a second drain was placed. At this time, she was also started on SBP prophylaxis with ciprofloxacin. She returned to the hospital a few weeks later with nausea, vomiting, generalized abdominal pain, and failure to thrive. Imaging showing worsening ascites with associated enhancement of the peritoneum. She underwent diagnostic paracentesis and was started on intravenous ceftriaxone for Spontaneous Bacterial Peritonitis. Fluid studies showed 98% polys, 4778 nucleated cell count and 78,250 RBCs. Her cultures later came back positive for Candida albicans following which Infectious Diseases was consulted and the patient was started on intravenous caspofungin. She was later transitioned to oral fluconazole and discharged to inpatient hospice.Discussion: Fungal peritonitis is noted to be prevalent in 1 to 15% of patients undergoing peritoneal dialysis. However, the incidence in non-dialysis patients is rare. There have only been a few case reports that have discussed fungal peritonitis in association with intra-abdominal malignancies. There are two types of fungal peritonitis: primary and secondary. Primary disease occurs when there is no apparent breach in the gastrointestinal tract causing the organism to translocate into the peritoneum. Secondary fungal peritonitis is related to a pathologic process in a visceral organ, such as perforation, trauma, or local abdominal infections. Aside from peritoneal dialysis, other risk factors include immunosuppression, abdominal malignancy, prolonged antibiotics, previous bacterial peritonitis, and bowel source infections. Our patient had secondary fungal peritonitis due to biliary drains and manipulation of the drains multiple times, with the additional risk factors of abdominal malignancy and immunosuppression. Overall, 70-90% of the cases with fungal peritonitis are attributable to Candida albicans. Treatment is initially with echinocandins which can be later de-escalated based on sensitivities.Conclusions: A high index of suspicion along with prompt diagnosis of fungal peritonitis in high risk patients is essential to reduce morbidity and mortality. Positive cultures in these patients should be treated immediately and not dismissed as a contaminant.References: 1. Miles et al. “Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients” Kidney international. 76:622-628, 2009. 2. Prasad et al. “Fungal peritonitis in peritoneal dialysis patients” Peritoneal Dialysis International. 25:207-222,2005. 3. Hu et al. “Fungal peritonitis in peritoneal dialysis: 5 year review from North China center” Infection. 47: 35-43, 2019.

1037 C. GLABRATA: PART OF NORMAL SKIN FLORA OR IS IT? 1335613 Megha Shalavadi UHS SOCAL MEC Humera Syeda Timothy Killeen C. GLABRATA: PART OF NORMAL SKIN FLORA OR IS IT? Accept Case Presentation: A 69 year old male with a medical history of oxygen dependent COPD, diabetes and hypertension presented with one week history of worsening shortness of breath and non-productive cough. Review of systems was positive for subjective fevers and negative for weight changes and hemoptysis. He had no recent travel history. The patient was in a homosexual relationship with a single partner for 25 years and non-smoker who denied intravenous illicit drug abuse. On presentation, he was afebrile and saturated 95% on 15 liters oxymizer with respiratory rate 18, remaining vitals were stable. Labs showed elevated WBC count 14.2 with 84.9% neutrophils. Lung examination showed diffuse bilateral crackles. Chest x-ray revealed mild to moderate interstitial infiltrate and/or edema bilaterally. Chest CT scan showed several bilateral infiltrates concerning for opportunistic infection like pneumocystis jirovecii and possible obstruction of right bronchus causing right lower lobe atelectasis. A decision was made to start dapsone and primaquine for pneumocystis. On hospital day 4, he was intubated for hypoxemic respiratory failure. Subsequently, underwent bronchoscopy that showed bilateral bronchitis, severe retained secretions and bloody plug obstructing right bronchial tree which was removed. Status post the procedure patient’s oxygenation mildly improved. Bronchial washings came back positive for candida glabrata. Serology for opportunistic infections including HIV, coccidioidomycosis and legionella were negative. Micafungin was initiated and dapsone and primaquine were discontinued. Patient symptoms improved and was extubated on hospital day 13, however 24 hours later his condition decompensated requiring reintubation for altered awareness. He expired on hospital day 14 as his family made the decision to withdraw medical care for poor prognosis in the setting of multi-organ failure.Discussion: Candida is a normal commensal of skin, respiratory flora, gastrointestinal tract and vagina. It is harmless in the immunocompetent population, but evident in the immunosuppressed and neutropenic, especially in those with HIV. Specific risk factors include prolonged hospitalization, prior antibiotic use, use of fluconazole and other immunosuppressive agents. [1] Candidiasis can manifests as an oropharyngeal lesion, vaginitis, or invasive candidiasis invades the bloodstream, heart, eyes, brain or bones. Hospitalizations due to pneumonia are especially common in the elderly, herein we present a case of primary Candida bronchopneumonia.Conclusions: As illustrated, this patient’s scenario was anomalous, his presentation resembled candida bronchopneumonia. Per literature review, conflicting data has been documented on the initiation of medical therapy between the Infectious disease and Critical Care intensivists [2]. On a significant note, non-albicans candida including the glabrata species, has developed resistance to the commonly used azole group of antifungals by upregulating ATP-binding cassette transporters, such as CDR1 and SNQ2, that effectively pump the drugs out of the yeast cell, recommended drug of choice is an echinocandin (such as caspofungin, micafungin, or anidulafungin), or the combination regimen of fluconazole and amphotericin B. [3,4] Fungal bronchopneumonia in non-neutropenic ICU patients is extremely rare, thus further studies are warranted to determine the predisposing factors in immunocompetent individuals such as our patient.References: [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC88907/ [2] https://core.ac.uk/download/pdf/159155547.pdf [3] https://www.frontiersin.org/articles/10.3389/fmicb.2016.01995/full [4] https://www.thoracic.org/statements/resources/tb-opi/treatment-of-fungal-infections-in-adult-pulmonary-critical-care-and-sleep-medicine.pdf

1061 DEBILITATION AFTER CANCER REMISSION: THE DEVASTATING CONSEQUENCES OF PARANEOPLASTIC NEUROLOGIC SYNDROMES 1335520 Kristen Simmons Baylor College of Medicine Emily Podany Michelle Sibille MD Anderson Cancer Center DEBILITATION AFTER CANCER REMISSION: THE DEVASTATING CONSEQUENCES OF PARANEOPLASTIC NEUROLOGIC SYNDROMES Accept Case Presentation: A 61-year-old woman with no pertinent past medical history presented to the hospital with two months of progressive numbness that began with her left foot and hands and eventually extended to her forearms. She developed clumsiness in her hands, gait unsteadiness, and had a 20-pound weight loss. A CT scan of the chest on arrival showed lymphadenopathy and a tumor concerning for primary malignancy in the right upper lobe. She underwent a bronchoscopy with lymph node biopsy that showed high grade large cell neuroendocrine carcinoma. Her serum was sent for paraneoplastic antibody testing and was positive for anti-ANNA1/anti-Hu antibodies. She underwent 7 cycles of carboplatin/etoposide systemic chemotherapy. Her tumor was highly responsive to chemotherapy, and she was found to be in remission on PET-CT after completion. She initially had mild improvement in her neurologic symptoms while on a high-dose prednisone taper. However, several months into cancer treatment she developed acute onset of an unusual and devastating constellation of symptoms including significantly worsened coordination, neuropathy, uncontrollable arm flailing, diplopia, unilateral hearing loss, urinary frequency, shallow breathing, muscular fasciculations and labile blood pressures concerning for autonomic dysfunction. She was unable to stand on her own and required help with all activities of daily living, despite being cancer-free. In an attempt to reverse her rapidly worsening symptoms, she was admitted for IV steroids and plasmapheresis. Unfortunately, there was no significant improvement in her neurological exam, and she was discharged to a SNF for physical therapy. At a follow up visit, she reported that with physical therapy she had regained the ability to feed herself but remained otherwise disabled.Discussion: Paraneoplastic neurologic syndromes are potentially devastating sequelae of cancers caused by an immunologic response directed against shared antigens expressed by the cancer and the nervous system. Classical paraneoplastic antibodies, such as the Hu antibody (ANNA-1), are directed against intracellular neuronal proteins, and their detection almost always indicates the presence of an underlying tumor. Anti-Hu paraneoplastic antibody syndrome typically presents with encephalomyelitis, cerebellar degeneration, sensory neuronopathy, and autonomic dysfunction. It is associated with small cell lung cancer predominantly, though it can be found in other cancers. There are two general approaches to treatment of paraneoplastic syndromes: removing the antigen source by treating the underlying tumor and suppressing the immune response with therapies such as steroids, plasma exchange, IVIG, or rituximab. Classical paraneoplastic syndromes that target intracellular antigens, such as anti-Hu, typically do not respond well to treatment and physicians can often only stabilize the symptoms at best, as seen in our patient.Conclusions: This case demonstrates the tragic consequences of paraneoplastic neurologic syndromes. Despite successful treatment of the lung cancer with chemotherapy, our patient continued to have major neurologic decline. Immune modulation with high dose steroids and plasma exchange were ineffective. We present this case in hopes that hospitalists will recognize the signs and symptoms of paraneoplastic neurologic syndromes early enough to attempt stabilization before it is too late.References: Dalamau, J., and M. Rosenfeld. "Overview of paraneoplastic syndromes of the nervous system." Waltham, MA: UptoDate(2018). Dalmau, Josep, et al. "Paraneoplastic and autoimmune encephalitis." Waltham, MA: UptoDate(2017). Douglas, Claire A., and John Ellershaw. "Anti-Hu antibodies may indicate a positive response to chemotherapy in paraneoplastic syndrome secondary to small cell lung cancer." Palliative medicine 17.7 (2003): 638-639. Senties-Madrid, H., and F. Vega-Boada. "Paraneoplastic syndromes associated with anti-Hu antibodies." The Israel Medical Association journal: IMAJ 3.2 (2001): 94-103.

1074 WHERE THERE'S VAPE, THERE ISN'T ALWAYS FIRE. 1334729 Christopher Smith University of Michigan David Paje WHERE THERE'S VAPE, THERE ISN'T ALWAYS FIRE. Accept Case Presentation: A 25-year-old woman with history of childhood asthma presented with 1 week of fever, dry cough and chest discomfort. She also had non-bloody diarrhea, nausea and vomiting. On review, she admitted vaping THC and CBD products for the past 9 months. She was afebrile with HR 115 bpm, BP 130/61 mmHg, RR 18/min and SaO2 95% on room air. She was ill-appearing, tachycardic with regular rhythm and had mild rales heard in the lower lung fields. Lab findings revealed a leukocytosis of 16,800 WBC/ul with 91% neutrophils. Chest x-ray was normal, but chest CT showed multifocal ground glass opacities with tiny pleural effusions and no pulmonary embolism (figure 1). Nasopharyngeal respiratory pathogen PCR and urine streptococcus and legionella antigens were negative. HIV antibody was negative and BNP was normal. Sputum culture grew oral flora, and AFB and fungal smears were negative. PCR from stool was positive for enteroaggregative E. coli and IV azithromycin was started. Bronchoscopy was limited due to severe procedural coughing; however, infectious studies from aspirated fluid were negative. ANA, ANCA, RF, CCP, C3, and C4 were normal. A diagnosis of vaping-induced lung injury was favored and IV steroids were started. She clinically improved after 2 days. Prior serology studies returned with positive mycoplasma pneumoniae IgM and IgG antibodies. Immunofluorescence testing for M. pneumoniae IgM was also positive. Given these findings and the prior GI PCR, she completed 5 days of azithromycin and was discharged on a rapid steroid taper. Two weeks later, she reported near-resolution of her cough and had no GI or systemic symptoms.Discussion: A form of acute lung injury related to the use of e-cigarettes, particularly those containing THC, has recently emerged. Presenting symptoms usually include cough, chest pain and shortness of breath, and frequently occur with concurrent abdominal pain, nausea, vomiting and diarrhea. Fever, chills and weight loss are also common. Chest exam is often unremarkable while chest x-ray may show pulmonary infiltrates or appear normal. Basilar-predominant consolidation and ground-glass opacities, with lobular or subpleural sparing, are often seen on CT. However, these same symptoms and findings are also found in other acute illnesses such as typical and atypical bacterial pneumonias, viral infections, endemic mycoses and opportunistic infections. This patient’s GI symptoms were likely due to E. coli enterocolitis. The initial respiratory PCR was negative for mycoplasma perhaps due to sampling only from the upper respiratory tract or the early disappearance of M. pneumoniae as a result of her immune response. Mycoplasma pneumonia is preferably diagnosed using serology combined with direct pathogen detection. If discordant, a significant rise in specific antibodies over time may more accurately provide evidence of active infection. Whether vaping synergistically worsens mycoplasma or other common pulmonary and/or GI illnesses is unknown.Conclusions: Although vaping-induced lung injury has become an epidemic among users of e-cigarette products, this remains a diagnosis of exclusion. Alternate etiologies of acute pulmonary and GI illness must be ruled out, particularly pulmonary mycoplasma infection. Empiric treatment for pneumonia when vaping-induced injury is suspected appears prudent. As in this case, hospitalists should be mindful of availability heuristic and anchoring bias when considering vaping-induced lung injury.References: 1. Atkinson TP, Balish MF, Waites KB. Epidemiology, clinical manifestations, pathogenesis and laboratory detection of Mycoplasma pneumoniae infections. FEMS Microbiol Rev 2008;32:956-73. 2. Daxboeck F, Krause R, Wenisch C. Laboratory diagnosis of Mycoplasma pneumoniae infection. Clin Microbiol Infect 2003;9:263-73. 3. Henry TS, Kanne JP, Kligerman SJ. Imaging of Vaping-Associated Lung Disease. N Engl J Med 2019;381:1486-7. 4. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury - United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:919-27.

1081 A RARE CASE OF ACQUIRED THROMBOTIC THROMBOCYTOPENIC PURPURA, TRIGGERED BY ACUTE PANCREATITIS 1335357 Metlapalli Venkata Sravanthi The Wright Center for Graduate Medical Education Sharmil Suma Kumaran The Wright Center for Graduate Medical Education Nishant Sharma A RARE CASE OF ACQUIRED THROMBOTIC THROMBOCYTOPENIC PURPURA, TRIGGERED BY ACUTE PANCREATITIS Accept Case Presentation: A 59-year-old female with a history of type 2 diabetes, hypertension, dyslipidemia, bipolar disorder, and daily alcohol use, presented with acute onset epigastric abdominal pain radiating to the back, nausea and vomiting. Physical examination was notable only for epigastric tenderness. Pertinent labs include neutrophilic leukocytosis, elevated lipase (2353 units/L) and lactic acidosis (2.4 mmol/L). Computed tomography (CT) of the abdomen was notable for interstitial pancreatic edema and inflammatory changes, suggestive of acute pancreatitis. He was treated conservatively with bowel rest, intravenous hydration, and symptomatic treatment, with satisfactory symptomatic improvement. On hospital day 2, he developed fever, acute kidney injury stage II, thrombocytopenia, and hemolytic anemia. His platelets downtrended to a nadir of 42 K/mm3. A peripheral smear revealed schistocytes. Further imaging and cultures ruled out an infectious etiology. A negative serotonin release assay and elevated fibrinogen did not favor the diagnosis of disseminated intravascular coagulation or heparin induced thrombocytopenia. The diagnosis of acquired thrombotic thrombocytopenic purpura (TTP) was made; he was treated with four sessions of plasmapheresis, in addition to intravenous steroids and supportive blood transfusions, with subsequent normalization of platelet counts, and stabilization of renal function.Discussion: Acquired thrombotic thrombocytopenic purpura (TTP) is a rare, fatal thrombotic microangiopathy with an estimated incidence of three cases per 1,000,000 adults per year. It can be triggered by various conditions such as sepsis, infections, and pregnancy. But, an inciting event is not usually identified in majority of the cases. In idiopathic acquired TTP, severe deficiency in ADAMTS13 protease results in accumulation of large vWF multimers. These multimers results in widespread formation of platelet microthrombi, with protean manifestations depending on the distribution of microthrombi. A high index of clinical suspicion should be maintained in a patient with hemolytic anemia and thrombocytopenia, despite the nature of presentation; timely diagnosis and treatment is paramount, given the high fatality rate. An ADAMTS13 activity assay confirms the diagnosis, but should not delay plasmapheresis, which is the mainstay of treatment. While pancreatic involvement in TTP is an established entity, acute pancreatitis as an inciting event of TTP is rare, with only a few reported cases in our literature review. Swisher et al, in his review of such cases, found a median interval of three days between the diagnosis of acute pancreatitis and TTP, corresponding to the timeline in this patient. Diffuse endothelial injury as a consequence of inflammatory cytokine release in association with the systemic inflammatory state observed with pancreatitis has been postulated to be the causative mechanism.Conclusions: This case demonstrates the rare occurrence of TTP as a consequence of acute pancreatitis. Clinicians should consider TTP upon encountering thrombocytopenia and microangiopathic hemolytic anemia in systemic inflammatory states. Early initiation of plasmapheresis is key to the clinical outcome.References: 1. Ali MA, Shaheen JS, Khan MA. Acute pancreatitis induced thrombotic thrombocytopenic purpura. Indian J Crit Care Med. 2014;18(2):107–9. 2. Gurjar M, Saigal S, Azim A, et al. Acute pancreatitis-induced thrombotic thrombocytopenic purpura. JOP. 2012;13:80–82. 3. Arimoto M, Komiyama Y, Okamae F, et al. A case of thrombotic thrombocytopenic purpura induced by acute pancreatitis. Int J Gen Med. 2012;5:307–11. 4. Swisher KK, Doan JT, Vesley SK, et al. Pancreatitis preceding acute episodes of thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: Report of five patients with a systematic review of published reports. Haematologica. 2007;92:936–43. 5. Rawala MS, Naqvi STS, Khan MY, El Toukhy A. A Rare Case of Thrombotic Thrombocytopenic Purpura Caused by Pancreatitis and Clopidogrel. Am J Case Rep. 2018 Oct 30;19:1288-1291.

1082 ANGIOTENSIN CONVERTING ENZYME INHIBITOR INDUCED VISCERAL ANGIOEDEMA: AN ELUSIVE DIAGNOSIS 1335625 Metlapalli Venkata Sravanthi The Wright Center for Graduate Medical Education Sharmil Suma Kumaran The Wright Center for Graduate Medical Education Nisha Kuruvadi ANGIOTENSIN CONVERTING ENZYME INHIBITOR INDUCED VISCERAL ANGIOEDEMA: AN ELUSIVE DIAGNOSIS Accept Case Presentation: A 44-year-old African-American male with past medical history of hypertension, asthma and obesity, presented to the emergency room with acute onset, constant, severe lower abdominal pain of two days duration which was throbbing and aching in quality without any radiation. He also endorsed nausea & loose stools. Of note, his hypertension was newly diagnosed 3 weeks before, and he was started on lisinopril at that time. The only other medication he had was an albuterol rescue inhaler. There were no known allergies to any medication. Physical examination revealed normal vital signs as well as a soft, protuberant abdomen with tenderness in lower quadrants and hypoactive bowel sounds. McBurney's sign was absent. Pertinent labs include slightly elevated creatinine of 1.4 mg/dL and normal white blood cell counts. Computed tomography (CT) scan of the abdomen and pelvis revealed thickened, inflamed loops of a long segment of the jejunum, with interloop fluid, areas of marked submucosal edema surrounded by enhancing mucosa and serosa (‘doughnut sign’), and mesenteric engorgement. Additional investigations showed normal C1 esterase and complement C4 levels, ruling out hereditary angioedema. He was clinically diagnosed with lisinopril-induced mesenteric angioedema and lisinopril was discontinued. He was managed supportively with bowel rest for a day, intravenous fluids, and H2 blockers. He improved clinically and his diet was progressively advanced as tolerated. He was discharged to his home after 48 hours.Discussion: Angiotensin Converting Enzyme (ACE) inhibitors are widely used in clinical practice for management of hypertension, heart failure and kidney disease. They are generally well tolerated. Among the few idiosyncratic side effects of ACE inhibitors, angioedema is relatively rare and potentially fatal with an estimated incidence of 0.1 to 0.7 % among recipients. Visceral angioedema is even rarer, with only a handful of cases reported in the literature. It can present with symptoms such as abdominal pain, diarrhea, vomiting, anorexia, and ascites, the differential diagnosis for which are numerous. In this case, the onset of symptoms were about three weeks after initiating lisinopril, which made the diagnosis relatively obvious. This is not always the case, as the angioedema can present within 72 hours of starting ACE inhibitor therapy, or after weeks to years of therapy. In such cases diagnosis depends on clinical suspicion in conjunction with helpful CT abdomen findings such as ‘doughnut sign’ as seen in this case, thickened mucosal folds with a ‘stacked coin’ appearance and mesenteric edema.Conclusions: The rarity, non-specificity of presentation, varied chronology, and absence of any confirmatory testing makes the diagnosis of ACE inhibitor induced visceral angioedema an elusive one, thus leading to unwarranted invasive procedures; this case illustrates the importance of a thorough history including a complete medication reconciliation.References: 1. Makani H, Messerli FH, Romero J, et al. Meta-analysis of randomized trials of angioedema as an adverse event of renin-angiotensin system inhibitors. Am J Cardiol 2012; 110:383. 2. Banerji A, Blumenthal KG, Lai KH, Zhou L. Epidemiology of ACE Inhibitor Angioedema Utilizing a Large Electronic Health Record. J Allergy Clin Immunol Pract 2017. 3. Schmidt TD, McGrath KM. Angiotensin-converting enzyme inhibitor angioedema of the intestine: a case report and review of the literature. Am J Med Sci 2002; 324:106. 4. Dietler V, Fusi-Schmidhauser T. Intestinal Angioedema in a Palliative Care Setting. Am J Med 2016; 129:e293. 5. Orr KK, Myers JR. Intermittent visceral edema induced by long-term enalapril administration. Ann Pharmacother 2004; 38:825. 6. Banerji A, Clark S, Blanda M, et al. Multicenter study of patients with angiotensin-converting enzyme inhibitor-induced angioedema who present to the emergency department. Ann Allergy Asthma Immunol 2008; 100:327. 7. Marmery H, Mirvis SE. Angiotensin-converting enzyme inhibitor-induced visceral angioedema. Clin Radiol 2006; 61:979. 8. Ciaccia D, Brazer SR, Baker ME. Acquired C1 esterase inhibitor deficiency causing intestinal angioedema: CT appearance. AJR Am J Roentgenol 1993; 161:1215.

1089 A RARE CAUSE OF PAINFUL OPHTHALMOPLEGIA: TOLOSA-HUNT SYNDROME 1334736 Devin Sullivan ChristianaCare Justin Nichols Chelsea Hastry Kevin Patel Ajeetpal Hans A RARE CAUSE OF PAINFUL OPHTHALMOPLEGIA: TOLOSA-HUNT SYNDROME Accept Case Presentation: A 42-year-old woman presented with a chief complaint of a 5-day, constant, 10/10, stabbing headache located behind her left eye that began suddenly. Associated symptoms were blurred vision, diplopia, photophobia, lacrimation, left facial numbness, and difficulty opening her left eye. Her medical history included migraine, obesity, asthma, diverticulitis, and osteoarthritis; home medications were Lortab, olanzapine, and rizatriptan which did not relieve her headache. She was afebrile and hemodynamically stable throughout her hospital course. Examination revealed left ptosis and periorbital numbness. She had a dilated pupil slowly reactive to light, diminished vertical gaze, medial deviation, and decreased visual acuity of the left eye. Labs were significant for mild neutrophilia. ACE receptor antibody, ANA multiplex, and ANCA studies were negative. RPR was non-reactive. Blood cultures were negative. CSF studies, including Lyme disease, were unremarkable. Chest x-ray and head CT scan, MRA, and MRV were unrevealing. However, MRI with contrast showed abnormal enhancement on the left lateral wall of the cavernous sinus. Two days of broad-spectrum IV antibiotics were completed without improvement. The patient was switched to steroids and within one day had considerable pain relief. Her negative workup, suggestive imaging, and response to steroids supported the final diagnosis of Tolosa-Hunt Syndrome (THS).Discussion: The differential for painful ophthalmoplegia is broad and includes traumatic, infectious, neoplastic, vascular, systemic, and inflammatory etiologies, such as THS. Appropriate hematologic tests, CSF studies, and neuroimaging must be completed. THS has been identified as a unique pathology for 65 years and remains a diagnosis of exclusion. The diagnosis of THS has high sensitivity, but low specificity. MRI is reported to be the most sensitive imaging study for THS. Notably, these MRI findings are nonspecific and can mimic lymphoma, meningioma, or sarcoidosis. Pathologically, THS is a nonspecific granulomatous inflammation within the cavernous sinus or superior orbital fissure that can compromise cranial nerves III, IV, VI and V1. This rare, idiopathic, and relapsing syndrome has no known triggers or geographic, gender, or racial predominance. Symptoms typically resolve without treatment within 8 weeks. Residual nerve palsy is a rare complication. Steroids are known t