Abstracts from the 2016 Society of General Internal Medicine Annual Meeting

use, indicating some polysubstance use across the sample. All participants had health


insurance. Participants described hospitalization as a wake up call. One participant said, “I wish I didn’t put myself in the predicament of coming to the hospital so much. It’s been an experience, a life-learning experience. But then again, coming here so much has helped me notice and realize—to wake up. It’s time to stop doing’ what I’m doing, to get to the sober and clean path.” Many described near death experiences, and that mortality was


motivating for change. As one woman stated, “I knew it was to that point where I almost


died the other day and I have a 3 year old little boy and it’s not where I want to be.”

STANCE USE DISORDERS Honora Englander1, 4; Christine Velez Klug3; Philip T.

Participants also described that hospitalization interrupted drug use and allowed for fresh

Korthuis2; Sarann Bielavitz2; Christina Nicolaidis3, 2. 1Oregon Health & Science Univer-

insight. Despite hospitalization being a reachable moment and highly motivating for

sity, Portand, OR; 2Oregon Health & Science University, Portland, OR; 3Portland State

change, participants described important barriers that impeded the ‘opportunity’ of the

University, Portland, OR; 4Central City Concern, Portland, OR. (Control ID #2469883)

moment. Many described an overwhelming compulsion to use. “My whole addiction to heroin, it’s going to end up killing me, and I still know that I’m going to go back out there

BACKGROUND: People with substance use disorders (SUD) have high rates of chronic

and do it, and that’s just so f**d up…” Participants described physical pain, trauma, life

illness, hospitalization and readmission. Frequently, people are admitted with direct

stressors, and poverty as significant barriers to recovery that are unchanged by acute

medical complications of their SUD. Despite this, many are not engaged in addiction

hospitalization. One participant who underwent medical detoxification in the hospital and

treatment. And though hospitalization addresses acute medical illness, it often fails to

expressed strong desire to quit reflected, “I almost see it like being futile… I have nowhere

address the underlying cause: the SUD. Hospitalization may be a reachable moment to

to go and nothing.” Participants provided insight as to how healthcare providers and health

initiate and coordinate addiction care. However, little is known about hospitalized pa-

systems can best leverage a reachable moment. Many emphasized the importance of

tients’ perceptions of their SUD and the mechanisms that may support or impede

choice: “when you tell me what to do, I’m a mule. I dig my hooves in and I’m like uh-uh

engagement and success in recovery. Our study explores the experiences of hospitalized

[shaking head], I make my own decisions. But if I have somebody to talk to that could

adults with SUD to inform future health system improvements.

understand where I’m coming from, yeah, I could see that helping people.” Some felt that

METHODS: We conducted in-person interviews of hospitalized adults reporting high-

being given a list of resources (often with long wait times and limited access) without

risk alcohol or drug use on the AUDIT-C and/or single item screener between September

support felt dismissive. She felt providers think: “give her the list of resources, if she wants

2014 and April 2015. This study was nested in a larger needs assessment at a large

help she’ll figure it out’…they feel it’s useless to waste their time when all I want is help.”

academic medical center. We excluded non-English speakers, incarcerated individuals,

Participants wanted providers that understand SUD—in particular to treat withdrawal to

those who were too sick or confused to participate, and those admitted to an ICU or

prevent people from leaving the hospital against medical advice and to provide access to

psychiatric ward. We interviewed all participants in their hospital room using a semi

medication-assisted treatment. And many noted the importance caring, non-judgmental

structured interview guide. Audio recordings were transcribed, de-identified and trans-


ferred to Atlas.ti (Version 7.5.9) for data analysis and retrieval. The coding

CONCLUSIONS: Our findings suggest that hospitalization may be a reachable moment

team—comprised of two general internists and one social worker—conducted a thematic

to initiate and coordinate addiction care. Hospitalization is often a wakeup call that is

analysis using an inductive approach at the semantic level. Using an iterative process, we

highly motivating. While some barriers such as poverty and trauma may be difficult to

selected a preliminary coding schema, independently coded transcripts, and then met as a

address through acute hospitalization, providers and systems can better align to engage

group or in dyads to discuss and reconcile codes, identify emergent themes, and to resolve

patients. Systems can support a culture of non-judgment, train staff about SUD, and

discrepancies through consensus. All three coders coded the initial 7 transcripts and

provide patients with choice, including access to medication-assisted treatment.

established a coding schema. One coder coded all transcripts; the other two coders divided the remaining transcripts. We employed a constructivist approach to data analysis in that we acknowledged no one reality; people are experts on their own lives.


RESULTS: Thirty-two hospitalized adults participated in our study. Mean age was


43 years. Seventy-five percent were male and 68 % identified as white. Participants


reported moderate to high-risk alcohol (56 %), amphetamine (56 %), and opioid (56 %)

Melissa Dattalo1, 2; Korey Kennelty1, 2; Elizabeth Chapman2; Andrea Gilmore-





Bykovskyi1, 2; Julia Loosen2; Emily Schmitz2, 1; Mary F. Wyman2; Nicole Rogus-Pulia1,

CONCLUSIONS: High-cost, high-need patients in this study reported having unique


; Nicole Werner2; Amy J. Kind2, 1; Barbara Bowers2. 1William S. Middleton VA

information that led to longer periods of stable outpatient management if that information

Hospital, Madison, WI; 2University of Wisconsin-Madison, Madison, WI. (Control ID

was used to individualize their treatment plans. Person-centered care interventions that


facilitate this information exchange have the potential to improve quality and reduce hospital utilization for high-cost, high-need patients.

BACKGROUND: High-cost, high-need patients account for disproportionate health care spending, with most costs accrued through hospital admissions. A threshold of 3 or more hospital admissions in a year can identify those in the top 5 % of health care spending. Within


the Medicare population, 5 % of fee-for-service beneficiaries account for 39 % of total


spending. The complex medical and social needs of these individuals are often mismatched

PHYSICIAN INTERACTIONS Rebekah Gardner1; Kimberly Pelland3; Rosa Baier2.

with traditional health services. Person-centered care has been associated with greater trust


and improved medication adherence, but high-cost, high-need patients are underrepresented

of Public Health, Providence, RI; 3Healthcentric Advisors, Providence, RI. (Control ID

in research studies. Understanding the goals, values, and perceptions of this population is


Alpert Medical School of Brown University, Providence, RI; 2Brown University School

critical to designing cost-effective interventions. The purpose of this grounded theory study was to identify the complex needs of high-cost, high-need patients by developing a theoret-

BACKGROUND: Electronic health records (EHRs) have the potential to reduce medical

ical model of factors contributing to their hospital utilization patterns.

errors and improve care, but their use may complicate the clinical encounter. Understanding

METHODS: Grounded theory is a qualitative research method that can both describe the

how EHRs impact patient-physician interactions can inform the development of interventions

complex interactions contributing to a process and generate theories that are grounded in

to improve how physicians incorporate EHRs when caring for patients. The objective of this

the lived experiences of participants. This qualitative method is designed to analyze in-

study is to describe office- and hospital-based physicians’ perceptions of the effect of EHRs

depth information from specific individuals, using small sample sizes. We conducted in-

on patient-physician interactions using a large statewide sample.

depth interviews with high-cost, high-need patients and any caregivers these patients

METHODS: We performed a qualitative analysis of free-text comments submitted in

identified as important to their health care. Participants were recruited from four sites: a

response to the 2014 Rhode Island Health Information Technology (HIT) Survey, using a

complex case management organization, a home health agency, an academic hospital, and

combination of deductive and inductive coding. The survey was administered via mail and

a managed care organization for dual-eligible patients. Patient eligibility criteria included:

email (if addresses available) to all physicians licensed in Rhode Island, in active practice,

age ≥55, ≥2 chronic health conditions, and ≥3 hospitalizations in a 12 month period.

and located in Rhode Island and adjacent states. Themes and subthemes among both

Consistent with grounded theory, data is being collected through theoretical sampling and

office- and hospital-based physician were derived from responses to the free-text survey

analysis will continue until theoretical saturation is reached. An interdisciplinary team

question, “How does using an EHR affect your interaction with patients?”

conducted dimensional analysis and identified “being listened to” as a core category. We

RESULTS: The Rhode Island HIT Survey’s response rate was 68.3 %. Among the

then conducted comparative analysis of times when participants perceived themselves as

respondents, 2236 (87.1 %) had EHRs; and among those, 744 (33.3 %) responded to question

“being listened to” and times when they perceived themselves as “not being listened to.”

asking how EHRs affected their interaction with patients. Five main themes emerged in our

We used memoing, member checking, and peer debriefing to enhance rigor.

qualitative analysis. Overall, physicians generally perceived EHRs as negatively altering

RESULTS: We completed interviews with 11 patients and 3 caregivers (n = 14). Patients

patient interactions, although the rank-order of the top two (most common) themes was

had an average age of 72.4 years, 7 self-reported chronic conditions, and 6.1 hospitaliza-

reversed for office- and hospital-based physicians: office-based physicians commented most

tions in their highest-utilizing year. Demographic questionnaires showed that 54.5 % (n =

frequently on EHRs worsening the quality of their interactions and relationships with patients,

6) of patients were female, 45.5 % (n = 5) lived alone, 54.5 % (n = 6) reported financial

while hospital-based physicians commented most frequently that they spend less time with

strain, and 81.8 % (n = 9) had at least a high school reading level. All participants reported

patients because they have to spend more time on computers. A smaller proportion of

managing serious illnesses that they perceived to be intermittently life-threating. Partici-

physicians commented that using an EHR has no effect on their interaction with patients.

pants who experienced reductions in hospitalization frequency attributed “being listened

One sub-theme, more common among hospital-based physicians, was that EHRs truly did not

to” by health care providers as a critical factor contributing to longer periods of stable

affect their interaction. A second sub-theme, more common among office-based physicians,

outpatient management. Patients and caregivers described unique information that did not

was that EHRs do not affect patient interactions because the physicians have altered their

exist in the medical record, and perceived this information as “being listened to” if it

workflow to prevent the EHR from having a negative impact. For example, physicians noted

influenced their diagnoses or treatment plans. Categories of unique information included:

that they document in their EHR before and after an encounter to avoid using a computer

goals and preferences, early warning signs, positive or negative effects of treatment, and

during their time with the patient. Positive responses focused on information access and use in

anticipated feasibility of treatment plans. Participants who perceived that this information

patient care. Comments that were generally positive and comments that detailed the patient’s

was “not listened to” either engaged in self-advocacy strategies or tried to address the

perspective comprised the least commonly observed themes for both settings.

unique issues on their own. Conditions facilitating “being listened to” included higher

CONCLUSIONS: Our analysis of the impact of EHRs on patient interactions, from a

severity of symptoms (versus mild to moderate “warning signs”), longer duration of the

large sample of physicians across most physician specialties, demonstrates that physicians

patient-provider relationship, and use of self-advocacy strategies by patients or caregivers.

in office- and hospital-based settings generally perceive EHRs as negatively altering

Effective self-advocacy strategies included preparing for clinic appointments by writing

patient interactions, although they emphasize different reasons. Although our analysis

questions and concerns, validating verbally-expressed concerns with written information

also describes benefits ranging from better information access to improved patient edu-

in the medical record, and engaging other health care providers in advocating on the

cation and communication, the unintended consequences are more frequent themes. These

patient’s behalf. Conditions inhibiting a perception of “being listened to” were having

findings can shape interventions to improve how EHRs are used in specific clinical

symptoms perceived as atypical, having concerns that conflicted with established treat-

settings and to tailor those interventions to specific specialties. Ultimately, by changing

ment protocols, and having a deferential approach to interactions with health care

the ways physicians use EHRs with patients, we hope to affect both physician satisfaction


and patient experience.











TION Adam P. Sawatsky; Hannah C. Nordhues; Stephen P. Merry; M. U. Bashir;


Frederic Hafferty. Mayo Clinic, Rochester, MN. (Control ID #2465354)

OF MEDICINE, DIVISION OF GERIATRICS Debora Afezolli; Janet Seo; Ashish Upadhyay; Jasvinder Bhatia; Christine Liu. Boston Medical Center, Boston, MA. (Control

BACKGROUND: Medical trainees are increasingly interested in global health, and a majority of residency programs offer international health elective (IHE) experiences for their

ID #2467447)

residents. There are numerous benefits to the residents involved in these experiences, BACKGROUND: Muscle wasting is common in older hemodialysis patients due to the

including gaining experience with a wide variety of pathology, learning to work with limited

metabolic acidosis associated with kidney failure. Older hemodialysis patients are weak

resources, developing clinical and surgical skills, and participating in resident education.

and have very limited endurance, which predisposes them to falls. Increasing physical

Residents who participate in IHEs seem more likely to eventually practice in underserved and

activity is one intervention proven to prevent falls. To assess whether a program of

international settings during their career, suggesting these can be transformative experiences.

increased physical activity for falls prevention is acceptable to older hemodialysis patients,

While much has been studied about the benefits to medical knowledge and patient care, less

our goal was to elucidate older hemodialysis patient attitudes regarding their physical

is understood about the transformative effects of these experiences on professional identity

function, falls, and physical activity.

formation. We used the lens of transformative learning theory to analyze resident reflections

METHODS: A convenience sample of hemodialysis patients aged 65 or older followed

on the challenges to professional identity posed by the “disorienting dilemma” of IHEs.

at an urban academic medical center underwent 30–40 min semi-structured interviews in

METHODS: We conducted a qualitative analysis, using constructivist grounded theory with

their homes. Questions included open-ended and Likert style questions about general

sensitizing concepts of professional identity formation and transformative learning theory to

physical function, falls, and physical activity. The Falls Efficacy Scale-International (FES-

guide analysis. Each resident at the Mayo Clinic who participates in an IHE is required to

I) was administered. Interviews were audiotaped and transcribed. Three research team

complete a reflective essay on their experience, and one paragraph about systems improve-

members simultaneously reviewed interview data and determined dominant themes by

ments based on their experience. Residents from all specialties and across all three Mayo

consensus discussion.

Clinic training sites are eligible to participate, and applications are reviewed by a selection

RESULTS: A total of 5 older hemodialysis patients (mean age 75 ± 6.7 years, 60 %

committee. Residents may go to one of the 14 Mayo International Health Program designated

female, 100 % African-American, mean years on hemodialysis treatments 4.3 ±

partnership sites, set up a rotation through an MIHP contact elsewhere, or choose an

3.5 years) were interviewed between November 2015 and January 2016. Mean

independent site with appropriate onsite mentoring. For this study, we analyzed all reflective

FES-I score was 22.3 ± 9.3 points, representing a moderate level of concern for

reports for all residents who participated in an IHE between 2001 and 2014. We created a

falling. Major themes that emerged were a near universal desire to increase

codebook a priori based on the six ACGME core competencies and three coders indepen-

physical activity, with knowledge that it can improve well-being. Most did not

dently coded the first 3 years of reflective reports in duplicate and reconciled differences

think hemodialysis was a contraindication to physical activity. Sixty percent

through consensus. Once we reached substantial agreement, we individually coded the

expressed willingness to undertake physical activity three times a week. The most

remaining reflective reports. Within the code of professionalism, we identified a major theme

common barrier to undertaking physical activity was a lack of motivation; other

of reflection around “why I went into medicine.” Using the lenses of professional identity

limitations included time constraints due to hemodialysis treatments, fatigue, and

formation and transformative learning theory, we identified themes identified by residents

the impact of co-morbidities such as arthritis (Table).

around this theme, and then expanded our analysis across all 377 reports to expand our

CONCLUSIONS: In this predominantly African-American sample, older hemodi-

understanding of the themes. We used the constant comparative method to refine our

alysis patients view themselves as capable of undertaking physical activity. Older

understanding of how IHE experiences influenced professional identity formation. This

hemodialysis patients understand physical activity has health and psychological

study was approved by the Mayo Clinic Institutional Review Board.

benefits. Although hemodialysis treatments are time intensive and physically

RESULTS: We analyzed 377 reflective reports by residents and fellows from 40 medical

draining, the majority is still willing to undertake physical activity multiple times

and surgical specialties across three Mayo Clinic training sites who traveled to 56

a week. The primary barrier to undertaking physical activity is a lack of motiva-

countries. We identified three main domains of professional identity: making a difference;

tion. Strategies for patient motivation, such as incentives, will need to be included

experiencing a meaningful patient-doctor relationship; and discovering the purest form of

if physical activity will be utilized as a potential intervention for fall prevention in

medical practice; Within the domain of “making a difference,” residents discussed the

this patient population. Future studies will focus on exploring the efficacy of

clearly apparent need of their patients, the sense that their patients have little or no other

various approaches to bolster motivation for physical activity in older hemodial-

options, and the experience of altruism. Within the domain of the patient-doctor relation-

ysis patients.

ship, residents discussed their experience of gratitude and trust from their patients, and the

Major barriers to physical activity in older hemodialysis patients

resilience of their patients in the face of need. This was contrasted to their experiences with patients in the US training environment, and called into question the “true needs of

Theme Lack of motivation

Time limitation Fatigue Co-morbidities

Examples “I would move more if I had a grandchild to pick up and get ready” “Having somewhere to be motivates me to move” “It would be good if there was something to do after hemodialysis, especially in the summer” “If I was not on hemodialysis I would do more” “I do not walk on dialysis days” “Hemodialysis just drains me out” “Fatigue prevents me from moving” “My back pain and knee pain prevent me from moving, regardless of whether I have hemodialysis”

patients.” Within the domain of “purest form” of medicine, residents discussed the limitations of medicine and technology and identified the key role of clinical skills in the practice of medicine. They discussed freedom from documentation, billing, and other “distractions” from patient care. They reflected on what was necessary for practice, and what was “just extra.” These reflections were facilitated by the stark contrast of their experiences between their IHE and normal practice and the role modeling of physicians they worked with on their IHE. These reflections brought humility, frustration and transformation for their future careers.



CONCLUSIONS: Through IHEs, residents found meaning in making a difference, experiencing a meaningful patient-doctor relationship, and recognizing “medicine in its purest form.” These findings help to understand the transformative power of IHEs on


Table 1. Emergent Themes Experiences with Pain Control

Treating chronic, noncancer pain left hospitalists feeling frustrated and unsatisfied.

Opioid Prescribing and Patient Satisfaction

Hospitalists were concerned that institutional expectations to achieve high satisfaction scores altered opioid prescribing.

Opioid Prescribing and Efficiency

Some hospitalists prescribed opioids to prevent readmissions and reduce costs.

residents’ professional identity, and why these experiences remain so popular among trainees. It also prompts discussion about the current resident training environment that causes them to forget “why [they] went into medicine.” Faculty mentors can use these findings to help guide resident reflections on their IHE experiences as they deal with the disorientation of these experiences, and facilitate true transformation.

“YOU ARE PULLED IN TWO DIFFERENT DIRECTIONS”: THE HOSPITALIST PERSPECTIVE ON OPIOID PRESCRIBING Susan L. Calcaterra2, 1; Anne Drabkin2, 1; Sarah E. Leslie6; Reina Doyle6; Steve Koester4; Joseph W. Frank1, 5; Ingrid A. Binswanger3. 1University of Colorado Department of Medicine, Aurora, CO; 2Denver Health Medical Center, Denver, CO; 3Kaiser Permanente Colorado, Dever, CO; 4University of Colorado Denver, Denver, CO; 5VA Eastern Colorado Health Care System,

“I have a hard time feeling like I’m successful with people who have chronic noncancer pain who come in for an exacerbation. Unless I can figure out clear reasons for that exacerbation, I rarely succeed in having the patient, nurses and providers be happy. It is an unrewarding situation.” “I’m well aware I’m being watched for my patient satisfaction scores. I don’t doubt in the least that patient satisfaction scores are a driver of opioid prescribing.” “Sometimes it feels utterly pragmatic [opioid prescribing at discharge]. If the patient comes back and gets readmitted because they don’t have pain medicine, it’s a $3,000.00 two-day stay in the hospital that was unnecessary.”

Denver, CO; 6Center for Health Systems Research, Denver Health Medical Center, Dever, CO. (Control ID #2448012)

BACKGROUND: Under the Patient Protection and Affordable Care Act, value-based incentive payments to hospitals are calculated based on Hospital Consumer Assessment of


Healthcare Providers and System (HCAHPS) survey scores. In the survey, patients are


asked to rate their experiences with pain control during their hospitalization. Hospitalists,

M. Jones2; Marya J. Cohen1. 1MGH, Boston, MA; 2Massachusetts General Hospital,

dedicated inpatient physicians, are encouraged to achieve high patient satisfaction scores

Boston, MA. (Control ID #2468621)

for pain to maximize federal incentive payments. Opioid stewardship, the practice of managing opioid prescribing in high-risk patients, may be at odds with current hospital

BACKGROUND: Due to an aging population and over 3 million people being insured

care, which focuses on in hospital pain control rather than long term consequences of

under the Affordable Care Act, the need for primary care services has drastically

opioid use. We aimed to understand physicians’ attitudes and practices towards opioid

increased. However, studies have shown that the number of medical students choosing

prescribing during hospitalization and discharge.

primary care residencies will not satisfy this high demand. The Crimson Care Collabora-

METHODS: We conducted semi-structured interviews from January 2015 to August

tive (CCC), a student-faculty collaborative clinic, was created in the hopes of establishing

2015 with hospitalists who worked in one of two university hospitals, a safety-net hospital,

a pipeline to primary care at Harvard Medical School. To determine the effectiveness of

a Veterans Affairs hospital, or a private hospital located in Denver, Colorado or Charles-

CCC, we have evaluated student perceptions of primary care before and after participation

ton, South Carolina. Hospitalists were recruited via email solicitation. We used purposive

in CCC.

sampling to achieve an even distribution with respect to gender and years in practice. We

METHODS: We compared data from surveys aimed at assessing attitudes toward and

developed an interview guide informed by the Theory of Planned Behavior. Interviews

knowledge about primary care that were administered to students before and after

were recorded, transcribed, and entered into qualitative software (ATLAS.ti). During

participation in CCC. CCC students were asked to rate the frequency of positive and

regular group meetings, we systematically analyzed interview transcripts and identified

negative comments about primary care heard from faculty/administration, residents, and

emerging themes using a team-based mixed inductive and deductive approach.

peers during medical school. They also rated the extent to which they agreed or disagreed

RESULTS: Of the 25 participants, 16 (64 %) were women and the majority were non-

with the comments. In addition, we also asked students to share the comments that they

Hispanic White, 21 (84 %). The largest proportion, twelve physicians (48 %), completed

have heard regarding primary care.

Internal Medicine residency within the past 5 to 10 years. Emergent themes which most

RESULTS: A total of 47 matching pre/post surveys were collected. After partic-

impacted physicians’ attitudes and practices towards opioid prescribing included 1)

ipation in CCC, students heard more positive comments about primary care from

unrewarding experiences with patient-perceived pain control, 2) institutional and systemic

residents (t = −2.470, p = 0.018). In addition, students significantly agreed more

pressure between opioid prescribing and meeting patient satisfaction metrics and 3)

with the positive comments from faculty/administration, residents, and peers after

competing demands between opioid prescribing and maintaining efficiency (Table 1).

participation in CCC (t = −2.150, p = 0.038). There were no significant differences

CONCLUSIONS: We identified important experiences and competing demands related

in the frequency of negative comments heard from faculty/administration, resi-

to opioid prescribing which may have unintended consequences on opioid prescribing

dents, and peers.

practices. Future work will focus on understanding how hospitalists overcome and

CONCLUSIONS: After participation in a primary care based student-faculty collabora-

respond to these challenges. Strategies to provide pain relief to patients which allow

tive clinic, positive perceptions towards primary care increased. Programs designed to

hospitalists to practice opioid stewardship while maintaining efficiency are urgently

offer students early exposure to primary care, such as CCC, are needed to meet the high


demand for primary care services.



Themes about Primary Care


4 year college degree. The survey for physicians and health professionals had a total of 458 respondents, of which 131 were physicians (response rate 75 % and 64 %, respec-

Positive Themes about Primary Care Long-term Relationships with Patients Meaningful and Innovative Work Holistic Care

Negative Themes about Primary Care High Burnout Boring Low Salary

tively). Four of the 26 practices were training sites, median staff size was 13 people, median number of physicians was 4. CONCLUSIONS: This study reports an assessment of baseline relational coordination

List of positive and negative themes about primary care gathered from comments by CCC

scores across one health care system, and the association of these scores with measure of

medical students.

patient satisfaction and with physician-perceived barriers to efficient workflow. Relational coordination has been shown to be associated with patient satisfaction in multiple settings. However, the one other study examining this relationship in primary care also did not find


an association between patient experience and relational coordination. This may be


because primary care is somehow different than other settings previously examined,

1, 4

; Renee Sednew ; Chi-Hong Tseng ; Holly Wilhalme ; Samuel A.

differences in statistical modeling, or publication bias. The lack of association of relational

Skootsky2, 3; Neil Wenger4. 1Baptist Health Medical Group, Coral Gables, FL; 2David

coordination with physician-perceived burden of care coordination may suggest that

Geffen School of Medicine at UCLA, Los Angeles, CA; 3UCLA, Los Angeles, CA;

relational coordination is not associated with physicians practicing at the top of their


license. Future research can focus on how to quantitatively evaluate how well systems are

(Control ID #2469827)

designed to facilitate physician workflow and the best use of their time. In order to develop

3, 2

Robin Clarke




University of California, Los Angeles, Los Angeles, CA; 5ucla, Los Angeles, CA.

and strengthen a “team-based” approach to care, many focus on workflow processes, team BACKGROUND: Despite the enthusiasm and focus on team-based care in the national

structure, or adding new members to teams. However, most transformation efforts do not

conversation on the transformation of primary care, relatively few studies directly measure

directly measure or track the working relationships which underlie team-based care. In

and report measures of teamwork as a metric of primary care redesign. Relational

order to achieve the envisioned synergies of team-based care in primary care redesign,

coordination has emerged as a dominant model for measuring team-based care. At the

there must be a purposeful effort to measure and monitor team dynamics.

same time, health systems recognize the importance of optimizing the primary care patient experience as they adopt population health models of care delivery. Relational coordina-

Association of Relational Coordination with Patient Experience

tion has been associated with higher levels of patient satisfaction in multiple settings. The


Coordinated care



6.6 (4.5)

3.9 (5.7)

1.9 (2.4)

4.2 (6.6)

−2.8 (7.2)

1.2 (3.1)

health system for the University of California, Los Angeles (UCLA Health) recently implemented a redesign of its primary care system, and sought to measure team-based care to better understand the potential value of focusing on this metric in its redesign. In this study, we hypothesized that teams with higher relational coordination would have lower emergency room visits. We hypothesized that patients in practices with higher relational coordination would report better experiences, and that doctors in those practices would

Relational coordination (unadjusted model) Relational coordination (adjusted model)

Recommend doctor

5.4 (3.8)

Overall doctor rating −0.9 (2.3)

3.0 (5.7)

−2.4 (3.0)

−0.2 (4.0)

3.2 (2.8)

report lower perceived burden of tasks that do not require their medical expertise. METHODS: UCLA Health is an urban academic system with 26 primary care practices caring for adult patients (internal medicine, family medicine, and geriatrics). Primary care

Scores reported as estimated (std error). Model adjusted for age, race/ethnicity, gender,

practices within UCLA Health are primarily traditional community-based practices with

overall health rating, education, total staff and percent md fte

full time physicians; four practices also have trainees. The health system uses the Clinician and Group Survey by Consumer Assessment of Healthcare Providers and Systems (CG-

Association of relational coordination and physician-perceived barriers to care

CAHPS®) 12-Month Survey to measure and track patient experience. The pre/post


differences in the six patient experience outcomes between the CC practices and non-

effects for the presence of a care coordinator, time period (pre/post), and care coordinator by time interaction, and a random clinic effect. Relational coordination is defined as a mutually reinforcing web of communication and relationships carried out for the purpose of task integration. Composite relational coordination scores were compared between CC practices and non-CC practices using an adjusted linear mixed effects model with a practice-level random effect and a fixed effect for the presence of a care coordinator. Five questions assessed physicians’ perceived burden of non-medical care coordination tasks,

Phone calls requiring medical expertise −0.06 (0.40)

Filling out forms

Orders requiring prior authorization

0.75 (0.47)

Familiarity with outstanding gaps in quality 0.97 (0.39) *

−0.63 (0.45)

1.55 (0.53) *

1.0 (0.80)

−0.02 (0.76)

−0.74 (0.59)

0.36 (0.70)

0.32 (0.94)

Difficulty scheduling specialists

CC practices were compared using an adjusted linear mixed effects model with fixed

Relational coordination (unadjusted model) Relational coordination (adjusted model)

each was scored on a 5-point scale where 5 was lowest perceived burden. Differences in scores of the barriers to coordinated care between the CC practices and non-CC practices

Association reported as estimates (std error)

were compared using an adjusted linear mixed effects model.

* p-value < 0.05

RESULTS: A total of 7279 patients completed the patient experience survey of which

Model adjusted for age, gender, years working at clinical site, years practicing as an MD,

65 % were female, 65 % were white, 87 % were not Hispanic, and 65 % had at least a

% MD FTE, and total clinic staff.





treatment for all cause avascular necrosis. However, in our study we found no difference in

WITH SICKLE CELL CRISIS Keri Holmes-Maybank; William P. Moran; Kit N.

cost, hospitalizations, and hospital days for sickle cell patients with avascular necrosis who

Simpson. Medical University of South Carolina, Charleston, SC. (Control ID #2467614)

had a joint replacement compared to those without a joint replacement. Identifying avascular necrosis as significant predictor of longer hospital stay in individuals experiencing sickle cell

BACKGROUND: Sickle cell disease is the most common inherited blood disease

crisis may be helpful in anticipating length of stay/treatment and discharge planning. It may

worldwide. It affects 1 in 375 African Americans in the United States, approximately

also be helpful in counseling patient expectations about length of hospitalization and

70,000–100,000 individuals. Patients with sickle cell disease suffer from chronic anemia,

treatment. Due to the significant impact of avascular necrosis on sickle cell crisis it should

chronic pain, and acute pain known as vaso-occlusive crises or pain crises. The survival

be further investigated as a marker of disease severity and to determine the best modality of

from childhood into adulthood has increased from 79 to 89 % with an increased projected


life expectancy of 53.5 years. As patients with sickle cell disease are living longer, they are experiencing more complications including end organ damage, some of which manifest as progressive bone disease and daily chronic pain. Bones are the second most common


organ affected. Avascular necrosis (also known as osteonecrosis, aseptic necrosis, and


bone infarct) is bone death, the end result of severe and prolonged ischemia. The

PLEX ELDERS Christine Patterson2; Peter Boling2; George Taler3; Jean Yudin1; Karl Eric

prevalence of avascular necrosis in adults with sickle cell disease is estimated up to

Dejonge3; Bruce Kinosian1. 1University of Pennsylvania, Philadelphia, PA; 2Virginia common-

50 % by 35 years of age. A study identifying risk factors for avascular necrosis found a

wealth University, Richmond, VA; 3Washington Hospital Center, Washington, DC. (Control ID

significantly higher rate of painful crises and hospitalizations per year in sickle cell disease


patients with avascular necrosis. We studied the effect of avascular necrosis in patients hospitalized with sickle cell crisis on number of hospitalizations, hospital days, and cost.

BACKGROUND: To determine if home-based primary care (HBPC) when integrated

METHODS: We examined the 2011 Agency for Healthcare Research and Quality’s

with supportive services can lower long term institutionalization (LTI) in frail, medically

Healthcare Cost and Utilization Project (HCUP) State-specific Inpatient Database in four

complex elders. Efforts to integrate medical and supportives services for frail elders have

states representing four geographic regions of the United States: New York, California,

frequently focused on payers, such as managed care organizations (MCOs), or provider-

Mississippi, and Iowa. The HCUP database is derived from administrative data and

payers such as PACE. The Mid-Atlantic Consortium, comprised of long operating home

contains encounter-level, clinical and nonclinical information including all listed diagno-

based primary care programs in Washington DC (WHC-20 years), Richmond (VCU-

ses and procedures, discharge status, patient demographics, and charges for all patients,

30 years) and Philadelphia (UPENN-20 years), deploy mobile, interdisicplinary teams to

regardless of payer (e.g. Medicare, Medicaid, private insurance, uninsured) beginning in

care for frail, homelimited elders. Medically complex, high cost HBPC cases (N = 721),

1988. We described the number of hospitalizations, number of hospital days, and cost in

managed under a FFS/shared savings arrangement, represent 35 % of the total patients

patients admitted with sickle cell crisis with and without avascular necrosis as well as joint

served by these hbpc programs. Each program uses a different form of integration with

replacement in those with avascular necrosis 18 years of age and older. Cost outcomes

their Area Agency on Agency (AAA), which provide community long term services and

utilized hospital-level charge data and publically available hospital-specific cost-to-charge

supports (LTSS). WHC has its social workers employed as AAA agents; U Penn has

ratios to estimate cumulative costs for each admission.

formed a dedicated interagency interdisciplinary team with their AAA, and VCU uses a

RESULTS: We found 11,879 hospital admissions for 4357 patients with sickle cell crisis

collaborative model with dedicated payer support.

in 2011 in Iowa, California, New York, and Mississippi. The average age was 33 years and

METHODS: Cohort study comparing death and LTI among frail elders receiving HBPC

55.37 % were female. 14.8 % of patients (644) had a diagnosis code indicating AVN.

in Philadelphia, Richmond and DC (2012–2015) with matched controls from the 2012 to

Patients with AVN had more admissions per year, 6.2 compared to 3.3 for patients without

13 Medicare 5 % Beneficiary, NPI-linked files. Selection criteria included fee-for-service

AVN (p < .0001). Similar patterns were observed for total number of hospital days per

(FFS) beneficiaries with a hospitalization in the prior 12 months, post-acute care episode

year (43.8 vs. 18.7, p < .0001), and mean cost per admission ($50,648 vs. $33,783,

in prior 12 months, 2 or more chronic conditions, and JEN frailty index [JFI] >6,

p < .0001). Total annual hospital charges were $259,442 for AVN patient and $113,231

(equivalent to 2+ impairments in Activities of Daily Living). ADL data were summarized

for sickle cell patients without an AVN diagnosis (p < .0001). However, only 4.0 %(28) of

into expected LTSS expenditures using the Minnesota Case Mix Classification (MN) and

patients with AVN received a hip or shoulder replacement done during the year. The mean

VA locally adjusted class-specific payments. Observed LTSS expenditures were available

annual charge for the AVN subgroup who received a joint replacement was $257,763,

for the Philadelphia site. Rates were adjusted for time observed; LTI and death were

similar to the mean charges of $259,512 (p = .6379) for patients with AVN who did not

modeled as competing risks. Primary comparison used matched controls who had not

have a joint replacement. The mean number of hospitalizations in individuals with AVN

received housecalls (HC) (n = 600), with a secondary comparison using controls who had

and joint replacement was 6 compared to 6.2 for those with AVN and no replacement

received HC (n = 103), as the Richmond and DC programs enrolled 30–50 % of 5 %

(p = .7074). There was a slight but insignificant difference in the mean charge per

sample patients, respectively.

admission ($42,553) in individuals with AVN with joint replacement compared to those

RESULTS: Average monthly census for this frail subgroup rose from 247 in Y1 to 356 in

without replacement ($50,998, p = .2886). Lastly, the mean number of hospital days for

Y3, with mortality averaging 25.8 % (range 22.6–29 %). The LTI rate declined from 8.9 %

patients with AVN and joint replacement was marginally less than those with joint

(Y1) to 3.2 % (Y3), with a 3-year average of 6.4 % (95 % CI 4.63–8.17). Mean MN class

replacement (38.5 vs. 44, p = .3339) respectively.

was “D” (4–6 ADL impairments), with expected LTSS expenditures of $2382 pbpm, and

CONCLUSIONS: Avascular necrosis was present in approximately 15 % of the sample

observed expenditures of $2151 (CI $1891–$2408) for the 64 % of patients receiving

population of patients admitted for sickle cell crisis in Iowa, California, New York, and

LTSS services. Controls who did not receive HCs had an annual mortality of 24.9 %, with

Mississippi in 2011. Avascular necrosis in sickle cell crisis patients has a major impact on the

an LTI rate of 17.1 %, while among controls who received HCs the mortality was 26.9 %

patients and the health care system. Sickle cell patients with avascular necrosis experienced

and LTI was 17.7 %, demonstrating modest adverse selection into housecall practices.

twice as many hospitalizations, over twice as many hospital days, and over twice as much

CONCLUSIONS: Integrated HBPC with social supports was associated with a 63 %

cost per year. Previous research has determined joint replacement is a successful, definitive

reduction in LTI compared to matched local controls. Expected costs of such supports are




$2300 pbpm, with observed expenditures for successful nursing home diversion consis-

RESULTS: Semi-structured interview results Twelve themes emerged from patient’s

tent with expected costs. Integration of social supports with home based primary care in a

conversation about readmission. They were: understanding [or not] their problem; de-

FFS, shared savings environment can reduce long term institutionalization among frail

scribing their physical state; problems with medication or equipment; ability to recall;

Medicare Beneficiaries, providing a provider managed FFS alternative to MCO-operated

relationship with inpatient care team members; their hopes and wishes; family involve-


ment [or not], assigning fault to themselves, providers or no one; their emotional reactions; their sense of agency [or not] in their own care; post-hospital care; and systems issues. The most frequently coded themes were statements about physical and emotional states.


Patients’ descriptions of physical states ranged from symptoms alone and to detailed


discussion of diagnosis and treatment interventions. Most patients stated they felt phys-

NENTS Taiju Miyagami. Juntendo University of school, Bunkyo-ku, Japan. (Control

ically well on discharge and many felt confident about their ability to manage themselves

ID #2467781)

with a strong sense of personal agency. Many described family and/or home care services. When these resources failed to provide support matching their needs, patients felt fearful

BACKGROUND: The aim of this study was to determine statistical cut-off points for

and frustrated. Patients’ emotional reactions included frustration at not understanding their

waist circumference (WC) and body mass index (BMI) as predictors of metabolic

diagnosis or having a solution to their problem at discharge [Example: “(I am)…discour-

syndrome (Mets) components.

aged because I do want a diagnosis so I can live like I was before.”]. Unstable symptoms

METHODS: Participants were individuals who received medical health checkups at

were associated with fearful anticipation [(“I’m) afraid it’s going to happen again.”] Some

NTT-Higashi Nihon Kanto Hospital from May 2006 to February 2011. Patients who were

patients described confidence in inpatient providers [“I have a good team because they all

treated for hypertension, dyslipidemia, diabetes mellitus, or hyperuricemia were excluded

work together.”]; others expressed dissatisfaction [“…they were adding too many medi-

from the study. Metabolic disorders were defined in accordance with the Mets diagnosis

cations and weren’t explaining anything.”] Few patients mentioned their primary care

criteria of Japan as follows: three classic components of Mets (elevated blood pressure,

physician’s (PCP) role during hospitalization or post-discharge. As patients experienced

dyslipidemia, and elevated blood glucose concentration) and elevated uric acid (>7.0 mg/

deterioration in their medical condition, they rarely connected with their PCP or home care

dl). A receiver operating characteristics curve was constructed to determine optimal cut-

services; rather they more frequently called 911. #Quantitaive results in table

off points of WC/BMI for two or more, three or more, and four components of Mets by

CONCLUSIONS: Readmitted patients were significantly more likely to be elderly, felt less


ready to go home at the time of their first discharge, hadn’t discussed their symptoms with

RESULTS: A total of 23,945 male (mean age, 47 years) and 9552 female participants

their PCP, and had significantly less understanding of their medications. Interviewed patients

(48 years) were considered eligible. Optimal WC/BMI cut-off points for two or more,

expressed frustration at not having a clear idea of their diagnosis, were fearful of their

three or more, and four Mets components were 85 cm/23.7 kg/m2, 85.8 cm/24.6 kg/m2,

condition deteriorating, and tended to call emergency services rather than their PCPs. These

and 87.2 cm/24.5 kg/m2, respectively, among men, and 81 cm/22.7 kg/m2, 82.1 cm/

findings suggest that patients, particularly in this age group, require a clear understanding of

21.8 kg/m2, and 90.5 cm/25.3 kg/m2, respectively, among women.

the diagnosis as well as tactics to execute and people to call if they deteriorate. Patients had

CONCLUSIONS: Optimal WC/BMI cut-off points for two or more Mets components

fears and feelings of uncertainty about their diagnoses. Both during hospitalization and at

were 85 cm/23.7 kg/m2 for men and 81 cm/22.7 kg/m2 for women. Our results underscore

discharge, providers should assess patients’ emotions and concerns in a systematic fashion.

the importance of maintaining ideal body weight for the prevention of lifestyle-related

As suggested in extant literature, a call from patients’ PCP practice within 48 h of discharge,


and a visit within 7 days may optimize care and reduce readmissions.

Quantitative results THROUGH THE PATIENT’S EYES: IDENTIFYING RISK FACTORS FOR HOSPITAL READMISSIONS Prakrati Acharya1; Aliya Laeeq1; Matthew Carmody1; Beth A. Lown2. 1Mount Auburn Hospital, Cambridge, MA; 2Schwartz Center for Compassionate Healthcare, Boston, MA. (Control ID #2469195)

BACKGROUND: One in 5 Medicare patients return to hospital within 30 days costing the country $12 billion annually. We conducted a study to analyze the patient’s perspective regarding factors that caused readmission and to identify methods to prevent them. METHODS: We recruited a convenience sample of English speaking patients >18 year

Felt ready to go home on discharge Discussed symptoms to call PCP Understood medication changes on discharge PCP office went over discharge plan on phone 80+ age group Needed more information at discharge Social support

NON READMITTED (N = 22) 100 % 86.4 % 90.9 %



79.3 % 59.3 % 69 %

0.03 0.03 0.048

85.7 %

54.5 %


25 % 19 % 95.5 %

41.7 % 34.5 % 85.2 %

0.038 0.13 0.36

old who were readmitted from home within 30 days of discharge for this mixed method study. We compared the questionnaire responses of 22 non-readmitted patients to those of 30 patients readmitted from home over a 5 month period. The 30-question survey queried


patient satisfaction, readiness at time of discharge, understanding of diagnosis, treatment


and medication changes, and knowledge about seeking medical attention after discharge.

LANCE; A GAP THAT NEEDS TO BE BRIDGED. Abhishek Karwa; Rushad Patell;

Two of the authors conducted semi-structures interviews of 30 of the readmitted patients

Rocio Lopez; Carol A. Burke. Cleveland Clinic, Cleveland, OH. (Control ID #2466359)

from this sample. We excluded 3 patients with cognitive impairment or insufficient responses to analyze. Interview questions queried events between the previous and present

BACKGROUND: Screening and surveillance have proven to decrease the incidence and

admission, experiences in hospital, concerns at time of discharge or at home, and help at

mortality of colorectal cancer (CRC). Unfortunately, data demonstrates clinicians in

home. Interviews were audio-recorded, transcribed, analyzed and coded by 4 physicians

practice do not follow the published guidelines for CRC screening and surveillance. Many

using the constant comparison approach.

factors contribute to this hiatus including knowledge, complexity and acceptance of




guidelines by clinicians. To date, no assessment of the knowledge of CRC screening or

RESULTS: Six hundred ninety-eight responses were received, which consisted of 575

surveillance guidelines nor the correct application of the guidelines has been performed in

trainees and 119 practicing physicians among 9 specialties: internal medicine (178),

medical trainees. Our objective was to assess and compare the knowledge gap in CRC

family medicine (179), primary care (24), gastroenterology (119), general surgery (57),

screening and surveillance guidelines in medical trainees.

ob/gyn (90), urology (17) and colorectal surgery (19). Eighty-five percent reported they

METHODS: An IRB approved 16 question anonymous web based survey was

ordered and 26 % performed colonoscopies. While 95 % reported they followed guide-

created requesting information on medical specialty, level of training, knowledge

lines when making recommendations only 69 and 51 % were confident in their ability to

of and perceived confidence in applying CRC screening and surveillance guide-

recall screening and surveillance guidelines respectively. SCREENING: 27 % identified

lines (US Multi-Society Task Force [2012], American College of Gastroenterology

all 5 factors used to determine onset of CRC screening, and 56 % got both vignettes

[2009], US Preventive Services Task Force [2008]). The 4 clinical vignettes

correct. Combined, the accuracy decreased to 17 %. SURVEILLANCE: 17 % identified

presented included 2 screening scenarios (a 40 year/old Caucasian whose mother

all 4 factors and 31 % got both surveillance vignettes correct. Combined, the accuracy

had CRC at age 65; and a 45 year/old African American with no additional risk

decreased to 8 %. There is a striking difference between specialties in their reported

factors) and 2 surveillance scenarios (a 63 year/old with a 5 mm tubular adenoma

confidence recalling screening (44–88 %) and surveillance (22–91 %) guidelines. Correct

and an 8 mm tubulovillous adenoma with high grade dysplasia; and a 58 year/old

responses to clinical vignettes was poor and varied by specialty (34–64 % for screening

with a 7 mm sessile serrated polyp without dysplasia). Respondents were also

and 26–51 % for surveillance). The respondents with the highest accuracy to identify all

asked to pick the specific factors utilized by guidelines in CRC screening (5 of

factors used in guidelines to determine age to initiate CRC screening was the PCP group at

15—age, family history of CRC, personal history of CRC, IBD or polyps) and

32 % and the lowest was ob-gyn/urology at 18 %. Similarly, the lowest group to identify

surveillance (4 of 9—polyp number, size, pathology and piecemeal resection).

factors used for surveillance intervals was ob-gyn/urology at 3 % and the highest was GI at

Program directors of all ACGME approved internal medicine; family medicine,

65 % (Table 1). The proportion that correctly answered all vignettes and identified all

surgery, ob/gyn, urology, gastroenterology and colorectal surgery training pro-

factors used in the guidelines varied from 3 to 22 % and 0 to 39 % for screening and

grams were sent an email request to forward the survey hyperlink to faculty,

surveillance respectively. Trainees had lower confidence in recalling screening guidelines

fellows and residents in their departments. Univariable analysis assessed whether

vs. practicing clinicians (68 vs. 77 %). However, they fared better in accurately answering

respondents’ attitude and/or knowledge of CRC screening and surveillance varied

the screening vignettes and identifying factors used in the guidelines (18 vs. 10 %).

by gender, specialty or experience. Pearson’s chi-square tests were used to assess

CONCLUSIONS: Primary care and subspecialty trainees exhibit a substantial gap

all associations. A comparison was made between primary care (family medicine,

between their reported confidence in recalling CRC screening and surveillance guidelines

internal medicine and geriatrics), gastroenterology fellows, surgery (general and

and the application of them on a survey. This discordance crosses specialties and stage of

colorectal) and others (gynecology and urology). Respondents were also compared

practice. Interventions need to be designed to assist care providers in making guideline-

based on stage of training. A p < 0.05 was considered statistically significant.

concordant CRC screening and surveillance recommendations.

Comparison of knowledge and attitudes of CRC screening and surveillance guidelines by specialty and experience.

Felt confident recalling guidelines Answered both vignettes correctly Accurately identified factors to determine start/interval Answered both vignettes identified all factors correctly

Screening Surveillance Screening Surveillance Screening Surveillance Screening Surveillance

PCP N = 383 (%) 71 [4] 44[2,3,4] 64[2] 27[2] 32[4] 5[2,3] 22[2] 1[2,3]

GI N = 119 (%) 88[1,3,4] 91[1,3,4] 33[1,3,4] 51[1,3,4] 20 65[1,3,4] 3[1,3] 39[1,3,4]

Surgery N = 76 (%) 68[2,4] 72[1,2,4] 57[2] 29[2] 29 20[1,2,4] 17[2] 5[1,2]

OBGYN/GU N = 119 (%) 44[1,2,3] 22[1,2,3] 53[2] 26[2] 18[1] 3[2,3] 13 0[2]

P value 3 months.

identify salient themes.

More pronounced weight loss was observed in patients (>3 months vs. ≤ 3 months)

RESULTS: Three months after screening, 63 % of the 82 U-M employees with predia-

at 6-month (−10.2 kg vs. −4.9 kg, p < 0.0001) and 12-month (−13.0 kg vs.

betes who we surveyed were attempting to lose weight and getting recommended levels of

−2.7 kg, p < 0.0001) follow up. Given the retrospective nature of analysis, the

physical activity, had asked their primary care provider about metformin for prevention of

weight measurements at predefined 6- and 12-months were available in 22/105

T2DM, or had attended a DPP. These employees had higher median levels of motivation

subjects that participated for 3 month participants,

to prevent T2DM (9/10 vs. 7/10, P = 0.01) and lower median estimations of their risk for

45/68 patients at 6-months and 30/68 patients at 12-months had weight measured.

T2DM (40 vs. 60 %, P = 0.04). Among 22 employees who had initially engaged in a

Overall 65 patients (38 %) had 6 month weights available. Among these, 67 %

recommended preventive behavior, key facilitators of engagement were high motivation

(n = 45) achieved >5 % weight loss. Weight at 12 months was available in 45

and social and external supports. Among 18 employees who had not initially engaged in a

patients, of these 34 % (n = 18) achieved >10 % weight loss. Sustained weight loss

recommended behavior, key barriers to engagement were lack of motivation, lack of

at 18 months was only noticeable in groups where patients actively participated for

resources, and competing demands.

>3 months. At 18 months weight loss was significantly higher in patients that

CONCLUSIONS: Most employees found to have prediabetes through a workplace

actively participated in the program for 4–6 months, 6–9 months, 9–12 months and

screening initially engaged in a recommended behavior to reduce their risk for

longer than 1 year (all p-values of multiple comparison 10 % is achievable in a primary

supports. More research is needed to measure longer-term engagement in behav-

care clinic even with limited resources. Active participation in the program for >3 months

iors to prevent T2DM among employees with prediabetes and test approaches to

is crucial for successful sustained weight loss. Overall compliance with weight loss

sustain their ongoing engagement.

programs is generally poor; however, in our pilot study the 40 % adherence rate for more than 3 months in the program is very encouraging. Our study is very promising and can serve as a model to incorporate into primary care practice. The predictors of success and


challenges with improving adherence to diet based weight loss programs merit further

CARE CLINIC Raveen Chawla; Susan Wolver; Puneet Puri; Terence Darcy; Miao-Shan


Yen; Karen Stewart. VCUHS, Richmond, VA. (Control ID #2466695)

Figure 1





VA New York Harbor Healthcare System, New York, NY; 3SUNY Downstate College

of Medicine, Brooklyn, NY. (Control ID #2470316)

BACKGROUND: Patients hospitalized with congestive heart failure (CHF) are required to adhere to many health behaviors after discharge. Unstructured education during the inpatient stay is insufficient to ensure that patients are adequately prepared to properly care for themselves following discharge. Augmenting structured inpatient CHF-specific patient education with weekly counseling calls to improve self-care may increase CHF knowledge and adherence to treatment. We conducted a pilot randomized clinical trial (RCT) to evaluate if a multicomponent health education intervention (HEI) that combines a) an interactive computer-based CHF education video (Kognito Inc, New York) geared toward helping patients understand CHF and its management, b) Educational mailings to reinforce the Kognito video, and c) phone counseling using motivational interviewing (MI) techniques improves knowledge, enhances quality of life (QOL), increases adherence to diet and medication regimens and lowers CHF recurrence. METHODS: This pilot RCT evaluated the impact of the multicomponent HEI compared to A MULTI-CENTER STUDY OF PRE-OPERATIVE NON-INVASIVE CARDIAC

current best practice (CBP) on post-discharge outcomes in Veterans hospitalized with CHF.


We enrolled 60 in patients with CHF and randomized them 1:1 to either a) the HEI, which

Sinvani1; Joanna Fishbein2; Guang Qui1; Roman Zeltser3; Amgad Makaryus3; Christian

included viewing the HF education video while hospitalized, weekly mailings and 4 weekly

Nouryan1; Gisele Wolf-Klein1. 1Northwell Health System, Manhasset, NY; 2Feinstein

post-discharge counseling sessions, or b) current best practice (CBP), which consisted of

Institute of Medical Research, Manhasset, NY; 3Nassau University Medical Center, East

CHF treatment as usual. The outcomes assessed 1 month post-discharge were knowledge

Meadow, NY. (Control ID #2469414)

using the Atlanta HF Knowledge Score, HF- specific quality of life using the Minnesota Living with Heart Failure questionnaire (HF-specific), general quality of life using the SF-36

BACKGROUND: Current guidelines for use of pharmacologic stress tests in pre-

physical component score, diet adherence using sodium intake estimated from 24-h dietary

operative non-invasive cardiac testing need further clarification, especially in older pa-

recall, and medication adherence using the Morisky Medication Adherence Scale. Days to

tients with elevated risk and poor functional capacity. This study evaluated the use of these

readmission was from data censored at 6 months. Except for HF-specific quality of life, for all

tests in patients admitted for hip fracture for time to surgery (TTS), and time to discharge

other outcomes, higher values indicate better outcomes. Since this was a small pilot study,

(TTD), measured in days.

results are primarily reported as point estimates (medians with interquartile range) or change

METHODS: A 2 year retrospective chart review of patients over 65, admitted after hip

in score (mean with standard deviation [SD]) without formal hypothesis testing.

fracture, was conducted across 15 hospitals from 1/01/13 to 6/30/15. Fishers exact test was

RESULTS: There were no differences between groups at baseline. Change in knowledge

used to assess associations between having a nuclear stress test (NST), an adverse event,

scores in the HEI group improved slightly after the 1 month program (0.95 [2.38] in HEI

30 day readmission and other categorical factors. Wilcoxon rank sum or Kruskal-Wallis

vs. 0.88 [2.67] in CBP) as did change in general quality of life (3.91 [9.15] vs. 2.50 [8.92]),

for factors over 2 levels, was employed as appropriate to assess association between each

change in HF-specific quality of life (−25.33 [18.72] vs −21.24 [24.36]) and median

categorical predictor of interest and TTS or TTD.

sodium intake (1701 [1300, 2071] mg vs. 2207 [1367, 3868] mg,). The median days to

RESULTS: Of the 2335 patients admitted, the first 88 who underwent hip repair were

readmission in HEI was 35 [20, 49] while it was 26.5 [10, 99.5] in CBP. Medication

analyzed. Median age was 81.5 years (IQR: 76–89), median LOS was 6.6 days (IQR: 4.7–

adherence improved more in the control arm after 1 month (0.05 [1.13] vs. 1.13 [2.32]).

9.8). No demographic data were significantly associated with having NST. Only 15 % had

However, except for sodium intake, which was of borderline significance (p = .088), none

a NST while 50 % had a transthoracic echocardiogram (TTE). NST and TTE did not

of the other comparisons reached statistical significance.

significantly change TTS and TTD. None of the 13 NST subjects underwent cardiac

CONCLUSIONS: Comprehensive web-based CHF education during the inpatient stay

catheterization (CCT), compared with 14 of 75 subjects without NST. While 7 % with a

coupled with mailings and tailored counseling telephone calls to improve patient knowledge

TTE had a CCT, 25 % of those without TTE had a CCT (p = 0.0385). Patients on the

of HF and its management as well as self-care shows promise and resulted in improvements in

surgical or orthopedic services had lower median TTS and TTD than those admitted to

the right direction. However, in this small pilot study (n = 30 in each group), no outcome reached

medicine (1.0, 1.5, 2.0; p = 0.0479; 4.2, 6.7, 8.0; p = 0.0106, respectively). Males had a

statistical significance. Future research with a larger sample size needs to be conducted.

longer TTS when compared with females (3 vs 1, p = 0.0061). CONCLUSIONS: The study highlights a striking inconsistency in pre-operative noninvasive cardiac testing in older patients with hip fractures. While the rate of NST was low,


a surprising and unsupported finding was the 50 % use of preoperative TTE. Yet, neither


NST or TTE changed hip fracture outcomes with regard to TTS and TTD. Of interest,

David Axelrod1; Elizabeth D. Pulte2; Paris Lovett3; Albert G. Crawford1; John McAna1;

patients on the surgical services had lower TTS and TTD, compared to patients admitted to

Lawrence Ward1. 1Thomas Jefferson University, Philadelphia, PA; 2German Cancer

medicine. These data support the urgent need for standardization in the care of older adults

Research Center, Heidelberg, Germany; 3Jackson Memorial Hospital, Miami, FL. (Con-

with hip fracture.

trol ID #2469875)




BACKGROUND: Sickle cell disease (SCD) is an inherited red blood cell disorder


marked by anemia, unpredictable episodes of pain, end organ damage, and early mortality.


While many acute pain episodes can be managed at home and in the outpatient setting,

TIENTS Tara O’Brien2, 3; Ian Stanaitis3; Noah Ivers2, 3; Pauline Pariser2, 1; Steven

acute uncomplicated pain episodes often result in unplanned care use including emergency

Friedman2, 4; Howard Abrams1; Geetha Mukerji2, 3; Laura Pus3; Gillian Hawker2.

department use and inpatient admissions, associated with high cost and burden to patients.


Evidence-based health system approaches for prevention and management of acute

ON, Canada; 3Women’s College Hospital, Toronto, ON, Canada; 4University Health

uncomplicated pain episodes are needed.

Network, Toronto, Canada. (Control ID #2462125)

University Health Network, Toronto, ON, Canada; 2University of Toronto, Toronto,

METHODS: We performed a retrospective study of unplanned care use (ED visits and inpatient admissions) pre- and post- initiation of a multidisciplinary care team intervention

BACKGROUND: Poor access to timely consultative services, difficulty in navigation of

at a single urban academic health center. The intervention comprised a monthly multidis-

the healthcare system and fragmented care may contribute to avoidable Emergency

ciplinary team conference with providers from primary care, hospitalist medicine, hema-

Department (ED) visits and hospital admissions for complex patients. SCOPE (Seamless

tology, the ED, and social work. During the meeting, every ED visit and admission for

Care Optimizing the Patient Experience) is a quality improvement collaboration between

uncomplicated sickle cell pain episode in the month prior is reviewed, with attention to

acute and community providers located in downtown Toronto, Canada (University Health

presenting symptoms, timeliness and appropriateness of pain management, and a com-

Network, Women’s College Hospital, Toronto Central Community Care Access Centre

parison to trends in prior 6 months. Potentially precipitating factors are discussed, such as

and solo community primary care physicians (PCPs)). The SCOPE objective is to

insurance-lapses or changes, medication adherence, housing stability, mental health

strengthen relationships between hospitals, primary, and community care to improve care

issues, or new medical conditions; an individualized care plan is created and updated

delivery for complex patients who are frequent users of the ED.

and made available to providers across the health system. We hypothesized that multidis-

METHODS: A multifaceted innovative model of care was designed whereby participat-

ciplinary care team intervention would lead to decreased ED utilization among patients

ing solo PCPs were provided a single access point via phone or email to a range of

with a history of high utilization patterns. We used a quasi-experimental design and

resources and providers. The SCOPE intervention included a general internist (GIM) on-

performed a retrospective review of ED electronic medical record data. The study

call for telephone advice or access to a GIM-led short stay medical unit that provided

population included individuals with a SCD-related ED visit from 11/1/2012–6/30/

urgent assessment, investigation, and management for patients with acute or chronic

2014. We calculated intra-individual change in ED visit rate and inpatient admission

medical conditions. SCOPE also offered a nurse navigator and homecare coordinator to

and pre- and post- intervention. A paired t-test and analysis of variance were used to

link PCPs with hospital and community resources, and online access to hospital-based

evaluate differences across strata of age, gender, insurance status, and high-utilization

patient records. Process measures including frequency of utilization, reason, and outcome

history in change of ED use and inpatient admission pre-post intervention. Change in

of PCP contacts were tracked. The primary outcome, rate of ED visits for patients in

utilization pre-post intervention was evaluated using the Wilcoxon rank-sum test.

participating practices, was assessed using an interrupted time series analysis. This was

RESULTS: A total of 242 individuals had any SCD-related visit with a total 1188 ED

compared to a propensity matched control cohort. Semi-structured one-on-one interviews

visits across all patients with SCD over the 20-month study period, including 833 ED

of participating PCPs with qualitative analysis were also performed.

visits in the 12 months pre-intervention and 355 ED visits in the 8 months post-

RESULTS: Twenty-nine PCPs agreed to participate and were able to access the SCOPE

intervention period. The study population was 57 % female, 100 % African-American,

intervention over an 18-month time period. In both the SCOPE PCP group and control

and ranged from age 18–70. Among the group, 33 % had three or more ED visits in the

group the rate of ED visits significantly decreased post intervention, but the pre-post

year prior to intervention, and thus were considered to have a history of high utilization.

change in per practice rate of ED visits was not significantly different in the SCOPE PCPs

Pre-intervention, participants had mean 3.7 ED visits per year, while post intervention the

compared to controls. However, qualitative analysis demonstrated that the intervention

mean was 2.1 ED visits per year. The mean number of inpatient admissions was smaller,

had beneficial effects. PCPs reported that the intervention had improved the quality and

with a mean 1.2 admissions for the population pre-intervention, and 0.6 admissions per

coordination of care provided to their patients; heightened awareness, enabled better

year post-intervention. There was a significant difference pre-post in utilization among the

provision of available services and demonstrated an enhanced ability to practice shared

total population. The mean intra-individual decrease in ED visits was −1.2 visits/year,

care for their complex patients within an interdisciplinary environment.

while the mean intra-individual decrease in inpatient admissions was −0.7 admissions/

CONCLUSIONS: The SCOPE intervention increased understanding of the challenges

year. When stratified by utilization, this statistically significant difference was only noted

solo PCPs face in caring for their complex patients. While we did not observe a decline in

among those patients with a history of high ED utilization. Stratified analysis of changes in

ED visits related to the SCOPE intervention, qualitative findings indicate the intervention

utilization by other demographic characteristics showed no difference across strata of age

had important effects at the PCP practice level, which may ultimately translate to reduced

group, gender, and insurance type.

ED use with longer observation.

CONCLUSIONS: Following implementation of a multidisciplinary care team intervention for management of uncomplicated SCD pain crises associated, we identified a significant decrease in ED utilization among those individuals with a history of high


utilization. These findings highlight the potential strength of leveraging shared resources


for multidisciplinary interventions, and suggest that the most value can be found from


targeting high utilizing subpopulations. A limitation of note is that the analysis included

Eng1; Matthew Manning2; Linda Robertson3; Christina Hardy1; Jennifer Schaal4; Dwight

only utilization at one health system, as such it is unknown if individuals included in

Heron3. 1University of North Carolina, Chapel Hill, NC; 2Cone Health, Greensboro, NC;

analysis accessed other health systems for acute care services in the study period. This


study suggests that multidisciplinary care teams targeting management of uncomplicated

Greensboro, NC. (Control ID #2467673)

University of Pittsburgh Medical Center, Pittsburgh, PA; 4The Partnership Project,

SCD pain episodes have potential to reduce the burden of unplanned acute care utilization; further studies could use claims data to assess the impact on utilization across all health

BACKGROUND: Lung cancer and breast cancer are the leading causes of cancer death

centers, and explore patient experiences of such interventions.

in the U.S. Despite the frequency of fatal outcomes, Black patients with potentially curable




disease consistently either don’t receive or don’t complete standard treatments more

fully automated data and the negative effect of low physician engagement and high staff

frequently than White patients contributing to higher mortality rates. The Accountability

turnover on implementation of system change. These issues need to be considered in

for Cancer Care through Undoing Racism and Equity (ACCURE) Study is an NCI

approaching real world dissemination and implementation projects.

sponsored intervention trial designed to implement system changes to reduce these treatment disparities. In this report, we describe the intervention in 2 cancer centers focusing on early results and factors that might have influenced differences between




METHODS: The intervention was derived using a community based participatory

Karin V. Rhodes2; Jessica X. Zuo1; Rathnam Venkat1; Daniel Polsky1. 1University of

research approach in partnership with a health disparities collaborative formed in 2003

Pennsylvania, Philadelphia, PA; 2Northwell Health, Great Neck, NY. (Control ID

in response to the IOM’s Unequal Treatment Report. The ACCURE intervention consists


of 4 components: (1) a real time warning system built with uploads from electronic health record data that automatically signals missed patient appointments or unmet milestones in

BACKGROUND: With implementation of the Affordable Care Act, there is concern that

expected care, (2) race-specific data feedback to each cancer center team regarding

newly insured individuals will be unable to access primary care. In a multi-state mystery

adherence to standard treatments, (3) a nurse navigator specially trained regarding health

shopper study prior to ACA implementation, individuals with Medicaid were much less

equity issues and race-specific barriers to care (randomized to ½ the patients), and (4)

likely to be offered a new patient appointment than those with private coverage. With

quarterly health equity trainings for cancer center staff based on concepts of an established

Medicaid expansion occurring in many states, it is important to measure primary care

undoing racism curriculum and locally acquired data. All data were collected using

access in ways that are similar to the experience of consumers. We conducted a mystery

uploads from electronic sources. Baseline data were obtained from cancer registry and

shopper study in a large urban area with the following objectives: 1) determine primary

billing records at each cancer center for all patients with early stage breast and lung cancer

care availability and wait times for newly insured adults and assess differences by

diagnosed from Jan. 1, 2007 to Dec. 31, 2011. The intervention cohort was enrolled at

insurance type (Medicaid vs. private coverage), and 2) determine whether small area

each cancer center starting in 2013. The primary outcome, “Treatment Complete”, is a

variations in primary care supply are associated with differences in appointment avail-

combined variable consisting of receipt of lung cancer surgery for early stage lung cancer

ability and wait times.

patients, breast cancer surgery for early stage breast cancer patients, and completion of at

METHODS: We conducted a census of all primary care practices in and near Philadel-

least 80 % of prescribed adjuvant radiation for lumpectomy patients and 80 % of

phia using data from SK&A, the largest commercial and Medicaid insurers in the region,

prescribed adjuvant chemotherapy for breast cancer patients for whom chemotherapy

the local department of public health, and organizations representing CHCs. We conduct-

had been started.

ed an initial telephone survey of each practice to quantify the number of primary care

RESULTS: At Center #1, 2532 patients were in the early stage cancer population identified

providers in order to calculate population to provider ratios for each census tract based on

in the retrospective review. Seven hundred twenty-four with lung cancer and 1808 with breast

the adult population and number of providers within a 5-min drive time from the centroid

cancer. The mean age was 63 years (+/−12), 21 % Black, 85 % female, 66 % stage I. For the

of each census tract. We identified six clusters of census tracts with the lowest supply. We

147 patients in the prospective study, 75 % had breast cancer. The mean age was 62 years,

then conducted a mystery shopper study by having two simulated patients call

37 % were Black, 8 % male, and 69 % had stage I disease. At Center #2, 5265 patients were

practices—one with private insurance (all practices) and one with Medicaid coverage

in the early stage cancer population identified in the retrospective review, 1125 with lung

(only for practices participating in a Medicaid plan). In each case, the simulated patient

cancer and 4140 with breast cancer. The mean age was 61 years (+/−12), 7.5 % Black, 89 %

requested the next available new patient appointment. Multiple and logistic regression

female, 64 % stage I. For the 126 patients in the prospective study, 49 % had breast cancer.

were used to assess relationships between local primary care supply and experienced

The mean age was 64 years, 40 % were Black, 21 % male, and 80 % had stage I disease.


During the 2 years of the prospective trial, Center 1 experienced an 80 % turnover of the

RESULTS: Of the 414 practices determined to be eligible for a private insurance call, 362

breast and lung oncology group while Center 2 had no turnover. For health equity sessions,

(87.4 %) offered the simulated patient a new patient appointment. Of the 317 practices

all cancer center physicians and staff were invited but attendance was voluntary. At Center 1,

eligible for a Medicaid patient call, 216 (68.1 %) offered the simulated patient a new

20 to 30 % of staff attended to date with minimal oncologist involvement while at Center 2,

patient appointment. Among practices that offered an appointment, the median wait time

most physicians attended with similar staff involvement. At both Centers, missing data from

for a private insurance appointment was 9 days versus 12 days for a Medicaid appoint-

the baseline data collection prevented calculation of the Treatment Complete variable for

ment. Median wait times were similar for private and Medicaid calls when restricting the

25 % of patients. For Center 1, unadjusted analysis reveals 80 % of White patients completed

analysis to practices that accept Medicaid. Median wait times for private calls were the

therapy at baseline compared to 67 % in the intervention period (p = .002). For Black patients,

same for practices that participate in Medicaid compared with those that do not (9 days).

baseline completion was 80 % compared to 81 % in the intervention (p = .86). Logistic

Appointment availability was similar for practices located in lower primary care supply

regression controlling for age, Charlson Score, clinical stage, race, and cohort (retrospective

areas compared to other areas (private: OR = 0.93, p = 0.891; Medicaid: OR = 1.63, p =

vs. prospective) showed no improvement attributable to the intervention. For Center 2, the

0.279). Similarly, wait times until the first available new patient appointment were similar

unadjusted analysis reveals Treatment Complete for 85 % of White patients at baseline

for practices in lower primary care supply areas compared to other areas (private:

compared to 89 % with the intervention (p = .33). For Black patients baseline completion was

−5.4 days, p = 0.135; Medicaid: −9.6 days, p = 0.063).

75 % compared to 86 % in the intervention (p = .11). Logistic regression demonstrated a

CONCLUSIONS: We found that new appointment availability was substantially lower

Black-White disparity pre-intervention (75 vs. 85 %, p = .01) that resolved with intervention

for individuals with Medicaid seeking a new patient appointment compared to those with

(86 vs. 89 %).

private coverage. However, once offered an appointment, wait times were similar for

CONCLUSIONS: A multimodal intervention to optimize treatment completion and

callers with both insurance types. Surprisingly, appointment availability and wait times did

reduce racial disparities seemed effective in one cancer center and ineffective in another.

not vary based on the primary care supply in the immediate area. Future studies should

The effective center had stable staffing and high physician engagement at Health Equity

explore other factors that contribute to variation in primary care appointment availability

sessions whereas the other center did not. These results show the current limitations of

and wait times.





BACKGROUND: National guidelines recommend that all smokers receive smoking


cessation counseling at every medical visit. Patients with opioid use disorder (OUD) have




PATIENT SATISFACTION Charlie M. Wray ; Stephanie Mueller ; Amber Pincavage ;

especially high rates of smoking-related morbidity and mortality. Additionally, achieving

Reshma Gupta3; Saima Chaudhry8; Rachel K. Miller6; Linda DeCherrie2; Karin

smoking cessation improves their addiction treatment outcomes. Buprenorphine is an

Ouchida7; Vineet M. Arora5. 1Brigham and Women, Boston, MA; 2Icahn School of

outpatient medication for OUD that is prescribed in both primary care and specialty

Medicine at Mount Sinai, New York, NY; 3University of California, Los Angeles, Los

settings. Buprenorphine visits offer a unique opportunity to assess the provision of

Angeles, CA; 4University of Chicago, Chicago, IL; 5University of Chicago Medical

smoking cessation counseling for patients with OUD. The aim of our study is to evaluate

Center, Chicago, IL; 6University of Pennsylvania, Philadelphia, PA; 7Weill Cornell

the frequency of smoking cessation counseling for patients prescribed buprenorphine by

Medical College, New York, NY; 8nslij, Manhasset, NY. (Control ID #2457425)

analyzing a nationally representative sample of outpatient visits for patients who smoke. Specifically, we examine the frequency of smoking cessation counseling that occurred in

BACKGROUND: Inpatient handoffs have been recognized as a vulnerable time during a

visits in which buprenorphine was prescribed compared to visits in which buprenorphine

patient’s hospitalization and are widely associated with adverse events and near misses. A

was not prescribed.

variety of strategies have been implemented in order to improve shift handoffs. To date, no

METHODS: We performed a cross-sectional analysis of a nationally representative

study has described how residency program leadership views these strategies, or how the

sample of adult smokers. Publicly available data from the National Ambulatory Care

implementation of these strategies would affect the hospitalized patient’s experience. Our

Survey (NAMCS) for years 2003–2010 and 2012, combined with data from the National

objective was to characterize the use of best practices in resident handoffs and evaluate the

Hospital Ambulatory Care Survey (NHAMCS) for years 2003–2010 were used to

association with internal medicine program director (PD) satisfaction and patient experi-

generate the sample. Complex survey analysis methods were used to account for

ence scores.

weighting and design effects. Descriptive statistics were utilized to characterize the sample

METHODS: We combined and analyzed the 2014 Association of Program Direc-

of adult smokers as a whole, and then stratified by whether or not the visit was associated

tors in Internal Medicine (APDIM) survey results with the Center for Medicare

with a buprenorphine prescription. Chi square testing was used to compute bivariate

and Medicaid Service’s Hospital Consumer Assessment of Healthcare Provider

analyses of our main predictor (buprenorphine vs. non-buprenorphine visits) and outcome

and Systems (HCAHPS) survey results. APDIM handoff survey items surveyed

(smoking cessation counseling) variables, first on the sample as a whole and then stratified

properties of written and verbal handoffs and educational interventions. Primary

by physician specialty. Finally, we constructed a multivariable logistic regression model

outcomes included PD satisfaction with the handoff process, and HCAHPS survey

with our main predictor and outcome variables, adjusting for year of visit.

items that assessed the 5-star composite scores regarding doctor communication,

RESULTS: The sample of adult smokers included 47,146 individual patient visits;

pain management, hospital rating, hospital recommendation, and overall summary

buprenorphine was prescribed in 242 of these visits. Overall, the patients seen in

rating for the primary affiliated hospital for each corresponding residency program.

buprenorphine visits were significantly younger (mean age 35.0 years vs. mean age

Each outcome variable was measured on a 5-point scale and dichotomized for

48.2 years; p < 0.001) and more likely to be insured by Medicaid (39.6 vs. 16 %;

analysis. Multivariable logistic regression models controlling for institution-

p < 0.001) than those for whom buprenorphine was not prescribed. Initial bivariate

specific characteristics tested associations between PD satisfaction and both hand-

analysis of our study sample as a whole demonstrated that smoking cessation counseling

off properties and HCAHPS patient experience outcomes.

was significantly more likely to occur in visits in which buprenorphine was prescribed

RESULTS: In total, 234/361 (65 %) of all APDIM member programs responded, with

(41.0 %) than in visits in which buprenorphine was not prescribed (19.5 %; p = 0.0051).

208/361 (58 %) responding to all of the handoff questions. Most program directors (60 %)

However, when results were stratified by physician specialty, we found that visits with

were satisfied with the handoff processes that were used during shift changes. Employing

psychiatrists and substance abuse specialists were driving the overall trend. Specifically,

a dedicated room (OR 3.18; 1.34–7.58), supervision by a senior resident (OR 2.44; 1.26–

for primary care physicians (PCPs), there was no difference in the rate of smoking

4.74), paper copies of sign outs for receivers (OR 2.32; 1.11–4.88), and interactive

cessation counseling between the buprenorphine (23.9 %) and non-buprenorphine visits

workshops (OR 2.17; 0.95–4.96) were positively associated with PD satisfaction, but

(24.2 %; p = 0.97), whereas for psychiatrists/substance abuse specialists, the rate of

were not associated with any patient experience outcomes. Use of Electronic Health

smoking cessation counseling was significantly higher in the buprenorphine (59.2 %)

Records (EHR) for the creation of a written handoff was associated with PD satisfaction

compared to the non-buprenorphine visits (17.7 %; p = 0.0004). In adjusted analysis, the

(OR 4.15; 1.51–11.37) and patient’s overall rating of their hospital care (OR 3.07; 1.43–

PCPs’ odds of smoking cessation counseling in buprenorphine compared to non-

6.58) and Summary Star rating (2.24; 1.00–5.02). PD reported application of these

buprenorphine visits was 0.99 (p = 0.98) and the psychiatrists’/substance abuse special-

measures ranged from 26 % for interactive workshops to 59 % for receiver obtaining a

ists’ odds of smoking cessation counseling in buprenorphine vs. non-buprenorphine visits

written copy of sign-out.

was 5.50 (p = 0.003).

CONCLUSIONS: While several handoff strategies are related to PD satisfaction, only

CONCLUSIONS: This study demonstrates a low level of smoking cessation counseling

the use of an EHR-based written handoff was shown to be associated with higher

overall, which unfortunately, is consistent with current literature of smoking cessation

HCAHPS scores. With less than half of all respondent programs utilizing an EHR-

counseling in outpatient settings. PCPs did not demonstrate differential counseling for

based handoff, this may represent an underutilized resource in patient handoffs, and

buprenorphine vs. non-buprenorphine visits. Psychiatrists performed much better than

may represent a future target for meaningful use criteria.

PCPs in offering smoking cessation counseling during buprenorphine visits, but their overall level of counseling was low. It is possible that psychiatrists who prescribe buprenorphine are more attuned to the relationship between opioid use disorder and


tobacco use disorder than are PCPs who prescribe buprenorphine. Our study highlights

BUPRENORPHINE VISITS Zoe M. Weinstein2, 1; Phoebe A. Cushman2, 1; Lewis

a missed opportunity for all providers to engage in smoking cessation counseling. Given

Kazis3; Howard Cabral3. 1Boston Medical Center, Boston, MA; 2Boston University,

the particular risks of smoking for patients with OUD, further work should address barriers

Boston, MA; 3Boston University School of Public Health, Boston, MA. (Control ID

to and facilitators of the performance of smoking cessation counseling by PCPs who


prescribe buprenorphine.





BACKGROUND: Patients who take an active role in their healthcare and partic-


ipate in shared decision-making (SDM) with their healthcare providers (HCPs) are

TION Lynn Bowlby1; Alex H. Cho1; Natasha T. Cunningham1, 1; Lawrence Greenblatt1;

better able to accomplish their management goals and maintain their health.

Adia K. Ross1, 3; Mark Sendak2; Daniella A. Zipkin1. 1Duke University School of

However, due to patients’ perceptions of their role, desires to be a “good patient,”

Medicine, Durham, NC; 2Duke University, Durham, NC; 3Duke University Hospital,

and the difference in knowledge and power between patients and HCPs, many

Durham, NC. (Control ID #2469741)

patients do not feel empowered to take an active role in their medical care. We developed a Patient Empowerment Program (PEP) with the goal of reframing the

BACKGROUND: Ambulatory care has become an increasing priority for medicine

roles of the patient and HCP and democratizing the patient-HCP relationship so

residency programs, the cornerstone of which is the continuity clinic, where residents

patients can fully participate in SDM. As part of the training, participants viewed

function as primary care doctors. These resident clinics often serve medically complex

examples of patient-HCP communication and practiced communication skills with

patients suffering from co-morbid mental health and substance abuse disorders, with

Standardized Healthcare Providers (SHPs). We report on how participants’ expec-

adverse home and community environments, and who are often uninsured or underin-

tations for communication with HCPs changed over the course of the program.

sured. Continuity is difficult to achieve given the competing clinical demands on trainees

METHODS: Patients with type 2 diabetes (DM) were recruited from Primary Care

and relative infrequency of clinical sessions. In our clinic, these issues were associated

clinics at two public hospitals in NYC to participate in PEP, a 4-h, two-session,

with low resident and staff satisfaction and high rates of emergency department and

performance-based workshop run by a Health Psychologist (L.A.) with extensive

hospital utilization by patients.

experience in health education. In Session 1, participants discussed shared

METHODS: Using an adapted DMAIC framework (define; measure; analyze; imple-

decision-making (SDM) in the medical encounter and viewed three sets of trigger

ment; control) in a process that engaged multiple institutional stakeholders, our interdis-

videos depicting patient-HCP interactions: 1) providing information about a diffi-

ciplinary clinic leadership team over the course of 2 years identified some of the major

culty, 2) asking for more information, and 3) negotiating an agreeable treatment

unmet needs of our population and trainees, and developed a multifaceted clinic redesign

plan. Each set of videos consisted of a less effective interaction followed by a

plan supported by our hospital administration, which could improve outcomes and reduce

more effective interaction. After each video participants rated both parties using 4-

the cost of care, while also improving the trainee experience. In many cases, these efforts

point behaviorally-anchored SDM checklists. In Session 2, participants role-played

built on or leveraged prior work done in the clinic on some of the same issues. Three main

two scenarios with SHPs, the second of which was tailored specifically for each

interventions were proposed and implemented: 1) creation of a clinic-based behavioral

participant based on an aspect of DM that they struggled with and that was

health-primary care coordinated care model (HomeBASE) for psychosocially complex,

difficult to discuss with their HCPs. After the final scenario, participants rated

high-utilizing patients; 2) dedication of a team within the clinic and workflow to manage

their own performance while SHPs rated the patient on the same 4-point

communications with and review of patients being discharged from the hospital; and 3)

behaviorally-anchored SDM checklist. At the end of each session, participants

establishment of “firm”-like resident groups within the clinic. Financial modeling was

also rated the session in terms of how much they learned. All SDM checklists and

done of decreased inappropriate ED utilization and reduction in hospital days to justify the

session ratings were visual Likert scales with a range of 0–3, where anchor term

initial investments required by the hospital and other partners. Importantly, the clinic itself

for 0 was “not at all” and the anchor term for 3 was “very well.”

would not need to see an increase in revenue. A dashboard was created a priori of metrics

RESULTS: We recruited 71 patients to participate in PEP, 45 of which attended

for measuring impact, and the means and process for obtaining and reporting them

Session 1 and 36 of which attended both sessions. Participants were predominately


male (53 %) with a mean age of 59.0 years (SD = 10.1), racial and ethnic

RESULTS: Over the past 2 years, substantial reductions were achieved in ED visits

minorities (29 % African-American, 40 % Hispanic), and had a low education

(−14.7 %) and hospitalizations (−16.8 %) for patients receiving primary care at the DOC,

level (40 % did not complete high school), low socioeconomic status (62 %

translating into direct cost savings of $767,878 in 2013–14 and $1,704,953 in 2014–15.

income under $10,000/year), and limited health literacy (76 %, as measured by

Overall return on investment was estimated at 2.0X in the first year and 6.3X in the

the Newest Vital Sign). In Session 1, participants rated the patient in each video

second. The impact on residents has also been powerful. Previously, residents often

(M = 0.98–2.40, SD = 0.84–1.13) significantly lower than the HCP (M = 1.86–

expressed feelings of helplessness when working with clinic patients. Now, residents

2.74, SD = 0.49–1.07), t(43) = 2.46–6.78, p = 75 years and in 2012 recommended against screening in men of any age. In 2013 the


American College of Physicians and the American Urologic Association recommended


shared decision making for PSA testing for men ages 50’s-69 and agreed that men > 70

Antoine Folly3; Marco Mancinetti3; Daniel Hayoz3; Jacques Donze1, 2. 1Inselspital, Bern

should not undergo routine PSA testing. Established risk factors for prostate cancer

University Hospital, Bern, Switzerland; 2Brigham and Women’s Hospital, Boston, MA;

include age, African American race, and family history of prostate cancer. The purpose


Fribourg Cantonal Hospital, Fribourg, Switzerland. (Control ID #2457208)

of this study is to assess the trends in utilization of PSA testing for prostate cancer screening in the primary care clinics of a large integrated health system as correlated with

BACKGROUND: In order to most efficiently improve transition of care, hospitals need

1) the release of these evolving guidelines and 2) known risk factors for prostate cancer.

to target intensive discharge interventions at those patients at high risk of unplanned

METHODS: We conducted a retrospective study using electronic medical record data

readmission. The “HOSPITAL” score, derived previously in the US, is an easy to use

from January 2007–June 2015. Our study population included all men ages 40 and above

prediction model that accurately identifies medical patients at high risk of readmission. It

with at least 1 visit in an Internal Medicine or Family Medicine clinic in the Cleveland

includes the following predictors: Hemoglobin, discharge from an Oncology service,

Clinic Health System in any of the study years. As our focus was on PSA screening testing

Sodium level, Procedure during the index admission, Index Type of admission (urgent

in primary care, we excluded men who had a visit with the urology department prior to the

or elective), number of Admission(s) during the last 12 months and Length of stay. This

PSA test in any study year and men with a history of prostate cancer. Any “diagnostic

score showed good performance in an international multicenter retrospective study. We

PSA” test or PSA tests associated with International Classification of Diseases - Ninth

aimed to demonstrate in a prospective study the accuracy of the HOSPITAL score to

revision (ICD-9) diagnosis codes for urinary symptoms or prostatic hypertrophy with

predict high risk for unplanned 30-day readmission and death.

symptoms were also excluded. We calculated PSA screening rates for men in the




following age groups: > 70, 50–69 and 40–49. We also calculated rates of screening for


men with established risk factors for prostate cancer including African American race and


documented family history of prostate cancer.


RESULTS: Prostate cancer screening rates with PSA testing in primary care clinics

Tudorascu1; Kathleen M. McTigue1; Cindy L. Bryce4; Kimberly A. Huber1; Laurey R.

for men > 70 years of age decreased steadily from 2007 to 2015 from 10 to 5 %,

Simkin-Silverman4; Rachel Hess3; Gary Fischer1; Molly B. Conroy1. 1University of

and rates of screening in men ages 40–49 remained low at 3–4 %. For men ages

Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh Medical Center, Pittsburgh, PA;

50–69, while a small decrease in screening rates was noted in 2012–13, temporally


corresponding with the initial release of the USPSTF guidelines, the rates have

Public Health, Pittsburgh, PA. (Control ID #2466630)

University of Utah, Salt Lake City, UT; 4University of Pittsburgh Graduate School of

remained stable at 13 % in both 2007 and 2015 (Figure). Including all men ages 40 and older, the rate of prostate cancer screening in African American men ranged

BACKGROUND: Interventions targeting weight loss often fail to demonstrate long-term

from 6.8 to 8.2 % and remained lower than screening rates in non-African

results. Primary care providers (PCPs) can play a critical role in supporting patients’

American men from 2007 to 2015. For all men with a documented family history

weight loss maintenance efforts, but lack of time and resources are barriers. A novel

of prostate cancer, PSA screening rates remained higher than for men without a

solution would be to use existing electronic health record (EHR) and linked personal

family history of prostate cancer throughout the study period (Table).

health record (PHR) resources along with non-physician clinical staff to support primary

CONCLUSIONS: Physicians in our sample appeared to embrace guideline recommen-

care patients’ weight loss maintenance and involve the PCP through timely updates.

dations against screening older men, but not those recommending against all screening.

Understanding the current PCP weight loss maintenance practices and soliciting feedback

Men with a family history of prostate cancer were more likely, and African American men

on integration of EHR tools into existing clinical workflow are key steps in creating

less likely, to be screened. Future work should address approaches to risk-based shared

weight loss maintenance interventions that will have the greatest potential for dissemina-

decision making for prostate cancer screening, specifically for African American men.

tion in diverse clinical settings. METHODS: Maintaining Activity and Nutrition through Technology-Assisted Innovation in

Rates of PSA Screening Testing in Men with High Risk for Prostate Cancer African American Men (N = 8669)

Year 2007 2008 2009 2010 2011 2012 2013 2014 2015

Rate (%) 6.8 7.0 7.8 8.2 8.2 7.1 7.4 7.9 8.2

Men with Family History of Prostate Cancer (N = 1718)

NonAfrican American Men ( N = 81828)

Rate (%) 7.1 7.7 8.1 9.0 9.7 8.5 7.8 9.5 9.6

p 0.28 0.03 0.30 0.02 40,000 ng/ml, triglycerides 250 mg/dL, and wors-

differentiated invasive squamous cell carcinoma with subsequent resection confirming

ening transaminitis and pancytopenia. Fibrinogen was normal and bone marrow

metastasis to adjacent lymph nodes. Patient also underwent lobectomy for the lung mass.

biopsy did not reveal hemophagocytic activity. Echocardiogram showed an enlarging

Pathology of the mass was without evidence of malignancy but did identify actinomycotic

pericardial effusion and the patient ultimately required a pericardial window. A new

sulfur granules within bronchial lumina.

diagnosis of SLE was made (based on pancytopenia, serositis, positive ANA, anti-

DISCUSSION: A non-resolving pneumonia is a presentation that the general internist

smith antibodies and nervous system involvement). Pulse dose steroids and

will inevitably encounter. When this presentation is accompanied by the appearance of a

Hydroxychloroquine were initiated. Anakinra was later added for treatment of

mass, one should then include the infectious causes such as mycobacteria, fungi, nocardia

presumed MAS. He responded quickly with improving encephalopathy,

and actinomyces in their differential in addition to malignancy. In our case, there was a

downtrending ferritin, and resolving cytopenias. His course was complicated by

mass found on imaging associated with a history of a pneumonia that had waxed and

development of seizures likely due to neuropsychiatric SLE, and he ultimately died

waned with short courses of antibiotics. This is a common presentation for actinomycotic

from septic shock secondary to invasive pulmonary aspergillosis. Histopathology on

infections as the empiric treatment duration for community acquired pneumonia is much

autopsy showed accumulation of macrophages in the cerebellum, a foci of inflam-

shorter than that which is required for appropriate treatment of actinomyces. The partial

mation in the spleen and confirmed the diagnosis of invasive pulmonary

treatment and thus chronicity of the infection may lead to fibrosis and the development of


a mass on imaging. In addition, symptoms such as fevers, night sweats and weight loss

DISCUSSION: MAS as the initial presentation of SLE is a rare phenomenon. Our case

may further sway the clinician toward suspicion of malignancy. The diagnosis may again

demonstrates the importance of early recognition and diagnosis of SLE and increased

be obscured by antecedent antibiotics when tissue samples are obtained. Therefore, it is

awareness of MAS as a complication that can increase mortality. Profound ferritin

not surprising that only a small minority of cases are diagnosed pre-operatively. When a

elevation is the hallmark of MAS and should prompt further investigation based on

concomitant malignancy is diagnosed with the associated infectious mass, as was the case

MAS and HLH criteria. High dose intravenous corticosteroids are the standard of care

with our patient, the likelihood of identifying actinomyces pre-operatively is even smaller.

and various immunomodulators have shown to be efficacious; however, the increased risk

The general internist must know when to evaluate a non-resolving pneumonia further and

of opportunistic infection must be considered.





causes. Multiple PA-L chest radiographs did not reveal signs of SEA nor did thoracic CT.

J. Tanenbaum. University of Washington, Seattle, WA. (Control ID #2462501)

This patient had no known risk factors for SEA and did not present with the classic triad of spinal pain, fever, and neurologic deficits which led to missed diagnosis. SEA is often

LEARNING OBJECTIVE #1: Diagnose spinal epidural abscess (SEA)

missed on initial presentation because the classic triad described above is rare (8 % of

CASE: Mr. R is a 65 year old man with no significant past medical history who presented

patients on initial visit). Back pain is the most common complaint with SEA, with 95 % of

to a primary care clinic with back pain. He described the gradual onset of razor-like

patients describing this at their initial visit, compared to 41 % reporting a neurologic deficit

bilateral upper back pain, 10/10 in intensity, starting adjacent to his spine and radiating to

and 33 % reporting fevers. MRI with gadolinium contrast is the diagnostic study of choice

the chest in a band-like distribution. The pain started 6 weeks ago while he was on a cross-

for SEA, with a sensitivity approaching 100 %. X-ray of the spine can often suggest an

country bike ride. The pain was made worse by inhalation but not exercise or movement.

abnormality and the need for further imaging. The exact sensitivities of plain radiography

Two weeks prior to the onset of pain, Mr. R experienced fevers, lethargy, night sweats,

and CT for SEA are unknown. Back pain is a common complaint in primary care and new

headache, and dysuria; all of these symptoms resolved over a 2-week period. On review of

non-mechanical back pain in an elderly patient must be taken seriously. One should not

systems, the patient denied recent skin changes. He endorsed being bit on his leg by a

rely on the classic triad of symptoms to suspect SEA, as most patients present with isolated

brown tick 1–2 years ago. His travel history over the past year includes riding his bike

spinal pain. MRI with contrast should be obtained when SEA is suspected.

through the American southwest, northeast, northwest, and south eastern Canada. He endorsed minimal consumption of alcohol and denied use of tobacco and illicit drugs. Five weeks ago he had presented to a different primary care clinic. A PA-L chest radiograph


revealed a possible left-sided pleural effusion. He was prescribed NSAIDs. He presented

SPOTLIGHT Shannon Ruzycki; Jay L. Patel; Margaret M. Kelly. University of Calgary,

to an emergency department 4 weeks ago. His vital signs were normal. A workup for acute

Calgary, AB, Canada. (Control ID #2457672)

coronary syndrome was negative. CBC revealed a mild normocytic anemia (Hb 12.9). Basic chemistries and liver function tests were within normal limits. A PA-L chest

LEARNING OBJECTIVE #1: Recognize the common manifestations of systemic

radiograph was normal, and a thoracic CT angiogram revealed a 7 mm pulmonary nodule

IgG4-related disease

in the left lower lobe and no pulmonary embolism. Two weeks ago, he presented to

LEARNING OBJECTIVE #2: Diagnose IgG4-related disease

another primary care office with persistent back pain. He was prescribed gabapentin. At

CASE: A 66-year old male without significant past medical history presented to the

this time the patient began taking oxycodone obtained from a friend. His pain was still

Urgent Eye Clinic with a 1 week history of painless right eye proptosis and epiphora.

poorly controlled. At the current visit, vital signs were: BP 105/74, Pulse 90, T 37.6C.

Computed tomography of the head demonstrated a homogenous, 3.7 × 1.7 cm enhancing

Physical exam revealed a healthy-appearing man who appeared younger than his stated

mass arising from the right lacrimal gland that displaced the lateral rectus muscle. Urgent

age. Heart and lung exams were normal. Neurological exam revealed: CN II-XII intact,

surgical biopsy was performed. Pathology demonstrated a lymphoplasmacytic infiltrate

strength 5/5 throughout, reflexes 2+ throughout. No sensory deficits. No spinal or

with storiform fibrosis and occasional eosinophils. Immunohistochemistry showed in-

paraspinal tenderness and ROM in his spine was normal. Digital rectal exam revealed

creased number of IgG4-positive plasma cells, constiting 75 % of total plasma cells. No

normal rectal tone and normal prostate. No rashes were seen. Lab testing revealed

granulomas or malignant cells were seen. Flow cytometry for lymphoma performed on the

normocytic anemia (Hb 12.0), HIV neg, UA normal, Hep C neg, Quantiferon Gold neg,

tissue was negative. Serum calcium, c-reactive protein (CRP), rheumatoid factor (RF),

ESR 62. His gabapentin dose was increased. Mr. R was called 1 week after this visit at our

angiotensin converting enzyme (ACE), anti-nuclear antibody (ANA), and anti-neutrophil

clinic to evaluate pain control. He reported that the pain was worsening. Nortriptyline and

cytoplasmic antibody (ANCA) were negative. Liver and renal function were within

naproxen were prescribed, and a thoracic MRI was ordered. The MRI revealed discitis/

normal limits. Serum immunoglobulin subclass analysis revealed an IgG4 level of

osteomyelitis of T4-T5 with erosive changes and associated epidural abscesses. Cord

3.50 g/L (normal range 0.01–1.40 g/L). A diagnosis of IgG4-related disease (IgG4-RD)

compression was noted without signal abnormality. The patient was contacted and

was made, and treatment was initiated with high-dose prednisone. Follow-up CT of the

admitted to the spine service. Culture from spinal biopsy revealed MSSA. T3-6

orbits demonstrated significant reduction in size of the lacrimal gland mass at 6 month

laminectomy and T4-T5 corprectomy were performed with surgical stabilization and

assessment. Prednisone was tapered over 3 months with ongoing improvement of the

hardware placement. Broad spectrum antibiotics were begun and later narrowed to

patient’s symptoms. At 1 year follow up, the patient had not relapsed or developed

nafcillin. His hospital course was complicated by meningitis. He was discharged with

symptomatic involvement of other organ systems.

levofloxacin and rifampin to complete a 6 week course. He was neurologically intact upon

DISCUSSION: IgG4-related disease is a recently described, systemic fibroinflammatory


disease defined by characteristic pathologic lesions. Its discovery linked many single-

DISCUSSION: Spinal Epidural Abscess (SEA) is a rare cause of back pain. The rate of

organ diseases, including autoimmune pancreatitis and idiopathic salivary gland fibrosis,

spontaneous SEA is believed to be 0.88 cases/100,000 person years. Major risk factors for

under a single disease spectrum by a common histopathology. Since the first description of

SEA in the absence of spinal surgery or instrumentation include concurrent infection,

the disease-defining IgG4-positive plasma cell infiltrate in 2003, IgG4-RD has been found

diabetes mellitus, immune system compromise, and intravenous drug use. Other risk

to affect nearly every organ. Thus, physicians from any speciality may encounter IgG4-

factors include alcohol abuse, recent spinal fracture, indwelling catheter, cancer, and

RD. Diagnosis of IgG4-RD has implications for treatment and prognosis, and should be

chronic renal failure. The vast majority of patients have at least one risk factor. This

sought in patients with classic clinical features for this illness. End organ damage in IgG4-

patient demonstrates the difficulty in early diagnosis of SEA. He presented to a primary

RD occurs due to infiltration of tissues by lymphocytes leading to organ enlargement,

care clinic with the common complaint of persistent back pain with normal vital signs and

reactive inflammation, and eventual fibrosis. The pancreas and salivary glands are the

prior negative imaging. His red flags were new back pain at an older age and the non-

most common affected. The most common presenting symptom of IgG4-RD is due to

mechanical nature of the pain. The sharp nature of the pain and apparent dermatomal

mass effect of the enlarging organ; for example, IgG4-related pancreatitis may present as

pattern raised the concern for a neurologic source. The primary diagnoses considered

obstructive jaundice secondary to pancreatitic head enlargement. Often, IgG4-RD is

included infectious causes (bilateral herpes zoster, West Nile Virus, Lyme disease),

discovered as a mass on imaging studies performed for other indications. Rarely, patients

structural causes (malignancy, compressive mass, spinal fracture), and musculoskeletal

present with symptoms of subacute organ failure. A retrospective review series suggested




that IgG4-RD of the orbit may account for up to 28 % of cases initially given a diagnosis of

of blood. The smear revealed numerous intracellular ring forms present in approximately

idiopathic orbital inflammation or orbital benign lymphoid hyperplasia, two idiopathic

80 % of the red cells. An infectious disease consult was placed as the initial smear was read

conditions that cause non-neoplastic orbital soft tissue enlargement. A recent consensus

as likely Plasmodium falciparum. The patient was then transferred to the medical ICU to

statement by an expert, international panel of specialists emphasizes the importance of

initiate IV quinidine, and a call was placed with the CDC for possible release of artusenate.

histopathology in diagnosis of IgG4-RD. The number of IgG4-positive plasma cells must

A review of the smear in the morning revealed the presence of extracellular forms, and

be elevated, with the threshold for diagnosis dependent on the organ. The proportion of

given the high parasite burden, it was felt much more likely to be due to be Babesia microti

IgG4-positive plasma cells must be greater than 40 % of total plasma cells. Further, there

infection, which was later confirmed by PCR assay at the New York City Department of

must be increased lymphocytes and evidence of fibrosis. Finally, IgG4-RD is a diagnosis

Health. The patient was also started on IV clindamycin Q8H, and over the next 12 h

of exclusion; other disorders associated with elevated tissue IgG4-positive plasma cells,

experienced improvement in his mental status. He was able to provide more history at this

such as ANCA-associated vasculitidies, rheumatoid arthritis, pernicious anemia, low-

point, and denied any recent travel out of his home neighborhood in Brooklyn, or travel

grade B-cell lymphomas, and other malignancies must be ruled out. Flow cytometry for

out of New York State since moving from Albania some 18 years prior. He did live in

lymphoma, and careful examination for granulomatous disease or malignancy should be

Staten Island for 6 years before moving to Brooklyn. A repeat smear 24 h after initiating

performed by an experienced pathologist. Elevated serum IgG4 levels (greater than 1.35 g/

therapy showed parasitemia of greater than 40 %, and the patient received an exchange

l) are supportive of, but not required for, a diagnosis of IgG4-RD. Many disorders,

transfusion of 8 units of PRBC. As his mental status continued to improve, he was

including B-cell lymphomas, Sjogren’s syndrome, and minimal change disease, are also

transitioned to oral quinine and clindamycin, with eventual clearance of his parasitemia

associated with elevated serum IgG4 levels. The sensitivity and specificity of an elevated

over 2 weeks time. As the patient had received blood approximately 6 weeks prior to

serum IgG4 level for IgG4-RD is 97.0 and 79.6 % respectively. Without compatible

presentation, the city department of health and the division of epidemiology at the CDC

histopathology, an isolated elevated serum IgG4 level is non-specific. IgG4-RD should be

were notified. Testing of the donor blood serology conducted by the department of health

suspected in a patient presenting with organ enlargement, fibrosis, or dysfunction of

was positive for B. microti.

unknown etiology. In general, expert opinion is that tissue biopsy with immunohisto-

DISCUSSION: Babesia microti is a blood-borne parasite transmitted via Ixodes

chemical staining for IgG4-RD should be considered in patients with pancreatitis, retro-

scapularis, commonly known as the deer tick, the same vector responsible for transmis-

peritoneal fibrosis, or lymphadenopathy of unknown etiology, any inflammatory

sion of Lyme Disease. The nymph form of the tick acquires the babesia parasite when they

pseudotumor, salivary gland enlargement, or sclerosing cholangitis. Management of

feed on mice, which is passed on to human hosts during feeding after the tick molts into

patients with IgG4-RD is based on expert opinion. Treatment is usually initiated in

the adult form. Symptoms of infection in healthy, immunocompetent adults are often

symptomatic patients or those with critical organ involvement to prevent progression to

nonspecific, including fever, chills, body aches, and fatigue. As the parasite inhabits red

organ fibrosis and failure. Small case series suggest that greater than 90 % of patients

blood cells, it can cause hemolytic anemia, particularly in immunocompromised or

improve on initial course of glucocorticoids; however, rates of relapse and requirement of

asplenic hosts, where infected cells are unable to be cleared effectively by the reticuloen-

long-term immunosuppression are reported in 20–70 % of patients as glucocorticoids are

dothelial system. Infected deer ticks can commonly be encountered the United States

tapered. Azathioprine, methotrexate, rituximab, and cyclophosphamide have all been

Northeast and Upper Midwest, particularly in New York, New Jersey, and New England.

trialed as steroid-sparing agents in IgG4-RD.

Detection of B. microti is commonly via blood smear, where the parasite can be seen as both intracellular and extracellular forms. The intracellular form can appear as the pathognomonic merozoite “maltese cross,” or the less specific trophozoite “ring form,”


which led to the initial lab read of P. falciparum. It should be noted that an 80 %

MIA Jeffrey A. Shrensel2; Aaron M. Etra3; Veenu Gill1. 1Mount Sinai Beth Israel,

parasitemia of P falciparum is nearly unheard of, and in addition, extracellular parasites

Brooklyn, NY; 2Mount Sinai Beth Israel, New York, NY; 3The Mount Sinai Hospital,

are generally not visualized on the smear in the case of P. falciparum, which can help

New York, NY. (Control ID #2467871)

differentiate the two. This asplenic patient almost certainly contracted babesiosis through contaminated blood, since he presented for this admission in March, and his surgery and

LEARNING OBJECTIVE #1: Recognize an emerging cause of Coombs negative

blood transfusion occurred in mid February, an uncommon window for contact with deer

hemolytic anemia in patients receiving blood transfusions

ticks in an urban setting,. Recently, a number of articles have argued for the routine testing

LEARNING OBJECTIVE #2: Recognize the additional risks of infection via blood

of donor blood for babesia infection, and this case illustrates the catastrophic risks that

transfusion in asplenic and immunocompromised patients

such infection poses for asplenic or immunocompromised patients.

CASE: DM, a 47 year old man with a medical history of type II diabetes mellitus, pancreatic adenocarcinoma status post Whipple procedure and splenectomy complicated by blood loss anemia requiring a transfusion of 1 unit of PRBC, presented 6 weeks after


surgery with a chief complaint of 2 weeks of bilateral leg pain and swelling. In the


emergency room, the patient was found to have bilateral deep vein thromboses and was

Murphy; Joseph Merrill. University of Washington School of Medicine, Seattle, WA.

admitted to the surgical service. Initial laboratory values were significant for moderate

(Control ID #2469763)

hyponatremia and anemia, with a hemoglobin level of 9.8 g/dl, similar to his discharge hemoglobin of 9.9 g/dl. A hematology consult was placed and the patient was started on a

LEARNING OBJECTIVE #1: Recognize the rare but potentially fatal complication of

heparin drip and then transitioned to rivaroxaban. A CT angiogram of the chest performed

drug reaction with eosinophilia and systemic symptoms (DRESS) with allopurinol.

the following morning revealed bilateral pulmonary emboli. Over the next 2 days, the

LEARNING OBJECTIVE #2: Distinguish common renal complications of DRESS

patient became increasingly lethargic and confused, during which time he developed a

from a rare case of necrotizing vasculitis.

Coombs’ negative hemolytic anemia, with hemoglobin dropping to 5.6 g/dl, bilirubin

CASE: A 59-year-old male patient with past medical history significant for coronary

rising to 8.2, and an undetectable haptoglobin. The patient was transferred to the step-

artery disease and chronic kidney disease (baseline creatinine 1.6 mg/dL) who was

down unit and a peripheral smear was prepared. The patient was then transfused two units

admitted with 1 week of progressive diffuse, desquamating, morbilliform rash, fever,




hemoptysis, malaise, and weight loss. One month earlier, he was prescribed allopurinol for

dL), direct bilirubin 10.7 mg/dL (normal
(2 g daily) and Metronidazole (1.5 g daily), mainly targeting oral anaerobes. In addition,

rights reserved.–>

we controlled his blood sugar level at least always below 200 mg/dl. His periodontal

DISCUSSION: Myeloproliferative neoplasms have been well documented to give rise to

disease was treated with strict oral hygiene, resection of poor granulation tissues and

a hypercoagulable state. PMF has been well associated with a plethora of thrombotic

decayed teeth, and removal of dental calculi. According to the positive result of blood

complications, including fatal and non-fatal conditions such as acute myocardial infarc-

cultures of anaerobic bacteria, P. micra, obtained 1 week later, we changed antibiotics to

tion, venous thromboembolism, ischemic stroke and peripheral arterial thrombosis. In

intravenous ampicillin-sulbactam (12 g daily), which was given for another week. The

addition, the risk of recurrence of thrombosis in patients presenting with thrombosis on

successful treatments with intravenous antibiotics were followed by 8 weeks of oral

diagnosis or a history of thrombosis is as high as 9 %. Risk factors found to confer the

minocycline (200 mg daily) on the outpatient basis. After the cessation of antibiotics,

highest risk of thrombosis in PMF include age > 65 years, leukocytosis > 15,000/uL and

the patient didn’t show any signs or symptoms of recurrence.

the presence of the JAK2 V617F mutation. Femoral avascular necrosis is a profoundly

DISCUSSION: P. micra is a nonspore-forming anaerobic gram-positive coccus widely

debilitating, progressive and often irreversible condition with limited joint-sparing treat-

distributed as commensal flora in the oral cavity that, under immunosuppressed conditions

ment options available. The value of core decompression in advanced or chronic disease is

including poor controlled diabetes mellitus or traumatic conditions, can become

questionable, and the safety of such a procedure in patients with bone marrow fibrosis and

pathogenic and cause sepsis, brain, liver, and thoracic infections, as well as

resulting thrombocytopenia that is often difficult to correct, is always an issue. The

generalized necrotizing soft tissue infections. Its strong proteolytic activity may




be significant in the development of mixed extraoral anaerobic abscesses.

lambda. The pathognomonic finding is presence of fibrillary deposits in the mesangium

Although P. micra was considered to be a relatively rare cause of disseminated

and glomerular capillary walls distinct from amyloidosis. The size of fibrils ranges from 8

infection, it has increasingly been recognized as an important oral pathogen.

to 15 nm in Amyloid and 12–24 nm in FGN. IgG is usually monoclonal in AL Amyloid as compared to polyclonal in FGN. The characteristic difference from amyloid is absence of reaction to histochemical dyes like Congo Red and Thioflavin T in FGN. One third of


FGN cases are associated with malignancy, monoclonal gammopathy and autoimmune

AMYLOID! ZAIN UL ABIDEEN ASAD1; Amna Mohyud Din Chaudhary3; Usman

disorders. In our case an extensive workup was negative for all these conditions.


Angiotensin inhibitors (ACEI) are used if the glomerular filtration rate is normal and

Oklahoma City, OK; 2University of Oklahoma Health Sciences Centeriversity of

proteinuria is present, to control blood pressure and reduce disease progression. Evidence

Oklahoma Health Sciences Center, Oklahoma City, OK; 3Nishtar Medical College &

for use of steroids and immunosuppressants is based on uncontrolled studies with variable

Hospital, Multan, Pakistan. (Control ID #2469929)

success. In our patient a limited trial of corticosteroids with mycophenolate resulted in some improvement in proteinuria along with ACEI.

LEARNING OBJECTIVE #1: Recognize fibrillary glomerulonephritis as a cause of proteinuria and renal failure to increase awareness among health care professionals about this rare condition.


LEARNING OBJECTIVE #2: Recognize Focal Segmental Glomerulosclerosis as an

Nway Koko2; Maryam Qadir1, 2; Sayed K. Ali1, 2. 1Orlando VA Medical Center, Orlando,

uncommon morphology in fibrillary glomerulonephritis.

FL; 2University of Central Florida, College of Medicine, Orlandi, FL. (Control ID

CASE: Introduction: Fibrillary glomerulonephritis is a rare disorder with a prevalence of


1 % in renal biopsies. The mean age of presentation is 50 years, proteinurea in 100 %, nephrotic syndrome in 70–75 %, renal insufficiency (Cr ≥1.5) in 50–55 %, hypertension

LEARNING OBJECTIVE #1: A. Recognizing flash pulmonary edema as a cause of

70 % and hematuria in 70 % cases. Etiology is unknown and diagnosis is established by

renal artery stenosis

pathognomonic electron microscopy findings. This case illustrates the presentation, work-

LEARNING OBJECTIVE #2: B. A unique scenario where revascularization might be

up and diagnosis of fibrillary glomerulonephritis (FGN). Case Description: A 49 year-old-

superior to medical management of renal artery stenosis.

female with history of hypertension, obstructive sleep apnea, non-steroidal anti inflam-

CASE: Flash pulmonary edema most often occurs when there has been an insult to the

matory drug use for chronic back pain presented with shortness of breath on exertion and

pumping function of the cardiac system. However, flash pulmonary edema due to renal

bilateral lower extremity swelling. Vital signs showed temperature 35.6 C, heart rate 75/

artery stenosis remains rare. We present a intricate case of recurrent flash pulmonary

min, respiratory rate 21/min and blood pressure 112/68 mmHg. She had mild respiratory

edema in a patient with uncontrolled hypertension and renal artery stenosis. A non- tanned

distress, bilateral crackles at lung bases, normal heart sounds, no murmurs and bilateral +2

68-year-old male with a history of coronary artery disease and uncontrolled hypertension,

pedal edema on physical examination. Complete blood count showed hemoglobin 10.7 g/

presented to our clinic complaining of monthly episodes of shortness of breath, due to

dl and normal white cell count. Complete metabolic panel showed creatinine 1.1 mg/dl,

flash pulmonary edema over the past 6 months. These episodes occurred suddenly, and

blood urea nitrogen 21 mg/dl, albumin 2.6 g/dl and normal electrolytes. Urinalysis showed

repeatedly required diuresis in an inpatient setting. Upon evaluation, the patient was found

pH 6.0, specific gravity 1.028, +4 proteinuria, +2 hematuria and no casts. 24 h urine

to have a history of difficult to control hypertension, despite a treatment regimen

collection showed 4.3 g/day nephrotic range proteinuria. Lipid profile showed cholesterol

consisting of four antihypertensive agents, including a diuretic. His physical exam

308 mg/dl and non-HDL cholesterol 246 mg/dl. Hepatitis C, HIV, Goodpasture Disease,

revealed an obese male with a mid-pitched systolic murmur and bilateral lower extremity

Cryoglobulinemia, Systemic Lupus Erythematosus and other autoimmune diseases were

trace edema. A review of his past medical records showed a normal sleep study and a 2D

ruled out by appropriate tests. Serum and urine protein electrophoresis were without M-

echo showing a normal EF of 65 % with moderate aortic stenosis. His creatinine was

spike but with high free Lambda (29.7 mg/dl) and Kappa chains (23.6 mg/dl). A diagnosis

reported at 2.1 mg/dL, renin 27.47 ng/mL/h and an aldosterone of 2 ng/dL. His urinalysis

of nephrotic syndrome was made due to the presence of edema, proteinuria, hypoalbu-

was normal with no hematuria or proteinuria. Further workup including an ANA, SPEP,

minemia and hyperlipidemia. A renal biopsy was done to evaluate the etiology of

UPEP and complement level analysis was performed, and returned normal. A renal

nephrotic syndrome. Biopsy showed focal segmental and global glomerulosclerosis with

ultrasound showed a left kidney measuring 9.8 × 4.5 × 4.6 cm while the right kidney

mild to moderate interstitial fibrosis and tubular atrophy. Immunofluorescence showed

measured 11.6 × 4.6 × 5 cm without any evidence of hydrouretronephrosis; however mild

staining of glomerular capillary walls and mesangium for IgG, kappa and lambda.

prostatic hypertrophy was noted. Due to his elevated creatinine and recurrent flash

Electron microscopy showed linear, non- branching fibrils in the mesangium that averaged

pulmonary edema, an abdominal MRA without contrast was pursued, which showed

20 nm in width (11.7–28.6 nm). Congo red staining was negative. A diagnosis of

significant stenosis of his bilateral renal arteries. A CO2 angiogram of both renal arteries

nephrotic syndrome with FGN was made due to characteristic electron microscopy

confirmed the diagnosis; high-grade renal artery stenosis due to atherosclerotic plaque,


which responded well to bilateral balloon angioplasty and primary stenting. The patient

DISCUSSION: This case illustrates the clinical presentation, workup and diagnosis of

did well post operatively, and was later discharged home. At time of follow up examina-

fibrillary glomerulonephritis (FGN). This patient presented with edema, hypertension,

tion, his creatinine had improved to 1.5 mg/dL. His blood pressure had gradually

shortness of breath, nephrotic proteinuria and the electron microscopy findings on biopsy

improved as well with home readings ranging from 130–140/70–80 mmHg. He was

established the diagnosis. A study of 66 cases identified most common histologic patterns

followed in our clinic at months 1, 3 and 6 following his stenting, and has remained

as mesangial, membranoproliferative, endocapillary proliferative, crescentic and necrotiz-

asymptomatic since without any recurrence of flash pulmonary edema.

ing, membranous and diffuse sclerosing in order of likelihood. This case had focal

DISCUSSION: Atherosclerotic renal artery stenosis is defined as a >50 % stenosis of the

segmental and global glomerulosclerosis that is a rare finding. In the same study immu-

proximal one third of the renal artery. It has been found to be associated with renal failure,

nofluorescence staining was positive for IgG in 100 %, C3 in 92 % and both kappa and

uncontrolled hypertension, and sudden onset fluid overload with resultant flash pulmonary

lambda in 84 % cases. This case also demonstrated positive staining for IgG, kappa and

edema. The exact mechanism of flash pulmonary edema is not fully understood but is




most likely related to the renin-angiotensin-aldosterone system. The management of renal

acute gastroenteritis, with V. parahaemolyticus responsible for 92.1 % of those cases. In

artery stenosis has yielded much debate with recent studies suggesting no added benefit to

contrast, V. vulnificus, the prototypic invasive human pathogen in this genus, was responsible

stenting over medical therapy. The role of revascularization in alleviating flash pulmonary

for all cases of bacteremia in the aforementioned study. Even though it is extremely rare,

edema has been studied in small prospective and observational trials, showing improve-

V. parahaemolyticus sepsis can occur and can be fatal if not rapidly diagnosed, as the

ment in renal function and symptoms. Individualized therapies should be considered based

organism usually has skin manifestations suggestive of skin and soft tissue infections, but is

on the clinical scenario, after weighing the risks and benefits of each treatment modality. In

not susceptible to empiric antibiotics routinely used to treat these infections. A case report by

this particular patient, due to his frequent episodes of flash pulmonary edema, revascu-

Ahmad et al. identified a patient who had fatal necrotizing fasciitis and sepsis from a wound

larization was pursued and proved to be successful overall. This case highlights one of the

infection by V. parahaemolyticus after sustaining a water skiing injury in brackish water.

few scenarios in which revascularization was found to be superior to medical management

What makes our patient unique is that he did not have any wound exposure; his exposure

in this unique presentation of renal artery stenosis.

was most likely through consumption of undercooked seafood. Given that the majority of V. parahaemolyticus infections cause only mild infection, it is important to identify the subset of patients at increased risk for severe, life-threatening disease. In a study of vibrio infections,


of patients with V. parahaemolyticus infection, those who presented with sepsis had a greater

A CAUSE OF GI DISTRESS Amir Kazerouninia2; Nicolas Cortes-Penfield2; Barbara

incidence of diabetes, alcoholism, and liver disorders than patients who presented with

Trautner1. 1BCM/ VA Hospital, Houston, TX; 2Baylor College of Medicine, Houston, TX.

gastroenteritis alone. In our case, diabetes may have been the predisposing factor for invasive

(Control ID #2469475)

disease and the elevated INR and bilirubin may have been indicative of underlying liver dysfunction. Of note, the patient from the Ahmad et al. case report was similarly morbidly

LEARNING OBJECTIVE #1: Identify patients susceptible to more severe manifesta-

obese and had diabetes mellitus.

tions of Vibrio parahaemolyticus infection. CASE: A 70-year-old gentleman with morbid obesity, uncontrolled diabetes mellitus, heart failure with preserved left ventricular function, and atrial fibrillation on warfarin


presented to the emergency room following collapse at home. In the preceding days, he


had experienced non-bloody diarrhea with progressive lower extremity swelling and

LATENT SYPHILIS Alan H. Baik; Madhavi Dandu. University of California, San

erythema. Although he denied fever and chills, his wife stated he had appeared sweaty

Francisco, San Francisco, CA. (Control ID #2469840)

and ill. Review of systems was positive for progressive complaints of shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. He denied focal weakness, loss of con-

LEARNING OBJECTIVE #1: Recognize the diagnostic value of the distribution of an

sciousness, and palpitations prior to collapse. Social history, which was not elicited in the

unidentified rash in a patient co-infected with HIV and syphilis

emergency room or initially upon admission, indicated that the patient enjoyed fresh water

LEARNING OBJECTIVE #2: Describe the manifestations of HIV photodermatitis

fishing and wading in Gulf waters (but had done neither recently), and that he had eaten

CASE: A 47 year-old Samoan man presented to the emergency room with 6 months of

seafood gumbo from a restaurant 5 days prior to his collapse. Vitals at presentation were

pruritic rash on the dorsal aspects of his bilateral hands, anterior lower extremities, and

temperature of 98.2 °F, heart rate of 90, blood pressure of 109/62, and respiratory rate of

posterior neck. He reported fevers, chills, night sweats, and 50-pound weight loss. He also

18. Examination revealed a sallow gentleman with bilateral 2+ pitting edema in the lower

endorsed 2 weeks of bilateral thigh myalgias. He did not take any medications or

extremities with erythema, warmth, tenderness to palpation, and several tense, purple

supplements. He reported unprotected sex only with his wife, with whom he was in a

bullae. Electrolytes, blood count, liver profile, and coagulation studies were notable for

monogamous relationship. He denied use of injection drugs. He had tattoos from Samoa

leukocytosis of 14,800 cells/ml with a neutrophil predominance of 85 %, INR of 7.79, and

that were made using sticks from a lime tree, which were not shared with others. He

total bilirubin of 1.8. The emergency room physician held warfarin then started furose-

reported inconsistent use of protective clothing while working in construction as a pipe

mide, vancomycin, and cefepime, and admitted the patient to acute care where antibiotics

layer. On examination, the patient was febrile to 39.4° Celsius, blood pressure was 148/

were changed to clindamycin. The patient deteriorated within 24 h of admission with

85 mmHg, and heart rate was 115 beats per minute. He had decreased breath sounds in

worsening skin findings and the development of sepsis. Ertapenem was started and later

bilateral upper lung fields. Skin examination revealed hyperpigmented thick plaques on

changed to cefepime. Admission blood cultures returned Vibrio parahaemolyticus sensi-

his posterior neck, scaly hyperpigmented violaceous papules coalescing into lichenified

tive to levofloxacin. Of note, only at this point was the patient’s ingestion of seafood

plaques on the dorsal aspects of his hands and forearms, and scaly papular nodules with

elicited. Following change in antibiotics, he improved and was discharged on hospital day

areas of hyper- and hypo-pigmentation on his anterior lower extremities. His trunk, palms,

seven to a skilled nursing facility, to complete 10 days of Gram-negative coverage on oral

soles, and mucocutaneous membranes were spared. There was no cervical, axillary, or

levofloxacin and for routine management of acute on chronic heart failure.

inguinal lymphadenopathy. Admission labs included WBC 2.5 × 109/L with ANC 1.28 ×

DISCUSSION: This case illustrates the importance of a thorough social history upon

109/L, Cr 1.62 mg/dL, LDH 472 U/L, lactate 1.2 mmol/L. ANA, dsDNA, anti-Smith, and

admission; the patient’s ingestion of seafood was an obvious risk factor for

complement levels were negative. Subsequent lab results included positive HIV antibody

V. parahaemolyticus. More importantly, however, this case presents an unusually severe

with CD4 count 57 × 106/L and viral load 5771 copies/mL. Rapid plasma reagin was

illness given the organism involved and the routine mechanism of infection.

positive with a 1:1 titer for treponemal antibody. Skin biopsy from his posterior neck prior

V. parahaemolyticus is a halophilic gram-negative bacillus found in warm coastal waters;

to exposure to penicillin showed lichenoid interface dermatitis with plasma cells, and was

infection is acquired by consumption of undercooked seafood or wound exposure to

negative for fungi, bacteria, and mycobacteria. Treponema pallidum immunoperoxidase

contaminated water. Annually, it causes 4,500 infections, with 215 culture-confirmed cases,

stain was negative. Histopathology was consistent with lichenoid photoeruption of HIV.

30 hospitalizations, and 1–2 deaths. V. parahaemolyticus typically causes gastroenteritis after

He was initiated on Emtricitabine/Tenofovir and Dalutegravir. He was discharged with

ingestion or cellulitis after wound exposure, while the syndrome of bullae, sepsis, and

plans to complete treatment for late-latent syphilis.

bacteremia as seen here is more commonly caused by ingestion of V. vulnificus. In a study

DISCUSSION: This case highlights the clinical dilemma of fever and rash in a patient co-

by Hou et al., 59.8 % of patients with vibrio infection (non Vibrio cholera) presented with

infected with HIV and syphilis. The photodistributed pattern of the rash narrowed the




differential into four broad categories: medication side effect, autoimmune, inherited, and

alcohol. Intravenous infusion of normal saline resulted in transient improvement in his

infectious. The presence of fever and absence of medication use made autoimmune and

level of alertness. Within 24 h the patient became more obtunded and was intubated for

infectious causes more likely; his autoimmune work up was negative. His fever was

airway protection. Subsequent magnetic resonance imaging study of his brain demon-

ultimately attributed to a concomitant infection with Pneumocystis pneumonia, rather than

strated bilateral thalamic and intraventricular hemorrhages. CT venogram and cerebral

related to the rash. Skin biopsy was notable for lichenoid interface dermatitis with

angiogram ruled out cerebral venous thrombosis and arteriovenous malformation, respec-

predominance of plasma cells, and negative immunoperoxidase stain for Treponema

tively. An external ventricular drain was placed for treatment of the cerebral hemorrhage.

pallidum, most consistent with HIV lichenoid photodermatitis. Rashes in sun exposed

A blood thiamine level was noted to be markedly low at 37 nmol/L (normal reference

areas are often secondary to medications or due to photoexacerbated dermatoses, most

range: 78 to 185), confirming the diagnosis of severe thiamine deficiency. Thiamine was

commonly cutaneous lupus erythematosus and dermatomyositis. Approximately 5 % of

repleted intravenously with gradual improvement in alertness over the following weeks.

HIV-seropositive patients have HIV photodermatitis, which includes actinic prurigo,

However, expressive aphasia and unsteady gait were among persistent remaining deficits.

porphyria cutanea tarda, and lichenoid photoeruption. Many of these rashes appear similar

He was discharged to a long-term acute rehabilitation facility hoping for further recovery.

to each other, often with hyperpigmented and lichenified plaques. Porphyria cutanea tarda

DISCUSSION: We present a case of severe thiamine deficiency in a non-alcoholic

usually causes a blistering rash. Chronic lichenoid actinic photodermatitis is characterized

presenting with bilateral thalamic hemorrhage, a complication of thiamine deficiency that

by hyperpigmented, pruritic, and scaly lesions on the neck, upper chest, and dorsal

has been reported very rarely in the literature. Thiamine (or vitamin B1) acts as a

surfaces of the hands and forearms. AIDS interface dermatitis causes a lichenoid reaction

coenzyme in a number of cellular processes, most notably, processes involving carbohy-

pattern rash that can resemble erythema multiforme or a fixed drug eruption. It is often

drate metabolism and glucose generation. Thiamine is ubiquitous in most foods and

preceded by new medication use, which was not present in this case. Histopathology is

adequate stores are easily obtained with a typical western diet. Due to its short half-life

important in the diagnosis of HIV photodermatitis due to non-specific skin findings. In this

of 9–18 days, deficiency can result from poor nutrition and/or high catabolic states (e.g.

case, it was unclear if the patient’s rash was a manifestation of syphilis or HIV, especially

hyperthyroid, infection, etc.). Thiamine deficiency, also referred to as beriberi, presents in

since syphilitic rashes can be altered in the setting of HIV co-infection and are typically

two forms: dry beriberi when the nervous system is affected and wet beriberi when the

characterized by plasma cell predominance on pathology. Lichenoid reactions can develop

cardiovascular system is affected. Classically, thiamine deficiency is associated with

in late stages of secondary syphilis, and cutaneous lesions can re-appear in latent syphilis

alcoholics who present with Wernicke’s encephalopathy, which is characterized by a triad

after the disappearance of lesions in secondary syphilis even without treatment. However,

of confusion, ophthalmoplegia, and ataxia. In our case, the patient likely had a poor

it is unusual for syphilitic rashes to have a photodistributed pattern. Negative immuno-

reserve of thiamine due to the lack of diversity in his diet, which consisted of mostly

chemistry and silver stains do not exclude the diagnosis of cutaneous syphilis, as their

processed foods (“pizza and chips”). A bout of gastroenteritis likely further precipitated

sensitivities are 70–90 % and 40 %, respectively. In conclusion, this patient’s rash was

acute thiamine deficiency from poor oral intake and rapid depletion of previously com-

thought to be HIV lichenoid photodermatitis based on appearance and histopathology

promised reserves during the illness. His initial clinical signs of thiamine deficiency were

findings. It was unlikely to be secondary to syphilis due to its photodistributed pattern, as

new onset gait disturbance, severe fatigue, and persistent anorexia that had further

well as the patient’s low RPR titer and negative T. pallidum immunoperoxidase stain.

exacerbated the deficiency. This ultimately led to encephalopathy and stupor. Our case highlights the development of bilateral thalamic hemorrhages as a rare complication of severe thiamine deficiency. Interestingly, a common gastroenteritis infection precipitated


this near-fatal complication. Our case illustrates how some symptoms of thiamine defi-


ciency, such as anorexia and fatigue, can perpetuate those very symptoms into an ever-

Brennan S. Mosch; Natasha Kassim; Jill Zupetic; Dayakar Kancherla. University of

worsening deficiency. Due to the short half-life of thiamine (9–18 days), clinicians should

Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #2466294)

consider the possibility of deficiency when evaluating patients with a history of poor oral intake over a period of weeks, regardless of history of alcohol use.

LEARNING OBJECTIVE #1: Recognize bilateral thalamic hemorrhage as a rare, but recognized complication in patients with thiamine deficiency LEARNING OBJECTIVE #2: Identify risk factors for development of thiamine



IMAGING Teresa Ratajczak1; Ameesh Vora2; Arpan Patel1; Timothy G. Petrie1; Mukul

CASE: A 48 year-old white male with a past medical history of morbid obesity,

Chandra1, 2. 1Wright State University, Beavercreek, OH; 2Wright State University,

hypertension, and coronary artery disease was admitted to the ICU after he was found

Dayton, OH. (Control ID #2431778)

unresponsive and incontinent of urine at home. Four weeks prior to presentation, family members reported acute onset of abdominal cramping, nausea, vomiting, diarrhea, an-

LEARNING OBJECTIVE #1: Coronary artery calcium can be identified on nongated

orexia, and poor oral intake. A week later, he developed unsteady gait and worsening

chest computer tomography, and should be considered suggestive of coronary artery

fatigue when he confined himself to bed for most of the day. Over the following weeks, his

disease. It is an underreported, noninvasive finding that could have great impact on patient

fatigue worsened and his oral intake remained poor. Initial work-up was largely negative.


Patient was afebrile with stable vitals. Neurologic exam was limited on account of

LEARNING OBJECTIVE #2: With the increased use of CT scans of the chest in the

patient’s lethargy and confusion, but notable for absence of nystagmus, presence of

emergency department and for lung cancer screening, a more uniform reporting of vessel

spontaneous movement of all extremities, normal deep tendon reflexes bilaterally of upper

calcifications can lead to secondary prevention of coronary artery disease.

and lower extremities, and downgoing plantar reflexes bilaterally. Labs were remarkable

CASE: 56 year old Caucasian female with past medical history significant for diabetes

for mildly elevated creatinine, normoglycemia, and negative toxicology screen. Initial

mellitus type II, hypertension, hyperlipidemia and family history of cardiac disease was

computerized tomography (CT) scan of the head, electroencephalogram, and cerebrospi-

found to have a pulmonary irregularity on standard chest xray done to rule out pneumonia.

nal fluid analysis were unremarkable. Per his family members, he maintained a poorly

She subsequently underwent a CT chest to evaluate the nodule which showed a benign

nutritious diet consisting strictly of “pizza and chips.” He was not known to consume

calcified lesion. The radiologist commented on the moderate to severe calcific plaques in




the left anterior descending, circumflex and right coronary arteries. She was referred to

ED visits and 2 readmissions for cellulitis with additional antibiotic regimen of cefepime

Cardiology where she described a 1-year history consistent with angina pectoris, endorsed

then keflex.

substernal chest pain occurring on exertion and relieved with rest. Lexiscan stress test

DISCUSSION: This case illustrates the growing incidence of Vibrio vulnificus infection

showed moderate size reversible perfusion defect and a moderate scar on the

in the Gulf Coast and its associated rapid morbidity. It further adds to the literature on the

posteriorlateral wall of the heart. Cardiac catheterization revealed multivessel disease

important distinction between the rare Vibrio vulnificus infection and the well-known

and a coronary artery bypass graft surgery was recommended. Patient was started on

Vibrio cholera infection. Vibrio illnesses are classified into 2 categories—cholera from

beta-blocker and continued on statin and aspirin. She underwent a triple bypass surgery

V. cholera and vibriosis from V. vulnificus. Both are gram negative rod bacteria in estuarine

and continued on optimal medical therapy for risk and lifestyle modification.

and marine settings. Ingestion of contaminated seafood is the primary mode of infection.

DISCUSSION: Coronary artery calcium scanning (CACS) is a method of noninva-

V. cholera either causes no symptoms or acute diarrhea which is usually mild and seldom

sively evaluating the coronary arteries in order to check for the presence of

life-threatening (~5–10 %). Infection is rare in the US but common in third-world nations.

atherosclerosis. It is used to risk stratify patients in the intermediate ASCVD

Antibiotics are hardly indicated and prompt high-volume rehydration results in full

risk group of 5–7.5 %. The technique uses ECG gated CT imaging synchro-

recovery, even in severe cases. On the other hand, V. vulnificus is found worldwide in

nized to diastole, to minimize motion artifacts. A score of 0 means the risk of

any warm coastal waters, peaking during the summer months and in the Gulf Coast region.

coronary artery disease is very low, 101 to 400 suggests mild disease, and >400

The increased incidence in the Gulf Coast is likely due to exposure of skin and soft-tissue

suggests a high likelihood of at least one significant coronary narrowing.

injuries to contaminated waters. This is surely the mode of infection for our patient. Social

However, most chest CT scans that are done on a daily basis in inpatient and

history of such exposure and associated risk factors is of utmost importance. Typically, V.

outpatient settings are nongated. It is estimated that about 13 million nongated

vulnificus causes three severe syndromes: primary bacteremia, wound infection and GI

CT scans are performed annually, in contrast to 0.7 million gated exams.

illness but pneumonia, osteomyelitis, eye infections, meningitis, and endocarditis have

Several studies have shown a favorable correlation between coronary calcium

also been reported. As true for our patient, V. vulnificus septicemia presents as abrupt fever

assessment using nongated and gated images. With the increased use of chest

and/or chills followed by hypotension and metastatic cutaneous lesions, which rapidly

CT scan for lung cancer screening, one study found that >40 % of patients had

evolve into hemorrhagic bullae and necrotic cutaneous ulcers. The presence of hemor-

a CAC of >1000, and were not taking the appropriate statin or antihypertensive

rhagic cutaneous bullae or necrotizing fasciitis is an important predictor of mortality. The

medications. Our patient was diagnosed with coronary disease using standard

presence of lesions involving two or more limbs and septic shock increases mortality risk.

nongated CT imaging that was done due to suspicion of pneumonia.

Over 50 % have a median survival of ~2 days. These 3 poor prognostic features may

Conclusion: Reporting of coronary artery calcification on nongated chest imag-

explain our patient’s ongoing morbidity. The most severe V. vulnificus cases have been

ing represents a great opportunity to implement strategies for primary and

reported in certain high-risk conditions, including chronic hepatitis, immunodeficiency

secondary prevention in order to reduce morbidity of patients.

states, iron-storage disorders, ESRD and diabetes. Those with chronic liver diseases are at highest risk with over 80-times higher likelihood of V. vulnificus septicemia. Yet our patient’s immunocompetent state should not mislead clinicians as severe cases have been

FROM SEAWATER TO BLOODSTREAM Amy J. Sheer1; Kristopher P. Kline1;

reported in healthy individuals. Early surgical intervention (e.g. incision/drainage, de-

Dhaval K. Naik2; Sherri Gampel2; Margaret C. Lo2. 1University of Florida, Gainesville,

bridement, fasciotomy, or amputation) is essential in treating soft tissue infections from

FL; 2University of Florida College of Medicine, Gainesville, FL. (Control ID #2469666)

V. vulnificus and significantly decreases mortality. This is the reason for our prompt surgical consultation. Immunocompromised people should be advised to avoid consuming

LEARNING OBJECTIVE #1: Compare and contrast the clinical and therapeutic

raw seafood and exposing wounds to seawater; all must wear gloves while handling

features of Vibrio vulnificus vs. Vibrio cholera infection

seafood. In addition to prevention, a detailed history of exposure, assessment of risk

LEARNING OBJECTIVE #2: Identify the risk factors and poor prognostic indicators

factors and identification of prognostic indicators are vital to expedite proper treatment and

for Vibrio vulnificus sepsis

prevent the rapid morbidity and mortality of V. vulnificus infection.

CASE: A 77 years-old male with history of chronic renal insufficiency (creatinine 1.4 mg/ dL) and provoked DVT on warfarin presented with an acute onset of a blistering rash on his right arm with severe pain, vomiting, chills and dizziness. He further reported crabbing


the day prior in the Gulf of Mexico and being stuck multiple times by crab claws. Exam

Hung; Jennifer Mandal. Kaiser Permanente, San Francisco, CA. (Control ID #2469896)

revealed hypotension (82/51 mmHg), confusion and severely tender ecchymosis with hemorrhagic bullae of right forearm. Initial labs showed leukocytosis (13200/uL) with

LEARNING OBJECTIVE #1: Diagnose and recognize the clinical presentation of

81 % PMN, acute on chronic renal dysfunction (creatinine 2 mg/dL) and lactic acidosis

periodic paralysis

(5.4 mmol/L) but normal CPK, D-dimer and LFTs. Right arm x-ray showed soft tissue

LEARNING OBJECTIVE #2: Treat severe hypokalemia caused by thyrotoxic periodic

edema of superficial and deep tissues but no gas or foreign body. Patient was admitted to


the MICU in septic shock, requiring vasopressor support. Vancomycin, doxycycline and

CASE: A 29 year old otherwise healthy Asian man presented to the ED with 3 weeks of

ceftriaxone were empirically started. Surgery was consulted for concerns of compartment

intermittent bilateral leg and arm weakness, and 1 day of repeated falls. He denied pain in

syndrome or necrotizing fasciitis but felt no surgical intervention was required. Aggressive

his extremities or head trauma. On review of systems, he endorsed palpitations, heat

wound care was continued. Over the next 24 h patient developed profound bandemia

intolerance, and frequent bowel movements. His only medication was an over-the-counter

(25 %) and mild CPK elevation (240 U/L) but was successfully weaned off vasopressors.

antihistamine as needed for allergic rhinitis. He denied illicit drug use or excessive alcohol.

Blood cultures grew out pan-sensitive Vibrio vulnificus. Antibiotic regimen was narrowed

On physical exam, temperature was 97.7, blood pressure was 167/76 mmHg, and heart

to ceftriaxone and doxycycline. Patient improved on this regimen and was discharged on a

rate was 101/min. Cardiac exam was notable for tachycardia and a soft systolic murmur.

6-week course of IV antibiotics with close follow-up with PCP, surgery, and wound care.

On neuro exam, he was alert and oriented, but he was unable to move against gravity in all

Over the next 3 months, he continued to suffer from ongoing right arm pain, requiring 2

four extremities. Deep tendon reflexes were absent, and sensation was grossly intact.




Laboratory tests revealed severe hypokalemia at 1.3 mEq/L (normal 3.5–5.3) without

room air. Her physical exam revealed a cachectic appearing woman with 3+ edema to her

evidence of potassium wasting in urine. Subsequent testing showed thyroid stimulating

umbilicus, jugular venous distention of the neck, several 0.5 cm papules on her forehead,

hormone 38.0

can be categorized as a diagnostic error. This year, the Institute of Medicine released the

C, and two positive KO blood cultures) modified Duke’s criteria for infective endocarditis.

Report on Diagnostic Error and they define diagnostic error as “the failure to (a) establish

To our knowledge, this is the second reported case of KO endocarditis in an adult that

an accurate and timely explanation of the patient’s health problem(s) or (b) communicate

completely meets the modified Duke criteria after J.-Y. Chen et al. reported the first one in

that explanation to the patient.” This case illustrates an example in which the diagnosis

2005. Our patient has an interval development of a severe AV incompetence with a large

was neither accurate nor timely.

vegetation on TTE that accompanied the new intermittent heart block. Based on these findings, we believe that he had a peri-valvular abscess that affected the conduction system of his heart. The pathogenesis is postulated to be from the


direct spread from of the infected valve ring to the conduction system or micro

COMPLETE HEART BLOCK Saad Ullah2; Omar Elbita2; Puneet Tuli2; Joshan

emboli through coronary arteries. TEE was the next step to the diagnosis.

Suri1. 1Conemaugh Memorial Medical Center, Jeannette, PA; 2Conemaugh Valley

However he was transferred to a tertiary care hospital for surgical intervention

Memorial Hospital, Johnstown, PA. (Control ID #2467738)

and succumbed to his sepsis 3 days later. The multiple co-morbidities, the type of organism involved and the presence of the alternative source may lead to the

LEARNING OBJECTIVE #1: A rare cause of Infective endocarditis presenting as

delay in diagnosis to the point that the infection affected the conductive system

variable degree of conduction abnormalities requiring transvenous pacing.

of the heart. The main potential clue for IE in our case was the variable cardiac

CASE: A 76 years old caucasian male was admitted with a right middle cerebral artery

conduction defects. Persistent gram negative bacteremia should always raise the

ischemic stroke. The patient had a dense left hemiplegia with respiratory failure that

suspicion of endocarditis when the primary source is controlled. None of the

required a tracheostomy on the 12th day of his admission. On his 14th hospital day, he

following blood cultures were positive in this patient. We treated him according

developed symptoms and signs of septic shock with fever of 39° celcius and hypotension.

to the sensitivity results. His sepsis continued to progress which indicates that

Cultures were obtained and empiric antibiotics were started for a suspicion of Ventilator

the organism may have developed resistance. According to American Heart

Associated Pneumonia. In addition, he also underwent percutaneous gall bladder (GB)

Association Guidelines, the recommended antibiotic treatment for gram negative

drainage and an ERCP based on an abdominal CT finding of a dilated common bile duct,

hospital acquired IE is a combination therapy because these organisms rapidly

concerns of cholecystitis and a clinical suspicion of cholangitis. His two blood cultures

develop resistance.

grew KO the same day. Antibiotics were tailored to Ceftriaxone based on the sensitivity results. None of his following blood cultures grew any organism. However, he continued to require vasopressors until a new onset intermittent complete heart block developed on


the 22nd day. On physical examination, the patient was afebrile while on minimal

CHINA Sumona Bhattacharya1; Gabriela Ferreira3; Ali Abbas Saifuddin2. 1Robert

ventilator settings. His blood pressure was 100/40 mmHg on a low dose of norepineph-

Wood Johnson University Hospital, Plainsboro, NJ; 2Rutgers, Robert Wood Johnson

rine. The cardiac monitor showed sinus rhythm most of the time. However, intermittent

Medical School, Kendall Park, NJ; 3Rutgers-Robert Wood Johnson Medical School,

periods of variable atrioventricular blocks ranging from first degree to complete heart

New Brunswick, NJ. (Control ID #2470002)

block with few occasions when the patient developed pauses up to 10 s. An emergent temporary transvenous pacemaker was inserted. Repeat echocardiography showed aortic

LEARNING OBJECTIVE #1: To learn the different microbiology of a hepatic abscess.

incompetence as compared to a 2nd day echocardiography, with a large vegetation

CASE: We introduce the case of a 68 year-old Chinese woman visiting the United States

measuring 1.7 cm in length and 0.6 cm in width. A diagnosis of Infective Endocarditis

who presented with 2 weeks of fevers to 104 F, dyspnea, nausea, and vomiting. Her

(IE) was confirmed at that point. The patient was transferred to a tertiary center for cardiac

temperature was 102.4 F, pulse 117, blood pressure 133/89, respiratory rate 18 and

surgery evaluation. He succumbed to his illness 3 days later because of septic shock. The

shallow, and oxygen saturation 90 % breathing room air. She was ill-appearing and looked

diagnosis of Klebsiella Oxytoca Infective Endocarditis was based on the two positive

dehydrated, with scleral icterus, clear lungs, and a distended and tender upper abdomen.

blood cultures and the presence of the valvular vegetation.

Her white blood cell count was 12.6, alkaline phosphatase 424, total bilirubin 3.4, direct

DISCUSSION: Klebsiella species account for 1.2 % of gram negative native valve

bilirubin 2.7, and lactate 5.4. An abdominal CT revealed a 10 cm unilocular abscess with

endocarditis and 4.1 % of prosthetic valve endocarditis and is associated with a higher

an adjacent 8 cm multilocular abscess. Blood cultures and amebic serology were drawn




and we empirically started piperacillin-tazobactam and metronidazole to provide coverage

spine. There is partial fusion of the skull base, C1, C2 and C3. C4 demonstrates a right

for enteric flora and Entamoeba histolytica, respectively. A percutaneous drain inserted

hemivertebra. Congenital fusion of C6, C7 and T1 is seen. T1 also demonstrates a

into the larger abscess released 200 mL of purulent bloody fluid. This fluid culture

hemivertebra. C3/C4 shows severe central canal stenosis with moderate right/severe left

revealed pan-sensitive Klebsiella pneumoniae, and, as the amebic serology was subse-

neuroforaminal narrowing. A cervical rib is also present. Clinical course: Patient is

quently negative, metronidazole was discontinued and piperacillin-tazobactam was re-

scheduled to undergo a cervical 3–4 decompressive laminectomy due to severe spinal

placed with ceftriaxone. The patient improved clinically and defervesced. A repeat

canal stenosis.

abdominal CT at 2 weeks showed near-complete resolution of the larger collection and

DISCUSSION: Klippel-Feil syndrome is a rare condition estimated to occur in approx-

a notable reduction of the smaller collection. The patient was discharged home to complete

imately 1 in 40,000–42,000 births. Mutations in the GDF6, GDF3, or MEOX1 gene,

3 weeks of intravenous ceftriaxone. A final abdominal CT at 4 weeks showed almost

which are involved in bone development, can cause Klippel-Feil syndrome. The defining

complete resolution of both abscesses.

feature of this condition is the congenital fusion of 2 or more cervical vertebrae, however

DISCUSSION: Hepatic abscesses are categorized as either amebic or pyogenic in origin.

patients can present with a wide range of other anatomic anomalies. The most common

Amebic abscesses, which are caused by Entamoeba histolytica, are more common in

anomalies in decreasing order of incidence are congenital scoliosis, rib abnormalities,

developing countries. Pyogenic abscesses, which have a mortality rate of up to 30 %, are

deafness, genitourinary abnormalities, Sprengel’s deformity, synkinesia, cervical ribs and

more common in developed countries and are typically polymicrobial, composed of gut

cardiovascular abnormalities. Treatment for this condition is guided by symptoms. Some

flora such as Escherichia coli, Enterobacter cloacae, and Bacteroides species. Recently,

patients will be asymptomatic and if discovered incidentally and cervical fusion are stable,

mono-microbial Klebsiella pneumoniae liver abscesses, which are frequent in Asia, are

no treatment may be needed. However, if patients complain of neurologic symptoms,

becoming more common in the United States. It is important to be aware of the micro-

decompression to relieve spinal stenosis, correction of scoliosis and stabilization of

biology of liver abscesses because Klebsiella abscesses may develop extra-hepatic ocular

unstable fusions through procedures such as occipitocervical arthropodesis may be war-

and nervous system involvement. Over the past few decades, pyogenic liver abscesses

ranted. Conclusion: Klippel-Feil syndrome is typically diagnosed in the pediatric popula-

have increased in incidence from 13 to 20 per 100,000 hospitalizations, while at the same

tion, however, primary care physicians should maintain a high suspicion in adult patients

time overall mortality has decreased. The microbiology of these abscesses has also shifted:

presenting with a short neck, decrease range of motion of neck extension and or flexion, in

the incidence of E. coli has decreased while the incidence of Klebsiella, Staphylococcus,

the presence of neck pain and neurologic symptoms. Prompt identification and interven-

Streptococcus, and Pseudomonas have increased. While in the Western hemisphere E. coli

tion may minimize potential for more serious and permanent neurologic injury and

is the most common pathogen, in the Eastern hemisphere Klebsiella is recognized as very

improve patient quality of life.

common. In fact, it is the most common pathogen in Hong Kong, Taiwan, Singapore, and South Korea. We choose to highlight this case as an example of the atypical microbiology that can present as the cause of pyogenic hepatic abscesses in the United States.

LAMBERT EATON MYASTHENIC SYNDROME ASSOCIATED WITH SMALL CELL LUNG CANCER-IS IT GOOD TO FEEL WEAK? Lindita Shehu1; Arian Majko1; Majlinda Xhikola1; Emily Chen1; Izabella Zathureczky2.






Htay ; Bryan S. Brockman ; Cristin Harper ; Michelle V. Conde ; KoKo Aung .


Capital Health Regional Medical Center, Trenton, NJ; 2Capital Health Regional

Medical Center, Lawrencewille, NJ. (Control ID #2466151)


UTHSCSA, San Antonio, TX; 2University of Texas Health Science Center at San

Antonio, Shavano Park, TX. (Control ID #2470188)

LEARNING OBJECTIVE #1: Recognize myasthenic syndromes associated with small cell lung cancer and their prognostic significance.

LEARNING OBJECTIVE #1: To recognize the clinical features and radiological

CASE: A 55 year old male with extensive tobacco history presented with 1 month of

findings in Klippel-Feil syndrome

progressive bilateral upper extremity proximal weakness, cough, hemoptysis, pleuritic chest

LEARNING OBJECTIVE #2: To heighten sense of awareness of childhood disorders

pain, shortness of breath and 1 week of progressive face and neck swelling. Vital signs

in adults

included blood pressure 131/ 83 mmHg; heart rate 108 bpm; respiration rate 25/min;

CASE: Introduction: Klippel-Feil syndrome describes a heterogeneous group of patients

temperature 97.9 F; oxygen saturation 97 % on ambient air. Physical examination was

unified by the presence of congenital defects in the formation or segmentation of the

significant for symmetrical face, neck and upper extremity swelling, jugular venous disten-

cervical spine. Diagnosis predominates in the pediatric population but does occur infre-

tion, chest wall tenderness, decreased breath sounds on the right and 1+ deep tendon reflexes.

quently in adults. Once cervical spinal defects consistent with Klippel-Feil are identified, a

Laboratory data was unremarkable. Chest x-ray showed a large heterogenous mass in the

thorough head-to-toe work-up must be conducted to evaluate for the numerous and

right upper lobe extending to the right hilum and paratracheal space. CT chest showed a

variable anomalies associated with this syndrome. Case Report: A 40 year-old male

paratracheal, retrocaval mass measuring 7.6 × 7.2 cm in the right mediastinum and SVC

presents to the clinic with worsening midline neck pain. Symptoms have been progressing

obstruction. The patient underwent endovascular stenting of SVC and thrombolysis with

for 7 years and now include left temporal headache with sharp shooting pain and

rapid relief of symptoms. Tissue from transbronchial biopsy was inadequate and non-

photophobia. He also reports left upper extremity weakness and numbness which inter-

diagnostic. A thoracentesis drained 2 l of turbid fluid, and pleural fluid cytology was

mittently involves his hand, the lateral aspect of his forearm, arm and shoulder. He denies

consistent with SCLC. Because of proximal upper extremity weakness, serum for antibodies

any bowel or bladder incontinence but does endorse a history of chronic lower back pain

directed against VGCC was sent to a reference laboratory and later returned positive. Patient

with radiation down to the right lateral thigh and knee and difficulty ambulating. Physical

received multiple cycles of Cisplatin and etoposide chemotherapy and radiation therapy. The

Exam: Physical exam is remarkable for short neck and restricted range of flexion and

initial lung mass was significantly reduced and at one year of diagnosis, is resolved. Patient

extension of cervical spine. Motor strength in right upper extremity and bilateral lower

gradually regained his weight, fatigue improved and proximal limb weakness resolved.

extremities are 5/5 throughout. Motor strength in left upper extremity is 4/5 throughout

Patient continues to receive chemotherapy and anticoagulation.

with intact sensation. Deep tendon reflexes are diminished in bilateral lower extremities.

DISCUSSION: Clinically, LEMS patients suffer from characteristic proximal muscle

Imaging: Imaging reveals moderate S-shaped scoliotic curvature of the cervicothoracic

weakness that is caused by the presence of antibodies directed against their voltage-gated




calcium channels (VGCC). These channels are localized in the presynaptic membrane of

patient’s PO intake and the tongue-biting was constant enough to cause excessive pain and

their motor nerve terminals. Binding of autoimmune antibodies to the VGCCs leads to

discomfort which was likely contributing to his cognitive dysfunction. Using an individualized

reduced neuromuscular transmission. Typically, muscle weakness is in the lower extrem-

approach including a combination of clinical judgment, risk-benefit analysis, and compassion

ities, however can be observed in the upper or all extremities. Atypical presentations

we suspected that these secondary complications of LAS were likely contributing to risk

should not preclude testing. Better understanding of the pathophysiological mechanisms

factors for delirium and that the benefits of the proposed treatments would outweigh the risks.

of LEMS has helped with the development of new diagnostic approaches and has led to

Thus, a trial of clonazepam was deemed appropriate and resulted in a desirable clinical

targeted symptomatic and immunosuppressive therapy. For LEMS patients with an

outcome. Conclusion: Treatment of LAS may be clinically challenging in the face of

underlying malignancy, specific tumor therapy is the first choice. Patients with SCLC

worsening delirium, especially in elderly patients who have experienced a prolonged hospi-

who develop LEMS have been suggested to have a more effective immunologic response

talization and previous signs of cognitive impairment. This complicated clinical picture can be

to the cancer, which may result in improved survival.

navigated by careful investigation into the direct causes and potentiators of confusion in the hospital setting which in our case was Lance-Adams syndrome.


LEAVE NO STONES UNTURNED Lisa Hirahara; Ryuichi Sada; Mitsuya Katayama.

Garcia2. 1Exempla Saint Joseph Hospital, Denver, CO; 2University of Colorado, Denver,

Kameda Medical Center, Kamogawa-shi,Chiba, Japan. (Control ID #2468294)

CO. (Control ID #2465550) LEARNING OBJECTIVE #1: Close discussion with pathologist and provision of LEARNING OBJECTIVE #1: Utilizing an individualized approach including a com-

pertinent clinical information to pathologist improve the accuracy of pathologic diagnosis.

bination of clinical judgment, risk-benefit analysis and compassion when treating Lance-

LEARNING OBJECTIVE #2: Enteropathy associated T cell lymphoma (EATL) usu-

Adams Syndrome (a.k.a post-hypoxic myoclonus) in the setting of delirium.

ally associated with celiac disease but EATL without celiac disease exist.

CASE: Introduction: Lance-Adams syndrome (LAS) is characterized by generalized

CASE: A 67-year-old man with past medical history of left urolithiasis presented to our

myoclonus with onset days to weeks after anoxic brain injury. It generally has a better

hospital with chronic diarrhea and fatigue. He was well until one and a half years before

prognosis than its more acute counterpart, myoclonic status epilepticus. Treatment typi-

admission, when nonbloody loose stools developed which were three times per day. Six

cally includes levetiracetam, benzodiazepines or valproic acid. We examine a case of LAS

months prior to the admission, the consistency of his stools became watery and the

in a patient with prolonged hospitalization already complicated by impaired cognition and

frequency increased to four to five times per day. He started having a 7 day history of

episodic delirium. Despite concerns that treatment with benzodiazepines might worsen the

mild abdominal cramping associated with fatigue. Review of systems revealed weight loss

cognitive disorder, we concluded that the LAS was potentially contributing to the delirium

of 12 kg in the last 10 months. He had no fever, chills, oral ulcers, arthralgia, rash, night

via secondary mechanisms of pain and sleep disturbances. After careful clinical consid-

sweats, food intolerance, and travel history. He took no regular medications. On exami-

eration, we initiated a trial of clonazepam which resulted in marked symptomatic im-

nation, he was afebrile, blood pressure was 103/70 mmHg, and pulse rate was 120 beats

provement. Case Report: A 65-year-old male with a recent prolonged ICU hospitalization

per minutes. Physical examination was unremarkable except for increased bowel sounds.

for necrotizing pancreatitis, complicated by a cardiopulmonary arrest requiring ACLS

No peripheral lymph nodes was palpable. The laboratory data showed elevated inflam-

intervention and approximately eight minutes of CPR, presented for volume overload. On

matory markers and renal failure of serum creatinine of 3.1 with elevated anion gap. Fecal

physical exam, he was noted to have anasarca, cognitive impairment with SLUMS 21/30

leukocyte was positive. The fecal osmotic gap was normal of 6 mOsmol/kg. A computed

and quick, irregular, involuntary myoclonic jerks with symmetrical hyperreflexia. Per the

tomography of abdomen revealed diffuse thickening of the intestinal walls. He was kept

patient’s wife, he began to experience the jerk-like movements approximately 2 weeks

nothing per oral since admission, however diarrhea was persistent. We evaluated these

after his hospital stay. At first the symptoms were mild, but then they became more

results were consistent with inflammatory or secretory diarrhea. Results of anti-neutrophil

frequent and occurred during sleep. They also caused the patient significant distress due to

antibody, blood and stool cultures, and ova and parasites were all negative. A colonoscopy

the inability to eat and tongue pain due to recurrent bite wounds. An EEG showed diffuse

showed erosion of the ascending colon, multiple ulcers of the sigmoid colon and rectum

slowing, but no epileptiform activity. His medication list was reviewed and metabolic

which biopsies were done. Pathological findings of the biopsy revealed medium sized

disturbances were corrected, but the myoclonus persisted. Based on clinical, imaging and

lymphocyte infiltration to the colon gland which was consistent with nonspecific colitis.

physical exam findings, his myoclonic jerks were felt to be due to multifocal cortical

The stains for amyloidosis and cytomegalovirus, and tuberculosis PCR were all negative.

irritability following post anoxic brain injury. After numerous discussions of the risk and

The patient also had esophagogastroduodenoscopy done which showed gastric ulcer and

benefits of treatment, he and his wife agreed to a trial of clonazepam (0.25 mg TID). Three

two depressed areas. Pathological findings of those biopsies presented the medium sized

days later his symptoms improved without further impairment in his cognition.

lymphocyte infiltration to the gastric gland which reportedly suggested Mucosa associated

DISCUSSION: As detailed in the case above, the persistent nature of LAS can cause

lymphoid tissue (MALT) lymphoma. The diagnosis of MALT lymphoma, however, could

significant distress via complications such as tongue-biting, sleep disorder and muscle exhaus-

not explain his clinical presentation, and we thought both changes in his stomach and

tion. However, there remains a paucity of randomized controlled trial data to define the proper

colon had the same etiology. Thereby, we provided pathologists the patient’s clinical

treatment of this condition. Typical treatment with either levetiracetam, benzodiazepines or

information and asked them to reassess of colon biopsies including histological staining

valproic acid is most commonly used. Doses are started low and titrated upward for symptom

for the work up of the lymphoma. Consequently, the histologic result showed natural killer

relief. Due to the possible side effects of these treatments, this can become extremely

(NK)/T cell invasion of the stomach and the colon mucosa. The T cell receptor gene

challenging for patients with concomitant LAS and delirium. When faced with this clinical

rearrangement are identical in both tissue, that is, clonal proliferation of NK/T cell was

situation, treatment must be weighed against the possibility of exacerbating a cognitive deficit,

found. Finally, the diagnosis of enteropathy associated T cell lymphoma (EATL) type 2

particularly one that could prove dangerous in the hospital setting. However, the risk of

was made.

undertreatment of the condition is not small and may prove more bothersome to the patient

DISCUSSION: EATL is a rare primary gastrointestinal lymphoma which is known to be

than is realized. In this case, the myoclonic jerks were preventing restful sleep, impairing the

strongly related to celiac disease. The current WHO classification divided EATL into two




subtypes based on the existence of celiac disease and the histology. Type 1 is a classic form of

patient missed his first follow-up appointment and in the subsequent clinic visit, reported

EATL with celiac disease and type 2, histological variant, is less common and often occurs

an interval cerebrovascular accident without residual focal deficits. Subsequently, he has

without celiac disease. In Asia, type 1 is extremely rare because celiac disease is also

been placed on a Life vest, oral anticoagulation, and home dobutamine infusion for

uncommon. The early diagnosis of type 2 EATL is quite difficult because of the nonspecific

worsening heart failure. Currently he is undergoing evaluation for Implantable

symptoms and a very low index of clinical suspicion due to its low incidence. Therefore, type 2

Cardioverter Defibrillator (ICD) placement and cardiac transplant.

EATL is often found in an advanced disease such as intestinal perforation, bowel obstruction or

DISCUSSION: LVNC can present as an isolated finding (as in our patient) or in

hemorrhage, and many EATL are diagnosed with the pathology findings from the surgical

association with neuromuscular or mitochondrial disorders or congenital heart defects.

specimen. In our diagnostic management, there are two learning points. First, we should not

The pathology is thought to be due to arrest of normal left ventricular (LV) myocardial

exclude EATL just because the patient does not have celiac disease especially in Asia.

compaction during embryogenesis, which leads to a two layered ventricular wall with

Although the presentation of this case resembled to celiac disease, chronic diarrhea was

prominent trabeculations in LV cavity. The clinical presentation can vary from being

occurred from EATL because symptoms were not improved while he was under gluten-free

asymptomatic to presenting with clinical features at any age. The Triad of heart failure

diet and anti-gliadin antibody was negative. Second, a close communication between clinician

(50 %), ventricular arrhythmia and sudden cardiac death (41 %) and systemic thrombo-

and pathologist is essential in the diagnostic management. EATL has no specific symptoms

embolic events (5–38 %) comprise the typical symptoms and complications of LVNC.

and he pathological findings guide us to the appropriate diagnosis. Type 2 EATL is charac-

Prognosis of LVNC varies widely. Presentation with heart failure or arrhythmia is

terized by monomorphic small-medium sized lymphocyte infiltration which is easily confused

associated with worse clinical prognosis compared to patients with incidental diagnosis

with benign lymphocyte infiltration or low-grade B cell lymphomas. Thus, the histologic

or familial forms of LVNC. Various criteria for diagnosis of LVNC have been proposed.

examination of intestinal biopsies is crucial in the diagnostic workup of EATL. In this case, the

Echocardiography is the first line imaging modality of choice. The characteristic finding is

histologic stains for colon biopsies were not performed because the initial pathology report

“spongy myocardium,” which refers to a bilayered myocardium composed of a thinner

showed a benign colitis. As the evaluation progressed, the likelihood of gastrointestinal

compact epicardial layer and an inner non-compacted endocardial layer with prominent

lymphoma was increased which led us to discuss with pathologists again and could reach

trabeculations and deep recesses which are in continuity with the LV cavity. However,

the final diagnosis. When the clinical suspicion of gastrointestinal lymphoma arises, it is crucial

correct diagnosis can pose a challenge since prominent trabeculations can also be found in

for clinicians to discuss closely with pathologists during evaluation of chronic diarrhea to make

healthy subjects (athletes, transiently in pregnancy) and lead to over diagnosis. Cardiac

a diagnosis of this rare disease. In fact, some observational studies reported that the provision of

MRI is considered the best modality for diagnostic confirmation and a diastolic non-

pertinent clinical information to pathologist improve the accuracy of pathologic diagnosis.

compacted to compacted ratio >2.3 diagnoses pathologic LVNC with high specificity. Genetic testing (for mutation in various myocardial proteins like tafazzins, αdystrobrevin) is of limited utility for diagnosis due to genetic heterogeneity and lack of


specific genotype-phenotype associations. The main treatment goals in LVNC are pre-


vention and management of the triad of complications. Asymptomatic patients should be

YOUNG ADULT Joydeep Chakraborty2; Nimesh Patel2; Maryam Sattari1; Juan M.

evaluated every 2–3 years with physical exam, echocardiography and Holter monitoring

2 1


Aranda . University of Florida College of Medicine, Gainesville, FL; University of

(to detect silent arrhythmias). Arrhythmia should be managed according to the current

Florida, Gainesville, FL. (Control ID #2467926)

arrhythmia management guidelines. Treatment for heart failure in LVNC is similar to that of dilated cardiomyopathy and consists of pharmacologic therapy, ICD placement and

LEARNING OBJECTIVE #1: Recognize Left Ventricular Non Compaction cardiomy-

evaluation for heart transplant. Routine anticoagulation remains controversial and merits

opathy (LVNC) as an underdiagnosed cause of heart failure in young adults without pre-

consideration in patients with LVNC and atrial fibrillation, significant LV dysfunction,

existing risk factors.

known ventricular thrombus or prior history of thromboembolic phenomenon. Decreased

LEARNING OBJECTIVE #2: Manage complications of LVNC, identify the indica-

awareness about LVNC among physicians has presumably led to its underdiagnoses. This

tions for anticoagulation in LVNC patients to prevent thromboembolic events and screen

case highlights the importance of considering LVNC in young patients without classic risk

for silent arrhythmias.

factors presenting with heart failure. Holter monitoring every 2–3 years and

CASE: An 18-year-old man with no known pre-existing medical problems presented to

anticoagulation in patients with significant LV systolic dysfunction merits special consid-

an outside hospital with 1 week of worsening non-productive cough and shortness of

eration in these patients to prevent thromboembolic events and subsequent morbidity and

breath. He denied fever, chest pain, palpitation, leg swelling, viral prodrome or family


history of heart disease, but endorsed marijuana use. Physical exam revealed tachycardia with normal systemic exam. Lab results revealed normal troponins, renal and thyroid function, leukocytosis, elevated BNP, and negative urine drug screen. Chest X-ray


demonstrated bilateral interstitial infiltrates. Despite antibiotic coverage for possible


community acquired pneumonia, the patient had worsening respiratory failure and even-

Shira Sachs; Arunima Misra. Baylor College of Medicine, Houston, TX. (Control ID

tually required intubation and mechanical ventilation. Echocardiogram showed left ven-


tricular ejection fraction (LVEF) of 5–10 % and he was started on dobutamine infusion for cardiogenic shock and transferred to our medical center. At our facility, we added

LEARNING OBJECTIVE #1: Recognize left-sided endocarditis as a rare complication

dopamine and intravenous diuretics to the dobutamine. He responded well and was

after right atrial central venous catheter-associated thrombus

weaned off inotropic support and extubated within 72 h. Repeat echocardiogram demon-

LEARNING OBJECTIVE #2: Recognize that anticoagulation strategy should be

strated severely reduced left ventricular systolic function (LVEF 15 %) and prominent left

individualized based on clinical scenario

ventricular trabeculae with deep intertrabecular recesses in the apical walls suggestive of

CASE: A 49 year old male with history of HIV (CD4 544, on HAART), hemodialysis-

LVNC. Cardiac MRI confirmed the diagnosis of LVNC. The patient was discharged on a

dependent end-stage renal disease (ESRD), untreated hepatitis C infection, controlled type

medical regimen that contained an ACE inhibitor, beta blocker and oral diuretics. The

II diabetes mellitus, and non-obstructive coronary artery disease presented with 2 months




of watery, non-bloody diarrhea. He was admitted for similar symptoms 1 month prior with

two, the urine legionella antigen returned as positive and the antibiotics were changed to

a negative infectious work up. At that time he was diagnosed with ESRD and was started

high-dose levofloxacin mono-therapy for treatment of Legionnaire’s disease. The patient

on dialysis via a right internal jugular dialysis catheter. During this admission, he was

continued to be intermittently febrile and hypoxic, requiring high flow nasal cannula. His

diagnosed with line-associated methicillin-sensitive Staphylococcus aureus bacteremia,

leukocytosis worsened to 45,000/mcL and his procalcitonin increased to 43 ng/mL. Given

prompting removal of the dialysis catheter. Physical exam was unremarkable without

his overall worsening clinical status and no new identified source of infection, tigecycline

stigmata of subacute endocarditis. Labs were significant for WBC of 15.8 × 109/L with

was added to his antibiotic regimen. Hypoxia slowly improved, and leukocytosis and

85 % neutrophils and baseline BUN and creatinine of 73 mg/dL and 8.5 mg/dL. A

procalcitonin downtrended. He completed a total of 21 days of levofloxacin and 7 days of

transthoracic echocardiogram (TTE) was performed and demonstrated a mobile, filamen-

tigecycline, and was discharged to an acute rehabilitation facility, where he continued to

tous mass (2.2 × 0.8 cm) on the atrial side of the posterior leaflet with mild mitral


regurgitation and normal left ventricular systolic function (LVEF 60–65 %). The patient

DISCUSSION: Rapid diagnosis of Legionnaire’s disease improves clinical outcomes and

subsequently developed isolated left lower extremity weakness and brain MRA showed a

may lead to recognition or prevention of other cases. The gold standard for diagnosis is

recent small left posterior cerebral artery infarct, concerning for septic embolism.

positive culture, but this requires selective media (buffered charcoal yeast extract plates)

Transesophageal echocardiogram (TEE) revealed a large, mobile filamentous vegetation

and prolonged incubation, which may delay diagnosis. A four-fold increase in serum

(1.8 × 1.9 cm) on the posterior mitral valve leaflet with valve perforation at the base of the

antibody is another method for diagnosis, but can only be used to make the diagnosis

posterior leaflet. The TEE also showed a thrombus in the right atrium and superior vena

retrospectively. The legionella urinary antigen test is a rapid, inexepensive, and widely

cava, continuing to the right internal jugular. This was attributed to the prior right internal

used test, but only detects Legionella pneumophila serogroup 1 and has a sensitivity of

jugular HD catheter. The patient was treated with IV nafcillin for endocarditis. However,

77 %. Polymerase chain reaction (PCR) is a new tool that can lead to rapid diagnosis of

given the recent embolic stroke, a decision was made not to start the patient on anticoag-

Legionella infection. Sputum PCR has a sensitivity of 94.5 % and specificity of 99 %, but

ulants for the thrombus. Additionally, based on the echocardiographic appearance, the

is expensive and requires dedicated laboratory equipment. PCR can be especially helpful

thrombus had characteristics of fibrosis and thus was believed less likely to cause further

in patients with severe pneumonia in which the urinary antigen test is negative but

embolic phenomena.

suspicion for Legionnaire’s disease remains. First line therapy for Legionnaire’s disease

DISCUSSION: In patients requiring dialysis, central venous catheters are temporarily used

includes macrolides or high-dose quinolones. Legionella species are intracellular bacteria

until arterio-venous shunts mature. Hemodialysis catheters have been associated with risk for

and are therefore unaffected by beta-lactam antibiotics. There have been no randomized,

right atrial thrombus formation, particularly in the chemotherapy pediatric population. The

controlled studies comparing antimicrobials in the treatment of Legionnaire’s disease but

mechanism is thought to be the catheter tip causing irritation of atrial walls. Although

several small observational studies have shown that treatment with levofloxacin compared

uncommon, it has also previously been suggested that catheter associated thrombi can

with macrolides had no mortality benefit but produced shorter time to defervescence,

become infected. However, left-sided endocarditis is a rare presentation for an infected

shorter time to stabilization, and shorter hospital stay. In vitro studies confirm quinolones

right-sided central venous catheter-associated thrombus. In patients with hemodialysis

have superior activity when compared to macrolides, but quinolones are concentration-

catheters, it is important to have high clinical suspicion not only for line-associated throm-

dependent drugs, so correct dosing is important. Tigecycline is a second line option for

bosis but also for infectious complications such as endocarditis. Literature suggests that TEE

treatment of Legionnaire’s disease. Intracellularly, tigecycline is superior to both quino-

is superior to TTE for evaluation of right atrial thrombosis. Consideration should also be

lones and macrolides in kill-time however there are only several case reports in the

given to prophylactic anticoagulation for prevention of embolic complications from both the

medical literature of patients being treated with tigecycline for Legionnaire’s disease.

thrombus as well as the endocarditis vegetation. However, such therapy must be individu-

Tigecycline is generally well tolerated with minimal drug interactions, and does not need

alized based on the clinical situation and based on the risks and benefits to the patient.

to be dose-adjusted for renal impairment or mild to moderate hepatic impairment, making it an excellent option for mono-therapy or combination therapy for Legionella pneumonia. Internists should be aware of the different methods available for diagnosing Legionella


pneumonia as well as their limitations. Swift diagnosis and appropriate treatment are

TIGECYCLINE Johanna Hase; Kevin Hauck. New York University School of

crucial in improving clinical outcomes for patients with Legionnaire’s disease.

Medicine, New York, NY. (Control ID #2467901)

LEARNING OBJECTIVE #1: Diagnose Legionnaire’s disease


LEARNING OBJECTIVE #2: Compare antibiotic choices for Legionnaire’s disease


CASE: The patient is an 84 year-old man who presented with 6 days of fevers, chills, and


productive cough. He last felt well 7 days prior to presentation and did not endorse any

Meera1; Sofia Terner3; Safeera Javed2. 1Montefiore Medical Center, Mamaroneck, NY;

sick contacts or recent travel. Associated symptoms included decreased appetite and two


episodes of non-bloody diarrhea. Vital signs were notable for tachycardia, and a blood

ID #2469387)

Montefiore medical center, NYC, NY; 3Montefiore Medical Center, Bronx, NY. (Control

pressure of 86/46 mmHg. The patient was tachypneic, and hypoxic to an oxygen saturation of 93 % on room air. On exam he was lethargic and had coarse rhonchorous

LEARNING OBJECTIVE #1: Identify individuals with high risk for cardiovascular

breath sounds bilaterally. Initial laboratory tests revealed leukocytosis (17,000/mcL with

events who have non specific symptoms on presentation

left shift), elevated creatinine (4.0 mg/dL), as well as elevated transaminases (AST 78 U/L,

LEARNING OBJECTIVE #2: Early diagnosis and treatment is imperative to prevent

ALT 44 U/L) and total bilirubin (3.2 mg/dL). Serum procalcitonin was 33 ng/mL.

catastrophic cardiac sequelae and sudden cardiac death

Computed tomography of the chest showed dense consolidation of the right upper lobe,

CASE: 57-year-old man with DM1 and cocaine and marijuana abuse presented with 1 day

right middle lobe and posterior right lower lobe, with small bilateral pleural effusions. The

of generalized weakness. He denied chest pain, dyspnea, diaphoresis, or palpitations.

patient was treated for severe community-acquired pneumonia and started on broad-

Initial blood pressure was 81/49 mmHg, heart rate was 106 beats/min, respiratory rate was

spectrum antibiotics with vancomycin, cefepime and azithromycin. On hospital day

16 breaths/min and oxygen saturation was 100 % on room air. Physical examination was




otherwise unremarkable. Initial EKG and troponins were normal . He had no ECHO or

Hepatitis C viral load was 623149 copies/mL. Serological test for hepatitis B and HIV

cardiac stress testing done in the past. Urine drug screen was negative. Labs on presen-

were negative. Urine microscopy revealed many RBCs, few hyaline and granular casts.

tation were consistent with diabetic ketoacidosis (DKA), was treated with fluids and

Urine drug screen was positive for cocaine. Blood and respiratory cultures were negative

insulin drip with improvement in blood glucose and anion gap. However patient

for bacteria, viruses and fungi. Chest radiography showed diffuse bilateral opacities. Chest

complained of persistent generalized weakness . Vitals and Repeat electrolytes were

tomography revealed multiple nodular opacities. Bronchoalveolar lavage showed pro-

normal . A repeat 12 lead EKG revealed new deep T wave inversions in anterior leads

gressively bloody lavage fluid over serial aliquots consistent with diffuse alveolar hem-

and next set of troponin began to rise, reached a peak level of 1.48 ng/mL. Diagnosis of

orrhage. On the fourth day of admission his fingers, toes, ears and nasal fold started to

non-ST elevation myocardial infarction (NSTEMI) was made and he received

develop necrotic skin changes. In lieu of the presentation and the presence of both anti-

Clopidogrel, Aspirin, Atorvastatin and Heparin drip. Echocardiogram revealed severe

MPO and anti-PR3, he was diagnosed with levamisole/cocaine induced systemic vascu-

mid-septal hypokinesis and mild apical hypokinesis with preserved ejection fraction. He

litis. He received 3 doses of pulse intravenous steroids followed by daily oral prednisone

underwent urgent coronary angiography, showing 70–80 % stenosis of the left anterior

and completed 11 sessions of plasmapheresis. Skin punch biopsy showed epidermal

descending coronary artery for which drug eluting stent was placed .

necrosis and widespread vascular thrombosis consistent with levamisole induced vascu-

DISCUSSION: Acute coronary syndrome (ACS) presents without chest pain in a

lopathy. Kidney biopsy showed global glomerulosclerosis, interstitial fibrosis, chronic

significant proportion of patients,particularly females, diabetics, and elderly and atypical

interstitial inflammation, no active crescents or necrotizing lesions and partly reabsorbed

symptoms are usually dyspnea, diaphoresis, nausea, vomiting, and syncope. ACS patients

deposits suggestive of a pauci-immune type glomerulonephritis in the past. Despite

presenting without chest pain often have adverse outcomes secondary to misdiagnoses and

treatment, his skin lesions continued to become more necrotic and the hemoptysis

under-treatment. These patients may have delays in seeking medical care, less aggressive

persisted. Due to lack of improvement, patient was terminally extubated on day 23 from

therapies, and increased in-hospital mortality. Atypical presentation of acute and chronic


ischemic heart disease in diabetic patients is under-investigated despite extensive research

DISCUSSION: Levamisole is a veterinary anti-helminthic medication which has immu-

into coronary artery disease.. In Diabetics, Atherosclerotic plaques develop earlier, ad-

nomodulatory properties. It had been used for the treatment of colorectal cancer, however

vance faster and are more diffuse .These factors contribute to a two to four-fold increased

it was removed from the United States market in 1999 due to significant side effects. It has

risk of cardiovascular events. Diabetic patients with silent myocardial ischemia have

been increasingly used to adulterate cocaine due to its psychotropic effects and morpho-

evidence of diffuse abnormality in metaiodobenzylguanidine (MIBG) uptake, suggesting

logical properties. Levamisole-induced vasculitis is characterized by neutropenia/

that sympathetic denervation may be linked to abnormalities in pain perception. In a

agranulocytosis, purpuric lesions involving the face, especially the ear lobes, with varying

retrospective Multicenter study conducted in 2013, STEMI Patients presenting with chest

frequencies of glomerulonephritis and lung hemorrhage. Serologic abnormalities include

pain were compared with patients presenting with non specific symptoms and outcomes

unusually high titers of p-ANCA, combined positivity for MPO and PR3 antibodies,

were analysed . Compared with those who presented with chest pain, patients admitted for

positivity for antiphospholipid antibodies as well as antinuclear and anti-double-stranded

other reasons waited longer before going to the hospital (prehospital delay < 12 h: 32.0 %

DNA antibodies and hypocomplementemia. Beside discontinuation of offending agents,

vs 73.3 %; P < 0.001), presented with more severe clinical symptoms (Killip score ≥ III:

there is no proven medical treatment. Therapy with immunosuppressive medications may

28.0 % vs 10.5 %; P = 0.001), waited longer to be examined in the hospital (waiting time >

be prohibitive in those with agranulocytosis and severe wounds. Resolution of the

1 h: 36.0 % vs 11.4 %; P < 0.001), were less likely to receive reperfusion therapy (40.7 %

vasculitic process after cessation of cocaine has been described. Our patient had fulminant

vs 77.1 %; P < 0.001) and had a higher mortality rate at 1 month (42.7 % vs 21.0 %;

form of vasculitis and had a fatal outcome. Pulse steroids and plasmapheresis could not

P < 0.001). This case demonstrates that ACS can present with atypical and nonspecific

reverse the vasculitic process. In an era where cocaine use is common, it is important for

symptoms in diabetic patients and clinicians must have a high degree of suspicion to

physicians to be aware of the signs of levamisole induced toxicity for early recognition and

accurately diagnose and provide urgent treatment to improve outcomes

withdrawal of the agent. More research needs to be done on treatment options.





2 1



Heights, MI; Henry Ford Hospital, Detroit, MI; Henry Ford Health System, Detroit, MI.

Michael J. Lau1; Akihiro Kobayashi2; Aloke Chakravarti1; Alfredo J. Astua1; Jose A.

(Control ID #2466582)

Cortes1. 1Mount Sinai Beth Israel, New York, NY; 2Mount Sinai Beth Israel, New York,

Ngansop ; Lenar Yessayan ; Daryl Sudasena . Henry Ford Health System, Madison 2

NY. (Control ID #2469540) LEARNING OBJECTIVE #1: To educate healthcare professionals on the systemic manifestations of levamisole contaminated cocaine for early recognition and intervention.

LEARNING OBJECTIVE #1: Describe differential diagnosis of lactic acidosis

LEARNING OBJECTIVE #2: To heighten awareness of adulterant (levamisole) use in

LEARNING OBJECTIVE #2: Identify the potential side effects of linezolid


CASE: A 77 year-old male with a past medical history of coronary artery disease, systolic

CASE: 49 year old African American male with a history of cocaine use, hypertension,

heart failure, lymphoma, type 2 diabetes mellitus, with a recent admission for right toe

hepatitis C and CKD presented with acute shortness of breath and hemoptysis. He was

osteomyelitis actively on treatment with linezolid and cefepime, presented with a 2-day

admitted to the ICU, intubated and started on broad spectrum antibiotics. Physical exam

history of shortness of breath and several episodes of hypoglycemia. He had a metatarsal

was remarkable for diffuse adventitious breath sounds and bluish discoloration of his

head resection for acute osteomyelitis of his first toe 6 weeks prior. The pathology of the

fingertips. Laboratory results were as follows: hemoglobin 5.8 g/dL; leukocyte count

metatarsal head proximal margin was initially negative for osteomyelitis, but the surgical

5.5 K/uL; platelet count 463 K/uL; serum creatinine 3.2 mg/dL. ANA, anti-MPO, anti-

site eventually became infected. A repeat biopsy 1 week later was positive for acute

PR3 and anti-cardiolipin antibodies were positive. Serum C3 and C4 levels were low;

osteomyelitis, and the bone culture grew vancomycin resistant enterococci and proteus

rheumatoid factor and serum cryoglobulins were undetectable. Anti-centromere, Anti-Scl-

mirabilis. The patient was subsequently discharged to a nursing home to complete a 6-

70, anti-Ro/SSA, anti-La/SSB, anti-GBM, anti-ENA antibodies were all negative.

week regimen consisting of linezolid and cefepime. During his treatment he became




increasingly lethargic and developed shortness of breath 2 days prior to admission and was

LEARNING OBJECTIVE #2: Longitudinally extensive transverse myelitis (LETM)

subsequently brought to the hospital. His initial vital signs showed a blood pressure of

has been known to occur with NMO (neuromyelitis Optica) but can sometimes occur with

115/80 mmHg, pulse rate of 72/min, respiratory rate of 18/min, oxygen saturation of 99 %

other autoimmune conditions even when they are on adequate treatment.

on room air and a body temperature of 98 °F. On physical examination, the surgical site of

CASE: A young 22 year old black female presented with bilateral leg tingling and

the right foot was clean, with no erythema, discharge or tenderness noted. Blood work

numbness for 3 days. Tingling sensation was in both legs below knee. Patient didn’t have

revealed a white blood cell count of 5.9 K/uL, platelet count of 17 K/uL, lactic acid of

any fall, weakness or imbalance. There was no fever, headache, nausea, vomiting, blurry

15 mmol/L, and an elevated anion gap of 29. A chest x-ray showed a mildly worsening

vision, loss of bladder or bowel control. Physical examination revealed bilateral decreased

pleural effusion. A critical care medicine consult was requested from the ED, and he was

sensation to temperature in stocking distribution, near-absent vibration in the toes and feet,

admitted to the MICU for sepsis, and severe lactic acidosis. Ongoing linezolid adminis-

and very poor proprioception in toes. Hyperreflexia was noted in bilateral lower and upper

trations were continued empirically, and an infectious disease consult was requested. The

extremities with positive Hoffman’s sign. Hypertonia was noted with wide based gait.

lactate failed to clear with adequate supportive care, and a Type B lactic acidosis secondary

There were no significant motor deficits. Patient’s past medical history was significant of

to Linezolid was suspected. After discontinuing linezolid, the lactic acid gradually

systemic lupus erythematosus (SLE) diagnosed 3 years ago. She was on immunosuppres-

decreased to 0.6 mmol/L, and his platelet count increased to 166 K/uL by hospital day

sion with Methylprednisolone and Mycophenolate started after complication of SLE

17. Additional bone resection was performed, however, the proximal margin was positive

nephropathy with WHO class 3 which was proven by kidney biopsy a year ago. She

again. Another bone culture grew pseudomonas resistant to cefepime, and he was

had stable chronic kidney disease stage 3. SLE flare up with neurological complication

discharged with oral ciprofloxacin.

was suspected but inflammatory markers including C reactive protein, complements (C3,

DISCUSSION: Lactic acidosis is a condition characterized by > 4–5 mmol/L serum lactic

C4) were normal. There were no other clinical findings like skin rash, arthralgia which are

acid and is the most common cause of metabolic acidosis in hospitalized patients. It is

commonly associated with acute flare up of SLE. Cerebrospinal fluid (CSF) analysis was

often associated with poor clinical prognosis, and sepsis is a well-known primary cause of

negative for herpes virus, cytomegalovirus, west nile virus, toxoplasma and histoplasma.

lactic acidosis. Type A lactic acidosis occurs by decreased end-organ perfusion or

There were normal CSF cell count, total protein and low lactate dehydrogenase. MRI of

oxygenation secondary to hypovolemia, cardiac failure, and sepsis. Type B lactic acidosis

brain was unremarkable. MRI of spine was consistent with extensive signal abnormality

occurs with no clinical evidence of hypoperfusion or oxygenation. Type B1 occurs by

within the spinal cord from level C1 through at least T9 which was most prominent in the

systemic diseases such as diabetes, renal failure and malignancy. Type B2 is caused by

central cord and dorsal columns representing a demyelinating process. There was no

drug intoxication. Type B3 is caused by inborn errors of metabolism. Some common

evidence of spinal cord compression, tumor or epidural abscess. Neuromyelitis optica was

causes of Type B lactic acidosis include DKA, ethanol intoxication, drug use, malignancy,

ruled out with negative Anti NMO serology. So diagnosis of transverse myelitis secondary

alcoholism, HIV, thiamine deficiency, mitochondrial myopathy, trauma, genetic diseases,

to SLE was made. Patient was treated with high dose of parenteral glucocorticoids which

among other causes of which the mechanism is not entirely clear. Drugs such as linezolid,

improved patient’s clinical symptoms. Patient was discharged with prophylactic long term

antiretroviral drugs, and propofol that can impair mitochondrial protein synthesis and

immunosuppression and close follow up with Rheumatology and Neurology.

reproduction can lead to type B lactic acidosis. Linezolid is an antibiotic of the

DISCUSSION: This patient had longitudinally extensive transverse myelitis (LETM)

oxazolidinone class, and is often used to manage drug-resistant gram-positive bacterial

with a lesion on MRI that extends sixteen vertebral segments. LETM is defined as a spinal

infections. This inhibits bacterial protein synthesis by binding to residues within the 23S

cord lesion that extends over three or more vertebrae which usually leads to complete or

ribosomal RNA of the 50S large subunit of bacterial ribosomes. Linezolid use can be

incomplete spinal cord dysfunction. LETM usually manifests with sudden onset of lower

associated with some adverse effect including thrombocytopenia, neuropathy, serotonin

extremity weakness and/or sensory loss, plus loss of rectal and urinary bladder sphincter

syndrome, and lactic acidosis. A longer duration of linezolid leads to greater exposure to

control. But this patient had only lower extremity sensory disturbances which could be

mitochondrial damage, therefore we expect that the duration of linezolid use is an

confusing with SLE peripheral neuropathy. It is important to know that SLE transverse

important risk factor for those adverse reaction. The primary treatment for linezolid-

myelitis is thought to be due to an arteritis, with resultant ischemic necrosis of the spinal

induced lactic acidosis is discontinuation of linezolid, and most of previous reports

cord. But there are normal inflammatory markers in this patients which are usually

demonstrated the recovery within 1–15 days. Although some other treatments such as

associated with vasculitis. CSF analysis in SLE transverse myelitis is usually consistent

hemodialysis or bicarbonate have been reported, there is still limited evidence to support

with elevated protein level and a moderate lymphocytic pleocytosis but this patient’s CSF

their clinical utility. The prognosis of linezolid-induced lactic acidosis is poor, and one

analysis showed normal lymphocytes and protein. It is debatable to rely on serological

case series revealed 26 % of mortality. Sepsis is often considered a major cause of lactic

inflammatory markers in patients who are already on immunosuppressive therapy. It is

acidosis. However, less common causes of lactic acidosis, such as drug adverse effects,

prudent to assess for rare causes of CNS inflammation before making definitive diagnosis

should also be considered. Clinicians should consider these causes when lactate trends are

of SLE transverse myelitis in immunosuppressed patients. Very few cases of LETM in

inconsistent with other clinical data.

association with SLE have been reported in the literature. LETM is most commonly described as a feature of neuromyelitis optica (NMO), but can be seen in other autoimmune diseases such as SLE, as in this case.

LONGITUDINALLY EXTENSIVE TRANSVERSE MYELITIS: A RARE COMPLICATION OF SLE Pranav D. Patel2; Srinidhi Jayadevappa Meera1; Eric J. Mariuma3; Keron Lezama2. 1Montefiore Medical Center, Mamaroneck, NY; 2Montefiore

LOST TO FOLLOW UP Douglas Lim; Michael P. Smith. University of Nebraska

Medical Center Wakefield Campus, Bronx, NY; 3Montefiore Medical Center, Bronx, NY.

Medical Center, Omaha, NE. (Control ID #2469916)

(Control ID #2469615) LEARNING OBJECTIVE #1: Recognize the severe clinical features of IgA LEARNING OBJECTIVE #1: Recognize the rare but potentially debilitating neurolog-


ical manifestation associated with systemic lupus erythematosus (SLE) and early treat-

LEARNING OBJECTIVE #2: Recognize that early pre-eclampsia can be an indication

ment to prevent permanent disability.

of primary renal disease.




CASE: A 25 year-old woman presents with 3 months of worsening dyspnea, weakness,

(AVN) of bilateral femoral head and an anterosuperior subchondral crescentic fracture

and chest pain. Her systolic blood pressure was 300. She had diffuse lung crackles with

with suggestion of a collapse of left femoral head. Since patient did not have any other risk

lower extremity edema. Urinalysis revealed significant blood and protein. Chest x-ray

factors, the AVN was attributed to his HIV and Protease Inhibitor-based HAART therapy

revealed cardiomegaly, pulmonary edema with bilateral effusions. Small hypo-echoic

The patient underwent total hip arthroplasty of left hip and HAART therapy was modified

kidneys were found on abdominal ultrasound. Her parathyroid hormone level was 500.

to elvitegravir, cobicistat, emtricitabine and tenofovir alafenamide. The patient was doing

A renal biopsy revealed IgA nephropathy with severe atrophy and fibrosis. On further

well on 1 month follow up visit.

questioning, she has a history of pre-eclampsia early in her previous pregnancy several

DISCUSSION: Avascular Necrosis (AVN) indicates ischemic death of the bone as a

years ago that was never followed post partum.

result of insufficient arterial blood supply. The incidence rate of AVN in HIV infected

DISCUSSION: Chronic kidney disease commonly presents with hypertension and

patients is greater than in general population. Though it is unclear whether this is the result

edema; these symptoms are frequently faced by general internists. IgA nephropathy is

of the HIV virus or the HAART treatment, the incidence has increased in the HAART era.

the most common glomerulonephritis in the world. Most patients are diagnosed with

The protease inhibitor drugs have been specifically reported to lead to AVN. Clinicians

hematuria or proteinuria detected on routine tests. If undetected longterm, a minority of

need to be aware of the subtle yet frequent complication of AVN in HIV patients on

patients present with reduced GFR, hypertension, and persistent proteinuria which are all

HAART therapy especially those patients on protease inhibitors. Preventive strategies

markers for worse prognosis. Severe hypertension can lead to cardiac failure such as in our

should focus on avoiding risk factors like corticosteroid use, smoking, alcohol, intrave-

patient. Pulmonary hemorrhage in the setting of IgA nephropathy is also a rare but poor

nous drug use, hyperlipidemia and radiation exposure.

prognostic maker when other causes of hemorrhage are excluded. IgA nephropathy is commonly associated with early onset pre-eclampsia. It is difficult to differentiate undiagnosed glomerulonephritis during pregnancy from pre-eclampsia induced kidney injury.


This is an important distinction because management is different for each condition. A

Muhammad A. Saeed; Bennal Perkins. Montefiore Medical Center, New York, NY.

renal biopsy is the definitive way to diagnose IgA nephropathy although this has been

(Control ID #2469295)

controversial during pregnancy. However, women who have continued hematuria and proteinuria postpartum should get a biopsy. Our patient experienced proteinuria and

LEARNING OBJECTIVE #1: Recognize squamous cell carcinoma as a differential in

hypertension at 22 weeks gestation thought to be due to pre-eclampsia. She had an

chronic leg ulcers and long standing lymphedema.

underlying primary renal disease that was undiscovered until she had severe symptoms

LEARNING OBJECTIVE #2: Identify paraneoplastic syndrome as an etiology for

several years later. Complications from progressive IgA nephropathy can be life threat-

hypercalcemia presenting with anemia, weight loss and venous thrombosis.

ening. Pre-eclampsia can mask underlying primary renal disease and the general internist

CASE: A 58 year old African American male with medical history of chronic lymph-

can prevent these complications if a high index of suspicion is maintained.

edema presented with chronic nonhealing left lower leg ulcer which had recently become foul smelling. On admission, he was febrile to 101.3; labs revealed leukocytosis, lactic acidosis, elevated creatinine, severe anemia, and severe hypercalcemia to 16.5. Imaging


LOVING HAART BUT LOSING HIP! Sreelakshmi Panginikkod ; Venu Pararath

revealed bone loss in the distal left tibia and fibula. Considering the clinical picture, there

Gopalakrishnan1; Niyati Gupta2; Bara Alzghoul1. 1Presence Saint Francis Hospital,

was high suspicion for osteomyelitis and he was started on antibiotics. Aggressive

Evanston, IL; 2Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India.

Intravenous hydration was done initially. He was given Calcitonin 30 mg and

(Control ID #2469377)

Pamidronate in several doses, totally 150 mg. As the patient was severely anemic, he was initially administered 4 units of packed red blood cells (he received a total of 6 units

LEARNING OBJECTIVE #1: Recognize Avascular Necrosis (AVN) as an increasingly

during hospital stay). Flow cytometry was normal. Serum Protein Electrophoresis re-

identified complication of protease inhibitor-based Highly Active Anti-Retroviral Therapy

vealed elevated kappa and lambda chains raising suspicion for multiple myeloma; how-


ever, his skeletal survey and bone biopsy were normal. We also evaluated his Parathyroid

LEARNING OBJECTIVE #2: Recognize Avascular Necrosis (AVN) as a cause of hip

hormone (PTH), which was low, but Parathyroid Hormone related Peptide (PTHrP) was

pain in HIV patients

high. He underwent left below the knee amputation (BKA) and biopsy was sent to

CASE: A 57 year old gentleman with past medical history significant for HIV presented

pathology. Preliminary biopsy obtained during BKA reported invasive squamous cell

with bilateral hip pain of 2 weeks duration. Pain was more on the left side, progressively

carcinoma (SCC). Upon discharge, an outpatient PET scan and Dermatology appointment

worsening and aggrevated with movement and ambulation. Patient denied any joint

was recommended to further evaluate surrounding scar tissue for SCC. He developed non-

stiffness or involvement of other joints. Review of system was negative for fever, chills,

occlusive thrombi in the right common iliac and right internal iliac veins and later in the

urinary symptoms or change in bowel habits. Patient denied any trauma or chronic steroid

left basilic vein. The need for life long anticoagulation was strengthened as he developed

use. He quit smoking 7 years ago and drinks about 1–2 cans of beer occasionally. He was

two venous thrombus emboli in the setting of malignancy.

diagnosed with HIV 10 years ago and was started on emtricitabine-tenofovir and

DISCUSSION: Squamous cell carcinoma has various etiologies and diagnosing it in

fosamprenavir 5 years ago. On physical examination, he was moderately built and

chronic ulcers poses a challenge to the physician. SCC commonly occurs on sun exposed

nourished with stable vitals. Hip examination did not show any warmth, swelling or joint

areas; often in the neck and on the back of fair skin people. Compared to Caucasians, SCC

tenderness, but was remarkable for painful range of motion bilaterally, especially on

in the African American population is not as common. Females tend to be more affected

passive internal rotation. Initial lab evaluation showed normal Complete Blood Count,

than males, and lower extremities being the most common site. No study has been done

Comprehensive Metabolic Panel and Urinalysis were normal. Inflammatory biomarkers

discussing etiologies of lower extremity SCC; however, it is suggested that lower extrem-

and Autoimmune panel were negative. Serum cortisol level and Thyroid Function Test

ity SCC are distinct and may exhibit a pathogenesis less reliant on actinic damage. Two

were normal . His CD4 count was 450 and HIV viral load was undetectable. X-ray of the

unique factors were involved in our case: chronic lymphedema and chronic ulcers. Only a

pelvis showed bilateral femoral head avascular necrosis and mild articular surface collapse

few case reports support SCC developing secondary to chronic lymphedema, which

of the left femoral head. Magnetic Resonance Imaging (MRI) revealed avascular necrosis

historically is related to lymphangiosarcoma not SCC. Incidence of SCC in chronic ulcers




has been reported to be approximately 1 % in a small retrospective study. Another

diagnoses such pulmonary embolism, pneumonia, and pneumothorax particularly in the

challenge in our case was hypercalcemia. Our patient was initially believed to have

young, otherwise healthy population. While this patient did have an elevated BNP, there

osteomyelitis or multiple myeloma based on clinical presentation of sepsis in setting of

was no clinical evidence for volume overload such as crackles or elevated JVP, and chest

chronic ulceration and hypercalcemia, respectively. Of note, hypercalcemia is not an

radiography confirmed clear lungs. Further, imaging studies and lab work also excluded

uncommon finding in both multiple myeloma and squamous cell carcinoma.

pneumonia, pulmonary embolism, or pneumothorax. Early diagnosis and treatment of

Maintaining a broad differential diagnosis is the cornerstone of managing similar cases.

SLE is the key to better outcomes. However, the clinical heterogeneity of SLE and the lack

The diagnosis of SCC in the setting of low PTH and high PTHrP explained paraneoplastic

of pathognomonic features or tests pose a diagnostic challenge for the clinician. Many use

syndrome of hypercalcemia secondary to malignancy and anemia. Internists should

the classification criteria proposed by American College of Rheumatology (ACR) to

consider Squamous cell carcinoma as a differential in chronic leg ulcers and long standing

document key disease features. A minimum of 4 of the 11 ACR criteria should be met

lymphedema; and maintain a broad differential for hypercalcemia presenting with anemia,

to diagnose SLE. The 11 ACR criteria are broken into systems: cutaneous,

weight loss and venous thrombosis.

musculosketetal nonerosive arthritis, cardiopulmonary pleuritis or pericarditis, renal, neurological disorder with seizures or psychosis due to unknown causes, and positive immunologic antibodies. We demonstrate with this case that SLE can present with acute


dyspnea and that SLE should be included in the wide range of differential diagnoses of

Michele Yeung; Marcelo Mendez; Faraj Faour. Mount Sinai Beth Israel, New York,

dyspnea particularly in a young patient where common etiologies have been ruled out.

NY. (Control ID #2468939)

This case reminds clinicians to be cognizant of atypical presentations of SLE.

LEARNING OBJECTIVE #1: Recognize that systemic lupus erythematous (SLE) has


varying manifestations and that pulmonary complaints can be the sole presenting

Atlanta, GA. (Control ID #2469599)

symptom LEARNING OBJECTIVE #2: Understand the American College of Rheumatology

LEARNING OBJECTIVE #1: Review the presentation of LGV

(ACR) diagnostic criteria for SLE

LEARNING OBJECTIVE #2: Discuss the importance of diagnosis and treatment of

CASE: A 21-year-old male with no past medical history presented to the hospital with

patient and sexual partners

2 days of shortness of breath. He had a routine physical by his primary care physician

CASE: 28 year old male with PMH of HIV/AIDS (CD4 101 VL 209,462) who had been

1 week prior to admission, at which time the only abnormal finding was a blood pressure

off antiretrovirals since September 2014 presenting due to abdominal pain and bloody

of 149/95. He described dyspnea exacerbated with exertion and lying flat; which was

diarrhea for 3 weeks. He reported 15 watery bowel movements per day. Also reported

associated with a nonproductive cough and intermittent pleuritic chest pain. He denied

fever and chills. He denied sick contacts or recent travel. He did engage in unprotected

fevers, chills, hematuria, dysuria, rhinitis, epistaxis, or hemoptysis. He further denied a

anal intercourse 3 months prior to onset of symptoms. On exam his abdomen was diffusely

history of prolonged immobilization, sinus infections, or asthma. The remainder of his

tender to palpation. He had small perirectal ulcerations and had inguinal lymphadenopathy

review of systems was negative, including lack of edema, arthralgias, myalgias, rashes, or

as well. Work up included CT abdomen/pelvis, which showed rectal wall thickening and

photosensitivity. The physical exam was only significant for hypertension (153–173/106–

adjacent fat stranding and adenopathy. Stool cultures were negative for cryptosporidium,

125) and sinus tachycardia (95–105). Lungs were clear and there was no rashes, oral

isospora, and cyclospora. Lymphadenopathy, hemorrhagic diarrhea and proctitis on im-

ulcers, joint abnormalities, peripheral edema, elevated JVD, or chest wall tenderness.

aging in the setting of HIV/AIDS was concerning for GC proctitis. GC PCR was positive

Initial labs revealed Cr 3.24 (0.66–1.25 mg/dL), BUN 58 (8–24 mg/dL), total protein 5.1

and he was treated with 21 day course of Doxycycline.

(6.3–8.2 g/dL), albumin 2.3 (3.5–5 g/dL), and B-type natriuretic peptide 393.8 (0–100 pg/

DISCUSSION: Lymphogranuloma venereum (LGV) is a genital ulcer disease caused by

ml). Serial cardiac enzymes were negative. Chest radiograph was normal. Ventilation

Chlamydia trachomatis. It was initially described in heterosexual males in tropical and

perfusion scan reported low probability for a pulmonary embolism and transesophageal

subtropical areas and in the early 2000s became increasingly prevalent in temperate

echocardiography without signs of heart failure. Further workup with urinalysis revealed

climates in men who have sex with men. In MSM HIV infection was a risk factor for

nephrotic range proteinuria, microscopic hematuria, along with dysmorphic red blood

acquiring LGV. LGV presents in multiple stages following infection. With primary

cells and red blood cell casts. Immunologic studies showed an elevated ANA with a 1:320

infection patients usually experience genital ulcer that can be small in size and often

titer, positive anti-dsDNA antibody, and low C3 /C4 levels. Given the suspicion for

missed. Two to six week following primary infection the secondary stage appears which is

intrinsic renal disease our patient underwent a renal biopsy. Pathology was consistent

caused by the direct spread of the infection to nearby lymph nodes. This stage is

with rapidly progressive glomerulonephritis (RPGN) due to lupus nephritis and the patient

characterized by inguinal lymphadenopathy that can form buboes. This stage can also

was started on methylprednisolone and cyclophosphamide. Patient’s initial complaints of

present with anorectal symptoms/ proctocolitis with rectal discharge, anal pain fever as

dyspnea were deemed to be secondary to pulmonary involvement of his newly diagnosed

well as hemorrhagic proctocolitis. If left untreated Diagnosis can be difficult as clinical


presentations vary and testing modalities are not standardized however NAAT testing has

DISCUSSION: We present an unusual case of Systemic lupus erythematous (SLE) in a

shown to have high sensitivity/specificity for detection of Chlamydia trachomatis.

male patient where the presenting symptom was a pulmonary complaint. It is well

Physicians should have a high index of suspicion for potential LGV infection in patient

established that SLE is substantially more common in females of child-bearing age, where

with underlying HIV infection presenting with symptoms of proctocolitis. It is important

the reported female:male ratio is 8–15:1. In addition, SLE is typically thought of as an

to consider LGV as a potential cause of hemorrhagic proctocolitis as untreated LGV can

autoimmune disease comprised mainly of musculoskeletal and dermatologic symptoms.

result in late complications including genital elephantiasis, anal fistulas, strictures, infer-

In fact, approximately 73 % of patients will present with cutaneous findings and 65 % with

tility. During proctocolitis episode there is also enhanced shedding of HIV that could

musculoskeletal manifestations. In contrast, less than 12 % of patients present with

increase the risk of HIV to uninfected partners. Partners of LGV positive patients should

pulmonary complaints. Of those 12 % of patients presenting with solely pulmonary

be screened and treated in order to prevent further spread and long term complications of

complaints such as pleurisy and dyspnea, clinicians are more likely to consider other

untreated disease. Asymptomatic partners should be empirically treated as well.





such as thermoactinomyces, klebsiella, naegleria, and acanthamoeba. However, it is also

Lawrence Purpura; John Moscona. Tulane University Health Sciences Center, New

important to avoid prolonged exposure to the disinfectant, as this can lead to lung injury

Orleans, LA. (Control ID #2468853)

and pulmonary fibrosis in a dose–response manner.

LEARNING OBJECTIVE #1: Recognize the clinical presentation of hypersensitivity pneumonitis


LEARNING OBJECTIVE #2: Recognize the importance of considering environmental


exposures for repetitive exacerbations of respiratory failure

Eric L. Matteson2; Alexandra Messerli1. 1Mayo Clinic School of Graduate Medical

CASE: A 28 year-old healthy woman presented with 4 days of progressive dyspnea. She

Education, Rochester, MN; 2Mayo Clinic, Rochester, MN. (Control ID #2462385)

had associated fever, chills, malaise, cough with productive sputum, congestion, and myalgias. She had been hospitalized 2 weeks prior with similar symptoms. Her symptoms

LEARNING OBJECTIVE #1: Recognize clinical presentation of macrophage activa-

had resolved prior to discharge without any treatments and her work-up was negative for

tion syndrome and identify appropriate diagnostic evaluation

pulmonary embolism. Her vital signs were notable for a heart rate of 120 beats per minute,

CASE: A 38 year-old woman with past medical history of asthma and ulcerative colitis

blood pressure of 126/95, respiratory rate of 38 breaths per minute, with a 97 % oxygen

presented with fever, nausea/ vomiting, abdominal pain and elevated liver enzyme tests

saturation on 21 % FiO2. She was diaphoretic with respiratory distress, accessory muscle

2 weeks after a second infusion of infliximab. The day after the infusion she developed

use, and had fine bibasilar crackles. Labs revealed hypoxia and leukocytosis but were

headache, dizziness, nausea, dry heaves and fever to 103 °F. Her symptoms progressed to

negative for influenza and HIV. The chest X-ray revealed diffuse opacities in all lobes with

include epistaxis, cough productive of blood-tinged sputum and tea-colored urine. On

small bilateral pleural effusions. The patient was treated for presumed atypical bacterial

initial evaluation at our facility, temperature was 39.4 °C, with tachycardia, tachypnea and

pneumonia and improved to baseline within 24 h of hospitalization. She was discharged

oxygen saturation of 94 % on room air. Physical exam was notable for mild scleral icterus,

but returned 5 days later with worsening tachypnea, hypoxia, tachycardia, and leukocy-

right upper quadrant tenderness with smooth hepatomegaly nearly to the umbilicus and

tosis. She was admitted to the intensive care unit for hypoxic respiratory distress and was

scattered lower extremity petechial rash. Complete blood count revealed mild leukocytosis

treated with Bipap and antibiotics. CT scan revealed innumerable centrilobular nodules.

with lymphocytic predominance and normal hemoglobin. Alkaline phosphatase (931 U/L,

This time the patient did not respond to antibiotics. Blood and respiratory cultures,

nl 37–98 U/L), AST (559 U/L, nl 8–43 U/L), ALT (409 U/L, nl 7–45 U/L), and total and

influenza PCR, and PCP and induced AFB sputum smears were negative. The immuno-

direct bilirubin (2.9 and 2.5 mg/dL, nl 0.1–1.0 mg/dL and 0.0–0.3 mg/dL, respectively)

deficiency panel was non-revealing. The patient was treated empirically for PCP pneu-

were all elevated; prothrombin time was normal. Computed tomography (CT) and

monia with bactrim and steroids and in 4 days, she returned to baseline and was discharged

ultrasonography of the abdomen revealed hepatomegaly without evidence of acute cho-

again without oxygen. She developed respiratory distress for a fourth time, 2 days after

lecystitis, and she was admitted with a diagnosis of acute hepatitis. The patient remained

finishing the steroid taper and was readmitted to the intensive care unit. She quickly

febrile over the next 10 days. Liver test abnormalities worsened with development of frank

responded to prednisone. Sputum AFB cultures became positive on day eight for a rapid

jaundice on day 4. Dyspnea and hypoxia worsened with progressive patchy pulmonary

grower. A bronchoscopic alveolar lavage and transbronchial biopsy revealed a moderate

opacities on chest radiograph. Initial infectious evaluation, including blood cultures and

lymphocytosis and ill defined non-caseating granulomas with clusters of acid-fast bacilli

serologies/PCR for hepatitis A, B, C, and E, Epstein-Barr virus, cytomegalovirus, HIV,

consistent with Mycobacterium Avium Complex. It was determined that she had devel-

HSV, VZV and syphilis, was negative. Clinical and serologic evaluation for autoimmune

oped hypersensitivity pneumonitis with underlying MAC after using a new humidifier at

hepatitis or lupus was also negative. Ferritin was markedly elevated at 17,810 mcg/L (nl

home. She was able to stop steroids after removing the humidifier from her home.

11–307 mcg/L). The erythrocyte sedimentation rate (ESR) was 3 mm/1 h (nl 0–29 mm/

DISCUSSION: If left undiagnosed, extrinsic allergic alveolitis can be a life-threatening

1 h), with C-reactive protein (CRP) elevated at 104.6 mg/L (nl 2400 U/mL. Management consists of supportive measures,

associated lactic acidosis. Despite findings that lactate levels have not been significantly

elimination of the inflammatory trigger and suppression of inflammation by immunosup-

impacted in patients with mild to moderate kidney disease that are taking metformin, this

pressive and/or cytotoxic drugs. As this case demonstrates, the cornerstone of treatment is

patient had severe renal impairment and was on hemodialysis. His metformin consump-

identification and treatment of the underlying cause, including evaluation for opportunistic

tion proved nearly fatal. The transition home following hospital admission is a vulnerable

infections in immunosuppressed patients. Prompt recognition and treatment is required, as

period for patients. Nearly half of hospitalized patients experience at least 1 medical error

estimated mortality for this condition approaches 40 %. Reference: Ramos-Casals M,

upon discharge. In one case study, post discharge injuries ranged from laboratory abnor-

Brito-Zerón P, López-Guillermo A, et al. Adult haemophagocytic syndrome. The Lancet;

malities to permanent disabilities. Many of the preventable or ameliorable injuries were

383: 1503–1516. DOI: 10.1016/s0140-6736(13)61048-x

results of ineffective communication, including errors reviewing medication regimens (Forster 2003). Adverse drug events, or injury due to medication, affect 11 to 17 % of patients during the first weeks after hospital discharge. In this case, the patient received


erroneous instructions to restart metformin after his prior hospital discharge, which


resulted in his admission for metformin associated lactic acidosis. REFERENCES

New Haven Hospital, New Haven, CT. (Control ID #2467919)

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Ann Intern Med.

LEARNING OBJECTIVE #1: Recognize metformin associated lactic acidosis

2003;138:161–167. doi:10.7326/0003-4819-138-3-200302040-00007 Inzucchi SE,

LEARNING OBJECTIVE #2: Improve medication reconciliation at hospital discharge

Lipsaky KJ, et al. Metformin in Patients with Type 2 Diabetes and Kidney Disease: A

to avoid adverse medical events

Systemic Reivew. JAMA. 2014; page, 2668–2675.

CASE: A 68-year-old man with Diabetes Mellitus, Peripheral Vascular Disease, and End Stage Renal Disease (ESRD) on hemodialysis for 1.5 years presented with lethargy and back pain for 1 week. In the Emergency Room, he was found to have temperature: 86 °F,


blood pressure: 82/54 mmHg, heart rate: 30 bpm. Finger stick glucose was 7 mmol/L.

MULTISYTEMIC SYMPTOMS Sinny Wang1; Margaret Park1, 2. 1UCLA Medical

His point of care venous blood gas showed: pH: 6.72, pCO2: 22 mmHg, lactate:

Center, Los Angeles, CA; 2Kaiser Permanente-Oakland Medical Center, Oakland, CA.

>20.0 mmol/L. His labs were also significant for potassium: 5.7 mEq/L, creatinine:

(Control ID #2470085)

7.6 mg/dL, white blood cell count: 32.8 × 103/mm3, and thyroid stimulating hormone: 4.45 μU/mL. His anion gap was too high to determine on admission, but was measured

LEARNING OBJECTIVE #1: Identify the presenting features, risk factors and preva-

to be 49 the next day. He was intubated, and started on broad-spectrum antibiotics and

lence of anorexia nervosa in a male patient

vasopressors. The differential diagnosis included: septic shock, myxedema coma, ische-

LEARNING OBJECTIVE #2: Manage eating disorders as a general internist

mic cardiac event, and hemorrhagic shock from patient’s past history of repaired abdom-

CASE: 25-year-old male with history of unexplained hypogonadism, hypothyroidism,

inal aortic aneurysm (AAA). However, a CT chest/abdomen/pelvis was negative for

pancytopenia, and asymptomatic sinus bradycardia presents to hepatology clinic for evalu-

evidence of acute inflammatory process, a trans-thoracic echocardiogram was negative

ation of transaminitis than began 4 years ago. He had undergone extensive prior work up

for focal wall motion abnormalities, and an abdominal ultrasound was negative for

including liver biopsy (lobular hepatitis with minimal activity), bone marrow biopsy

ruptured AAA. Blood cultures showed no growth. He was on norepinephrine and

(hypocellular marrow with serous fat atrophy), fat pad biopsy (depletion of fatty tissue,

dopamine drips at this time, and was maintaining adequate blood pressure with mean

negative stain for amyloidosis), transthoracic echocardiogram (aortic root dilatation without

arterial pressures >65 mmHg. Considering his low vasopressor requirement and high

other dysfunction), and whole body PET CT (no foci of increased metabolism). Despite

lactic acidosis, the team began to consider Type B lactic acidosis as the primary etiology

negative serologies, he was presumed to have autoimmune hepatitis and was empirically

causing the patient’s hemodynamic instability. Upon further chart review it was deter-

treated with steroids with some improvements. Prior to his illness, he was reportedly healthy

mined that the patient had been admitted 1 month prior with colitis, treated with

and was a competitive athlete in an elite college program. He had been taking testosterone

antibiotics, and discharged with instructions to restart metformin, which had previously

and levothyroxine, and had stopped steroids due to psychiatric side effects. He does not

been discontinued secondary to his severe renal disease. Metformin associated lactic

smoke and does not use any illicit drugs. Review of systems is remarkable for fatigue,

acidosis became the most likely diagnosis. Continues veno-venous hemodialysis was

frequent infections. He also had unintentional weight loss of 45 lb in 4 years, despite rigidly

emergently started and his lactic acid downtrended immediately and normalized after

adhering to a regimented diet of >5000 kcal daily. To cope with his depression and anxiety,

3 days. He was transitioned to conventional hemodialysis and extubated. His metformin

he exercises 6–7 h daily. On exam he appeared cachectic with body-mass index (BMI) of




14.8, significant bitemporal and total body muscle wasting with trace lower extremity

LEARNING OBJECTIVE #1: Recognize the signs and symptoms of malignant pleural

edema. He did not exhibit signs of chronic liver disease. Patient had a withdrawn affect

mesothelioma as a rare cause of hemorrhagic pleural effusions.

despite constant fidgeting. Labs showed hyponatremia (127 mmol/dL); non-obstructive

CASE: A 56 year old male presented with a recent history over the last month of recurrent

transaminitis (AST 171 U/L, ALT 123 U/L) with elevated total bilirubin (3.2 mg/dL);

left hemorrhagic pleural effusion of unclear etiology. He was admitted to our hospital with

pancytopenia with normocytic anemia (hemoglobin 11.8 g/dL). He underwent repeat liver

a leaking chest tube in place after hospitalization in Tijuana. The patient’s past medical

biopsy, showing nodular regenerative hyperplasia without features of autoimmune or

history included COPD, atrial fibrillation, hypertension, Type II diabetes mellitus and

infectious liver disease. Upon recognition of his underlying anorexia nervosa (restrictive

latent TB status post INH therapy. Social history was significant for current 5 year

type with compulsive exercise) complicated by multisystem medical issues, patient was

employment as a machine worker in an aluminum factory and history of an 11-year

transferred to inpatient Psychiatry/Eating Disorder Unit (EDU) for further care. His course

employment in construction work. The patient was a light smoker for 2 years and quit

was complicated by refeeding syndrome while in EDU. He also was also diagnosed with

10 years prior. The patient initially presented 1 month prior to another hospital for acute

comorbid psychiatric conditions including major depressive disorder and obsessive-

respiratory failure secondary to a left pleural effusion; 2 l of hemorrhagic fluid were

compulsive disorder. He eventually refused the recommended transfer to higher level of

drained via thoracentesis and the patient was discharged home. Approximately 2 weeks

care at a dedicated male eating disorder facility. He transitioned to outpatient internal

later, while vacationing in Tijuana, Mexico, the patient again developed severe dyspnea

medicine clinic for close medical supervision and refused further inpatient psychiatric

and was admitted for recurrent left pleural effusion. Tube thoracostomy was performed


and 4 l of hemorrhagic fluid were drained. The patient was discharged from the hospital in

DISCUSSION: Diagnostic and Statistical Manual of Mental Disorders, 5th edition

Tijuana with a water-sealed chest tube in place and was promptly brought to our hospital.

(DSM-5) defines feeding and eating disorders (ED) are a group of disorders character-

Upon presentation, the patient was admitted for chest tube evaluation for leakage and

ized by persistent disturbance in eating behaviors. Despite some common features, these

found to have a pneumothorax with subcutaneous emphysema of the left chest and

heterogeneous diagnoses differ significantly in their outcomes and treatments.

serosanguinous fluid draining from the chest tube. Physical exam was significant for

Specifically, Anorexia Nervosa (AN) is a disorder of “restriction of energy intake

crepitus localized at the tube insertion site, decreased breath sounds and a pleural rub in the

relative to requirements,” with “persistent behavior that interferes with weight gain…

left posterior lung field and an irregularly irregular heart rhythm. Lab findings demon-

lack of recognition of the seriousness of the current low body weight.” AN is generally

strated normal electrolytes, renal and liver function with the exception of reduced serum

thought of as predominantly affecting young females, with an estimated 12-month

albumin (2.6 g/dL). Serum LDH 237 U/L and protein total 6.6 g/dL. Pleural fluid analysis

prevalence of 0.4 %. In comparison, minimal data exist for its prevalence among males,

revealed glucose 88 mg/dL, LDH 251 U/L, and protein 2.9 g/dL, while fluid cytology

but clinic populations estimate approximately 10:1 female-to-male ratio. Studies focus-

revealed brown turbid fluid with few eosinophils, elevated WBC 846 with 68 % lympho-

ing on male patients diagnosed with ED have been limited by sample size and study

cytes and macrophages, and RBC count of 26076; no malignant cells were identified.

methods. In general, the majority of male patients presenting for care had very low BMI

Blood and pleural fluid cultures were negative. A chest radiograph and CT with contrast

percentile for age (0.5. Given evidence of serosal involvement (exudative

significantly below 4 mg/dl. Measuring ionized serum calcium, as was done in this case,

ascites and pleural fluid), constitutional symptoms, anemia, leukopenia, and persistent sub-

is accurate and is not affected by the total albumin level. The standard of care is to replace

nephrotic proteinuria, we were suspicious of systemic lupus erythematosus (SLE). Further

calcium aggressively if the patient is symptomatic (carpopedal spasms, tetany, seizures or

rheumatologic work-up revealed a + ANA 1:80 (speckled pattern), low complements (C3 of

a prolongted QT interval) or if the ionized calcium is 300 mg/dL. Whole body PET scan revealed hypermetabolic activity in the

done with tissue plasminogen activator (tPA). After complete thrombolysis a metallic

following organs: bilateral lacrimal glands, retrobulbar right orbital apex and ocular

stent was deployed in Left common and external iliac vein to correct the anatomical

muscles, extensive cervical, thoracic, abdominal and pelvic lymphadenopathy, soft tissue

defect. She had uneventful recovery and was discharged home on coumadin for

in bilateral renal pelvises and right middle lobe in the lung. Patient was started on

6 months.

prednisone 40 mg daily for treatment of IgG4-related disease. The patient was also

DISCUSSION: May-Thurner syndrome (MTS) is an anatomical defect described as

incidentally found to have rectal adenocarcinoma and underwent transanal excision of

external compression of left common iliac vein by right common iliac artery against

the rectal polyp.

fifth lumbar vertebrae. Long standing compression leads to intimal fibrosis with

DISCUSSION: IgG4-related sclerosing disease is a fibroinflammatory condition that is

venous spur formation resulting in venous stasis & thrombosing tendency as per

characterized by dense lymphoplasmacytic infiltration consisting of IgG4-positive plas-

Virchow’s triad. MTS has a reported prevalence of 22–34 % in cadaveric studies,

ma cells organized in a storiform pattern, obliterative phlebitis, eosinophil infiltration,

however, only 2–3 % of overall left lower extremity DVTs are reported as MTS

and at times, elevated IgG4 serum concentrations. The disease process has been

related. A reason for such under diagnosis is probably because patients often have

described in almost every organ system, linked by the same histopathological charac-

easily identifiable risk factors and work up is generally stopped once the diagnosis of

teristics, and usually presents subclinically. Clinical pathology can include but is not

DVT is confirmed. MTS in our case too was a completely unanticipated incidental

limited to lymphadenopathy, autoimmune pancreatitis, chronic sclerosing dacryoadenitis

diagnosis. MTS related DVTs are commonly associated with excessive clot burden

and sialadenitis. About 40 % of patients also have symptoms of asthma or allergies.

which increases the risk of emolism, compartmental syndrome and post-thrombotic

Given this varied presentation and little information on this entity, it was often not

syndrome. Because of excesive clot burden and associated risks treatment of MTS

placed on the differential. Diagnosis is made through tissue biopsy and the presence of

related DVTs require catheter directed thrombolysis (CDT) along with anticoagulation.

defining pathological characteristics. No optimal treatment has been established, while

After completion of thrombolysis anatomical defect i.e. luminal narrowing caused by

the international consensus among experts agrees that glucocorticoids are the first line

venous spur and external compression by artery should be recanalized with venous

treatment. Most patients have been shown to improve clinically within weeks. B-cell

stenting. This is followed by maintenance anticoagulantion for 6 months like provoked

depletion therapy with rituximab has been effective in cases refractory to glucocorti-

DVTs. CDT and Venoplasty has good immediate and intermediate term outcome.

coids in case series, but has not been studied in randomized trials. Interestingly, some

Venous stent patency rate is reported as high as 83 % at the end of 1 year. Failure to

studies have shown increased risk of malignancy in patients with IgG4-related disease,

correct anatomical defect predisposes recurrent DVTs, PE and even iliac vein rupture.

especially in the year after diagnosis. IgG4-related sclerosing disease is an increasingly

Given the prevalence and promising outcome of endovascular treatment, May-Thurner

recognized disorder, which affects multiple organ systems. Due to its non-specific

syndrome should be sought for in unprovoked left lower extremity DVTs especially in

presenting symptoms, diagnosis is often challenging, leading to possible disease

the absence of thrombophilia and risk factors.





of dextrose during hospitalization. Biochemical tests to evaluate hypoglycemia showed

THROMBOSIS Nabeel Siddiqui; Ubaid Sherwani. Presence Saint Francis Hospital,

low insulin, low C- peptide, low IGF-I and normal cortisol levels at time of hypoglycemia

Evanston, IL. (Control ID #2469926)

which was consistent with consumptive mechanism. He was started on alpha-adrenergic blockade with doxazosin; hydrocodone for pain control and bowel regimen was maxi-

LEARNING OBJECTIVE #1: To consider rare causes of Deep Venous Thrombosis

mized with inclusion of polyethylene glycol, docusate, lactulose and magnesium citrate.

such as May-Thurner Syndrome in young patients with no identifiable etiology

Despite maximal medical treatment the catecholamine excess resulted in worsening of

LEARNING OBJECTIVE #2: To recognize the role of stent placement as a means of

hypoglycemia, ileus and abdominal pain. His symptoms necessitated urgent chemother-

treating May-Thurner Syndrome

apy, surgery was not indicated due to hyper-vascularity of the tumor. He received

CASE: A 20-year-old female presented to the hospital with left lower extremity pain and

cyclophosphamide, vincristine, dacarbazine. Two days after initiation of chemotherapy

swelling for 1 week. The swelling was initially in her foot and traveled up to her thigh, and

patient was able to pass flatus. After completion of 3 cycles, ileus improved and patient

the pain made her unable to ambulate. She denied any recent immobilization, travel or

had a bowel movements. Even though the patient improved symptomatically, considering

limb trauma. She reported oral contraceptive use and history of smoking one cigarette

the poor prognosis of his malignant pheochromocytoma, he opted for palliative care and

daily each for the past 1 year. She denied any history of blood clots and her family history

had a PEG tube placed for nutrition and hypoglycemia.

was insignificant. She had stable vital signs. On exam, she had unilateral pitting edema in

DISCUSSION: Malignant pheochromocytoma is a rare disease. Paralytic ileus, megacolon and

her left lower extremity up to the thigh, and tenderness to palpation in left posterior leg. D-

refractory hypoglycemia are it’s rare and life threatening complications. Typical presenting

Dimer was elevated at 7.2. Her coagulation profile and other tests for hereditary throm-

symptoms of pheochromocytoma include hypertension, anxiety attacks and palpitations. Ileus

botic disorders were normal. Ultrasound venous duplex identified a blood clot from the

and megacolon are unusual presentations of pheochromocytoma. The physiology behind this

calf extending cephalad proximal to the femoral head, confirming the presence of DVT.

complication is proposed to be secondary to excess amount of catecholamine secretion by the

She was started on anticoagulation with therapeutic enoxaparin. To prevent clot emboli-

tumor. The elevated catecholamines in pheochromocytoma can lead to constipation affecting up to

zation, inferior vena cava filter (IVC) was placed. Moreover, tissue plasminogen activator

13 % of the patients. Improvement of gastrointestinal manifestations of pheochromocytoma by

was infused through a catheter in the left iliac vein. However, her pain persisted. CT

use of an alpha blockers indicates catecholamines may indeed be involved to cause constipation,

angiogram showed extensive thrombus within the left common iliac vein, left external

paralytic ileus or megacolon. Catecholamines affect glucose homeostasis through both alpha and

iliac vein and left femoral vein. There was also found to be narrowing in the distal aspect

beta receptors. Habra et al. proposed that the cause of hypoglycemia might be related to rapid

of left common iliac vein secondary to compression from a crossing left common iliac

consumption of glucose. The findings in this case with low insulin, C peptide are consistent with

artery. This suggested the diagnosis of a variant of May-Thurner Syndrome. She

this hypothesis. Malignant pheochromocytoma should be considered into differential diagnosis of

underwent placement of stents in left common iliac vein and left iliac vein at level of

unusual cases of megacolon or refractory hypoglycemia as illustrated in this case.

pelvic rim. Eventually, her symptoms of pain and swelling resolved with the preceding interventions. Her IVC filter was removed, and she was started on warfarin. Once cinically stable, she was discharged with follow up arranged with her hematologist.


DISCUSSION: May-Thurner syndrome is a rare condition usually involving compres-

Harsha Mudrakola. Baylor College of Medicine, Houston, TX. (Control ID #2470015)

sion of the left common iliac vein by the overlying right common iliac artery, however, other variants like the one in our patient also exist. This can result in stasis of blood,

LEARNING OBJECTIVE #1: Recognize the risk of electrolyte abnormalities and their

leading to thrombosis. Vascular ultrasound or CT angiogram are used to establish the

sequelae in patients dependent on tube feedings

diagnosis. Treatment is based on angioplasty and stenting of iliac vein. Our case demon-

LEARNING OBJECTIVE #2: Recognize the risk of patient morbidity with lack of

strates that one should consider rare causes of DVT such as May-Thurner syndrome in

proper communication with patients and their families

young patients with no other identifiable causes. Thorough investigation and imaging can

CASE: A 64 year old female with recently diagnosed tonsillar squamous cell carcinoma

help identify the condition, and hence, prevent re-thrombosis in such patients.

was brought in by her family due to altered mentation. The patient had been diagnosed 3 months prior and was subsequently started on chemotherapy with cisplatin and concomitant external radiation therapy (XRT). 1 month prior to presentation, the patient


developed mucositis and severe dysphagia. A percutaneous endoscopic gastrostomy

Manne; Hardik Satashia; Ashwini Sharma. UAB Montgomery, Montgomery, AL.

(PEG) tube was placed and the patient was placed exclusively on tube feeds. Over the

(Control ID #2470337)

following month, the patient’s family reported that she became more lethargic, confused, and weaker. On examination, the patient was lethargic and somnolent. She was

LEARNING OBJECTIVE #1: We present a case of pheochromocytoma who presented

afebrile, but had dry mucous membranes and was tachycardic. Neurological exam

with megacolon, resistant hypoglycemia and was managed successfully, novel strategy

revealed intact cranial nerves and global weakness, but it was without focal deficits.

with use of chemotherapeutic drugs.

Laboratory abnormalities included a sodium of 181, chloride of 134, bicarbonate of 33,

CASE: A 42 year old male with no significant past medical history presented with

blood urea nitrogen (BUN) of 53, creatinine of 1.2, and glucose of 182. Urine

6 months history of gradual worsening of right upper quadrant abdominal pain. He was

osmolality was mOsm/kg. Computed tomography (CT) of the brain did not reveal

unable to tolerate food for past 2 days and had lost 10 lbs in past 2 weeks. On physical

any abnormalities. The patient’s symptoms were attributed to her severe hypernatremia.

exam he had abdominal tenderness with guarding but no rigidity, heart rate of 120, rest of

The etiology was lack of sufficient free water wit her tube feeds. During the previous

vitals were normal. Radiograph of the abdomen showed megacolon. Computed tomog-

hospitalization, the patient was prescribed 150 cc of Nutren 2.0 every 4 h along with

raphy revealed a right adrenal mass measuring 15 × 13 × 19 cm with necrosis and cystic

free water flushes of 200 cc every four hours. The patient’s husband had never received

changes, necrotic retroperitoneal lymphadenopathy and hepatic hypodensities.

explicit tube feeding instructions and had been giving the patient feeds three times a day

Biochemical tests showed elevated levels of plasma normetanephrine, metanephrine and

without any free water. Her calculated free water deficit was 11.5 l. The hypernatremia

chromagnin A. Patient also had persistent hypoglycemia and required continuous infusion

was corrected with intravenous infusion of D5W and free water via the PEG tube at a




rate of 8–10 meq/L per day. The patient’s symptoms resolved completely upon correc-

Syndrome. Treatment starts with controlling the hormone-excess state to attenuate clinical

tion of her serum sodium.

symptoms. Treatment must also target the tumor itself, and can include traditional

DISCUSSION: Encephalopathy due to metabolic disturbances is common in patients

chemotherapy, somatostatin analogs, mTOR and tyrosine kinase inhibitors, and hepatic

with cancer. Hypernatremia typically does not cause symptoms, but in this patient it was

arterial chemoembolization. Given the unpredictable nature of NETs, as in our patient’s

profound enough to do so. Correcting the hypernatremia should be done gradually—no

case, it is important for clinicians to anticipate that new symptoms in a NET patient may

more than 10–12 meq/L per day—to avoid cerebral edema and the resulting sequelae. The

herald new hormone production or worsening metastatic disease.

free water deficit can be easily calculated to find out exactly how much extra water the patient requires. The most common etiology of hypernatremia is the inability to replace free water losses from the skin, gastrointestinal tract and kidneys. This inability arises from


a pre-existing condition precluding enough water intake—dementia, delirium, intubation/

Osman Bhatty; Karishma Bhatia. Creighton University, Omaha, NE. (Control ID

sedation in the ICU setting etc. It may also be as simple as lack of proper communication


with patients and their families as in this case. This case demonstrates the importance of properly educating patients in addition to properly managing their illnesses.

LEARNING OBJECTIVE #1: Recognize a rare radiological manifestation of prostate cancer metastases CASE: A 76 year old male with past medial history of hypertension, gastroesophageal


reflux disease, colonic tubular adenoma and chronic low back pain presented to the

CUSHING’S SYNDROME Andrew P. Scatola2; Virginia O. Volpe1; Amy Kost2.

emergency department with new onset dyspnea on exertion for 3 day’s duration. He


denied any associated cough, fevers, chills, lower extremity swelling and prior respiratory

Medicine, Farmington, CT. (Control ID #2467858)

or cardiac problems. His other complaint was worsening of chronic low back pain that he

University of Connecticut, Farmington, CT; 2University of Connecticut School of

was experiencing some relief of with acetominophen. This was an ongoing issue but at the LEARNING OBJECTIVE #1: Recognize and treat neuroendocrine tumors presenting

time he felt it had acutely worsened over the past few weeks. Other history was significant

as Cushing’s Syndrome

for alcohol use (one drink a day) and chewing tobacco. Physical exam was noncontrib-

LEARNING OBJECTIVE #2: Appreciate that pancreatic neuroendocrine tumors can

utory and review of systems was unimpressive. Patient’s workup revealed D dimer grossly

transform hormone production

elevated to about 1100 along with a marked elevation in alkaline phosphatase as well as

CASE: A 37 year old male presents to clinic with new onset proximal weakness and

gamma glutamyl transferase. Mild elevation in aspartate transferase, alanine transferase

hypertension. The patient was diagnosed 18 months ago with metastatic neuroendocrine

and total bilirubin was also noted. He was admitted for workup of his hypoxia of unknown

tumor (NET) of the head of the pancreas following a work-up for unexplained jaundice.

etiology and elevated liver enzymes. CT-Angiogram revealed no thromboembolic disease.

Biopsy revealed that the NET produced. proinsulin, gastrin and chromagranin A. Initial

The liver was visualized and had an appearance consistent with chronic liver disease. A

symptoms were minimal, except for pain from liver metastases. He had a positive

right upper quadrant ultrasound of the abdomen showed findings that corresponded to

octreotide scan and was started on long-acting octreotide depot and everolimus, which

fatty liver disease. Due to the elevation of gamma glutamyl transferase liver specific

lead to normalization of his fasting gastrin, proinsulin and chromagranin A. Cortisol and

etiology was higher in the differential and thus a hepatitis panel, acetaminophen and

ACTH levels were normal at that time. A surveillance octreotide scan was suspicious for

alcohol level were ordered which were all negative. Gastroenterology service was then

increased uptake in his liver metastases, however there were no new metastatic lesions. A

consulted and a MRCP was done which showed innumerable hepatic metastases and

month after the repeat scan, he was found to have the aforementioned findings, new

multifocal retraction of the capsule consistent with pseudocirrhosis/carcinomatous cirrho-

hyperglycemia and a serum potassium of 2.5 mEq/L. An evening cortisol and ACTH were

sis appearance of the liver. PSA was then checked which was markedly elevated and a

elevated at 44 mcg/dL (3–12 mcg/dL) and 225 pg/mL (7–69 pg/mL) respectively. Due to

bone scan was ordered considering his history of worsening back pain. His results showed

concern for Cushing’s Syndrome, he underwent an 8 mg dexamethasone suppression test,

multiple regions of uptake (ribs, hips, femur, pelvis, spine). A diagnosis of metastatic

with cortisol and ACTH remaining unchanged. MRI of the brain revealed no pituitary

prostate cancer was thus made.

lesions, and MRI of the abdomen revealed new liver metastases with no changes in his

DISCUSSION: Pseudocirrhosis or metastatic carcinomatous cirrhosis refers to a radio-

prior lesions. Given this and the non-suppression of the dexamethasone test, it was felt

graphic finding that resembles macronodular cirrhosis, but in which histopathological

these new metastatic lesions were responsible for his ACTH production and Cushing’s

specimens fail to show the typical findings of cirrhosis. This condition has been observed

Syndrome. He was started on metyrapone in order to prevent further symptom develop-

in patients with cancer metastatic to the liver, both in those who have undergone prior

ment and he experienced normalization of his serum cortisol.

systemic chemotherapy and those who have not. Pseudocirrhosis has been most widely

DISCUSSION: Pancreatic NETs are rare, with an incidence of 1–5 cases per million

described with metastatic breast cancer, however, cirrhotic changes have also been reported

population. The most common types are insulinomas, gastrinomas and non-functional

in hepatic metastasis of a variety of cancers, including pancreatic cancer, esophageal cancer,

tumors, while primary ectopic ACTH producing NETs are exceedingly rare. The term

small-cell lung cancer, and thyroid cancer. Here we describe, to the best of our knowledge

nonfunctional is misleading since most of these tumors produce peptides but not a clinical

the first reported case of prostate cancer with metastasis to the liver with radiographic

syndrome. Symptoms typically only arise as a physical consequence of the tumor itself.

appearance of pseudocirrhosis. The radiographic features of pseudocirrhosis are similar to

Due to severe symptoms, functional tumors usually present early with a small primary

liver cirrhosis: nodularity of the liver contour with capsular retraction, decreased size of the

tumor, while nonfunctional NETs present later with invasive tumors and metastatic

liver, diffuse heterogeneity associated confluent fibrosis, and enlargement of the caudate

lesions. NETs may produce one or more hormones and their clinical course may be

lobe. In our patient ultrasound of the right upper quadrant revealed cirrhotic appearance of

unpredictable. Reports exist of new metastatic lesions with de novo ACTH secretion,

the liver, computed tomography suggested abnormal liver morphology representing chronic

which have even occurred years after initial resection of a non-ACTH secreting, non-

liver disease and magnetic resonance cholangiopancreatography demonstrated markedly

metastatic primary tumor. This suggests that metastatic lesions can dedifferentiate and are

heterogeneous liver with surface nodularity and multifocal retraction of the capsule com-

principally responsible for ectopic ACTH secretion and development of Cushing’s

patible with pseudocirrhosis secondary to metastatic disease. The precise mechanism




underlying development of pseudocirrhosis remains unclear. Based on previous studies,

previously in cases of heat strokes. This made acute myocardial infarction a less likely

pseudocirrhosis occurs in cases in which hepatic histopathology shows evidence of extensive

cause of shock, and cardiac catheterization was not deemed necessary especially in the

fibrosis representing a profound desmoplastic response to the infiltrating tumor, which is

face of ongoing sepsis and multi-organ failure. While both hyperthermia and high doses of

potentially related to an altered expression pattern of adhesion molecules. Despite its name,

amphetamines are cardio-toxic, their combination may have a synergistic effect on

‘pseudocirrhosis’, its clinical significance is equivalent to that of ‘true’ liver cirrhosis as it can

myocardial injury. More studies are needed to fully elucidate mechanisms and potential

cause hepatic decompensation and complications of portal hypertension, such as hepatic

cardiovascular effects of the combination of amphetamines and hyperthermia. This case

encephalopathy and variceal bleeding and have an effect on prognosis. Therefore, these

highlights that methamphetamines and hyperthermia can be a fatal association and more

patients should be monitored carefully for progression of hepatic failure.

awareness is needed among the people to prevent future episodes. 1. Darke S, et al. Major physical and psychological harms of methamphetamine use. Drug Alcohol Rev. 2008, 27: 253–262. 2. Turdi S, et al. Acute methamphetamine exposure inhibits cardiac contractile


function. Toxicol Lett. 2009, 189: 152–1528. 3. Volkow ND, et al. Distribution and

VEGAS: A DEADLY COMBINATION! Simran Kaur B. Matta. University of

pharmacokinetics of methamphetamine in the human body: Clinical implications. PLoS

Nevada School of Medicine, Las Vegas, NV. (Control ID #2470259)

One. 2010, 5 (12): e15269-10.137. 4. Suffredini A, et al. The cardiovascular response of

LEARNING OBJECTIVE #1: To understand the effects of methamphetamines and

Hausfater P, et al. Elevation of cardiac troponin I during non-exertional heat-related

hyperthermia on cardiovascular system

illnesses in the context of a heatwave. Crit Care. 2010;14(3):R99. 6. Wakino S, et al. A

LEARNING OBJECTIVE #2: To identify that the two may potentiate the effect of each

case of severe heat stroke with abnormal cardiac findings. Int Heart J. 2005

other and worsen the outcome


normal humans to the administration of endotoxin. N Engl J Med 1989; 321:280–87 5.

CASE: A 20-year-old male with no known past medical history was brought in from Electric Daisy Carnival in Las Vegas. He had seizures for 15 min and had to be intubated at the field for airway protection. His core temperature was as high as 108.7° Fahrenheit. The


EKG obtained in the ER showed diffuse ST-T depressions. He had been tachycardic in

Michelle L. Kraslow2; Ryan Nall1. 1University of Florida, Gainseville, FL; 2University of

140–160 s but maintained a stable BP initially. Pertinent labs: Urine drug screen was

Florida College of Medicine, Gainesville, FL. (Control ID #2468985)

positive for amphetamines. The initial troponin was 0.33 which continued to trend up to 50.00 ng/ml. CK levels were elevated and quickly increased to >40800 U/L. He had a

LEARNING OBJECTIVE #1: Recognize the neurological clinical manifestations of

potassium level of 6.6 mmol/L, bicarbonate of 15 mmol/L and lactic acid of 7.5 mmol/L


The echocardiogram showed global left ventricular dysfunction with an EF of 20–25 %.

LEARNING OBJECTIVE #2: Describe the diagnostic approach to neurosarcoidosis.

Pulmonary catheterization revealed low PCWP, low SVR and a high cardiac index. The

CASE: A 31 year old African American male with no significant past medical history

patient also suffered DIC, shock liver and renal failure. He also developed severe sepsis

presented with a 2 month history of constant headache and a migrating Bell’s palsy. Two

and was on antibiotics for much of his hospital stay. He was on multiple vasopressors. We

months prior to evaluation, patient experienced a facial palsy of his right lower face

continued to provide supportive care and cooling measures to bring the temperature down.

associated with dysarthria of complex words. One week later, he developed a persistent

The patient persistently remained in respiratory failure requiring high FiO2 and PEEP.

headache (8/10 in severity). Additional symptoms included a dry cough, swollen right

Unfortunately he developed cardiac arrest on Day 23 and expired.

preauricular lymph node, right eye blurred vision, and photosensitivity. Three weeks later,

DISCUSSION: Reports of methamphetamine-related emergency room visits suggest that

his left lower face became paralyzed, associated with left eye blurred vision, photosensi-

elevated body temperature is a universal presenting symptom, with lethal overdoses

tivity, and lagophthalmos. As he developed left-sided palsy, he regained motor function in

generally associated with extreme hyperthermia. The mechanisms through which meth-

the right lower face, but noted persistent tingling and numbness. Headache, tinnitus,

amphetamine affects body temperature include both central and peripheral targets. It

dizziness, and left-sided facial palsy continued to presentation. Prior to admission, the

stimulates the HPA axis, increases metabolic activity, pyrogen formation and release,

patient took prednisone to reduce his facial palsy symptoms. He denied seizures, memory

and promotes heat generation and retention while suppressing responses that would

loss, coordination impairments, skin rashes, joint pain, fever, fatigue, shortness of breath,

facilitate heat dissipation. Stimulated alpha- and beta-adrenergic receptors produce hyper-

wheezing, or hemoptysis. On physical exam, patient was alert and oriented. Cranial nerve

tension, tachycardia, hyperthermia, and vasospasm. High catecholamine levels are also

(CN) examination revealed normal bilateral sensation to light touch. Unable to smile on

known to be cardiotoxic. Resulting coronary artery vasospasm and/or atherosclerotic

left, normal movement on right. Right cheek could puff air, but it seeped out of the left side

plaque rupture can cause ACS. Myocardial necrosis and recurrent vasospasm from

of the mouth. Left eye could be pried open. All other cranial nerves intact. Babinski sign

chronic use have been also proposed to result in methamphetamine-induced cardiomyop-

positive in left foot. Exam otherwise unremarkable except for minimal expiratory wheez-

athy1,2,3. Hyperthermia, on its own, has been known to cause cardiac injury. In animal

ing in the right lower lobe. Contrast MRI of the brain revealed a cyst in the corpus

studies, elevation of body temperature to 40° Celcius was associated with increased portal

callosum and enhancement around right Meckel’s cave and right CN VII extending into

and systemic arterial lipopolysaccharide (endotoxin) concentration. Such high levels have

the proximal right mandibular nerve. Chest CT showed bilateral centrilobular pulmonary

been identified to cause pulmonary and systemic edema and cardiac dysfunction4. The

nodules with mediastinal and hilar lymphadenopathy. A fine needle biopsy of mediastinal

exact mechanisms, however, of myocardial injury from hyperthermia remain unclear. The

lymph nodes indicated epithelioid granulomas consistent with sarcoidosis. CSF analysis

degree of troponin elevation has been shown to reflect the severity of heat stroke in rat

revealed elevated protein and leukocytosis (95 % lymphocytes) with normal glucose.

models5. It has been suggested that simple cooling techniques alone may abate the EKG

Infectious workup was negative. Patient was started on 60 mg oral prednisone once daily

changes and lower the troponins since the changes are not always related to a coronary

to be tapered every 2 weeks. Given no improvement at 6 weeks, methotrexate was added

lesion6. However, concurrent amphetamine overdose complicates the case and the possi-

for long-term immunosuppression.

bility of true AMI in such situations cannot be excluded. Our patient had classic hyper-

DISCUSSION: Sarcoidosis is an idiopathic multisystemic non-infectious inflammatory

circulatory hemodynamic profile on pulmonary catheterization as has been reported

disorder characterized by noncaseating granulomas. Only 5–10 % of patients with systemic




sarcoidosis have neurological complications resulting in neurosarcoidosis (NS). However

any acute pathology. Repeat labs on arrival to the medicine floor revealed worsening

post-mortem studies indicate central nervous system (CNS) involvement in up to 25 %,

combined anion gap and non-gap metabolic acidosis with serum bicarbonate 10, chloride

suggesting the underdiagnosis of NS. Clinical diagnosis relies on the Zajicek criteria, which

111, and serum glucose of 78. Venous blood gas showed pH 7.14 and pCO2 51.6, and the

defines the likelihood of a NS diagnosis as definitive, probable, or possible, based on the

patient was visibly distressed, vomiting and diaphoretic. She was treated overnight with

amount of evidence. Noncaseating granulomas in the CNS are the histopathological hall-

intravenous fluid boluses and anti-emetics. Arterial blood gas obtained a few hours later

mark of NS and are the only definitive diagnostic marker, however biopsy of brain

showed pH 7.05, pCO2 26.9, bicarbonate 7, and lactate 1.1. The patient was started on a

parenchyma is highly invasive. Neurosarcoidosis is probable when neurological inflamma-

bicarbonate infusion and transferred to the MICU, where an insulin infusion was initiated.

tion is concurrent with systemic disease and possible as a diagnosis of exclusion when

Repeat labs and arterial blood gas showed resolving metabolic acidosis, and the patient’s

patients present with typical neurological symptoms. Neurosarcoidosis most commonly

nausea and vomiting improved. Her anion gap closed within 24 h, and she was started on

manifests as cranial nerve abnormalities, especially optic (CN II) and facial (CN VII)

weight-based insulin glargine with mealtime lispro. Notably, review of outside records,

neuropathies. Vestibulocochlear (CN VIII) and trigeminal (CN V) neuropathies may also

where the patient received her diabetes care, suggested a diagnosis of latent autoimmune

present, resulting in facial sensory loss, hearing loss, and dizziness. Aseptic meningitis is the

diabetes of adults, or LADA. This form of diabetes is sometimes referred to as late-onset type

next most common neurological sign of sarcoidosis. Patients may less commonly display

1 diabetes due to its common pathogenesis of pancreatic beta cell destruction versus the

hypothalamic-pituitary dysfunction, encephalopathies, seizures, focal deficits due to mass

insulin resistance that characterizes type 2 diabetes.

effect of cerebral lesions, cerebral vasculopathy, and peripheral neuropathies or myopathies.

DISCUSSION: This case illustrates an important cause of euglycemic diabetic

Since no individual non-invasive test is specific for NS, practitioners should utilize a wide

ketoacidosis (DKA) associated with a novel class of oral antidiabetic medications, the

scope of diagnostic tools to confidently differentiate NS from neoplasms, inflammatory

SGLT2 inhibitors. Their mechanism of action is blockade of the sodium-dependent

diseases, and infections. When NS is suspected, contrast enhanced T1-weighted MRI is the

glucose cotransporter in the renal proximal tubules, which is responsible for urinary

most sensitive and preferred diagnostic imaging technique. Basilar leptomeningeal enhance-

glucose reabsorption. This leads to marked glycosuria and polyuria due to osmotic

ment is most often observed on MRI, but other common findings include focal lesions,

diuresis, and it also promotes weight loss without a significant risk of hypoglycemia.

diffuse dural thickening, hypothalamic-pituitary enhancement, and cranial nerve enhance-

Canagliflozin, the first SGLT2 inhibitor to be released, has been on the market in the

ment. Cerebrovascular findings, hydrocephalus, and spinal cord lesions are less common.

United States since 2013, and post-marketing surveillance has led to multiple case reports

CSF analysis may reveal elevated protein or white blood cells, decreased glucose, and

of euglycemic ketoacidosis, mostly in type 1 diabetics. The exact mechanism by which

increased IgG; however, increased sIL2-receptor alpha chain levels >150 pg/mL and

SGLT2 inhibitors are linked to DKA has yet to be fully elucidated, but the number and

elevated ACE are the most specific findings in the CSF for NS. Electromyography may

severity of case reports that have arisen prompted the FDA to issue a warning in

be used to determine peripheral nervous system involvement. Malignancy and infectious

May 2015. Furthermore, this case depicts a clinical scenario in which common heuristics

meningitis can result in MRI and CSF findings similar to NS. Therefore, cytology, flow

were employed, particularly the framing and availability biases. Upon transfer to the ED,

cytometry, and cultures are used to rule out these processes. Lymphadenopathy and nodules

the patient was initially framed as a diabetic with an unknown source of infection; her

on chest, abdomen, and pelvis CT can be indicative of systemic sarcoidosis and add further

headache and back pain were major presenting symptoms because she had been trans-

evidence to the overall clinical and diagnostic picture for neurosarcoidosis.

ferred specifically for an MRI to rule out epidural abscess. Later, the patient’s elevated anion gap, ketonuria, and worsening acidosis with concomitant nausea and vomiting strongly suggested DKA, but her blood glucose was normal. The leading differential

MINDING THE ANION GAP Meaghan S. Roche. Boston University Medical Center,

diagnosis was starvation ketoacidosis in the setting of a viral illness, which was based on

Boston, MA. (Control ID #2454741)

review of available common etiologies of elevated anion gap metabolic acidosis. As the patient’s acidosis worsened, her new medication was investigated further, and the link

LEARNING OBJECTIVE #1: Identify euglycemic diabetic ketoacidosis in an appro-

between SGLT2 inhibitors and euglycemic DKA was discovered. The patient’s brisk

priate clinical context

response to insulin and bicarbonate infusions supported this diagnosis. While this patient

LEARNING OBJECTIVE #2: Recognize common cognitive biases seen in clinical

had a very good outcome, her diagnosis was not obvious or a well-described phenomenon.


It is important to recognize common clinical reasoning “shortcuts” in cases like this one

CASE: A 47-year-old woman with a history of insulin-dependent diabetes, Graves’ disease,

and to re-evaluate both the patient and the clinical data frequently in order to ensure timely

prior spinal fusion surgery with indwelling hardware, and fibromyalgia presented to the ED

diagnosis and correct management.

with complaints of severe low back pain, myalgias, headache, nausea, and vomiting of 2 days’ duration. She smoked one-half pack of cigarettes daily and denied alcohol or illicit drug use. She had not had any recent illnesses or sick contacts. Of note, her diabetes was


poorly controlled despite insulin therapy for the past 8 years, and she had started


canagliflozin, a novel SGLT2 inhibitor, 2 weeks prior to her presentation. She was initially

Jumayli1; Mohamed Hassanein2; Bipinpreet Nagra3. 1Capital Health Regional Medical

seen at an outside ED and transferred for MRI of the lumbar spine given concern for epidural

Center, Plainsboro, NJ; 2Capital health regional medical center, Plainsboro, NJ; 3Capital

abscess. On arrival to the ED, the patient was afebrile, and her vital signs were stable.

Health Medical Center, Trenton, NJ. (Control ID #2470334)

Physical exam was remarkable for an ill-appearing woman without localized pain, tenderness, or focal neurologic deficits. Initial labs were notable for serum bicarbonate of 16,

LEARNING OBJECTIVE #1: Staphylococcus intermedius associated infections are

creatinine 0.76, glucose 152, lactate 0.9, and anion gap of 17. Serum and urine toxicology

very rare in human beings but should always be considered among the differential diagnosis

screens were negative. Venous blood gas revealed pH 7.20 and pCO2 43, and urinalysis

in serious invasive infections, especially among patients who are in close contact with dogs

showed moderate ketones and large glucose. The patient underwent lumbar puncture and

LEARNING OBJECTIVE #2: Canine associated zoonotic disease should always be

lumbar spine MRI, and she was treated with broad-spectrum antibiotics, anti-emetics, and

considered under differential diagnosis especially in patients who are immunocom-

aggressive fluid resuscitation with normal saline. Neither lumbar puncture nor MRI showed

promised and having intimate contact with dogs




CASE: A 60 year old male with a history of diabetes, hypertension, pituitary mass,

DISCUSSION: Moraxella osloensis is a Gram-negative coccobacilli which exists on skin

hypothyroidism and end stage renal disease on dialysis presented with complaints of fever,

and in environment. It can rarely cause invasive infections in pediatric, adult, immune-

transient confusion and lethargy. The patient denied headache, neck pain, change in

competent, or immune-compromised patients. It has been reported to cause bacteremia,

vision, nausea, vomiting, shortness of breath, recent fall, chest pain or palpitations.

osteomyelitis, endophthalmitis, meningitis, endocarditis and septic arthritis. Bacteremia

Patient has been on long term peritoneal dialysis and recently switched to hemodialysis

has also been reported in patients with reactive airway disease or with impetigo. It is

for which he had tunneled dialysis catheter. There were reports of patient maintaining an

usually susceptible to penicillin, cephalosporins and aminoglycosides. Our patient’s likely

intimate contact with his dog, where dog was licking him on several occasion. Patient had

source was the upper respiratory tract or leg impetigo. He was treated with ceftriaxone

temperature of 102 ° F and tachycardia on arrival. Laboratory evaluation showed leuko-

given the reported resistance to penicillin. We could not rule out endocarditis or cervical

cytosis of 18.4 with 16 % bandemia. CT of head showed no change in pre-existing

osteomyelitis, which were still suspected given the clinical findings. Moraxella osloensis

pituitary mass and chest X-ray was normal. Blood cultures returned positive for

bacteremia could be serious. The source should be investigated extensively since M.

S. intermedius and therefore transesophageal echocardiogram was done which showed a

osloensis could cause many infections. It might be associated with upper respiratory or

mobile vegetation which was attached to the posterior mitral leaflet measuring approxi-

skin infections as seen in this case. Physicians should be aware of this organism as a cause

mately 18 mm. The patient was initially started on nafcillin resulting in a significant

of bacteremia in order to seek the appropriate consultation.

improvement in his condition. The patient was eventually discharged on cefazolin during which time he was asymptomatic and repeat blood cultures were negative for the microorganism


DISCUSSION: Zoonotic diseases are those that can be transferred between animals and


humans. The CDC estimates that more than 6 out of every 10 infectious diseases in

Nicoletta Machin; Rahul A. Parikh. UPMC, Pittsburgh, PA. (Control ID #2466523)

humans are spread from animals; fortunately the numbers are low in North America. The risk in humans becomes greater with immunosupression. Skin and oral flora of dogs

LEARNING OBJECTIVE #1: Hormonal evaluation to determine etiology of Cushing

harbor various pathogenic microorganisms including Staphylococcus intermedius. Case


reports of human infections from this microorganism are relatively rare, but the true

LEARNING OBJECTIVE #2: Diagnosis and management of secretory adreno-cortical

incidence is unknown because the pathogen is frequently misidentified as


Staphylococcus aureus. There are only 16 cases in the literature that have described

CASE: A 55 year-old male with a history of previously well controlled hypertension and

S. intermedius as a cause of infection in humans ranging from soft tissue infections to

pre-diabetes on metformin presented to his PCP with uncontrolled hypertension and blood

bacterial endocarditis. Most of these cases have been described in association with

glucoses >500 mg/dl. The patient also noted increasing fatigue, weakness and rapid

exposure to animals, mostly dogs. Above we report a rare case of S. intermedius causing

weight gain. He was started on a four drug anti-hypertensive regiment and basal/bolus

bacterial endocarditis in a dialysis patient. The presumed source of infection was the

insulin. The patient subsequently presented to the ED with worsening symptoms and new

patient’s dog. Although very rare in human beings, disease caused by S. intermedius

onset chest. In the ED the patient was afebrile, hypertensive 165/101 on amlodipine,

should always be considered among the differential diagnosis of serious invasive infec-

carvedilol, furosemide, hydrochlorothiazide and valsartan. No abnormal physical exam

tions, especially among patients who are in close contact with dogs

findings were noted on this encounter. Laboratory examination revealed a potassium of 2.9 mEq/l, CO2 35 mEq/l and serum glucose of 263 mg/dL. During his evaluation a CT chest angiogram identified a right (10.6 cm × 11.1 cm) adrenal mass. The patient was


evaluated by Endocrinology and Endocrine Surgery and on repeat examination was noted

Seungjun Kim2. 1The Miriam Hospital, Providence, RI; 2Brown University, Providence,

to have facial plethora, moon facies, truncal obesity, atrophic skin over the hands and shins

RI. (Control ID #2469818)

with multiple ecchymosis and violaceous abdominal striae. A hormonal evaluation was conducted revealing 24 h cortisol elevated at 675 ug/dl (range 4–50). Followed by an

LEARNING OBJECTIVE #1: Recognize the clinical manifestations and treatment of

afternoon ACTH level, which was suppressed at < 5. The patient’s DHEA-S level, urine

Moraxella bacteremia

catecholamines and urine metanephrines were unremarkable. His laboratory evaluation

CASE: A 62-year-old man with a history of chronic obstructive pulmonary disease (COPD)

was consistent with ACTH independent disease and given his CT findings the most likely

on home oxygen (3 L/min), coronary artery disease, diabetes, congestive heart failure and

diagnosis was a cortisol producing adrenal tumor. He underwent open adrenalectomy and

hypertension presented with dyspnea on exertion, orthopnea, chills, legs edema and productive

was found to have a pT2Nx Stage II, 12 cm × 7 cm adrenal cortical carcinoma with large

cough with whitish sputum. He also had painful right shin lesions after a local trauma. He was

vessel venous invasion. The patient was subsequently started on adjuvant mitotane

found to have a temperature of 101.9 °F, pulse of 125/min, blood pressure of 192/79 and

therapy to reduce the risk of developing distant metastatic disease.

oxygen saturation of 92 % on 6 L/min of supplemental oxygen. Exam showed wheezing and

DISCUSSION: Cushing’s syndrome is a constellation of clinical and laboratory abnor-

bibasilar lung crackles, regular heart rhythm, and right leg pus-filled pustules (2 cm) with 2

malities secondary to excessive glucocorticoid ingestion or production. For a primary care

smaller ulcers. Laboratory work revealed leukocytosis of 17.400 /μL. Chest radiography

provider, the principle challenge is to determine when to consider it, given the large

showed mild edema. He was started on vancomycin and piperacillin/tazobactam, and

number of patients with diabetes and hypertension who are seen in clinic daily. The

underwent surgical debridement of the leg lesions. Additionally he was treated for COPD

Endocrine Society’s clinical practice guidelines recommend after the exclusion of exog-

and CHF exacerbations. Blood cultures grew Moraxella osloensis and Micrococcus species.

enous glucocorticoid, cortisol testing is recommended for patients with multiple, progres-

The latter was considered a contaminant, while M. osloensis was treated with ceftriaxone for

sive discriminating features of the disease including, exam findings of easy bruising, facial

14 days, and other antibiotics were discontinued. Transthoracic echocardiogram showed no

plethora, proximal myopathy and striae. Combined with new onset or worsening of

vegetations but suspected severe mitral regurgitation. He refused transesophageal echocardio-

previously controlled hypertension, new or worsening glucose intolerance and rapid

gram as well as spine imaging despite briefly worsening chronic neck pain at the site of old

weight gain. Additionally, any patient with an incidental adrenal mass and one of the

hardware. He was discharged after improvement.

above findings should undergo screening for Cushing’s syndrome. Recommended initial




tests include urine free cortisol, late-night salivary cortisol, 1-mg overnight dexametha-

compensatory development of extensive collateral circulation. This collateral network

sone suppression test or low does dexamethasone suppression testing over 48 h. Our

of vessels gives a characteristic “puff of smoke” appearance on angiography, giving the

patient’s progressive hypertension, worsening glycemic control, weight gain and physical

disease its name, “moyamoya” in Japanese. This characteristic angiopathic pattern is

findings meet criteria for diagnostic evaluation. For patients found to have hormonally

referred to as moyamoya phenomenon, which either exists as an isolated idiopathic

confirmed Cushing’s syndrome the next step is determination of source i.e. pituitary vs

disease entity called moyamoya disease, or it can be associated with a variety of

ectopic. Our patient presented with a new adrenal mass, elevated cortisol and suppressed

conditions, including infections, autoimmune, hematological disorders and connective

ACTH consistent with ectopic cortisol production secondary to an adrenal cortical

tissue disorders, thus giving rise to the concept of moyamoya syndrome. Diagnosis of

carcinoma. Adrenal cortical carcinomas (ACC) are rare tumors with an incidence of

moyamoya angiopathy is based on radiological visualization of steno-occlusive disease

0.7–2 per million and only a subset of these tumors are hormonally active or secretory.

in the branches of circle of Willis as well as visualization of an abnormal arterial

Overall, ACC have a poor prognosis secondary to late diagnosis (Stages III, IV).

collateral circulation in the vicinity of the steno-occlusive lesions. Infections are a well-

Management of these tumors is based on whether surgical resection is possible, if so open

recognized cause of intracranial vasculopathy with progression to moyamoya syndrome.

resection is currently recommended. Tumors less than 10 cms in size, which are resected

The inflammation associated with infections can lead to a progressive angiopathy which

with negative surgical margins or tumor spillage portend the best prognosis.

may represent a pathophysiologic mechanism for the arterial occlusion seen in

Unfortunately, our patient’s surgical margins were 200, D-dimer of 1280 and fibrinogen of 284. She had an incision and drainage of the breast mass by the surgery team and the fluid collection was found to be a hematoma. After this procedure, her


hemoglobin continued to drop to 4.7, she was intubated and required vasopressor support.

Lesley Jackson; Vimal Patel; Daniel Ely. UT Graduate School of Medicine, Knoxville,

She was taken back to the operating room twice more for washout and cauterization due to

TN. (Control ID #2466257)

continued bleeding from the wound. Hematology was consulted and mixing studies showed failure of PTT correction and she was found to have factor VIII, IX and XI

LEARNING OBJECTIVE #1: Diagnose amyloidosis when initial diagnostic tests are

inhibitor proteins. Her quantitative inhibitor level initially was 702. Autoimmune work-up


including ANA, rheumatoid factor and lupus anticoagulant were negative. Her CD4 was

LEARNING OBJECTIVE #2: List the clinical signs that help diagnose amyloidosis in

18 and her viral load was 175. She was treated with intravenous Solumedrol 500 mg twice

the presence of an associated underlying plasma cell dyscrasia

daily for 3 days followed by Prednisone 60 mg daily and Cyclophosphamide 100 mg

CASE: We present a case of a 68 year old African American male with a history of

daily. She received three doses of Human Prothrombin Complex Concentrate (Kcentra)

chronic diastolic heart failure, type II diabetes, hypertension, generalized weakness,

which was later switched to Recombinant Human Coagulation Factor VIIa (Novoseven)

dysphagia with weight loss, and normocytic anemia. He presented with progressive

at 30 mcg/kg every 4 h. Attempts at weaning off Novoseven were complicated by

dyspnea of 6 months duration. Previously he had been admitted for a heart failure

recurrent bleeding from previous intravascular line sites and at the breast hematoma

exacerbation and treated with aggressive diuresis. He endorsed orthopnea, exercise

pocket itself. PT monitoring had shown a decreasing trend hence frequent Novoseven

intolerance, weight loss, and fatigue. On exam, he had diminished breath sounds in the

dosing was stopped as thrombosis was of concern. She was switched to Factor 8 Inhibitor

bases and 1+ pitting leg edema. Labs revealed mild anemia (HGB 10.2 g/dL). BMP was

Bypassing Activity (FEIBA) twice daily with complete cessation of bleeding allowing her

significant for a sodium of 130 mEq/L, albumin 3.3 g/dL, and creatinine 0.8 mg/dL; BNP

to be completely taken off treatments. The patient was discharged to a rehabilitation

was elevated at 329 pg/mL. Chest x-ray showed bilateral pleural effusions. A prior chest

facility on Prednisone and Cyclophosphamide. Her quantitative inhibitor level decreased

CT noted hilar and mediastinal adenopathy and granulomatous calcifications in the right

from 702 to 19.5 by the time of her discharge and further declined to zero within 2 months

hilar region. Transthoracic echocardiography showed a normal ejection fraction (EF) of

as an outpatient. Throughout her hospitalization, she was transfused a total of 24 units of

55–60 % with left ventricular hypertrophy and slight “speckling” which was considered

PRBC, 11 units of FFP, 3 units of cryoprecipitate and 2 units of platelets. It was

compatible with either hypertrophic or infiltrative cardiomyopathy. Pulmonary function

determined that this persistent left breast hematoma was secondary to acquired hemophilia

tests revealed a restrictive pattern with FVC and FEV1 between 40 and 50 %. Due to

from HIV.

progressive neurological symptoms despite therapy, our differential included some neu-

DISCUSSION: Acquired hemophilia is a rare but life-threatening bleeding disorder

romuscular disorders and amyloidosis. We obtained a repeat echocardiogram. This re-

caused by the development of autoantibodies (inhibitors) targeting plasma coagulation

vealed restrictive cardiomyopathy with progressive left ventricular dysfunction showing a

factors. Characteristically, there is spontaneous hemorrhaging in soft tissue and within

reduced EF of 40–45 %. An abdominal fat pad biopsy was obtained to evaluate for

intramuscular planes in a patient with no previous personal or family history of bleeding as

amyloidosis but this was negative for amyloid in routine and Congo red stains.

opposed to inherited hemophilia wherein males are more affected and bleeding most

Amyloidosis remained high on our differential diagnosis, thus we pursued

commonly occurs intra-articularly. Several risk factors have been linked to this coagulop-

endomyocardial biopsy. This showed subendocardial fibrosis and positive staining with

athy including malignancy, autoimmune disease, infection (HBV, HCV, HHV, HIV) and

Congo red for amyloid. A cardiac MRI showed diffuse subendocardial enhancement

drugs, however, the majority are thought to be idiopathic. Goals of management are to

pattern and other findings very suggestive of cardiac amyloidosis. Serum protein electro-

control bleeding and decrease factor inhibitor levels. Our patient is the first case to be

phoresis was suggestive of paraproteinemia, with immunofixation studies noting elevated

reported of multiple acquired factor deficiencies (FVIII, FIX, FXI) occurring in a female

IgA and lambda light chains. Urine free light chains and urine/lambda light chains were

presenting with left breast hematoma and known controlled HIV on ART. Our patient’s

also elevated. Bone marrow biopsy revealed a monoclonal lambda restricted plasma cell

presentation is unique in scope due to the severity of the multiple factor inhibition

neoplasm and negative Congo red stain. Nerve conduction studies showed presence of a

exhibited in a setting of controlled HIV resulting to clinically significant refractory

severe symmetrical sensorimotor axonal neuropathy and electromyographic examination

hemorrhaging. Other potential concomitant causes of acquired hemophilia, which may

showed presence of a severe proximal myopathic process. A diagnosis of multiple

have contributed to this patient’s disease severity, were effectively ruled out. The tendency

myeloma with amyloidosis was made at that time. He received weekly dexamethasone.

for certain patients to develop acquired hemophilia is thought to be due to the presence of

His symptoms stabilized, and he was discharged to a rehabilitation center, where Revlimid

certain gene polymorphisms or autoreactive CD4+ T-lymphocytes. It is presumed that

was later initiated for further treatment of the myeloma. Unfortunately, the patient did

high physiologic stress states involving humoral overactivity such as during immune

succumb to his illness and passed away at home from respiratory failure.

reconstitution, parturition, exposure to an immunomodulatory agent, autoimmunity and

DISCUSSION: This case demonstrates that diagnosing amyloidosis can be elusive, and often

active malignancy lead to increased antibody production in a milieu of T-cell imbalance

multiple diagnostic techniques may be necessary. Amyloidosis is a condition in which a variety

and dysregulation of cytokine, plasma cell and antibody formation. While the generation

of serum proteins arranged in an abnormal configuration of fibrils deposit in extracellular

of autoantibodies are controlled with immunosuppression, minor bleeding with low

matrix. The serum proteins are often derived from either monoclonal immunoglobulin light

inhibitor levels are treated with Desmopressin or high purity factor VIII concentrate

chain fragments (as in AL amyloidosis) or from the acute phase reactant serum amyloid A (as

whereas more fulminant cases with high inhibitor levels call for the use of bypassing

seen in chronic inflammatory disorders). Deposition occurs in multiple organs, including the

agents or recombinant porcine factor VIII concentrate. It is important to be aware of this

heart, liver, lung, kidney, and nervous system, and often results in significant morbidity and

rare although potentially lethal entity especially when a patient presents with known risk

mortality. It is suspected in patients that present with any of the following: restrictive




cardiomyopathy, nephrotic range proteinuria, unexplained edema, increased NT-proBNP

plain radiography is its high false-negative rate of 30–70 %, leading to significant

without known primary heart disease, or macroglossia. Congo red stained tissue showing

underestimation in diagnosis. MRI is the most sensitive modality for imaging lesions in

the presence of apple-green birefringence when subjected to polarized light microscopy is

the spine but it misses skull and rib lesions so should be used in conjunction with plain

pathognomonic of the disease. Diagnosis is confirmed only by biopsy, often initially by

radiographs. CT is the preferred imaging modality in detecting the osteolytic lesions of

sampling an abdominal fat pad biopsy, as it is generally an uninvolved site with less risk of

multiple myeloma and has a higher sensitivity than plain radiography and outperforms

bleeding. Alternatively, biopsies can be obtained from other noninvolved sites such as minor

MRI. Further imaging is indicated either when there is uncertainty about the extent of

salivary glands or rectal mucosa, or from dysfunctional organs like the kidney, nerve, or heart.

disease or if bone pain is present without any skeletal survey abnormality. When bone pain

Amyloidosis is in itself a type of monoclonal plasma cell proliferative disease as manifested by

is the only symptom there is added prognostic value in detailed imaging given that a lesion

the presence of serum or urine monoclonal proteins (M protein), clonal plasma cells in the bone

of >5 mm or multiple lesions are predictive of progression to end-organ damage in 80 % of

marrow, or an atypical serum free light chain ratio. It can occur alone or in the presence of an

patients. When to image a patient in primary care presenting with chest pain is more

underlying plasma cell disorder like MGUS, multiple myeloma, or Waldenstrom macroglob-

nuanced as there is little evidence or guidelines to support decision making. The persis-

ulinemia, which makes diagnosis problematic. Amyloidosis should be suspected in patients

tence of symptoms without a cause in this case justified further imaging and future

with known underlying plasma cell dyscrasia that also have heavy proteinuria, edema,

research may focus on when and how to image. Physicians should recall that the time

peripheral neuropathy, hepatosplenomegaly, or carpal tunnel syndrome. However, the high

course of symptoms is a key aspect of the history and to not prematurely close on a

prevalence of MGUS in the general aging population means that the presence of M protein

diagnosis that does not fit the chronicity of illness but rather widen the differential

along with deposition of amyloid is not diagnostic of amyloidosis. One should examine the

diagnosis and consider more uncommon diagnoses.

biopsy of amyloid directly to verify the presence of light chains using spectrometry-based proteomic analysis or immunoelectron microscopy. MYCOBACTERIA ARUPENSE OLECRANON BURSITIS IN AN IMMUNOCOMPETENT KAYAKER John D. Herlihy; James Horton. Carolinas MUSCULOSKELETAL CHEST PAIN- NOT JUST A DIAGNOSIS OF

Medical Center, Charlotte, NC. (Control ID #2466036)

EXCLUSION Daniel J. Howell; Matthew Shaines. Montefiore Medical Center, Bronx, NY. (Control ID #2469436)

LEARNING OBJECTIVE #1: Recognize exposure risk factors and presentation of atypical Mycobacteria infection

LEARNING OBJECTIVE #1: Recognize the presenting features of multiple myeloma

CASE: 68 year old male without significant medical who presents with recurrent right

LEARNING OBJECTIVE #2: Identify appropriate imaging studies in myeloma and

elbow pain and swelling over the past 8 months. The patient had been previously healthy

chest pain

and was an active kayaker and rock climber. Symptoms started shortly after a kayaking

CASE: This 65 year-old woman with a history of hypertension presented with central

trip to Utah. He denied fever, chills, nausea, vomiting, shortness of breath, or diarrhea. He

chest pain. The pain had been present at low intensity throughout the year with occasional

did complain of a nonproductive cough which had been going on for approximately

random exacerbations for which she had had repeated non-diagnostic workups with EKG,

3 weeks. Aspirate from the elbow showed no organisms, but acid fast bacilli in blood

cardiac markers and chest radiographs. Other than chest wall tenderness her vitals and

culture after incubation was grown out. Synovial fluid showed 20,000 RBC, 3,500

exam were unremarkable. On labs hemoglobin was 13.4 g/dl, WBC 3.9 × 1000/μL,

nucleated cells, 84 % sets, 16 % lymphocytes. The patient was taken for debridement

creatinine 1.0 mg/dl, albumin 3.8 g/dL, total protein 8.5 g/dL, calcium 9.9 mg/dL,

and cultures were sent for regular and cooler temperature cultures to look for atypical

troponin T undetectable. A CT Thorax to better evaluate her persistent chest pain revealed

mycobacterium. Post op chest x-ray showed a 10 mm pulmonary nodule in the lower

several expansible lytic lesions with associated cortical destruction and soft tissue exten-

lateral right lung and a 13 mm nodule in the left costophrenic angle. The patient was

sion in the body of the sternum. Subsequent biopsy revealed a sheet of atypical plasma cell

started on Doxycycline and Levaquin while culture results grew out. The surgical culture

infiltrate expressing CD138 and lambda restricted consistent with plasma cell myeloma.

results eventually grew out Mycobacteria arupense approximately 2 months after being

SPEP was positive for an IgG-lambda monoclonal protein and her bone marrow revealed

drawn. At that time antibiotics were changed to Clarithromycin, Ethambutol, and

0.5 % polytypic plasma cells. A skeletal survey showed no lytic lesions. She commenced

Rifabutin for planned 6 month course. The patient’s cough resolved shortly after starting

Lenalidomide and Dexamethasone and is currently doing well.

antibiotics. His elbow pain and swelling resolved with debridement and antibiotic treat-

DISCUSSION: Chest pain is a commonly encountered complaint in primary care and it is

ment. He had no further joint pain or stiffness. Chest CT was done to further evaluate the

the second most common chief complaint in the ED. 36.2 % of chest pain presentations in

pulmonary nodules and it showed a 1 cm discrete round nodule in the right lower lobe and

primary care are due to musculoskeletal disease, the vast majority of which is self-limiting.

a similar 1 cm nodule laterally within the left lower lobe. A follow up chest CT 6 months

While more serious causes of musculoskeletal chest pain are uncommon, bone pain as a

later showed the pulmonary nodules to be unchanged in size or appearance. The patient is

feature of multiple myeloma is not. It is in fact present in 58 % of individuals at

to have scheduled CT scans every 6 months for continued monitoring of these pulmonary

presentation. In this patient the location of the bone pain in the chest and presentation


on multiple occasions to the ED rather than to primary care may have distracted from

DISCUSSION: Mycobacteria arupense was first described in 2006 by Cloud et al. (2) and

suspicion of the diagnosis. However in patients with myeloma causing only a bone lesion

since that time there have been numerous case reports of infections caused by the bacteria. On

around 20 % will involve the sternum, rib, scapula or clavicle and therefore it is a

review of the literature only one case report describes large joint infection caused by M.

reasonable diagnosis to consider in chronic chest pain. While additional findings of

arupense. Seidl and Lindeque in 2014 described a patient with a history of traumatic knee

anemia, renal failure and hypercalcemia are often associated with myeloma, they are

arthrotomy in the past who presented with knee swelling and inability to bear weight. The

absent in 26, 52 and 62 % of patients respectively who present with myeloma. Thus, the

patient was found to have osteoarticular infection secondary to M. arupense which responded

lack of these hallmark clinical features should not dissuade one from pursuing a diagnostic

well to debridement and appropriate antibiotics. Beam et al. (1) presented a case report of an

workup. While almost 80 % of patients with multiple myeloma will have radiological

otherwise healthy farmer who developed flexor tenosynovitis of his fingers and swelling of his

evidence of skeletal involvement on the skeletal survey, one of the major disadvantages of

entire right hand with the only pertinent history being a remote history of blunt trauma to his




hand. Beam et al. divided the presentation of M. arupense into 3 clinical syndromes with the

another generalized tonic-clonic seizure. Examination revealed no focal neurological

first being tenosynovitis/extremity infection after traumatic injury and environmental contam-

deficits, there was no neck stiffness or papilledema. A head CT revealed no mass lesion

ination, the second being pulmonary infection, and finally disseminated infection in immuno-

or ischemia. Her symptoms included seizures, headache and confusion. Her blood work

compromised host. Antibiotic susceptibility testing by Beam et al. (1) showed that 97.5–100 %

was negative for any significant metabolic abnormalities and her urine toxicology was

of isolates to be susceptible to clarithromycin, ethambutol, and rifabutin. Greater than 78 % of

positive for opiates. Her blood pressure was treated acutely with hydralazine intravenously

these isolates were resistant to ciprofloxacin, moxifloxacin, rifampin, and doxycycline. Most

and clonidine orally. She had another witnessed seizure for which she received lorazepam

reported cases show rapid improvement with initiation of antibiotics except for the cases in

and levetiracetam intravenously. She was admitted to the medical intensive care unit to

immunocompromised patients with disseminated disease. Based on a review of the available

begin nicardipine intravenous drip and to continue intravenous levetiracetam. Once

literature, most described peripheral infections from M. arupense tend to be tenosynovitis of

stabilized, an electroencephalogram (EEG) showed frequent left temporal sharp waves,

the hand. The case described above is the second reported case of large joint infection. The

with no epileptiform activity. Cerebral MRI showed symmetric signal abnormality in-

patient has history of kayaking with trauma to the elbows suggesting a water source for the

volving the cortex and subcortex of the occipital lobes. The MRI did not show a signal

infection . The bacteria has been found to be prevalent in the water supply as shown by

abnormality of the medial temporal lobes to correspond with the EEG findings. Based on

Castillo-Rosal et al. in 2012 (3) where they analyzed the water distribution system from the

the clinical presentation and imaging abnormalities, a diagnosis of Posterior Reversible

Mexico City Metropolitan Area and found M. arupense to be prevalent in the water supply.

Encephalopathy Syndrome (PRES) was made. Further testing revealed a homogeneous

Given the prevalence of M. arapense in water supplies and the time and difficulty to culture

ANA at a titer of 1:1280, markedly elevated dsDNA antibody level of 146 [2 is positive) and her systemic score was 9

Heacock. The Ohio State University Wexner Medical Center, Columbus, OH. (Control

(>6 is positive). An FBN1 gene sequencing test revealed a mutation in one of two gene

ID #2469519)

copies resulting in a premature stop codon causing premature peptide truncation, confirming the MFS diagnosis.

LEARNING OBJECTIVE #1: Recognize the clinical signs and symptoms of isolated

DISCUSSION: MFS is an autosomal dominant disease involving the fibrillin-1 (FBN1)

alveolar hemorrhage in Goodpasture’s (anti-GBM) disease

gene with an estimated prevalence of 1.5–15 per 100,000 people. Twenty-five percent of

LEARNING OBJECTIVE #2: Diagnose and treat patients with Goodpasture’s (anti-

these mutations are likely de novo and the disease occurs in all populations without

GBM) Disease and isolated alveolar hemorrhage

significant differences in genetic penetrance or incidence. When considering evaluating a

CASE: 29 year old man presented with 1 week of progressive pleuritic midsternal chest pain

patient for MFS, findings associated with a higher likelihood of MFS diagnosis include: a

and dyspnea on exertion. The symptoms were associated with two episodes of “quarter size,

diagnosis of MFS in childhood (88 %), eye manifestations (83 %), family history of MFS

cherry-red” hemoptysis the week prior. He did not have fever, chills, or night sweats. No

(52 %), aortic dissection (50 %), pneumothorax (43 %), skeletal features (30 %) and joint

signs of bleeding from bowel or bladder and no change in urine output. Past medical history

hypermobility (14 %). Recognition of MFS in a patient is imperative to avoid the mortality

included anxiety and alcohol abuse. Family history was significant for rheumatoid arthritis.

associated with cardiovascular complications. Prior to prophylatic aortic root replacement,

He smoked a cigar a week. He did not have exposure to other inhalants. He denied

the mean age of death in patients with MFS was 32 years old with approximately 90 % of

intravenous drug abuse and had only had one sexual partner in the last year. He had no sick

deaths related to cardiac complications, most commonly from aortic valve insufficiency,

contacts and recent travel. He had one cat and no other animal exposures. Initial physical

aortic aneurysm rupture and congestive heart failure. The discovery of the FBN1 gene

exam was notable for a heart rate of 120, respiratory rate of 18 and oxygen saturation of 84 %

association with MFS in 1991 represented a new frontier for diagnosis. Despite the known

on RA initially. Patient looked in mild distress but had no increased work of breathing.

genetic connection between the FBN1 gene and MFS, a genetic defect without clinical

Lungs auscultation revealed course breathe sounds but no wheezes or rhonchi. Labs on

symptoms consistent with MFS is not diagnostic of the disease. Despite an improved

admission were significant for a white blood count of 12.6 (74 % neutrophils), Hemoglobin

understanding of FBN1 mutations, consistently predicting which mutations produce a

of 6.1, MCV of 95 and retic count of 10.8 %. Chemistry including creatinine was normal.

Marfan phenotype remains challenging and no consistent correlation between FBN1

Urinalysis showed trace blood with bacteria present. Electrocardiogram showed sinus

mutations and a phenotype has been determined. Since MFS represents a constellation

tachycardia. Chest Xray revealed diffuse bilateral airspace opacification with a nodular

of clinical findings without a clear reference standard, a true sensitivity and specificity

appearance. Follow up Chest Tomography Pulmonary Embolism Study had diffuse bilateral

cannot be determined solely by genomic testing. The modified Ghent nosology remains

nodular ground glass opacities and centrilobular nodules greater at the bases. The patient was

the gold standard for diagnosis. Once MFS has been diagnosed, appropriate monitoring,

admitted to the hospital and had worsening hypoxia requiring 15 l of oxygen to maintain

medical therapy, genetic counseling and prophylactic surgery improve the length and

saturations. Bronchoscopy was performed and the findings were consistent with alveolar

quality of life for patients. MFS patients should undergo at least yearly echocardiograms to

hemorrhage. Workup was begun but patient had persistent hypoxia so underwent video

monitor for aortic root dilation that could require aortic root replacement. Patients should

assisted thoracotomy for lung biopsy which was complicated by worsening hypoxia and

be referred for aortic root replacement if dilation progresses at more than 0.5 cm per year

inability to come off the ventilator. At that time his anti-glomerular basement membrane

or the aortic root dilates to 5.0 cm at the sinus of Valsalva, although some advocate

antibodies came back positive, while anti-nuclear antibody and anti-neutrophil cytoplasmic

replacement at 4.5 cm. Additional recommendations include exercise, weight lifting,

antibody were negative. He was started on methylprednisolone and plasmapheresis 6 days

pregnancy, vision exams, musculoskeletal exams and medical management. Beta-

after presentation. He was extubated 2 days later and quickly weaned to room air. He

blockers are a staple of therapy for MFS based on clinical trials despite an unclear impact

completed 3 days of pulse steroids and a total of nine plasmapheresis treatments. He was

on survival as they reduce wall stress by reducing inotropy and chronotropy.

discharged on oral prednisone. On follow up 2 weeks later he had a normal chest xray. Two

Developments in the pathophysiology of MFS suggest an abnormality in the transforming

months later he continues to have no lung function deficit by report and has maintained an

growth factor (TGF-β) pathway and matrix metalloproteinase (MMP) may play a role in

normal creatinine. He will be continued on a long term steroid taper potentially followed by

aortic enlargement. MMP pathogenesis is an evolving concept with animal models


suggesting altered MMP gene expression resulting in inappropriate extracellular mem-

DISCUSSION: Our patient was diagnosed with anti-glomerular basement membrane

brane remodeling. In addition, over activity of TGF-β signaling with increased serum

disease (Anti-GBM) or Goodpasture’s disease. A rare disease which occurs in less than

levels of TGF-β has been positively associated with progressive aortic root enlargement in

one million with only 5 % presenting with isolated aveolar hemorrhage such as our patient.

MFS as well as other genetic aortopathies. Subsequent animal studies have suggested

Diagnosis of anti-GBM disease peaks in second and seventh decade of life. Alveolar

angiotensin receptor blockers (ARBs) attenuate the TGF-β pathway by lowering TGF-β

hemorrhage should be diagnosed by broncho-alveolar lavage after suspicion from clinical

ligands, receptors and activators. Several small studies suggest ARBs reduce the rate of

symptoms such as dyspnea, cough, hemoptysis and anemia. Chest xray and chest

aortic dilation both as a monotherapy and in combination with beta-blockers; however,

tomography may show bilateral alveolar opacities including ground glass to consolida-

robust efficacy in large randomized studies is lacking. Statins, doxycycline and

tions. Some chest imaging may be normal so suspicion should be high for alveolar

peroxisome-proliferator-activated receptor (PPAR) gamma agonists have also been theo-

hemorrhage. While most patients have both alveolar hemorrhage and glomulonephritis,

rized to have a role in treatment as they have both anti-MMP and TGF-β compound

a small minority of patients with severe alveolar hemorrhage have normal creatinine. As in

effects, but clinical efficacy remains unclear. Overall, MFS is a clinical syndrome with a

our patient, most of these patients have minor urinary abnormalities usually trace hema-

genetic causative mutation diagnosed with the modified Ghent nosology criteria. With

turia. Diagnosis requires presence of Anti-GBM antibodies which can be detected through




serologic testing or renal biopsy. It is uncertain at this time if the subset of patients that

patient, testing can be non-diagnostic. Treatment in these cases may follow the presump-

have isolated alveolar hemorrhage without detectable renal disease are early in their

tive diagnosis. This case describes a young adult patient with new onset diabetes where

disease process or a variant of the disease. Initial renal function has been shown to be

testing was not consistent with Type 1 or Type 2 diabetes, and demonstrates the appro-

the strongest determinant of long term renal function in anti-GBM disease. Treatment with

priate diagnostic and therapeutic approach when MODY is suspected.

high dose glucocorticoids, immunosuppressive agents and plasma exchange has been shown to stop auto-antibody production and induce remission especially if started early in disease course. Therefore, early detection of alveolar hemorrhage by broncho-alveolar


lavage with systematic diagnosis of Anti-GBM disease in these rare cases may lead to


improved outcomes especially a higher chance of renal survival.

MANIFESTATION OF GRAVES’ DISEASE IN 15-YEAR-OLD ADOLESCENT. Kanako Horibe1; Shadia Constantine1; Hotaka Kamasaki2; Noeru Miyake1; Shuji Sai1;


Takako Takeuchi2; Hiroyuki Tsutsumi2. 1Teine Keijinkai Hospital, Sapporo, Japan;

Askin. UCSF, San Francisco, CA. (Control ID #2466329)


LEARNING OBJECTIVE #1: Review Mature Onset Diabetes of the Young (MODY)

LEARNING OBJECTIVE #1: List thyrotoxic periodic paralysis in the differential

LEARNING OBJECTIVE #2: Recognize when to refer diabetics for genetic evaluation

diagnosis of muscle weakness and/or acute paralysis.

CASE: A healthy 31 year old male presented to the emergency department with a 2 week

LEARNING OBJECTIVE #2: Recognize that normal potassium level during paralytic

history of insatiable thirst and fatigue. He took no medications. Family history included

attacks does not exclude the diagnosis of thyrotoxic periodic paralysis.

type 1 diabetes in his mother and pre-diabetes in his sister. On exam, he had a thin body

CASE: A 15-year-old Japanese adolescent male presented to our hospital with a 2-week

habitus. Laboratory studies were remarkable for blood glucose of 576, normal anion gap,

history of intermittent, proximal femoral weakness. These episodes were associated with

elevated beta-hydroxybutyrate, and hemoglobin A1c of 14.5. Bloodwork was negative for

femoral pain, worsened with movement and occurred only at night to early morning.

autoantibodies including islet cell, GAD 65, insulin, islet cell antigen 512, and zinc

During the episode, he was unable to stand up or walk. The symptoms usually resolved

transporter 8. Review of the mother’s medical records indicated she was diagnosed around

spontaneously without any intervention. The rest of the review of systems was negative.

age 35 but was still producing c-peptide into age 60s. The patient was started on a basal-

The patient had no significant past medical history. Nobody in his family had history of

bolus insulin regimen during hospitalization, but, after discharge, his insulin requirements

similar paralytic episodes or other diseases. He had been nervous and irritable which he

rapidly decreased. Given frequent hypoglycemia, his insulin was switched to short-acting

attributed to lack of sleep and stress for the upcoming high school entrance exams. His

mealtime coverage only. Repeat A1c was 8.2 then 6.9. The endocrinologists suspected

vital signs revealed mild hypertension (135/79 mmHg) and tachycardia (104/min). The

Mature Onset Diabetes of the Young (MODY), but an initial panel of MODY testing

musculoskeletal exam was significant for slightly decreased iliopsoas muscle strength (5-

returned negative. Further genetic testing was deferred due to cost.

on the right and 4+ on the left.) Deep tendon reflexes were normal. Initial blood work was

DISCUSSION: While this patient’s disease initially appeared consistent with Type 1

normal including creatinine phosphokinase (126 U/L) and potassium levels (3.6 mEq/L).

diabetes, there are elements which stand out. First, despite his thin body habitus, relatively

The electrocardiogram and spine X-ray showed no abnormal findings. We were unable to

young age, and presentation in a catabolic state (consistent with Type 1), he never

make a specific diagnosis at that time so he was discharged the next day with a referral to

exhibited diabetic ketoacidosis (more consistent with Type 2). Second, his autoantibody

the outpatient clinic. As an outpatient, periodic paralysis was considered, despite the

testing was negative (nearly excluding Type 1). Third, after his initial presentation, his

absence of other typical symptoms of hyperthyroidism, by the characteristics of paralytic

insulin requirements were low, without need for basal insulin (not consistent with Type 1).

episodes. Then additional blood testing was ordered, and findings revealed hyperthyroid-

Fourth, there was a strong family history of diabetes (more consistent with Type 2 or

ism; serum free thyroxine (FT4) was greater than 7.70 ng/dL (range, 1.00–1.80), free

genetic types of diabetes), with a mother still producing c-peptide (inconsistent with Type

triiodothyronine (FT3) was 30.10 pg/mL (2.20–4.40) and thyroid-stimulating hormone

1). In such a case, with a mixture of “types,” particularly with lean body habitus, and

(TSH) was lower than 0.01 μIU/mL (0.27–4.20). High levels of thyroid stimulating

negative autoantibody testing, it is appropriate to suspect a non-Type 1 or Type 2 diagnosis

antibodies were detected at 2822 % (0–120). Thyroid ultrasonography showed a mild

and to refer to endocrinology. There are many diabetes syndromes. One can classify these

diffusely enlarged thyroid gland with hypervascularity. He was diagnosed with Graves’

as involving either (a) destruction of beta cells or (b) genetic changes affecting the activity

disease with secondary normokalemic thyrotoxic periodic paralysis (TPP). He began

of insulin production or uptake. MODY falls into the latter category and makes up 2–5 %

treatment with methimazole, potassium iodine and beta-blocker, and shortly after his

of diabetics. Thirteen autosomal dominant genes have been implicated, though only

thyroid function became controlled and his TPP gradually resolved.

three—hepatocyte nuclear factor 1-alpha (HNF1a), glucokinase (GCK), and hepatocyte

DISCUSSION: Graves’ disease (GD) is very rare in adolescent males, and it often

nuclear factor-4-alpha (HNF4a) - make up roughly 90 % of the disease. These genes all

presents with behavioral disturbances such as decreased attention span, difficulty concen-

affect glucose sensing or insulin production by beta cells rather than insulin activity.

trating, hyperactivity and difficulty sleeping instead of the typical thyrotoxic symptoms.

Clinically, MODY is characterized by early onset (before age 25), normal or lean body

TPP is a rare complication of hyperthyroidism and it occurs mostly in Asian male. Its

habitus, a family history of early onset diabetes, and negative autoantibodies. Insulin

incidence among Asian patients with hyperthyroidism is approximately 2 %, on the other

resistance is not consistent with MODY. MODY is diagnosed through genetic testing.

hand is 0.1 % in non-Asian populations, and seldom seen in adolescence. TPP is typically

Distinguishing MODY from Type 1 and Type 2 diabetes as well as determining the

characterized by acute paralytic attacks with hypokalemia, and its etiology remains

specific MODY gene has implications for treatment. No MODY types require insulin. Of

unclear. TPP can be a life threatening condition since it can lead to cardiac arrhythmias

the three most common, HNF1a and HNF4a are treated with sulfonylureas, and GCK with

and respiratory failure. It is challenging to diagnose TPP during the initial presentation as it

lifestyle modification. Further, genetic testing can also alert other family members to the

is a rare condition, and moreover, because the clinical features of hyperthyroidism tend to

diagnosis and need for testing themselves. However, genetic testing is limited. First, by

be subtle in patients with TPP. Although hypokalemia is said to be a typical factor of TPP,

cost. Even with insurance coverage, out-of-pocket costs may be hundreds of dollars.

there are a few reported cases in the literature with preserved serum potassium levels called

Second, most laboratories only test for HNF1a, HNF4a, and GCK. Thus, in the case of our

‘normokalemic’ TPP. The presentation resembles other conditions such as Guillain-Barre

Sapporo Medical University Hospital, Sapporo, Japan. (Control ID #2468342)




syndrome, myasthenia gravis, multiple sclerosis, transverse myelitis, botulism and psy-

manifestation of invasive disease. Together, pneumococcal meningitis, endocarditis, and

chogenic paralysis. In our case, we reached the diagnosis of normokalemic TPP secondary

pneumonia form a clinical triad called Austrian’s syndrome originally described by William

to GD based on his characteristic clinical history of episodic paralytic attacks. This is a first

Osler, now rare in the penicillin era. Septic arthritis is a relatively uncommon manifestation

report of normokalemic TPP seen in an adolescent. In conclusion, diagnosis of GD in

of invasive pneumococcal disease. However, in case reviews of septic arthritis by Ispahani

adolescence is often delayed due to their atypical symptoms and it can present as

et al. and Ross et al., S. pneumoniae is the second most common pathogen occurring

normokalemic TPP. TPP is a highly treatable disorder and early diagnosis could prevent

between 6 and 8 %. Staphylococcus aureus comprises the majority of cases of septic arthritis.

lethal complications. Therefore, clinicians should consider TPP in the differential diagno-

Although multiple myeloma was the underlying risk factor in 6 % of patients, it preceded or

sis of muscle weakness or acute paralysis, even with normal potassium levels.

prompted the diagnosis in multiple cases. In our patient, this diagnosis was considered in light of transfusion-dependent anemia and persistent renal dysfunction. An abnormal SPEP, UPEP, and IF and a lytic bone lesion increased clinical suspicion. S. pneumoniae is one of


the most common pathogens in multiple myeloma. As an encapsulated organism, it takes


advantage of the immunocompromised state in MM due to polyclonal

Jun2; Roger W. Sands2; Amar Kohli1. 1UPMC, Pittsburgh, PA; 2University of Pittsburgh

hypogammaglobulinemia and defects in the complement system, amongst other deficien-

Medical Center, Pittsburgh, PA. (Control ID #2465959)

cies. Hypogammaglobulinemia stems from the neoplastic proliferation of plasma cells in MM, one of the diagnostic criteria in MM. Specifically, MM is diagnosed by the following

LEARNING OBJECTIVE #1: Describe the epidemiology and clinical manifestations

according to the International Myeloma Working Group: clonal bone marrow plasma cells ≥

of Strepococcus pneumoniae infections

10 % or biopsy-proven plasmacytoma, evidence of end-organ damage (hypercalcemia, renal

LEARNING OBJECTIVE #2: List important pathogens and risk factors for septic

insufficiency, anemia, or osteolytic bone lesions) and/or positive biomarkers such as an

arthritis Review the diagnostic criteria for multiple myeloma

involved:uninvolved serum free light chain ratio ≥100. Monoclonal gammopathy of unde-

CASE: The patient is a 66-year-old Caucasian male with a history of tobacco use,

termined significance and smoldering multiple myeloma are asymptomatic plasma cell

hypertension, poorly controlled diabetes mellitus, and medication non-compliance who

dyscrasias that are at risk of progressing to MM. This case represents an interesting

presented to the hospital with malaise, nausea, progressive right knee pain, swelling, and

unmasking of an underlying immunodeficiency in a patient initially with invasive pneumo-

decreased ambulation in the week prior to presentation. Upon arrival to the hospital, the

coccal disease.

patient was tachycardic to the 110 s but was otherwise hemodynamically stable. Physical exam was notable for right knee anterior erythema and palpable effusion. His bloodwork demonstrated a white count of 25.1 (88 % neutrophils, 32 % bands), elevated CRP 35.3


and ESR 76, Cr 1.57 from baseline 1.0, Ca 8.7, albumin 2.4, and total protein 6.4.

Christopher Di Felice1; MARK SCHAUER2. 1Western Michigan Universiry Homer

Immediate joint aspiration drained turbid fluid containing WBC of 560000 (95 % neu-

Stryker M.D. School of Medicine, Portage, MI; 2Western Michigan University Homer

trophils) concerning for a septic joint. He was started on broad-spectrum antibiotics and

Stryker MD School of Medicine, Kalamazoo, MI. (Control ID #2435414)

underwent two irrigation and debridement procedures. Gram stain and cultures from the synovial fluid and blood cultures all subsequently grew penicillin-resistant S. pneumoniae.

LEARNING OBJECTIVE #1: Recognize the differences between types of scleroderma

Antibiotics were narrowed to vancomycin and a 4-week course of treatment was planned.

LEARNING OBJECTIVE #2: Recognize the clinical features and serologies of

His hospital course was complicated by a right lower extremity DVT, the treatment of


which was made difficult by a transfusion-dependent anemia without source and epistaxis

CASE: A 75 year old white male initially noticed finger swelling and polyarthralgias

requiring an IVC filter, and significant delirium. Extensive testing was performed to

8 months prior to admission. Subsequently he developed worsening skin thickening

determine a possible source of the pathogen, including a CT head/sinuses, CT chest/

advancing proximally to mid-forearm and mid-thigh. He was diagnosed with scleroderma.

abdomen/pelvis, and an echocardiogram, all of which were unremarkable. Lumbar

The skin thickening progressed until his walking was impaired by the reduced range of

puncture was deferred due to low suspicion for meningitis. After discussing with our

motion at his knees and ankles. He could not flex his fingers into a fist and exhibited facial

Infectious Disease team, testing for an immunodeficiency was performed. Serum and

involvement with decreased mouth opening at 40 mm. Intermittent skin pruritis occurred

urine electrophoresis (SPEP, UPEP) testing revealed elevated gamma globulin fractions,

over the affected areas. He complained of progressively worsening dyspnea on exertion

and immunofixation (IF) confirmed an IgG-kappa gammopathy. The patient also

and underwent HRCT which confirmed interstitial pulmonary fibrosis. He was initially

displayed an elevated kappa:lambda ratio of 14.8 and an elevated beta-2 microglobulin

treated with diltiazem, losartan, methotrexate, and prednisone. His hypertension worsened

at 6.56 mg/L, the latter portending a poor prognosis. Skeletal survey revealed a 1 cm

and continued to be difficult to control. The addition of mycophenolate mofetil increased

osteolytic lesion in the left proximal humerus. Even with strong clinical suspicion, the

his range of motion somewhat. However, his renal function progressively declined during

Hematology/Oncology team recommended bone marrow biopsy to confirm multiple

the 4 months after diagnosis. He underwent renal biopsy which demonstrated ATN and

myeloma (MM). However, due to stress of the acute illness, the patient and his family

findings consistent with scleroderma renal crisis. While awaiting the results of this biopsy

deferred the procedure as an outpatient and this still remains pending.

his dyspnea and fatigue acutely worsened and he was admitted to the inpatient medical

DISCUSSION: S. pneumoniae is familiar to physicians as one of the infectious agents in

floor. Hemodialysis was initiated. Captopril was used to control his hypertension.

community-acquired pneumonia. If S. pneumoniae is isolated from the blood or CSF,

Serology revealed that he was PM-SCL negative but he was RNA Polymerase III strongly

normally sterile sites unlike the sputum, then the disease is termed invasive pneumococcal

positive at >150.

disease. Incidence is highest in patients greater than 65 years old or less than 2 years old or in

DISCUSSION: Scleroderma also called systemic sclerosis is actually a group of disorders

those with underlying risk factors such as rheumatoid arthritis, alcoholism, degenerative joint

characterized by abnormal inflammation and subsequent overproduction of collagen

disease or prosthetic joints, steroid use, HIV, malignancy, and other chronic disease states.

resulting in skin thickening and hardening, along with multi-organ system involvement,

The most frequent complication of invasive pneumococcal disease is meningitis, which has a

and vascular dysfunction. Women are affected four to nine times more often than men and

high mortality rate of 20–30 %. Pneumococcal endocarditis is another more typical clinical

are generally diagnosed between the ages of 20 and 50 years old. Although clinical




presentation is the foundation of diagnosis, there are numerous serologies that help support

NOT JUST ANOTHER CASE OF BACK PAIN Micah Yost; Andrew Greenlund.

a diagnosis of scleroderma for example: ANA, Anti-Scl-70, Anticentromere antibodies,

Mayo Clinic, Rochester, MN. (Control ID #2464352)

anti-RNA polymerase III. This case is unusual for several reasons. First, the patient was an elderly male. Scleroderma usually presents in younger women. His disease, RNA poly-

LEARNING OBJECTIVE #1: Recognize red flag symptoms in a patient with back pain

merase III positive scleroderma, is rapidly progressive. Typically other sclerodermas

and systematically work through a case to detect the underlying cause

demonstrate a more indolent course. In addition he was Scl-70 negative and yet had

LEARNING OBJECTIVE #2: Identify the importance of not anchoring on a premature

severe systemic disease including skin, lung, and renal manifestations, which is a hallmark


of RNA polymerase III positive scleroderma. RNA polymerase III positive scleroderma is

CASE: A 62-year-old male presented for progressive lower back pain with bilateral lower

a significant risk factor for scleroderma renal crisis which this patient developed. In

extremity weakness and numbness. His medical history was significant for post-polio

addition, scleroderma renal crisis can be precipitated by corticosteroids which he received.

syndrome characterized by chronic weakness of the proximal right lower extremity as well

It should be kept in mind that not all scleroderma is the same and that there are significant

as chronic back pain. Symptoms began 6 weeks earlier with weakness and numbness in

differences in disease manifestations and progression which can in part be predicted by

both lower extremities, which progressed to difficulty ambulating. The back pain was


located in the lumbar area midline and radiated to the abdomen. Also of note, he had a diarrheal illness 2 weeks before symptoms started. He worked a desk job and denied tobacco, alcohol, illicit and prescription drug abuse. He informed us that he was MSM


with approximately 50 different partners dating back over 20 years. He used protection

Mohamad Firas Barbour1; Jaleh Fallah1; Claire Thomson2; Valeria Fabre2; Taro Minami2.

only intermittently and had previously been treated for genital herpes. On initial presen-


tation his pain and weakness had worsened and the numbness had spread proximally up

Island, Pawtucket, RI. (Control ID #2463988)

his legs and also involved his hands and forearms bilaterally. Exam showed bilateral

Memorial Hospital Of Rhode Island, Pawtucket, RI; 2Memorial Hospital of Rhode

proximal lower extremity weakness, right worse than left, as well as left triceps weakness. LEARNING OBJECTIVE #1: Maintain a high clinical suspicion for tuberculosis in this

Muscle wasting was noted over the medial and lateral quadriceps, right worse than left. He

vulnerable population.

was areflexic throughout with flexor plantar response bilaterally. Decreased superficial

CASE: Introduction: Despite advances in therapy, tuberculosis represents a major burden

pain sensation was also noted in the left lateral leg and foot without a clear sensory level.

of disease worldwide with 9 million cases and 1.5 million deaths annually. Laryngeal

Lab studies including TSH, CK, aldolase, B12, thiamine, ceruloplasmin, monoclonal

tuberculosis, once a common presentation of Mycobacterium tuberculosis infection, has

protein, ANA, ENA’s, tickborne disease panel, and HIV did not reveal a cause for his

become increasingly rare since the advent of effective antitubercular therapy. The follow-

symptoms. EMG was complicated due to his history of polio as well as compressive

ing describes a case of laryngeal tuberculosis presenting as acute epiglottitis. Case report:

polyradiculopathy. It suggested an acute on chronic process, likely a

A 48-year-old man with a history of binge drinking and a positive PPD 20 years prior

polyradiculoneuropathy with mixed axonal and demyelinating features. Motor neuron

presented to the emergency department complaining of worsening sore throat, dysphagia

disease could not be excluded due to prominent fibrillation potentials. Lumbar puncture

and hoarseness for 1 week. Review of systems revealed a 15-lb weight loss and productive

was performed and showed protein of 111, total nucleated cells 27 with 93 % lymphocytes

cough over the previous 6 months. He migrated to the United States from Guatemala

glucose 71 with blood glucose 143 and cytology negative for malignancy. All viral studies

22 years prior to presentation and denied any exposure to tuberculosis. Physical exami-

performed on the CSF were negative. VDRL was ordered on the CSF and RPR was

nation was remarkable for hoarseness and oropharyngeal thrush. Computed tomography

ordered on serum along with syphilis IgG Ab. At this point a tentative diagnosis of

(CT) of the neck revealed epiglottitis and CT of the chest showed a large cavitary lesion in

inflammatory demyelinating polyradiculoneuropathy was made. Treatment with plasma

the right upper lobe. Flexible laryngoscopy revealed supraglottic edema as well as

exchange was initiated and five treatments were performed. The patient’s symptoms did

granular, superficial ulceration on the laryngeal surface of the epiglottis. Laboratory

not change significantly. At this point the VDRL, RPR, and syphilis IgG Ab all returned

findings were remarkable for a lymphocyte count of 300 cells/μl. Anti-HIV antibody,

positive and a diagnosis of neurosyphilis was made. Treatment with 5 million units IV

respiratory viral panel, legionella and Streptococcus pneumoniae urine antigens, and

Penicillin G was initiated followed by continuous infusion of 24 million units of Penicillin

blood cultures were negative. Sputum samples showed numerous acid fast bacilli and

G daily for 14 days. Retinal photo was obtained, and he was noted to have some mild optic

nucleic acid testing confirmed the presence of Mycobacterium tuberculosis organisms. His

disc edema. MRI head and orbits showed left optic disc edema. He was discharged to a

oropharyngeal symptoms improved with fluconazole and dexamethasone. He was started

skilled nursing facility with plans to recheck the CSF every 6 months until the VDRL, cell

on isoniazid, rifampin, ethambutol, and pyrazinamide for laryngeal and pulmonary

count, and protein return to normal. These labs will also be used as a measure of the need

tuberculosis and was eventually discharged home with isolation precautions after coordi-

for retreatment. Follow-up with neurology and ophthalmology was planned.

nation with the State Department of Health.

DISCUSSION: Syphilis is an infection with Treponema pallidum and can affect many

DISCUSSION: Discussion: Laryngeal tuberculosis (LT) is an increasingly rare manifestation

systems including the integumentary, musculoskeletal, cardiovascular, and central nervous

of tuberculosis, now seen in only 1 % of cases. Diagnosis requires a high index of suspicion,

systems. Currently, neurosyphilis is most frequently seen in HIV infected patients, though it

particularly in US natives or migrants who have resided in the US for a long time, as LT is

is not known if this is due to a difference in patient-to-patient susceptibility, or it simply

frequently confused with laryngeal carcinoma in these populations. On laryngoscopy, lesions

reflects patient lifestyle and common risk factors. Presentations vary based on the site of

vary in both appearance and location, and may appear ulcerative, ulcerofungative, or polypoid.

infection and can be anywhere from asymptomatic to potentially fatal. Infection begins with

While LT is typically associated with concomitant pulmonary tuberculosis, as seen in our case,

invasion of the CSF and spreads to the meninges, blood vessels, spinal cord, brain, or nerve

up to 20 % of LT cases present as primary disease. Typically LT presents in men in their forties

roots. The presentation we observed in our patient was a polyradiculopathy presenting with

or fifties and the most frequent complaints are dysphonia and weight loss. Risk factors include

back pain, weakness, sensory symptoms, and muscle wasting. Neurosyphilis is diagnosed

lack of prior vaccination with BCG, tobacco or alcohol use, acquired immunosuppression or

with lumbar puncture and both treponemal and non-treponemal testing. Non-treponemal

malnutrition. Our patient serves as a reminder to maintain a high clinical suspicion for

testing is primarily helpful as treponemal studies may be negative in late stage syphilis.

tuberculosis in this vulnerable population.

Treatment typically involves IV penicillin by continuous infusion for 10–14 days. In our




patient the primary risk factor was unprotected sexual intercourse. His situation was

is recommended since the majority of effects are self-limited. When there is end-organ

complicated by his history of polio as well as his spine disease. Inflammatory demyelinating

involvement, as in our patient, immunosuppression is warranted. Corticosteroids, azathi-

polyradiculoneuropathy was initially suspected due to his history of recent diarrheal illness,

oprine, and cyclophosphamide have been used successfully. In addition, rituximab has

areflexia, and lower extremity predominant symptoms. Elevated CSF protein was noted,

proven to be non-inferior to cyclophosphamide for ANCA-associated vasculitis therefore

although he did not have the classic albuminocytologic dissociation as his total nucleated

it is also a therapeutic option.

cells were 27. By not anchoring on the diagnosis of inflammatory demyelinating polyradiculoneuropathy we were able to determine the true cause of our patient’s symptoms. In his classic syphilis text Modern Clinical Syphilology, John Stokes wrote “The frequency

N O T Y O U R AV E R A G E B A B Y B U M P : P R E G N A N C Y A N D

of neurosyphilis in general medical practice depends to a large extent on the thoroughness of

THROMBOCYTOPENIC PURPURA (TTP) Jillian Edmunds; Kathryn Jobbins.

the search for signs of neuraxis involvement and the frequency with which the spinal fluid

Baystate Medical Center, Enfield, CT. (Control ID #2467249)

examination is employed.” This case is a good reminder that this remains true today, and testing for “the great imitator” should be considered when investigating neurologic disease.

LEARNING OBJECTIVE #1: Recognize thrombotic microangiopathy (TMA) syndromes and distinguish between acquired and hereditary thrombocytopenic purpura (TTP) LEARNING OBJECTIVE #2: Understand the management of hereditary TTP in



ADULTERATED COCAINE Megan Jagosky; Kristi M. Moore; Leslie Ranken.

CASE: Sister 1 A 34 year-old female at 25 weeks gestation with past medical history of

Carolinas Medical Center, Charlotte, NC. (Control ID #2467771)

psoriasis presented with headache and epistaxis. Physical exam was notable for petechial rash on abdomen and lower legs. She had marked thrombocytopenia with platelets of

LEARNING OBJECTIVE #1: Recognize the potential complications of ingesting

17,000 mm3 and hemolytic anemia with hemoglobin of 8.7 g/dL and hematocrit of

levamisole-adulterated cocaine.

24.3 %, LDH of 840 units/L and haptoglobin 95 % on ambient air. Pulmonary

Rest of the examination was unremarkable. Patient underwent excisional biopsy with wide

exam was notable for ronchi in the right lower lobe; physical exam was otherwise




unremarkable. Initial laboratory work including comprehensive metabolic panel and

triglyceride (TG) level of approximately 1000 mg/dL or greater increases the risk of acute

complete blood count were within normal limits. Chest radiograph was without abnor-

pancreatitis (AP), although some patients have developed AP at lower levels. The risk of

mality, however subsequent chest CT scan revealed a 3–4 cm cavitary lesion in the basilar

developing acute pancreatitis is approximately 5 % with TG >1000 mg/dL and 10 to 20 %

anterior segment of the right lower lobe. He was admitted and underwent work-up for both

with TG >2000 mg/dL. The optimal approach to hypertriglyceridemia induced pancrea-

infectious and non-infectious causes of hemoptysis and cavitary lung lesions. On hospital

titis has not been established in will designed clinical trials. Case Report A 48 Hispanic

day 3, he underwent bronchoscopy which yielded a foreign body lodged at the bifurcation

female presented with epigastric pain, radiated to the back, associated with nausea and 3

of the right lower lobe with surrounding inflammation and nodular protrusions. The

episodes of non-bloody vomiting. There was no fever, change of bowel habits or urinary

foreign body was easily removed and proved to be a full, intact, sunflower seed. On

symptoms. Her past medical history was significant for alcohol induced pancreatitis

review of the diagnosis with the patient, he was able to recall an episode approximately

10 years prior. She took no medication, and last alcohol drink was a few weeks previously.

18 months prior in which aspirated a sunflower seed. He was discharged with a short

There was a positive family history of dyslipidemia. On physical examination T 97.8, BP

course of amoxicillin-clavulanic acid and scheduled for interval repeat CT scan to ensure

140/87, Heart rate 118, RR 22 and BMI 32. Mucous membranes were dry. There was

resolution of the cavitary lesion.

significant epigastric tenderness with no rebound tenderness. Laboratory findings: Lipase

DISCUSSION: Foreign body aspiration is a rare occurrence in the adult population and

of 1682 Units/L, amylase 504 Units/L, Total Bilirubin 0.8 mg/dl, WBC 21.2 cells/mm3.

requires a high index of suspicion to make the diagnosis. Foreign body aspiration occurs in

Hb 12.2, lactic acid 3.7 mg/dl, Triglyceride 3321 mg/dL. The blood sample was extremely

less than 1 per 100,000 person years (LIMPER 1990), but are higher among the elderly

lipophilic and needed to be tested multiple times to obtain accurate results. Computed

and those with neuromuscular disorders. Unlike in pediatrics where patients often present

tomography showed severe inflammatory stranding abutting the pancreas and duodenum,

acutely with life-threatening tracheal or upper airway obstruction, adults often present with

compatible with pancreatitis. Ultrasound of the gall bladder showed no cholelithiasis or

chronic symptoms due to lower airway obstruction. Frequently, there is no memory of the

cholecystitis. Conservative treatment of AP was started including bowel rest, aggressive

inciting aspiration event. Presenting symptoms often mimic infection and include chronic

fluid resuscitation, and parenteral analgesia. The patient was still severely symptomatic so

cough in 80 % of patients. Other symptoms include hemoptysis, fever and pleuritic chest

plasmapheresis was initiated. After 2 sessions of plasmapheresis, the patient improved

pain. Symptoms are due to both airway obstruction by the foreign body as well as

significantly and she was able to start oral intake and required less parenteral analgesics.

parenchymal inflammation from the irritant properties of the foreign body. The lack of

By the fifth day of hospitalization, TGs decreased to 347 mg/dL, and she was able to

sensitive, non-invasive diagnositic testing adds further challenge to making the diagnosis

tolerate a full liquid diet and oral analgesics. Statin therapy and finofibrates were initiated.

of foreign body aspiration. The majority of aspirated items are radiolucent and not visible

The pancreatitis resolved and she was discharged home on the seventh day of

on chest radiographs. CT scans of the chest have less than 85 % sensitivity for detecting


endobronchial foreign bodies (ZISSEN 2001). When present, CT findings are variable and

DISCUSSION: Discussion: This case demonstrates plasmapheresis was an effective

include cavitary lesions, bronchiectasis, volume loss and hyperluciency. While invasive,

modality in treating HTG-induced acute pancreatitis. Medical therapy of severe hypertri-

bronchoscopy with direct visualization of the foreign body is the gold standard for

glyceridemia is effective but may take time to achieve a result that allows resolution of AP.

diagnosis. Fortunately, bronchoscopy is often simultaneously diagnostic and therapeutic,

Intravenous insulin is frequently used for rapid correction of severe hypertriglyceridemia,

with success rates for initial bronchoscopy approaching 75 % (CHEN 1997). Due to the

however use of plasmapharesis in the acute setting is recognized as a viable alternative.

subtle nature of presentation, it is paramount that the clinician consider foreign body

Our experience suggests that plasmapharesis is rapid and effective not only for the

aspiration on the differential diagnosis for a variety of pulmonary conditions including

hypertriglyceridemia but for the AP as well. A large case control analysis or prospective

chronic cough, recurrent pneumonia, hemoptysis and abrupt onset obstructive lung

clinical trial is warranted to establish the best approach to this challenging condition.

disease. Early broncoscopy is both diagnostic and therapeutic and is key to management of foreign body aspiration. REFERENCES: Chen, C. H., C. L. Lai, T. T. Tsai, Y. C. Lee, and R. P. Perng. “Foreign Body Aspiration Into the Lower Airway in Chinese Adults.”


CHEST Journal CHEST 112.1 (1997): 129. Limper, A. H., and U. B. Prakash.

IN AN IMMUNOCOMPROMISED HOST Rina Mauricio; Jennifer S. Mulliken;

“Tracheobronchial Foreign Bodies in Adults.” Annals Of Internal Medicine 112 (1990):

Ronald Goldenberg. New York University Langone Medical Center, New York, NY.

604–09. Zissin, R., Myra Shapiro-Feinberg, Judit Rozenman, Sara Apter, Jehoshua

(Control ID #2469496)

Smorjik, and Marjorie Hertz. “CT Findings of the Chest in Adults with Aspirated LEARNING OBJECTIVE #1: Review the risk factors for purulent pericarditis and the

Foreign Bodies.” European Radiology 11.4 (2001): 606–11.

common pathogens involved. LEARNING OBJECTIVE #2: Recognize the clinical features of purulent pericarditis PLASMAPHERESIS AS AN EFFECTIVE MODALITY FOR TREATMENT OF

and when to have a high index of suspicion for infection.


CASE: A 69 year-old man with a history of advanced gastric adenocarcinoma undergoing

Mohamed Hassanein3; Majlinda Xhikola2; Daniel Goldsmith1; Tania Calzada1; Emily

chemotherapy presented with progressively worsening right knee pain and swelling for


4 1


Chen ; Manish Gugnani . Capital Health Regional Medical Center, Trenton, NJ; Capital

1 month. He denied preceding knee trauma or surgery, though prior to the onset of

health Regional Medical Center, Trenton, NJ; 3Capital health regional medical center,

symptoms he had received a course of ciprofloxacin for a right lower extremity cellulitis.

Plainsboro, NJ; 4Capital Health Medical Regional Center, Trenton, NJ. (Control ID

His knee pain progressed to the point of immobility, and he subsequently developed


pleuritic chest pain and shortness of breath. On arrival to our hospital he was tachycardic, tachypneic, and hypotensive. He had distant heart sounds on exam with elevated jugular

LEARNING OBJECTIVE #1: To demonstrate that Plasmapheresis as an effective

venous pressure. The right knee was erythematous, warm, and swollen with severe pain on

modality for treatment of hypertriglyceridemia induced pancreatitis.

small movements. Labs were notable for a leukocytosis to 40.8/mm3 (75 % neutrophils)

CASE: Background Hypertriglyceridemia is the third most common cause of acute

and an elevated lactate. Knee arthrocentesis revealed purulent synovial fluid with a white

pancreatitis, accounting for 1 to 4 % of cases presenting to the hospital. A serum

blood cell count of 53,800/mm3 and 97 % neutrophils. There were innumerable white




blood cells on gram stain. A transthoracic echocardiogram showed a large pericardial

day 12, her platelet counts abruptly declined to 17,000/mm3 from 211,000/mm3 the

effusion with tamponade physiology. The patient received intravenous fluids and broad-

previous day. Physical examination was only significant for petechiae on the buccal

spectrum antibiotics and was admitted to the intensive care unit. Synovial fluid culture

mucosa. Within a span of 8 h, platelet counts reached a nadir of 4,000/mm3 despite

later speciated to Streptococcus pneumoniae. On hospital day two, the patient underwent a

transfusion with 2 units of platelets. Examination of the peripheral smear for suspected

pericardial window with 300 cc of purulent fluid drained from the pericardium. Gram stain

microangiopathic coagulopathies showed no evidence of schistocytes, and

showed innumerable white blood cells, but cultures of the pericardial fluid and of the

pseudothrombocytopenia was excluded based upon the absence of platelet clumping.

excised pericardium were sterile. Blood cultures throughout the admission were negative,

Blood urea nitrogen, creatinine, fibrinogen, prothrombin time and partial thromboplastin

however none of these was collected before the initiation of antibiotics. On hospital day

time were within normal ranges, thus ruling out disseminated intravascular coagulation

three, the patient developed worsening septic shock on maximum dose vasopressors. The

(DIC). Blood cultures showed no growth. The absence of recent exposure to

decision was made to stop escalating care, and the patient expired on hospital day four.

unfractionated or low molecular weight heparin excluded the possibility of heparin

DISCUSSION: Purulent pericarditis is characterized by frank pus in the pericardial sac or

induced thrombocytopenia (HIT). The patient was given a presumptive clinical diagnosis

by microscopic purulence. Most cases are caused by gram-positive organisms, with

of post-transfusion purpura (PTP) and empirically started on intravenous Immune globulin

Staphylococcus aureus and Streptococcus pneumoniae accounting for the majority of

(IVIG) at 1 g/kg for 2 consecutive days in addition to prednisone 40 mg orally twice a day

infections. Gram-negative and fungal organisms are less common pathogens. Infection

for 7 days. Antibiotics were discontinued and patient’s blood sample was sent to the Blood

usually spreads hematogenously from another site but can also arise from an intrathoracic

Center of Wisconsin for platelet serology and genotyping. Six days after IVIG infusion,

or intracardiac source. Primary bacterial infection of the pericardium is rare. Purulent

the patient’s platelet count reached 56,000/mm3 and she was discharged. Platelet genotyp-

pericarditis requires prompt identification, but diagnosis can be challenging. Patients

ing results showed human platelet antigen (HPA)-1b/1b and 3b/3b alleles and serological

typically present with fever, chest pain, and cough, however the index of suspicion is

studies indicated the presence of anti-HPA-1a and probable anti-HPA-3a platelet reactive

typically low in the absence of recent cardiothoracic surgery or a known pulmonary or

antibodies, confirming the diagnosis of PTP. She was discharged in a stable condition and

cardiac infection. In addition, patients may not have the classic symptoms of pericarditis

has had no further episodes of thrombocytopenia.

including chest pain, a pericardial friction rub, or electrocardiographic abnormalities. As a

DISCUSSION: Differential diagnoses of thrombocytopenia entertained in this case

result, purulent pericarditis often goes unrecognized until the late stages of infection. Once

included pseudothrombocytopenia, DIC, idiopathic thrombocytopenia (ITP), antibiotic-

purulent pericarditis is suspected, empiric intravenous antibiotics should be promptly

induced thrombocytopenia and HIT, each of which was considered less likely as described

administered and pericardial drainage should be performed. Without treatment the infec-

above. In patients who have previously received blood transfusions with mismatched

tion is universally fatal. Death usually occurs secondary to septic shock or obstructive

HPA, subsequent exposure to PRBC, platelet concentrates or plasma leads to an increase

shock from either tamponade or constrictive pericarditis. Even with appropriate treatment,

in HPA antibody levels, resulting in the characteristic severe thrombocytopenia (60, male sex, injection

represent acute coronary syndrome and can result from common non-ischemic process-

drug use, poor dentition, structural heart disease, Intravascular devices, prosthetic heart

es such as pericarditis. Indeed, literature cites at least 12 cases of acute pericarditis

valves, hemodialysis and HIV. Our patient had a bicuspid aortic valve which increases risk

misdiagnosed as acute myocardial infarction, some receiving thrombolysis. Key diag-

of IE. Most common cause is Staph. Aureus, CONS accounts for 10 % cases. Usual

nostic clues lie in the symptomology, risk factors and EKG findings. Acute pericarditis




typically presents as sharp, pleuritic chest pain, worsened with lying down and relieved

thrombocytopenic purpura (TTP) and acute cerebrovascular attack diagnosed in 1997, and

with leaning forward. EKG showing diffuse ST elevation with PR depression is

a recurrent attack of thrombotic thrombocytopenic purpura which resulted in a splenec-

pathognomonic. Our patient had these classic symptoms of pericarditis. His initial

tomy in 1999. She also has a history of hyperthyroidism, and hyperlipidemia. Patient has

atypical EKG should not mislead clinicians. One case series report 43 % of pericarditis

not had any issues with platelets or symptoms since her splenectomy in 1999. Family

with atypical EKGs, mostly seen in ESRD and hypothyroidism. If so, a TTE is

history was not significant. Physical exam at the time of admission revealed a well

indicated for further evaluation and over 50 % show pericardial effusion, as true in

appearing, alert and oriented female. She had a fine petechial rash on the bilateral lower

this case. Our case further emphasizes the need to distinguish between acute pericarditis

extremities and neurological exam was intact without focal deficits. Initial laboratory

vs. recurrent pericarditis given differing etiologies and therapies. While acute pericar-

studies showed elevated reticulocyte count, lactate dehydrogenase, indirect bilirubin and

ditis is mostly idiopathic or infectious, recurrent pericarditis is often autoimmune in

fibrinogen. Initial platelet count was 17 and she had decreased haptoglobin prompting

etiology. This case suggests additional risk factors for recurrent pericarditis, namely

urgent treatment with steroids while awaiting further testing. Peripheral smear revealed

ESRD and DAPT. ESRD patients with no typical risk factors of autoimmune condi-

multiple schistocytes. Imaging of her abdomen revealed evidence of her previous sple-

tions, repeat infections, or metabolic abnormalities can develop recurrent dialysis-

nectomy and lack of accessory spleen formation. Hematology/oncology as well as

associated pericarditis. Incidence can be as high as 20 %. The predisposition for uremic

nephrology were consulted, who agreed the patient was likely experiencing a repeat

bleeding from platelet dysfunction and the use of heparin during hemodialysis elevates

occurrence of thrombotic thrombocytopenic purpura. Interventional Radiology was then

this risk to the hemorrhagic form of pericarditis. These risk factors along with active

consulted for temporary dialysis catheter placement and the patient began plasmapheresis.

DAPT resulted in our patient’s recurrent hemorrhagic pericarditis. Poor prognostic

In the meantime, the patient’s ADAMTS13 activity returned low. Patient improved and

indicators include worsening anemia, volume overload state, and rapid accumulation

platelets increased to 127 at time of discharge. Her steroids were continued on discharge as

of pericardial effusion. Close monitoring with serial CBCs and TTEs is recommended.

a prolonged taper. Patient was followed closely by Hematology and Nephrology.

Treatment of acute pericarditis involves NSAIDS as first line therapy and colchicine as

DISCUSSION: This case illustrates the potential for recurrence of TTP in patients with a

adjunct therapy to improve symptoms and decrease recurrence. For recurrent pericardi-

history of TTP, including those who have previously undergone splenectomy. Although

tis, the NSAIDs-colchicine combination can be effective as well. However, those

post splenectomy patients were previously presumed to have a lower risk of recurrence,

refractory to NSAID therapy may warrant a short course of high dose glucocorticoids

new studies show this may not be the case. Prompt initiation of plasmapheresis and

to be slowly tapered in conjunction with a prolonged course of colchicine.

steroids are the cornerstones of therapy to decrease morbidity and mortality. There is no

Glucocorticoids are not recommended in one episode of acute pericarditis due to an

consensus regarding the benefit of splenectomy in patients with recurrent TTP and risks

increase recurrence rate of pericarditis. Additionally, ESRD patients on active DAPT

outweigh potential benefits. These include overwhelming infection with encapsulated

should avoid NSAIDS and be switched to a heparin-free dialysis protocol to prevent the

organisms and abdominal vein thrombosis, which prompt the need for postoperative

hemorrhagic type of recurrent pericarditis. Colchicine should also be encouraged as it

prophylactic vaccination, thromboembolism prophylaxis, and patient education. This case

reduces recurrences of uremic pericarditis. Timely recognition of pericarditis in ESRD

also provides insight on the spectrum of presentation of TTP. Thrombotic thrombocyto-

patients may not aid in prevention but will certainly reduce costly and harmful

penic purpura is characterized classically by the presence of fever, anemia, thrombocyto-

interventions. Of importance is the clinical history with consideration of patients’ risk

penia, renal insufficiency, and neurological changes ranging from headache to coma.

factors and assessment of diagnostic needs, including EKG and TTE. Further distinction

However, it exists on a spectrum from mild signs and symptoms to fulminant TTP with

between acute pericarditis and recurrent pericarditis in ESRD patients is essential in the

coma. Many patients with milder initial manifestations may present to their primary care

proper management of this potentially fatal condition.

physician’s office or prompt care where the diagnosis may be missed. Clinicians in ambulatory care facilities should also keep a high index of suspicion they may be seeing a patient present with early signs and symptoms of TTP, and obtain platelet counts and a


peripheral smear.

POST SPLENECTOMY PATIENT Preeti Patel. UICOMP, Peoria, IL. (Control ID #2466016) RECURRENT DELAYED TRALI Andrei Yankovich1; Tatiana McKenna2; Stephen LEARNING OBJECTIVE #1: A high index of suspicion for recurrence of thrombotic

Tieku3. 1Capital Health Regional Medical Center, Levittown, PA; 2Capital Helath

thrombocytopenic purpura should be maintained in any patient with a previous history of

Regional Medical Center, Hopewell, NJ; 3Capital Health, TRENTON, NJ. (Control ID

TTP, including those who are status post splenectomy.


LEARNING OBJECTIVE #2: Patients may present with thrombotic thrombocytopenic purpura early in the disease course with only minor signs and symptoms such as gingival

LEARNING OBJECTIVE #1: Clinicians need to recognize this condition, as it has high

bleeding. These patients frequently present to their primary care physician’s office.

prevalence in critically ill patients and carries a high mortality risk.

Physicians should be aware that early recognition and prompt imitation of steroids and

LEARNING OBJECTIVE #2: A patient with history of TRALI requiring blood

plasmapheresis will decrease mortality.

transfusion needs special attention; blood products should have minimal length of storage,

CASE: A 54-year-old female presented to the emergency department with gingival

and transfusion should be performed using leukocyte filters. Conservative transfusion

bleeding, hematuria and bilateral lower extremity petechial rash. A few days prior, she

practices, such as using the cut off for Hb of less than 7 mg/dl for non-cardiac patients,

presented to a prompt care with concerns of prolonged gingival bleeding after brushing her

may decrease transfusion reaction rates

teeth. She was offered supportive care and a follow up appointment in 1 week if she had no

CASE: A 48 year old Caucasian male with history of Type 2 Diabetes, ESRD, testicular

improvement. Within 24 h, she developed gross hematuria followed by a petechial lower

cancer, and polysubstance abuse was admitted to the hospital with sepsis secondary to legs

extremity rash prompting her to visit the emergency department. She denied any head-

cellulitis. On day 2, he was transfused with 2 Units of PRBC’s for a hemoglobin of 7.0 mg/

aches, recent changes in mental status or any recent infections. Her past medical history

dL. Patient’s condition was relatively stable, with no leukocytosis or fever, but 5 days later,

was significant for idiopathic thrombocytopenic purpura diagnosed in 1995, thrombotic

he developed acute respiratory failure with picture of ARDS. There was no cardiomegaly




on CXR and PO2/FiO2 122, and patient required mechanical ventilation with PEEP of 8.

Although Malignant insulinoma, a very rare variant, needs to be identified early and

Echocardiogram showed EF 55 % with impaired diastolic relaxation. The patient received

differentiated from more common benign variant as the management of both the entity is

supportive treatment including IV methylprednisolone. On day 3 after intubation the

entirely different. Most patients present with characteristic symptoms such as hypoglyce-

patient showed significant improvement and on a day 4 was successfully extubated. The

mia, weakness, blurred vision, palpitations though the loss of consciousness and seizures

patient was discharged with diagnosis of noncardiogenic pulmonary edema. Two months

is described. The fasting plasma levels of insulin, C-peptide, and, to a lesser degree,

later, the patient was readmitted to the hospital with left foot gangrene and leg cellulitis. He

proinsulin are elevated. Imaging techniques are then used to localize the tumor, most

was treated with vancomycin, aztreonam, and metronidazole and had great toe amputa-

frequently transabdominal or endoscopic ultrasound, CT, MRI, or somatostatin receptor

tion. After the surgery, the patient required PRBC transfusion. He was relatively stable

scintigraphy. Medical treatments of insulinomas include diazoxide and octreotide.

without fever. Three days later, the patient developed respiratory failure and ARDS picture

Resection of insulinoma is often curative in benign cases, but metastasis reduces survival

without cardiomegaly on CXR, PO2/FiO2 112, and NT-proBNP 6191. Initially he

rates by 60 %. Hepatic artery embolization, radiofrequency ablation, and hepatic resection

received trial of diuretics but later required mechanical ventilation with PEEP of 8. The

can be tried in hepatic metastasis.

patient responded well to supportive treatment including IV steroids, and on a day three after intubation was successfully weaned from ventilator. DISCUSSION: The classic TRALI syndrome is a rare condition characterized by the


acute onset of respiratory failure within hours of the transfusion of a blood product. The

Jawish2; Robert Asbury1; Yazan Samhouri1. 1Rochester Regional Health/Unity Hospital,

transfusion of blood products in critically ill patients increases the risk for the development

Rochester, NY; 2Unity Hospital, Rochester, NY. (Control ID #2469688)

of lung injury 6–72 h after the transfusion. The syndrome known as a “Delayed TRALI” is occurs in up to 25 % of critically ill patients receiving a blood transfusion, and is

LEARNING OBJECTIVE #1: To recognize the need to broaden the differential after

associated with a mortality of up to 40 %. “Delayed TRALI syndrome” is more common

failed therapy for sinusitis in a patient with prior Non Hodgkin lymphoma (NHL).

than we thought. The risk increases as the number of transfused blood products increase.

CASE: A 74 years old female with the past medical history of Chronic Lymphocytic

Leukodepletion may reduce the incidence of delayed TRALI as leukocyte reduction has

Lymphoma (CLL) was treated with two cycles of Bendamustine 2 years ago. She

been demonstrated to reduce the accumulation of biologically active mediators in stored

presented to the ED with nasal congestion, sinus headache, and post-nasal drip for the

blood. Recipient’s antiplatelet antibody and the length of blood storage before transfusion

last 3 weeks. Patient had multiple similar attacks in the last couple months, and she was

may increase the risk of developing delayed TRALI.

treated with Cephalexin, Amoxicillin, and Prednisone without complete relief of her symptoms. Her physical exam showed a low grade fever of 37.5C, sinus tachycardia, cervical lymphadenopathy and right deviation of her intranasal septum. Her CBC and


chemistry were unremarkable. Patient was started on intravenous (IV) fluid,

INSULINOMA Md U. Ali2; Mohammed AL-Jumayli2; Daniel Eichorn1; Agustin

Methylprednisolone, and IV Moxifloxacin. A sinus CT showed moderate to severe

Busta3; Phaniram Sumanam1. 1Capital Health Regional, Hamilton, NJ; 2Capital Health

mucosal thickening of the bilateral ethmoid, maxillary, and sphenoid sinuses. Patient


Regional Medical Center, Plainsboro, NJ; Mount Sinai Beth Israel, New York, NY.

was symptomatically improved with the steroid, so she was discharged home on oral

(Control ID #2468867)

Cetirizine and nasal fluticasone with instructions to follow up with an Otolaryngologist. She had an outpatient nasal diagnostic endoscopy that showed a lobulated soft tissue

LEARNING OBJECTIVE #1: Recurrent hypoglycemia presenting as a seizure in a

filling the nasopharynx. A biopsy was performed and the patient was diagnosed with low

patient underscores the need to assay insulin, C peptide, and proinsulin

grade B-cell lymphoma with positive CD20, CD19, and CD5, and negative for CD23.

LEARNING OBJECTIVE #2: The essential aspect of the diagnosis of insulinoma is a

Patient had a CT scan of chest/abdomen/pelvic that revealed mildly enlarged axillary

high index of clinical suspicion in the setting of unexplained recurrent hypoglycemia, and

lymph nodes and interval progression of mesenteric, retroperitoneal, and iliac chain

it is associated symptoms

lymphadenopathy. Treatment with Bendamustine and Rituxan was instituted.

CASE: A 65-year-old man with a history of ulcerative colitis and hypertension presented

DISCUSSION: Lymphoma is a malignant neoplasm of lymphocytes. The two major

with seizures in the setting of severe hypoglycemia. Workup included a CT abdomen that

classes of lymphoma are Hodgkin disease which typically arises in the lymph node,

showed multiple liver masses in both lobes of the liver. Blood sugar, Proinsulin, Insulin

and Non-Hodgkin lymphoma (NHL) which presents as extranodal disease. NHL may

and C- peptide were 32, 83.2 (normal 50 % mortality from

obtained more historical information. The patient described having oral sex with her

appendicitis is in this age group as most wait > 24 h until seeking help. Only 1/3 of

partner about 3 days prior to the onset of symptoms and recalled the same timing of

elderly patients present with classic symptoms of appendicitis. The differential also

symptoms after the same sexual contact 1 month prior. We performed nucleic acid

includes mesenteric ischemia, diverticulitis, bowel obstruction, AAA, malignancy and

amplification testing for neisseria gonorrhea and chlamydia trachomatis, and the former

gynecologic causes in women. This case highlights a common diagnosis in a more

was positive. A single injection of ceftriaxone cured her infection.

unusual age group and should prompt the need to “think outside the box” regarding other

DISCUSSION: The Centor Criteria were developed in 1981 as an aide to the correct

diagnosis such as malignancy given her age and social history. Cancers of the appendix

diagnosis of group A Streptococcal sore throat. The Centor criteria are: ●Tonsillar

themselves are very rare, found accidentally in 1 % of appendectomies and account for

exudates ●Tender anterior cervical adenopathy ●Fever by history ●Absence of cough

0.5 % all GI tumors overall. Over 80 % are carcinoid whereas remainder are adenocar-

The likelihood of having group A Streptococcal infection increases with the number of

cinoma. Majority occur in 55–65 year-old. This case was an adenocarcinoma ex goblet

Centor criteria. Patients having two or fewer of the criteria are not likely to have the

cell tumor, found almost exclusively in the appendix with the most frequent presenting

infection so testing and treatment costs can be saved. In this scenario, other causes must be

symptom as appendicitis (60–75 % cases), as they occur at the base compared to classic

entertained. The differential diagnosis of sore throat includes viruses (HIV, Herpes,

carcinoid which occurs at the tip of appendix. Classic symptoms of carcinoid are rare to

Epstein-Barr), bacteria (other Streptococci, Fusobacteria, Corynebacterium, Neisseria,

begin with ( 2 cm, a right

case we asked about sexual practices, HIV risks, and rashes before testing for gonorrhea

hemicolectomy and possibly adjuvant therapy with imaging 3 months follow up is the

and other sexually transmitted infections. Gonococcal pharyngitis is seen most often in

initial route. If < 1 cm (75–80 % tumors) appendectomy alone is suffice. If 1–2 cm and

people who practice oral sex. There are no pathognomonic findings with gonococcal

evidence mesoappendiceal extension, positive margins or involving cecum/high grade,

pharyngitis. The infection is more likely after fellatio than cunnilingus. The prevalence of

then an approach is similar to > 2 cm one. In general, only 5 % of appendiceal cancers are

infection in patients with sore throat is 1–6 %. Asymptomatic infections are common.

metastasized at presentation, and the overall prognosis, particularly with this subtype, has

Besides pharyngitis, Gonococcal infection can manifest as cervicitis, urethritis, pelvic

an 80 % 5 year survival with treatment.

inflammatory disease, epididymitis, proctitis, Bartholin gland infection, and disseminated disease. In this case, application of the Centor criteria appropriately broadened our differential diagnosis and helped us highlight risk factors for rarer pathogens.

WHEN IT’S JUST NOT HOT FLASHES Maile Ray; Jenny J. Lin. Icahn School of Medicine at Mount Sinai, New York, NY. (Control ID #2469310)


LEARNING OBJECTIVE #1: Recognize side effects of hormonal therapy for breast



DICITIS Andrew Trifan; Amar Kohli. UPMC, Mars, PA. (Control ID #2469450)

LEARNING OBJECTIVE #2: Understand treatment options for hormonal therapy side effects

LEARNING OBJECTIVE #1: To formulate a differential for abdominal pain in elderly

CASE: A 46 year-old woman with a history of estrogen-receptor positive stage IIA breast


cancer diagnosed 2 years ago was seen in primary care for regular follow-up. Her breast

LEARNING OBJECTIVE #2: To describe the treatment approach to adenocarcinoma

cancer had been treated with lumpectomy followed by chemotherapy and she had done

of the appendix

well with treatment, continuing to work almost full time. Currently taking tamoxifen, she

CASE: A 67-year-old woman presented to the emergency department with diffuse

had experienced only some hot flashes a few months after starting the medication. She had

bilateral lower abdominal pain for a few days. Her vitals were stable aside from a low

no other past medical history and was taking no other medications. At this visit, she

grade temperature and labs unremarkable except for a slight leukocytosis. Her exam

reported that she was experiencing more dyspareunia over the past several months to the

consisted of diffuse abdominal pain but no rebound or guarding. Given her symptoms

point where it was starting to impact her relationship with her partner. Due to the pain with

along with nausea that co-incided with the pain, a CT scan was done showing findings

intercourse and other hormonal changes, she no longer had any libido and was becoming

concerning for appendicits. She underwent a laparoscopic appendectomy without any

more depressed. She reported anhedonia, insomnia, decreased concentration and appetite.

complications, though given the enlarged thickened appendix adherent to the cecum, it

Exam revealed a tearful young woman, PHQ-9 score was 18 and gynecological exam

was sent off for pathology. The report came back as adenocarcinoma ex goblet cell

showed moderate vaginal atrophy. Patient was recommended to start regular use of a

carcinoid tumor. Invasive carcinoma was noted in proximal margins along with perineural

vaginal moisturizer and referred for behavioral counseling and to consider starting anti-




depressants. Several months later, patient returned after having started to see a therapist

LEARNING OBJECTIVE #1: Recognize the association of chronic marijuana use with

and psychiatrist regularly. She had been started on an anti-depressant, started to exercise

acute pancreatitis

regularly, and had also been referred to a sexual health psychologist. She was doing pelvic

LEARNING OBJECTIVE #2: Identify that increasing prevalence of marijuana use

floor exercises, using vaginal moisturizers, and using vaginal lubricants during sex. She

could increase incidence of hitherto rare complications

had also started using herbal remedies to help improve her sexual functioning. She was

CASE: A 33 year old man with no significant past medical history presented for

able to continue on tamoxifen.

evaluation of gradually progressive mid abdominal pain of 6 days duration. He was in

DISCUSSION: Hormonal therapy for breast cancer (HT), including tamoxifen and

his usual state of health, working as a software specialist prior to onset of symptoms. He

aromatase inhibitors (AIs), is known for its abrupt and dramatic estrogen depletion, which

noted severe, “punching” abdominal pain, worsened on food intake and associated with

often leads to menopausal symptoms often more severe than those seen in natural

nausea. He denied fevers, sick contacts, excess alcohol intake (last intake was a month

menopause. While hot flashes and musculoskeletal symptoms are the side effects most

prior) or excess fatty food consumption, yellowing of skin, rashes, joint pains or right

commonly associated with HT, sexual side effects are actually more prevalent and tend to

upper quadrant abdominal pain. He denied using any medications. He was found to have

be underreported. Estrogen helps maintain good sexual health in many ways, including

moderate epigastric tenderness with negative Murphy’s and McBurney’s signs, and no

objective measures (vaginal pH, maturation index, cornification index) and subjective

evidence of jaundice. Laboratory results revealed elevated lipase of 1200 U/L and amylase

measures (libido, sexual satisfaction, dyspareunia). Estrogen deprivation can cause the

of 450 U/L which correlated with CT scan findings of heterogeneous and enlarged

loss of genital tissue elasticity and lubrication, as well as changes in vaginal pH, resulting

pancreatic head consistent with pancreatitis. An abdominal ultrasound did not reveal

in an array of sexual symptoms such as dyspareunia, vaginal dryness, soreness, irritation,

gallstones or biliary ductal dilatation. Further workup revealed normal triglyceride levels,

discharge, and decreased libido. Our patient presented with loss of libido, moderate

negative alcohol level, negative hepatitis serologies and negative autoimmune serologies.

vaginal atrophy, and moderate dyspareunia. Our patient also presented with depression.

On further questioning, he revealed that he had been growing and smoking marijuana

Mood disturbances are also common with HT yet can be stigmatized. Depression can also

daily since age 16, and had last smoked marijuana on the morning of presentation. He

be attributed, in part, to other factors associated with a cancer diagnosis. Estrogen is

improved clinically and lipase levels normalized after 3 days of conservative management

thought to have a neuroprotective effect and also acts on multiple neurotransmitter

with intravenous fluids, pain control, and slow advancement of diet.

systems, including those that regulate serotonin, dopamine, GABA, glutamate, and

DISCUSSION: Marijuana is the most commonly used illicit drug in the United States,

monoamine oxidase. Our patient presented with several classic symptoms of depression,

and its prevalence is increasing, with almost 20 million current users aged 12 or older

including anhedonia, decreased appetite, and cognitive difficulties. Treatment for the

(7.5 % of the population) up from almost 15 million users (5.8 %) in 2007. Despite its

sexual and mood side effects of HT can be complex because some potential treatments

current Federal classification as a Schedule I substance (having no medicinal use and high

may interfere with HT itself. Estrogen supplementation is often used in postmenopausal

risk for abuse), marijuana has been legalized for adult recreational use in four states at

women without a breast cancer predisposition as a treatment for menopausal symptoms.

present and nineteen other states (and the District of Columbia) have legalized use of

However, because estrogen feeds estrogen receptor-positive cancers, it is contraindicated

marijuana for medical purposes. As its prevalence of use increases, we are uncovering rare

to use estrogen supplementation to alleviate HT symptoms. Instead, other treatment

complications seen after long term use. While alcohol and gall stones remain the most

strategies are needed. Sexual health symptoms are best addressed by interventions that

common etiologies for acute pancreatitis, drugs are a contributory cause in a small yet

maintain or restore the natural vaginal pH and replenish intracellular fluids to the vaginal

considerable portion of acute pancreatitis cases. Marijuana (Cannabis) has several chem-

epithelium. The primary evidence-based strategies to accomplish this include vaginal

ical constituents, the chief among them being Tetrahydrocannabinol (THC). Cannabinoid

moisturizers, such as polycarbophil gel and hyaluronic acid, and the herbal supplement,

receptors in the human body are of two known types—CB1 and CB2, both of which are

red clover. There is also mixed evidence that red clover may improve libido. Further, pelvic

expressed throughout the body. CB1 is predominantly found in the central and peripheral

floor exercises and vaginal dilator therapy help women increase control over pelvic floor

nervous systems whereas CB2 is found in macrophages and immune tissues such as

muscles, thereby alleviating some of the pain associated with vaginal atrophy. While there is

spleen, tonsils and thymus. Both CB1 and CB2 are present in pancreatic tissue. Both are

limited evidence base for these treatments, a combination of them did alleviate symptoms

present in the Islet of Langerhans; CB1 receptors are seen in glucagon-containing α cells

substantially in our patient. Our patient used traditional strategies to treat depression, not

while CB2 receptors are seen in both α and insulin-containing β cells. Cannabinoids have

specific to symptomatology brought on by estrogen depletion. There is a significant evidence

been shown to have both protective and destructive effects on different parts of the gut.

base for the use of antidepressants and regular exercise to reduce or eliminate depressive

They have been used in prevention and treatment of nausea and stimulation of appetite in

symptoms. There are many differing views on the use of phytoestrogens, such as red clover.

the treatment of anorexia. In the stomach, cannabinoids act to relax the lower esophageal

Some say phytoestrogens prevent side effects without significant estrogenic effect or cancer

sphincter, reduce gastric acid secretion and delay gastric emptying. They also decrease

risk, while others contend phytoestrogens may increase breast cancer risk and should be

small intestinal secretions and increase GI transit times. However, a harmful effect of

avoided, at least among women with breast cancer predisposition. The interaction of

cannabinoids has been observed in the small intestine where they activate the capsaicin-

phytoestrogens with the ERα and ERβ receptors appears complex and may differ according

sensitive vanilloid receptor (transient receptor potential vanilloid 1–TRPV1) and can

to cancer status. Our patient showed significant improvement in sexual symptoms after

cause or worsen ileitis. In addition, administration of a CB1 receptor antagonist (SR

2 months of treatment. Additionally, her depression lifted within a month. She will likely

141716) has been shown to reduce TNF-α levels and reduce ulceration of the small

benefit from long-term treatment to alleviate sexual and mood symptoms so she may

intestine in rodents. In the pancreas, studies have shown that cannabinoids worsen

continue using tamoxifen to prevent a recurrence of breast cancer.

cerulein-induced pancreatitis in mice. Pre-treatment with Anandamide, an endocannabinoid, increased the severity of pancreatic tissue damage, increased serum levels of pancreatic enzymes and levels of pro-inflammatory cytokines like interleukin-


1β. With increasingly prevalent use of marijuana, rare complications of its use must be

MARIJUANA USE Sabrina N. Huq2; Bharadwaj Ravi1; Sofia Terner2. 1Kasturba

considered in diagnosis. THC-induced pancreatitis has been seen in patients with exces-

Medical College & Hospital, Boston, MA; 2Montefiore Medical Center, Wakefield,

sive use of marijuana and is considered dose related. The exact mechanism is yet

Bronx, NY. (Control ID #2467863)

unknown. With discontinuation of usage, regression of symptoms has been reported in




most cases. However, the diagnosis of marijuana-induced pancreatitis is to remain one of

CASE: A 53 year old Korean speaking female with a past medical history significant for

exclusion, only after having ruled out more common etiologies such as alcohol, choleli-

cirrhosis due to chronic hepatitis B infection presented with sub-acute mild progressive

thiasis, infections, trauma, tumors or other medications.

shortness of breath in the setting of a recent flu-like illness and exposure to sick contacts. In the ED she was found to be hypoxic to 83 % on room air. She was also found to have bilateral hand and feet clubbing on physical examination. Infectious etiologies were investigated;


Influenza and other viral respiratory pathogens were negative by PCR. Mycoplasma, HIV

ISCHEMIC STROKE Tahmina Begum; Sarah Ahmed; Miles Grant; Roger D.

and TB were negative too, and her CXR was unremarkable. CT pulmonary angiogram was

Smalligan. Texas Tech Univ Health Sc Center - Amarillo, Amarillo, TX. (Control ID

also non-diagnostic for a pulmonary embolism. She continued to be hypoxic though clinically


looked well. On further questioning, given her signs of chronic hypoxia consisting of clubbing, we were able to discern the pattern of her dyspnea, as platypnea, which lead to

LEARNING OBJECTIVE #1: Reminder that hormonal contraceptive methods place

the consideration of hepatopulmonary syndrome. This was further corroborated by positive

women at risk for ischemic stroke.

orthostatic desaturations or orthodeoxia. The diagnosis was confirmed with a trans-thoracic

LEARNING OBJECTIVE #2: Young people may present with atypical clinical features

contrast induced ECHO with agitated saline which showed a moderate-to-severe right-to-left

of ischemic stroke.

shunt with delay suggesting an intra-pulmonary shunt indicative of a hepatopulmonary

CASE: A 24-year-old previously healthy young woman was admitted with sudden onset

syndrome. Furthermore, it also showed an elevated pulmonary artery pressure and A-a

confusion, trembling and weakness of the left side of her body. At the time of the event she

gradient which both also support a diagnosis of hepatopulmonary syndrome. A formal

had just fallen off her jet ski but she denied any significant trauma as she entered the water

pulmonary angiogram was not done due the recent CT pulmonary angiogram that did not

with her life vest on. She was carried out of the water by her friends who found her

show any evidence of a collateral pulmonary pathway. She was discharged on supplemental

confused and unable to walk. She felt numb on her left side, was nauseated and vomited in

oxygen with a follow up to arrange for a liver transplant.

the emergency room. Past medical history was completely negative and her only medi-

DISCUSSION: The clinical features of hepatopulmonary syndrome (HPS) are the

cation was birth control using an etonogestrel/ethinyl estradiol vaginal ring (NuvaRing)a

consequences of both hepatic and pulmonary dysfunction. More than 80 % of patients

NuvaRing which had been using for some time. She did not smoke, use illicit drugs or

present with symptoms of liver disease; the remainder experience dyspnea as their

drink alcohol to excess. No family history of premature vascular disease or events or

initial symptom . Most patients with HPS eventually develop dyspnea on exertion, at

coagulation disorders. On physical exam she was alert but anxious, BP 150/90, P 80, R 18,

rest, or both, usually after years of liver disease. However, dyspnea is a non-specific

afebrile, mild left facial droop, neck supple, lungs, heart, abdomen and extremities normal,

finding in patients with liver disease because it may also be the consequence of a

strength 4/5 in left arm and left leg. Labs including CBC, complete metabolic panel and

hepatic hydrothorax, Porto pulmonary hypertension, anemia, ascites, fluid retention,

coagulation studies were normal. Noncontrast head CT was negative but MRI showed a

and muscle wasting. Dyspnea may be accompanied by pulmonary findings that are

right middle cerebral artery ischemic infarction. She was started on aspirin and atorvastatin

more specific for HPS like Platypnea which is an increase in dyspnea that is induced

and showed rapid though partial recovery. She was sent to an inpatient rehabilitation unit.

by moving into an upright position and relieved by recumbency. Another specific

DISCUSSION: The NuvaRing is a small, flexible vaginal ring used to prevent pregnancy.

sign is Orthodeoxia which refers to a decrease in the arterial oxygen tension (by more

It delivers etonogestrel/ethinyl estradiol 0.12 mg/0.015 mg daily. Although the amount of

than 4 mmHg [0.5 kPa]) or arterial oxyhemoglobin desaturation (by more than 5 %)

delivered hormone is very small, it still can cause significant morbidity related to

when the patient moves from a supine to an upright position, which is improved by

thromboembolism to different organ systems including the brain, the heart, the lungs or

returning to the recumbent position. The presence of orthodeoxia in a patient with

the extremities. A recent meta analysis showed the odds ratio for first-ever ischemic stroke

liver disease is strongly suggestive of HPS, although it can be seen in other situations

risk associated with current oral contraceptive pill (OCP) use compared with noncurrent

(eg, post-pneumonectomy, recurrent pulmonary emboli, atrial septal defects, and

OCP use was 2.47 [95 % confidence interval (CI), 2.04–2.99]. The risk of ischemic stroke

chronic lung disease) . Orthodeoxia affects up to 88 % of patients with HPS,

among current OCP users decreased significantly with decreasing estrogen dose: OCPs of

compared to 5 % or fewer of patients with cirrhosis alone . The diagnostic tests that

≥50 μg ethinyl estradiol (EE) OR 3.28; 30–40 ug EE OR 1.75; 20 ug EE OR 1.56. All

can be used to detect IPVDs include contrast-enhanced echocardiography,

different generations of progestin only pills were associated with an elevated risk of

technetium-99 m-labeled macro aggregated albumin scanning, and pulmonary arte-

ischemic stroke as well. Based on this data and other studies, the NuvaRing has a black

riography . Contrast-enhanced echocardiography is generally preferred because it is

box warning by the FDA regarding use in active smokers and those over age 35 due to the

more sensitive than technetium-99 m-labeled macro aggregated albumin scanning

high risk of stroke or thromboembolism. Our case is an unfortunate example of this very

and less invasive than pulmonary arteriography, with an intrapulmonary shunt,

risk except that she was young and had no history of smoking or other risk factors.

contrast generally appears in the left heart three to six heart beats after its appearance

Physicians need to continue to discuss these thromboembolic risks with all women

in the right heart . In patients with liver disease, detection of an intrapulmonary right-

choosing hormonal contraceptive methods.

to-left shunt is considered indicative of IPVDs.

WHEN YOUR LIVER CAN NOT BREATHE Issra Jamal. Baystate medical center,


Broad Brook, CT. (Control ID #2469511)

PENIAS Cameron Kemal1; Daniel M. Huck2; Viraj V. Patel1. 1Albert Einstein College of Medicine, Bronx, NY; 2Montefiore Medical Center, Bronx, NY. (Control ID #2466414)

LEARNING OBJECTIVE #1: Recognize the signs and symptoms of chronic hypoxia as a presenting symptom of hepatopulmonary syndrome in patients with an underlying

LEARNING OBJECTIVE #1: Diagnose Waldenström Macroglobulinemia based on

liver disease

clinical features, laboratory values, and diagnostic studies

LEARNING OBJECTIVE #2: Recognize the importance of discerning pattern of

LEARNING OBJECTIVE #2: Recognize common and uncommon autoimmune man-

dyspnea when assessing cirrhotic patients presenting with shortness of breath

ifestations of Waldenström Macroglobulinemia




CASE: An 86 year old woman presented with 2 weeks of dizziness, fatigue, several days

LEARNING OBJECTIVE #1: Recognize symptoms and appropriate management of

of abdominal pain and constipation, and noted a 30 lb weight loss over the past year. She

neuropsychiatric lupus

denied having fevers, chills, night sweats, or appetite changes. She had paresthesias in her

LEARNING OBJECTIVE #2: Identify the typical disease course and prognosis in

lower extremities and a 2-year history of isolated neutropenia. On exam, she had a 2/6

neuropsychiatric lupus

systolic crescendo-decrescendo murmur heard throughout the precordium and conjuncti-

CASE: A 25 year old African-American woman was brought into the emergency department

val pallor, but no splenomegaly or hepatomegaly. Initial diagnostic work up revealed

by EMS after she was found unresponsive in her apartment. Her mother had called 911 as she

pancytopenia with a white blood cell count of 4.4 K/uL, low absolute neutrophil count of

was unable to reach her daughter for a day. Police found the patient unconscious and unable to

1.0 K/uL, and a normal lymphocyte count, low platelet count of (47 K/uL), and low

be aroused, lying in her own feces and urine, with no witnesses or medical history available. In

hemoglobin (6.8 g/dL) and hematocrit (21 %) with a slightly elevated MCV (97.2 fL) and

the ED, physical exam showed an obtunded female with GCS of 6 T. Neurological exam

reticulocyte count of 2.6 %. LDH was elevated (1187 U/L). A Direct Coombs test was

revealed a left eye gaze with horizontal nystagmus, absent Babinski reflex, 3+ reflexes in

positive for a pan-agglutinin (IgG) antibody, erythrocyte sedimentation rate was elevated

upper extremity, and 4+ reflexes in lower extremity bilaterally. CT head did not demonstrate

(140 mm/h), and an anti-nuclear antibody (ANA) test was negative. Serum immunoglob-

acute hemorrhage or masses. The patient was intubated to protect her airway and admitted to

ulin analysis revealed a markedly elevated IgM of 1820 mg/dL with a kappa/lambda ratio

the ICU. She was started on empiric therapy for seizure with levetiracetam and for meningo-

of 44. Based on these preliminary findings, we entertained a diagnosis of malignancy

encephalitis with ceftriaxone, vancomycin, and acyclovir. Lumbar puncture revealed no

versus autoimmune disease. Prednisone was initiated to treat autoimmune hemolytic

infection, and urine drug screen was normal. Brain MRI showed restricted diffusion along

anemia. On day 3, we performed a bone marrow biopsy which revealed a

the posterior frontal, parietal and temporal cortices bilaterally with diffuse pachymeningeal

lymphoplasmacytic infiltration consistent with Waldenström Macroglobulinemia. Che-

enhancement concerning for an autoimmune process. Using the regional online health

motherapy was initiated with bendamustine and rituximab and a tapering steroid course

information exchange, we discovered that the patient had been diagnosed with SLE at a

was continued with improvement in hemoglobin (11.0 g/dL), platelet count (126 K/uL)

nearby hospital, 2 weeks prior to this admission. She had been started on steroids and

and absolute neutrophil count (3.9 K/uL) at 2 months after initiation.

hydroxychloroquine, and was discharged with plans for rheumatology follow-up. However,

DISCUSSION: Waldenström Macroglobulinemia (WM) is a rare malignant plasma cell

she missed that appointment, and medication compliance was unknown. Workup at the other

dyscrasia characterized by a monoclonal IgM gammopathy and lymphoplasmacytic

facility revealed a mixed lupus and Sjogren’s picture, with evidence of renal and hematologic

infiltration of the bone marrow or lymphatic tissue. The incidence of Waldenström

involvement of her SLE. In our ICU, the patient was treated with levetiracetam, lacosamide,

macroglobulinemia is estimated around 2 to 5 cases per 1 million most commonly

and pregabalin for seizures, and diagnostic EEG was performed. She was also started on pulse

diagnosed in white males with a median age of 65 years. The most common clinical

dose steroids and cyclophosphamide for SLE. Her neurologic status remained unimproved,

presentations of WM are fatigue and weakness, peripheral neuropathy, anemia, constitu-

and her ICU course was marked by multiple complications, including massive hemoptysis at

tional “B” symptoms, and abnormal bleeding. There are also unique manifestations

her tracheostomy site, prolonged seizures, and anoxia. Her chance of recovery was believed to

accountable to the monoclonal gammopathy of IgM antibody, including hyperviscosity

be very poor given intensity of her condition. She was transferred to the medical floor on day

syndrome and autoimmune manifestations. Currently, several criteria exist for the diag-

26 after passing tracheostomy collar trial, but she continued to have no purposeful movements.

nosis of WM including the World Health Organization Lymphoma Classification as well

Over the next 2 months, she slowly regained neurological function in her extremities, and was

as the Mayo Clinic. Clinically, however, monoclonal IgM gammopathy in the presence of

discharged to inpatient rehabilitation on oral prednisone and lacosamide. She returned home,

10 % or more lymphoplasmacytic infiltrate of the bone marrow can be considered

and in the rheumatology clinic 1 month after discharge, had regained full neurological

diagnostic for WM if other lymphoproliferative diseases (including chronic lymphocytic

function. She began her third dose of cyclophosphamide and was continued on her seizure

leukemia and mantle cell lymphoma) have been excluded. This lymphocytic infiltrate

medications, and returned to work. She continues to follow with rheumatology and neurology.

must demonstrate plasmacytoid or plasma cell differentiation and one of many typical

DISCUSSION: SLE affects the neurological system by affecting inflammatory, vascu-

immunophenotypes. Autoimmune manifestations in WM are varied. A mutation in

litic, thromboembolic, and meningeal pathways through a series of complex mechanisms.

myeloid differentiation of factor 88 (MYD88) is found in almost all WM cases, causing

As a result, patient may experience a range of symptoms including stroke, seizures,

malignant proliferation and likely having a role in the autoimmune manifestations in the

cognitive dysfunction, and headaches. Risk factors for neuropsychiatric SLE include the

disease. Recent studies suggest that autoimmune cytopenias are relatively common in

presence of antiphospholipid antibodies, nephritis, young age, and African American

WM with anemia most frequently the result of autoimmune hemolytic anemia; both cold

ethnicity. Recognizing neuropsychiatric manifestations of SLE is important as manage-

(IgM) and warm (IgG) subtypes have been associated with the disease. Immune throm-

ment involves treating both the neurological symptoms and the underlying SLE. Symp-

bocytopenia (ITP) can also occur in the setting of WM, thought to be due to a platelet

toms of neuropsychiatric SLE should be evaluated and treated just as in patients without

associated IgM or IgG antibody. Neutropenia as seen in this patient has not been well

lupus. Our patient presented with a likely seizure, and was treated empirically for seizure.

described in the literature. A past medical history of neutropenia, persistence at the time of

Lupus patients with stroke should be treated as any other stroke patients. Airway,

this admission and responsiveness to corticosteroid treatment would suggest an autoim-

breathing, and circulation should always be assessed first when a patient presents with

mune causation. Peripheral neuropathy due to monoclonal IgM antibodies to neural

severe neurological symptoms, followed by an appropriate workup to rule out any

antigens, and rheumatic diseases including rheumatoid arthritis and antiphospholipid

common causes of neurological dysfunction. Once the patient has been stabilized and

syndrome are also associated with WM. In summary we present an unusual case of

started on appropriate neurological treatments, SLE treatments such as pulse dose steroids

Waldenström Macroglobulinemia presenting as isolated neutropenia that then evolved

are initiated to help recover from the underlying disease. Neurological symptoms may

into pancytopenia in the presence of autoimmune hemolytic anemia.

persist longer in SLE patients, leading to a long and difficult hospital course. Our patient was initially thought to have a very low chance of regaining neurological function. Despite these concerns, she recovered fully after 68 hospital days and an additional 16 days in


inpatient rehab. Because neuropsychiatric symptoms of SLE are often indistinguishable


from non-SLE neurological symptoms, diagnosis can be difficult, requiring strong clinical

Jillian Catalanotti. George Washington University, Arlington, VA. (Control ID #2465977)

suspicion and accurate medical history,





cancer. She had undergone a transurethral resection while admitted and was awaiting

New York Presbyterian Queens, Flushing, NY. (Control ID #2468805)

further outpatient oncologic care. On review of systems, the patient reported primary amenorrhea. On further questioning, she noted that a pelvic ultrasound in her twenties had

LEARNING OBJECTIVE #1: Recognize the implications of chronic corticosteroids

shown absence of ovaries. The patient had been informed she would likely not be able to

use in patients that require lifelong maintenance on immunosuppressants

bear children. No additional work-up was pursued. Physical exam was notable for a height

LEARNING OBJECTIVE #2: Recognize the presentation of atypical hemolytic uremic

of 58 in., small breasts with widely spaced nipples, and a broad chest. Labs revealed an


A1c of 9.2 %, total cholesterol of 212, and LDL of 118. Given her history of primary

CASE: A 51 year old female with known polymyositis on chronic prednisone presented

amenorrhea and physical features, the patient was counseled on the possibility of Turner’s

with 4 months of diarrhea. She denied any other symptoms. Physical examination was

Syndrome, and agreed to a karyotype which confirmed 45, X. For additional risk

notable for tachycardia of 110, temperature of 37.5C, abdomen was non tender. Laboratory

stratification, a DEXA scan was performed diagnosing osteoporosis (T score PA spine

testing showed hypoalbuminemia, elevated creatinine kinase, leukocytosis and microcytic

−2.7, left hip total −3.0 and femoral neck −2.9). An echocardiogram did not identify any

anemia. Her subsequent stool testing was positive for Strongyloides stercoralis. Despite

congenital cardiac abnormalities.

treatment with ivermectin and albendazole, her condition worsened. She developed gram

DISCUSSION: Turner’s Syndrome (TS) results from the complete or partial absence of

negative bacteremia with Bacteroides fragilis and Klebsiella pneumoniae. Subsequently, her

the second X chromosome. It affects about 1 in every 2500 live-born females. Typically a

platelet count and hemoglobin dropped and her kidney function worsened. A peripheral

diagnosis is made prenatally or during the pediatric years based on suspicion from

blood smear revealed the presence of schistocytes. ADAMSTS-13 activity was 77 %. Her

ultrasound findings in utero and physical exam features, with confirmation by karyotype.

deteriorating kidney function required her to be initiated on hemodialysis. She was intubated

It is, therefore, uncommon to make an adult diagnosis of TS. Only about 10 % of women

as she developed acute respiratory syndrome (ARDS) and was moved to the intensive care

with TS are diagnosed as adults. Women with TS are of short stature, typically 52–60 in..

unit. The patient’s diagnosis was atypical hemolytic uremic syndrome.

Due to altered skeletal growth, they have upper bodies which are larger and out of

DISCUSSION: Strongloides stercolaris is a human intestinal parasite, usually treated

proportion to the lower body, resulting in a “shield chest” appearance. Other phenotypic

with albendazole or ivermectin. Because of chronic corticosteroid therapy, our patient had

features may include micrognathia, cubitus valgus, webbed neck, low posterior hairline,

hyperinfection syndrome characterized by cycles of autoinfection. It is often accompanied

convex nails and edema of the hands and feet. As a result of gonadal failure, most TS

by sepsis from intestinal bacteria, hypothesized to be from the intestinal parasites migrat-

patients lack pubertal development and suffer from infertility. Therefore management in

ing through the enteric mucosa. In our case, the severe sepsis triggered a thrombotic

early adulthood often is focused on treatment of hypoestrogenic state and reproductive

microangiopathic syndrome. This syndrome is a diverse group of disorders united by

assistance. There are also many psychosocial ramifications of this diagnosis, prompting

common features: microangiopathic hemolytic anemia with thrombocytopenia. Hemolyt-

early intervention through social work and counseling. The workup for a woman of any

ic uremic syndrome (HUS) is usually precipitated by Escherichia coli O157:H7 and other

age newly diagnosed with TS includes a karyotype in addition to bloodwork to screen for

Shiga toxin producing bacteria. On the other side, thrombotic thrombocytopenic purpura

associated conditions. All women need fasting glucose and cholesterol testing, a yearly

(TTP) is caused by a deficiency of ADAMSTS-13, a protease that cleaves the von

TSH, urinalysis, and serum creatinine. Blood pressure should be monitored closely as the

Willebrand factor multimers. As our patient had normal ADAMSTS-13 activity and no

risk for hypertension is increased 3-fold in women with TS. Imaging of the heart and aorta

evidence of Shiga toxin producing bacteria, her diagnosis was atypical hemolytic uremic

is crucial to assess for cardiac abnormalities, such as bicuspid aortic valve and aortic arch

syndrome (aHUS). It is thought to be provoked by an uncontrolled activation of the

defects. Approximately one-third of TS patients have aortic enlargement putting them at

complement system. The distinction between these different syndromes is not only

risk for fatal aortic dissection or rupture. Even those without anatomic abnormalities are at

academic but also gears physicians towards treatment. HUS and TTP are treated with

twice the average risk for ischemic heart disease due to metabolic complications. The liver

plasma exchange in adults whereas aHUS is treated with eculizumab. Eculizumab is a

should be closely monitored since women with TS have a five-fold increased risk for

humanized monoclonal antibody that binds C5 complement protein. Given the patient’s

cirrhosis. A pelvic ultrasound must be obtained in patients with Y chromosome mosaicism

septicemia and hyperinfection with Strongyloides, initiating an immunosuppressant

to assess for gonadal dysgenesis. If the patient has “streak ovaries,” prophylactic removal

would worsen the infectious process. So eculizumab therapy was not initiated. This case

is recommended to reduce the risk for gonadoblastoma. Renal ultrasounds are needed for

highlights the adverse effects of chronic corticosteroid therapy. An otherwise simple

newly diagnosed patients, as structural abnormalities are common resulting in frequent

parasitic infection caused bacteremia, complicated by atypical HUS. Patients should be

urinary tract infections as well as hydronephrosis. Hearing and vision screenings are also

aware of the implication of steroids use and given alternatives when possible such as

important. Later in life, patients are at risk of cardiovascular disease, metabolic syndrome

biologic therapies. Biologic agents would offer a more targeted immune suppression and

and osteoporosis as long term side effects of low estrogen. In most cases, this is mitigated

fewer side effects.

through early diagnosis and treatment with supplemental estrogen therapy. Our patient exemplifies the unfortunate result of decades without estrogen: advanced osteoporosis and metabolic syndrome. However, with a clear diagnosis these and other comorbidities will

XOXO: MANAGING THE MISSING X Kristi Larned; Rebecca Glassman. Beth Israel

be routinely screened for, caught early and treated appropriately.

Deaconess Medical Center, Boston, MA. (Control ID #2469405)

LEARNING OBJECTIVE #1: Describe the signs, symptoms, and evaluation of Tur-


ner’s Syndrome LEARNING OBJECTIVE #2: Recognize the deleterious effects of long-term


hypoestrogenic states

(FIRST) Halle G. Sobel6; Rachel Swigris2; Karen Chacko1; Alison R. Landrey6; Monica

CASE: A 49-year-old woman with no significant past medical history presented to

C. McNulty3; Kaitlyn Vennard6; Susan M. Nikels3; Suddarth Kathleen4; Edward N.

establish care with an internist after 35 years without medical care. She had presented to

Murphy4; Eva M. Aagaard5. 1Univeristy of Colorado Denver, Aurora, CO; 2University

the emergency department 3 weeks prior for hematuria and was found to have bladder

of Colorado, Denver, CO; 3University of Colorado Denver, Aurora, CO; 4University of




Colorado School of Medicine, Denver, CO; 5University of Colorado School of Medicine,

on the value on resident assessments combined with a focus on patient outcomes, research

Aurora, CO; 6University of Vermont Medical Center, Burlington, VT. (Control ID

assessing the impact of new models of scheduling is needed.


NEEDS AND OBJECTIVES: Many Internal Medicine residency programs have im-


plemented block-scheduling templates (X + Y models). In an attempt to maximize


continuity between supervising faculty and residents in the outpatient setting, some

PLEXITY PATIENTS Anna Strewler2; Nathan Ewigman1; Bridget O’Brien1; Jessica

programs have also adjusted faculty precepting schedules to mimic those of the residents.

A. Eng1; Rebecca L. Shunk3. 1SFVA/UCSF, San Francisco, CA; 2San Francisco VA

“Intensivist” preceptors are assigned to a cohort of residents and precept this cohort during

Medical Center, San Bruno, CA; 3UCSF, San Francisco, CA. (Control ID #2469960)

the majority of the days during their outpatient weeks. In contrast, “traditional” preceptors generally precept one half day per week. Little is known about the impact of these different

NEEDS AND OBJECTIVES: Team-based care and interprofessional collaboration are

types of faculty schedules on residents, faculty or the patients they serve.

central tenets of the Patient-Centered Medical Home (PCMH), yet despite educational and

SETTING AND PARTICIPANTS: Our study included two internal medicine resident

clinical training in this setting, trainees are still greatly challenged by caring for patients with

continuity clinics at the University of Colorado: the Lowry Clinic and the Anshutz clinic.

the most complex medical and psychosocial needs. To build the skills necessary to function

Our study also included the single continuity clinic at the University of Vermont Medical

optimally in a PCMH while simultaneously aiming to improve the care of highly complex

Center. A total of 97 internal medicine residents and 37 faculty members were included in

patients, we introduced a monthly clinical case conference in July 2014 entitled Patient-

the study. Faculty members who were part of the study did not participate in the surveys.

Aligned Care Teams Interprofessional Care Update (PACT-ICU). The goals of the confer-

All the clinics operate with a 4 + 1 block scheduling model. In this model, residents are in

ence are to develop a collaborative, interprofessional treatment plan and to increase trainees’

their continuity clinic for 1 week followed by in-patient rotations or other electives for

understanding of the roles each team-member can play in caring for complex patients.

4 weeks and this template repeats throughout the year. The Lowry and Vermont clinics

SETTING AND PARTICIPANTS: PACT-ICU is part of the curriculum of the San

have an intensivist preceptor model and the Anshutz clinic has a traditional precepting

Francisco VA Center of Excellence in Primary Care Education (CoEPCE). The SFVA


CoEPCE trains core internal medicine residents and nurse practitioner trainees to deliver

DESCRIPTION: Our study examined the impact of intensivist and traditional faculty

team-based patient-centered care through Patient Aligned Care Teams (PACTs), the VA’s

scheduling models at two academic medical centers. We examined faculty and resident

version of PCMH. A PACT team consists of an RN, LVN, and clerk as well as the core and

perceptions of the ability of faculty to assess resident progress, resident and faculty ability

associated health trainees (clinical psychology fellows, clinical pharmacy residents, social

to develop interpersonal relationships with each other, faculty familiarity with residents’

work interns, and dietetic interns). PACT Intensive Management (PIM) is a case manage-

complex chronic patients, and their opportunity to discuss patients and their results both

ment program into which all PACT-ICU patients are referred. PIM consists of a geriatri-

during and in between clinic weeks. Residents and faculty at both sites were surveyed in

cian, RN’s, social workers, and a clinical psychologist.

December of 2014 using either a web-based or paper survey. The survey included

DESCRIPTION: Core trainees use a risk stratification tool developed by the VA called the

definitions of intensivist and traditional faculty preceptors, basic demographic information

(Care Assessment Need) CAN Score to choose patients with a high risk of hospitalization or

and likert scale questions (1 = strongly disagree and 5 = strongly agree) assessing percep-

mortality to present at PACT-ICU. Trainees write a patient narrative from the trainee and

tions of each of the domains noted above. To analyze differences between intensivist and

patient perspectives and present the patient during the hour-long conference. Interprofessional

traditional models, we used the Wilcoxon Rank Sum test. We did not keep track of the

trainees, staff, and PACT and PIM team members discuss the case and formulate a treatment

actual number of clinic sessions each type of preceptor spent with the residents.

plan with assigned action items. Staff-members with relevant expertise are also invited to

EVALUATION: There were 26 faculty survey responses (83 % response rate) and 75

present a clinical teaching pearl. The patient is automatically referred into PIM, which works

resident survey responses (77 % response rate). Intensivist preceptors reported feeling

in tandem with the trainee and PACT team for a period of 6–12 months to support the

more familiar with the residents’ complex patients (4.00 ± 0.76 vs. 2.88 ± 1.23, p = 0.05)

patient’s needs. To date, twenty-five patients have been presented.

and more comfortable evaluating their residents’ performance (4.38 ± 0.52 vs. 3.72 ± 0.67,

EVALUATION: Evaluation of PACT-ICU includes conference evaluation forms after

p = 0.02) than traditional preceptors. Intensivist preceptors and traditional preceptors

each session, a retrospective pre-post survey after the first session, and patient intervention

reported adequate opportunity to get to know the resident interpersonally (4.25 ± 0.71

outcomes. Over the course of 1 year, participants rated “participation by a variety of health

vs. 4.0 1.06, p = 0.636). Both preceptor groups noted a limited opportunity to discuss

professionals” and “collaborative nature of discussion during the session” very good to

results between clinic weeks (Intensivist 1.62 ± 0.92 vs. 2.11 ± 1.23, p = 0.352) and an

excellent (mean 4.6/5; sd 0.6; n = 96). Learners indicated that the conference was helpful

overall sense of being reasonably satisfied with quality of care provided (Intensivist 3.62

for their development of a treatment plan for the patient (mean 4.1/5, sd 1.1; n = 17).

± 1.06 vs. 3.72 ± 9.6, p = 0.902). Patterns similar to the faculty results were found among

Trainees indicated that their understanding of the roles that each team member could play

the residents with the exception that residents identified greater satisfaction with the ability

in hard to manage patients’ care was 2.7 (SD 1.0) before the session and 4.1 (SD 0.7) after

to follow-up with intensivist preceptors between clinic compared to traditional preceptors

the session (scale 1 = minimal, 3 = adequate, 5 = excellent; n = 17). Comments from

(3.21 ± 1.00 vs. 2.4 2 ± 0 .94, p = 0.001).

conference evaluation forms revealed that trainees found the “interdisciplinary aspect,”


“learning about different resources available at the VA and how to access them,” and

tween residents and faculty in block-schedule outpatient clinics impacts faculty and, to a

“subspecialty teaching topics” most valuable. Constructive feedback included requests to

lesser extent, resident perceptions regarding faculty ability to assess residents and their

“make the session shorter” and to “explain med[ical] issues briefly to be more inclusive of

familiarity with the residents’ complex patients. Such models may help to deliver

non-medical providers.” A qualitative list of trainee, PACT, and PIM interventions for

milestone- feedback in a way that enhances resident development especially in the age

patients following PACT-ICU conferences has been obtained by chart biopsy. Prominent

of hand-offs when some faculty evaluators may not have the oppportunity to know

examples include co-visits between trainee providers and PIM team-members, frequent

residents well. The lack of opportunity to discuss patients and results in between clinic

motivational interviewing, and assisting with in-home support and long-term care

weeks as noted by the residents should be further explored. In the era of increasing weight






were reported for other items including “(the framework) helped me create a comprehensive

member who mentors trainees and helps coordinate the conference has been critical.

problem list” (3.8 {1.4}), and “(the team used the framework to) help utilize resources in

Based on feedback from trainees, the faculty made several changes to PACT-ICU. The

nursing, pharmacy, and social work” (3.5 {1.4}). Comments were uniformly positive, and

faculty mentor started sending patient identifiers via secure email to interprofessional

included “This was a great exercise and really helped my patient.”, “Would be great to do on

trainees and PACT team-members prior to the conference so they could feel more prepared

every patient…”, and “Very helpful…Ensures complete H and P”. Nine of the 15 write-ups

and comfortable participating. They also invited experts, rather than trainees, to present

included information for 4 or more domains; only 2 included all 6 domains. Domains most

clinical pearls, which made the content more accessible to non- medical trainees and team-

frequently missing were Behavioral Health (missing in 10) and Functional Status (missing in

members. The faculty mentor needed to prepare experts for time-efficient clinical teaching

9). Seven write-ups misclassified information by domain.

in order to increase inclusiveness, while still providing satisfactory clinical content. The


partnership developed between PACT-ICU and PIM has been an important component of

domain framework for patient assessment was useful in facilitating medical students’

our conference. Patients and their trainee providers and PACT teams receive case man-

identification of clinically relevant issues not included in the traditional ‘H and P’ without

agement services, often provided in the home setting, beyond the capabilities of clinic-

feeling burdened by the more comprehensive approach. It also appears useful in facilitat-

based PACT team. The PIM team elicits the valuable perspectives of the trainee provider,

ing care planning involving other physician and non-physician members of the health care

PACT team, and interprofessional trainees at the conference and collaboratively formu-

team. We plan to investigate the validity and feasibility of applying the 6-domain

lates a treatment plan before enrolling and providing individualized services to the patient.

framework in other inpatient and outpatient teaching settings for students and residents. Primary barriers to implementation will be the need for faculty development and resistance in the dominant culture to expanding the scope of ‘physicians’ work’ to include


biopsychosocial and social determinants of health in patient care. 1. Engel GL. From


biomedical to biopsychosocial. Psychother Psychosom 1997;66:57–62. 2. Astin JA,

INFORMATION Denege A. Ward; Davoren Chick; Paula T. Ross; Patricia Mullan;

Sierpina VS, Forys K, Clarridge B. Integration of the biopsychosocial model: Perspectives

Brent C. Williams. University of Michigan, Ann Arbor, MI. (Control ID #2466473)

of medical students and residents. Academic Medicine: Journal of the Association of American Medical Colleges 2008;83:20–27. 3. Morley CP, Flad JR, Arthur M, Recker-

NEEDS AND OBJECTIVES: Clinical assessment and planning by physicians frequently

Hughes C, et al., Pilot evaluation of a piopsychosocial integrated standardized patient

omits psychosocial information necessary for mutual goal setting, facilitating patient self-

examination in a family medicine clerkship. Intl J Psychiatry in Medicine 2011;41:309–

management, and identifying and addressing barriers to care. Physicians cite as barriers to

328. 4. Hsieh H-F, Shannon SF. Three approaches to qualitative content analysis. Qual-

gathering more complete biopsychosocial information: a) limited time, b) limited skills and

itative Health Research 2005; 15:1277–88.

responsibility for managing non-biomedical problems, and c) that social determinants of health require interventions other than health care. The traditional ‘History and Physical’ data gathering format emphasizes biomedical diseases and underemphasizes behavioral, environ-


mental, and social determinants of health. We sought to provide physician learners a method


for efficiently gathering information from patients during routine clinical care that would: a)

Roy3; Zoe M. Weinstein1; David Yuh4; Linda Neville4; Alexander Y. Walley2. 1Boston Medical

enhance identification of clinically relevant behavioral and social factors, b) be perceived as

Center, Boston, MA; 2Boston Univ, Boston, MA; 3Boston University Medical Center, Boston,

immediately relevant to physicians’ work, and c) facilitate mobilization and collaboration with

MA; 4Boston University School of Medicine, Boston, MA. (Control ID #2465573)

non-physician health care providers. SETTING AND PARTICIPANTS: Participants were fourth-year medical students on a

NEEDS AND OBJECTIVES: Residents at academic teaching hospitals are the frontline

1-month rotation on an ‘uncovered’ (without residents) general medicine inpatient service.

of inpatient care. They frequently care for patients with substance use, with approximately

Fifteen students participation from May to July, 2015.

1 out of every 6 hospital stays including a substance-related diagnosis at our institution.

DESCRIPTION: Based on best practices in settings emphasizing comprehensive care

However, resident physicians are significantly less likely to experience satisfaction in

planning—geriatrics, mental health, and care of homeless persons—we developed a 6-

managing addiction in comparison to other medical issues. This low satisfaction is

domain framework for patient assessment. The domains are: 1) Biomedical Conditions, 2)

associated with low confidence in assessment and treatment of substance use disorders

Mental Health, 3) Behavioral Health, 4) Social Support, 5) Resources and Living Envi-

(SUD). At our institution, usual inpatient practice for patients with SUD is to manage

ronment, and 6) Functional Status. Students underwent a 1-h orientation to the framework

acute withdrawal symptoms and provide information for patients to self-refer to further

at the beginning of the rotation, and were assigned to use the framework to: a) complete an

addiction treatment and mutual support groups, without initiation of long-term pharma-

admission or progress note (‘write-up’), and b) identify one problem to address with the

cotherapy or direct linkage to post-hospitalization addiction treatment. This is a lost

health care team. At the end of the rotation students answered 10 (5-point) Likert-type

opportunity for residents to improve the overall health of their patients and their own

questions about the usefulness of the framework and provided free-text comments

job satisfaction. We addressed these gaps in knowledge and satisfaction by providing a


(available for 10 students). Two authors (DW and BW) applied content analysis to the

medical curriculum as part of our new Addiction Consult Service (ACS) with three

15 write-ups to determine whether: a) information on all 6 domains was included, and b)

objectives: increase resident ability to identify and treat addiction; improve resident

information was misclassified by domain. Authors independently rated the write-ups for

satisfaction in managing patients with addiction; and provide linkage to addiction care

completeness and accuracy, and resolved the few differences by consensus.

after hospital discharge.

EVALUATION: Student ratings of the 6-domain framework were highly positive, indicat-

SETTING AND PARTICIPANTS: Setting: academic safety net hospital. Primary

ing that the framework was “helpful in identifying barriers to care and follow-up” (mean

Curricular Participants: Internal Medicine (IM) and Family Medicine (FM) residents

{SD} rating 4 {1.1)), “improved my understanding of my patient and their needs” (4.2

rotating on the ACS. Secondary: IM residents who consult the service.

{0.8}), that “there were resources to help with barriers” (4.4 {0.7}), and that they were “able

DESCRIPTION: The Addiction Consult Service (ACS) is a new medical service at our

to develop a plan to address at least one barrier to care” (4.4 {0.8}). Lower but positive ratings

hospital aimed to improve the care of hospitalized patients with SUD. Consults have




included initiation of pharmacotherapy for alcohol and opioid use disorder, complicated

patient-centered discharge care techniques that included our teaching video of one patient’s

benzodiazepine withdrawal, and pain management for patients on opioid agonist therapy.

flawed care transition and a reflective small group exercise. To promote direct observation, a

IM and FM residents at our hospital rotate on the service as a 1 week elective. The purpose

mobile application tool was designed for attendings and residents to observe students

of the curriculum is to improve resident knowledge and satisfaction in managing addic-

providing discharge care. Students were required to complete one observed discharge

tion, which occurs in several ways. Firstly, residents on the elective serve as primary

education and encouraged to attend one post-hospital follow-up visit. For assessment,

consultant for 1–2 new patients per day, which includes obtaining a thorough substance-

surveys were administered in the academic year before and after the curriculum.

related history and physical, presenting on rounds, developing a plan, relaying recom-

EVALUATION: There was a pre-curriculum response rate of 84 % (73/87) and a post-

mendations to the primary team, and managing follow-up. Residents have a rotation-

curriculum response rate of 80 % (68/85). Compared to pre-curriculum, after the curric-

specific curriculum we developed using ACGME Core Competencies. This curriculum is

ulum more students completed a post-hospitalization telephone call (53 % vs. 91 %, p =

a 14-page document emailed to every resident before starting the rotation and includes 16

5 min) reviewing discharge materials with

education with staff psychiatrists to discuss difficult patient cases. Finally, residents who

patients (81 % vs. 94 %, p = 0.03). Students were more often directly observed completing

consult the ACS have increased exposure to SUD and its treatment from direct commu-

discharge paperwork (52 % vs. 78 %, p = 0.004) and at a hospital follow-up visit (21 % vs.

nication with the ACS team.

43 %, p = 0.004). Students also were more likely to elicit patients’ perspectives about

EVALUATION: A resident quality improvement project, prior to the initiation of the

hospital discharge more than twice per clerkship (78 % vs. 96 %, p = 0.006). Student

ACS, demonstrated a local need for more resident expertise in addiction medicine.

satisfaction with their discharge care (33 % to 60 %, p = 0.05 for all).

standard deviation 0.89). Students were more likely to rate that they were “uncomfortable”

DISCUSSION / REFLECTION / LESSONS LEARNED: A short faculty training on

with medical Spanish (mean 1.95, standard deviation 0.9). When asked to consider a variety

patient-centered EMR use could be associated with increased patient satisfaction with

of clinical scenarios, students were generally “somewhat likely” to use a Spanish interpreter

EMR-related communication. Best practices on patient-centered EMR use can be taught

for an initial outpatient encounter. They responded that they were “very likely” to use a

and positive objective behaviors (i.e. screen sharing and good eye contact) were reported

Spanish interpreter to explain a new diagnosis or counseling on disease management. We will

by patients post training. Areas for improvement include ongoing faculty training and

be comparing participants’ performance on pre- and post-course examinations as an objective

assessment of patient-perceptions, as well as formal training and evaluation of resident and

measure of progress. We will also administer post-course surveys to assess participants’

medical student skills. Our short curricula can be easily adapted for use at other institu-

comfort level with Spanish language after completing our curriculum.

tions. Furthermore, a potential avenue for training can include incorporating best practices


into existing required EMR onboarding training at academic institutions, thereby taking

riculum has been extremely well-received by both medical students and residents, with

advantage of available resources and champions.

requested enrollment far exceeding our capacity. Our curriculum is innovative in that it integrates in-person instruction, online modules and simulated and real patient encounters with real-time feedback. In addition, since participants are grouped by pre-test performance


rather than level of medical training, classroom participation has improved and medical

CAL STUDENTS AND RESIDENTS Colin Robinson1; Michelle Aguilar2; Kristen A.

students have learned how to better take patient histories at an earlier stage. Ultimately, with

Kipps1. 1University of California, Los Angeles, Los Angeles, CA; 2St. John Well Child

success in our second pilot year, we will formally study the effect of our course on the Spanish

and Family Center, Los Angeles, CA. (Control ID #2468136)

of our trainees and expand to other departments within the hospital.





study, to be an effective training method. It was also an efficient model from the resident’s


perspectives, because it did not require additional scheduled time and was integrated into

1, 2

Siddhartha Kattamanchi

1, 2

; Lisa Benson

2 1

; Andrew Weier . Marshfield Clinic, Marsh-

field, WI; 2Ministry St Joseph’s Hospital, MARSHFIELD, WI. (Control ID #2468827)

their current workflow. By using one-on-one interaction, the feedback was personalized and customized, with a better chance of improving communication skills among individuals. An advantage of using HCAHPS was that it offered a standardized measurement tool

NEEDS AND OBJECTIVES: Effective communication has been shown to influence

utilized by most hospitals without requiring development of a new questionnaire.

rate of patient recovery, effective symptom control, treatment adherence, psychological

ONLINE RESOURCE URL (OPTIONAL): 1. . Cantwell BM, Ramirez AJ. Doctor-

stability, and satisfaction with care.1 So important is communication and interpersonal

patient communication: a study of junior house officers. Med Educ. 1997;31(1):17–21. 2.

skills that the Accreditation Council for Graduate Medical Education (ACGME) has

Accreditation Council for Graduate Medical Education. ACGME Outcome Project; 2007.

recognized and designated it as one of the six core competencies.2 Opportunity for

http://www.acgme.org/outcome/comp/compFull.asp. Accessed April 14, 2014. 3.

improved patient-physician communication was identified through assessment of patient

Langewitz WA, Eich P, Kiss A, Wossmer B. Improving communication skills: a random-

experience through HCAHPS (Hospital Consumer Assessment of Healthcare Providers

ized controlled behaviorally oriented intervention study for residents in internal medicine.

and Systems) score on the general internal medicine residency service, which was around

Psychosom Med. 1998;60(3):268–276.

57 %, well below state and national averages for physicians. To improve physician-patient communication, a prospective interventional trial was proposed to assess whether training residents in communication skills would impact patient communication scores, which


could be assessed through HCAHPS score.


SETTING AND PARTICIPANTS: A total of 37 residents from internal medicine,

Heather D. Hirsch2; Megan McNamara4; Abby Spencer1; Pelin Batur2; Pete Spanos3.

combined medicine-pediatrics, and transitional year training programs participated in


the coaching sessions while they were working on internal medicine wards during the

Cleveland VA Medical Center, Cleveland, OH; 4Louis Stokes Cleveland VAMC, Cleve-

Cleveland Clinic, Chagrin Falls, OH; 2Cleveland Clinic, Cleveland, OH; 3Louis Stokes

1-year measurement period (January-December 2013). This cohort was selected because

land, OH. (Control ID #2462129)

they carried the lowest physician communication scores in the hospital. DESCRIPTION: Beginning in January 2013, the preceptor identified each resident

NEEDS AND OBJECTIVES: Knowledge is insufficient among practicing clinicians

working on the inpatient service during that month and emailed them approximately 3

regarding contraceptive counseling, with particular deficit in intrauterine device (IUD)

to 5 days before the start of the rotation, letting them know of the one-on-one coaching

literacy. IUDs are becoming increasingly popular, and their efficacy and cost-effectiveness

expectation. On that day, the preceptor shadowed each resident during one patient

has been found in multiple studies to be superior to almost all other forms of birth control

interaction (new admission, pre-rounds, follow-up visit, etc.) for approximately15–

methods. Program directors (PDs) of internal medicine residencies are reporting that

30 min. After the patient interaction, the preceptor provided the resident with brief

despite national guidelines endorsing women’s health education, they find a negative

feedback. The feedback included objective observations on a few specific behaviors and

discrepancy between what they feel residents should master and what the estimate they

subjective feedback on what was done well, with two to three suggestions for improving

master, necessitating the need to re-examine how providers and users are selecting their

communication techniques. The resident’s performance was logged. Most residents were

method of birth control. The objective of this trial was to determine if exposure to a multi-

shadowed at least 2–3 times during the study period. The HCAHPS score before the study

component educational intervention for internal medicine residents, which included online

served as the pretest data. This was compared to the HCAHPS score during the study

lectures, videos, and a “hands on” experience, as compared to the traditional lecture based

period. The goal was to improve patient experience and communication by achieving a

curriculum, would improve provider knowledge, referral patterns, and self-reported ability

percent “always” response on the HCAHPS survey questions specific to physician

to counsel on IUDs. Primary objectives included a change in IUD general knowledge, a

communication of 70 % in 1 year.

change in self-reported comfort regarding IUD counseling, the number of referrals made

EVALUATION: When compared, the HCAHPS score between pre- and post-

for IUDs, and satisfaction with the simulation workshop.

intervention showed significant improvement after intervention. Overall communication

SETTING AND PARTICIPANTS: Participation in the study was open to all first year

improved from 61 to 81 %, indicating a 20 % change from baseline with a p-value of

Internal Medicine residents at both the University Hospitals (UH) Case Medical Center,

0.0019. Even the sub-group analysis showed a significant improvement in all three

and the Cleveland Clinic (CC) hospital systems. Enrollment began in March of 2015 and

components of the communication. The response related to “treated with courtesy and

extends to April of 2016. Thirty-six first-year residents in the UH program and 53 first-

respect” improved by 23 %, and the response related to “listened carefully” scored 80 % in

year residents in the CC program were eligible for enrollment. Ten residents who were co-

the post-intervention measurement, which was an 18 % improvement compared to

enrolled as “centers of excellence” learners, a pathway focused heavily on ambulatory

baseline. Performance in the response “explained things in a way you could understand”

medicine, were excluded from study participation. Enrollment was voluntary and partic-

improved from 51 to 70 %. The p-value for all variables was 10 % increase in the rate of lab follow-up in the 4 month study period and improved

(5.71 %) in January 2014, compared to a post-intervention rate of 16 out of 38 (42.11 %) in

resident confidence that labs were being followed up. Limitations are that this process

January 2015. In the years prior to implementation, PGY-1 completion rates by the end of

relies on individual compliance and buy-in and is a cumbersome extra step in busy clinic

the academic year for two PDSA cycles were 5 out of 38 (13.16 %) in June 2013 and 1 out

settings. Additional PDSA cycles have been instituted to improve the layout of the

of 34 (2.94 %) in June 2014, compared to a post-intervention rate of 8 out of 37 (21.62 %)

spreadsheet to make it more user-friendly and to limit information inputed to only the

in June 2015. Select comments after the first PDSA cycles were as follows: “I was actually

most essential items. Future plans include training providers that cover follow-up respon-

surprised that my patient census was a pretty accurate representation of the general US

sibilities while residents are not in clinic. We plan to continue utilizing this tool and to

population…given how sick my patients seem to be in clinic, I expected more of them to

expand it to include imaging and other studies. This tool is low-cost and requires little

be obese.” “I also noticed that I would spend more time discussing lifestyle modification

training, and could be implemented in multiple clinic settings where there is no automated

with a patient that had obesity on their problem list” “By adding this I have found that I am

system for forwarding lab results to covering providers and where providers are out of

less likely to consider obesity as an unalterable fact about a patient and more likely to see it

clinic for periods of time, such as in other residencies with a 4 + 1 schedule.

as a treatable problem like hypertension…This project helped me to realize that there may




be other aspects of a patient’s history that I treat in similar ways… I could have probably


predicted this change before starting my PDSA however it is valuable to actually perform


the act and realize how much of a difference one small change can make.”



Blake R. Barker1; Heather Wickless3. 1UT Southwestern, Colleyville, TX; 2UT South-

low-resource intervention significantly increased the expected PDSA completion rate of two

western Medical School, Dallas, TX; 3UT Southwestern Medical Center at Dallas, Dallas,

per year among internal medicine residents at UCSD. Completion rates were still lower than

TX. (Control ID #2465850)

expected and desired, and the effect of the intervention waned by the second PDSA cycle. Differences in patient populations, clinic resources, faculty involvement, and electronic

NEEDS AND OBJECTIVES: A cutaneous issue is the primary complaint in 5 % of

medical records at the different continuity clinic sites may contribute to variability in PDSA

patient visits to internists. Despite the prevalence of these conditions, medical students

completion. Next steps include assessing the quality of PDSA projects in addition to the

only receive a median of 10 h of formal dermatology education. Medical students at our

quantity, and assessing resident and faculty knowledge and attitudes about PDSAs.

institution received no formal teaching regarding dermatological physical diagnosis during the third year of medical school prior to 2014. Through informal feedback, our students often expressed a lack of comfort with basic physical diagnosis skills for


dermatological conditions. Our objective was to implement dermatology-focused curric-

TURED PEER FEEDBACK Kathleen Lane; Andrew Olson. University of Minnesota,

ula within the Internal Medicine (IM) Core Clerkship after which students should be able

Minneapolis, MN. (Control ID #2466310)

to perform the following tasks adapted from the American Academy of Dermatology (AAD) Basic Dermatology Curriculum: (1) Develop a systematic approach to skin

NEEDS AND OBJECTIVES: Trainees on nightfloat rotations admit approximately

examination; (2) Effectively communicate a description of common skin conditions using

40 % of the patients who are cared for by daytime ward teams. However, these trainees

appropriate dermatological terms; and (3) Develop a differential diagnosis for common

typically receive little formal feedback regarding their diagnostic reasoning. Instead, it is

dermatologic manifestations.

up to the nightfloat trainees’ prerogative to determine how patients’ disease courses

SETTING AND PARTICIPANTS: All UTSW third-year medical students during their

evolved, why the differential diagnoses shifted, and if cognitive errors occurred. Effective

Internal Medicine Core Clerkship (240 per year).

feedback and calibration of medical-decision-making is critical for trainee development.

DESCRIPTION: In the 2014–2015 academic year, two new dermatology-focused

Trainees perceive this lack of feedback: 40 % of University of Minnesota Internal

sessions were integrated into the IM Core Clerkship. All students were exposed to each

Medicine residents are dissatisfied with the feedback they receive. Training programs

session. Each week, a faculty dermatologist lead 5 students on “Skin Rounds”, a 1-h

lack regular, standardized, formal feedback regarding diagnostic reasoning. Thus, we

dermatology-focused physical diagnosis rounds session. Patients are identified by the

aimed to create and study a solution that allows for standardized, rapid, and effective

inpatient dermatology consult service or by the medical students from their general

feedback about diagnostic reasoning for nightfloat trainees.

medicine inpatient service. Students are asked to describe skin findings at the bedside

SETTING AND PARTICIPANTS: We developed and piloted the “Diagnostic Reason-

and form a differential diagnosis with the assistance from the dermatologist. Students also

ing Feedback (DxRF) Form” at the University of Minnesota Medical Center with Internal

participated in a large group 1.5 h case-based active learning session on common

Medicine and Internal Medicine-Pediatrics trainees on ward day and nightfloat teams.

dermatologic findings called “Dermatology: What’s Your Diagnosis?” A faculty derma-

DESCRIPTION: When a patient was admitted by a nightfloat trainee, the day team

tologist reviews 20 high-definition images of common dermatologic conditions drawn

accepting that patient was requested to discuss the case and fill out the feedback form, briefly

from the AAD Basic Dermatology Curriculum with a group of 20–25 students. For each

explaining if, how, and why the patient’s differential diagnosis changed over the first day of

slide, one student is asked to describe the condition utilizing appropriate terminology and

admission, and provide relevant clinical pearls. The form was designed to be a concise tool

offer a differential diagnosis.

that would be easily incorporated into the teams’ preexisting workflow while simultaneously

EVALUATION: The impact of these sessions was assessed through online survey

provoking analysis of the decision-making that occurred at the time of admission. This

student feedback and standardized test performance. The survey was distributed to all

program allowed for formative feedback over the course of that trainee’s nightfloat rotation

2014–2015 students including two questions regarding the new dermatology sessions,

directly from his or her colleagues.

utilizing a 5-point Likert scale (strongly agree to strongly disagree). Response rate was

EVALUATION: A total of 25 participants completed 66 feedback forms during the 2-

32 %. Nearly 98 % of students strongly agreed or agreed that the activity was effective and

month pilot. Trainee self-perception of diagnostic reasoning skills trended towards in-

useful. Additionally, 92 % of students agreed or strongly agreed that they felt more

creased confidence. Trainees rated attending physicians as less frequently discussing why

confident describing skin lesions. Many students commented that they would like more

a differential diagnosis was established or prioritized after the project (3.95 vs. 3.43, p =

of these sessions. Medical student performance within the “Diseases of Skin and the

0.01). Additionally, trainees reported increased confidence in identifying strategies to

Nervous and Musculoskeletal Systems” content area of the National Board of Medical

mitigate cognitive bias (3.05 vs. 3.5, p = 0.049). The pilot had neutral impact on trainee

Examiners Internal Medicine Subject Examination was also analyzed before (2013–2014)

feedback satisfaction. Overall, trainees viewed the project favorably.

and after (2014–2015) implementation of the dermatology teaching sessions. Specifically,

DISCUSSION / REFLECTION / LESSONS LEARNED: After the pilot phase of this

we analyzed the percent of items within this content area that were answered correctly

program, DxRF was made a permanent part of inpatient training at the University of

prior to and after intervention using an independent samples z-test. While not statistically

Minnesota. The program will be refined and studied further at partnering institutions. In an

significant at p < 0.05, students improved from an average of 77 % before intervention to

era of heightened awareness regarding diagnostic error, feedback systems for trainees are

79 % afterwards (p = 0.60). This increase was seen despite a national decrease from 68 to

critical. With improved feedback in training programs, all trainees will be able to hone

66 % over the same time frame (p = 0.51). Total test mean score was analyzed using an

their diagnostic reasoning skills and improve patient care. Structured peer feedback is

independent samples t-test. There was a 1 point increase in total test mean after the

acceptable to trainees and effective in improving self-perception of diagnostic reasoning

intervention; this increase also lacked statistical significance (p = 0.18).

skills by providing a forum for open communication and encouraging a culture of effective


feedback for all providers.

school found that 4th year medical students were highly dissatisfied with their




dermatology training and were able to correctly diagnose less than 50 % of common

responsibilities of nursing staff and 84 % stated they are able to collaborate more

dermatologic conditions. Our intervention was designed to address inadequacies in

effectively on an interprofessional team. Qualitatively, the majority of residents

medical student dermatologic education by embedding activities within the IM clerkship.

described it was most beneficial for learning about “what happens behind the scenes”

We utilized bedside teaching and case-based active learning, which have been shown to be

and understanding different roles of nursing staff. Overall, 84 % of residents were

superior to lectures at increasing medical student confidence in their ability to diagnose

satisfied with the clinical experience and 74 % would recommend it to future PGY1s.

dermatologic disease. Additionally, these sessions were led by a faculty dermatologist,

Clinical experiences are ongoing through spring 2016; final data will be presented at

which has been shown to be superior at increasing diagnostic self-confidence relative to

the conference.

training from a primary care physician. Our intervention was met with high satisfaction

DISCUSSION / REFLECTION / LESSONS LEARNED: The literature includes few

from medical students, and they reported increased confidence describing skin lesions. We

curricula designed to provide formal training for residents physicians in interprofessional

also saw a trend towards improvement in the dermatology questions on a national

collaborative practice, particularly in the clinic setting. We successfully implemented a

examination although this lacked statistical significance. Case-based and bedside teaching

curriculum to provide formal training in IPCP for resident physicians by utilizing IPCP

utilizing real patients improves medical students’ confidence in approaching a dermato-

competencies and empowering nursing staff to be educators for resident physicians.

logic patient. This intervention can serve as a model for implementation of curricula within

Future studies will need to examine the impact of this curriculum on teamwork in the

the IM clerkship to address specific inadequacies at other institutions.

clinic and on patient-level outcomes.




TIENT CENTERED MEDICAL HOME Stefani Russo1; Andrew Schreiner2;

Natalia Lipin1; Gianna Sparks1; LaToya Bradford3; George Weyer3; Julie Oyler2. 1Uni-

Kimberly S. Davis2. 1Jefferson University, Philadelphia, PA; 2Medical University of

versity of Chicago, Chicago, IL; 2University of Chicago Medical Center, Chicago, IL;

South Carolina, Charleston, SC. (Control ID #2468913)


University of Chicago Medicine, Chicago, IL. (Control ID #2468962) NEEDS AND OBJECTIVES: As the Patient Centered Medical Home model of care

NEEDS AND OBJECTIVES: In the current climate of health care reform, primary

delivery moves to the forefront of primary care re-design nationally, it is critical that

care is increasingly delivered by interprofessional (IP) teams that aim to provide

medical students understand the principles of PCMH and are given hands-on opportunities

high quality, high value care to individuals and populations. Prior studies have

to put these concepts into practice. We agree with a joint statement from multiple primary

demonstrated that highly functioning IP teams improve both patient satisfaction

care professional organizations citing a “remaining need” to “provide a foundation in

and patient outcomes; they also improve employee satisfaction and retention.

primary care medicine and PCMH relevant for all students.” To this end, we created a

Thus, it is essential for physicians to learn the foundational skills to work within

fourth year medical student elective to teach students the concepts of PCMH. Our

and lead IP teams. Despite this, formal training in interprofessional collaboration

objectives were: 1. To create a PCMH curricular map, cross-walking medical student

has traditionally been limited. The objective was to enhance interprofessional

learning objectives with entrustable professional activities (EPAs) and ACGME core

collaborative practice (IPCP) among resident physicians in a primary care clinic.

competencies. 2. To embed students within a PCMH, and include multi-disciplinary

SETTING AND PARTICIPANTS: First year internal medicine and medicine-pediatrics

members of the PCMH care team as part of the students’ educational team. 3. To

residents (PGY1) and ambulatory clinic nursing staff at one academic medical center

implement a small group curriculum to teach PCMH concepts. 4. To assess students’

between July 2015 and April 2016.

understanding of PCMH concepts before and after participation in our elective. 5. To

DESCRIPTION: Through an application of Kern’s model for curriculum development,

identify barriers to implementation.

we developed and evaluated an IPCP curriculum for PGY1s residents in the ambulatory

SETTING AND PARTICIPANTS: Fourth year medical students were given the oppor-

setting. A literature review and needs assessment informed the curriculum development.

tunity to participate in our PCMH elective. Participating students spent one half day per

Clinic nursing staff, including registered nurses (RN), licensed practical nurses (LPN), and

week in the classroom and 4.5 days per week in our NCQA-recognized Level 3 PCMH.

medical assistants (MA), served as educators in the curriculum. Following Kolb’s learning

DESCRIPTION: The overarching goal of our 4-week elective was to teach students

cycle, the curriculum consists of: 1. Seminar led jointly by an RN, LPN, MA, and a

about the PCMH mode of care by pairing a rich hands-on clinical experience in a PCMH

physician. 2. Clinical experiences where residents worked one-on-one with nursing staff

with a small group didactic component.

within the setting. 3. Application in clinical care. The curriculum promoted the acquisition

EVALUATION: Students were asked to complete a survey both before and after their

of core competencies of IPCP: values for interprofessional practice, roles and responsi-

participation in our elective. The survey asked students, “As of today, how well do you

bilities, communication, and teamwork.

understand…” on a scale of 1 to 5, with a score of 1 being “not at all” and a score of 5

EVALUATION: During the pilot year, 45 PGY1 residents and 16 nursing staff

being “completely.” We have pre and post-elective survey results for three students who

members have participated in the curriculum. At the start of the curriculum, 95.6 %

have completed our elective. All students reported an increase in their understanding of the

of residents (n = 43) completed survey instruments focused on knowledge, skills, and

PCMH model (pre-participation average 2.33 increased to 4.0 post-participation), person-

attitudes for IPCP. Residents were most confident in their teamwork abilities (mean =

al physician (3.0 à4.33), physician-directed medical practice (1.67 à4.33), whole person

4.0/5.0) and less confident with responsibilities (mean = 3.6/5.0) and giving feedback

orientation (2.33 à4.0), integrated and coordinated care (2.33 à4.0), quality and safety (2.0

to team members (mean 3.4/5.0). Residents rated the case-based seminar highly; 97 %

à4.0), enhanced access (3.33 à4.0) and payment (1.0 à4.0). We are continuing ongoing

stated it was beneficial for understanding responsibilities, learning effective commu-

data collection.

nication skills, and learning skills for working in and leading IP teams. Overall, 97 %


residents were satisfied with the seminar (mean 4.42, SD 0.56). To date, 21 of the 45

dents spent 4 weeks working with us in our level 3 PCMH. Because we wanted students to

PGY1s (47 %) have completed clinical experiences with nursing staff. As a result of

learn about the roles and responsibilities of all of our staff, all clinical team members were

the experience, 95 % of PGY1s reported they have a better understanding of

included as part of the students’ educational team. Students had assigned times to work




with our LPNs, RNs, case managers, pharmacists, as well as a list of skills to practice with

medication assistance for smoking cessation. Information was presented through an

these team members, such as vaccine administration and insulin teaching. Students saw

interactive PowerPoint presentation that included low-literacy pictorial education mate-

patients with our attending physicians, and were encouraged to follow up with patients by

rials from ThumbsUpForHealth.org. Patients received a printed workbook to help create

phone to check on their progress. Students also participated in multi-disciplinary weekly

their individualized plan. If appropriate, patients were prescribed varenicline, bupropion,

team meetings. Their clinical assignments mirrored concepts taught in our small groups,

and/or nicotine replacement therapy during the group visit. Feedback and communication

and included creating patient education hand-outs, assessing barriers to care, using

with patient’s referring PCP and/or mental health provider was provided.

motivational interviewing, and setting self-management goals. Small group: Our small

EVALUATION: All 30 eligible primary care residents participated in the 1 h training

group didactics focused on the following key PCMH concepts: personal physician,

program. Twelve residents had schedules permitting them to lead the group visits. Informal

physician-directed medical practice, whole person orientation, integrated and coordinated

resident feedback was collected after each group visit, which was uniformly positive. All

care, quality and safety, patient access, and payment. These were taught in an interactive

residents reported improved knowledge about smoking cessation medications and practical

small group setting led by a faculty member with expertise in PCMH. Students received

aspects of prescribing, including cost and insurance coverage. Residents who participated as

training in clinical microsystem design and population health, and were asked to design a

group visit leaders reported improved confidence in counseling patients about smoking

quality improvement project during their elective that allowed for further immersion in

cessation using simple motivational interviewing techniques. To assess patient outcomes,

these concepts. With our faculty leader, students discussed areas for improvement in our

participants completed pre/post-program surveys and a 1 month follow-up telephone survey.

practice, and identified specific, measurable, and patient-centered outcomes for an ongo-

Patients were asked about smoking history, nicotine dependence (ex. Fagerstrom Test for

ing quality improvement project. Lessons learned: Integrating fourth year medical stu-

Nicotine Dependence [FT]), and attitudes about smoking cessation. All statistical analyses

dents into the daily activities of LPNs, RNs, and case managers required additional

were performed with Microsoft Excel using paired t-test for difference in means for

education for the interdisciplinary team. With varying degrees of direct teaching experi-

continuous variables. At 6 months, 62 patients were referred to the program but only 12

ence, team members needed reinforcement of learning objectives, strategies for learner

attended (19.5 %). Six patients completed the pre/post-program surveys which were includ-

engagement, and tools to provide student feedback. Additionally, in a departure from

ed in the analysis. At post-program, 50 % (n = 3) quit smoking, average smoked cigarettes

historical faculty precepting, student education in the PCMH model required exposure to

per day decreased from 20.7 to 9.2 cigarettes (p < 0.05), and FT scores decreased from 5.2 to

elements of care delivery outside of the exam room. As such, the amount of protected

2.8 (p = 0.51). Mean readiness and confidence to quit increased from 8.8 to 9 (p = 0.81) and

faculty time needed was greater than originally anticipated.

6.2 to 7.5 (p = 0.22) respectively. Most participants (85 %, n = 5) thought the group was very helpful and all attendees requested to repeat the program. DISCUSSION / REFLECTION / LESSONS LEARNED: We were successful in


developing a comprehensive tobacco education curriculum using low-literacy pictorial


patient education materials. We found group visits to be a dedicated venue for residents to

Ng1; Susan Oliverio1; Mindy Sobota2. 1Alpert Medical School of Brown University/

learn and to practice motivational interviewing for smoking cessation, but the experience

Rhode Island Hospital, Providence, RI; 2Brown, Providence, RI. (Control ID #2465031)

can be inefficient due to low patient attendance. The subset of patients who completed all three sessions had improved smoking behaviors and motivation to quit. There were likely

NEEDS AND OBJECTIVES: Tobacco cessation counseling is a grade A USPSTF

multiple factors contributing to the low patient attendance, including inconvenient pro-

recommendation. A 2012 Cochrane review showed that training health professionals in

gram schedules, poor winter weather conditions that led to program cancellations, and

tobacco counseling led to increased discussions about quit dates and abstinence (Carson

referrals by PCPs when patients were pre-contemplative about quitting. In the future, we

et al.). However there is limited literature about effective tobacco cessation training

want to explore pairing residents with faculty to deliver point of care tobacco cessation

programs for internal medicine residents. Our objective was to develop a comprehensive

counseling for patients identified by medical assistants.

tobacco education curriculum with low-literacy pictorial patient education materials and to

ONLINE RESOURCE URL (OPTIONAL): http://www.thumbsupforhealth.org

determine the feasibility of training residents to provide tobacco counseling in group visits. Our primary outcomes were to train 30 primary care residents and provide an opportunity for them to counsel smokers using a group visit model. Our secondary


outcomes were to assess the efficacy of a group program in changing patients’ attitudes


about smoking, readiness and confidence to quit, and quit rates.

ETHICS. Liam P. Howley; Laura Hinkle. Indiana University, Indianapolis, IN. (Control

SETTING AND PARTICIPANTS: Our smoking cessation program took place at a

ID #2468952)

large academic resident clinic that serves predominantly underserved, multilingual patients in Providence, RI. Patient participants were clinic patients referred by their PCP

NEEDS AND OBJECTIVES: Students receive a plethora of didactic lectures through-

from Sept 2014 to Feb 2015. Thirty primary care residents who were on their ambulatory

out their medical education. And a majority of the learning during medical school is

block were eligible to be trained as group visit leaders.

isolated from other health services students (such as nursing, dental and pharmacy).

DESCRIPTION: Our program included 3 weekly sessions that repeated each month in

Medical ethics is a unique topic that allows for alternative and collaborative methods of

English or Spanish for 6 months. Sessions were approximately 2 h long and were led by 1–

learning. Previously, the ethics mini-course at Indiana University School of Medicine

2 residents and a supervising attending experienced in tobacco cessation and motivational

(IUSM) had only involved medical students discussing and analyzing ethical cases from

interviewing. Prior to leading the group visits, residents participated in a 1 h tobacco

the perspective of a medical student or physician. The medical ethics course directors for

counseling training program led by the senior resident and supervising attending who

IUSM saw this mini-course as a wonderful opportunity to incorporate interprofessional

created the pilot program. During the group visits, residents practiced motivational

education into the analysis of common healthcare ethical scenarios.

interviewing techniques to help participants reflect about their smoking behaviors and

SETTING AND PARTICIPANTS: At IUSM, there is an established mini-course to

develop individualized quit plans. Patients also learned about the health and financial

teach concepts in medical ethics to third-year medical students. This time is divided into

consequences of tobacco use, potential behavior strategies to avoid smoking and

two sessions, one 3-h session at the start of their Obstetrics and Gynecology rotation and a




2-h session at the end of the rotation (approximately 6 weeks apart). The meetings include

Internal Medicine Residency who pursue careers in primary care, and to equip these

didactic sessions on concepts such as the history of medical ethics, medical research

residents with skills to succeed as leaders in healthcare.

ethics, disclosing medical errors, and interactions with the pharmaceutical industry. The

SETTING AND PARTICIPANTS: During AY14-15 and AY15-16, 19 of 110 eligible

interprofessional small group exercise has been incorporating into the three-hour orienta-

internal medicine residents at an academic tertiary medical center (17 %) self-identified as

tion session.

having interest in Primary Care and enrolled into the PCLP. The program provides didactic

DESCRIPTION: The full group (approximately 100 students from the schools of

and virtual classroom content in clinical, administrative and leadership realms as well as

medicine, nursing and dentistry) is divided into ten or 15 smaller groups. After about

1:1 resident-to-faculty mentorship and social networking. In AY15-16, the residency

ten minutes of introduction and a short ice-breaker activity, the groups are given one of

restructured to a “4 + 1” model allowing PCLP residents to be cohorted into a firm to

five cases to read and discuss. They then are asked to analyze the ethical principles

create a sense of community and deliver synchronous experiences and educational content

involved in the case and to respond to a specific question about the next step in resolving

during their “+1” ambulatory weeks.

their case. After approximately 30 min in the small groups, the large group reconvenes and

DESCRIPTION: Since its inception PCLP residents have participated in didactic ses-

each case is reviewed with a representative from each of the small groups summarizing the

sions on topics such as resiliency and burnout, fundamentals of business in Medicine,

ethical dilemma along with which principles of ethics are involved in their case and how

fundamentals of medical education and LEAN quality improvement training. We provid-

they chose to resolve the situation. Of note, there is a facilitator assigned to each small

ed online training done individually by the resident from resources such as the Institute for

group who is available to guide the group through the discussion.

Healthcare Improvement leadership modules and MedU: High Value Care Modules. We

EVALUATION: Surveys are distributed to all student participants at the end of each

developed clinical experiences in homeless health, endocrinology and behavioral health.

session to assess both the comfort of analyzing ethical situation and also to gauge the

We invited residents to attend the UMass Leadership Seminar Series, which include topics

students’ perceptions on the value of the interprofessional small group exercise using an

on “Leading Interprofessional Teams” and ”Transformational Leadership.” We paired

adapted version of the Attitudes Towards Interprofessional Health Care Teams survey. The

residents with primary care faculty members in 1:1 mentor relationships to provide

feedback has been very positive, with 85 % of student participants agreeing with the

counseling in career development and work-life balance.

statement “I have a better understanding of other disciplines’/health professions’ perspec-

EVALUATION: Metrics of evaluation include the percentage of residents who chose to

tive” and 83 % agreeing with the statement “Working in a group with students from other

participate in the PCLP, along with the percentage of graduates that subsequently enter

disciplines/health professions during this seminar contributed to my learning.”

primary care. Currently, we have 15 residents involved with the PCLP (14 % of all

DISCUSSION / REFLECTION / LESSONS LEARNED: This interprofessional small

categorical residents.) The class of 2015, which coincided with the first year of the PCLP,

group session during the IUSM ethics mini-course has been a unique & innovative way to

produced 7 residents who went on to fields in primary care (23 % of the class), a marked

enhance medical ethics learning. Our limitations are that the activity may not be translatable

increase over an average of 11 % in the past 10 years.

to other institutions who do note have other professional schools on the same medical

DISCUSSION / REFLECTION / LESSONS LEARNED: Prior to the development of

campus, or who don’t have the leadership and resources we have in Indianapolis through the

the PCLP, residents did not have the opportunity to explore primary care in a comprehen-

Indiana University Center for Interprofessional Health Education and Practice. In the future

sive and coordinated fashion beyond their mandated longitudinal clinic. The creation of

we plan to expand the audience to include other professional students—we have had some

the PCLP in the context of the transition to a 4 + 1 block schedule allowed us to focus

sporadic participation from the School of Pharmacy, and plan to include other groups such as

educational resources and mentorship on a self-identified group of residents interested in

the Schools of Physical Therapy and Occupational Therapy in upcoming semesters.

primary care. Events currently being finalized and scheduled include outpatient procedure clinics, DiSC Personal Assessment Workshop, Clifton StrengthsFinder Workshop, Crucial Conversations, Crucial Accountability and an Evidence-Based Medicine workshop. Our


future focus will be to redesign 4-week subspecialty experiences to focus on the outpatient


aspect of the care that they deliver. We will also develop thematic blocks that would group

Nancy T. Skehan2; Allen Chang1; Sheri Keitz2. 1UMASS, Worcester, MA; 2University of

many specialties in one coordinated rotation such as a rotation in Metabolic Health, which

Massachusetts Medical School, Worcester, MA. (Control ID #2467836)

would include experiences in diabetes clinic, nutrition, and cardiology. We will offer

NEEDS AND OBJECTIVES: The increasing need for PCPs in the United States has

identify as being critical for an excellent primary care internist. Our leadership curriculum

been well-documented, and it has been noted that residents participating in designated

will feature collaborative programming with our institution’s Career Development and

primary care internal medicine residency tracks are twice as likely to become general

Research Office, Junior Faculty Development Program, as well as area colleges. Ulti-

internists when compared to their categorical counterparts. Additionally, trends in

mately, this will be a comprehensive curriculum that spans the 3-year cycle of a resident’s

healthcare delivery suggest that there is increasing need for physician leadership with

training, complemented by a set of unique clinical experiences to help prepare them for a

the rise of population management, accountable care organizations, and advances in health

career in primary care.

rotations in Women’s Health, Dermatology, Musculoskeletal Health and other skills we

information technology. The University of Massachusetts Medical School (UMMS) has long valued its role in providing primary care for the Commonwealth and has an established reputation for its excellence in primary care education. However, in the past


decade, on average only 11 % of the graduates from our categorical internal medicine


residency have gone on to enter primary care, compared to 22 % at the national level. To

Schaye1; Lynn Bui1; Mark D. Schwartz2, 1. 1NYU School of Medicine, New York, NY;

address these needs, we recruited a community of self-identified categorical residents


VA NY Harbor Health Care System, New York, NY. (Control ID #2469267)

interested in primary care and developed curriculum to enhance outpatient skills and provide structured leadership training. Implementation of 4 + 1 scheduling in the residen-

NEEDS AND OBJECTIVES: Clinician educators (CE) are the primary teachers of

cy program afforded opportunities for a cohesive structure and deployment of novel

medical students and residents; however most have not had any formal training in how to

curriculum. Our primary goal was to increase the number of graduates from the UMMS

teach. CE want to improve their teaching skills but choose to attend clinically oriented




CME programs. Engaging CE in faculty development programs (FDP) that focus on


teaching skills is a challenge. To meet this challenge we created a FDP that combined


clinical and educational skill learning. The goals of the program were to improve CE

Donelan4; Craig Roth2, 1; Peter Weissmann2, 1; Sophia Gladding1; Alisa Duran1. 1Uni-

teaching skill confidence, performance and self reported behavior change.

versity of Minnesota, Edina, MN; 2Minneapolis VA Medical Center, Minneapolis, MN;

SETTING AND PARTICIPANTS: A total of 37 CE completed our 8 month long


program. All participants teach medical students or residents, and were recruited from

Minneapolis, MN. (Control ID #2464429)

University of Minnesota, MInneapolis, MN; 4University of Minnesota Medical School,

NYU’s main 3 academic affiliate hospitals. The first cohort included 18 hospitalists and the second cohort included 19 outpatient CE. Participants completed training an average

NEEDS AND OBJECTIVES: With health care costs soaring in the United States,

of 5 years ago (range 1 to 15 years).

physicians have a greater responsibility to assess the value of the tests and therapeutics

DESCRIPTION: We interviewed educational and clinical leaders to identify the educational

they order for their patients and balance that with the potential harm and costs. Many

skill needs of our faculty based on student and resident feedback. We conducted an assessment

residents do not understand their role in driving costs, how to integrate value into their

of CE FDP participants regarding their clinical and educational skill needs. The teaching skills

decision-making, and communicating their reasoning to their patients. We developed an

identified by the needs assessments were observation and feedback, teaching a physical

innovative high value care (HVC) communication skills intervention for our trainees,

examination or procedural skill, precepting, and leading ward rounds. The identified clinical

using the “Four Habits Model” as a framework. The objectives of the value-based care

skills were the dermatologic and shoulder exams, pain management, and lumbar punctures.

communication skills innovation include: 1. Apply the 4-Habits communication model to

The FDP consisted of five 3-h small group (8–10 faculty) sessions. The first and last sessions

high value care discussions with patients 2. Practice and improve value-based communi-

were 3-station Observed Structured Teaching Examinations (OSTE) that assessed partici-

cation skills with the use of standardized patients 3. Train faculty in the communication

pants’ educational and clinical skill performance. The workshops for the hospitalist cohort

and role modeling of value based communication skills

were 1. Teaching Procedures: Performing Lumbar Punctures 2. Observation and Feedback:

SETTING AND PARTICIPANTS: This study is being conducted at the University of

Dermatologic Examination and 3. Ward Rounds: Pain Management. The workshops for the

Minnesota and involves all first postgraduate year residents (PGY-I) in Internal Medicine

outpatient CEs were 1. Precepting: Pain Management 2. Observation and Feedback: Derma-

(n = 31), Medicine-Dermatology (n = 2) and Medicine-Pediatrics (n = 10) at the Univer-

tologic Examination and 3. Teaching Physical Examination: Shoulder Exam. Each workshop

sity of Minnesota during the 2015–2016 academic year. Participants were randomized to a

began with an interactive discussion of the clinical topic led by local experts followed by an

standard value based care curriculum, including a HVC communication skills encounter,

introduction to the educational skill. The faculty were divided in to groups of 3–4 and

or the standard curriculum plus a high intensity communication skills curriculum.

participated in a series of role-plays. For the workshop “Ward Rounds: Pain Management”,

DESCRIPTION: All interns (n = 43) participated in a single station, video-recorded,

the first hour was a discussion of pain management strategies led by a pain specialist followed

standardized patient (SP) encounter during orientation as part of the standard value-based

by review of an educational skill—the 5 step clinical Microskills. The participants practiced

care curriculum. This session focused on the communication of value-based decision making

using the Microskills through role-play. During the role-play the participants assumed the role

and avoidance of unnecessary testing on a patient presenting with back pain. Half of the

of intern, student, resident or attending. The “intern” presented a case of a patient in pain to the

interns participated in the high-intensity communication curriculum plus standard, and half in

“attending”. The “attending” led a discussion using the Microskills and practiced their new

the current standard. The high intensity curriculum included a 90-min facilitated small-group

pain management knowledge. Following each role-play, the participants and medical educa-

review session of the video SP encounters with a communications expert facilitator, a junior

tion experts provided peer to peer feedback to the “attending” on their teaching skills, and then

faculty co-facilitator and peer participation and feedback. Two months later, interns partici-

switched roles so all participants could practice leading ward rounds. At the end a medical

pated in a 10 min SP phone encounter focused on value based prescribing, followed by a

education expert led a discussion on how to contextualize the learning, and participants

second, 60-min review of the audio encounters. Small group participants received expert

completed commitment to change statements (CTC).

feedback from the group facilitators and from their peers as well. All interns participated in a

EVALUATION: We measured change in teaching confidence using retrospective pre-post

second video-recorded standardized encounter 11 months after the initial encounter; to

surveys at the conclusion of each workshop, and pre and post program surveys. Teaching

measure an improvement in value based communication skills using a validated checklist.

performance was assessed using OSTEs. Behavior change was measured by assessing

EVALUATION: We evaluted the success of our intervention through the following

participant’s ability to implement their CTC statements at the conclusion of the program.

methods: 1. Surveys of intern and faculty satisfaction with the communication skills

DISCUSSION / REFLECTION / LESSONS LEARNED: Participants in the program

program as well as the overall educational value of the training program. 2. Pre/post

significantly increased their teaching confidence in covered teaching domains and im-

assessment during SP encounters to identify improvement in value-based communication

proved their teaching performance in observation and feedback. At the end of the program

skills. This checklist was based upon the Four Habits model and was validated using a

69 % of participants had either fully or partially implemented their teaching behavior

Delphi technique with a group of communication experts.

change goals from their commitment to change statements. The greatest barrier to


implementation of the FDP was scheduling participants due to their heavy clinical

over an 11-month period. Preliminary feedback revealed that interns found participation in

responsibilities which we overcame by scheduling sessions 6 months in advance and

the SP encounters and small groups to be beneficial to their communication skills.

holding each workshop three times. Conducting needs assessments with participants and

Similarly, junior faculty serving as co-facilitators with communication experts have found

educational and clinical leaders led to tremendous support for the program and facilitated

this to be of educational value as well. Final data analysis will be completed prior to the

support for coverage of clinical time so faculty could participate. Combining educational

abstract presentation. Our intervention provided necessary, focused training on the com-

skills with clinical skill learning helped create interest and buy in from the participants.

munication of value-based decision making, which is becoming increasing important in

Although many participated in the program for the clinical skills in the end they were

our health care systems. Challenges faced during our intervention period included the

equally likely to make clinical and educational behavior change commitments. With future

timing of the small group sessions and conflicts with the redesign of our continuity clinics

programs we plan to include a component of peer to peer observation in the participants

into a block schedule. Additionally, one intern did not respond to any communication from

teaching environment as participants reported challenges implementing new clinical and

our group and did not participate in the small group review serssions. We concluded that

teaching skills in their setting.

future interventions may function better administered as a workshop.





our teaching endeavor was primarily to improve upon this disconnect by having residents

AND MEDICATION RECONCILIATION Katelyn Stepanyan2; Josette Rivera1; Joan

identify and brainstorm improved workflows to highlight PCMH principles in their own





1 1

Abrams ; Michi Yukawa ; Anna Chang ; Yali Brennan ; Stephanie Rennke . University

practice sites. Through a modified nominal group technique and brainstorming session

of California San Francisco, San Francisco, CA; 2UCLA David Geffen School of

described here residents were thus placed on a path to develop their own PCMH based

Medicine, Los Angeles, CA. (Control ID #2469074)

educational curriculum. The objectives of our innovation can serve to help other residency clinic faculty 1) recognize that nominal group technique can be used to have medical trainees

NEEDS AND OBJECTIVES: Medication errors are common, and more than half of

identify their own unmet curricular needs, 2) perform a brainstorming session to devise

hospital patients are estimated to have one or more unintended medication discrepancies at

curricular change encouraging the inclusion of PCMH principles in a trainee’s ambulatory

admission. Medication reconciliation can identify errors. Although there has been signif-

experience, and 3) list EPAs within a PCMH training site to target for curricular efforts.

icant investigation into the most effective strategies for performing medicine reconciliation

SETTING AND PARTICIPANTS: All interns and residents on weekly firm ambulatory

within the healthcare system, there is little published on teaching this skill to medical

assignments attended the nominal group and brainstorming session at one of our two

students and direct impact on medication management in the hospital. The objectives for

ambulatory teaching sites over a 5 week period during our Thursday morning “academic

this skills-based curriculum for students included: 1) Apply skills in patient interviews to

half days”, with protected time from clinical responsibilities. The session was moderated

obtain a medication history (best possible medication history or BPMH); 2) Identify

by 2–3 teaching attendings, with one attending introducing basic PCMH principles in a

medication discrepancies during transitions of care and 3) Assess for facilitators and

framing discussion at the start of the session. Four medical or clerical office assistants also

barriers to medication safety and provide recommendations to the primary team.

actively participated in the framing talk and the brainstorming session.

SETTING AND PARTICIPANTS: The curriculum was piloted with 21 first year medical

DESCRIPTION: A weekly series of sessions was held for 5 weeks across the internal

students in 2014 and 2015 at 3 hospitals affiliated with an academic medical center (tertiary

medicine residency in ambulatory clinic during which a) PCMH principles and values

care center, county hospital and veterans affairs hospital).

were reviewed, b) a modified nominal group technique was held ascertaining which

DESCRIPTION: Over the course of ten half-day sessions, students met with a faculty

PCMH entrustable professional activities (EPAs) were not being appreciated by resident

facilitator and identified patients for medication reconciliation. Using a “med rec”

learners at their site, and c) resident led brainstorming ensued. The list of PCMH EPAs

worksheet each student performed at least one patient interview per session completing

were presented to the residents via review of: Chang et al. Transforming Primary Care

the BPMH, including all medication discrepancies and identified facilitators and barriers

Training—Patient Centered Medical Home Entrustable Patient Activities for Internal

to medication management (e.g. adherence, cost, polypharmacy). The students contacted

Medicine Residents, JGIM, 2012. 28 (6): 801–9. Each resident then named which three

the primary hospital providers using a templated communication form, including recom-

EPAs they felt individually most in need of experiencial exposures. Small groups reflected

mendations regarding patient-reported barriers.

on care based activities and curricular improvements to address one of three most

EVALUATION: On average students identified 2.3 medication errors and one or more

frequently chosen EPAs and reported out to the overall group. The resulting curricular

barriers to medication management per patient encounter. Compared to pre-test findings, there

project list across five firms at two clinic sites now represents the substrate for resident led

was a measurable improvement in students’ knowledge and skills. Using a 5-point Likert

curricular design in PCMH training. Ambulatory faculty will now target the recommended

scale after the curriculum, all students agreed or strongly agreed that they applied these skills

educational content and PCMH minded workflow improvements to be made.

during their clinical rotations. Students independently identified several areas involving the

EVALUATION: Pre and post session surveys assessing PCMH principle awareness and

electronic health record and communication between providers as potential systems gaps in

understanding, and awareness of clinic site infrastructure and inter-professional services

safe medication management during care transitions. Hospitalist faculty and residents highly

available for patient care, are being administered. Educational and clinical outcomes that

rated the student communications to the primary team and identified a plan to implement at

are PCMH minded will also be tracked once curricular improvements are put in place.

least one of the recommendations for each patient.


DISCUSSION / REFLECTION / LESSONS LEARNED: This skills-based curriculum

exercise demonstrates that nominal group technique as a way of performing trainee needs

embedded early medical students into the workplace in value-added roles for a critical patient

analysis followed by a brainstorming session is an effective means of galvanizing learner

safety activity. The curriculum provided a systematic and comprehensive approach to

paticipation with curricular design. A core principle in curricular design is learner needs analysis

medication reconciliation and medication management. In learning skills such as medication

and in this exercise, internal medicine residents identified PCMH EPAs that represented gaps in

reconciliation, early medical students can have direct positive impact on patient care systems

their training experience at both a PCMH certified training site and in a second site preparing its

and contribute to high quality care.

PCMH application. In particular, the EPAs most chosen among five firm teams involved 1) interrogation of a registry and use of risk stratifcation tools to better manage an entire panel, 2) activation and orchestration of community resources to meet a patient’s or population’s needs,


and 3) performance of a root cause analysis and reflection on items such as medical error, near


miss, preventable emergency room visits or readmissions, or patient complaints. Resident ideas


to modify educational content and clinical workflow to serve these PCMH anchored activities



2 1

Cacace ; Jennifer Verbsky ; Jason Ehrlich . Hofstra North Shore LIJ, Great Neck, NY;

will be enthusiastically cultivated and implemented. The authors believe conducting this session


has focused efforts to guide trainees and faculty to fill important gaps, and to advance PCMH

(Control ID #2467955)

values and improve patient care in the residency clinic. It has proven to be a high yield

North Shore LIJ, Great Neck, NY; 3North Shore LIJ Health System, Great Neck, NY.

innovation in curricular development for our clinic that was easy to implement. NEEDS AND OBJECTIVES: Training residents in an ambulatory patient centered medical home should solidify exposure to patient centered team based care that is more coordinated among inter-professionals and serves patient and population based outcomes.


Prior surveys delving into trainee awareness and understanding of PCMH principles at our

Deepa Bhatnagar; Ahmed G. Mohiuddin; Cathy Lazarus. Tulane University, New

institution revealed a disconnect from the site infrastructure already in place. The objective of

Orleans, LA. (Control ID #2470320)




NEEDS AND OBJECTIVES: In medical education today, there is a desire to enhance

year can be used to refine certain skills necessary at the beginning of internship. Our

the value of the fourth year of medical school by clarifying its purpose and reducing its

curriculum demonstrates that students can consistently perform well on data gathering

ambiguity. Both fourth year medical students and GME program directors are interested in

through history-taking and physical exam after third year clerkships. This curriculum,

ensuring that students are clinically rounded and prepared for residency. The AAMC

however, can be helpful in assisting students in evaluating urgent and emergent conditions

recently released a framework for clinical skills expected of medical students at the start of

effectively and improving communication skills with interdisciplinary team members.

internship—13 core professional entrustable activities. Fourth year sub-internships provide an ideal venue to solidify these skills. However, currently at our institution and nationwide (CDIM 2014 survey), our fourth year medical students have minimal oppor-


tunities available for observation of the acute issues that arise during nighttime patient


care. To prepare students for this environment, education on transitions of care and the

TRAINING Lollita Alkureishi1; Wei Wei Lee1; Sandra Webb1; Vineet M. Arora2.

delivery of patient care at night is needed. Through a new curriculum at our institution, we


hoped to educate our fourth year students on evaluating urgent or emergent conditions and

IL. (Control ID #2467460)

University of Chicago, Chicago, IL; 2University of Chicago Medical Center, Chicago,

developing interpersonal communication skills with peers and nurses involved in hospital care.

NEEDS AND OBJECTIVES: EMR use with patients in clinical care is the new norm.

SETTING AND PARTICIPANTS: We worked with 40 fourth year medical students

Despite ACGME competencies regarding professional documentation expectations and

rotating on Internal Medicine Sub-internship over the course of four 1-month blocks. We

interpersonal communication skill development in order utilize patient-centered education

developed and implemented case-based learning to experience nighttime coverage and to

strategies, few institutions provide formal curricula on patient-centered EMR use. Fur-

understand hand-overs of care for hospitalized patients.

thermore even if such curricula exist, it is difficult to practically deliver it to all institutional

DESCRIPTION: The curriculum was introduced during sub-internship orientation. In

trainees, thus limiting training to specific departments. Without required institutional

the second week of the block, we conducted a classroom, small group teaching session

education, trainees are left to rely on the hidden curriculum to learn EMR integration

that provided a structured template for written and verbal sign-out. The third week of the

strategies and can adopt unprofessional documentation practices. Our objective was to

block, we utilized the Simulation Center, allowing each fourth year medical student to act

develop and provide mandatory patient-centered EMR training to all incoming post-

as a night float intern with other students acting as the night shift nurse. We discussed data

graduate medical trainees at the University of Chicago.

gathering and communication in time-sensitive evaluations of patients and the develop-

SETTING AND PARTICIPANTS: We aimed to embed training on institutional docu-

ment of management plans on acute care patients. Each case was followed by debriefing to

mentation expectations and patient-centered EMR use strategies for all incoming post-

provide feedback on each scenario based on direct observation of each student in the

graduate medical trainees at the University of Chicago (UChicago) into their required


EPIC onboarding training and assess the impact of our curricula.

EVALUATION: To evaluate the effectiveness of this curriculum, we utilized standard-

DESCRIPTION: After reviewing the literature, we developed a 10-min presentation on

ized patients in the beginning and end of the block of the Internal Medicine sub-internship.

patient-centered EMR use best practices and issues related to documentation profession-

Each student interacted with a nurse followed by a patient—roles both played by

alism including “cut and paste” and authorship. UChicago EPIC trainers were instructed

standardized patients. 36 of the 40 medical students completed the pre and post-test

by the PI’s on curricula content and delivered it as part of the 8-h required EMR training

evaluation. Using a checklist to score performance, students were evaluated on their

for all 2015 new interns, residents and fellows. Post-training, a 10-item Likert-scale survey

interaction with the nurse, their medical decision to evaluate a patient based on triage of

was used to evaluate trainee self-assessed patient-centered EMR use knowledge, ability,

information, their interaction with the patient, and their evaluation of the patient. Follow-

and likelihood to change clinical practice. Likert responses at the high end of the scale

ing the curriculum, students improved in their communication with the nurse (0 % – >

were grouped to dichotomize data (i.e. 4 = agree and 5 = strongly agree combined as

14 %) and medical decision-making in an acute setting (61 % – > 81 %). Students


consistently introduced themselves to the patient (80 % – > 86 %) but improved in

EVALUATION: One hundred fifty-eight trainees completed evaluations (72 residents

clarification of their role as a night float physician (58 % – > 75 %). Both pre and post

and fellows, 86 interns; 32 primary care and 126 surgical or specialty trainees in 27

curriculum, the students performed a targeted history and physical exam in the acute

specialties). Trainees reported increases in their knowledge of patient-centered EMR use

setting but improved in communication to the patient about possible diagnoses and next

barriers (Pre-training 3.1 (0.9 SD) vs Post-training 3.9 (SD 0.8), p < 0.001), best practices

steps (69 % – > 97 %). Some representative comments about the curriculum include “I do

(Pre-training 3.1 (0.9 SD) vs Post-training 3.9 (SD 0.8), p < 0.001), and ability to

think that the SIM center cases helped me feel a lot more prepared and comfortable when

implement best practices (Pre-training 3.1 (0.9 SD) vs Post-training 3.9 (SD 0.8),

faced with the SP encounter the second time around! I also think that the sign-out part of

p < 0.001). Most felt the training was effective (90.5 %, n = 143), that it should be required

the curriculum has improved the quality of the written list and the oral sign-out that I give

(86.7 %, n = 137) and that it would change their future clinical practice as a result (70.9 %,

to night float” and “I really like this part of the sub-I curriculum. In fact, since starting my

n = 112). When comparing program type, primary care trainees were more likely to report

sub-I I have been in at least one emergent situation where I was making decisions . . . And I

training was effective (4.34 vs 4.09, p = 0.003) and that it would change their future

think we do NOT have adequate training thus far for triage and emergent situations.”

practice (4.13 vs 3.73, p = 0.02).

Students expressed a desire to debrief following the standardized patient encounters.


While many students agreed that the scenarios were moderately or extremely believable,

tion faculty partnership with EMR trainers who do routine required on-boarding is a novel,

students were interested in having more time and/or information to evaluate the patient.

timely and effective method to facilitate training on patient-centered EMR communication


strategies and professional documentation expectations across a variety of residency and

2014 demonstrates, fourth year medical students are interested in using this time to prepare

post-residency training programs. Future training should aim to longitudinally reinforce

for residency. This dedicated curriculum on important entrustable professional activities

best practices for trainees, train faculty to promote positive role-modeling in order to

can improve the clinical skills of fourth year medical students. While third year rotations

proactively shape the hidden curriculum’ of EMR use, and measure patient-satisfaction

often focus on the attainment of medical knowledge in various subject areas, the fourth

with trainee communication to determine if training was effective in creating an




institution-wide shared model of professionalism and high quality patient care in the

would like to develop pediatric MSK medicine and MSK procedure content. Lastly, we

computerized setting. Given the success of training and its reception by both trainees and

plan to disseminate the app more widely both in our own institution as well as in

trainers, the curriculum will continue yearly for all incoming trainees and also be

collaboration with other institutions in the future.

incorporated into all new hire EMR training for attendings, nurses and support staff at


UChicago. This curricula capitalizes on existing support structure available at most

downloading home page: http://meded.ucsf.edu/tel/msk-exam-tutor-ios-app-iphone-ipad

academic settings, involves minimal effort on part of the faculty and EMR trainers, and does not require additional cost making it extremely feasible and easily replicated at other institutions.

PHYSICIAN ADVOCATE AND HEALER ATTORNEY: A HEALTH LAW PARTNERSHIP IMPROVES HEALTH AND EDUCATION Mukta Panda1; Benjamin Danford2. 1University of Tennessee, Chattanooga, TN; 2Legal Aid of East Tennessee;


Chattanooga, Chattanooga, TN. (Control ID #2469114)

Carlin Senter1; Dylan Alegria2; Christy K. Boscardin1; Chandler Mayfield1. 1University of California San Francisco, San Francisco, CA; 2University of California Los Angeles,

NEEDS AND OBJECTIVES: In order to deliver holistic patient centered care, health

Los Angeles, CA. (Control ID #2467796)

care trainees must demonstrate an awareness of and responsiveness to the larger context of the health care system as well as the ability to call effectively on other resources in the

NEEDS AND OBJECTIVES: Musculoskeletal (MSK) problems are the second most

system to provide optimal health care. While the hospital is proficient at providing medical

common reason that people seek medical care in the United States; however, many

treatment, some of these patients have unmet legal needs that can exacerbate their medical

primary care providers lack competence and confidence in practicing MSK medicine.

conditions. One in six individuals in the United States live in poverty, and current research

To address this gap in knowledge and skills, we created the UCSF Musculoskeletal

shows that each of these individuals has at least one civil legal problem that negatively

Physical Exam App. The app teaches the MSK physical exam to novice-intermediate

affects their health. The introduction of a poverty-law attorney into the hospital provides

learners and serves as a resource for practicing clinicians. Based on a needs assessment

an opportunity to identify and address legal problems as an integral part of overall patient

using data on frequency of referrals from primary care internal medicine to orthopaedic

care from the outset, instead of only providing a referral to an attorney upon discharge.

surgery at UCSF and with faculty input, we chose seven key MSK problems on which to

This challenge led to the creation of the University of Tennessee (UT) Health Law

focus app content: meniscus tear of the knee, adhesive capsulitis and impingement


syndrome of the shoulder, carpal tunnel syndrome, hip osteoarthritis, ankle sprain, and

SETTING AND PARTICIPANTS: The attorneys are key members of an integrated

ankylosing spondylitis. Learning objectives: Upon mastery of each case in the app, the

multi-disciplinary team, bringing together medical residents, students, physicians, mid-

learner will be able to: 1. Name the exam maneuvers needed, 2. Identify the abnormal

levels practitioners, nurse managers, nurses, case management personnel (case managers,

exam findings, and 3. Use case history and exam findings to make the correct diagnosis.

documentation specialists, resource utilization specialist), physical, occupational, speech

Self-assessments are embedded in each case to allow the learner to measure his or her

and respiratory therapists, dietitians, pharmacists, legal aid staff, and chaplains.

success in achieving these objectives.

DESCRIPTION: Once a patient with a legal problem is identified, a member of the

SETTING AND PARTICIPANTS: The app is recommended curriculum for UCSF

clinical team alerts the attorney. Subsequently, a meeting is arranged either at the attorney’s

School of Medicine first-year anatomy students and for UCSF primary care internal

office inside the hospital or at the patient’s bedside, thus establishing an attorney-client

medicine residents. The app was provided to participants of a Sports Medicine continuing

relationship and providing much needed services without requiring the patient to ever

medical education course. The app is available for free download to the UCSF community

leave the hospital. Some of the legal services include planning documents, such as,

and to the public through the Apple app store.

advanced care plans, durable power of attorney documents, wills, and healthcare power

DESCRIPTION: The app contains two main sections. First, there are seven patient cases,

of attorney documents.

each of which focuses on one of the key MSK problems. Each case contains embedded

EVALUATION: Over the 3 years, the UT Health Law Partnership has provided assis-

questions and a learner assessment at the end. The learner can repeat the cases as many times

tance to individuals with more than 300 distinct legal problems and created monetary

as they wish. Second, the app contains exam maneuver video clips with text describing the

benefits for patients and clients in excess of 1.1 million US dollars. The partnership has

maneuver as well as its clinical utility, sensitivity, and specificity. These short video clips are

demonstrated better health care outcomes as evidenced by improved patient care and

meant for targeted review or on-the-fly use in clinical settings. Content was written by

compliance, securing reimbursement for medical expenses, reducing unnecessary

Technology Enhanced Learning Medical Education Fellow (DA), and edited by faculty lead

readmissions, and decreased length of stay. Hospital patients benefit by meeting with an

(CS) with resident and faculty experts. UCSF faculty, students, and patients volunteered to

attorney in an efficient manner while in the hospital, and without having to wait or

participate in filming. Content was filmed by a professional crew. The app was created by a

navigate the additional obstacles to obtain the necessary legal services. Other much needed

developer using an existing platform.

services inherent to having additional in-house resources available to assist patients deal

EVALUATION: The app has been downloaded by 345 internal (UCSF) and 509 external

with problems outside of the traditional scope of case management, including issues

users in 31 countries. Learners accessed the app 138 times in the last month. The top 3

related to domestic violence, housing, public benefits, planning documents, and the

maneuvers accessed by learners since the app’s inception are: AC joint crossover, Hawkins

protection of a patient’s income.

impingement test (shoulder), and knee range of motion. We are in the process of evaluating


the app’s efficacy in improving retention of MSK exam knowledge among primary care

an attorney into the hospital that interacts with clinical staff as a member of the

providers after attending a Sports Medicine continuing medical education course.

patient care team. Utilizing the services of an attorney as stated above is the


important first step in eliminating one of the most persistent problems in providing

in version 2.0 of the app: 1.) Clustering exam maneuvers according to use (not alphabet-

legal services to indigent patients. This way, many of the obstacles that prevent

ically), 2.) Including only the essential exam maneuvers for the target audience, and 3.)

patients from seeking legal services are eliminated. The traditional delivery system

Porting the app to all mobile platforms (currently iOS only). Due to user feedback, we

for legal services is a tedious one that involves a multi-step process: making




contact with legal services over the phone, preparing an application for assistance

regarding the utility of this new tool. While we feel that our pilot study brings to light several

with intake staff, scheduling an appointment to meet with an attorney or other

barriers with respect to integration of POCUS in IM Programs, our study was a small group

staff, then arranging for transportation to and from the appointment. By placing an

of self-selected faculty with N = 15. Faculty clearly benefitted from this brief intensive

attorney in the hospital, the traditionally cumbersome procedure has been stream-

training course, but it remains unclear how long this higher level of skill is maintained in

lined. Both patients and clinical staff benefit from the increased predictability and

the absence of continued training.

decreased anxiety as the result of having conveyed important decisions to the decision making authority. This interdisciplinary model is exemplary of providing not only patient centered care but developing a relationship centered care and an


educational opportunity for training the future generations of healthcare providers

ENHANCE CLINICAL REASONING Sirisha Narayana; Alvin Rajkomar; James D.

with countless advantages for both the patient and health care system as outlined

Harrison; Victoria Valencia; Gurpreet Dhaliwal; Sumant Ranji. University of California


San Francisco, San Francisco, CA. (Control ID #2447394)

NEEDS AND OBJECTIVES: Feedback on patients’ longitudinal clinical courses may POINT OF CARE ULTRASOUND FACULTY DEVELOPMENT FOR GENER-

enhance physicians’ learning, improve their understanding of health systems, and reduce

AL INTERNISTS Anna Maw; Cathy Jalali; Deanna Jannat-Khah; Kirana Gudi; Lia S.

diagnostic error. However, few trainees have the opportunity to follow up on their patients

Logio; Stacy Anderson; Joshua B. Smith; Arthur Evans. Weill Cornell Medical College,

after discharge. Barriers to longitudinal follow-up include time constraints, discontinuous

New York, NY. (Control ID #2463028)

training environments, and difficulty accessing patient information. We developed a novel program to teach internal medicine interns how to conduct post-discharge follow-up on

NEEDS AND OBJECTIVES: Needs: There is growing evidence that the use point of

their patients, with the goal of enhancing life-long learning by stimulating self-directed

care ultrasound (POCUS) improves patient care. Internal Medicine (IM) Residency


programs have been slow to adopt the routine use of POCUS to augment the traditional

SETTING AND PARTICIPANTS: Interns on their 4-week patient safety rotation at an

physical exam. One of the identified barriers to integration of POCUS into IM residency

academic internal medicine residency program.

training is lack of faculty expertise. Objectives: Following completion of training work-

DESCRIPTION: We developed a worksheet outlining a process for structured chart

shop, the internists were expected to 1) demonstrate skills in acquiring and interpreting

review and reflection. At the beginning of their rotation, interns were given lists of

images and 2) report enhanced confidence in using POCUS in patient care.

hospitalized patients they cared for earlier in the year generated from the electronic health

SETTING AND PARTICIPANTS: Over a 10-week period, 15 full-time academic

record (EHR). They collected information on patients’ post-discharge courses using the

general medicine faculty members at a single urban academic medical center participated

EHR and completed reflection worksheets for a sample of these patients. They then met at

in a 12-h (2-h online didactic by SonoSim® and 10 h of small-group hands-on POCUS

the end of the rotation to debrief with their peers about what they learned.

sessions) faculty development course led by an academic hospitalist.

EVALUATION: We thematically analyzed four debrief sessions and 104 completed

DESCRIPTION: Hands on sessions consisted of 1–4 faculty members performing

patient reflection worksheets from 22 interns to assess initial perceptions of the curriculum

supervised scanning of medical inpatients, who volunteered to be examined for the

and evaluate the content of reflections.

purposes of the course and included modules of the diagnostic characteristics and


limitations of the POCUS exams most useful for an internist including: vascular, pulmo-

from our analysis. Interns reported that post-discharge patient follow-up was extremely

nary, cardiovascular, biliary, and renal. All faculty participants completed pre and post-

valuable to their professional development. It helped them appreciate the natural history of

intervention exams and surveys to assess knowledge of and attitudes toward POCUS. The

disease and the variability of illness course in patients with complex disorders. They also

questions centered on test characteristics, image acquisition, interpretation, and clinical

reported that reviewing patients’ clinical courses would change their future practices by

correlation of bedside echocardiography including IVC assessment, lung examination,

advocating for earlier end-of-life counseling, improving discharge transitions, and

abdominal/aortic and renal imaging, and lower extremity DVT evaluation.

adjusting their clinical decision-making while the patient was still hospitalized. Sample

EVALUATION: Pre and post-test scores were analyzed using paired t-test. Surveys of pre

reflection worksheet questions and interns’ responses are highlighted below: What med-

and post attitudes towards POCUS were analyzed using Paired-Sample Wilcoxon Signed

ical questions or concerns did you have at the time of this patient’s discharge? ● Would this

Rank Test. STATA software (Stata Statistical Software: Release 13) was used to analyze

patient adhere to insulin after multiple admissions for DKA? ● Was atrial fibrillation the

the data.

source of this patient’s stroke? ● How would this patient adjust to hospice given her


functional status? What lessons did you learn from this patient’s post-discharge course? ●

significant improvements in their ability to interpret ultrasound data (pretest mean score =

Anticipate patient positioning during tube feeding prior to discharge. ● Begin conversa-

40.3 %, post-test mean score = 73.9 %, p < 0.001). Prior to the training session, most faculty

tions about prognosis and disease severity early on. ● Patients with advanced cancer can

reported minimal to no comfort in their ability to understand and operate the ultrasound

decompensate and die quickly. ● Be cognizant of the realities of depression at a skilled

equipment (90 %). After training, they all (100 %) reported at least moderate comfort (p =

nursing facility. What would you do differently the next time you have a similar patient or

0.003). Similarly, most participants had very limited confidence with respect to understanding

case? ● Continue addressing goals of care even in short-term stays in the hospital. ● I

the capabilities and limitations of ultrasound and this attitude was also significantly improved

would engage family members so all are working towards a similar goal. ● I would do

by the training provided (p = 0.003). We asked the participants about perceived barriers to

more research into the procedure I was recommending. ● I would ensure the date and time

integrating bedside ultrasound into their practice. Pre-test survey data revealed that most

for the PCP appointment is set prior to discharge. Future evaluation will include

identified access to training resources (67 %) and lack of time to acquire training (73 %) as the

surveying interns before and after the intervention to determine if participation encourages

greatest obstacles to achieving this goal. This pilot study showed that a brief intensive course

habits of regular patient follow-up. In summary, a structured program coupling post-

that included didactics and hands-on training yielded significant improvements in the ability

discharge follow-up data from an EHR with reflection has the potential to influence

of our faculty to obtain and interpret ultrasound data as well as change faculty attitudes

trainees’ professional development and to mold their clinical reasoning.





Professional Responsibility, and by academic thought-leaders in the field(1,2). Social


determinants are critical to improving health outcomes, and thus the responsibility of



2, 3

2, 1 1


Graduate Medical Education (GME) extends beyond a commitment to providing direct

San Francisco, CA; 2University of California, San Francisco, San Francisco, CA; 3JAMA

care for impoverished patients and toward advocating around the conditions that underlie

Internal Medicine, Chicago, IL. (Control ID #2469835)

to health disparities (3). Given the public funding nature of residency programs, GME has

Rachel J. Stern ; Blake Charlton ; Rita F. Redberg

; Jeff Kohlwes

a responsibility to incorporate social accountability into training.(4) In fact since 2011 the NEEDS AND OBJECTIVES: Many internal medicine residents aspire to academic

ACGME has incorporated advocacy as a curriculum requirement for pediatrics programs

careers. Skills in academic writing and manuscript review are needed for a successful

(5). While pediatric and family residencies have developed several models for incorpo-

academic career, but building them is not part of traditional residency curricula. To meet

rating advocacy into their curricula, internal medicine curriculum models are scarce. (6,7)

these career training needs, the UCSF Internal Medicine residency and JAMA Internal

Objectives To empower residents to affect social determinants of health through hands-on

Medicine (JAMA IM) developed two mentored, longitudinal editorial experiences to be

experiences in health advocacy, providing them with the skills, confidence and contacts

completed within senior residents’ existing project/administrative time.

necessary to be an advocate and leader in their career To foster a community of change-

SETTING AND PARTICIPANTS: Sixteen second and third year internal medicine

making individuals who can support each other in their work To elevate the role of the

residents at the University of California, San Francisco (UCSF) who were interested in

physician-advocate for residents in training To increase capacity for meaningful hands-on

gaining manuscript review skills and writing opportunities were selected after a compet-

research among residents, leading to increased national reputation and increased funding

itive application process.

SETTING AND PARTICIPANTS: Up to four interns per year will be selected for this

DESCRIPTION: The JAMA IM editor-in-chief, residency leadership, and two

program. Those selected will remain in the program for their entire residency, giving the

residents collaborated to create two experiences: an editorial fellowship and an

program a size of approximately twelve people. Monthly advocacy track dinners are open

editorial elective. The editorial fellowship is a 2-year apprenticeship. Two new

to all members of the Tulane community, including medical students and faculty. Six

JAMA IM editorial fellows annually participate in the editorial decision making

faculty mentors participate in the track and are individually matched with resident mentees

process, scholarly writing, and manuscript review during their six outpatient

based on area of interest.

months. Fellows also coordinate the elective and provide near-peer mentoring to

DESCRIPTION: Tulane’s Advocacy and Leadership Track seeks to train a small group

the 12 senior resident elective participants each year. After completing a self-

of health advocates and leaders who will receive personalized attention and increased

guided curriculum on high-quality peer review, elective residents review three

focus on career development from institutional mentors. Residents will collaborate with an

manuscripts and complete a scholarly manuscript over a 4-month period. Journal

organization working on an issue of health justice during years two and three, partnering

editors provide feedback on residents’ reviews and faculty members mentor resi-

on a campaign with specific policy outcomes during two, 2-week blocks each year. By the

dents’ writing projects.

end of the 3-year program, residents should be able to develop a strategy for a successful

EVALUATION: From inception in August 2014 to the present, four housestaff have

campaign, communicate with media around policy issues, advocate with legislators

served as fellows. Six others have participated in the 2-month elective. These residents

around an issue of their choice, and lay the foundations for a successful career through

have completed 10 mentored, peer-reviews of submitted manuscripts and have published

personal leadership development and networking. The advocacy track will hold a

12 peer-reviewed manuscripts themselves- five editor’s notes, four commentaries, one

protected 3-week course for interns annually. All participants will begin an Advocacy

review, one perspective and one piece of original research. These were published in

Portfolio at that time, strategizing about their personal goals for this experience. Each

JAMA IM, JAMA, BMJ, JGIM and AJIM. Initial participants report high satisfaction.

resident will present the results of their project prior to graduation. We hope this track will

The JAMA-IM editors greatly value the residents work and contributions. They comment

create long-lasting partnerships with local and national organizations working on health

that the trainees offer an important new perspective on many of the manuscripts, in

advocacy campaigns. An academic objective of the track is to create a curriculum that

addition to help with journal-related projects. All of the resident manuscript reviews were

models advocacy training as a part of internal medicine residency.

rated Very Good to Excellent by the editors. Qualitative comments from housestaff

EVALUATION: We plan to use qualitative evaluation for interns after their 3-week course.

participants include “[the elective] built my confidence and my ability to critically evaluate

The program will track resident progress through evaluation of each resident’s advocacy

research” and “made me feel like my voice mattered.”

portfolio, looking at their campaign-specific action plan and a menu of advocacy milestones.


Given that activist and community-based approaches often generate unanticipated benefits,

formal reviewing are discrete, teachable skills that can feasibly integrated into residency

we also will track serendipitous occurrences as a result of coalitions and new partnerships

curricula. With existing project time, faculty mentoring, and a self-guided curriculum, our

formed. In the future we will survey newly-matched interns to determine whether the

residents successfully improved their peer review skills and published their work. Journal

advocacy track contributed to their rank decision. The development of measurable compe-

editors are an underutilized source of mentoring for trainees interested in academic careers.

tencies in social justice and advocacy training is both vital and lacking (2). By evaluating our

Our elective model could be replicated at any institution where faculty members regularly

curriculum and milestones longitudinally, we hope to contribute to this conversation.

review manuscripts.

DISCUSSION / REFLECTION / LESSONS LEARNED: One of the difficulties of any longitudinal curriculum (i.e. monthly dinners, campaign work) is that residents will give up free time to participate. We have attempted to mitigate this by having weeks set


aside for campaign work that will balance this out. Additionally finding the right issue for


each resident can be a challenge; some residents can find an issue they are passionate

MEDICAL RESIDENTS Jane Andrews; Kris Coontz. Tulane School of Medicine, New

about that is also current (i.e. gun sense legislation), for others we struggle to find one that

Orleans, LA. (Control ID #2457560)

matches them personally and has a movement in progress. Using national networks is one technique that has been successful.

NEEDS AND OBJECTIVES: Advocacy is regarded as a fundamental principle of

ONLINE RESOURCE URL (OPTIONAL): http://tulane.edu/som/advocacy-leader-

professionalism for physicians in the ABIM charter, the AMA’s Declaration of






NEEDS AND OBJECTIVES: With rising healthcare costs and focus on quality, there is

TIAL LEARNING Margaret Horlick1; Patrick M. Cocks3; Lisa Altshuler2; Colleen

a growing need to promote resource stewardship in medical education. One driver of


2 1


Gillespie ; Sondra Zabar . NY Harbor VA Healthcare Center, Brooklyn, NY; NYU

overuse is patient request for unnecessary testing. As emphasized in the Choosing

School of Medicine, New York, NY; 3NYU School of Medicine, New York, NY; 4NYU

Wisely® campaign, physicians can play a critical role in ensuring delivery of high-value

SoM, Brooklyn, NY. (Control ID #2467148)

care. Training residents to engage with patients in shared decision making about appropriate resource utilization is one important strategy to prevent overuse. With the increased

NEEDS AND OBJECTIVES: Medical trainees may experience stigma when seek-

emphasis on competency based medical education, evaluating residents’ ability and

ing help for mental illness and burnout. Renewed attention has focused on main-

uptake of these learned skills is equally important. Objectives: 1) Deliver an experiential

taining wellness and supporting trainees with mental illness after the alleged

curriculum on resource stewardship to develop residents’ skills to counsel patients about

deaths from suicide of two IM interns in 2014. Our objectives were to: 1) Change

unnecessary testing; 2) Evaluate the effectiveness of this curriculum in improving resident

the culture at our institution and 2) Equip our chiefs, residents and core faculty

knowledge of resource stewardship and communication skills with patients to reduce

with skills to recognize struggling residents and knowledge of resources available.


SETTING AND PARTICIPANTS: Large, urban academic medical center. 16 chief

SETTING AND PARTICIPANTS: Participants were third year residents in the post-

residents, 74 residents and 6 faculty participated in program

graduate internal medicine program (N = 45) and first to third year residents in the

DESCRIPTION: We instituted two experiential learning activities to change our

postgraduate pediatrics program (N = 38) at the University of Toronto.

residency’s culture around the approach to burnout and mental illness. Over the

DESCRIPTION: The project involved 2 phases. In Phase 1, a 2-h experiential

2014–2015 academic year we included a “struggling colleague” case in the

workshop on resource stewardship with a focus on developing communication skills

established intern and PGY-2 OSCEs and instituted a group three-station OSCE on

to counsel patients about unnecessary testing was delivered to internal medicine and

struggling residents for the chief residents in our IM program. The learning objectives

pediatric residents. The workshop included 4 components: 1) an introductory didactic

were that learners would 1) understand their role in identifying and assisting strug-

mini-lecture providing an overview of resource stewardship, 2) a trigger video that

gling colleagues 2) recognize problem behaviors, 3) effectively discuss concerns with

introduced attendees to a communication framework with four key elements (provide

colleagues who may be impaired and, 4) identify available resources. The intern and

clear recommendations to patients; elicit patients’ beliefs and concerns; provide

PGY-2 OSCE case portrayed a colleague who struggled with depression and alcohol

empathy, partnership and legitimation; and confirm agreement), 3) role play with

abuse. The station involved 10 min with the standardized learner, then immediate

residents in small group break-out sessions and 4) a large group facilitated interactive

feedback and discussion with faculty. The three-station group OSCE for the chiefs

discussion. In Phase 2, we carried out a structured assessment of residents’ commu-

was preceded by a discussion of the impaired physician and the epidemiology of

nication skills with patients requesting an unnecessary diagnostic test as part of a

substance abuse, burnout and mental illness in our profession and chief residents’ role

larger formative observed structured clinical examination (OSCE) approximately

in identifying and assisting struggling trainees. Cases included standardized trainees

6 months after the delivery of the workshop. Standardized patients completed a

who evidenced alcohol abuse, depression, and adjustment disorder and who had

multi-item scoring sheet and rated performance on a 5-point Likert scale. Residents

varied insight and willingness to accept help.

also completed a knowledge questionnaire to assess their knowledge of resource

EVALUATION: Both housestaff and chief residents noted the value of this learning

stewardship. We compared residents’ scores who attended the workshop on the

experience. Of the housestaff (41 interns and 33 PGY-2 s) who participated in the OSCE,

knowledge assessment to those who did not using a T-test. We also summarized

one-third felt unprepared for the case. Most struggled with roles and boundary issues

resident skills using descriptive statistics, and performed a mixed-effects linear

discussing concerns with peers rather than patients. All 16 chief residents who completed

regression to identify predictors of better performance on the skills assessment.

the group OSCE valued reviewing their role and learning approaches to these conversa-

EVALUATION: This study included 83 residents, 57(69 %) of whom attended the

tions. Themes expressed at 1 month follow up included: support for group OSCE,

resource stewardship workshop. On delayed knowledge testing, residents who

importance of seeing alternate approaches to these conversations, new perspective on

attended the workshop scored significantly better on the knowledge questionnaire

skills needed for their job and the relevance of available resources.

than residents who did not attend the workshop (4.25 ± 1.90 vs. 3.09 ± 1.65 out of


8, p = 0.01). The mean overall score on the structured assessment was 3.95 ± 0.68

learning activities with chiefs, residents and faculty on mental illness and burnout can

on a 5-point Likert scale. The linear regression found that both higher training

generate greater awareness of the problem, promote skills in approaching these situations

level and higher score on the delayed knowledge assessment were independent

and effectively disseminate resources. Learners valued the opportunity to discuss re-

positive correlates of better overall performance on skills assessment after

sources directly with faculty and understand program’s supportive environment. More-

adjusting for gender, training program and level, workshop attendance, and self-

over, it demonstrated leadership’s awareness of these issues and reinforced efforts at

reported prior feedback on communication skills.

culture change.

DISCUSSION / REFLECTION / LESSONS LEARNED: A workshop on resource stewardship that introduced a structured approach to communicating with patients about unnecessary diagnostic tests improved residents’ knowledge on a delayed


knowledge assessment tool. Improved knowledge, in addition to higher training


level, was independently correlated with improved performance on a structured


assessment of communication skills. This study demonstrates that an easily

DIAGNOSIS TESTS Adina Weinerman1; Geetha Mukerji2, 3; Sarah Schwartz3, 4; Adelle

implementable resource stewardship workshop can improve residents’ knowledge

R. Atkinson3, 4; Lynfa Stroud1, 3; Brian Wong1, 3. 1Sunnybrook Health Sciences Centre,

in this area, which in this study correlated with improved performance on a

Toronto, ON, Canada; 2Women’s College Hospital, Toronto, ON, Canada; 3University of

standardized communication station. This is one step in ensuring that these nec-

Toronto, Toronto, ON, Canada; 4Hospital for Sick Children, Toronto, ON, Canada.

essary skills can be transferrable into actual practice, to ensure delivery of high-

(Control ID #2467809)

value care and prevent overuse.





97 % favorable rating (“agree” or “somewhat agree”) to the statement “this conference


effectively discussed the drivers of overuse/underuse.” Similarly 94 % of respondents

Murphy4; Fred R. Buckhold1; Tyler M. Miller2, 6; Darlene Tad-y3; Brandon Combs2, 5.

gave favorable ratings to “this conference uncovered opportunities for improving quality


Saint Louis University School of Medicine, St. Louis, MO; 2University of Colorado,

of care.” 88 % of the respondents found the information applicable to their practice. For

Denver, CO; 3University of Colorado Denver School of Medicine, Aurora, CO; 4Univer-

two presentations to a total of 27 internal medicine residents, there were unanimous

sity of Colorado School of Medicine, Denver, CO; 5Lown Institute, Brookline, MA; 6VA

favorable ratings to the same statements and unanimous agreement that the information

Medical Center, Denver, CO. (Control ID #2469561)

was applicable to their practice. These data suggest that the RightCare Rounds format is easily implemented and well received by medical trainees. Most trainees noted that issues

NEEDS AND OBJECTIVES: The practice of high-value, patient-centered care is a key

pertaining to medical overuse and underuse were directly applicable to daily practice. As

competency for medical trainees and providers. However, there is high variability in how

training programs look for innovative ways to promote competencies in high value care,

and to what extent these principles have been incorporated at individual institutions. We

the positive responses to RightCare Rounds obtained thus far indicate RightCare Rounds

sought to implement an educational conference format that would 1) Enable recognition of

is an effective means to address this unmet need.

medical overuse as a significant barrier to high-value care, 2) Provide a forum for

ONLINE RESOURCE URL (OPTIONAL): http://lowninstitute.org/toolkit-2/

participants to analyze the drivers of medical overuse and underuse, and 3) Diagnose shortcomings in care delivery to identify individual and systems-level opportunities to enhance the value of patient care


SETTING AND PARTICIPANTS: RightCare Rounds is an adaptation of the familiar


case conference format and thus is appropriate for a multitude of settings including

COURSE (MOOC) Monica L. Lypson3, 2; Paula T. Ross1; Kathryn Goldrath4. 1Univer-

morning report and grand rounds. The intended audience is any group with need for

sity of Michigan Medical School, Ann Arbor, MI; 2University of Michigan, Ann Arbor,

heightened awareness of the detrimental effects of medical overuse and underuse on the

MI; 3Ann Arbor VA Healthcare System, Ann Arbor, MI; 4University of Michigan Medical

delivery of high-value care. While our initial focus has been on medical trainees,

Scholl, Ann Arbor, MI. (Control ID #2463778)

RightCare Rounds is appropriate for audiences composed of trainees, faculty, private practitioners or any combination of those groups.

NEEDS AND OBJECTIVES: With over 200,000 veterans reintegrate into civilian life

DESCRIPTION: RightCare Rounds is an initiative promoting a new paradigm of doing

each year, it is important that training programs identify appropriate content to educate

“as much as possible for the patient and as little as possible to the patient.” Initially

health professions on caring for veteran patients; this content is critical in the development

conceived by the Lown Institute, an organization determined to improve value of care

of the necessary clinical acumen whether working in Veteran Affairs (VHA) Healthcare

through elimination of unnecessary medical treatment, RightCare Rounds transforms the

System or civilian clinical settings. Educating trainees on issues related to veteran centered

familiar case presentation format to facilitate an evidence-based discussion with the goal

care is critical given that 11 % of US citizens have served in the military; however, only

of improving value and promoting appropriate patient care. This initiative was promoted

30 % of veterans seek care in the VHA. In addition, each year approximately 150,000

nationally to chief residents from several specialties as part of an educational program

health professional trainees rotate in VHA facilities. We developed a Massive Open

aimed at improving awareness around the origins and harms related to low-value care.

Online Course (MOOC) to introduce health professionals to critical concepts in providing

RightCare Rounds is structured to address the whole patient and the entire continuum of

veteran centered care.

care providing a unique opportunity to reflect more deeply on patient preferences, social or

SETTING AND PARTICIPANTS: The MOOC format will facilitate the delivery of this

cultural contexts and systems-level dysfunction that is often “business as usual.” It also

much needed content in an easily accessible manner. The on-line format incorporates key

explores the many drivers of overuse and underuse that may obstruct appropriate medical

domains of e-learning: lessons that communicate information and lessons that develop

care. RightCare Rounds borrows on the traditional case presentation model and uses a

skills. The MOOC will allow for open global enrollment.

familiar cause and effect diagram, or “RightCare Fishbone,” to identify the drivers of low-

DESCRIPTION: The course is delivered over 7 weeks and include lecture videos,

value care. This familiarity and adaptability allow RightCare Rounds to be tailored to each

content expert commentary, perspectives from veterans, educational readings, documen-

programs’ need and can be used to explore these issues in both inpatient and outpatient

tary footage, and active learning techniques (e.g., photo-elicitation, reflective writing) to

environments. By providing a venue for discussion and tools for analysis, RightCare

help learners recognize their own biases regarding veterans specifically, but for all patients

Rounds enables practitioners to translate lessons from the conference to their own practice.

in general. The active learning techniques and approach to assessment was an important

EVALUATION: RightCare Rounds has been presented to audiences at division and

valued added part of the development of the course to attempt to evaluate some aspects of

department Grand Rounds and as noon conference to graduate medical education trainees.

the affective domain. Each week also includes a learner assessment using multiple choice

Qualitative information has been obtained from surveys of the audience members. The

questions and peer assessment. (March-April 2016)

survey was created by the Lown Institute for evaluation of RightCare Rounds and includes

EVALUATION: In year one of the live course 66.6 % of students strongly agreed/agreed

questions asking the respondents level of agreement with statements such as “this conference

that exercises helped with my observational & critical-thinking, as well as noting this

effectively discussed the drivers of overuse/underuse,” and “this conference uncovered

activity heightened my awareness about providing patient-centered health care. Also

opportunities for improving quality of care.” Respondents could choose one of 4 responses:

83.3 % strongly agreed/agreed the photographs helped me to reflect on my own attitudes

agree, somewhat agree, somewhat disagree and disagree. Also respondents were asked if the

toward people from different racial groups. In year two of the live course implementation

information from RightCare Rounds was useful in their practice answered as yes or no.

sample comments related to the role providers have in addressing disparities: “Providers


need to check their own biases so they don’t propagate them. Providers also need to join

Rounds has been adopted as part of the curricula at 32 residency programs across a range

together to advocate for and address health disparities.” “I need to check my own biases

of specialties including internal medicine, family medicine, emergency medicine, and

frequently so that they propagate into patient care as little as possible.” Also, 100 % of the

general surgery. To date, survey data from three presentations at two institutions is

students agreed or strongly agreed that the photographs helped me to reflect on my own

available. An internal medicine Grand Rounds with 33 respondents was notable for

attitudes toward veterans.





EVALUATION: As the pathway is in its infancy, with the first cohort beginning in

collaboration with staff at the University of Michigan’s Digital Education & Innovation

June 2016, the expectation is that most of the evaluation will take place over the next few

(DEI). We plan to offer the course as an on-demand enrollment session offer flexibility to

years including pre and post surveys of resident trainees as well as patients. Each resident

learners and provide a platform for completion prior to healthcare encounters with

that goes through the pathway will be expected to complete: − Capstone Project, Collo-

veterans or at a VHA healthcare facility. Teaching: .The development of a quality MOOC

quium or Service Initiative—Presentation at Regional or National Conference

takes the input and resources of a large university infrastructure to ensure high fidelity.


Learning how to approach and evaluate learning analytics developed from peer-

privilege of providing care to patients of all social and ethnic backgrounds, requiring a

assessment and reflections will be an important strategy for course evaluation. The views

nuanced approach that considers the social determinants and community context of health.

expressed in this poster are those of the authors and do not necessarily reflect the position

Yet there often is little consideration to this nuance in daily education and system

or policy of the Department of Veterans Affairs or the U.S. government

modeling. Addressing these considerations is increasingly important as our institutions

ONLINE RESOURCE URL (OPTIONAL): http://digitaleducation.umich.edu/dei/va-

try to engage patients in their homes and neighborhoods. Many residency programs across


the country have taken on this challenge by developing social justice programming to ensure that residents and other health professional trainees are trained in the skills and afforded the opportunity to consider the social challenges that impact patient health.


Through the experiences of other training programs we learned that rather than creating

PATHWAY IN RESIDENCY TRAINING Utibe R. Essien; Julian Mitton. Massachu-

a track where residents were expected to follow a strict set of rotations over their training

setts General Hospital, Boston, MA. (Control ID #2469731)

period, we would create a pathway, pairing residents with faculty mentors to tailor an interdisciplinary training experience through the preferential selection of several electives,

NEEDS AND OBJECTIVES: The work of a physician is complementary with that of a

leadership opportunities and community opportunities. We hope to share this innovative

social justice pioneer and community organizer. Those interdependent social roles can add value

approach to increasing social justice and community advocacy training in residency while

and meaning to practice across all clinical environments. Such efforts require unique skills and

seeking opportunities for further collaboration that will help sustain this work of address-

experiences that are not traditionally emphasized in medical education. As such, through this

ing the social determinants of health.

Social Justice and Community Advocacy (SJCA) pathway we aimed to: − provide Internal

ONLINE RESOURCE URL (OPTIONAL): http://www.altfutures.org/pubs/

Medicine resident trainees and medical students with a longitudinal pathway in the interdisci-


plinary practice of social justice and community advocacy; − draw on opportunities at the academic medical center, Massachusetts General Hospital (MGH), Harvard Medical School, Harvard University and in the greater Boston community; − assist residents in tailoring their


3 years of residency toward the acquisition of leadership and clinical skills needed to impact


change in the lives of their patients; − create and maintain a pathway that is mentored, patient-

EDUCATION John Marshall1; Rita K. Kuwahara3; Aziza Dang2. 1Emory University,

and community-centered and culminates in a final project or service initiative.

Atlanta, GA; 2Virginia Commonwealth University, Richmond, VA; 3University of North

SETTING AND PARTICIPANTS: The pathway includes a series of experiences aimed

Carolina at Chapel Hill School of Medicine, Durham, NC. (Control ID #2469847)

at skill acquisition and mentored advocacy. Pathway design is tailored to the particular interests of the resident, ideally within the context of patient care and their clinic

NEEDS AND OBJECTIVES: In the US, caring for the top one percent of health care

community. There are suggested rotations and experiences in all 3 years in a graduated

utilizers constitutes twenty percent of national health care expenditures. Our health

and longitudinal fashion, with increasing responsibility in the second and third year.

professions education system is currently failing to prepare students for the highly

Activities will culminate in a senior capstone project, colloquium or service initiative.

interprofessional, high-touch work required to serve these patients. Our objectives includ-

Each resident is mentored through their pathway, working with an assigned faculty

ed: 1. To provide an immersive, longitudinal, patient-driven experience in interprofes-

member to acquire the unique skill set and experiences needed for the trainee to impact

sional education at our major academic medical institutions 2. To provide case-based

change in the lives of their patients and/or community of interest. Mentorship is also

training in skills required to care for medically and socially complex patients with

promoted in social gatherings, aimed at connecting residents with local and national

recurrent hospitalizations, including motivational interviewing, barrier recognition and

leaders. Longitudinal mentorship will help residents culminate their work in a final

troubleshooting, and patient advocacy

project, research colloquium or service initiative during the senior year. It is the hope that

SETTING AND PARTICIPANTS: Teams consisted of five to six members and were

these senior capstones will be presented at a national forum.

required to be interprofessional. Students represented a variety of fields, including medicine,

DESCRIPTION: Through the SJCA pathway, residents have the opportunity to tailor

nursing, public health, social work, physical and occupational therapy, divinity, and business.

their pathway with required experiences and elective outpatient rotations, leadership

In the inaugural year, 2014, ten schools completed the pilot program. Ten more joined in

opportunities and community experiences: Advocacy and community leadership Global

2015, with all twenty recently completing the wrap-up conference in Camden, NJ.

Health rotation Homeless Health Prison Health Addiction Medicine Refugee/Immigrant

DESCRIPTION: After assembling an interprofessional team of students with at least one

Health Away rotations (Uganda, South Dakota/Indian Health Services, Boston Public

faculty mentor, institutions applied for a hotspotting mini-grant through the AAMC, Camden

Health Commission) Hospital administration Medical writing Research Through the

Coalition of Healthcare Providers, and Primary Care Progress. Teams attended a kick-off

pathway there are also leadership experiences through the newly created Social Justice

conference in Camden, NJ with training in teamwork and an introduction to high utilizing

Interest Group, developing resident report and noon conference case presentations.

work. Teams were then given autonomy as they recruited and worked with five to six patients

Community engagement is key to the pathway and involves participation in extracurric-

with multiple health and social needs. Interventions were unique to each patient but typically

ular activity programming within the Department of Medicine and other clinically-based

included home visits, accompaniment to health provider visits, care coordination, and assis-

community health staff including community health workers, population health managers,

tance with health systems navigation. Patient education and empowerment were emphasized,

mental health and addiction medicine specialists and local community leaders.

culminating in having patients graduate the program and move towards more independent




functioning. For students, relevant background information and skills were taught via monthly

EVALUATION: Redesign of resident assessment tools was identified as the highest

webinars. MacArthur Genius award winner and pioneer in high utilizing work, Dr. Jeffrey

priority project. Redesign of assessment tools is in process and includes review of content

Brenner, who founded and serves as executive director of the Camden Coalition of Healthcare

domains, revision of items, alignment with sub-competencies, and examination of fre-

Providers, provided regular guidance as students presented their cases during monthly calls. At

quency and timing of assessment tool distribution.

the conclusion, teams reassembled in Camden for a wrap-up conference complete with poster


presentations and leadership training.

the first time an educational assessment system within a residency program has been

EVALUATION: Most immediately, poster presentations demonstrated both the intangi-

improved using QI techniques. Through systematic, iterative QI approaches, seemingly

bles learned by teams and their patients, as well as “utilization EKGs,” which visually

entrenched and “unfixable” problems can be ameliorated.

represented timing and costs of healthcare utilization events before and during the intervention. Evaluations completed by each team as well as a student advisory council help provide feedback on the project itself. At some institutions students were able to


receive elective credit, for which the faculty mentor evaluated students per institution-


specific guidelines.



CONTINUITY CLINIC Jennifer R. Lukela. University of Michigan Medical School,

interprofessional education, including scheduling, poor avenues of communication, and lack

Ann Arbor, MI. (Control ID #2466819)

of joint mission. However, shared experiences during training and adopting a narrative-based approach to understanding patient stories is essential to addressing the crisis of persistently

NEEDS AND OBJECTIVES: It has previously been reported that internal medicine

poor health outcomes among our nation’s most disenfranchised and frequently ill individuals.

residents do not value their experiences in outpatient continuity clinic as highly as they

Participating students cited this program not just as an opportunity to further skills in patient

value their inpatient clinical rotations. Questions remain about the cause and significance

communication, but also to directly learn scope of practice across health disciplines and to

of this finding. Not surprisingly, there is evidence that higher resident satisfaction with

practice effective team communication and project management.

their continuity clinic experience positively influences residents’ likelihood in choosing a

ONLINE RESOURCE URL (OPTIONAL): Online information regarding the mini-

career in outpatient general medicine. Therefore, innovations to improve both residents’

grant: https://www.aamc.org/initiatives/hotspotter/

perceived value and satisfaction in continuity clinic are important to potentially increase the number of general outpatient internists in the future. Previous work demonstrates that early immersion weeks and short term (ie, 2 day) ambulatory boot camps are helpful in


improving intern confidence. We sought to show that a primary care focused month-long


ambulatory block rotation could have similar impact. In the past few years, we have made


changes to our continuity clinic curriculum including the introduction of week-long intern

Colbert; Andrei Brateanu; Eric Holizna. CCF, Cleveland, OH. (Control ID #2470147)

immersion weeks during elective time. For the 2015–2016 academic year, we modified the clinical content of our month-long intern ambulatory block rotations to provide a

NEEDS AND OBJECTIVES: Clinical Competency Committee (CCC) reviews of

“deeper dive” into outpatient general medicine in a variety of primary care settings. With

resident progress are dependent upon quality of the data used to assess residents; faculty

this intervention, we sought to address several questions: would a focused ambulatory

assessor and CCC reviewer training; and time invested in the assessment process main-

block rotation in primary care improve intern confidence in managing acute complaints

tenance and redesign. Analyses of the CCC assessment process and faculty evaluation

and chronic illness routinely seen in continuity clinic? Would a deeper dive in outpatient

completion rates per rotation were performed previously within the Cleveland Clinic

general medicine early in training impact resident interest in a future career in outpatient

Internal Medicine residency program (N = 168 residents) and identified gaps in the

general medicine? Two additional questions we sought to address focused on interns’ past

assessment system. Our goal was to improve the residency program assessment system

experience in outpatient general medicine during medical school: what influence did

using quality improvement techniques.

outpatient general medicine exposure in medical school have on incoming intern confi-

SETTING AND PARTICIPANTS: A hybrid of Six Sigma - DMAIC (Define, Measure,

dence in managing common outpatient complaints and chronic illness? Did the extent or

Analyze, Improve, Control) and Lean tools was chosen due to the complexity of the

type (ie, longitudinal vs. episodic) of exposure to outpatient medicine in medical school

residency assessment system and variability of each resident’s assessment path. The initial

impact interest in a future career in outpatient general medicine?

analysis identified high variability in the spectrum of potential critical assessment points

SETTING AND PARTICIPANTS: All categorical Interal Medicine interns in our program

for each resident, number of contributing assessors, assessment tools used, and stake-

(total number 44) participate in at least one of 4 month long ambulatory block rotations during

holders’ knowledge of their roles in the assessment system.

their HO1 training year. Each intern also maintains a continuity clinic at one of three clinical

DESCRIPTION: A swim lane diagram was used to model current assessment workflow,

sites: a large hospital-based academic general medicine practice, a University-affiliated

while capturing variable inputs. Horizontal swim lanes identified all assessment system

community-based ambulatory care clinic or the general medicine clinic at our affiliated Veteran’s

stakeholders and vertical lanes identified points at which residents interacted with an

Administration Hospital.

assessor or assessment tool during the academic year. Next, an “Effort vs. Impact” model

DESCRIPTION: After our curricular re-design, each intern ambulatory block rotation

was used to prioritize each gap into the appropriate quadrant and identify concurrent

included 3–4 half day sessions/week in the intern’s own continuity clinic, 3 half day

themes. As a result, low effort/high impact or high effort /high impact processes were

sessions/week in a community-based outpatient general medicine clinic and 1–4 half day

identified, requiring immediate adjustments, or rigorous, systematic approaches, respec-

sessions/month working in a clinic for underserved or high risk populations. In addition,

tively. For projects requiring controlled and cyclical improvement tools, a Lean A3

interns participated in other aspects of our overall ambulatory curriculum including daily

approach was selected. In addition, resetting the improvement cycle to repeatedly assess

ambulatory morning report and a half day per week of didactic sessions throughout the month.

progress and successful gap closures and identify new gaps is essential to reducing

EVALUATION: At the end of each month, all interns who have completed an ambula-

variability in the resident assessment process.

tory block rotation are invited to participate in a voluntary post-rotation survey seeking to




address the questions noted above. Data collection is currently on-going. At this point, we

from 2.80 to 3.15 (1 = poor, 5 = excellent); mean learner ratings of small group sessions

have collected data for a total of 6 months. 19 of the 23 interns who have completed their

ranged from 3.12 to 3.57. Most learners agreed or strongly agreed (75–91 %) that they met

ambulatory block rotation have completed the survey (83 % response rate). In addition to

individual learning objectives for the sessions. Mean faculty ratings of the value of the

questions about intern confidence in outpatient medicine, the survey also collects infor-

online modules ranged from 3.75 to 4.46 and the small group sessions ranged from 4.13 to

mation on past experiences in outpatient medicine during their time in medical school.

4.38. Focus groups revealed that students perceived that the curriculum was an “add-on”


to existing curriculum. Students appreciated the flexibility of the online modules, but felt

results is ongoing. Initial results do not demonstrate a clear correlation between past

that they were too lengthy and desired greater interactivity. Students desired more time to

medical school exposure to primary care and either confidence among incoming interns to

interact informally in small group sessions and commented on the challenges of creating

provide care in the outpatient setting or interest in a career in general medicine. Partici-

activities that integrated all professions and were appropriate to learner skills and varying

pation in our revised intern ambulatory block rotation did appear to improve self-reported

degrees of clinical experience. Students also commented that the quality of the small

intern confidence in addressing common outpatient conditions and managing chronic

group sessions was dependent upon faculty facilitator skills which were

illnesses often seen in continuity clinic. Initial review suggests participation in the rotation


had minimal impact on interest in careers in outpatient general medicine, though the

DISCUSSION / REFLECTION / LESSONS LEARNED: Learners are satisfied with

overall trend was positive. Further work will need to address whether an early deep dive in

online materials developed to teach IP collaborative care skills using a blended learning

outpatient general medicine impacts overall resident competence (vs. confidence) in the

approach. While learners value the flexibility of online content, IP small group sessions

skills necessary to function in the outpatient setting. Our hypothesis is that with improved

are rated more highly. Faculty rate both the online and face-to-face sessions more highly

confidence and competence in outpatient medicine, resident satisfaction and their overall

than students. Students desire better integration of IPE curriculum into their core curric-

assessment of educational value of continuity clinic will improve. Further work is needed

ulum. Course planning/development and course implementation were very resource

to address this hypothesis and to identify other strategies to improve resident’s perception


of the value of their continuity clinic experience.







Angel Chen ; Cathi Dennehy ; Amber Fitzsimmons ; Susan Hyde ; Kirby Lee ; Bridget 2


1, 5 1

C. OBrien ; Josette Rivera ; Rebecca L. Shunk


. UCSF, San Francisco, CA; Univ of

California, San Francisco, San Rafael, CA; 3University of California, San Francisco, San

HTN DISPARITY QI CURRICULUM Erika L. Hoffman4; Jaishree Hariharan3; Elena Lebduska2; Amar Kohli1. 1UPMC, Mars, PA; 2University of Pittsburgh Medical Center, Pittsburgh, PA; 3University of Pittsburgh Medical center, Pittsburgh, PA; 4VA Pittsburgh Healthcare System and The University of Pittsburgh School of Medicine, Pittsburgh, PA. (Control ID #2469555)

Francisco, CA; 4University of California San Francisco, San Francisco, CA; 5VA Medical Center, San Francisco, CA. (Control ID #2469804)

NEEDS AND OBJECTIVES: In reviewing VA Pittsburgh quality metric data, a disparity in blood pressure (bp) control between white and black hypertensive patients with and

NEEDS AND OBJECTIVES: There is growing recognition of the need to teach

without diabetes was found. We saw this as an opportunity to teach QI principles using a

interprofessional (IP) collaborative competencies to health professions learners. Barriers

new curriculum developed at the University of Pittsburgh. While components of quality

to implementing curricula include scheduling, geographical constraints and resources.

improvement education are infused into our residency education, hands on practice using

Asynchronous online learning may overcome these barriers. Studies support the effec-

resident-level population databases to help drive performance improvement were lacking.

tiveness of online learning to teach IP concepts, but suggest that a blended learning

Residents had an opportunity to develop patient, provider and system-based interventions.

approach may appeal more to learners. We developed a blended course to teach core IP

SETTING AND PARTICIPANTS: The setting was a VA Primary Care Clinic serving as

concepts to students. Representative learning objectives for the course include the follow-

a training site for 56 residents. 4011 patients were cared for in medical home (PACT)

ing: 1) Discuss the role of teamwork and communication in medical errors. 2) Describe the

teams. 7 teams were each supported by an attending, MSA, LPN, and RN along with

training program and potential career paths of some of the health professions. 3) Demon-

Pharm Ds, social workers, and telehealth specialists.

strate the use of strategies and tools that facilitate effective communication and collabo-

DESCRIPTION: Didactic sessions were given on principles of QI. Residents were

ration. 4) Demonstrate a three-step approach to managing conflict. 5) Identify and analyze

introduced to the VSSC and disparity databases. They completed worksheets for

leadership compass styles and discuss how to support team members with different styles.

their patient panels which sought information on the percent of their patients with

SETTING AND PARTICIPANTS: The curriculum was developed at a health sciences

bp >150/90 and >160/100. They looked at the number of their patients who had

university with five health professional training programs (dentistry, medicine, nursing,

not been to clinic in over 6 months. Residents drilled down to patient level data

pharmacy and physical therapy). All first-year learners participated in the curriculum.

and used chart review to reflect on possible patient, provider and system-based

DESCRIPTION: We developed 5 ninety-minute online modules to teach learners core

barriers to bp control. Resident team leaders were chosen for each clinic day. Team

concepts in IP collaborative practice: 1) core IP concepts 2) roles and responsibilities of

leaders completed worksheets, collating team data along with potential solutions to

healthcare professionals 3) effective IP communication 4) conflict management 5) team

pilot to overcome barriers. Teams created aim statements. They chose 3 agreed

leadership and membership. Each module includes interactive cases, demonstrations and

upon ideas to present as pilots. Ideas were presented to VA leadership via a QI

expert interviews and is paired with a facilitated small group session for skills practice.

council. At the QI council, interventions were prioritized and voted on by the team

Sessions are required and held quarterly throughout the first and second-year.

leaders. The QI nurse discussed feasibility of ideas. The QI council chose to

EVALUATION: Learners and faculty facilitators were surveyed after each small group

implement several clinic-based interventions. Blood pressure technique training

session and learner focus groups were conducted at the end of the first-year of the

was standardized for the LPNs and became part of their annual competency. A free

curriculum. Six-hundred learners and 55 faculty facilitators participated in the first-year

LPN-driven blood pressure clinic was created to help alleviate patient perceived

of the curriculum. Mean learner ratings of the overall value of the online modules ranged

financial barriers to care. This was piloted in one of seven academic PACT teams.




Residents chose to increase home telehealth use to decrease cost associated with

Improvement, based on the “Plan, Do, Study, Act” (PDSA) cycle. Students are divided into

travel and visits for care. Residents asked for team based data to track performance

groups of 5 and, at the second meeting, are guided through a “Define the Problem” Workshop,

improvement. The number of combination medications in clinic quick order sets

with the goal of clearly articulating a problem observed in the free clinic and establishing a

was maximized to help decrease cost of drugs. Residents received patient-based

quantitative goal. Over the next 8 months, students collect baseline data in the clinic, and

outlier lists, paying attention patients who had not been to clinic in >6 months.

implement 1–3 PDSA cycles consisting of piloted improvements and evaluations of these

EVALUATION: All residents learned to use VA databases to assist in panel management.

changes. At monthly meetings, they present their findings and receive feedback from faculty

Initially, there was a disparity in bp control between black and white patients of 7.4 %. For

and peers. At the end of the year, students present their findings at EHHOP QIC Grand

diabetics the disparity was 6.6 %. At the end of the project, the disparity was 7.5 and

Rounds. Successful projects are incorporated into the standard operating procedures of the

4.2 %, respectively. We could not drill down into the data in order to know the impact

clinic. In total, 19 projects have been completed. In the first year, projects focused on day-to-

individual providers made in closing the disparity gap. At the end of the project, 100 % of

day clinic operations issues, such as reducing referral completion time, reducing patient no-

the team LPNs met with a nurse educator who assessed clinical skills & competency. For

shows, and improving physician recruitment. Most recently, projects have focused on patient

the PACT team trialing the LPN bp clinic, residents documented proposed plans of care in

experiences and outcomes, such as medication adherence and diet/exercise goal adherence; or

the medical record for the LPN to follow. Preceptors supported the LPN if the resident

tackled larger operational issues such as medication costs.

could not be contacted. 4/6 residents in the LPN clinic pilot team saw a reduction in the

EVALUATION: Each year, projects pursued by students are recorded in a table and their

percentage of patients with stage II hypertension. 1 pilot resident saw a reduction in the

main interventions, main outcomes, strengths and challenges are recorded. Over time, this

percent of patients with stage II hypertension that fell from 33. 1 to 13.3 %. 13/46 residents

institutional knowledge has been used to guide groups toward achievable projects.

in teams without LPN bp clinics saw a reduction in the percentage of patients with stage II

Qualitative feedback on learning experience has been solicited from each class and used

hypertension. Residents not involved in a pilot team either personally contacted patients

to improve the class structure; for example, by limiting class size and providing peer

from their outlier list or sought the help of a PACT team member and made plans to

feedback in an anonymized fashion.

address elevated blood pressures. At the end of 6 months, LPNs blood pressure clinics


were established for all resident PACT teams. Data analysis continues.

has succeeded in establishing numerous improvements in clinic standard operating proce-

DISCUSSION / REFLECTION / LESSONS LEARNED: Resident feedback about the

dures, including establishment of a permanent referrals and patient navigation team known as

curriculum was positive. Residents felt they had a bigger role in QI this year, improving

Access to Care Team (ACT), and building a mobile knowledge management system

their ability to impact outcome and process. They said that seeing data helped them to

(mKMS) app known as the EHHapp. Over time, the focus of QIC projects has shifted from

understand how they were doing. Residents said they never thought of those patients who

internal operational problems (e.g. physician recruitment, referrals) to issues directly related

don’t come to clinic as something they should address. They identified important process

to patient outcomes (e.g. medication adherence, diet/exercise goal adherence). Student

changes to help keep the momentum going, asking for time to review outlier lists and to

presentations and feedback indicate that they gain a strong working knowledge of QI

call patients. They noted that end of year transitions of care should be evaluated in future

principles and the anatomy of a successful health care improvement project.

QI phases. Designing projects that can yield significant outcomes in a short time frame can be a challenge. Some residents saw no improvement in the percentage of their patients who had uncontrolled bp and pointed out that 6 months may not be enough time for


evaluation. Many asked us to continue to follow our hypertensive population. This year,


we will continue to focus on bp control and will add glucose control as our next resident

Spagnoletti2; Amar Kohli1; Erika L. Hoffman5; Gary Fischer2; Jaishree Hariharan4.

QI project.


UPMC, Mars, PA; 2University of Pittsburgh, Pittsburgh, PA; 3University of Pittsburgh

Medical Center, Pittsburgh, PA; 4University of Pittsburgh Medical center, Pittsburgh, PA; 5

VAPHS/Univeristy of Pittsburgh, Pittsburgh, PA. (Control ID #2465365)

TEACHING QUALITY IMPROVEMENT IN THE STUDENT-RUN FREE CLINIC Robert A. Rifkin3; Ammar Siddiqui3; Brijen Shah2; David C. Thomas1; Yasmin 4 1


NEEDS AND OBJECTIVES: ACGME recognizes that internal medicine (IM) trainees

S. Meah . Icahn Scholl of Medicine at Mount Sinai, New York, NY; Icahn School of

must achieve competence in systems based practices. The outpatient setting is an ideal

Medicine, New York, NY; 3Icahn School of Medicine at Mount Sinai, New York, NY;

place to teach these skills. With many residency programs going to an inpatient/outpatient


“block system”, achieving continuity for quality improvement (QI) projects in the outpa-

Mount Sinai School of Medicine, New York, NY. (Control ID #2469670)

tient setting becomes a greater challenge. With this in mind, we implemented an educaNEEDS AND OBJECTIVES: Quality Improvement (QI) is an essential skillset for

tional initiative that aimed to: 1) Increase resident participation in QI projects in the

increasing efficiency and patient safety in healthcare, but most US medical students

outpatient setting by using a resident-driven team-based approach; 2) Improve patient

receive little or no classroom or hands-on instruction in QI.

level chronic disease outcomes measures; 3) Evaluate resident attitudes and interest in

SETTING AND PARTICIPANTS: The East Harlem Health Outreach Partnership

interdisciplinary QI projects.

(EHHOP) is a student-run, free clinic for the uninsured in New York City, sponsored by

SETTING AND PARTICIPANTS: Participants were the 140 residents affiliated with

the Icahn School of Medicine at Mount Sinai (ISMMS). ISMMS students (n = 100) in

the University of Pittsburgh Medical Center. All residents followed a panel of continuity

their second year were participants in the described course.

patients with faculty supervision in one of three hospital-based clinical sites: a university

DESCRIPTION: Launched in 2010, Quality Improvement Council (QIC) is a year-long,

clinic (n = 52), a community clinic (n = 36) and a VA clinic (n = 52). In the new block

hands-on course for second-year medical students. Meetings are monthly and provide an

system, residents have clinic one full day each week (Monday-Thursday) for 4 weeks,

opportunity for two-way communication between faculty and students. Between meetings,

followed by no clinic for 4 weeks. Residents were placed into QI teams based on their

students work in groups and communicate regularly with faculty and student leaders by email.

clinic day, for a total of 8 interdisciplinary QI teams per site.

The course uses a combination of didactic and project-based learning. At the first meeting,

DESCRIPTION: The focus of our curriculum was on using a longitudinal, multistep,

students receive an overview of the Institute for Healthcare Improvement (IHI) Model for

innovative approach to teach QI by focusing on single area patient level outcomes measure




with the lowest compliance rates. At non-VA clinic sites, the focus of the resident QI

communication skills while managing the demands of the EMR. Further, given the

project was on diabetes, with improving eye and foot exam rates as the goal for the 2014–

important function faculty serve as role-models, effective education on EMR best com-

2015 academic year, and followed these steps: Step 1) Residents received a short didactic

munication practices is critically important so they can in turn demonstrate and teach best

session on principles of QI. Step 2) Using automated chart review, residents identified

behaviors to resident and student trainees. Our objective was to develop and evaluate a

their diabetic patients who had not received these exams. Each resident then used a

faculty workshop to improve knowledge and ability to implement best practices regarding

worksheet to review their patients’ charts to identify key barriers and then brainstormed

patient-centered EMR use.

interventions for improvement. Step 4) Residents joined together in their QI teams and

SETTING AND PARTICIPANTS: We developed a four hour patient-centered EMR

compiled their individual data using a team worksheet. They then selected interventions

use workshop for primary care faculty at the Cleveland Clinic (CC), which was then

for implementation. Step 5) A resident “team leader” from each group, along with

adapted for University of Chicago (UC) faculty in 90 min. We aimed to assess 1) faculty

ancillary staff, the clinic director, and faculty clinicians, convened to form a QI council.

learner satisfaction 2) post-training self-assessed knowledge, attitude, skills 3) efficacy of

Interventions developed by the teams were voted on and the top 3–4 were selected to be

longer vs. shorter patient-centered EMR training.

clinic-wide QI interventions. Step 6) Team leaders worked with ancillary staff to finalize

DESCRIPTION: After literature review, we developed a faculty workshop to improve

protocols for the chosen interventions, and these were initiated. QI Teams met every other

patient-centered EMR use which consisted of: (1) a lecture highlighting barriers and best

month to review process measures and make adjustments. The VA-based clinic residents

practices for patient-centered EMR use; (2) a Group-Objective Structured Clinical Exam

followed a similar 7-step approach but focused their QI interventions on improving

(GOSCE) to practice skills with a standardized patient (SP) and mock patient chart in an

hypertension metrics.

EPIC training environment. Faculty interacted with the SP to take a history, integrate the

EVALUATION: Results from the 2014–2015 pilot year are discussed here. Worksheets

EMR for chart review and document a HPI. Groups consisted of 2–4 faculty, 1 facilitator

were developed to assist individual residents and QI teams with Steps 1–3. Data derived

and 1 SP with immediate performance feedback. At CC, training was completed during a

from the university hospital site (52 residents), showed that 47 of 52 completed individual

dedicated 4-h block routinely reserved for Continuing Medical Education (CME). At UC,

worksheets (participation rate (PR) = 90 %) and all 8 QI teams completed worksheets

because such a block did not exist, time constraints necessitated a 90 min session (1-h of

(PR = 100 %). Effectiveness of the QI curriculum was assessed with quarterly patient

lunch with 30 additional minutes of time donated by the clinic). All faculty received CME

outcomes reports. At the university hospital site the residents had 328 diabetic patients in

credit. The longer CC workshop included; 75 min lecture, 100 min GOSCE, two 20 min

June 2014. From June 2014 to June 2015, resident patients’ eye exam rates increased from

breaks, 25 min of closing feedback. The shorter UC workshop included; 20 min lecture,

42 to 69 % (p < .001) and in addition foot exam rates increased from 58 to 78 % (p < .001).

60 min GOSCE, 10 min of feedback.

Post curriculum both eye and foot exam rates remained stable in Sept 2015. All residents

EVALUATION: 32 academic primary care faculty [Family Medicine (FM) and General

were surveyed at the end of June 2015 on the QI curriculum. Over 78 % of residents

Internal Medicine (GIM)] at two academic medical centers completed training [13 cm3

thought that the topic of QI was important or very important to their residency training,

faculty (5 FM; 8 GIM) and 19 UC (GIM)]. All faculty completed a 23 item post-workshop

and over 90 % believed that working in an interdisciplinary team was important or very

evaluation assessing knowledge, attitude and skills. Responses to Likert items were

important to a successful QI project. QI team leaders met regularly to collate successes and

dichotomized at the high end of the scale to denote agreement (i.e. agree/strongly agree).

failures and performed a Plan Do Study Act (PDSA) cycle of the curriculum, allowing

Descriptive statistics were summarized and compared between sites. We analyzed 30/32

changes to be made in real time.

(94 %) post-workshop evaluations. Overall, the majority (67 %, 20/30) of respondents


were female (CC 50 % vs UC 72 %, p = 0.22), with mean age of 48 (range 31–65) (CC 47

cational initiative to teach residents about QI and to improve patients’ chronic disease

years old vs UC 45 years old, p = 0.59). Overall, 100 % (30/30) of faculty agreed it was

management. It is unique in that it is resident-driven and it utilizes an innovative stepwise

‘important to receive training,’ ‘relevant to their practice,’ and enabled them ‘to better

approach that can easily be extrapolated to a variety of QI interventions at different clinical

teach and role model patient-centered care for trainees’, with no difference in mean ratings

sites and institutions. To date, the initiative has successfully engaged nearly 140 residents

between CC and UC faculty (4.75 vs 4.72, 4.64 vs 4.89, 4.42 vs 4.50, p > 0.05 for all).

in the QI process, has fostered collaboration between residents and ancillary clinic staff, as

Overall, 97 % (29/30) agreed that the workshop should be ‘required for all health care

well as led to improved patient outcomes. By switching the focus of resident QI education

providers’ with no difference between CC and UC (4.75 vs 4.56, p = 0.40). There

from knowledge to practice, we were able to see improvement in patient level outcomes in

were significant post-workshop increases in mean scores of ‘awareness of barriers’

a relatively short period of time. Getting resident buy in, compiling clinic resources for a

and ‘best practices’ at both sites with no site differences (pre vs. post; 3.7 vs 4.5 and

focused QI project, making quality metric data transparent, and using resident-driven QI

3.1 vs 4.3 respectively, p < 0.001 for both). Additionally, there was a significant post

interdisciplinary teams were keys to success. Because of this success in the 2014–2015

workshop increase in mean ratings on ability to ‘implement best practices’ and ‘teach

pilot year, our program intends on continuing this curriculum indefinitely.

trainees how to implement best practices’ (3.3 vs. 4.2 and 2.9 vs 4.1 respectively, p < 0.001 for both) with no site differences. While almost all faculty (29/30, 97 %) agreed the GOSCE was an ‘effective way to practice skills,’ the CC mean ratings were


significantly higher than UC (4.58 vs 4.12, p = 0.04). However, more faculty at the


UC agreed that the workshop was ‘informative and effective’ and that they ‘gained

USE FOR BUSY CLINICIANS Wei Wei Lee3; Lollita Alkureishi3; J. H. Isaacson1;

new knowledge’ (4.45 vs 4.83 p = 0.04; 4.12 vs. 4.67 p = 0.21 respectively).

Mark Mayer2; Vineet M. Arora4. 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic


Lerner College of Medicine, Cleveland, OH; 3University of Chicago, Chicago, IL;

developing faculty training on patient-centered EMR use for busy faculty at two academic


medical centers, which included adapting a 4 h workshop into a 90 min session. Faculty

University of Chicago Medical Center, Chicago, IL. (Control ID #2467410)

reported training in patient-centered EMR use was important, relevant and should be NEEDS AND OBJECTIVES: Electronic medical record (EMR) use in exam rooms can

required for all providers and no difference was found between the longer and shorter

distract providers from their patients. Despite rapid EMR adoption in academic institu-

training curricular. Faculty participating in longer training reported higher GOSCE effi-

tions, few faculty receive training or feedback on how to integrate patient-centered

cacy, however the shorter workshop appeared more informative and effective with higher




reported rates of gaining new knowledge. Given busy primary care clinician schedules and

EVALUATION: The TBL model is engaging and fun for both faculty and the learners.

demands, shorter patient-centered EMR training may be a feasible and effective way to

Our residents stay engaged, look forward to the ‘soft’ competitive nature of the session

spread this model to other institutions and other levels of trainees.

and are motivated to prepare well so that they can contribute to their team’s success. We will compare resident medical knowledge in general internal medicine as reflected by ITE scores in the academic year before and after implementation of the TBL sessions. We also


plan to anonymously survey the residents for their satisfaction with this novel method of

PATIENT INTERNAL MEDICINE Mirela Feurdean; Ahmad Yousaf; Neil Kothari;


Ana Natale-Pereira. Rutgers NJMS, Newark, NJ. (Control ID #2467615)

DISCUSSION / REFLECTION / LESSONS LEARNED: The team based learning (TBL) model is a successful model of teaching in the undergraduate world, but sparingly

NEEDS AND OBJECTIVES: Providing adequate academic and experiential educa-

used in post graduate medical education. TBL is engaging and fun for both faculty and the

tion in outpatient general internal medicine is a focus of Internal Medicine residency

residents. It requires more faculty preparation before the sessions compared to the

programs, in keeping with the societal needs for improved Primary Care for our aging

traditional models where learners present assignments. With the exception of session

population. An Academic Half Day (AHD) dedicated to education in Ambulatory

preparation time by faculty, there is minimal additional cost.

Medicine was implemented in July 2013, 1 year after the introduction of an x + y ambulatory block schedule. In our experience, it was hard to motivate residents to do the required readings, difficult to keep them engaged during the 2.5 h weekly


sessions, and challenging to remain excited and enthusiastic as educators. For these


reasons, in July 2015 the program transitioned to a Team Based Learning (TBL)

O’Brien6, 5; Maya H. Dulay3; Gillian Earnest5; Terry Keene1; Rebecca L. Shunk2; Denise

format in which the focus was shifted to high yield topics that residents reported

L. Davis4. 1San Francisico VA Health Care System, San Francisco, CA; 2UCSF, San

having a difficult time with in the clinic. We maintained Evidence Based Medicine

Francisco, CA; 3UCSF/VA, San Francisco, CA; 4Univeristy of Califonia San Francisco,

sessions, journal clubs and documentation workshops, as well as the requirement for

San Francisco, CA; 5San Francisco VA, San Francisco, CA; 6University of CA, San

independent study using online ambulatory care modules.

Francisco, San Francisco, CA. (Control ID #2469846)

SETTING AND PARTICIPANTS: Our residency program (Rutgers New Jersey Medical School) is the largest program in the state, and includes 90 categorical residents across

NEEDS AND OBJECTIVES: Primary care trainees such as internal medicine (IM)

3 years of training. In the x + y schedule, every 8 weeks of core rotations is followed by

residents and nurse practitioner (NP) students need to be prepared to work in team-based

2 weeks in the continuity clinic, such that all categorical residents are exposed to at least

medical home settings. A team-based approach is critical to managing the health care needs

five 2-week ambulatory blocks per academic year. Every Friday of the ambulatory block

for patients who have part-time trainee providers. High-functioning teams require trainees

residents must attend the AHD in Ambulatory Medicine.

and staff to learn and practice skills together, and to know each other both professionally and

DESCRIPTION: The AHD curriculum spans over the 2 weeks of the ambulatory block, as

personally. This can be limited by irregular trainee schedules and lack of protected time for

follows: 1st Friday : TBL1 + Clinical vignette from clinic (group develops question in PICO

team development during a trainee clinic day. To address this challenge, we developed and

format) + Workshop (librarian, documentation and coding, substance use disorders) 2nd

delivered a team retreat curriculum with the following objectives: −Provide protected time

Friday: TBL 2 + Answers to PICO based on literature review (assigned resident presents) +

for discussion of members’ roles, team communication and panel management processes

Journal Club Topics are organized thematically as much as possible (e.g. substance use

-Provide an opportunity to review team performance, discuss team goals and areas for

disorder topics during 1st week are followed by HIV related skin disorders in the second.)

improvement -Train faculty in group facilitation skills

Topics are chosen to supplement the online ambulatory care modules which residents are

SETTING AND PARTICIPANTS: At the San Francisco VA Medical Center of Excel-

assigned to complete during each block. The TBL sessions include a pre-test based on the

lence in Primary Care Education (COEPC), IM residents, NP students and associated

assigned reading material, followed by the group application of knowledge to clinical

health trainees practice in teams in a medical home setting. Trainees are assigned to a

scenarios. We focus on high yield materials that residents report having a difficult time with

Patient Aligned Care Team (PACT) consisting of a Registered Nurse (RN), Licensed

in the clinic (Dermatology, Diabetes, Obesity, Preoperative evaluation, Substance Use

Vocational Nurse (LVN), and Medical Support Assistant (MSA). All 2nd year IM

Disorders). The Pre-Test is a short (10 min) quiz, and is followed by 10–15 min of collective

residents, NP students, associated health trainees and PACT teams participate in an annual

review of answers, moderated by the faculty preceptor. The pre-test is used as a way to assess

half-day retreat. The retreat is delivered on two different days each fall to reduce the

whether residents have read the materials assigned at the beginning of the ambulatory block.

impact on staffing in the clinic.

It is also a self-assessment of individual knowledge, hence raises interest in the discussion of

DESCRIPTION: In 2011, the COEPC invited the American Academy of Communica-

correct answers. For the TBL session (45–60 min), residents are split up into groups of four or

tion in Healthcare to deliver and facilitate PACT retreats with trainees. In subsequent

five, with residents at each PGY level represented. Complex, case based, multiple choice

years, retreats have been led by local interprofessional (IP) faculty and are structured

questions are posed and time is given for each group to discuss internally (team leaders are

primarily as small group meetings with one PACT team, their affiliated trainees (5–8

encouraged to involve interns in the discussion). Questions are purposely vague and often

participants) and two IP facilitators. These facilitators are often junior faculty who are

have more than one possible answer. When time for internal debate is up, the team leader

competent but not necessarily proficient in the content. To help deliver a robust retreat

raises the answer placard(s) and each team’s answers are written on the board. Each answer

each year, we developed a retreat curriculum “kit” that includes: −A standardized template

choice is debated out loud. Points are given for correct answers and for well thought out

with timeline of logistical items to complete starting several months prior to retreat date -A

arguments. The discussion is moderated by the faculty preceptor and the Ambulatory Chief

detailed facilitator guide with specific scripts -Facilitator training material in preparation

Resident. The tone of the process is ‘fun and competitive’ but the focus is on knowledge

for retreat to be delivered during a faculty preparation session. Also, material for case

application and clinical teaching points, while winning is secondary. Winners are given token

based session on tips for challenging facilitation scenarios for advanced faculty develop-

prizes based on the topic at hand (e.g. Pre-Operative Evaluation TBL winners received EKG

ment -A description of team retreat goals and activities such as speed meeting to get to

pins for their white coats.)

know team members personally, discussing challenging team experiences to improve




communication, reviewing roles of team members, and identifying specific team goals for

appointments, the impact of high no show rates on health outcomes and healthcare

the future -A survey, completed by each team member prior to the retreat, to assess

utilization, and methods to address patient barriers to fulfilling office visits. The use of

baseline team function (Team Development Measure) -An electronic folder of materials

telephone visits was suggested as an alternative method of communication with patients

for retreat participants including communication tools and retreat evaluation forms

who do not show for appointments. Guidance on how to conduct and document a

EVALUATION: The team retreat has been attended by 72 IM residents, 33 NP

telephone visit was provided. After the session was completed, residents were assigned

trainees, 42 associated health trainees and 109 PACT staff since 2011. Participants

the task of performing a telephone visit with at least of their patients who missed an

completed post-activity evaluations that showed the overall high quality of the team


retreat (mean 4.5/5; strongly disagree = 1 to strongly agree = 5; n = 257). Most par-

EVALUATION: To evaluate the residents’ perspective on missed appointments and to

ticipants strongly agreed that they know their team members better on both a personal

assess the impact of their telephone visit, residents were asked to reflect upon the

and professional level after attending the retreat (mean = 4.6/5, n = 181;). Participants

telephone encounter using a structured reflection tool and report back to their clinic group

rated the question “I am likely to make changes in my interactions with my team as a

3 weeks later. Questions about this experience will be included in the annual resident

result of this retreat” as 4.4/5 (n = 119). Additionally, the qualitative comments from


retreat evaluations consistently reflected the benefits of protected time together and


discussion of team member roles. We also identified themes related to improved

resident clinic patient with a complex medical history and several barriers to

communication, huddling, and team processes.

fulfilling clinic appointments coupled with resident clinic patient demographic


data, showed residents to recognize that there are several social determinants of

significant curricular activity for team development among trainees and staff on primary

health that limit patients’ ability to attend their appointments. While recognizing

care teams to manage a panel of primary care patients. Role clarity, communication and

the barriers is the first step and often takes time to incorporate into daily practice,

team processes are small group content that can be valuable for all interprofessional

the curriculum educated residents to address these barriers with clinic resources as

participants. Lessons learned over 4 years of team retreats include: −Advanced planning

well as external references. Because of our patients’ socioeconomic status we

to coordinate schedules to maximize attendance is key. -Support from primary care

educated residents about how to conduct a telephone visit instead of employing

leadership is critical in order to allow release from clinical duties for all participating staff.

web-based communication. We thought a telephone visit was the most ideal form

Retreats can address broader medical center population management goals as well. -Team

of communication that could substitute for the face-to-face clinic encounter.

retreats can also be a time to review team performance or panel management data -Retreats

Trainees used telephone visits to address current symptoms, chronic medical

using trained primary care faculty as facilitators can be as successful as using ‘expert’

conditions, refills, and to start to work on barriers to clinic visits for those who

outside facilitators; this also has the added benefit of strengthening connections between

could not routinely follow up in person. This curriculum attempted to tackle the

faculty, staff, and trainees. -Future steps include dissemination of a team retreat curriculum

trainees’ attitudes about frequent no show patients while providing them with tools

toolkit for implementation at other sites.

to address the complexity surrounding a patient’s inability to fulfill an appointment. The pre-clinic conference permitted residents to use information about their own patients and to learn to provide care that meets the individual needs of their


patients. The hope is that by reaching out to their patients via telephone, residents


will deepen their relationship with their patients who do not routinely come to

Wishwa N. Kapoor1, 2; Peggy B. Hasley1, 2. 1Univ of Pitstburgh, Pittsburgh, PA; 2Uni-

clinic. This may help attendance and improve the health care for no show patients.

versity of Pittsburgh Medical Center, Pittsburgh, PA. (Control ID #2455762)

NEEDS AND OBJECTIVES: An evaluation of resident and patient surveys was

T H E D I S C H A R G E P R O C E S S A N D U N E X P E C T E D < 3 0 - D AY

performed and identified multiple reasons for frequent missed appointments in resident


continuity clinics. To specifically address the resident-patient relationship, and to improve


the show rates to resident clinic, a pre-clinic conference was developed to enhanec resident

Miller; Jennifer S. Myers; Lisa Bellini. University of Pennsylvania, Philadelphia, PA.

understanding of patient barriers to regular attendance to clinic appointments. The pre-

(Control ID #2447521)

clinic conference including the following objectives: 1) Recognize that there are multiple factors that influence a person’s ability to make it to their scheduled clinic appointments 2)

NEEDS AND OBJECTIVES: Hospitals across the country are increasingly focusing on

Report clinic data about patient demographics specifically of those who miss appoint-

improving discharge transitions as the number of 12 months.

rating transparency. This agenda of program innovation will be the first to rigorously test

265 of these patients had DM as well as Ischemic Vascular Disease—our target population

the incremental impact of using behavioral principles in physician incentive design.

for intervention. 265 charts were reviewed by the clinical team 121 were not appropriate for intervention (patients had moved, were intolerant to statins or were in control by the beginning of the project) 144 patients were appropriate for the intervention 57/144 patients


were at goal with LDL

AN ACADEMIC PRIMARY CARE CLINIC Mara Terras; Neda Laiteerapong; Lisa

12 months or who had LDL. > 100 –used as a proxy for suboptimal control likely due to

M. Vinci; Daniel Yohanna; Pooja Dave; Nancy Beckman; Erin M. Staab. University of

nonadherence or suboptimal statin choice or dose was obtained through the patient

Chicago, Chicago, IL. (Control ID #2469893)

registries. Charts were reviewed and if appropriate for intervention, letters were sent to patients asking them to come in for lab work which was ordered by our team nurse


practitioner. Results were reviewed and medications were adjusted as appropriate. The

healthcare co-located in the primary care setting aims to improve patient access to vital

patient’s provider was also informed of results and medication changes that were made.

services; however, barriers, such as stigma, may prevent use of available integrated

Patients who did not respond to the initial outreach were called by our team RN and

behavioral health providers.

medication adherence was assessed and patients were encouraged to come in for testing.


Providers were aware of this pilot project and were very supportive. An algorithm for

OBJECTIVES): 1) Measure rates of referred, scheduled, and completed appointments

decision support on choice of statin and dose was developed by the clinical leadership and

for our co-located behavioral health clinic 2) Evaluate the impact of in-person referrals

posted in all the exam rooms and teaching areas in the practice. Other barriers to optimal

(“warm hand offs”) on the rate of completed patient appointments

lipid control including need for prior approvals (PA) for high intensity statins or high


copays was also addressed during this pilot project. We have recently been informed that


one of our managed medicaid plans with the highest enrollment will add atrovastatin to

COMMUNITY CHARACTERISTICS): Behavioral health specialists began providing

their formulary without need for a PA – in large part due to the advocacy that was made

co-located care in our academic internal medicine primary care clinic in April 2015.

during this lipid management project.

Behavioral health and internal medicine providers shared common workspace to increase


visibility and seamless collaboration; the co-located services were also advertised to


attendings, residents, and clinical staff through oral presentations by an internal medicine

INTERVENTION): Metrics that were used to evaluate this program included: Number

physician “champion” and flyers posted in the clinic. We also carved out dedicated time

of patients in the intervention group who responded to the outreach—either by letter or by

for “warm hand offs” wherein the primary care provider could introduce the behavioral

phone. Number of patients in the intervention group who were at goal for their lipid

health provider to their patient at the same visit that the referral for behavioral health

management by the end of the project. Patients in the intervention group who had an

services was placed. Our behavioral health specialists were available 4 half-days a week.

improvement in control of hypertension and DM. Htn control, DM control and lipid


control in all patients in the diabetes registry through the year.



INTERVENTION): We measured the monthly rates of referrals to psychiatry/

BE DISCUSSED): There were 4409 patients in the Diabetes registry at the beginning of

behavioral health, average wait times for an appointment, rates of scheduled




appointments, rates of completed appointments overall and for patients who received a

ability to order repeat labs for CBC and CHEM7 for more than 3 consecutive days as of

“warm hand off.”

March 1, 2014. 4. Subsequently, our hospital implemented a new electronic medical


record system. At the time of this transition in March 2015, we collaborated with the Chief

BE DISCUSSED): Of the 811 referrals made to psychiatry/behavioral health from April

Technology Officer and further restricted the ability to order repeat CBC and Chem7 labs

to December 2015, only 53 % were scheduled. Of the 428 scheduled appointments, 381

to 1 day only. Lab ordering data for CBC and Chem7 tests for patients admitted for >

(89 %) were for psychiatry and 47 (11 %) were for behavioral health. The wait time for a

3 days were again collected on April 2014 (post-intervention n = 851)

psychiatry/behavioral health appointment decreased from 45 days (April/May) to 24 days


(October/November). For patients who received a warm hand off to a behavioral health


provider (49 patients), the wait time for an appointment was 14.3 vs. 32.2 days (p = 0.01)

INTERVENTION): We assessed the difference in unnecessary lab tests at our baseline

and the rate of completed appointments was 65 % overall for patients who received a

before intervention in October 2012, and then in April 2014 post intervention. We stratified

warm hand off compared to only 33 % (p < .001) for patients who did not.

data according to service (Medicine versus Non-Medicine), acuity of care (Critical vs. Non-


Critical), and type of medical team (Teaching vs. Non-Teaching). Additionally, we collected


physician level data to determine the percentage of doctors who ordered repeat labs on all of

found that implementing a co-located behavioral health clinic improved access to care

their patients. We plan to collect an additional set of data from October 2015 of the same

for primary care patients needing psychiatry/behavioral health care. When primary care

metrics after the new electronic medical record system was implemented.

providers facilitated a “warm hand off” to the behavioral health specialists, there was a


significant decrease in wait times and increase in completed appointments. However,

BE DISCUSSED): At baseline overall, 80 % of medical patients had at least 3 consec-

nearly half of referrals to psychiatry/behavioral health were not scheduled. Successful

utive days of repeated CBC, while 79 % had repeat Chem 7 performed. Non-Department

implementation of a collaborative co-located model for behavioral health in primary care

of Medicine patients did not routinely have daily blood work. For medicine patients,

requires more than just increased proximity between providers to increase access and

consecutive ordering decreased to 57 and 59 % respectively (29 and 26 % decline) in April

improve patient outcomes. Next steps include creating workflows to ensure improved

2014. The decline was driven by non-critical care patients; critical care patients had

communication between primary care and psychiatry/behavioral medicine regarding

minimal improvement. The decline was similar for hospitalist and teaching services.

referrals and also evaluating patient satisfaction with the referral process.

Unnecessary blood tests declined from 29 to 13 % for CBCs (52 % decline; p < 0.01) and from 54 to 46 % for Chem7 (14 % decline; p < 0.01). This represents 198 patients having fewer repetitive CBC and 172 patients having fewer repetitive Chem7. The


number of physicians who ordered repeat labs on all of their patients reduced from

Garg1; Leonard Mermel2; Ross W. Hilliard2; Lynn McNicoll2. 1San Francisco VA Medical

30 % to less than 10 %. By May 2016, we anticipate adding one more set of data from

Center, University of California San Francisco, San Francisco, CA; 2Alpert Medical

October 2015, which will allow us to further assess the sustainability of our intervention

School of Brown University, Providence, RI. (Control ID #2469654)

and the effect of the final intervention of limiting lab draw ordering capabilities within our new electronic medical record system.



laboratory testing in the inpatient setting causes patient discomfort and increases cost of


care, yet increased diagnostic testing has not been shown to improve mortality or length of

developed a simple method for determining excess repeated blood tests at our hospital.


We implemented a multi-step educational and systemic intervention that has led to a


significant, sustained decline in repeated and unnecessary blood tests. We added systemic

OBJECTIVES): 1. Quantify the extent of excess blood testing in a large academic

changes—computer order entry restrictions in stepwise fashion, and changes to the

medical center 2. Analyze the impact of an educational and systemic intervention to

medicine evaluation forms—that will be sustainable in the long run. The educational

reduce this excess

intervention improved the practices of house staff and faculty that may carry through in


future practice regardless of future specialty and institution. Significance of computer


order entry changes cannot be underestimated—we saw changes across the hospital even

COMMUNITY CHARACTERISTICS): At our 719-bed academic medical center,

in the surgical services that were not a part of our intervention, which were likely due to the

we performed a prospective observational study and intervention. In collaboration with

systems changes we implemented.

the Department of Pathology, we obtained lab ordering data for CBC and Chem7 tests for medicine and non-medicine patients admitted for >3 days for October 2012 (baseline n = 878). Medicine patients included Internal Medicine and subspecialties including the


Heme/Onc service, medical and cardiac intensive care units. Non-medical services in-


cluded neurology and all surgical services. Unnecessary blood tests were defined as 3

Schectman1; Kathryn Corrigan1. 1Veterans Affairs Central Office, Milwaukee, WI; 2VA

consecutive days of normal results, near normal (grossly within 10 % of normal), or

San Diego Healthcare System, San Diego, CA; 3University of California, San Diego, San

abnormal but stable (varying less than 10 % over 3 days) results. We stratified the data by

Diego, CA. (Control ID #2466037)

critical care status and teaching versus non-teaching (i.e. hospitalist) service. Our interventions were as follows: 1. Dissemination of the baseline results at Medicine Grand


Rounds, hospital committee meetings, and meetings within Divisions of General Internal

addition of virtual visits among Veterans receiving traditional primary care improve

Medicine and Hospitalist Medicine beginning in October 2013. 2. Change of the evalu-

clinical outcomes, satisfaction and reduce cost of care?

ation form for faculty and residents for the teaching service to include a competency on


proper utilization of blood tests. 3. Implementation of a hospital-wide restriction of the

OBJECTIVES): To examine the impact of virtual visits, in addition to traditional primary




care, on outpatient quality measures, healthcare utilization, cost and satisfaction among

these clinics is limited by the ability to impact care decisions while patients are admitted to

Veterans at 4 sites.

the hospital.




OBJECTIVES): 1) Inpatient rounding will tighten connections between inpatient teams

COMMUNITY CHARACTERISTICS): The Veterans Health Administration’s (VHA)

and outpatient providers in an ambulatory ICU. 2) Discharge planning, to include

Patient-Aligned Care Team (PACT), is a team-based approach to delivering patient-centered

medication reconciliation, disposition, end-of-life planning, and clinic follow-up, will be

primary care with the aim of enhanced access and coordinated care management. Core PACT

facilitated through daily hospital rounding from ambulatory ICU medical providers. 3)

team members include the primary care provider, the registered nurse care manager, the

Quality and utilization metrics, to include readmission, length of stay, patient satisfaction,

clinical assistant and the clerical assistant. To date, PACT has successfully increased reliance

and staff satisfaction—will be enhanced by this intervention.

on non-traditional means of accessing care, such as use of secure messaging and teleprimary


care into a rural clinic setting. The “Virtual PACT” expands on the concept of convenient


virtual access by offering the option of virtual care in the Veteran’s home by incorporating the

COMMUNITY CHARACTERISTICS): The Intensive Outpatient Clinic (IOC) at Den-

use of Clinical Video Technology (CVT). For this initial proof of concept pilot, four medical

ver Health is an ambulatory ICU clinic devised within the context of greater system-wide

centers were invited to participate (two large urban sites, one small urban site and one rural

efforts to right-size care for patients according to their needs. The IOC has become a medical

site). Each site identified two physicians with open panel access as Virtual PACT providers.

home for approximately 300 of the sickest and most high-risk patients at Denver Health. The

Veterans will be selected for participation in the pilot by their PACT based on several criteria,

IOC is comprised of an interdisciplinary team, including physicians, a physician assistant, a

including willingness to participate, ability to use a computer or tablet, and likelihood to

nurse practitioner, a licensed clinical social worker, registered nurses, a medical assistant, a

benefit from the pilot (e.g. difficulty accessing care due to physical disability or geographic

clerical specialist, and a patient navigator. This team operates M-F from 8–5 to deliver

distance from clinic, frequent ER/hospital admission, multiple psychosocial or medical

primary health care, including high intensity acute medical and behavioral health care, to

comorbidities). Veterans will be trained to use the tablet or computer software for the virtual

patients who suffer from chronic end-stage organ dysfunction, behavioral health problems,

visit by a nurse trained in this technology. Veterans have the option of using a VHA-issued

chronic pain, substance abuse, and/or homelessness. The IOC operates within a network of

tablet, or the use of their own computer for the pilot. Each tablet is supplied with a

primary care clinics that are a part of Denver Health, an integrated health system that includes

stethoscope, wireless thermometer and blood pressure cuff. Each pilot site will enroll between

a tertiary care teaching hospital. In December 2014, a pilot was undertaken to enhance the

10 and 15 Veterans to participate in virtual visits, in addition to traditional care, over 6–

efforts of inpatient providers by offering bedside rounding from an IOC provider. This has

12 months beginning in October 2015.

evolved into a daily effort from the MDs who make up approximately half of the IOC


provider staff. IOC providers coordinate care across the health system and with outside


entities, including home health agencies, insurers, assisted living facilities, and pharmacies.

INTERVENTION): We will assess the impact of virtual visits on clinical quality metrics,

They communicate with inpatient teams and consultant providers to facilitate an expedited

such as hemoglobin A1c and blood pressure, and on process measures like cancer

discharge, when possible, or a discharge that takes into account pre-hospital characteristics

screening and receipt of vaccinations. The direct cost of virtual encounters will be

along with post-discharge needs. The project described was supported by Grant Number

compared to face-to-face encounters. Veteran satisfaction will be assessed through admin-

1C1CMS331064 from the Department of Health and Human Services, Centers for Medicare

istration of a validated survey. We will also report on the process of implementation, as

& Medicaid Services. The contents of this publication are solely the responsibility of the

well as provider and staff experience, via in-depth interviews.

authors and do not necessarily represent the official views of the U.S. Department of Health


and Human Services or any of its agencies. The research presented here was conducted by the

BE DISCUSSED): Four medical centers have enrolled in the pilot study and all PACT

awardee. Findings might or might not be consistent with or confirmed by the findings of the

members have completed the necessary training. As of January 2016, 8 Veterans have

independent evaluation contractor.

enrolled and 4 virtual visits have taken place at one site. We anticipate enrolling between


40 and 60 Veterans across 4 sites for the duration of the pilot.



INTERVENTION): 1) Hospital admission data, including length of stay 2) Patient


satisfaction 3) Staff satisfaction 4) Patient attendance at hospital follow-up appointments

Implementing virtual encounters presents a novel opportunity to enhance patient-


centered care for organizations interested in leveraging technology to expand access in

BE DISCUSSED): 1) Hospitalist staff report greatly enhanced communication with IOC

primary care. The findings from this pilot study will provide valuable information

staff 2) Average daily census for IOC admitted patients has decreased 3) Patient satisfac-

regarding the quality and cost of virtual primary care encounters. It will also identify

tion has improved – Patients report that seeing outpatient providers at their bedside during

patients who would benefit most from this technology and inform organizations on

hospital admissions makes their stay better

processes of implementation and patient experience



Medical providers from an ambulatory ICU can enhance care planning for high-risk hospi-


talized patients. 2) Communication improves when care teams collaborate real-time between

ADULT INPATIENTS Jeremy Long; Vishnu Kulasekaran; Amber Wobbekind; Cynthia

the inpatient and outpatient settings. 3) The “Old Model” of generalist physicians pro-

Crews; Diana Botton. Denver Health, Denver, CO. (Control ID #2457061)

viding both inpatient and outpatient care has new relevance in the setting of high-risk patients.

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): Ambulatory ICU Clinics have become popular in larger health systems as a way to create a novel medical home for patients categorized as “super-utilizers”—unfortunately, the scope of

Abstracts from the 2016 Society of General Internal Medicine Annual Meeting.

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