2017 seldin research symposium abstracts...2nd annual donald w. seldin, m.d. research symposium may...

The 2nd Annual

Donald W. Seldin, M.D. Research Symposium

May 4-5, 2017

The Department of Internal Medicine Presents

2ndANNUALDONALDW.SELDIN,M.D.RESEARCHSYMPOSIUMMay4-5,2017

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RobertL.Johnson,Jr.,M.D.LectureshipinInternalMedicine

MarleneRabinovitch,M.D.DwightandVeraDunlevieProfessorinPediatricCardiology

Dr.RabinovitchobtainedhermedicaldegreefromMcGillUniversityinMontreal,Quebec,Canada.FollowinginternshipandresidencyinPediatricsattheUniversityofColorado,shecompletedfellowshiptraininginPediatricCardiologyatTexasChildren’s

HospitalinHouston,Texas,andclinicalandresearchfellowshipsatChildren’sHospital,HarvardMedicalSchool,Boston,Massachusetts.ShewasafacultymemberattheUniversityofToronto,Ontario,anddirectedtheHospitalforSickChildrenCardiovascularResearchInstitute,beforemovingtoStanfordUniversitySchoolofMedicinewhereshenowco-directsPediatricTranslationalResearchattheStanfordCardiovascularInstitute.

Dr.Rabinovitch’sresearchcentersonthepulmonarycirculationincongenitalheartdiseaseandpulmonaryhypertension.Herlaboratorystudiesthemolecularmechanismsregulatingvascularendothelialandsmoothmusclecell-extracellularmatrixinteractionsaswellasgeneregulationandgenetherapyforcardiovasculardevelopmentanddisease.HerresearchhasbeencontinuouslysupportedbytheNationalInstituteofHeathandotherfundingagencies.

Dr.RabinovitchhasreceivedmanyawardsincludingfromtheAmericanThoracicSocietyandtheAmericanHeartAssociation.ShepublishesextensivelyandservesontheEditorialBoardsofseveralmajorjournalsinthefieldandontheAdvisoryBoardsandcommitteesattheNationalInstitutesofHealthandotherresearchorganizations.Shehasmentoredmanyyoungscientistsandisapopularinvitedspeaker.


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SymposiumSchedule

May4,2017

v 12:30-4:00pm,McDermottPlaza-PosterPresentationandJudgingv 4:30-6:30pm,A.W.HarrisFacultyClub-SymposiumReception

May5,2017

v 8:00-9:00am,McDermottPlaza,D1.502-InternalMedicineGrandRoundsSpeaker,MarleneRabinovitch,M.D.

v 9:00am,AnnouncementofsixFosterFellowfinalists

May12,2017

v 8:00-9:00am,McDermottPlaza,D1.502-Oralpresentationsofsixposterfinalists,attendeeswillselecttheSeldinScholar


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Poster#1

Presenter:YvonneNicolleCovin

Authors:YvonneNicolleCovinMD,NedaWick,BlakeBarkerMD,PalmaLongoPhD

Title:InvestigatingValidityofaClinicalReasoningAssessmentStrategytoIdentifyActionableFeedbackforStrugglingMedicalStudents

Abstract:Background:Althoughclinicalreasoningisafoundationalskillforphysicians,educatorshavelimitedtoolsforitsstandardizedassessmenttoresultinactionablefeedbacktomedicalstudents.Wesoughttoassessthepotentialutilityofanovel'ThinkAloudProtocol'assessmentstrategy,theClinicalReasoningTaskChecklist(CRT),toidentifyspecificdeficitsinclinicalreasoningamongthird-yearmedicalstudentscomparedtothecurrentvalidatedmultiple-choiceinstrument,theClinicalDataInterpretation(CDI)Test,whichprovidesaglobalassessmentofclinicalknowledgebutdoesnotassessproficiencyinspecificclinicalreasoningtasks.

Methods:Weconductedapilotstudyofthird-yearmedicalstudentsduringtheirinternalmedicineclerkshipatonelargeUSmedicalschool.WeassessedclinicalreasoningusingtheCDIamongallstudentsbeforeagroupproject-basedlearningexercise,duringwhicheachgroupcreatedaSOAPnote.OnestudentrepresentativefromeachgroupthenparticipatedinastructuredThinkAloudProtocol,whichconsistedofastructuredinterviewassessingthejustificationforassessment,differentialdiagnosisandplanforthepatientcase.EachThinkAloudProtocolinterviewwasrecordedandscoredbytwoindependentreviewersusingthevalidatedCRTtoidentifyactionabledeficitsintheclinicalreasoningprocess(kappa=0.88).WeassessedcorrelationofCRTtoCDIscoreswiththePearsoncorrelationcoefficient.

Results:Eighteenstudentsparticipatedinthestudy.ThemeanCDIscoreamongallparticipantswas46.2(SD=7.0).AmongThinkAloudparticipants,theaverageCDIscorewas44.6(SD=7.38).ThinkAloudparticipantsusedonly11ofthepossible24tasks.Onaverage,eachstudentuttered15.83tasks[range8-23]todiscussthecase.Studentsmostfrequentlyusedthetask'selectdiagnosticinvestigations';onaverage,eachstudentselectedfour[range3-5].ThinkAloudParticipantCRTandCDIscoreswerestronglypositivelycorrelated,butdidnotreachstatisticalsignificance.(R=0.768,p=0.074).

Conclusions:AssessmentofThinkAloudprotocolsusingthevalidatedCRTprovidesaglobalassessmentofmedicalstudentclinicalreasoningabilitythatcorrelateswithassessmentviatheexistingCDI,butalsoadditionalprovidesstudentswithactionablefeedbackonspecificdeficitsinclinicalreasoning.ThinkAloudusedinconjunctionwiththeCRTmaybemorehelpfulinidentifyingspecificskillsforremediationamongmedicalstudentsstrugglingwithclinicalreasoningandproblemsolving.


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Poster#2

Presenter:BrooksBrodrick

Authors:BrooksBrodrickMD,HuaLin,EthanHalmMD,MPH,MichaelE.BowenMD

Title:Timetorepeatdiabetesscreeninginpatientswithprediabetesinanurbansafety-nethealthcaresystemBackground:Diabetesscreeningguidelinesrecommendrepeatscreeningevery12monthsforthosewithprediabetesandevery36monthsforthosewithnormalscreeningresults.However,littleisknownaboutfrequencyandtimingofrepeatdiabetesscreeninginclinicalpractice.

Methods:Weconductedaretrospectivecohortstudyinalarge,safety-nethealthcaresystemusingelectronicmedicalrecord(EMR)datafrom2010until2014.Eligiblepatientswereage18-65,non-pregnant,andhadanindex,outpatientvisitandaresultedgoldstandarddiabetesscreeningtest(fastingglucoseorhemoglobinA1C)betweenJanuary2010andJune2013.EligiblepatientshadoneormoreadditionalofficevisitsbeforeDecember2014.PatientswithdiabeteswereexcludedusingICD-9codesandtestresultsconsistentwithdiabetes.Wedescribethefrequencyofrescreeningandexaminecharacteristicsassociatedwithrescreening.UsingaCoxproportionalhazardsregressionmodel,wedescribethetimetorepeatdiabetestestinginnormalvs.prediabetespatientsviaunivariateandmultivariateanalysis,adjustingforage,sex,race,BMI,hypertension,hyperlipidemia,andfamilyhistory.

Results:Atotalof18323patientsmetinclusioncriteria.Onaverage,patientswere48yearsoldandhadaBMIof31.7.Overall,62%werefemale,83%werenon-white,53%hadafamilyhistoryofdiabetes,57%hadhypertension,and78%wereuninsured.Averagefollowupwas398days.Overall,37%ofpatientscompletedrepeatscreening.Rescreeningwasmorecommonamongthosethatwereolder,female,hadahigherBMI,hypertension,andhyperlipidemia(p<0.01).Thosewithprediabetesontheirinitialscreening(N=6585)weremorelikelytoberescreenedcomparedwiththosewithnormoglycemia(HR=1.33)inmultivariateanalysis.However,at12months,only25%ofthosewithprediabeteshadbeenrescreened,andby18and36months,repeatscreeningimprovedtoonly34%and41%respectively.Thosewithhigh-riskprediabetes(A1C≥6%orFBG≥110mg/dL)weremorelikelyberescreenedthanthosewithlowriskprediabetesat12months(34%vs18%),18months(42%vs.28%),and36months(49%vs.36%)(p<0.01forall).Amongthosewhowererescreened,17.4%transitionedfromnormaltoprediabetes,3.2%transitionedfromnormaltodiabetes,and8.7%fromprediabetestodiabetes.

Conclusions:Althoughpatientswithprediabetesaremorelikelytoberescreenedthanthosewithnormoglycemia,onlyonethirdofpatientswithprediabetescompleterepeatdiabetesscreeningat18months.Improved,systematicapproachestopromotetimelyrescreeninginpatientswithprediabetesareneeded.


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Poster#3

Presenter:CarolinaDeLaFlor

Authors:C.DeLaFlorMD,E.PorsaMD,MPH,A.NijhawanMD,MPH,MSCS

Title:Opt-outHIVandHCVtestingamongjailinmates

Abstract:Background:TheburdenofHIVisfourtimeshigherandtheHCVpositivityrateisuptotentimeshigherincorrectionalfacilitiescomparedtothegeneralpopulation.TheCDCrecommendsroutineopt-outHIVtestinginjailsandprisons,howeveronly19%ofprisonsand35%ofjailsofferthisservice.TheWHOrecommendsthatallinmatesshouldbetestedforHCV,howeveronly12-15statesintheUSreportperformingroutineHCVscreening.IntheUS,HCVscreeningisfocusedmainlyonindividualsbornbetween1945-1965('babyboomer'cohort).Objectives:Todescribetheresultsofanopt-outcombinedHIV/HCVtestingprograminacriminaljusticesystem,andtodeterminetheprevalenceanddemographiccharacteristicsofHIV/HCVinthispopulation.Methods:Opt-outHIV/HCVtestingwasofferedtoindividualsenteringtheDallasCountyJailbetweenOctober2015-July2016atthetimeofascheduledblooddraw.4thgenerationAg/AbtestforHIVandHCVantibodyassaywereused.Basicdemographicswereextractedfromelectronichealthrecords.ForthosewhotestedHIVpositive,riskfactors,priorengagementincare(seenbyandHIVproviderwithin6monthsprevioustoincarceration),re-engagementincare(receiptofHIVcareduringincarceration),andpostengagementincare(seenbyandHIVproviderwithin6monthsafterrelease)wereassessed.ForthosewhotestedHCVpositive,priorseropositivitywasdetermined.SASstatisticalsoftware,v9.4wasusedforallanalyses.Results:HIVopt-outtesting:Overall,1.3%(41/3155)hadapositiveHIVscreeningtest.Ofthese,24%werefalsepositives(positive4thgenerationAg/AbtestwithnegativeHIV1/2Abdifferentiationtest).Ofthoseremaining,16%werenewlydiagnosed,ofwhom100%werelinkedtocare.AmongthosepreviouslyknowntobeHIV-positive,one-thirdwerenotengagedincarebeforeincarcerationthough88%werelinkedbacktoHIVcareinjail.HCVopt-outtesting:Overall,16%(500/3042)hadapositiveHCVAbscreeningtest.Meanagewas49,80%weremen,andourcohortwasraciallydiverse(43%White,42%Black,and15%Hispanic).One-thirdofinmatesself-reportedHCVpositivitybeforebeingtested.Only52%oftheHCV-positivewerebabyboomers.Withinbaby-boomers,60%wereblackand31%werewhite,vsamongthenon-boomergroup23%wereblackand56%werewhite.Conclusions:Routineopt-outtestinginajailsettingidentifiedmultipleHIVandHCVinfections.NewHIVdiagnoseswererare,thoughaboveCDCrecommendedthresholdsfortesting;linkagetoHIVcareandre-engagementincarewerehigh.TherateofHCVAbpositivitywashighandone-thirdwasalreadyawareofthisdiagnosis.HCVAbpositivitywas>2XhigherinWhitesvsBlacksamongthosebornafter1965,andnearly2XhigheramonginBlackvsWhitebaby-boomers.TestingonlythoseinthebabyboomercohortwouldhavemissedapproximatelyhalfofHCVinfections,predominatelyamongwhites.


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Poster#4

Presenter:LuizFernandoLeonaviciusFranco

Authors:LuizFrancoPhD,NawafEl-Rehani,XilongLiPhD,BeverleyHuetMS,NilumRajoraMD,KhashayarSakhaeeMD,ShelbyHoltMD,NaimMaaloufMD

Title:OutcomesofParathyroidectomyforSecondaryandTertiaryHyperparathyroidism:TheUTSouthwesternExperience

Abstract:Background:Parathyroidectomy(PTX)isfrequentlyrecommendedformedicallyrefractorysecondaryandtertiaryhyperparathyroidisminpatientswithend-stagerenaldiseaseorpost-renaltransplantation.However,PTXisassociatedwithshort-andlong-termcomplicationsincludinghypocalcemiafromhypoparathyroidismandrecurrenthyperparathyroidism.Moreover,theimpactofsurgicalapproachontheseclinicaloutcomesispoorlyunderstood.

Methods:Tobetterunderstandpost-PTXoutcomesfor2ryor3ryhyperparathyroidism,weperformedaretrospectivestudyofpatientsundergoingPTXbetween2009-2016attheUTSouthwesternUniversityHospitals.Weevaluatedin-hospitalandpost-dischargeoutcomes,andexaminedtheimpactofrenalfunctionattimeofPTX,andofsurgicalapproach[subtotalPTX(STPTX)vstotalPTXwithforearmauto-transplantation(TPTX-FA)].

Results:Chartsof73patientswereanalyzed;meanagewas49±13yearsand46.5%werewomen.84%ofpatientswereondialysisattimeofPTX,anddialysisneedwasassociatedwithgreaterIVcalciumuseandlongerpost-PTXhospitalization.48%ofpatientsunderwentSTPTXand52%hadTPTX-FA.Age,bodymassindex,andgenderandracedistributionweresimilarbetweenthese2surgeries.TPTX-FApatientsweresignificantlymorelikelythanSTPTXpatientstorequireIVcalciumpost-PTX(82%vs.26%,p<0.001)andhadasignificantlylongerhospitalization(6.6±3.6vs.3.8±5.0days,p<0.001).Thesesignificantdifferencespersistedwhentheanalysiswasrestrictedtodialysispatients.Serumcalciumwasnotsignificantlydifferentattimeofdischargebetweenthe2surgerytypes.Long-termfollow-updata(>6months)afterPTXwasavailablein31(42%)ofpatients.Inthatsubgroup,16%hadpermanenthypoparathyroidism,23%hadpersistent/recurrenthyperparathyroidism,and16%requiredasecondPTX,withnosignificantdifferencesintheseoutcomesbetweentheTPTX-FAandSTPTXgroups(intheentirepopulationorwhenrestrictinganalysistodialysispatients).

Conclusions:Thisstudysuggeststhatsurgicalapproachandrenalfunctionhaveasignificantimpactonin-hospitaloutcomesofpatientswith2ryor3ryhyperparathyroidismundergoingPTX(includinggreaterIVcalciumuseandlongerhospitalstayfollowingtotalPTXwithFA).AsignificantproportionofpatientsrequiresrepeatPTXordevelopshypoparathyroidism.Improvedpost-dischargefollow-upisneededtobetterdeterminelong-termpost-PTXoutcomes.


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Poster#5

Presenter:EddieHacklerIII

Authors:EddieHacklerIIIMD,ColbyR.AyersMS,JeanneyLewMD,KamakkiBanksMD,DarrenK.McGuireMD,MHSc,AmitKheraMD,MSC,AnandRohatgiMD,IanJ.NeelandMD,JamesA.deLemosMD

Title:RacialandEthnicDifferencesinCardiovascularBiomarkers

Abstract:Background:Theincidenceandclinicalmanifestationsofcardiovasculardisease(CVD)differbetweenblacksandwhites.Blackshaveincreasedratesofheartfailure,PVD,DVTandstrokebutdecreasedratesofatrialfibrillation.WhiteshavemoreadvancedcoronaryatherosclerosisbutsimilarorlowerratesMI.Currentlythereislimitedunderstandingofpathophysiologicalmechanismsunderlyingtheseracialdifferences.InvestigationofracialandethnicdifferencesinbiomarkersassociatedwithCVDmayprovideinsightsintobiologicalpathwayscontributingtotheseracialandethnicdifferences.

Methods:Across-sectionalanalysiswasperformedusingdatafromtheDallasHeartStudy,amulti-ethnicprobabilitybasedcohortstudy.ParticipantswithexistingCVDwereexcluded.Associationsbetweenrace/ethnicity(AfricanAmerican,CaucasianandHispanic)and30distinctbiomarkerswereevaluatedusingmultivariablelinearregressionadjustingforage,race,traditionalCVDriskfactors,MRIandDEXAmeasuresofbodycompositionandfatdistribution,renalfunction,insulinresistance,LVmassbyMRI,andsocioeconomicfactors.

Results:Thestudypopulationincluded3,214individuals,meanage43,51%AfricanAmericanand18%Hispanic.Significantrace/ethnicitybaseddifferenceswereseeninmultiplecategoriesofbiomarkers,includinglipids,adipokines,andbiomarkersofinflammationandmyocyteinjuryandstress.Infullyadjustedmodels,AAwomenhadhigherlevelsofLp(a),Leptin,D-Dimer,OPG,ANA,SDMAandHomoarginineincomparisonwithCaucasianwomen,andAAmenhadhigherlevelsofHDL-c,Lp(a),Leptin,D-Dimer,hs-CRP,ANA,SDMA,Homoarginine,hsTnTandST2incomparisonwithCaucasianmen(Table).

Conclustion:Blackandwhiteadultsdemonstratesubstantialdifferencesinbiomarkerprofilesafteraccountingforriskfactors,bodycomposition,andsocioeconomicfactors.Thesefindingsyieldinformationthatcouldbeusedclinicallytoriskstratifyat-riskpopulationsearlierinthetreatmentandpreventionofCVD.FuturestudiesareneededtodistinguishwhetherpathophysiologicalprocessesdelineatedbythesebiomarkerscontributetoracialandethnicdifferencesinthedevelopmentandcomplicationsofCVD.


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Poster#6

Presenter:LuiginoBernabela

Authors:LuiginoBernabela

Title:Felty'sSyndromeandRheumatoidneutrophilicDermatosisinapatientwithRheumatoidArthritisA61-year-oldCaucasianmalewasevaluatedforworseningarthritisandpersistentleukopeniaandrash.HehadapastmedicalhistorysignificantforactiveHepatitisC,Hypertension,GERD.Threeyearsago,hewasdiagnosedwithseropositiveerosiveRheumatoidarthritis(RA).AspartofhisHepatitisCevaluationhewasnotedtohaveanenlargedSpleen.HishepatitisCwasnevertreated.Throughthenextfewyearshisrheumatoidarthritiswasneverundercontrolduetonon-complianceandadverseside-effectsfromDMARDs.Hewasalsodevelopingworseningneutropenia.Onpresentationinthehospitalhehadincreasingjointpains,morningstiffness,subjectivefeversandarashonhisextremitiesandpersistentLeukopenia.Onexaminationhehadactivesynovitisinhiswristsandhands.Palpableerythtematousrashwasnotedinvolvingallextremitiesincludingpalmsandsoles.Theselesionswerenotblanchable.Noskinulcerationsorneuropathywasnoted.Abdominalexamrevealedanenlargedspleen.LaboratoryevaluationrevealedWBC1.1,ANC:560,HepatitisCviralload:2.5Million,Genotype3,ESR77,CRP5.7,RFandCCPandcryoglobulinswerepositive.ProminentSplenomegalyof19cmandmildhepatomegalywasnotedonCToftheabdomen.BonemarrowaspirationshowedNormocellularmarrow.PeripheralBloodsmearconfirmedmarkedNeutropenia.HehadnofindingssupportingLargegranularlymphocyticLeukemia.HissplenomegalywasnotedtobeoutofproportiontodegreeofsuspectedfibrosisandportalhypertensionandtherefelttobeduetoFelty'ssyndrome.Patientdeclinedtransjugalarbiopywithportalpressureevaluationforconfirmationofabove.SkinbiopsyrevealedDiffuseNeutrophilicinfiltrationmainlyinthedermissupportingadiagnosisforRheumatoidNeutrophilicDermatosis.Novasculitiswaspresent.HewasstartedonRituximabinfusionsastherapyresultinginmodestimprovementsofhisjointsandNeutropenia.Discussion:Felty'sSyndromeremainsveryrareandoccurringin<1%ofpatientswithrheumatoidarthritis.Itisclassicallycharacterizedbytriadofseropositiverheumatoid,splenomegalyandneutropenia(ANC<1500/mm3).Itshouldbenotedthathiscompletetriadisnotanabsoluterequirement,butpersistentneutropeniawithanabsoluteneutrophilcount(ANC)generallylessthan1500/mm3isnecessaryforestablishingthediagnosis.Skinmanifestationsarethemostfrequentextra-articularmanifestationsinRheumatoidarthritis.Lessfrequentlyneutrophiliclobularpanniculitis,andneutrophilicdermatosessuchasSweetsyndromeandrheumatoidneutrophilicdermatosiscanbeseen.Conclusion:ThereislargebodyofevidencethatRApatientswithextra-articularmanifestationshaveworseprognosisandmoremortality.It'simportanttorecognizetheseearlyintheRAdiseaseprocessinordertoescalatetherapyandimprovepatientoutcomes.


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Poster#7

Presenter:AmiDeWaters

Authors:AmiL.DeWatersMD,HildaLoria,HelenMayo

Title:TheImpactofResidencyBlockScheduling:ASystematicReview

Abstract:Background:Inanefforttoimprovethequalityofandresidentsatisfactionwithambulatorytraining,manyinternalmedicineresidencieshaveredesignedtraditionalambulatoryschedules(ahalfdayofclinic/week)intoablockschedule(longitudinalclinictimeofferedforweeksatatime).Theauthorsconductedasystematicreviewtoexaminetheimpactofblockversustraditionalambulatoryschedulingonresidentandpatientsatisfaction,ambulatorytrainingtime,continuityofpatientcare,theconflictbetweeninpatientandoutpatientresponsibilities,andpatienthealthoutcomes.

Methods:WesearchedOvidMEDLINE,OvidMEDLINEInProcess,EBSCOCINAHL,EBSCOERICandtheCochraneLibraryfrominceptiontoMarch2017.Theauthorsincludedstudiesthatcomparedtraditionalandblockschedulingfortheoutcomesofinterest.

Results:Of7,741citationsreviewed,9studiesmetinclusioncriteria.Overall,blockschedulingwasassociatedwithanincreaseinresidentsatisfaction(effectsize0.7-0.9),increaseinambulatorytrainingtime(32-66%increaseinclinicsessions),anddecreaseinresidents'perceivedconflictbetweeninpatientandoutpatientresponsibilities(effectsize0.3-2.6).Blockschedulinghaddecreasedproviderperspectivecontinuityofcare(10.2-15%decreaseinvisitsPCPsawtheirownpatient),unchangedpatientsatisfaction,anditwasunclearwhetherpatienthealthoutcomeswerechanged.

Conclusions:Residentsatisfactionwithambulatorytrainingandambulatorytrainingtimeincreasedwithblockscheduling,whiledecreasingconflictbetweeninpatientandoutpatientresponsibilities.Patientsatisfactionwasunaffectedbythechangeinscheduling.However,providercontinuityofcaredeclinedintheblockschedule,anditisunclearwhetherpatienthealthoutcomeswerealtered.


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Poster#8

Presenter:AmiDeWaters

Authors:AmiDeWatersMD,JamaelThomas,DanielMejia,MichaelBowen,MD

Title:WhatDoPatientsReallyDoWhenTheyFast?Patients'PracticesandPerceptionstowardsFastingBloodWork

Abstract:Background:Fastingglucoseisanimportantscreeningtestfordiabetes.However,littleisknownaboutpatients'behaviorsandattitudestowardsfastingbloodwork.Toimproveourunderstanding,weconductedasurveytoassesspatients'practicesandperceptionsoffastingbloodworkinclinicalpractice.

Methods:Wedesignedandadministeredasurveytoassessfastingbehaviorsinaconveniencesampleofpatientspresentingforoutpatientbloodworkatanacademicmedicalcenterinthefallof2016.WeinvitedEnglishspeakingadultsâ‰¥18yearsold,whopresentedtothelabtoparticipate.WesubsequentlyreviewedtheEHRandextracteddemographics,comorbidities,andlaboratoryresultsfromthelaboratoryvisitonthedayofthesurvey.Participantswhohadnothingtoeatordrinkexceptwaterforatleast8hourswereconsideredfasting,inaccordancewiththeAmericanDiabetesAssociationfastingdefinition.Wedescribethefrequenciesoffastingbehaviorsandexaminedifferencesincharacteristicsbetweenfastingandnon-fastingparticipantsusingChi2andFisher'sExacttestsasappropriate.

Results:Inthis6weekpilotstudy,wecollected79surveystowardthestudygoalof550.Onaverage,surveyparticipantswere52yearsold,58%female,30%non-white,and22%haddiagnoseddiabetes.Overall,75%(N=59)ofparticipantsself-identifiedasfasting,and93%ofthosemetourfastingdefinition.Surprisingly,53%ofallparticipantsfeltitwasimportanttofastforeverybloodtest.Importantly,94%ofpatientswithdiagnoseddiabetes(N=17)fastedonthedayofthesurvey,and100%reportedtakingtheirdiabetesmedicationsasprescribedthedayoftheirlabvisit,including5of6patientsoninsulin.Weobservednodifferencesinfastingbehaviorbypatientcharacteristicsandcommoncomorbiditiesincludinghypertensionandhyperlipidemia.Ofthe19patientswithoutdiabeteswhofastedunbeknownsttotheircliniciansandhadaglucosemeasured,3casesofprediabetesand1caseofdiabetesweremissed.

Conclusion:PatientscommonlyfastforroutinelaboratorytestsandadheretoADAfastingguidelines.Fastingiscommonamongpatientswithdiabetestakinghypoglycemicmedications,whichposessignificantsafetyconcerns.Developmentofstandardizedprotocolstoassessfastingstatuswhenpatientspresentforroutinebloodworkmayimproverecognitionanddiagnosisofprediabetesanddiabetesinclinicalpractice.


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Poster#9

Presenter:LannaLittle

Authors:LannaLittle,MatthewLeveno,CatherineChen

Title:ImprovingtheManagementofAlcoholWithdrawalatPMH

Abstract:Background:Recognitionandmanagementofalcoholwithdrawalisofuniversalinterestinthemedicalcommunityasalcoholusedisorderisprevalentin15-40%ofgeneralhospitaladmissions.Benzodiazepines(BZDs)havebeenthemainstayofalcoholwithdrawaltherapysincethe1960sastheylessenthesymptomsofwithdrawal,andreducethelikelihoodofseizuresanddeliriumtremens.TheClinicalInstituteWithdrawalAssessment(CIWA)wasdevisedinthe1980sasanobjectivealcoholwithdrawalseverityscale,anditsrevision,theCIWA-Ar,iswidelyutilizedtoday.Inthe1990s,symptomtriggeredtherapy(STT)supplantedfixeddosetapersasstudiesdemonstratedthatSTTresultedindecreasedBZDuseanddurationwithoutincreasedriskofseverewithdrawal.AlthoughinitialstudiesevaluatingCIWA-ArSTTprotocolswereperformedinsubjectswithpurealcoholwithdrawal,useofCIWA-ArSTTprotocolshavegainedafootholdinthemanagementofgeneralmedicinepatientswithalcoholusedisorder.Withsuchwidespreaduse,limitationsoftheCIWA-ArSTTprotocolmaybepoorlyunderstood.StatementoftheProblem:Over1100CIWAprotocolswereorderedin6monthsatParkland.Anecdotally,providershavenotedcasesofpatientswithmild/moderatealcoholwithdrawalwhoprogresstoseverewithdrawaldespiteuseoftheCIWAprotocol.WehypothesizedthatproviderspoorlyunderstandthelimitationsoftheCIWAprotocol,resultingininappropriatepatientselectionandpoorprotocoladherence.Methods:Theelectronicmedicalrecord(EMR)wasqueriedforhospitalencountersbetweenFebruary1,2015andAugust19,2015,associatedwithaCIWAprotocolorder.Atotalof1102suchencounterswereidentified.Werandomlyselected220casestoreviewforappropriatenessofCIWAuse.Ofthe1102cases,230carriedaprimaryadmissiondiagnosisofalcoholwithdrawal,andweremanuallyreviewedtodetermineprotocoladherence.Findings:Oftherandomsample,50%ofpatientswereappropriatecandidatesforCIWAprotocol.Ofthosewithaprimarydiagnosisofalcoholwithdrawal,31.3%ofpatientshadCIWAscorescheckedatthecorrectinterval>75%ofthetime.LessthanhalfofCIWAprotocol-prescribedlorazepamdosesweregiven,and10.3%ofpatientsreceivedprotocol-prescribedlorazepamdoses>75%ofthetime.Discussion:TheCIWAprotocolisoftenorderedinappropriately,andadherencetotheprotocolispoor.Thescoreisoftencheckedtooearlyortoolate,andprescribedbenzodiazepinesarecommonlynotadministered.Intervention:WeareimplementingstaffeducationandclinicaldecisionsupportintheEMR.Wearedevelopinganeducationprogramaboutalcoholwithdrawaltoprovidetrainingtonursingandphysicians.WithintheEMR,theCIWAprotocolordersethasbeensimplifiedandclinicaldecisionsupporttechniqueshavebeenconstructedtoguidenursesanddoctorsinproperprotocoluse.


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Poster#10

Presenter:NicoleBitencourt

Authors:NicoleBitencourt,G.AndresQuicenoMD,FatemehEzzatiMD

Title:RituximabinANCA-AssociatedGlomerulonephritiswithRelapsingPolychondritis

Abstract:A51-year-oldGuatemalanfemalewithahistoryofmildseasonalallergiesinitiallypresentedtotheemergencyroomon5/2016witha2-weekhistoryofrightpinnaerythemaandedemanotresponsivetoceftriaxoneandAugmentin.Shewasnotedtohaveperipheraleosinophiliato15.6%(absoluteeosinophilcountorAECof2010)withnormalrenalfunction(creatinine0.82)andwasdischargedwithciprofloxacin.ShewasseeninJunebyanophthalmologistforbilateralphotophobia,erythema,andeyepainandwasdiagnosedwithcornealulcersforwhichtopicalprednisolonedropswereprescribed.InAugust2016,shewasagainseenintheERwitha1-weekhistoryofleftpinnapain,swelling,anderythemawhichhadnotimproveddespite5daysofBactrim.InNovember2016,shewasadmittedwithacuterenalfailure.Creatininewasnow3.45andurinalysisshowed182RBCswitha24-hourproteinof1920mg.Eosinophiliapersistedat19.7%withAEC2110.P-ANCAwaspositivewithnegativeC-ANCA;anti-myeloperoxidasewaselevatedto4.2(normal<0.4,positive>1.0).ArenalbiopsyrevealedANCA-associatedcrescentic(70%)glomerulonephritiswithglobalandsegmentalglomerulosclerosis.Thepatientwastreatedwithpulsesteroidsandataperingdoseofprednisoneaswellasrituximab,whichwasre-dosedat4months.Asoflastvisit,creatininewasdownto1.35andtherewerenoobvioussignsofdiseaserelapse.Relapsingpolychondritis(RP)isararedisorderofepisodicinflammationofcartilageoustissueclassicallyaffectingthenasalbridge,theauricularcartilage(withsparingoftheearlobes),theeye,andthetrachobronchialtree.Aninflammatoryarthritisisoftenseenandpartoftheclassificationcriteria.Aortitiswithaorticrootdilatationisalsocommon.RPhasbeenassociatedwithotherimmunemediateddisordersormyelodysplasiainabout25-30%ofcases.Inoneseriesof112patients,thisincludedmostcommonlythesystemicvasculitides(9.8%)andrheumatoidarthritis(7.2%).Renalinvolvementisrelativelyuncommon;inoneseriesof129patients,crescenticnecrotizingglomerulonephritiswasnotedamong8ofthe11whounderwentbiopsy.Inasmallcaseseriesof6patientswithvasculitis(2withc-ANCApositiveGPA,3withMPA),symptomsofRPdevelopedafterthediagnosisofvasculitis.ThereisnostandardizedapproachtothetreatmentofRP.Whilerituximabwasreportedtobeeffectivein3patientsbycasereports,anothersmallseriesof9patientsdidnotappeartoconfirmitsbenefits.However,noneofthosepatientshadANCApositivityorrenalinvolvement.WehereinreportthefirstcaseofapatientwithANCA-associatedbiopsyprovencrescenticglomerulonephritis(GN)withassociatedRPthatrespondedwelltorituximab.WepostulatethatANCApresenceandGNmayidentifyasubsetofpatientsresponsivetoB-celldepletioninRP


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Poster#11

Presenter:MehwishIsmaily

Authors:M.IsmailyMD,A.VanderheidenMD,M.YatesMD,A.DeguemeMD,B.Adams-HuetPhD,S.BasaniMD,M.AbreuMD,I.LingvayMD

Title:InsulinDoseChangesPost-Hospitalization

Abstract:Determininganadequateandsafeinsulindoseatthetimeofhospitaldischargeischallengingasmultiplefactorscontributetoeachindividuals'insulinrequirement.Weexploredpatientcharacteristicsthatwouldpredictpost-dischargeinsulinrequirementstoaidinguidinginsulindosedecisionatthetimeofhospitaldischarge.

Wereviewed797chartsofconsecutivepatientsdischargedoninsulinfromParklandHospital(largestsafetynethospitalinthenation)whohadanoutpatientfollow-upwithin6monthsofdischarge.Thepatientswerecategorizedintothosethatrequiredaninsulindosedecrease(n=378),insulindoseincrease(n=102)andnochangeininsulindose(n=317)atfollow-up.Insulindosedecreaseisdefinedas>5%changeintotaldailydose(TDD)fromdischargetofollow-up,doseincreaseisdefinedas<5%changeinTDD,andnochangeindoseisdefinedaswithin5%oftheTDD.Themediantimetothepost-dischargefollow-upwas33days,atwhichtimemostpatients(46.4%)requiredaninsulindosedecrease.Resultsshowedseveraldifferencesinpatientandtreatmentcharacteristicsbetweenthegroupswhorequiredanincrease,decrease,andnochangeininsulindosepost-discharge.

AdmissionTDDofinsulin,hemoglobinA1c,age,gender,andprincipaladmissiondiagnosis(DKA,HHS,Hyperglycemia,GIrelated,Infectious)didnotshowastatisticallysignificantrelationshipwithpost-dischargeinsulindosechanges.AnanalysisofvarianceshowedtheeffectofBMIonpost-dischargeinsulindosechangeswassignificant,F(2,794)=3.64,p=0.026.Achisquaretestofindependencewasperformedtoexaminetherelationshipbetweenpatientswithnewlydiagnoseddiabetesandpost-dischargeinsulinchanges.Therelationshipbetweenthesevariableswassignificant,X2(2,N=797)=114.22,p=<0.001.Wealsoobservedastrongassociationwithinsulin-naÃ¯vepatients(X2(2,N=797)=75.24,p=<0.001)anddiabetestype(type1,type2,orketosis-pronediabetes)withpost-dischargeinsulinchanges(X2(2,N=797)=114.22,p=<0.001).

Amultivariateregressionmodelswasalsocreatedusingvariouspatientfactorstodetermineapossibledischargealgorithmforpatientstransitioningfromtheinpatienttooutpatientside.Themostsignificantpredictorsofadecreaseinpost-dischargeinsulindoseincludedadiagnosisofketosispronediabetes,thosewithnewlydiagnoseddiabetes,higherdischargedose,anddischargemetforminuse.Factorsthatwerenotsignificantpredictorsincludedage,gender,andethnicity.Theseelementsshouldbefactoredintocreateasafedischargeinsulindoseplan.


14

Poster#12

Presenter:OkeefeSimmons

Authors:OkeefeSimmonsMD,PoojaDharwadkarMD,HenningDrechslerMD,MarcusKoumaPharmD,GeriBrownMD,RogerBedimoMD

Title:LipidProfilesafterTherapywithDirect-ActingAntiviralsinHCVmono-infectedandHCV/HIVco-infectedPatients

Abstract:Background:HepatitisCinfectionisassociatedwithsignificantdecreasesinlow-densitycholesterol(LDL-c)andtriglycerides(TG)whichmaybepartiallyreversedbyinterferon-basedtherapy.ExplanationsincludeinteractionsbetweenlipidmetabolismandhepatitisCvirallife-cycle,viral-associatedinflammationorhepaticfibrosis.Itisuncleariftherapywithdirectactingantivirals(DAARx)alterslipidprofiles,and,ifso,whetherthesechangesdifferamongHepatitisCmono-infected(HCV)andHCV/HIVco-infected(HCV/HIV)patientsandwhethertheycorrelatewithhepaticsyntheticfunctionorfibrosisscores(FIB-4).

Methods:WecomparedLDL-c,TG,andFIB-4scoresatbaseline(BL)until1yearafterendofDAARxinHCVandHCV/HIVpatientswithsustainedvirologicresponseafterDAARxattheVANorthTexasHealthCareSystemfrom01/2014until10/2015.WeanalyzedchangesandcorrelationsusingWilcoxonsignedranktestandSpearman'srho,respectively.

Results:118consecutivepatientswereincludedintheanalyses,23(19%)ofwhomwereHIV/HCV(allonstablecombinationantiretroviraltherapywithHIVviralloads<100copies/mL).Medianagewas61years,inter-quartilerange(IQR):58-65,95%weremale.MedianBLHCVviralload(VL)was6.4logcopies/mL,(IQR6.0-6.8),81%hadHCV-genotype1,91%receivedsofosbuvir-basedtherapy,86%for12weeks,and31patientstookanti-hyperlipidemictherapy.MedianBLFIB-4scorewassignificantlylowerinHIV/HCVthaninHCV:2.1(IQR1.7-3.5)vs.4.5,(IQR2.9-6.4),p<0.001whilethemedianBLLDLwasnotdifferent:80mg/dL(IQR60-107)vs.66mg/dL(IQR54-81),p=0.13.BLLDL-candBLHCVVLwereinverselycorrelatedinHCV(r=-0.28,p=0.009)butnotinHIV/HCV(p=0.45).AfterDAARx,medianFIB-4scoresdeclinedmoreinHCV:-1.8(IQR-0.6to-3.3)thaninHIV/HCV:-.3(IQR0to-0.6),p=0.01.MedianLDL-cincreasedsimilarly:+25mg/dL(IQR6-36,p<0.001)inHCVand+25mg/dL(IQR-5to+41,p=0.003)inHIV/HCV.LDL-candFIB-4changeswereinverselycorrelated(r=-0.35;p=0.046)inHCVpatientsonly.OverallmedianTGdeclined:-20mg/dL(IQR+10to-45,p=0.01)withnodifferencesbetweengroups(p=0.95).

Conclusion:SuccessfulDAARxwasaccompaniedbysignificantLDL-cincreasesregardlessofHIVco-infectionstatus.InHCVpatients-inwhomfibrosisscoresweremuchhigheratbaseline-thiswasinverselycorrelatedwithFIB-4improvements.


15

Poster#13


Authors:OkeefeSimmonsMD,NeemaSaraiyaMD,RoopaVemulapalliMD

Title:AnUnderrecognizedSyndromeFollowingColonicPolypectomyUsingSnareElectrocautery

Abstract:A64-year-oldwomanwithalcoholiccirrhosispresentedwithsixhoursofnausea,non-bloodydiarrhea,andsevereabdominalpain.Sheunderwentascreeningcolonoscopythedaypriortopresentationandhadeightpolypsremovedviasnarepolypectomywithandwithoutelectrocautery.Vitalsignswereremarkableforatemperatureof100.2degreesFahrenheit,bloodpressure102/76mmHg,andapulseof84beatsperminute.Herabdomenwasdiffuselytendertopalpationwithnormoactivebowelsoundsandnorebound,guarding,distention,orfluidwave.Noevidenceofperforationwasseenonanabdominalplainfilm.Shewastreatedasanoutpatientwithafive-daycourseofantibioticsandconservativelymanagedwithresolutionofhersymptoms.Althoughitisararecomplicationfollowinghotsnarepolypectomy,healthcareprovidersmustmaintainahighindexofsuspicionforpost-polypectomysyndromeintheappropriateclinicalcontexttopreventexcessiveandpotentiallyharmfuldiagnosticevaluations,aswellasunnecessaryinpatientadmissions.


16

Poster#14


Authors:OkeefeSimmonsMD,CaitlynEllerbePhD,WilliamLeeMD

Title:TransplantListingandOutcomesinAcetaminophen-InducedAcuteLiverFailure:AMulti-CenterAnalysis

Abstract:Background:Althoughacetaminophen-inducedacuteliverfailure(APAP-ALF)isthemostcommoncauseofALFintheUnitedStatesandEurope,APAP-ALFpatientsarelistedforlivertransplantation(LT)atadisproportionallylowratecomparedtonon-APAPetiologiesofALF.Presumedreasonsfornotlistingthesepatientsincludeafavorabletransplant-freeprognosisandpsychosocialconcerns,primarilysubstanceabuseand/orawillfulsuicideattempt.Todate,nolargestudieshaveexaminedthereasonswhymoreAPAP-ALFpatientsarenotlistedfortransplantation.

Methods:1,859subjectswereenrolledintheALFSGregistrybetweenJanuary1,2000andDecember31,2015withadiagnosisofALF,including872APAP-ALFpatientswhometcriteria:ahistoryofpotentiallytoxicAPAPingestion,measurableAPAPlevelintheserum,and/orALT>1000withanyhistoryofAPAPingestionirrespectiveofAPAPlevel.Subjectswereclassifiedasintentional(37.3%ofAPAPsubjects)ifingestionoccurredatasingletimepointusuallywithadmissionofsuicidalintent;patientswereclassifiedasunintentional(51.7%)withmultipletimepointingestionswithoutsuicidalintent,orotherwiseclassifiedasunknown(11.0%)ifintentcouldnotbedetermined.Extensiveclinicalandlaboratorydatawerecollectedforthefirst7daysoruntiltransplant,dischargeordeath.

Results:OftheAPAP-ALFsubjects,79%werenotlistedfortransplant,ofwhom75%werespontaneoussurvivorsat21days.OfthepatientslistedforLT,34%receivedanorgan,and29%died(47/54)priortoLT.AmongAPAP-ALFsubjects,suicidalpatientstendedtobeyounger(p<0.001),butwereotherwisesimilarinmostdemographicandlaboratoryparameters.Therewerenodifferencesobservedbetweensuicidalandunintentionalpatientsininterventions(N-acetylcysteine,vasopressors,renalreplacementtherapy),listingrate,transplantation,ordeath(regardlessoflistingstatus).Suicidalpatientsweremorelikelytohaveapsychiatricconcernwhichprecludedthemfromlisting(38.7%vs27.5%),thoughamongpsychiatricreasonstheywerelesslikelytohaveactivesubstanceabuse(43%vs91%).

Conclusions:DespiteapresumedbiasagainsttheintentionalAPAPoverdosepatient,therewerenodifferencesobservedbetweenintentionalandunintentionalAPAP-ALFpatientsinthefrequencyofinterventions(N-acetylcysteine,vasopressors,renalreplacementtherapy),listingrate,oroutcomes,includingtransplantationordeath.


17

Poster#15

Presenter:PedroCastillo

Authors:PedroCastilloMD,ElizabethSolowMD

Title:ComparingCardiovascularRiskFactorsandDiseasePrevalenceinRheumatoidArthritisPatientsSeparatedbyEthnicityandRace

Abstract:AssessmentofcardiovasculardiseaseandcardiovascularriskfactorsinrheumatoidarthritispatientsseenatParklandHealthandHospitalSystemusingthenovelsoftwareSlicerDicer.

Rheumatoidarthritis(RA)patientssufferfromincreasedmorbidityandmortalityduetocardiovasculardisease(CVD).ThemajorityoftheliteratureregardingcardiovascularoutcomesinRAisproducedfrompredominatelyCaucasiancohorts.Ethnicminoritieshavebeenfoundtohaveworseoutcomesinotherrheumaticdiseases.StudiesdirectlycomparingtheHispanicandAfricanAmerican(AA)cohortstotheCaucasianRApopulationarelimited.AregistryinSanAntonio,TexascalledORALEcontainsapproximately60%Hispanic,7%AAand23%Caucasiansubjects,andtheauthorshavereportedincreasedriskofdeathinRAsubjectsassociatedwithdiseaseseverityindependentoftraditionalcardiovascularriskfactors.Thesedeathswereduetocardiovascularevents.

ThenovelsoftwareprogramSlicerDicerallowstheusertocreateandsplitpopulationsbyfactorswhichinturncanbeusedaspreliminarydataforfurtherevaluation.WeusedSlicerDicertodeterminetheprevalenceofCVD(myocardialinfarction,transientischemicattack,stroke,peripheralvasculardisease)andcardiovascularriskfactors(hypertension,diabetes,obesity,hyperlipidemia)presentinpatientswithanencounterdiagnosisofRA,splitintogroupsbasedonethnicityandrace.Apopulation1366RApatientsweregroupedbyHispanic,Caucasian,andAfricanAmericandesignations.OurRAcohortwas50%Hispanic,33%AA,and16%Caucasian.WefoundthatRApatientswhoidentifiedasHispanicwerelesslikelytoexperiencecardiovasculareventscomparedtotheAAandCaucasianpatientgroup(17%,27%,33%,respectively).CardiovascularriskfactorswerealsocomparedbetweenHispanic,AfricanAmerican,andWhitepopulations,respectively,includingdiabetes(17%,18%,13%,respectively),obesity(62%,61%,50%,respectively),hyperlipidemia(50%,52%,49%,respectively),andhypertension(42%,67%,48%,respectively.)

ThispreliminarydatasuggestslowerratesofcardiovasculardiseaseinHispanicsandAfricanAmericanswithRAcomparedtoCaucasiansdespitesimilarandinsomecasesworseratesofriskfactors.NextstepswillincludeassessmentofRAdiseaseactivityandtimingofdevelopmentofcardiovascularevents.


18

Poster#16

Presenter:NicoleRich

Authors:NicoleRichMD,AdamYoppMD,MobolajiOdewoleBS,MPH,CaitlinMurphyPhD,MPH,JorgeA.MarreroMD,MS,AmitG.SingalMD,MS

Title:Racial/EthnicDisparitiesinHCCPresentationandPrognosis

Abstract:Background:Racial/ethnicminoritieshavebeenshowntohavehigherhepatocellularcarcinoma(HCC)mortalitythannon-HispanicWhites.However,priorresearchislimitedtoadministrativedata,whichlackgranularclinicalinformationontumorcharacteristicsandliverfunction.

Aim:Characterizeracial/ethnicdisparitiesinpresentation,treatment,andsurvivalamongpatientswithHCC.

Methods:WeconductedacohortstudyofpatientsdiagnosedwithHCCattwohealthsystemsbetweenJanuary2008andDecember2016.Weusedunivariateandmultivariatelogisticregressionmodelstocomparepatientcharacteristicsbyrace/ethnicity.SurvivalwascharacterizedusingKaplan-Meieranalysisandcomparedusinglogranktest.

Results:Of952HCCpatients,32.7%wereWhite,31.0%Black,26.3%Hispanicand10.1%otherraces.ComparedtoWhites,Blacksweremorelikelytohaveviralhepatitis(OR2.89,95%CI1.84-4.53)andHispanicsmoreoftenhadfattyliverdisease(OR3.45,95%CI2.38-4.99).AtHCCdiagnosis,ahigherproportionofHispanicshadliverdysfunctionthanWhitesandBlacks(ChildBorC:62.6%vs.50.8%and45.6%,respectively;p<0.001forboth).Thoughtherewasnodifferenceintheproportiondetectedbyscreening(p=0.22),Hispanicswerelesslikelytobedetectedatanearlystage(BCLC0/A)thanWhites(36.7%vs.45.6%;OR0.69,95%CI0.49-0.97);however,therewasnodifferenceinearlydetectionbetweenBlacksandWhites(OR0.82,95%CI0.60-1.13)orBlacksandHispanics(OR1.19,95%CI0.84-1.68).Afteradjustingfortumorstage,HispanicswerelesslikelythanWhites(13.6%vs.21.5%;OR0.61,95%CI0.37-1.00)andBlacks(13.6%vs.23.1%;OR0.48,95%CI0.29-0.79)toreceivecurativetherapybuttherewasnodifferencebetweenBlacksandWhites(OR1.28,95%CI0.83-1.95).Mediansurvivalofallpatientswas9.6months.SurvivaldidnotdifferbetweenWhitesandHispanics(HR1.15,95%CI0.93-1.42)butwasshorterinBlacksthanWhites(7.9vs.12.7months;HR1.52;95%CI1.25-1.86)afteradjustingforHCCstageandcurativetreatmentreceipt.

Conclusion:Hispanic-WhitedisparitiesinHCCprognosisappeartobedrivenbydifferentfactorsthanBlack-Whitedisparities.Hispanicswerediagnosedatalatertumorstage,buthavesimilarstage-adjustedsurvival.However,BlackshaveworsesurvivalthanWhitesdespitealackofdifferenceintumorstageandcurativetreatmentreceipt.


19

Poster#17

Presenter:AnLu

Authors:AnLuMD,RosechelleRuggieroMD

Title:SurvivingSepsis:TimetoLactate

Abstract:Background:Sepsisisoneoftheimportantcausesofhealthcareexpendituregloballyanditcausessignificantmorbidityandmortalityinhospitalizedpatients.Lactatelevelisausefulmarkerinidentifyingtissuehypoperfusionand,therefore,severityofillness.Manyhospitalshaveimplementedasepsisprotocoltoincreaseadherencetobestpracticeswhichincludesmeasuringalactatewithin3hoursofdiagnosisofsepsis.Despitethis,manyhospitalsstrugglewithmeetingthismetric.AtParklandHospital,our3-hourcompositemetricbundle(whichincludesbloodculturespriortobroadspectrumantibioticsandmeasurementofalactatewas36%inFY2016,Themeasurementoffirstlactatewithin3hoursisapproximately66%.

Objective:Aqualityimprovementprojecttoidentifypotentialbarrierspreventingtheachievementofobtaininglactateinthefirst3hours.

Design:Aretrospectivestudyofpatientsadmittedwithsepsis,severesepsisandsepticshocktoParklandHospitalduringNovember2016.Chartreviewwasperformedonthesepatientsaftersepsiscriteriaaremettoidentifywhetherlactatewasdrawninthefirst3hoursandtodeterminethepotentialbarriersifthe3-hourtimelinewasnotmet.

Result:DuringNovember2016,therewere206patientsadmittedforsepsis,severesepsisandsepticshock.Lactateswereobtainedwithin3hoursofarrivalin148patients(71.8%).Thirtythreepatientsdidnothavelactateinthefirst3hours(16%)and25patientshadnolactatedrawn(12.1%).Reasonsincludes:lactatewerenotordereduntilevaluatedbyprimaryadmittingteam(13),untilpatientdecompensated(7),delaybetweenorderingandgettinglabdrawn(3),difficultpatient(agitation,IVaccess)(2),transferofcare(1),andunidentified(7).Wewereunabletodeterminethereasonsthatpatientsdidnothavealactateobtainedduetotheretrospectivenatureofthestudy.

ConclusionwithFutureImplications:Basedontheaboveresults,planforinterventionincludeseducationregardingsepsiscriteriaandbundlewithinformativepostersandmeetings,encouragetheutilizationofsepsisalertandsepsisordersetintheelectronicmedicalrecord.WealsoaimtoimprovethetriageprocessandhopefullytocreateasepsisiconintheEDtrackboardtoincreaseawarenessandhelptoprioritizetheinitialworkupandmanagementofthesesepticpatients.Aftertheseinterventionsarecompleted,wewillconductanotherstudyinthefuturetoassessforimprovement.


20

Poster#18

Presenter:NeilKeshvaniAuthors:NeilKeshvaniMD,BernardTawfikMD,WeinaChenMD,PhD,DavidH.JohnsonMDTitle:VitaminB12DeficiencyMasqueradingasMalignancyIntroduction:B12deficiencyisaverywellknowncauseofmegaloblasticanemia,andtheclassicpresentationinvolvesamacrocyticanemiawithunexplainedneurologicsignsandsymptomssuchasparesthesiaorsensoryataxia,buttherecanbeatypicalpresentations.CaseDescription:A41-year-oldHispanicfemalewithahistoryofhypothyroidismpresentedtotheemergencydepartmentwithchiefcomplaintofdyspnea.Thisdyspneawasprogressivelyworseningforthepastfourweeksandwasalsoaccompaniedbyseverefatigue,anorexia,andgeneralizedmalaise.Reviewofsystemswaspositiveforchills,non-drenchingnightsweats,bleedingfromthegumswhilebrushing,easybruising,andafortypoundweightlossoverthepastyear.Physicalexamwaspositiveonlyforbruisingoverthebilaterallowerextremities.Laboratorytestingshowedawhitebloodcellcountof2,600/µL,hemoglobinof5.3g/dL,ahematocritof15.8%,aplateletcountof51,000/µL,andanLDHof2450U/L.Thedifferentialshowedanabsoluteneutropenia(580/µL)withleftshiftincluding3%blasts,occasionalnucleatedRBCs,andteardropcells.Hypersegmentedneutrophilswereabsent.Athyroid-stimulatinghormonewaswithinnormallimits.Hematologywasconsultedgivenconcernforacuteleukemiaandanemergentbonemarrow(BM)biopsywasperformed.BMexaminationrevealedahypercellularbonemarrowwithmegaloblasticerythrocytichyperplasiaandgiantbandsingranulocyticlineagecells.AvitaminB12levelwasmeasuredthefollowingdayandfoundtobeundetectable(<30ng/L).Bothhomocysteineandmethylmalonicacidlevelswereincreasedto76.4mcmol/dL(referencerange<15)and36nmol/dL(referencerange<0.4),respectively.Anti-parietalcellantibodiesandanti-intrinsicfactorantibodieswerepositive.Anesophagogastroduodenoscopy(EGD)revealedanatrophicappearingmucosawithmildantralgastritis.Biopsyresultsshowedautoimmunegastritisconsistentwithperniciousanemia.ThepatientwastreatedwithsubcutaneousinjectionsofVitaminB12daily1,000mcg.Thepatientwasseeninclinic8weekspost-dischargewithnearresolutionofallofhersymptomsandnormalizationofherCBC,methylmalonicacid,andhomocysteinelevels.Discussion:WhatmakesthiscaseatypicalfortraditionalVitaminB12deficienciesisthelackofneurologicsymptoms,theseverepancytopenia,andtheimmatureprecursorsonperipheralsmearincludingblastswithouthyperlobulatedneutrophils.Thisclinicalpicturewassoconcerningforacuteleukemiathatanurgentbonemarrowbiopsywasperformed.Duetointramedullaryhemolysiscausedbyineffectivehematopoiesis,theLDHisoftenextremelyelevatedasseeninthispatient.ElevatedlevelsofmethylmalonicacidandhomocysteinecanbeusedtoconfirmthediagnosisofvitaminB12deficiency.ThesetestsaremoresensitiveandspecificthantheassayusedtomeasuredirectvitaminB12levels.Lastly,patientswithperniciousanemiahaveanincreasedriskofgastriccarcinomaandshouldbefollowedbygastroenterology.


21

Poster#19

Presenter:ShreyaRao

Authors:ShreyaRaoMD,AmbarishPandeyMD,SushilGargMD,HelenMayo,BryanParkMD,IanJ.NeelandMD

Title:ImpactofExerciseandPharmacologicInterventionsonChangesinVisceralAdiposity:AMeta-AnalysisofRandomizedControlledTrials

Abstract:Background:IncreasedBMIandvisceraladiposetissue(VAT)areassociatedwithelevatedriskofadversecardiovascularoutcomes.WhileseveralexerciseandpharmacologicalinterventionshavebeenshowntoreduceBMI,theirimpactonVATisnotwellestablished.

Methods:Weincludedrandomizedcontrolledtrials(RCTs)thatevaluatedtheefficacyofexerciseorpharmacologicalinterventionsinVATreduction.OutcomeassessedwaschangeinVATmeasuredasvisceralfatarea(cm2)usingCTorMRIimaging.Separatepooledanalysiswasusingrandom-effectmodelswithpooledestimatesofchangeinVATfrombaselinetofollowingreportedasstandardizedmeandifference(SMD).MagnitudeofeffectwascomparedbasedonSMDestimates.

Results:Theprimaryanalysisincluded4,380participantsfrom25RCTs.Inpooledanalysis,bothexercisetrainingandpharmacologicalinterventionswereassociatedwithsignificantreductionsinvisceraladiposity(seefigure).ExercisetrainingwasassociatedwithamoderatereductioninVATmeasures[SMD(95%CI):-0.71(-0.93to-0.49)].Incontrast,moresubstantialdecreaseinVATwasobservedwithpharmacologicaltherapies[SMD(95%CI):-0.91(-1.42to-0.40)].

Conclusions:ExerciseandpharmacologicinterventionsareassociatedwithsignificantreductioninVAT,withmoresubstantialbenefitsfrompharmacologicaltherapies.Futurestudiesareneededtodetermineifthefavorableeffectsoftheseinterventionsmayalsolowertheriskforadversecardiovascularoutcomes.


22

Poster#20

Presenter:TimilH.Patel

Authors:TimilH.PatelMD;NamrahSiddiqMD;SrikanthNagallaMD.

Title:QuantitativeInterpretationofOpticalDensityMeasurementsForHeparin-InducedThrombocytopenia

Abstract:Introduction:Thediagnosisofheparin-inducedthrombocytopenia(HIT)isbasedonadecreaseintheplateletcountofmorethan50%orthrombosisbeginning5to10daysafterthestartofheparin,inassociationwiththeappearanceofplatelet-activatingHITantibodies,asshownbymeansofafunctionalassay(serotonin-releaseassay)orinferredbymeansofastrongpositiveimmunoassay(PF4-heparinIgGimmunoassay).

Theinitiallaboratorytestforheparin-inducedthrombocytopenia(HIT)usesaPF4-dependentenzyme-immunoassay(EIA).EIAisexpressedinopticaldensity(OD)units.ThestandarddiagnosticcutoffforapositiveODvalueis0.40andabove.Anti-PF4-heparinenzymeimmunoassayshaveanexcellentnegativepredictivevalue(98to99%)butalowpositivepredictivevalue,inpartduetodetectingclinicallyinsignificantanti-PF4-heparinantibodies.

DiagnosticaccuracyforHITisimprovedwiththeuseofbothananti-PF4-heparinenzymeimmunoassayandaserotonin-releaseassay(SRA).AnSRAismuchmorespecificthanenzymeimmunoassaysforclinicallyrelevantantibodiesandthusanegativefunctionalassayessentiallyrulesoutHIT,butthetestistechnicallydemandingandperformedbyfewlaboratories.

WesoughttodeterminewhetherthequantitativedegreeofapositiveEIAresult,expressedinopticaldensity(OD)units,predictsriskofHITantibodies,definedasastrong-positiveplateletserotonin-releaseassay(SRA)result(>50%serotoninrelease).

Methods:Weretrospectivelyreviewedtheserologicaldatafor127patientstestedforHITattheUniversityofTexasSouthwesternMedicalCenterfromJanuary2012toDecember2016usingEIA-IgGandSRA.

Results:Forpatientswithaweak-positiveEIAresult(0.4to<1ODunits),10outof49patientshadastrong-positiveSRA(>50%).Forpatientswithastrong-positiveEIAresult(>1ODunits),19outof57patientshadastrong-positiveSRA(>50%).Ofthepatientswhohadaweak-positiveEIAresult(0.4to<1ODunits)andastrong-positiveSRA(>50%),theaverageODunitwas0.68(range0.42to0.83).

Conclusions:ThelikelihoodofHITantibodies(strong-positiveSRAresult)inferredbyapositivePF4-dependentEIAvariesconsiderablyinrelationtothequantitativedegreeoftheEIAresult,expressedasODvalues.Therefore,ratherthanasinglecutofftodetermineapositiveODvalue,itmaybereasonabletointerpretanyspecificODvalueasaprobabilityforthepresenceofHITantibodies.


23

Poster#21

Presenter:TimilPatel

Authors:TimilH.PatelMD;RandallHughesMD;ThomasFroehlichMD;ArthurFrankel,MD

Title:SubacuteProgressiveEncephalopathyFromMiliaryMelanoma

Abstract:A54-year-oldCaucasianmalewithmetastaticmelanoma(BRAF-positive)presentedwithone-weekhistoryofalteredmentalstatus.

Thepatientwasdiagnosedwithmelanomaofthelowerbackin2002andtreatedwithwide-localresection.InAugust2016,hewasnotedtohaverecurrencewithbiopsyprovenBRAF-mutationmelanoma,withmetastaticdiseasetothelungs,liver,mediastinumandbone.Hewasinitiallytreatedwithipilumumabandnivolumabbutdevelopedworseningdyspneasohischemotherapywaschangedtotrametinibanddabrafenib.

InNovember2016,hepresentedwithprogressivelyworseningconfusionandlossoffunction.Normalatbaseline,thepatientwasnowdisorientedanddependentforallactivitiesofdailyliving.Aninfectiousandseizurework-upwerenegative.MRofthebrainrevealeddiffuse,innumerousscatteredfociofhypo-intenselesions,concerningformicro-hemorrhageversusmetastaticdisease.Hislumbarpuncturefluidcytologyconfirmedmelanoma.Duetotherapidlydeterioratingconditionandadismalprognosis,afteraninterdisciplinarydiscussionwithoncologists,neurologists,radiationoncologistsandpalliativecarephysicians,thedecisionwasmadetotransitiontocomfortcareandthepatientpassedawayshortlythereafter.

Wedescribeacaseofamilitarypatternofmetastaticmelanomathatisbothveryrareandportendsapoorprognosis.Metastaticmelanomarepresentsthethirdmostcommoncauseforcentralnervoussystemmetastasesafterbreastandlungcancer.Nevertheless,onlyabout5%ofthepatientswithmetastaticmelanomahavemorethanfiveintracerebralmetastaticlesionsandtherearebeenonlyafewcasereportsworldwideforamiliarymetastaticpatternformelanoma.ItremainstobeseenifthereisanassociationbetweenBRAFstatusandamiliarypatternofmetastasis.


24

Poster#22

Presenter:JenniferFan

Authors:YuZuoMD,JenniferFanMD,RaviSarodeMD,DavidKarpMD,Yu-MinShen

Title:Identifying'SecondHit'RiskFactorsAssociatedwithThrombosisandPregnancyMorbidityinaPLsPositivePatients

Abstract:Background:Theevaluationofthromboticandpregnancyrisksassociatedwithantiphospholipidantibodies(aPL)inindividualpatientswithoutAPSclinicalmanifestationischallenging.

Aims:ToidentifypotentialpredictorsofthrombosisandpregnancymorbiditiesamongaPLpositivepatients.

Methods:Thisstudyincluded229consecutivepersistentaPLpositivepatientswhoattendedclinicatUniversityofTexasSouthwesternMedicalCenter.Allpatientshadpersistenthightiter(99percentiles)aPL.TheaPLprofileswereassessedwithcommercialassay.Hypertension(HTN)wasclassifiedbasedon8thJointNationalCommitteeguidelines.Hyperlipidemia(HLD)wasdefinedasfastingtotalcholesterol>200mg/dl.Whenassessingriskfactorsassociatedwithpregnancymorbidities,onlyreproductiveage(age<45)femalecontrolswereused.PearsonChi-squaredanalysisandmultivariablelogisticregressionwereusedtoevaluatecorrelationbetweendifferentriskfactorsandclinicalmanifestations.

Results:Ofthe229aPLpositivepatients,130(56.8%)patientshadcriteriaAPSclinicalmanifestationsand99patientsdidnot.AmongAPSpatients,98(75.4%)patientshadprimaryAPS.WhencomparingAPSpatientstoasymptomaticaPLpositivecontrolpatients,HTN(OR=3.827,95%CI1.603-8.761,P=0.0018)wassignificantlyassociatedwitharterialthrombosis(Fig1)andthepresenceoflupusanticoagulant(OR=3.308,95%CI1.501-6.949,P=0.0015)wassignificantlyassociatedwithvenousthrombosis(Fig2).Age,HLD,smoking,raynaud,livedoreticularis,presenceofIgAaPLortriplepositiveaPLdidnotdemonstratesignificantcorrelationwitheitherarterialorvenousthrombosis.NoneoftheanalyzedclinicalcharacteristicsoraPLprofilesshowedsignificantcorrelationwithobstetricmanifestations.

Conclusion:HTNisapotentialpredictorofarterialthrombosisandthepresenceofLAisapotentialpredictorofvenousthrombosisinaPLpositivepatients.


25

Poster#23

Presenter:NiveditaArora

Authors:NiveditaArora,ArjunGuptaMBBS,HongZhuPhD,AlanaChristie,JeffreyJ.MeyerMD,SaadA.KhanMD,MuhammadS.BegMD

Title:RacialandGenderDisparitiesintheTherapyandOutcomesofSquamousCellCarcinomaoftheAnus

Abstract:Background:Squamouscellcarcinomaoftheanus(SCCA)isoneofthefewcancerswitharisingincidenceintheUnitedStates.Weaimedtocharacterizeraceandgender-baseddisparitiesinreceiptoftherapyandoverallsurvival(OS)ofSCCAusingtheSurveillance,EpidemiologyandEndResults(SEER)database.

Methods:CasesoflocoregionalSCCA(T2-T4,anyN,M0)diagnosedbetween2000-2012intheSEERdatabasewereincluded.Demographics,tumorcharacteristics,therapyandoutcomeswereextracted.UnivariableandmultivariableCoxproportionalhazardmodelswereconstructedtotestfactorsassociatedwithOS.Datawerereportedashazardratios(HR)and95%confidenceintervals(CI).

Results:Weidentified7882casesoflocoregionalSCCA,medianage58years,61.2%women,86.3%white.Majorityofpatients(82.3%)receivedradiationtherapy;withthelowestrateinblackmales(76.7%)andhighestinwhitefemales(86.1%).ThemedianOSwas135months.OSwaslowerinelderlypatients,(>65yearsold)(68months),men(108months),blacks(109months)andthosewhodidnotreceiveradiationtherapy(121months).Inmultivariableanalysis,age(HR1.19,95%CI1.17-1.21per5yearsincrease),gender(HR1.59,95%CI1.47-1.73,menvswomen),race(HR1.51,95%CI1.34-1.71,blackvswhite),andradiationtherapy(HR0.90,95%CI0.82-0.99),wereindependentlyassociatedwithOS(p<0.05).

Conclusions:Significantracialandgender-baseddisparitiesexistinsurvivalofpatientswithlocoregionalSCCA.Furtherinvestigationintocausesofandmethodstoeliminatethesedisparitiesarewarranted.


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Poster#24

Presenter:NiveditaArora

Authors:NiveditaAroraMD;LauretteFemnou-MbuntumMD;ArjunGuptaMD;SujataBhushanMD.

Title:TypeBLacticAcidosisinapatientwithMetastaticSquamousCellLungCancerCase:A63-year-oldmanwithpoorlydifferentiatedsquamouscellcarcinomaoftherightlungpresentedwithworseningshortnessofbreath.Hedeniedfevers,sickcontacts,travel,orfocalsymptoms.Medicationsincludedhydrocodone,ranitidineandsenna.Hewasafebrile,hemodynamicallystable,wellperfusedwithoxygensaturation97%onroomair.Decreasedbreathsoundsovertherightupperlungfieldandnon-tenderhepatomegalywerenoted.Laboratorytestingshowedunremarkablebloodcountsandrenalfunction,bicarbonate20mmol/L(ref22-30),aniongap21mmol/L(ref8-16),AST174U/L(ref15-41),ALT90U/L(ref5-58),Alkalinephosphatase931U/L(ref40-129)andlactate7.6mmol/L(ref0.5-2.2).CTscanrevealedintervalenlargementofthelungmasswithinnumerablemetastaticlesionsintheliverandhepatomegaly.Hehadnosymptomatic,laboratoryorimagingevidenceofinfection.Hewashemodynamicallystable,euvolemicandwasnottakinganymedicationsthatcouldcontributetolacticacidosis.Arepeatlactatewas9.2mmol/L.Hiselevatedlactatewaspresumedsecondarytoextensivetumorburdenandliverdysfunction.Hedeclinedfurthertesting/treatmentandwastransitionedtohospicecare.Impact:Thiscasedescribeslacticacidosisinapatientwithasolidtumorandliverdysfunctionsecondarytometastasis.ThoughtypeBlacticacidosisisknowntooccurinhaematologicalaswellassolidmalignancies,itremainsadiagnosisofexclusionanditisnecessarytoruleoutsepsis,tissuehypoperfusionordrugeffects(alcohol,salicylates,reversetranscriptaseinhibitors)aspotentialcausesoftheelevatedlactate.Discussion:Lacticacidosiscanoccurinthepresence(typeA)orabsence(typeB)oftissuehypoperfusion.Ithashighsensitivitybutpoorspecificityfortissuehypoperfusion.TypeBlacticacidosiscanbeseenwithcancer,renalorliverdisease,drugortoxiningestionorcongenitalenzymedeficiency.Cancer-associatedtypeBlacticacidosishasrarelybeendescribedwithsolidtumors.ThisispostulatedtobearesultoftheWarburgphenomenonofalteredenergymetabolismincancercells,wherebytheypreferentiallyundergoaerobicglycolysis,leadingtoproductionoflactatefrompyruvate,insteadofthemoreenergyefficientoxidativephosphorylation.Liverdysfunctionsecondarytometastasiswithresultantdecreasedclearanceofcirculatinglactatebytheliver(CoriCycle)likelyalsoplayedaroleinlacticacidosisinthispatient.Theetiologyofmalignancyassociatedhyperlactatemiaisthuslikelymultifactorial.Hyperlactatemiahasbeenshowntobeanegativeprognosticmarkerincancerpatients.Thiscasehighlightsanunusualcauseoflacticacidosisinapatientpresentingwithprogressionandmetastasisoflungcancerwithhightumorburden.


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Poster#25

Presenter:NimishN.Shah

Authors:NimishN.ShahMD,JoelTaurogMD

Title:SlightofHand:DiabeticCheiroarthropathyandthePrayerSignAbstract:A60-year-oldwomanwithahistoryoftype1diabetesmellitusandapriordiagnosisofseropositiverheumatoidarthritis(RA)presentedforevaluationandmanagementofRAdiagnosedseveralyearsago.Shewasbrieflytreatedwithcorticosteroidsfor1month,buthadotherwisenotreceivedanyimmunosuppressivetreatment.Asidefrom1hourofpainlessmorningstiffnessinherrightknee,shoulders,andhands,hersymptomswereminimal.Hermedicationsincludedacalcium-vitaminD3supplement,atorvastatin,insulinglargine,insulinaspart,lisinopril,ranitidine,andacetaminophen.Herexamrevealedmildjointswellingandtendernessattheleftwrist,thickenedskinovertherightsecondproximalinterphalangealjointwithoutswelling,andmildcontracturesattheproximalinterphalangealjointsbilaterallywithapositive'prayersign'(Figure1).Theremainderofherexamwasunremarkable.HerlabsweresignificantforHgbA1cof8.7,WBCof8.38,ESRof68,positivespeckledANAwithatiterof1:80,CCPof209.97,andRFof50.Theremainderofherimmunologicstudieswerenegative.RatherthanRA,thispatientwasultimatelydiagnosedwithdiabeticcheiroarthropathy,aclinicaldiagnosissuggestedbythe'prayersign,'ortheinabilitytoapproximatethepalmarsurfacesofthedigitswiththepalmsopposed.Itisarecognizedcomplicationoflong-standingdiabetes,thoughttobemorecommoninType1diabetesthaninType2duetothelongerdiseaseduration.Itisattributedtoglycosylationandcrosslinkingofcollagencausingcollagenstiffening,inadditiontocollagendegradation.Microvasculopathymayalsoplayaroleininducingischemiaofskintissue.Thesechangesmaybereversedoratleastimprovedwithtightenedglycemiccontrol.Thiscaserepresentsateachablemoment,whereinthediagnosisofdiabeticcheiroarthropathymaybemissedinfavorofadiagnosisofseropositiveRA.Indeed,thispatientreportedpolyarticularmorningstiffness,hadanexamsuggestiveofsynovitis,andhadpositiveRFandCCPserologytosuggestRA.UsingACRclassificationcriteriaforRAwithoutconsideringcheiroarthropathyinthedifferential,thispatientwouldreceiveatleast7points,consistentwithdefiniteRA.WithadiagnosisofRA,thispatientwouldhavebeenacandidatefordisease-modifyingantirheumaticdrug(DMARD)therapy,andlikelywouldhaveinitiallyreceivedmethotrexate(MTX),adrugthatmaypotentiatehepatoxicity.IfMTXwasineffectiveatcontrollingsymptoms,shewouldthenhavebeenexposedtoadditionalDMARDS,includingbiologicDMARDS,whichplacethepatientatriskofopportunisticinfectionsduetotheirimmunosuppressiveeffects.However,theACRcriteriaareonlyapplicableforpatientswithsynovitisnotbetterexplainedbyanotherdisease.Here,thediagnosisofdiabeticcheiroarthropathynotonlyexplainsthepatient'spresentation,butalsoprecludesexposuretopotentialadversedrugreactionsassociatedwithRAmanagement.Thepatientwascounselledonimprovingherglycemiccontrolandofferedwristsplintingwithphysicaltherapyforsymptomaticrelief.


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Poster#26

Presenter:LaurenSmith

Authors:LaurenN.SmithMD,AnilN.MakamMD,MAS,DouglasDardenMD,HelenMayoMLS,SandeepR.DasMD,MPH,EthanA.HalmMD,MPH,OanhKieuNguyenMD,MAS

Title:AcuteMyocardialInfarctionReadmissionRiskPredictionModels:ASystematicReviewOfModelPerformance

Abstract:Background:Hospitalsaresubjecttofederalfinancialpenaltiesforexcessive30-dayhospitalreadmissionsforacutemyocardialinfarction(AMI).ProspectivelyidentifyingAMIpatientsathighriskforreadmissioncouldhelpprevent30-dayreadmissionsbyenablingtargetedinterventions.However,theperformanceofAMIreadmissionriskpredictionmodelsisunknown.

MethodsandResults:WesystematicallysearchedthecurrentlypublishedliteraturethroughMarch2017forstudiesofriskpredictionmodelsfor30-dayhospitalreadmissionamongadultswithAMI.Weidentified11studiesof18riskpredictionmodelsacrossdiversesettingsprimarilyintheU.S.,ofwhich16modelswerespecifictoAMI.Overallobservedall-causereadmissionratesacrossstudieswere10.6-21.0%.Sixmodelswerebasedonadministrativedata;fouronelectronichealthrecorddata;threeonclinicalhospitaldata;andfiveoncardiacregistrydata.Modelsincluded7-37predictors,ofwhichdemographics,comorbidities,andutilizationmetricswerethemostfrequentlyincludeddomains.Mostmodels,includingtheCentersforMedicareandMedicaidServicesAMIadministrativemodelhadmodestdiscrimination(C-statisticrange0.53-0.79,median0.65).Ofthe16AMI-specificmodels,only8modelswereassessedinavalidationcohortinthereportedanalysis,limitinggeneralizability.Observedrisk-stratifiedreadmissionratesrangedfrom3.0%amongthelowestriskindividualsto43.0%amongthehighestriskindividuals,suggestinggoodriskstratification.

Conclusions:CurrentAMIreadmissionriskpredictionmodelshavemodestpredictiveabilitybutuncertaingeneralizabilitygivenmethodologicallimitations.Fewexistingmodelsprovideactionableinformationinreal-timetoenableearlyidentificationandrisk-stratificationofAMIpatientspriortohospitaldischarge,afunctionalityneededtooptimizethepotentialeffectivenessofreadmissionreductioninterventions.Futurestudiesshouldfocusnotonlyondevelopingmodelswithimprovedaccuracy,butthatalsoonmodelsthatareparsimoniousandprovideclinicallyactionableinformationinreal-time.


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Poster#27

Presenter:LaurenN.Smith,MeredithK.Greer

Authors:LaurenN.SmithMD,MeredithK.GreerMD,LanceTeradaMD

Title:Rheumatoidpneumoconiosis,delayeddiagnosisandharmfultreatments

Abstract:Introduction:A33-year-oldHIV-negativeHispanicmale,workingasastonebreaker,presentedwithrecurrentpolyarthritisandincidentalfindingofpulmonarynodules.Hewasultimatelydiagnosedwithrheumatoidpneumoconiosis(Caplan'ssyndrome)butwouldremainseronegativeuntilalmostoneyearintohisdiseasecourse.

CasePresentation:Ourpatientfirstpresentedwithachiefcomplaintofright-sidedshoulderpain.Routineshoulderx-raynotedpulmonarynodules.SubsequentCTchestshowedinnumerablerandomlydistributedpulmonarynodules.Aninfectiousworkupwaspursuedbutalltests,includingTB,camebacknegative.Autoimmuneworkupwasalsopursued,allofwhichwasnegative.Forthefollowingsevenmonths,hereturnedtotheEDforevaluationofrecurrentepisodesofpolyarthritistreatedwithNSAIDS,andoccasionallyprednisone,butwasneveradmittedforfurtherworkup.Eventually,hewasreferredtorheumatologyclinicwhereexamdemonstratedsynovitisthusautoimmunetestingwasagainpursued.Thistime,RFpositive,CCP>250.Hewasstartedonprednisone,sulfasalazine,andleflunomideatthistime.FollowupCTchestshowedprogressionofdisease.ThepatientunderwentaVATSprocedurewithpathologydemonstratingnumerousnoduleswithcentralnecrosisborderedbypalisadinghistiocytesaswellasdust-likeparticlesseenunderpolarizinglight.InthesettingofRA,workhistoryofconstruction,andpathologyfindingspatientwasdiagnosedwithrheumatoidpneumoconiosis,orCaplan'ssyndrome.Unfortunatelythepatient'streatmentcoursehasbeendifficultduetoworseningofpulmonarynodules.Therewasconcernfordruginducedrheumatoidnodulesfromleflunomideandalsoetanercept,whichthepatientwasonbriefly,thushehasnowbeenswitchedtoplaquenil.

Discussion:Bothdiagnosisandtreatmenthavebeendifficultinthiscase.Thediagnosiswasdelayedduetonegativeinitialserologiesandunremarkablefindingsoninitialmusculoskeletalexams.However,inCaplan'ssyndromefeaturesofRAcanbeabsentordeveloplaterafterpulmonarymanifestationsbecomeevident.IntheoriginalCaplanpaper,severalpatientswithclassiclungfindingsonCXRdidnotdeveloparthritisorpositiveserologiesuntilyearslater.Similarly,otherliteraturehasfoundthatsomepatientswitharthritisandlungnoduleshavenegativeserologicalmarkersoninitialpresentationbutconvertdowntheroad.Overall,thereisaminorityofpatientsthatremainseronegativethroughoutthediseasecourseandthusisnotarequirementfordiagnosis.Patientswithhighsuspicionofdiseaseshouldbetreatedearlierregardlessofserologicaltestingandarthritismanifestations.Lastly,casestudieshaveshownthatseveralcommontreatmentsforRAincludingmethotrexateandleflunomidehavebeenassociatedwithdevelopmentofrheumatoidnodulesinthelung.ForpatientswithRA


30

whopresentwithlunginvolvementthesetherapiesshouldbeavoidedandplaquenilusedasfirstlinesinceitisnotshowntocauselungmanifestations.

Conclusions:Thiscaseillustratestheimportanceofhistorytaking,patternrecognition,andcontinueddiagnosticre-evaluationtominimizedelayindiagnosisoflesscommonconditionswhenlaboratorydataandphysicalexaminationarenotconclusive.Furthermore,insystemicdiseasesphysiciansmustbeawareofpotentialdrugsideeffectsbeforestartingnewtherapiesandquicklyidentifyalternativestoreduceharmfuloutcomes.


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Poster#28

Presenter:JosephMoore

Authors:JosephMooreMD,LouiseGligaMD,SrikanthNagallaMD

Title:ThyroidStorm&WarmAutoimmuneHemolyticAnemia

Abstract:Introduction:Graves'diseaseisoftenassociatedwithotherautoimmunedisorders,includingrareassociationswithautoimmunehemolyticanemia(AIHA).Wedescribeauniquepresentationofthyroidstormandwarmautoimmunehemolyticanemiadiagnosedconcurrently.

CasePresentation:A20-year-oldChinesefemalewithhistoryofhyperthyroidismpresentedtoourhospitalwithnausea,vomiting,diarrheaandalteredmentalstatus.Onadmission,temperaturewas101.9°Fandheartratewas160/min.Physicalexamwasnotablefordisorientation,scleralicterus,diffusenontenderenlargementofthyroidgland,mildtremorsandjaundice.Laboratorystudiesrevealedhemoglobin3.9g/dL,platelets171x109/L,haptoglobin<5mg/dL,reticulocytosis,andpositivedirectantiglobulintest(IgG,warm).Additionalworkuprevealedserumthyroidstimulatinghormone(TSH)<0.01µIU/mLandserumfree-T4(FT4)level7.8ng/dL.OurpatientwasdiagnosedwithconcurrentthyroidstormandwarmAIHA.Shewasstartedonglucocorticoids(prednisone1mg/kg/day)totreatbothwarmAIHAandthyroidstorm,aswellasmethimazole,propranololandfolicacid.Duetoprofoundanemiaandconcernforhemodynamicinstability,thepatientwastransfusedthreeunitsofuncrossmatchedpackedredbloodcellsslowlyandtoleratedthiswell.Thepatientwassuccessfullytreatedwithbothmethimazoleandprednisonetaper,andachievedcompleteresolutionofthethyrotoxicosisandanemia.

Discussion:Hyperthyroidismcanaffectallthreebloodcelllineagesofthehematopoieticsystem.Anemiacanbeseenin10-20%ofpatientswiththyrotoxicosis.SeveralautoimmuneprocessescanleadtoanemiainGraves'disease,includingperniciousanemia,celiacdisease,andwarmAIHA.Oftheseprocesses,AIHAistherarestandlimitedtosinglecasereports.ThepathophysiologyofAIHAinGraves'diseaseisnotcompletelyunderstood.First-linetherapyforwarmAIHAisglucocorticoidsandfortunatelyourpatientrespondedwelltothistreatment.ThiscaseillustratesararelydescribedpresentationofapatientwithGraves'diseasepresentingwiththyroidstormandwarmautoimmunehemolyticanemia.Tothebestofourknowledge,thisrepresentsthefirstsuchcasedescribed.


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Poster#29

Presenter:ChristinaMosher

Authors:ChristinaA.MosherMD,RebeccaF.YarboroughMD,BretEversMD,PhD,SalahuddinKaziMD

Title:Immunoglobulinfreelightchainsasaharbingerforlupusmyositis

Abstract:Systemiclupuserythematosus(SLE)isanautoimmunediseasethatcanaffectanyorgansystemandismarkedbyflaresalternatingwithremission.Flaresaretreatedwithimmunosuppressantsonlyafteractivediseasebecomesclinicallyapparent,whenirreversibletissuedamagemayhavealreadyoccurred.Skeletalmuscleinvolvementismostcommonlysubclinical,butrarecasesofovertmyositisdemonstratesignificantinflammatorydamage,andpatientsoverallhaveaworseprognosis.EspeciallyinseveremanifestationssuchasSLEmyositis,biomarkerscreeningcouldallowearlytreatmentinitiationthatcurtailstheextentofinflammatorydamage.RecentworkhasattemptedtocorrelateSLEdiseaseactivitywithserumlevelsofvariousimmunologicparameters,andthusfindabiomarkerpredictiveofflares.PolyclonalfreelightchainshavebeenshowntocorrelatewithSLEdiseaseactivity.ThedetectionofelevatedurinaryFLCcanprecederelapsesbyfourtoeightweeks.Thesestudiessuggestthatserumlightchainsmaybeusedtoindicateanimpendingflare.Here,wedescribeanunusualcaseofSLEwhosepresentingsymptomwasseveremyositisandwasfoundtohaveelevatedserumandurinefreelightchains.


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Poster#30

Presenter:BernardTawfik

Authors:BernardTawfikMD,SeemaJabarMD,BarbaraHaleyMD

Title:RefractoryThrombocytopeniaDuetoHLASpecificAntigens

Abstract:HistoryofPresentIllness:61-year-oldCaucasianwomanwithhistoryofBRCA2+breastcancer1994s/plumpectomy,chemotherapyandCD34+selectedAutologousStemCellTransplant(ASCT)whopresentswithrefractorythrombocytopenia.AfterASCT,thepatientrecallsbeingtransfusiondependentforoneyearwithpersistentpancytopeniasincethattime.Previouslyseenbybenignhematology5yearspriorwithbonemarrowbiopsyshowingnormocellulartrilineagehematopoiesiswith50-60%cellularity.Atthetimeofpresentation,sheisactivelyundergoingtreatmentforrecentlydiagnosedp16+analSCCwithdosereducedMitomycinC/CapecitabinewithconcurrentXRT.Shebegantohavesevereanemiaandthrombocytopeniarefractorytoplatelet(plt)transfusions.ShelastreceivedMitomycinC18dayspriortoadmission,ceasedCapecitabine11dayspriorandreceivedXRT1dayprior.Shehadnosignificantepisodesofbleeding.Shewassentfromclinicafterherplateletcountof5,000onlyroseto10,000afteroneunitplatelets.HospitalCourse:Patientscorrectedcountincrement(CCI)wascalculatedas~3,000indicatinganinappropriatelylowplateletresponse.Apltantibodyscreenwassentandfurthertypespecificpltswereadministeredbutshecontinuedtoberefractory.Bonemarrowbiopsywasobtainedwhichshowedprofoundlyhypocellularmarrow(5-10%)withtrilineagehypoplasiawithoutanymalignancy.PltantibodyscreenresultsreturnedpositiveandHLAtypingonthepatientwasperformed.InitialHLAmatchedplts(B1U1X:4outof6antigensmatch,1homozygousallele,1crossreactiveantigen)continuedtoshowaninadequateresponse.TypicallythismatchwouldbeappropriatesofurthertestingforHLAantigenantibodieswereorderedtodeterminetheantigenspecificantibodies.Oncedetermined,thenextHLAmatchedunitwasstillB1U1X;however,itwasnegativefortheseantigens.Afterthisplttransfusion,thepltcountincreasedfrom7,000to45,000whichshemaintainedfortwodays.Shewasgiventhe2ndbagofplateletsfromthissamedonorandhadasimilarresponseof15,000pltsto56,000plts.Discussion:• CD34+selectedASCToftenresultedinsuboptimaldepositionofstemcellsand

significantresultantpancytopenia• mitomycinCalkylatesDNAtoproduceDNAcross-linkingandpatientswithBRCA

mutationmaybeunabletorepairthesecrosslinksasBRCAisaDNAdoublestrandbreakrepairprotein

• TheabovetwofactorsincombinationwithcapecitabineandXRTlikelyexplainstheseveremyelosuppression

• HeavilytransfusedpatientscandeveloppltantibodiestoHLAandHPA-1AandmayneedHLAmatchedand/ortestingforantigenspecificantibodies(Figure2)


34

Poster#31

Presenter:ElizabethMcGehee

Authors:ElizabethMcGeheeMD,JoanReischPhD,DavidGerberMD,JonathanDowellMD

Title:Treatmentandoutcomesofprimarypericardialmesothelioma:asystematicreview

Abstract:Purpose:Primarypericardialmesothelioma(PPM)isararecancer,forwhichthereisnoconsensusontreatment.WeperformedaretrospectivesystematicreviewofrecentlypublishedPPMcasestocharacterizeriskfactors,treatmentpatterns,andclinicaloutcomes.

Methods:Publishedliteraturefrom2000-2016wassearchedusingtheterms'primarypericardialmesothelioma','pericardialmesothelioma'and'malignantpericardialmesothelioma'.T-tests,Chi-square,andmultivariablestepwiselogisticregressionwereemployedtocorrelatedemographics,diseasecharacteristics,andtreatmentwithmortality.

Results:Weidentified6caseseriesand84casereportsforatotalof103PPMcases.Medianageatdiagnosiswas55;agerangewas19to87.39%werefemaleand61%weremale.Themeantimefromdiagnosistodeathwas5.6months.Tobaccoexposureandasbestosexposurewerereportedin15%and25%,respectively.Neitherexposurewaspredictiveofmortality.46%ofpatientsunderwentsurgery,8%receivedradiation,37%receivedchemotherapyand23%receivednotreatment.For13%ofpatients,thetreatmentreceived,ifany,wasunknown.Radiationtreatmentwasnotassociatedwithamortalitybenefit(p=0.54).Overall,surgerydidnotprovideamortalitybenefit(p=0.13).Whilepericardiectomyalonewasnotassociatedwithamortalitybenefit(20%aliveatlastfollow-up,p=0.77),patientswhoreceivedmassresectionwithorwithoutpericardiectomydidhaveastatisticallysignificantsurvivalbenefit(47%aliveatlastfollow-up,p=0.0047).Amortalitybenefitwasnotedinthosewhoreceivedchemotherapy(p=0.0022),specificallypemetrexed(p=0.0038)orplatinumagents(p=0.003).Gemcitabinewasnotassociatedwithamortalitybenefit(p=0.101).

Conclusion:Totheauthors'knowledge,thisisthefirstcomprehensiveanalysisofpublishedPPMcasesinthemodernera.Inthisretrospectivesystematicreview,amortalitybenefitwasseenwithtumorresectionandchemotherapy.Selectionbiasmayaccountforsomeofthiseffect.However,giventheinabilitytoperformprospectivestudiesinthispopulationduetosmallpatientnumbers,itseemsreasonabletooffersurgicalandmedicaltherapytoeligiblepatientswithPPM.


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Poster#32

Presenter:JosephWang

Authors:JosephWangMD,RebeccaVigenMD,MSCS,ChristopherClark,SandeepDasMD,MPH

Title:TheAssociationbetweenMedicationAdherenceandTimeinTherapeuticRange(TTR)amongpatientswithAtrialFibrillationtreatedwithWarfarin:LessonsfromtheParklandHealthandHospitalSystem

Abstract:Background:Timeintherapeuticrange(TTR)impactsthetreatmentbenefitofwarfarinrequiringatleastTTR>65%.Noveloralanticoagulants(NOACs)arenon-inferiororsuperiortowarfarinanddonotrequiremaintaininganarrowtherapeuticwindow.AtransitionfromwarfarintoNOACshasbeensuggestedtoimprovereal-worldeffectivenessofanticoagulation.However,totheextentthatlowTTRsimplyreflectsnon-adherence,switchingtoNOACswithoutexplicitlyconsideringadherencemaynotimproveoutcomes.ThegoalofthisstudywastoexamineTTRinasafety-nethospitalanddeterminepredictorsofreducedTTR.

Methods:WequeriedtheParklandHealthandHospitalSystemelectronicmedicalrecordforallpatientsfromJanuary2010to2016withadiagnosisofatrialfibrillationorflutteronEKGwhowereonwarfarinandhadINRresultsavailableduringthestudyperiod.TTRwascalculatedusingtheRosendaalmethod.PatientsweregroupedintoTTRquartiles.Adherencetowarfarinwasdefinedbytheproportionofdayscoveredtothemedication(0-100%).MultivariablelinearregressionmodelingwasusedtoassesstheassociationsbetweenTTRwithdemographicfactors,comorbidconditions,andadherence.

Results:Atotalof2,626patientswereincludedintheanalysis.TherewassignificantvariabilityintheTTRwiththemedianTTRof50%andIQRof31-66.Youngerage,blackrace,alcoholanddrugusehistory,useofantiplateletmedications,andsystolicbloodpressure>160wasassociatedwithhavingTTRinthelowestquartile(<31%)aftermultivariableadjustment.MedicarestatuswasassociatedwithalowerlikelihoodofbeinginthelowestquartileofTTR.Finally,loweradherencewasassociatedwithanincreasedlikelihoodofbeinginthelowestquartileofTTR.

Conclusions:TTRonwarfarininthisunderservedpopulationissuboptimal.SinceTTRisinfluencedbyadherencetowarfarin,weneedtobeawareofthepotentialimpactofnon-adherenceonpreventingstroke.AlthoughitispossiblethatNOACswouldhavegreaterease-of-useandthereforehigheradherencethanwarfarin,NOACslacktwoimportantfeedbackmechanismswhencomparedwithwarfarin:theINRandfrequentanticoagulationclinicvisits.WeneedtohavemechanismsinplacetomonitorandoptimizeNOACadherenceinordertomakesurethetransitionfromwarfarintoNOACsisassafeaspossible.


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Poster#33

Presenter:MeredithGreer

Authors:MeredithGreerMD,FrankHannallahMD

Title:SevereCoarctationoftheAortainanAsymptomaticAdult,AnIncidentalDiscovery

Abstract:Coarctationoftheaortaaccountsfor5-8%ofallcongenitalheartdefectsandisassociatedwithabicuspidaorticvalvein30-66%ofpatients.Presentationisusuallyduringchildhoodandwithoutcorrectioncanresultinheartfailureandstrokewiththeaverageageofdeathbeing30-40yearsold.Wepresentacaseofa39-year-oldHispanicmalewhowasincidentallyfoundtohavecoarctationofhisaortaalongwithabicuspidaorticvalvewithminimalcomplications-ararepresentationofthiswellknownanomaly.

Ourpatientpresentedforalteredmentalstatusandwasfoundtobehypertensive,tachycardic,andintoxicated-consistentwithalcoholwithdrawal.Hewasadmittedtotheintensivecareunitforalorazepamdrip.Althoughhismentationandheartrateimproved,heremainedhypertensivedespiteincreasingdosesoflorazepam.Armandlegbloodpressureswerecomparedrevealingadifferenceinsystolicpressuresof60mmHg.Closerexaminationofpulsesrevealedaradio-femoraldelay.Chestx-rayshowedthe'configurationofthree'signaswellasribnotching.CTangiographyaortawasperformedwithnearcompleteobliterationoftheaorticlumenattheleveloftheductusarteriosumandmultiplechestwall,abdominalwallandmediastinalcollateralvessels.Echocardiographyshowedabicuspidaorticvalve,butintactsystolicbiventricularfunction.Interestingly,ondiscussionwiththefamily,themotherendorsedahistoryofchildhoodmurmurandfatigueonexertion.Therewasnohistoryofstroke,chestpain,claudication,orsyncopalepisodes.

Theaveragelifeexpectancyforpatientswithcoarctationoftheaortaisabout30years.Whileourpatienthasarelativelycommoncongenitalmalformation,hispresentationwithminimalhistoricalsymptomstosuggestaorticcoarctationbynearlythefifthdecadeoflifemakeshiscaseveryunusual.Littleseemstobeknownaboutwhethertheminimallysymptomaticadultbenefitsmorefromconservativeversusinvasivecorrectivemeasures.Giventherelativelybenigncomplicationsofourpatient'saorticcoarctationdespitehisage,hemayrepresentauniquepatientpopulationthatbenefitsmostfromconservativemanagement.OurpatientachievedbloodpressurecontrolonACEinhibitoraloneandisawaitingcardiaccatheterizationforfurtherdelineationofhisanatomyatwhichpointhiscandidacyforstentingversusaorticbypasssurgicalrepairwillbeconsidered.Thiscaseemphasizestheimportancethatotherwiseinconsistentsignsandsymptomsdeservemoreelaborateetiologicconsiderations-suchassecondaryhypertensioncausesinanotherwisehealthypatientsuchasours.


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Poster#34

Presenter:BenjaminNanes

Authors:BenjaminA.NanesMD,PhD,BenjaminF.ChongMD,MSCS

Title:Predictorsofclinicalresponseincutaneouslupus:AlongitudinalstudyfromtheUTSWCutaneousLupusRegistry

Abstract:Whileabroadrangeoftherapiesareavailableforpatientswithcutaneouslupuserythematosus(CLE),theresponsetotreatmentofindividualpatientsisdifficulttopredict.Toidentifypatientfactorsassociatedwithclinicalresponse,weanalyzedprospectivelongitudinaldatafrompatientswithCLEenrolledintheUTSWCutaneousLupusRegistry.Thesedataincludedemographics,diseasehistory,medicationhistory,smokinghistory,anddiseaseseverityscoressuchasCutaneousLupusActivityandSeverityIndex(CLASI).PatientswithbaselineCLASIactivityscore≥5and≥2studyvisitswereincludedintheanalysis.WedesignatedtwoclinicalresponseendpointsbasedonrelativedecreaseinCLASIactivityscoreof≥50%and≥75%onconsecutivevisits.Univariateandmultivariatelogisticregressionmodelsidentifiedpatientfactorsassociatedwithclinicalresponse.71patientswith129visit-pairsbetween7/2009and2/2017wereanalyzed.Atthe≥50%CLASIactivityreductionendpoint,higherinitialCLASIactivity(OR1.1/CLASIpoint(95%CI:1.02-1.19),p=0.01)andolderageofCLEdevelopment(1.04/year(1.00-1.07),p=0.04)wereassociatedwithhigherresponserates,whilebaselineuseofsteroid-sparingimmunosuppressants(0.29(0.1-0.86),p=0.03)wasassociatedwithlowerresponserates.Atthe≥75%CLASIactivityreductionendpoint,predominanceofsubacuteCLElesions(4.72(1.33-16.78),p=0.02)wasassociatedwithhigherresponserates,whilecurrentsmokinguse(0.19(0.04-0.86),p=0.03)wasassociatedwithlowerresponserates.Morestudyvisitsarenecessarytoperformsub-analysesofdifferenttreatmentmodalities.Thiswillhelpformulateevidence-basedguidelinesforCLEtreatmentladdersandestablishpatientinclusioncriteriaforclinicaltrials.


38

Poster#35

Presenter:AnuargMehta

Authors:AnuragMehtaMD,ParagH.JoshiMD,ColbyR.AyersMS,KhurramNasirMD,JarrettD.BerryMD,MS,AnandRohatgiMD,AmitKheraMD

Title:CoronaryarterycalciumzerowarrantyvariesbyASCVDrisk:insightsfromtheDallasHeartStudy

Abstract:Introduction:Absenceofcoronaryarterycalciumisassociatedwithfavorablecardiovascularoutcomesandcanbeusefulfordown-classifyingriskinasymptomaticindividuals.IdentifyingpredictorsofincidentCACcanhelpinformthosethatmayneedheightenedsurveillance.

Objectives:Toassesstheassociationbetweenpredicted10-yearatheroscleroticcardiovasculardisease(ASCVD)riskandincidentCACamongparticipantsofayoung,multi-ethnic,population-basedcohortwithbaselinezeroCACscore.

Methods:ParticipantsoftheDallasHeartStudy(DHS)underwentrepeatCACscanningatamedianintervalof6.7years.ParticipantswithbaselinezeroCACscorewereincluded,andthosewithclinicalASCVDoronstatinswereexcluded.IncidentCACwasanalyzedasCAC>0andCAC>10AUatfollowup.Ten-yearASCVDriskwascalculatedusingthe2013AHA/ACCpooledcohortequations.

Results:BaselinezeroCACscorewasfoundin756DHSparticipantsmeetingexclusioncriteria,withameanageof42years,34%men,and42%blacks.Amongtheseindividuals,incidentCACoccurredin23.8%usingCAC>0andin8.3%usingCAC>10AU.RiskmarkersassociatedwithincidentCAC>0includedbaseline10-yearASCVDrisk,BMI,andtriglyceridelevels;whileonly10-yearASCVDriskwasassociatedwithincidentCAC>10AU.Ten-yearASCVDrisk≤7.5%wasassociatedwithhigheroddsofdevelopingincidentCAC>0and>10AUinfullyadjustedlogisticregressionmodels(adjustedoddsratio2.7[95%C.I.1.3-5.4]and3.8[95%C.I.1.6-8.9],respectively).

Conclusions:Inthisyoungcohort,oneinfourindividualswithbaselinezeroCACscoredevelopedincidentCACafter6.7years.Reassessingrisk,includingconsiderationofrepeatCACmeasurementinthosewithhigherbaseline10-yearASCVDrisk,maybewarranted.


39

Poster#36

Presenter:AnuragMehta

Authors:AnuragMehtaMD,JaideepPatelMD,MahmoudA.RifaiMD,MPH,ColbyAyersMS,IanJ.NeelandMD,AlkaM.KanayaMD,NamrathaKandulaMDMPH,MichaelJ.BlahaMD,MPH,KhurramNasirMD,MPH,RogerS.BlumenthalMD,ParagH.JoshiMD,MHS

Title:InflammationandCoronaryArteryCalcificationinSouthAsians:TheMediatorsofAtherosclerosisinSouthAsiansLivinginAmerica(MASALA)study

Abstract:Introduction:Inflammatorybiomarkersandadipocytokines(IBA)maycontributetoatherosclerosisbypromotingvascularinflammation.TheassociationbetweenIBAandcoronaryarterycalcium(CAC),amarkerofsubclinicalatherosclerosisandpredictorofincidentatheroscleroticcardiovasculardisease(ASCVD),isnotwelldefinedinSouthAsians(SA).

Hypothesis:IBA(highsensitivityC-reactiveprotein[hsCRP],tumornecrosisfactoralpha[TNF-α]adiponectin,andleptin)areindependentlyassociatedwithandimprovediscriminationofCACwhenaddedtotraditionalriskfactors(TRF).

Methods:WeanalyzedIBAandCACamong906participantsoftheMASALAstudy.Logisticregressionmodelswereusedtoexaminethecross-sectionalassociationofIBAwithCACpresence(CAC>0)andburden(CAC>100).IBAwerecategorizedasuppertertilevs.lowertwo(hsCRP,TNF-α,leptin)andlowertertilevs.uppertwo(adiponectin).C-statisticswereusedtoassessincrementalcontributionofeachIBAtoelementsofthe2013PooledCohortEquations(PCE)forthediscriminationofCAC.

Results:SAwomenhadsignificantlyhigherlevelsofhsCRP,adiponectin,andleptinbutlowerlevelsofTNF-αthanmen(p<0.01forall).TherewasnosignificantassociationbetweenanyofthefourIBAandeitherCACcategoryinmultivariable-adjustedmodels.Insex-stratifiedanalysis,loweradiponectinlevelsinwomenwereinverselyassociatedwithCACpresence(adjustedOR0.32,95%CI0.13-0.81).NoneoftheIBAimproveddiscriminationofCACpresenceorburdenwhenaddedtoTRF.

Conclusion:IBAwerenotassociatedwithanddidnotimprovediscriminationofCACpresenceorburdenintheoverallSApopulation.TherewasaninverseassociationbetweenlowadiponectinlevelsandCACpresenceamongSAwomen.IBAmaynothelpidentifySAswithahighburdenofsubclinicalatherosclerosis.


40

Poster#37

Presenter:SpencerCarter

Authors:SpencerCarterMD

Title:TBConstrictivePericarditisinanHIVnegativeMale

Abstract:CaseDescription:A34-year-oldformerlyhomelessmalewithnopastmedicalhistorypresentswiththreeweeksofcough,Bsymptoms,andweightloss.Hestatesthathewasfeelingwelluntilthreeweeksagowhenhebegantoexperiencenightlyfevers,sheetdrenchingsweats,acoughproductiveofclearsputum,4pilloworthopnea,15lbsofweightloss,andedematotheankles.

Examwasnotablefortachycardia,feverto39,RR28,diaphoresis,distantheartsounds,bibasilarralesand2+pittingedematothemidshin.Pulsusparodoxuswas20.

Labdatawasremarkableforhyponatremiaat127,nlwhitecount,negativeHIV,cbcwithoutleukocytosis.CXRshowedcardiomegalyandbilateralpleuraleffusions,TTErevealedlargeanteriorpericardialeffusionwithfibrousmaterial.

Emergentpericardiocentesisrevealedserousfluidwith2000nucleatedcellswithalymphocyticpredominance(61%),ADAwasnormalat4.9,AFBsmearreturnednegativex3andMTBPCRalsoreturnednegative.BacterialCultureresultedwithGPCsat24h.Givenconcernforsuppurativepericardialeffusionhewastakenforemergentthoracotomy/sub-totalpericardioectomyandstartedonbroadspectrumantibiotics.Heremainedtachycardicinthe120swithpersistentfeversto39Cforthenextfewdays.GPCsgrewoutascoagnegativestaph.OnHD8pathologyreturnedshowingcaseatinggranulomaswith+stainformycobacterium.HewasstartedonRIPEandsteroidswithdefervescencesoonthereafter.TTEbeforedischargewasconcerningforconstrictivepericarditiswithmedial>laterale’.

Discussion:Thiscaseillustratedseveralimportanttopics1)theprevalenceandriskfactorsforTBinourcommunity,2)therelativeinsensitivityoflaboratorytestingforTBpericardialeffusions,3)thehighprevalenceofconstrictivepericarditisinTBpatientswithpericardialinvolvement,and4)continuedre-evaluationofpatientswhodonotrespondtotreatmentasexpected.


41

Poster#38

Presenter:ShahzadChindhy

Authors:ShahzadChindhyMD,NicholasHendrenMD,KayleeShepherdMD

Title:GramNegativeRodMeningitisduetoStrongyloidesstercoralis

Abstract:A57-year-oldHispanicmalewithahistoryofembryonalsarcomaoftheliverpresentedwithonedayofconfusion,mildheadache,andfevers.HewasdiagnosedwithstageIVembryonalsarcomaoftheliveroneyearpriortoadmissionanddespitecurrenttherapies,hiscancerprogressedwithrecurrentliverlesionsandmetastaticspinaldiseaserequiringpalliativeradiationanddexamethasonetherapy.Ofnote,hewasacitizenofMexicoandlasttraveledtoMexicoin2008.Hisvitalswereunremarkableandexamwasonlypertinentforbaselinerightupperquadrantandbackpain.BloodcultureswerepositiveforEscherichiacoliandalumbarpuncturerevealedE.colimeningitis.Givenhisimmunosuppression,travelhistoryandmeningitis,astoolovaandparasitewasobtainedtoscreenforStrongyloidesstercoralis.HisstoolwasmarkedlypositiveforStrongyloidesstercoralislarvaeandhewasdiagnosedwithStrongyloideshyperinfectionsyndrome.Givenhispoorprognosis,thepatientdeclinedmedicaltherapyandelectedhomehospice.

Strongyloidesstercoralisisaneglectedtropicaldiseasethatnotonlyinfectspeopleindevelopingcountries,butremainsendemicinruralpocketsoftheUnitedStates.OurpatientlikelyhadachronicasymptomaticStrongyloidesinfectionacquiredinMexicothatbecameahyperinfectionafterstartinghighdosesofdexamethasoneforspinalmetastaticdisease.ThisledtobacterialtranslocationresultinginaclassiccaseofGNRinfectionsecondarytoStrongyloideshyperinfection.CliniciansshouldhaveahighlevelofsuspicionforStrongyloidesstercoralisinpatientswithunexplainedGNRinfectionsandahistoryoftraveltoendemicareasoftransmission.Suspicionshouldbefurtherheightenedforpatientsonsteroidsorwithanimmunocompromisedstate.


42

Poster#39

Presenter:JeanneyLew

Authors:JeanneyLewMD,AnandRohatgiMD,MonicaSanghaviMD,MSCS,DarrenK.McGuireMD,MHSc,ColbyR.AyersMS,MariaO.GoreMD,JarettD.BerryMD,MS,AmitKheraMD,MSC,JamesA.deLemosMD

Title:UnderstandingtheVenusandMarsEffect:Sex-BasedDifferencesinCardiovascularBiomarkers

Abstract:Evaluationofcirculatingbiomarkersmayprovidemechanisticinsightintoimportantsex-baseddifferencesincardiovasculardisease(CVD)inthepopulation.Fewdataareavailableinwhichlargepanelsofbiomarkersreflectinguniquebiologicalpathwaysarecomparedbetweenwomenandmen,withcomprehensiveadjustmentfordifferencesinriskfactorsandbodycomposition.

Methods:Across-sectionalanalysiswasperformedusingdatafromtheDallasHeartStudy,amulti-ethnicprobabilitybasedcohortstudy.ParticipantswithexistingCVDwereexcluded.Associationsbetweensexand26biomarkerswereevaluatedusingmultivariablelinearregressionadjustingforage,race,traditionalCVDriskfactors,MRIandDEXAmeasuresofbodycompositionandfatdistribution,renalfunction,insulinresistance,LVmassbyMRI,andmenopausalstatus.

Results:Thestudypopulationincluded3557individuals,meanage43,56%femaleand52%AfricanAmerican.Significantsex-baseddifferenceswereseeninmultiplecategoriesofbiomarkers,includinglipids,adipokines,andbiomarkersofinflammation,endothelialdysfunction,myocyteinjuryandstress,andrenaldysfunction.Infullyadjustedmodels,womenhadhigherlevelsofHDL,leptin,d-dimer,osteoprotegerin(OPG),andNT-proBNPandlowerlevelsoflipoprotein-associatedphospholipaseA2(LP-PLA2),monocytechemoattractantprotein-1(MCP-1),solubleendothelialcelladhesionmolecule(sESAM),symmetricdimethylarginine(SDMA),hs-cTnT,andcystatinc(Table).

Conclution:Evenafteraccountingforsex-baseddifferencesintraditionalriskfactors,bodycompositionandinsulinresistance,importantdifferencesinbiomarkerprofilesexistbetweenwomenandmenwithoutCVDinthepopulation.Futurestudiesareneededtocharacterizewhetherpathophysiologicalprocessesdelineatedbythesebiomarkerscontributetosex-baseddifferencesinthedevelopmentandcomplicationsofCVD.


43

Poster#40

Presenter:OmerMirza

Authors:OmerMirzaMD,CatherineChenMD

Title:ParainfectuousVasculitis:AnUnexpectedComplicationofStreptococcusPneumoniaeMeningitis

Abstract:Parainfectiousvasculitisisadeadlycomplicationthathasbeenreportedinupto30%ofcasesofS.pneumococcusmeningitisdespiteoptimalmedicalmanagement.Wereportacaseofa49-year-oldfemalewithnopriormedicalhistorywhowasadmittedtotheMICUfromanoutsidehospitalwithmeningitis.Thepatientinitiallypresentedtotheoutsidefacilitywithleftearpainforoneweekandheadache,nausea,vomiting,anddizzinessforthreedays.Cerebralspinalfluidstudieswerenotableforglucose<1g,proteinof777,andacloudyappearanceconsistentwithbacterialmeningitis.Shereceivedceftriaxoneandlinezolid,thenwastransferredtoParklandMemorialHospitalforfurthermanagement.

FollowingarrivaltoParkland,ceftriaxonewascontinuedandafour-daycourseofdexamethasonewasstarted.CulturesgrewS.pneumococcussensitivetoceftriaxone.Thepatientinitiallyimprovedandbyhospitalday9shewasabletoparticipateinphysicaltherapy,sowastransferredoutoftheICU.FollowingtransferoutoftheICU,mentalstatusgraduallydeteriorated,soshewasintubatedforairwayprotectionandtransferredbacktotheMICU.Repeatlumbarpunctureshowed1200nucleatedcellswith85%polymorphicnucleatedcells.Cefepime,vancomycin,andmetronidazolewerestarted,butMRIbrainshowednewmultifocalinfarcts.MRAbrainshowedvesselwallthickeningconsistentwithvasculitis.Shewasrestartedonhigh-dosesteroidsbutremainedunarousableoffallsedationanddevelopedhydrocephalus.Followingdiscussionwiththepatient'sfamily,thepatientwastransitionedtocomfortmeasuresanddiedinhospitalday26.

Parainfectiousvasculitishaslongbeenrecognizedasacomplicationofbacterialmeningitisandcauses67%ofischemicinjuriesassociatedwithmeningitis.Pneumococcalautolysiscausesproinflammatorycytokinerelease,resultingindisruptionoftheblood-brainbarrier.Casereportssuggestthatearlyre-initiationofhighdosesteroidsandtheadditionofimmunosuppressivetherapycanhalttheprogressionofparainfectiousvasculitis,althoughneurologicoutcomesremainpoor.Currentlythereisminimalliteratureexaminingtheoutcomesofreinitiatinghighdosesteroidsafterdevelopmentofmeningitis-associatedvasculitis.Thiscaseillustratesthatfurtherresearchisneededinordertoadequatelymanagemeningitis-associatedparainfectiousvasculitis.


44

Poster#41

Presenter:BryanWilner

Authors:BryanR.WilnerMD,ColbyR.AyersMD,IanJ.NeelandMD

Title:IsthereaLinkbetweenFamilyHistoryofCardiometabolicDiseaseandBodyFatProfile?Background:Bodyfatdistributionhasbeenimplicatedinthepathogenesisofcardiovasculardiseases(CVD)anddiabetesmellitus(DMII).Theinfluenceofafamilyhistoryofcardiometabolicdisease,asasurrogateforgeneticrisk,onfatdistributionisunknown.

Methods:ParticipantswithoutCVDorDMIIintheDallasHeartStudyunderwentassessmentoffamilyhistory(CVD,hypertension,DMII,stroke,orheartfailure)byinterviewandbodyfatdistributionbyMRIandDXA.Multivariable-adjustedassociationsbetweenfamilyhistoryandfatprofilewereassessedbylinearregression.

Results:Thestudycohort(n=1,881)hadameanage44yearsandwas54%male,55%AfricanAmerican,withmeanBMI29kg/m2.81%hadoneormorefamilyhistoryfactorsandthemeannumberoffactorswas1.8.Thosewithafamilyhistoryofcardiometabolicdiseasehadhigherbloodpressure,totalcholesterolandLDLcholesterol(p<0.05forall).Aftermultivariableadjustment,afamilyhistoryofDMIIwassignificantlyassociatedwithlesslowerbodyfatbuttherelationshipsoffamilyhistorywithotherfatdepotswerenotsignificant(Table).

Conclusion:Afamilyhistoryofcardiometabolicdiseaseisnotindependentlyassociatedwithfatdistributioninthegeneralpopulation.FamilyhistoryofDMIImaybeassociatedwithlesslowerbodyfat,aprotectivefatdepot.Environmentalfactorsmayplayamoreimportantroleinfatdistribution,suggestingafundamentalroleforlifestylemodificationinthetreatmentofobesity.

Table.Relationshipoffamilyhistoryofcardiometabolicdiseasewithbodyfat Anyfamilyhistoryofcardiometabolic

diseaseFamilyhistoryofDMII

Model1 Model2 Model1 Model2β P-value β P-value β P-value β P-value

Visceraladiposetissue(kg)

0.06 0.01 0.02 0.26 0.06 0.01 0.01 0.36

Subcutaneousadiposetissue(kg)

0.12 <0.0001 0.01 0.46 0.09 <0.0001 0.01 0.24

Lowerbodyfat(kg) 0.10 <0.0001 -0.01 0.51 0.04 0.09 -0.03

0.01

LiverFat(%) 0.06 0.01 0.01 0.55 0.07 0.002 0.04 0.07

Standardizedß-coefficientrepresentstheestimatedunitchangein1-standarddeviationoftheadiposetissueparameterperanyfamilyhistoryofcardiometabolicdiseaseorafamilyhistoryofdiabetesmellitustypeII(DMII).Model1-unadjustedModel2-adjustedforage,sex,race,physicalactivity,smoking,BMI


45

Poster#42

Presenter:TimothyJBrown

Authors:TimothyJ.BrownMD,PraptiA.PatelMD,RobertH.CollinsJr.MD

Title:ClonalimplicationsofmastcellsarcomainapatientwithpriorAML

Abstract:A61-year-oldmalewithahistoryofacutemyeloidleukemia(AML)inremissionpresentedwithabdominalpain.ACToftheabdomenshowedalyticlesioninthepubicramusconcerningformalignancy.Abiopsywasdiagnosticformastcellsarcoma(MCS).AFoundationOnegeneticpanelperformedontheMCSrevealedIDH2andSRSF2mutations,andac-KITmutationsensitivetoimatinib.AFoundationOnepanelperformedretrospectivelyonhispriorAMLshowedaknownFLT3-ITDmutation,aswellasIDH2,andSRSF2mutations.TheMCSandtheAMLsharedidenticalIDH2andSRSF2mutations,implicatingaclonalrelationbetweenthemalignancies.Hereceivedirradiationanddailyimatinibandiswithoutevidenceofdisease21monthsafterdiagnosis.Thisisthe25threportedcaseofmastcellsarcomaandthefirsttobedemonstratedtoberelatedtoanotherneoplasm.


46

Poster#43

Presenter:TimothyJ.Brown

Authors:TimothyJ.BrownMD,DanielaBotaMD,PhD,ElizabethMaherMD,PhD,DawitAregawiMD,LindaM.Liau,PaulD.BrownMD,JanBucknerMD,MichaelWellerMD,MartinJ.vanDenBentMD.PhD,MitchelS.BergerMD,MichaelGlantzMD

Title:Numbersneededtotreatforneurosurgicalinterventionsinlow-gradeglioma-asystematicreviewandstudy-levelmeta-analysis

Abstract:Background:Low-gradegliomas(LGG)accountfor17-22%ofallprimarybraintumors.Optimalsurgicalmanagementconsistsofoptimumsaferesectionwiththegoalofcompleteresection.Weperformedasystematicreviewandmeta-analysistoquantifytheassociationofextentofresectionwithlikelihoodofsurvival,expressingourresultsinnumbersneededtotreat(NNT).

Methods:Asystematicreviewandstudy-levelmeta-analysistodeterminetheassociationofresectionwithoverallsurvivalandprogression-freesurvivalinnewlydiagnosed,supratentorialLGGinadultswasperformedbyqueryingPubMed.Datawereextractedtocomparegrosstotalresection(GTR)tosubtotalresection(STR)andSTRtobiopsy(Bx)todeterminerelativerisks(RR)ofdeathandprogressionat2,5,and10years.Datawereanalyzedusingarandomeffectsmodel.NNTwerecalculatedfromsignificantcomparisonsandroundeduptothenearestwholenumber.QualityofevidencewasdeterminedbyAmericanAcademyofNeurologycriteria.

Results:Thesystematicreviewresultedin283potentialstudies.Ultimately29studieswereincludedinatleastonecomparison.Therewerenohighquality(classIandII)orprospectivestudiesdiscoveredinthereview.ComparingGTRtoSTR,RRwith95%confidenceintervals(CI)ofdeathat2,5,and10years,andNNTtoavoidonedeathat2,5,and10years(GTRvs.STR)were0.29[0.17-0.52,p<0.0001,NNT17],0.39[0.29-0.51,p<0.00001,NNT6],and0.50[0.35-0.70,p<0.0001NNT4].RRandNNTforprogression(GTRvs.STR)at2,5,and10yearswere0.37[0.24-0.57,p<0.0001NNT7],0.50[0.39-0.64,p<0.0001NNT4],and0.67[0.53-0.84,p=0.0005NNT4].ComparingSTRtoBx,RRofdeathat2,5,and10yearswere0.55[0.34-0.88,p=0.01NNT10],0.9[0.61-1.34],and0.95[0.73-1.23].

Conclusions:Increasingresectionthresholdsappeartobeassociatedwithimprovedoverallandprogressionfreesurvival,butthebodyofliteratureconsistsoflowqualitystudies.Prospectivestudiesarerequiredtoexplorewhetherextentofresectionmattersorwhetherresectabletumorsshareafavorablebiologyassociatedwithbetteroutcome.


47

Poster#44

Presenter:ChristinaYek

Authors:ChristinaYekMD,ArjunGuptaMBBS,JulianMcCrearyPharmD,TiffanyKnightPharmD,AllisonStephensonPA,KristinS.AlvarezPharmD,MarkCooperMD

Title:ACaseofPhenytoinToxicity:RootCauseAnalysisandPerformanceImprovement

Abstract:Situation:A64-year-oldmanwithseizuredisorder,chronicobstructivepulmonarydisease(COPD)andtraumaticT4-paraplegiapresentedwithaCOPDexacerbation.Regularmedicationsincludedoralphenytoin300mgoncedaily.Onday3ofhospitalization,thepatientdevelopednystagmusanddystonicmovementsofhisupperextremities.Itwasnotedthatanexcessivedoseofphenytoin(300mgthreetimesdaily)hadbeenerroneouslyprescribed.Serumtotalphenytoinlevelwas68.0mcg/mL(goalrange10-20mcg/mL).Thepatientwasdiagnosedwithiatrogenicphenytoinoverdoseleadingtocentralnervoussystemtoxicity.

Background:Medicationerrorsareubiquitousinthehealthcaresettingandcanleadtoadversedrugeventsincludingincreasedpatientmorbidityandmortality,increasedlengthofhospitalization,andhighercostofcare.Medicationsthatrequireloading,re-dosingand/ormonitoringarecommonlyassociatedwitherror;ofthese,phenytoinisanotoriouscauseofsevereharmandmedication-relatedfatality.

Assessment:Arootcauseanalysiswasperformedtoidentifysystem-basederrorsunderlyingtheevent.Processandtechnologyerrorsidentifiedincludeddelayinverificationofprior-to-admissionmedications,multipleorderentryinterfacesthatpermittedtheprovidertocircumventmedicationreconciliationonadmission,anddefaultingofthecomputerizedphenytoinordertothreetimesdailydosing.

Recommendations/Results:Severalinterventionswereimplementedtocorrectidentifiederrors:first,thephenytoinordersetwasadjustedtodefaulttooncedailydosing;next,educationonphenytoinprescriptionandupdatedreconciliationpracticeswasdevelopedanddisseminatedtohospitalstaff;anewactionwasimplementedallowingforpharmaciststoorderphenytoinlevelswhenclinicallyindicated;finally,quarterlyauditswereinitiatedtoensureuseofcorrecttemplateswhenperformingmedicationhistories.Additionalareasforimprovementattheorganizationallevelwererecognizedandwillrequiretargetedeffortsforfutureimprovementtoreducetheincidenceofmedication-relatedadversedrugeventsinParklandHospital.


48

Poster#45

Presenter:ArjunGupta

Authors:ArjunGuptaMBBS,RaseenTariq,SiddharthSingh,DarrellS.Pardi,SahilKhanna

Title:GastricAcidSuppressionandRecurrentClostridiumdifficileInfection:ASystematicReviewandMeta-Analysis

Abstract:Importance:GastricacidsuppressionhasbeenassociatedwithanincreasedriskofprimaryClostridiumdifficileinfection,buttheriskofrecurrentCdifficileinfectioninpatientstakingacidsuppressionmedicationsisunclear.Objective:Weperformedasystematicreviewandmeta-analysistoevaluatetheassociationbetweenacidsuppressionmedicationsandrecurrentCdifficileinfection.DataSources:WesearchedMEDLINE,Embase,andWebofScienceuptoSeptember2015forstudiesassessingtheassociationbetweengastricacidsuppressionexposureandrecurrentCdifficileinfection.StudySelection:Weincludedcase-controlstudies,cohortstudies,orclinicaltrialsthatincludedpatientswithCdifficileinfectionwhodidanddidnotreceivegastricacidsuppressiontherapyandthatevaluatedforrecurrentCdifficileinfection,withnorestrictiononstudysetting(inpatientoroutpatient).DataExtractionandSynthesis:TheNewcastle-Ottawascalewasusedtoassessthemethodologicqualityofincludedstudies.Datawereindependentlyabstractedtoapredeterminedcollectionformby2investigators.Summaryoddsratioestimateswith95%CIswerecalculatedusingtherandom-effectsmodelandMetaXLversion5.1softwaretocalculatethepooledeffectsizeofstudiesreportingmultivariateanalyses.MainOutcomesandMeasures:WeassessedtheriskofrecurrentinfectioninpatientswithCdifficileinfectionanditsassociationwithgastricacidsuppressionmedicationuse.Results:Sixteenobservationalstudieswereincluded,with1,525casesofrecurrentCdifficileinfectionamong7,703patientswithCdifficileinfection(19.8%).TherateofrecurrentCdifficileinfectioninpatientswithacidsuppressionwas22.1%,comparedwith17.3%inpatientswithoutacidsuppression,whichindicatedanincreasedriskbymeta-analysis(oddsratio,1.52;95%CI,1.20-1.94;P<.001).Therewassignificantheterogeneityamongthestudies,withanI2of64%.SubgroupanalysesofstudiesadjustingforageandpotentialconfoundersconfirmedanincreasedriskofrecurrentCdifficileinfectionwithacidsuppression(oddsratio,1.38;95%CI,1.08-1.76).ConclusionandRelevance:Meta-analysesofexistingobservationalstudiessuggestthatpatientsprescribedacidsuppressionmedicationsmaybeatincreasedriskforrecurrentCdifficileinfection.Thesedatashouldbeinterpretedwithcautionbecausetheymaybeconfoundedduetotheobservationalnatureoftheindividualstudies.Itmaybereasonabletore-evaluatetheneedforthesemedicationsinpatientswithCdifficileinfection.


49

Poster#46


Authors:ArjunGuptaMBBS,TylerStewart,YingDongPhD,ZainRahimi,TonyPaul,KimberliSmith,ChadRethorstPhD,MuhammadS.BegMD

Title:Feasibilityofwearablephysicalactivitymonitorsincancerpatients(PAMCaP)

Abstract:Background:Wearablephysicalactivitymonitors(PAMs)provideadegreeoffunctionalassessmentnotpossiblewithpriorclinicalinstruments.Subjectiveassessmentsoffunctionalstatusarepronetoinaccuracyandcurrentobjectiveassessmenttechniquesarelimitedtotheresearchsetting.Therelevanceofphysicalactivitymonitors(PAMs)tomeasurefunctionalstatusincancerpatientsisunclear.Thefeasibilityofusingthesedevicesincancerpatientsisnotknown.

Methods:ThisisaprospectivepilottrialofacommerciallyavailablePAMincancerpatients.PatientswithEasternCooperativeGroupperformancestatus(ECOGPS)0-2receivingsystemictherapyatanNCIDesignatedComprehensiveCancerCenterwereenrolled.(NCT02583815).TheprimaryobjectivewastodeterminefeasibilityofPAMuse,definedasdeviceuseofmorethan50%ofthestudyobservationperiod.SecondaryobjectivesweretocorrelatePAM-reportedmeasures:median,minimumandmaximumsteps/day,minutesofactivity/day,(light/fairlyactive/veryactive);with1)clinicianassessedECOGPSand2)qualityoflifetoolscores(FACT-G,QIDS,PQSIandBFI).PatientexperiencewithwearablePAMswasassessedattheendofstudy.

Results:Weenrolled32patients:medianage=56years(range23-72),female=67%,andwhite=78%.Mostpatientshadgastrointestinal(52%)andbreast(19%)primaries.ClinicianassessedPSwasECOG0in56%,1in37%and2in7%.Majorityofpatients(81%)mettheprimaryendpoint.MeanPAMmeasuredstepsforECOG0was5911steps/d,ECOG1was1890steps/dandECOG2was845steps/d(p=0.002).Minimumsteps/daycorrelatedwithBFI(r=-0.56,p<.01),FACT-G(r=0.45,p0.01)andQIDS(novsmildvsmoderatedepression,p0.01).Patientsreportedapositiveexperiencewiththedevices(74%).

Conclusions:WearablePAMsareafeasibletooltomeasurephysicalactivityincancerpatientsreceivingsystemictherapy.PAMderivedmeasurescorrelatewithclinicianassessmentsofperformancestatus.FutureworkshoulddevelopmethodstosystematicallyincorporatePAMsinoncologyclinicaltrialsandpractice.


50

Poster#47


Authors:ArjunGuptaMBBS,UdayanShahMD,HtetKhineMD,TravisVandergriffMD,ThomasFroehlichMD

Title:Antiphospholipidsyndromeassociatedwithcombinedimmunecheckpointinhibitortherapy

Abstract:Immunotherapyisfastemergingasaneffectiveanti-neoplastictreatment,alternativetochemotherapyforanumberofmalignancies.Anti-CTLA-4agents(ipilimumab)andanti-PD1agents(nivolumab,pembrolizumab)arealreadyapprovedforuseinmetastaticmelanomaandnon-smallcelllungcancer,andtheiruseisbeinginvestigatedinmultipleothercancers.Combinationtherapyhasbeenshowntobemoreefficaciousthansingleagentimmunecheckpointinhibitortherapy.Incontrasttothedirectactionoftraditionalcytotoxicantineoplasticagents,theseagentsresultinaugmentedhostT-cellimmunityandasustainedimmuneresponseagainsttumorcellsduetolossoftolerance.Thisimmunedysregulationalsoleadstoasystemiclossoftoleranceandhasbeenassociatedwiththedevelopmentofseveralimmune-relatedadverseeffects(irAEs),includingdermatitis,pneumonitis,endocrinopathies,uveitis,hepatitis,myocarditisandcolitis.Combinedimmunotherapyisassociatedwithhigherratesofgrade3-4adverseevents(>50%)andneedfortreatmentdiscontinuationin36.4%patients,andthesearelargelyduetodiarrhea,fatigueandpruritis.


51

Poster#48

Presenter:ChristinaYek

Authors:ChristinaYekMD,NicholasS.HendrenMD,JasonMullMD,JamesB.CutrellMD

Title:DisseminatedHistoplasmosisPresentingasMultipleOralUlcers

Abstract:Background:Oralulcerscanbeaproteanandoftenvexingclinicalpresentationduetolimitedclinicianexposure.Theetiologyoforalulcersrepresentsabroaddifferential,rangingfromisolatedoraldiseasetoseveresystemicdisease.WepresentacaseofunremittingoralulcersinaHIV-infectedpatient.

CaseDescription:A61-year-oldfemalewithahistoryofadvancedHIVdiseaseandchronichepatitisBpresentedwithpainfuloralulcers.Reviewofsystemswasunremarkable.Onadmission,vitalsignswerenormal.Examinationoftheoropharynxrevealedoralthrushandmultipleclean-basedulcersonthetongueandhardpalate.Pulmonary,cardiac,abdominal,neurological,skin,andmusculoskeletalexamswereunremarkable.LaboratoryanalysiswasnotableforCD4T-cellcountof88cells/mL3andtransaminitis.Abiopsyofthetonguelesionswasobtainedthatshowedmultiplehistiocytescontainingintracellularyeastforms,consistentwithadiagnosisofdisseminatedhistoplasmosispresentingasoralulcers.

Discussion:Oralulcersaremostcommonlycausedbymechanicaltrauma.Secondaryulcersmayrepresentinfectiousetiologies(e.g.herpessimplexvirus,cytomegalovirus,coxsackievirus,secondarysyphilis,histoplasmosis),malignancy,andautoimmunedisease(e.g.vasculitis,lichenplanus,pemphigusvulgaris).Giventhebroaddifferential,anyunexplainedoralulcersthatdonotresolvewithintwoweeksshouldbeconsideredforbiopsy.Oralulcersareacommonfeatureofdisseminatedhistoplasmosis,occurringin25-45%ofcases.Othermanifestationsofthediseaseincludepulmonarydisease,hepatosplenomegaly,lymphadenopathy,andskinlesions.Directvisualizationoforganismsinbiopsiedtissueenablesrapidandaccuratediagnosis;alternatively,positivehistoplasmaplasmaand/orurineantigenlevelsaresuggestiveofactiveinfection.First-linetreatmentinvolvesatleast2weeksofliposomalamphotericin3mg/kgdaily,followedbyoralitraconazole(200mgthreetimesdailyfor3days,then200mgtwicedaily)for1year.

Outcome:Thepatientwasstartedonamphotericin,withwhichherorallesionsimprovedsignificantly.Shewassubsequentlydischargedonoralitraconazole.Shecontinuestofollowinclinicandremainsasymptomaticwithnodiseaserecurrencefivemonthsafterdiagnosis.


52

Poster#49

Presenter:NicholasHendren

Authors:NicholasS.HendrenMD,TimothyJ.BrownMD,ThalvinderSanghaMD

Title:AnEverlastingAppetite:Insulinoma-InducedHypoglycemia

Abstract:A53-year-oldwomanpresentedwithtwoyearsofworseningepisodictremors,sweating,weightgainandconfusionthatrapidlyimprovedwithjuice(Whipple'striad).Thisledtonearlyconstantsnacking.Labsrevealedelevatedlevelsofseruminsulin,serumproinsulinandserumC-peptide.Computedtomography(CT)oftheabdomenrevealedapancreatictailmassandnumerousmassesintheliverconsistentwithmalignancy.Aliverbiopsydemonstratedawell-differentiatedneuroendocrinetumor.Givenhersymptoms,anelevatedendogenousinsulinlevelandabdominalmasses,shewasdiagnosedwithametastaticinsulinoma.Theburdenofherdiseaseprecludedsurgicalmanagement,necessitatingmedicalmanagement.Herbloodglucoseswereinitiallystabilizedwithsubcutaneousoctreotideinjectionsanddiazoxidetablets.Atendocrinologyfollow-up,shewastransitionedtomonotherapywithpasireotidelong-actingrelease60mgsubcutaneousmonthlyinjectionswhichprovidedsustainedcontrolofherbloodsugarsatclinicalfollow-up.

Insulinoma-inducedhypoglycemiaisarare,butimportantconditionthatshouldbeconsideredinthedifferentialofhypoglycemiathatisreadilyidentifiedclassicallybyWhipple'striad.Curativetreatmentofthesetumorsisusuallysurgical,withlimitedmedicaltherapyavailableforthosewhoarenotsurgicalcandidates.Insulinoma-inducedhypoglycemiatreatedwithlong-actingpasireotidehasrarelybeendescribedintheliterature.Ourcasedemonstratesacaseofsymptomatichypoglycemiamanagedwithmonthlypasireotideinjections.Thisclinicalcasesupportsfurtherinvestigationofpasireotideformanagementofsymptomatichypoglycemiaduetoaninsulinoma.


53

Poster#50


Authors:NicholasHendrenMD,SenthilSukumarMD,CraigGlazerMD

Title:Vibriovulnificussepsisduetoacontaminatedtattoo

Abstract:WepresentacaseofVibriovulnificussepsisandcellulitisinapatientwithchronicliverdiseasethatoccurredafterobtainingalegtattoowithsubsequentseawaterexposureintheGulfofMexico.InitialsuspicionforVibriovulnificuswashighandhewasstartedonempiricdoxycyclineandceftriaxoneatadmission.BloodandwoundculturesgrewoxidasepositiveandcommashapedgramnegativerodsultimatelyconfirmedtobeVibriovulnificus.Despiteaggressiveinitialtreatmentthepatientdevelopedsepticshockanddied.ThiscasehighlightstheassociationofchronicliverdiseaseandhighmortalityassociatedwithinfectionsofVibriovulnificus.

Vibriovulnificusisclassicallyassociatedwithsepsisandbullousskinlesionsinpatientswithchronicliverdiseaseafterexposuretoseawateroringestionofrawoysters.Healthypatientsappeartoaccountfor<5%ofallreportedcasesofVibriovulnificussepsisintheUnitedStates.Allpatientswithchronicliverdiseaseandhemochromatosisshouldbeinstructedtoavoidrawoysteringestionandavoidswimminginseawaterwithopenskinwounds.Ahighindexofsuspicionisimperativeasempirictreatmentwithdoxycyclineisnotroutinelyinitiatedforsepsis.TheCDCrecommendsdualtreatmentwithdoxycyclineandathirdgenerationcephalosporinfor7-14daysinadditiontosurgicaldebridementforsofttissueinfections.Symptomscanrapidlyprogresstosepticshockduringthefirsttwelvehoursofpresentationwhichrepresentsaverypoorprognosis.ThemortalityrateforsepsisduetoVibriovulnificusishighwithreportedratesof50-60%inallpatients.Insum,healthprovidersshouldremainvigilantforVibriovulnificusinfectionsinpatientswithchronicliverdiseaseandrawoysteringestionorseawaterexposure.


54

Poster#51


Authors:NicholasS.HendrenMD,JosephA.MooreMD,SeemaJabbarMD,SiayarehRamballyMD

Title:AcuteHepatitisBAssociatedAplasticAnemia

Abstract:Hepatitis-associatedaplasticanemiaisararevariantofaplasticanemiainwhichbonemarrowfailurefollowsanacuteepisodeofhepatitis.Mostepisodesofhepatitisprecedingaplasticanemiaarecausedbynon-hepatitisBandCviruses.Apreviouslyhealthy44-year-oldwomanpresentedwiththreedaysofworseningpetechialrash,epistaxis,malaiseandfatigue.Skinexamwasnotablefornon-blanching,non-palpablepetechialrashinvolvingthepalate,torsoandextremities.Admissionlabsrevealedpancytopeniawithreticulocytopeniaandelevatedliverenzymetestswithahepatocellularinjurypattern.HepatitisBsurfaceantigenandantibodytestswereconsistentwithacutehepatitisBvirus(HBV)infection.HBVpolymerasechainreactionreturnedwith>170millionIU/mLconfirmingthediagnosisofacutehepatitisBinfection.Aperipheralbloodsmearconfirmedpancytopeniawithoutovertdysplasiaorblasts.Bonemarrowbiopsydemonstratedaprofoundlyhypocellularbonemarrowconsistentwithaplasticanemia.Assuch,shewasdiagnosedwithhepatitis-associatedaplasticanemiaduetoacuteHBVinfection.OurpatientwasstartedontenofovirfortheHBVinfection,aswellasimmunosuppressivetherapywithanti-thymocyteglobulin(ATG)andcyclosporinefortheaplasticanemia.Shehadarapidcompletehematologicresponseandremainsonmaintenanceimmunosuppressionwithcyclosporine.Insum,aplasticanemiaisarareconditiondefinedbypancytopeniawithhypocellularbonemarrowreplacedwithadiposetissueandtheabsenceofmyelodysplasia.Hepatitis-associatedaplasticanemiaisararevariantofaplasticanemiainwhichbonemarrowfailurefollowsanacuteboutofhepatitis.AplasticanemiacomplicatingacutehepatitisBinfectionisextremelyuncommon.Tothebestofourknowledge,onlyfiveothercaseshavebeenreported,allbutonepriortotheavailabilityofhepatitisBantiviralmedications.WereportacaseofacutehepatitisBassociatedaplasticanemiasuccessfullytreatedwithacombinationofantiviralmedicationforhepatitisBandimmunosuppressivetherapyforaplasticanemia.


55

Poster#52

Presenter:SarojaBangaru

Authors:SarojaBangaruMD,DwainThieleMD,JayaprakashSreenarasimhaiahMD,DeepakAgrawalMD

Title:MarkedElevationofTransaminasesandBilirubininCholedocholithiasis

Abstract:Background:Choledocholithiasisistypicallyassociatedwithmildtomoderateelevationsinlivertests(LFTs).However,veryhighserumlevelsofalanineaminotransferase(ALT)andaspartateaminotransferase(AST)havebeenreportedinsmallcaseseries.Ourstudyaimedtodescribetheincidenceoftransaminases>1000U/Landtotalbilirubin>10mg/dlinpatientswithcholedocholithiasis.

Methods:AretrospectivechartreviewwasperformedofpatientsundergoingERCPforcholedocholithiasisatourtertiaryreferralhospitalfromJuly2007toJune2014.Thefollowinginformationwascollected:demographicinformation,findingsofabdominalultrasound,CTandMRI,andLFTsatvariouspointsduringadmission.Patientswithpre-proceduralASTand/orALT>1000U/Lortotalbilirubin>10mg/dLwereidentified.Patientswithbiliarystrictureduetoanycause,hepatobiliaryorpancreaticmalignancy,andactiveviralhepatitiswereexcluded.

Results:CholedocholithiasiswaspresentonERCPin740patients.Ofthese,45patients(6.1%)hadpre-proceduralASTorALT>1000and35patients(4.7%)hadpre-proceduraltotalbilirubin>10mg/dl.AST,ALTandbilirubindecreaseddramaticallyin1-10days,inallpatientsafterERCP.ThemeandecreaseinASTwas79%+/-3%,ALT56%+/-3%andbilirubin64%+/-4%.Only1patienthadbothALT>1000U/Landtotalbilirubin>10mg/dL.Comparedtogroupwithelevatedbilirubin,thegroupwithelevatedtransaminaseshadsignificantlymorefemales(93%vs.43%),hadsmallerCBD(8.5mmvs.10.6mm)andmorelikelytohavehadcholecystectomy(40%vs.14%).Therewasnosignificantdifferenceinincidenceoffattyliver,hepatomegaly,LDHlevelandracialdistribution.MostpatientswithdramaticelevationsinLFTsunderwentextratests:36patientshadachronicliverdiseasework-up,22patientshadCTorMRIscansandhepatologywasconsultedin6patients.Theaveragelengthofhospitalizationforthesepatientswas5.4+/-0.5days,whichwassignificantlymorecomparedtootherpatientswithcholedocholithiasis.

Conclusion:Veryhightransaminasesandbilirubincanbeseeninupto11%ofpatientswithcholedocholithiasisbuttheyalwaysdecreaserapidly.Awarenessofthiscandecreaseunnecessarywork-uptolookforothercausesofelevatedlivertestsinthesepatients.


56

Poster#53

Presenter:SarojaBangaru

Authors:SarojaBangaruMD,AmandaStricklandMD,StephenDicksonMD,NaineshShahMD

Title:AnElusiveDiagnosisRevealedwithDeath

Abstract:Case:A45-year-oldmanwithahistoryofAIDS(CD434)whorecentlyre-startedantiretroviraltherapyafterprolongednoncompliancepresentedwithfever(40C),diarrheaandwasadmittedforsepticshock.Hislabworkwasnotableforhemoglobin7.9,leukocytecount3.6,platelets126,andferritin2500.Infectiouswork-upincludingbacterial,fungal,andacidfastbacillibloodcultures;sputum,urine,andstoolstudies;andcytomegalovirus(CMV)PCRwasnegative.Heimprovedinitiallywithfluids,empiricantibiotics,andsteroidsbuthisshockrecurredtwoweekslaterandwasassociatedwithrapidlyprogressivesomnolenceandtransfusion-dependentcytopenias.Amoreextensivework-upwasnegativeforEBV,disseminatedHSV,parvovirus,HHV6,tuberculosis,disseminatedhistoplasmosis,cryptococcus,brucellosis,andbartonella.Computedtomographyofchest,abdomen,andpelvisrevealedhepatosplenomegalyanddiffuselymphadenopathy.Hewasstartedonempirictreatmentfordisseminatedmycobacteriumavium-intracellulare.Hemophagocyticlymphohistiocytosis(HLH)wasconsideredgivenpersistentfever,splenomegaly,lowfibrinogen(106mg/dL),highferritin(7125ng/mL),andseverelyelevatedIL-2receptorlevel(18,890pg/mL(normal=<1033).BonemarrowbiopsydidnotshowhemophagocytosisbutwasunabletoruleoutHLH,sohigh-dosedexamethasonewasinitiatedtotreatHLH.Thepatientdidnotimprove,though,andhisfamilyelectedforcomfortcare.Hediedtwodayslater.Postmortemexamviaautopsyrevealedprofoundhemophagocytosisinthebonemarrow,spleenandlymphnodes,affirmingadiagnosisofHLH.ItalsodemonstratedpulmonaryKaposi'ssarcoma(KS)withscatteredHHV-8positivecells.HHV-8serumPCRresulted210,000DNAcopies/mL.ThepostmortemdiagnosiswasHLHsecondarytoHHV-8andassociatedKSinthesettingofadvancedAIDS.Impact:ThiscasebringstoattentionHLH,ararehematologicdiagnosisthatshouldbeontheinternist'searlydifferentialforadecompensatingpatientwithpoorlycontrolledAIDS.Thispatient'sdiagnosisaddstoonlyafewreportedcasesofHHV8-associatedHLHintheHIVpopulationDiscussion:InHIV/AIDSpatients,HLHisunderstoodtobedrivenbyanunderlyinginfectionormalignancy.ThemainstayofmanagementofsecondaryHLHistreatmentoftheunderlyingcause,butpatientswithHHV-8-associatedHLHhavebenefitedfromsteroids/chemotherapyperHLHtreatmentprotocol.Autopsyrateshavedeclinedmorethan50percentover4decades,butinourcase,HHV-8positivity,KS,andHLHwereallpostmortemdiagnoses,illustratingthepowerofautopsytoprovidediagnosesthatarecomplicatedandcanevadeclinicalevaluation.Thusitmaintainsvalueinmodernclinicalmedicine.Asprovidersofendoflifecareandinanefforttoadvancemedicalknowledge,itisimperativeforinterniststodiscussautopsywithpatientsandfamilies.


57

Poster#54

Presenter:WallyOmar

Authors:WallyOmarMD,AmbarishPandeyMD,RohanKheraMD,AkhilParashar,MD

Title:ImplantableCardioverterDefibrillatorsforthePreventionofMortalityinPatientswithNon-ischemicCardiomyopathy:AMeta-analysisofRandomizedControlledTrials

Abstract:Background:WhileICDtherapyimprovessurvivalinheartfailurepatientswithischemiccardiomyopathy,itsusefulnessinthosewithnon-ischemiccardiomyopathy(NICM)islesswellestablished.WesoughttodeterminewhetherICDtherapyreducesall-causemortalityinpatientswithNICMusingupdatedmedicalliteraturebyperformingastudylevelmeta-analysis.

Methods:Acomprehensivecomputerizedliteraturesearchofmedicaldatabaseswasconducted.Randomizedcontrolledtrials(RCT)forprimarypreventionwereincludedinthefinalanalysistominimizeheterogeneityandobtainrobustpooledestimates.Primaryefficacyoutcomewasall-causemortalityamongpatientswithNICMrandomizedtoICDversusoptimaltherapyinprimarypreventionstudies.Weusedrandomeffectsmodelingtoconductameta-analysisoftheprimaryoutcomefromincludedstudies.

Results:Sixstudieswithenrolling2970NICMpatientswereidentified.Thepooledanalysisrevealedasignificantreductioninall-causemortality(figure1)amongpatientsrandomizedtoICDversusoptimaltherapywithoutICD(riskratio:0.79;95%confidenceinterval:0.66-0.91;P=0.003).Inmeta-regressionanalysis,therewasnoassociationbetweenproportionaluseofbeta-blockersorACE-inhibitorsandrisk-reductionwithICDuse.

Conclusion:ICDtherapysignificantlyreducesmortalityinpatientswithNICMinthepooledanalysisofprimarypreventionrandomizedtrials.


58

Poster#55

Presenter:WallyOmar

Authors:WallyOmarMD,SatyamSarmaMD,ErinHowdenPhD,BenjaminD.LevineMD

Title:TheEffectofHighIntensityAerobicExerciseTrainingoverTwoYearsonBiologicAorticAge

Abstract:Introduction:Lifelongexercisetrainingmaintainsyouthfulcomplianceofthecentralarteries.Theexactmechanismbywhichlifelongaerobicfitnessconferscardiovascularbenefitisunknown.Aorticage,ameasureoftheintrinsicstiffeningofthecentralarteries,isonemeansbywhichchangesinarterialfunctioncanbequantified.Priortrainingstudiesinseniorshaveshownminimalimprovementinbiologicaorticage.Middleagemayrepresentalifeperiodinwhichvascularplasticitystillexists..Wehypothesizedaorticagewoulddecreaseaftera2-yearhighintensityaerobictrainingprogram(HIAT)inpreviouslysedentarymiddleageadults.

Methods:Sixtyonesedentary,healthymiddle-agedsubjectswererandomizedtoeitheryogaorHIAT(2-3moderateaerobicexercisesessions/weekand1-2'4x4'aerobicintervalsessions/week)for2years.Foursubjectsintheyogagroupand5intheexercisegroupwithdrewpriortocompletionofthestudy.Aorticagewasnotanalyzablein2subjects.AorticagewascalculatedfromModelflowreconstructionofthefingerbloodpressurewaveform(BMEYE)andstrokevolume(acetyleneforeigngasrebreathingmethod)atbaselineandpost-intervention.

Results:AdherencetoprescribedexercisesessionsintheHATgroupover2yearswas90%.After2years,aorticageincreasedwithameanof5.7yearsintheyogagroup,andremainedrelativelyunchangedintheHATgroup(p<0.19)

Conclusions:Highintensityaerobictrainingover2yearsslowedbutdidnotsignificantlydecreaseaorticageinsedentaryadults.Theseresultssuggestthatwhilereversalmaynotbeachievedwithexercise,retardingfurtheraorticagingmaybepossible.


59

Poster#56

Presenter:WallyOmar

Authors:WallyOmarMD,JosephWangMD,ShahAliMD

Title:WhenEosinophilsAttack:ARareCaseofLoefflerEndocarditis

Abstract:Presentation:A57-year-oldVietnamesewomanwithahistoryofmildpersistentasthma,onnomedicationsathome,presentedtotheEmergencyDepartmentwithchestpain.Shenotedthreeweeksofflulikesymptomspriortopresentationwithasubsequentdevelopmentofsqueezingchestpain.GiventhefactthatshehadanelevatedtroponinandinferolateralTwaveinversions,thepatientwastakenforaleftheartcatheterization,andwasfoundtohavenon-obstructivecoronaryarterydisease.Hertransthoracicechocardiogram,however,showeda'spadesign',afindingthatischaracteristicofanapicalvariantofhypertrophiccardiomyopathy.Assuch,thepatientwasfurtherevaluatedwithacardiacMRI,whichwasconcerningforinfiltrativedisease,asshehadcircumferentialdelayedhyper-enhancementthroughouttheleftventriclewall,mostprominentlytowardstheapicalsegments.Inaddition,shewasfoundtohavemultipleleftventricularthrombi.

Diagnosis:Giventheabovefindings,aswellasthepatient'shistoryofasthmaandeosinophiliaonherCBC,therewasastrongconcernforLoefflerEndocarditis(LE).Thepatientunderwentarightventricularbiopsy,whichshowedendocardialtissuewithnumerouseosinophils,lymphocytes,plasmacells,andrareneutrophils,confirmingthatshehadeosinophilicendomyocarditis,betterknownasLoefflerEndocarditis.

Afterherdiagnosiswasconfirmed,theetiologyofherhypereosinophilicsyndromewasinvestigated.Aspreviouslystated,thepatienthadelevatedIgElevelswithmultipleCBCsdemonstratingeosinophilia.Assuch,therewascontinuedconcernforChurgStraussSyndrome.WhileawaitingtheresultsofherP-ANCAandMPOantibodytests,shewasruledoutforHIV,Strongyloidiasisandhelminths,malignanciesincludinglymphoma,aswellasDRESS.AfterapositiveP-ANCAandMPOtiter,shewasdiagnosedwithEosinophilicGranulomatosiswithPolyangiitis,formerlyknownasChurgStraussSyndrome.

Treatment:ThepatientwasstartedoncorticosteroidswithPrednisone40mgdailyduringherhospitalization,andshowedimmediateclinicalandlaboratoryresponse,witheradicationofhereosinophilia.Shewasstartedoncyclophosphamideforinductiontherapyastreatment,withaslowtaperofcorticosteroids.Threemonthsintotreatment,thepatientremainedinremission,butwasunabletotoleratethesideeffectsofcytoxantherapy,asshehadpersistentnausea/vomiting,weightloss,hairloss,andmultipleinfections.Giventhisintolerance,shewasswitchedovertoAzathioprine.


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Results:Today,thepatientremainssymptomfreefromherEGPA,andlaboratorystudiesshownoevidenceofeosinophilia9monthsafterherinitialpresentation.Weplantocontinueheronazathioprinetokeepherinremission.

Background:LofflerEndocarditisisarareformofendocarditisorendomyocarditiscausedbyeosinophilicinfiltrationintotheendo/myocardium,firstdescribedin1936.Theetiologyofthisdiseasevaries,butremainscongruentwiththeetiologyofHypereosinophilicSyndromes(HES)ingeneral,namelyparasiticinfections,EPGA,fungalinfection,malignancies,mastocytosis,andrarely,hypoadrenalism.Thetreatmentfortheconditiondependsontheetiology,howevergiventhepaucityofdataforthisspecificcomplicationofHES,thereisnodefinitiveprognosisdescribedforLE.Ifleftuntreated,patientscanrapidlydevelopmyocardialfibrosisandrestrictivecardiomyopathy,withamediansurvivalof2-5years.


61

Poster#57

Presenter:Tien-ChunChen

Authors:Tien-ChunChenMD,AlvinChandraMD,ZhouwenTangMD

Title:RiskofVaricealHemorrhageinCirrhoticPatientsUndergoingTransesophagealEchocardiography

Abstract:BackgroundandAim:Transesophagealechocardiography(TEE)hasbecomeawidespreadclinicaltoolforavarietyofclinicalindications.Theroleanesophagogastroduodenoscopy(EGD)priortoTEEforvaricealscreeningandsurveillancetopreventpotentialvaricealdisruptionandvaricealbleedingduringTEEisunknown.AlthoughtheAmericanSocietyofAnesthesiologists(ASA)andAmericanSocietyofEchocardiography(ASE)recommendsexpertconsultationpriortoTEEinthesepatients,itremainsunclearwhethergastroesophagealvaricesarisingfromchronicliverdiseaseandcirrhosisconstituteascontraindicationtoTEE.Theaimofthisstudywastoretrospectivelycharacterizethefrequencyandtype(s)ofgastrointestinalcomplicationsinpatientswithcirrhosiswhoundergotransesophagealechocardiography,andcompareratesofTEEcomplicationsinthosewhoreceiveduptodatevaricealscreeningversusthosewhohavenotpriortoTEE.

Methods:Weanalyzeddatafrom199cirrhoticpatientswhounderwentTEEbetweenJanuary2010toApril2016.77of203patientsreceiveduptodateendoscopicvaricealscreeningandsurveillanceperAmericanAssociationfortheStudyofLiverDiseases(AASLD)guidelinespriortoTEE.Ratesofpost-proceduralbleeding,hospitaladmission,andcardiopulmonarycomplicationswereevaluated.

Results:Theratesofimmediateadverseevents,immediateGIbleeding,delayedGIbleedingandmortalityrelatedtoGIbleedingdidnotdifferbetweenthosewhoreceiveduptodatevaricealscreeningversusthosewhodidnot.

Conclusion:Completionofelectivevaricealscreening/surveillancepriortoTEEdoesnotappeartoimpactrate(s)ofpost-TEEvaricealbleeding,hospitaladmission,andoverallmortality.


62

Poster#58

Presenter:SarahKiani

Authors:SarahKiani,AnLu,ChristiParker,HetalPatelMD

Title:Severeprothrombintimederangement;ratpoisoningorvitaminKdeficiencybleeding?

Abstract:Summary:WedescribethecaseofanadultwithendstagerenaldiseaseandchronicpancreatitiswhowasadmittedforthemanagementofgastrointestinalbleedinginthesettingofsevereacquiredcoagulopathyafterDoxycyclineandRifampinuse.Casedescription:66-year-oldmalepresentedtothehospitalwiththreeweeksofnauseaandvomiting,darkstoolandtwoepisodesofhematemesis.Pastmedicalhistorywasnotableforendstagerenalandchronicpancreatitis.About3weekspriortopresentation,patientwasprescribedDoxycyclineandRifampinforasuperficialinfectionofarteriovenousgraft.Therewasnohistoryofanticoagulationuse.Physicalexaminationwasnotableformultiplescatteredbruisesonlimbs.Abdomenwassoftandnon-tender.Serumhemoglobinwas7.0g/dl,downfrom9.1g/dltwodaysago.Plateletandwhitebloodcellcountwasnormal.Serumprothrombintime(PT)>120s,InternationalNormalizedRatio(INR)>12andpartialthromboplastintime(PTT)83.9sincomparisontonormallevelsthreemonthsago.FactorVIIactivitywas2%andFactorIIassaywas3%.Fatsolublevitamindeficiencywasnotedandserumwarfarinlevelwasundetectable.AdmittedtotheIntensiveCareUnitandreceivedprothrombincomplexconcentrate,vitaminK,desmopressinandpackedredbloodcells.Esophagogastroduodenoscopywasconsistentwithdoxycyclineinducedesophagitiswithnonbleedingulcersinesophagusandduodenum.Rifampinanddoxycyclinewerediscontinued.Fatsolublevitaminsupplementationwasstartedandpancreaticenzymedoseincreased.At1monthfollow-up,nauseawasimprovedandtherewasnofurtherevidenceofbleeding.Thepatient'shemoglobinwasstableandPT/INR&PTTwerewithinthenormalrange.Discussion:VitaminKisabsorbedviatwopathways:dietaryphylloquinoneisabsorbedfromthesmallbowelandmenaquinoneisbacteriallysynthesized.Coagulopathycanresultwithanycauseoffatmalabsorptionoreradicationofintestinalmicroflora.ThecoagulationabnormalitiescausedbyvitaminKdeficiencyaremanifestedasprolongedPT/INRandinseveredeficiency,prolongedPTT.Forourpatient,multiplefactorscontributedtogastrointestinalbleeding.HelikelyhadsubclinicalvitaminKdeficiencyduetoendstagerenaldiseaseandchronicpancreatitis.ThismayhavebeenprecipitatedinthesettingofRifampinandDoxycyclineuse.RifampinisknowntointeractwithWarfarinduetoitseffectsonvitaminKmetabolism.


63

However,thedegreeofcoagulopathyseeninthiscasehasnotbeendescribedinliteratureintheabsenceofwarfarinuse.Furtherresearchiswarrantedtobetterunderstandthepathophysiologyofthisprocess.Untilthen,werecommendantibioticsthateffectvitaminKmetabolism,particularlyRifampin,shouldbeusedwithcautioninpatientspredisposedtovitaminKdeficiency.


64

Poster#59

Presenter:AyadAlkhatib

Authors:SairaBilal,AyadAlkhatib,ElizabethSolowMD,SanjeevaKavla

Title:SegmentalArterialMediolysis:Arisingentityinvasculitismimics

Abstract:SegmentalArterialMediolysisisanon-inflammatory,non-atherosclerotic,non-immunevasculopathyinvolvingmediumtolargevessels,characterizedbydissectinganeurysmsandstenosiswithresultantischemicandhemorrhagicmanifestations.FirstdescribedbySalvinandGonzalez-Vitaleain1976withanunclearetiology.Thisconditionisanimportantmimickerofvasculitiswithonehypothesisdescribingrepeatedvasoconstrictivestimulicausingdegenerationofsmoothmusclesinthemediaasapossiblecause.Accordingtoarecentsystemicreview,about101casesofSAMhavebeendescribedinliteraturebetween1976to2015.Herewedescriberetrospectively4casesofSegmentalArterialMediolysisdiagnosedbetween2013to2016atUniversityofTexasSouthwesternMedicalCenter.

Therearetwoprimarygoalsofthisretrospectivestudy.Oneistoevaluatethose4caseswithregardtotreatment,followup,newlesionsrates,andcomplicationrates.Secondprimarygoalistoeducateinternists,rheumatologists,andradiologistsaboutthismimickerofvasculitis;asacorrectdiagnosisisessentialforpropermanagementandtreatment,whichwouldbeaspirinandoptimalBPcontrolinthesecasesratherthanimmunosuppression.


65

Poster#60

Presenter:JustinChen

Authors:JustinR.ChenMD,ScottA.TarverPharmD,KristinS.AlvarezPharmD,ChiNguyen,DavidA.KhanMD

Title:ReflexivePenicillinAllergyTestingwithIn-HospitalAztreonamUse

Abstract:Rationale:Aztreonamisconsideredsafeforpenicillin-allergicpatients.However,mostpatientsreportingpenicillinallergiesaretolerant,leadingtounnecessaryuseofthisexpensiveantibiotic.Wepresentaninitiativetobundlepenicillinallergytestingwithinpatientaztreonamorders.

Methods:Anelectronicpanelwascreatedlinkingpenicillinallergyconsultationswithaztreonamorders.Providerscouldretainorremovetherequest(i.e.nopenicillinallergy)attheirdiscretion.Consultswerereviewedonweekdaysbyanallergy-trainedclinicalpharmacistwhoperformedinpatientpenicillinskintestingandchallenge.Patientswithnegativetestshadtheirallergiesremovedfromtherecord.

Results:Seventyconsultationswereplacedoveran8monthperiodforaztreonamrecipientsreportingpenicillinallergy.Fifty-sevenrequestsoccurredwhilethepatientwasintheemergencydepartment.Twenty-one(30%)weretested,allofwhomwerenegativeandsubsequentlyclearedtousepenicillin.Themediantimefromadmissiontotestwas1.05days[IQR0.90-3.43],reducedfrom3.69days[IQR1.39-6.95]for22patientsreceivingaztreonaminthe15monthsprior(p=0.014).Thereasonsfornottestingincludedantihistamineuse(27%),dischargebeforebeingseen(19%),mentalstatuspreventingconsent(14%),severecardiopulmonarycomorbidity(6%)andpatientrefusal(4%).Patientstestingnegativethenaccumulated46.8inpatientdaysofpenicillinand25daysofcephalosporinswithdirectantibioticcostsof$573.64and$138.13,respectivelyandtotaling$711.71.Incontrast,anidenticaldurationofaztreonam1-2gperdosecosts$4,305.35to$9,290.61,aprojectedsavingsof84-92%or$171.12-$402.52perpatient.

Conclusions:Couplingallergytestingwithordersofhigh-costaztreonamfacilitatesearlyawarenessandremovalofinaccuratepenicillinallergydiagnoses.Thisdecreasessuperfluousantibioticuseandfinanciallybenefitshealthcareinstitutions.


66

Poster#61

Presenter:L.ParkerGregg

Authors:L.ParkerGreggMD,XilongLiPhD,BeverleyAdams-HuetMS;JamesdeLemosMD,S.SusanHedayatiMD,MHSc

Title:TroponinT,BNP,andNT-pro-BNPimprovemoartalityandcardiovascularriskpredictioninchronickidneydisease

Abstract:Background:Fewstudiesexploredwhethercardiacbiomarkersaddprognosticinformationtotraditionalcardiovascular(CV)riskfactorsinnon-dialysischronickidneydisease(CKD)patients.

Methods:Westudied3,218participantsoftheDallasHeartStudy,amultiethniccommunity-basedcohortwithmedian12.5-yearfollow-up,ofwhom279hadCKD(eGFR<60mL/min/1.73m2oralbuminuriaof≥17mg/ginmenor≥25inwomen).Wecomparedabasemodeloftraditionalriskfactors(age,sex,race,diabetes,hypertension,smoking,hyperlipidemia,andHDLcholesterol)alonevs.withadditionofhighsensitivitycardiactroponinT(TnT)≥3ng/L,brainnatriureticpeptide(BNP)andN-terminal-pro-BNP(NT-pro-BNP)≥75thpercentileforsexforpredictionofdeathorCVdeath/event(myocardialinfarction,stroke,CVrevascularization,orhospitalizationforheartfailureoratrialfibrillation).Coxproportionalhazardsregressionassessedassociationsbetweenbiomarkersandoutcomes.Likelihoodratiotestsassessedtheprognosticimprovementofnestedmodelsattainedwiththeadditionofone,thentwobiomarkerstothebasemodel.

Results:Thecohortwas52%Blacks,29%Caucasians,17%Hispanics,and2%otherraces.Proportionswithstages1,2,3,and4-5CKDwere50,26,20,and3%.Therewere296deathsand218CVdeaths/events.Ofthenon-CKDgroup7%diedand6%hadCVdeath/eventvs.32%and30%oftheCKDgroup,P<.001forboth.TherewasasignificantBNPxCKDinteractionfordeathsuchthattheaHRwasintensifiedandsignificantinCKDbutnotsignificantinthenon-CKDgroup.CKDalsomodifiedassociationsofBNPandTnTwithCVdeath/event,withstrongerassociationsinCKD.AdditionofBNPorNT-pro-BNPtothebasemodelimprovedpredictionfordeath,andadditionofanycardiacbiomarkerimproveddiscriminationforCVdeath/eventintheCKDgroup.TheC-statistic(95%CI)forall-causedeathintheCKDgroupwas.71(.66,.76)forthebasemodel,andimprovedto.75(.70,.80)whenaddingbothTnTandNT-pro-BNP,P<.05.ForCVdeath/eventinCKD,theC-statisticimprovedfrom.71(.65,.77)forthebasemodelto.78(.73,.83)withtheadditionofTnTandNT-pro-BNP,P<.05.

Conclusions:TnT,BNP,andNT-pro-BNPprovideindependentprognosticinformationinCKD,withstrongerassociationsforBNPandTnTinCKDthaninnon-CKD.Cardiacbiomarkers,thoughcommonlyelevatedinCKD,addprognosticinformationtothatobtainedfromtraditionalCVriskfactorsaloneinCKDpatients.


67

Poster#62

Presenter:CarlosPatrickCardenas

Authors:CarlosCardenasMD,MarkWeinrichMD,JakeHuttoMD,CatherineChenMD

Title:ACaseofSerpentineEnvenomationandIschemicBowel

Abstract:CaseReport:IntheUnitedStates(U.S.)thereareapproximately5,000snakebitesperyearwithamortalityrateof0.06%.Successfultreatmentrequirespromptdefinitivemedicalevaluationandtimelyadministrationofantivenomwhenindicated.Here,wedescribeacaseofa51-year-oldmalewhosufferedapoisonoussnakebiteleadingtocirculatoryshock,acuterenalfailure,severecoagulopathy,andischemicbowelrequiringbowelresection.

Description:A51-year-oldmalewasbittenbyanunknownspeciesofsnakeontheleftanklewhilelightingfireworksinruralTexas.Hequicklydevelopednauseaandnumbnessoftheleftlegthatprogressedtoconfusionandunresponsivenesswhileenroutetoanoutsidehospital.Onpresentationhewasgiven3unitsofOvinepolyvalentCrotalinaeimmuneFab(Cro-Fab),theantivenomcommerciallyavailableintheU.S.,withoutinitialimprovement,sohewasintubatedandtransferredtoatertiarycarehospital.Onarrivalthepatienthadapulselesselectricalactivityarrestwithreturnofspontaneouscirculationaftertworoundsofcardiopulmonaryresuscitation.Physicalexamwassignificantforcoolandmottledextremities,epistaxis,distendedandtympanicabdomenwithdecreasedbowelsounds,andasmallleftanklesnakebitewoundwithoutsurroundingerythemaorevidenceofcompartmentsyndrome.Labswereconsistentwithlacticacidosis,acuterenalfailure,andseverecoagulopathythatworseneddespiteadequatefluidresuscitation,antibiotics,continuousrenalreplacementtherapy,andtheadministrationof6moreunitsofCro-fab.Acomputedtomographyoftheabdomenshowedpneumotosisinthesmallbowelandleftcolon.Anemergentexploratorylaparotomyrevealedtransmuralischemicnecrosisofthesmallandlargebowelforwhicharighthemicolectomyandsmallbowelresectionwereperformed.Hereceivedatotalof33unitsofCro-fabduringthefirst24hourswithresolutionofcoagulopathyandlacticacidosis.Heultimatelysurvivedandwasdischargedtoaninpatientrehabilitationcenteronhemodialysisafter25daysinthehospital.

Discussion:Thepatientpresentedaftersnakeenvenomationwithcirculatoryshock,lacticacidosis,acuterenalfailure,profoundcoagulopathy,andischemiccolitisthatnecessitatedemergenthemicolectomyandsmallbowelresection.Pathologyrevealedinnumerablemicrothrombiwithinthevasculatureofthebowel.Hehadminimallocaltissueinvolvementbutseveresystemicsignssuggestingpossibledirectintravascularenvenomation.Ischemiccolitisduetosnakeenvenomationisexceedinglyrare,buttherehavebeensomereportedcasesintheliterature.


68

Poster#63

Presenter:AlexMonroe

Authors:AlexMonroeMD,MBA,CraigGlazer,MD

Title:Anti-synthetasesyndrome:ararecauseofinterstitiallungdisease

Abstract:Introduction:Theanti-synthetasesyndromeisanuncommonconditionassociatedwithinterstitiallungdisease.Inthiscase,wedescribeawomanwhopresentswithhypoxemiaandislaterdiagnosedwiththisdisease.

CaseDescription:A30-year-oldwomanwithnosignificantpastmedicalhistorypresentedtotheemergencydepartmentcomplainingofshortnessofbreathatrestandonexertionforthepast2months.Atthetimehersymptomsbegan,sheexperiencedafewdaysofwristpainandswelling.Herprimarycaredoctorprescribedher1-2weekcoursesoflevofloxacinandprednisone,thelatterofwhichimprovedhersymptomssomewhat.

Onpresentationtothisfacility,oxygensaturationwas88%;thisimprovedto96%with2litersofoxygen.Shewasafebrile.Lungswerecleartoauscultationandshehadnodermatologicfindings.Theremainderoftheexamwasnormal.Whitebloodcellcountwas13.24(neutrophilicpredominance),D-dimerwas0.67,andtheremainderofthelabswereunremarkable.Chestx-rayshowednoinfiltratesandCTangiographyofthechestshowednon-specificscatteredgroundglassopacities.Shewastreatedforcommunity-acquiredpneumoniabutstillrequiredoxygenatrest.Anautoimmuneworkupwasinitiated.Anti-nuclearantibodywaselevatedat1:2560(nucleolarpanel).CKandaldolasewerenegativeandshehadnoclinicalsignsofmyositis.Thepatientwasstartedonasteroidtaperforsuspectedanti-synthetasesyndromeorotherconnectivetissuedisease.Hersymptomsrapidlyimprovedthereafter,andheroxygenrequirementresolved.Furtherworkuprevealedweaklypositiveanti-threonyl-tRNAsynthetase(anti-PL-7)antibodies,confirmingthediagnosisofanti-synthetasesyndrome.

Discussion:Anti-synthetasesyndromeisarelativelynewcondition.Thefirstdiagnosticcriteriaforthisdiseasewerepublishedin2010.Themainclinicalfeaturesofanti-synthetasesyndromeareantibodiesagainstatRNAsynthetasealongwitheitherILDthatcan'tbeattributedtoanothercause,polymyositis,ordermatomyositis.Theantibodyidentifiedinthispatient'scase,anti-PL7,isassociatedwithsevereILD.Becauseoftherelativelyrecentemergenceofthisdisease,therearenolargerandomizedtrialsonthetreatmentofanti-synthetasesyndrome.Steroidsandmycophenolatearecommonlyusedtoimprovelungfunction.


69

Poster#64

Presenter:AlexMonroe

Authors:AlexMonroeMD,MBA

Title:Dermato-neurosyndrome:ararecomplicationofscleromyxedema

Abstract:Introduction:Scleromyxedemaisararedermatologicconditioncharacterizedbyincreasedmucinproductionandfibroblastproliferation.Thiscasedescribesayoungmanwiththisskinconditionwhodevelopsthedermato-neurosyndrome,averyrareandoftenfatalcomplicationofscleromyxedema.Case:Thepatientisa27-year-oldmanwithscleromyxedemacomplicatedonlybydysphagiafrompharyngealinvolvement.HehadbeentreatedwithIVIGeveryfewweekswithnocomplications.Hisdermatologistwasgraduallyincreasingtheintervalbetweentreatments,andatthetimeofpresentationhewasoverdueforaninfusionby2weeks.Heexperiencedflu-likesymptomsforafewdayspriortopresentation,andonthedayofpresentationhehadaseizureandwastakentoanoutsidehospitalwherehehadanotherseizure.Hewastreatedwithbenzodiazepinesandlevetiracetam.Computedtomographyofthebrainwasnormal.Beforetransfer,hewasintubatedforairwayprotection.Vitalsonpresentationtoourhospitalweresignificantfortachycardiato121.Hewasafebrile.Abnormallabsincludedlactateof4.0,troponinof0.11,andCKof2091.TreatmentwithIVIG(500mg/kgonceonadmission,then1000mg/kgdailyfor2doses)andmethylprednisolone(0.3mg/kgdailyfor7days)wasinitiated.Hewastreatedforbacterialmeningitisuntillumbarpuncturewascompleted,butatthatpointhewastreatedforherpesencephalitisbecauseofthepresenceof3000RBCintheCSF.MRbrainwasnotsuggestiveofHSVencephalitis.Heremainedintubatedfor6daysafteradmission.Onceextubated,mentalstatuswasabnormal(thepatientwasnon-verbalandnotfollowingcommands).Overthecourseofthenextweekheregainedhisabilitytospeak(initiallyjusthisname,thenhisfamilymembers'names)andafter2weeksinthehospitalhecouldfollowcommandsandwasappropriateinconversationbutstillwasstillslowtorespondtoquestions.Bythetimeofdischarge22daysafteradmission,hewasbacktohisbaselinementalstatus.However,hisbaselinedysphagiahadworsenedwhichrequiredtheplacementofaPEGtube.Discussion:Thedermato-neurosyndromeisaveryrarecomplicationofarareskindisorder.Thesyndromeischaracterizedbyatriadoffever,seizures,andcoma.Onereviewoftheliteratureshowedacasefatalityrateof32%.Somewhorecoveredfromcomahadpersistentmajorneurologicdeficits,butmostpatientshadminorornodeficitsafterrecovery.Thepatientinthiscasehadnonewmajorneurologicdeficits,thoughatthetimeofdischargehisdysphagiawasworsethanhisbaseline.Therehavebeennorandomizedtrialsonthebesttreatmentofdermato-neurosyndrome.ThiscasefollowsahandfulofothercasesthatillustratepossiblebenefitofIVIGandIVsteroidsintreatingthissyndrome.Italsodemonstratesthatthesepatientsmayhaveaprolongedcourseduetoslowrecoveryofbaselinementalstatus.


70

Poster#65

Presenter:StephenD.Dickson

Authors:NickBrownellMD,FranckHannallahMD

Title:LVADfailurepresentingasVentricularfibrillationfrompLADemboliafteranightoutwiththegirls

Abstract:CaseDescription:Awhite72-year-oldfemalewithahistoryofnonischemiccardiomyopathystatuspostdestinationleftventricularassistdevice(LVAD)withcompletelyoversewnaorticvalve3yearspriorpresentstotheemergencyroomafterbeingshockedtwicebyherimplanteddefribillatoratoneinthemorning.Patientwithouthistoryofventriculararrhythmia,hadrecentlybeenadmitted3weekspriorforGIbleed.Deviceinterrogationshowed2episodesofventricularfibrillationwsuccessfulcardioversion.LDHelevated,CTAchestshowedpossibleclotwithintheinflowandoutflowLVADcannulasoanticoagulationparametersheightened.HospitalcoursecomplicatedbysuddenonsetshortnessofbreathandnauseainsettingofdecreasedLVADflows.Leftheartcathshowed99percentocclusionofproximalLADpresumablyembolicinnature,successfullytreatedwithdrugeludingstent.HospitalcoursefurthercomplicatedbycompleteLVADpumpfailurerequiringemergentdevicechangeoutbyCardiothoracicsurgery.Patientwithspeedyrecoverywalkinghalls,dischargedhome10daysafterLVADdevicechangeout.


71

Poster#66

Presenter:NamPham

Authors:NamD.Pham,Poh-ChooPang,SoumyaKrishnamurthyPhD,AmberlynWandsPhD,PaolaGrassi,AnneDell,StuartM.Haslam,JenniferJ.KohlerPhD

Title:NewinsightsintopathwaysunderlyingGNEMyopathy,amusclediseaseofaging

Abstract:GNEmyopathyisararemusclediseaseofagingthatisrelatedtosporadicinclusionbodymyositis(sIBM),themostcommonacquiredmusclediseaseofaging.ThepathogenesisofsIBMisunknownbuttherelatedGNEmyopathyisassociatedwithmutationsintheenzymeGNE(UDP-GlcNAc2-epimerase/ManNAckinase).GNEencompassesaproteinwithtwoenzymaticactivitiesrequiredforbiosynthesisofsialicacidinmammaliancells.MutationstobothGNEdomainsarelinkedtoGNEmyopathy.However,thecorrelationbetweenmutation-associatedreductionsinsialicacidproductionanddiseaseseverityisimperfect.ToinvestigateotherpotentialeffectsofGNEmutations,wecomparedcelllinesexpressingwild-typeormutantformsofGNE.Althoughwedidnotdetectanydifferencesattributabletodisease-associatedmutations,byusingacombinationofflowcytometry,high-performanceliquidchromatography(HPLC),andglycanmassspectrometrywediddiscoverthatGNEdeficiencyisassociatedwithunanticipatedeffectsonthestructureofcell-surfaceglycans.GNE-deficientcellsproduceddistinctN-linkedglycanstructureswithincreasedbranchingandextendedpoly-N-acetyllactosamine(polyLacNAc).GNEdeficiencymayalsoaffectlevelsofUDP-GlcNAc,acentralmetabolitealsoassociatedwithaging.Notably,theN-linkedglycansproducedbyGNE-deficientcellsdisplayedenhancedbindingtogalectin-1,indicatingthatchangesinGNEactivitycanaffecttheaffinityofcell-surfaceglycoproteinsforthegalectinlattice.ThesefindingssuggestanunanticipatedmechanismbywhichalterationsinGNEactivitymightaffectsignalingthroughcell-surfacereceptors.Takentogether,thisworkhighlightspathwaysthatmayunderlieGNEmyopathy,sIBM,andotherdiseasesofaging.


72

Poster#67

Presenter:DavidCarruthers

Authors:DavidCarruthersMD,ParagH.JoshiMD,ColbyR.AyersMS,ChristopherMaroulesMD,JamesGentry,PhilipAagaard,RoryHachamovitch,ReginaldDunn,AndrewLincoln,AndrewTucker,KeziaAlexander,DermotPhelan

Title:PooledCohortEquationandCoronaryArteryCalciuminFormerNationalFootballLeagueAthletes

Abstract:Background:TheperformanceoftheACC/AHApooledcohortequation(PCE)10-yearriskofatheroscleroticcardiovasculardisease(ASCVD)hasnotbeenevaluatedineliteformerathletes.

Methods:Inthiscross-sectionalstudy,wecompared104retiredNationalFootballLeague(NFL)playerswithasampleof618CaucasianorAfricanAmericanmenaged40-75yearsoldwithBMI>20fromthepopulationbasedDallasHeartStudy(DHS).Coronaryarterycalcium(CAC)scoringwasperformedinallparticipantsatbaseline.Weestimated10-yearASCVDriskusingthe2013ACC/AHAPCE.Toevaluatediscordance,wecomparedtheproportionsofNFLandDHSparticipantswithCAC=0andCAC>100acrosscategoriesofestimatedASCVDrisk.

Results:RetiredNFLplayershadhigherbodymassindicesandsystolicbloodpressure,butotherwiseamorefavorableriskfactorprofile(Table).TherewasatrendtowardlowermedianASCVDriskamongNFLplayers(Table).TherewasnosignificantdifferenceintheprevalenceofCAC>0.ComparingNFLplayerstoDHS,therewasnosignificantdifferenceintheoddsofhavingCAC=0amonghighASCVDriskparticipants(OR1.37;95%CI:0.36,5.17)norintheoddsofhavinghighCAC(CAC>100)amonglowASCVDriskparticipants(OR1.28;95%CI:0.64,2.54)

Conclusion:Overall,the10-yearASCVDriskcalculatorperformedsimilarlybetweenretiredNFLplayersandtheDHS.ClinicallyrelevantdiscordancebetweenASCVDriskestimateandCACburdenwassimilarinthetwogroups.


73

Poster#68

Presenter:RohanKhera

Authors:RohanKheraMD,AmbarishPandeyMD,ColbyAyersMS,VijayAgusalaBS,SandiPruittPhD,EthanHalmMD,MPH,MarkDraznerMD,SandeepR.DasMD,MPH,JamesA.deLemosMD,JarettD.BerryMD,MS

Title:ContemporaryEpidemiologyofHeartFailureinFee-for-serviceMedicareBeneficiariesBackground:ToassessthecurrentlandscapeoftheheartfailureepidemicandprovidetargetsforfuturehealthpolicyinterventionsinMedicare,acontemporaryappraisaloftheepidemiologyofheartfailureacrossinpatientandoutpatientcaresettingsisneeded.Methods:Inanational5%sampleofMedicarebeneficiariesfrom2002-2013,weidentifiedacohortof2,331,939uniquefee-for-serviceMedicarebeneficiaries≥65yearsofagewith≥1yearofenrollmentinbothMedicarepartsAandB,andfollowedthemforalltheirinpatientandoutpatientencountersovera10-yearperiod(2004-2013).Heartfailureencounterswereidentifiedinclaimfilesusingpreviously-validatedInternationalClassificationofDiseases-9theditioncodes.Pre-existingheartfailurewasdefinedbyanyheartfailureencounter(inpatient/outpatient)duringthefirstyearofstudyentry,andincidentheartfailurewasdefinedwitheitheroneinpatientortwooutpatientencounterswithoutanypriorencountersforheartfailure.Results:Atstudyentry,meanageofthecohortwas72years;57%werewomen,and86%and8%wereCaucasianandBlack,respectively.Withinthiscohort,518,223patientshadpre-existingheartfailure,andamongthosewithoutpre-existingdisease,349,826hadanewdiagnosisofheartfailureduringthestudy-period.During2004-2013,theratesofincidentheartfailuredeclined32%,from38.7per1000beneficiariesduring2004to26.2per1000beneficiariesduring2013.Similartrendswereobservedindemographicssubgroupsbyage,sex(men/women),race/ethnicity(white/black)andUScensusregions,withadvancedage,malesexandblackraceassociatedwiththehighestincidenceofheartfailure.Incontrasttoincidentdisease,prevalentheartfailureincreasedduringourstudyperiodfrom162per1000in2004to172per1000beneficiariesduring2013.Finally,theoverall1-yearmortalityamongpatientswithincidentheartfailureishigh(24.7%)witha0.4%absolutedeclineannuallyduringthestudyperiod,withamorepronounceddecreaseamongthosediagnosedinaninpatientvsoutpatientsetting(Pforinteraction<.001)Conclusions:Inrecentyears,therehasbeenasubstantialdeclineinincidentheartfailureinfee-for-serviceMedicarebeneficiaries,diagnosedinbothinpatientandoutpatientsettings,alongwithadecreasein1-yearmortalityinpatientswithafteradiagnosisheartfailure.However,despiteimprovements,theoverallburdenofheartfailureintheelderlyMedicarepopulationcontinuestoincrease.Moreover,whiletherehasbeenaconsistentdeclineinincidentheartfailureacrossdemographicsubgroupsofsexandrace,thoseatelevatedrisk(men,blacks)continuetoexperiencethehighestburdenofheartfailure.


74

Poster#69

Presenter:GraceLiu

Authors:GraceS.LiuMD,AngelaOrlinoMD

Title:CaseReport:RituximabInducedSerumSickness

Abstract:A44-year-oldmalewithnephroticsyndrome,who1weekpriortopresentationwastreatedwitharituximabinfusion,presentedwithpolyarthralgiaandswellingassociatedwithpainfulrangeofmotion.HisPMHincludedhypertension,dyslipidemia,andnephroticsyndromesecondarytoidiopathicmembranousnephropathy,forwhichhewasonchronicimmunosuppressionwithcyclosporine.

Onpresentation,hereportedarthralgiasthatstartedinhandsandwrists,whichwerefollowedbyarthralgiainthebackofhisneck,rightknee,andbilateralankles.Hewasinitiallyafebrileonadmission,howeverhistemperaturebecameelevatedto37.8Cafewhourslater.Hisrightkneewasswollenandtenderwithaneffusion.Therestofhisvitalsandphysicalwereunremarkable.LaboratorystudiesshowedWBCof17.43x10^3.HisBMPwassignificantforanAKI.HiswristX-raysdidnotshowanyabnormalities,whereashiskneeX-raysindicatedasmallsuprapatellareffusionoftherightknee.Jointaspirationoftherightkneeshowedtotalnucleatedcellsof53Kwith97%PMLand3%monocytesandnocrystalswereseenbymicroscopy.

Hewasstartedonempiricvancomycintherapyforpossiblesepticjointalongwithtramadolandhydrocodoneforpaincontrol.Thefollowingday,hiskneepainhadimprovedbuthewascomplainingofpaininthemedialaspectofhisfeetalongwithcontinuedswellingandweakness.Basedonthemigratoryprogressionofhissymptoms,anexaminconsistentwithsepticarthritis,andnegativegramstainofthejointfluid,Orthopedicsstatedtherewasnosurgicalindication.Hisinitialleukocytosisimprovedonthevancomycin.Weattributedhisoverallpresentationtopost-viralreactivearthritis,asapriorrheumatologicalwork-upwasnegative.

Itwasnotuntilthedayafterdischarge,whenhewenttohisnephrologisttogetanotherRituximabinfusion,thatitwasnotedhispresentationwashighlysuspiciousforRituximab-inducedserumsickness(RISS).Hisfever,migratorypolyarthralgiaswithanegativeinfectiousworkup,includinganegativegonorrhea/chlamydia,wereallconsistentwiththisdiagnosis.Hisrituximabtreatmentwascanceledandhewasgivenathree-weekcourseofprednisonetaper.SerumsicknessisatypeIIIhypersensitivityreactionresultingfrominjectionofforeignproteinandsubsequentformationofantibodies,usuallyoccurring4-10daysafterexposure.Clinicalsymptomscanincludefever,rash,andarthralgia,butthisclassictriadisreportedinonly48.5%ofcases.Althoughuncommon,RISShasbeenimplicatedrepeatedly.ItisimportanttorecognizeRISSclinically,asitmaymimicexacerbationofvariousrheumatologicalconditions.AlthoughRISSistypicallyself-limited,furtherinfusionsofRitximabshouldbeavoidedtolimitdevelopmentofmoreseveresymptoms.


75

Poster#70

Presenter:AliA.Saherwala

Authors:AliA.SaherwalaMD,SonjaStutzmanPhD,JunaidKalia,StephenFigueroaMD,VenkateshAiyagariMD,DaiWaiOlsonPhD,RN

Title:ExploringAssociationsbetweenInvasiveandNon-InvasiveBloodPressureMonitoringinPatientsReceivingVasoactiveMedicationInfusions

Abstract:Bloodpressure(BP)canbemeasuredincritically-illpatientsusingnon-invasive(oscillometric)bloodpressure(NIBP)andintra-arterialbloodpressure(IABP)monitoring.TheaccuracyofNIBPcomparedtothe'goldstandard,'AIBP,hasbeenquestioned.NIBPmonitorsgenerallytendtoover-readatlowvaluesandunder-readathighvaluescomparedtoIABP.PreviousstudiesexploringNIBP-IABPcorrelationshavegenerallybeenperformedonpatientsnotreceivingcontinuousinfusionsofvasoactivemedications.Sincemanycritically-illpatientsreceivevasopressorsandantihypertensiveagents,wewantedtostudytherelationshipbetweensimultaneously-measuredNIBPandIABPrecordingsinthispatientpopulation.

Weprospectivelyidentifiedpatients(N=25,targetN=70)admittedtoaNeurosciencesICU,whohadsimultaneousIABPandNIBPmonitoringwhilereceivingintravenousinfusionsofvasopressors/antihypertensiveagents.Followinginformedconsent,pairedNIBP/IAPBobservationsweremanuallyabstractedviaretrospectivechartaudit.Covariateanddemographicvariableswerealsoabstractedandenteredintoanelectronicspreadsheet.StatisticalanalysisperformedusingSASv9.4.

Initialresultsfrom25subjects(60%Caucasian,56%male,meanage60.3years,meanBMI30.3),receivedvasopressors(n=13)orantihypertensiveagents(n=12),with857pairedNIBP/IABPobservations.Independent-samplest-testsshowedasignificantdifferencebetweenNIBPvsIABPreadings:[SBP:m=125vs130mmHgrespectively].Bland-Altmanplotsdemonstratedgoodinter-methodagreementbetweenNIBP-IABPmeasures(whenvisuallyexcludingoutliers)anddemonstratedmarkedNIBP-AIBPSBPdifferencesathigherbloodpressures.

PreliminaryanalysisindicatesastatisticallysignificantdifferencebetweenNIBP-IABPreadingsforpatientsonvasoactivemedications.Yetwhenvisuallyexcludingoutliers,thereisgoodinter-methodagreement.DatafromtheentirecohortwillbeavailablesoonandwillbehelpfulinchoosingappropriateBPmonitoringmethodsforpatientsonvasoactiveinfusionsinboththeNeurosciencesICUaswellasanyCriticalCaresetting.


76

Poster#71

Presenter:NicholasKeisukeBrownell

Authors:NicholasK.BrownellMD,AmitKheraMD,MS,JamesA.deLemosMD,ColbyR.AyersMS,AnandRohatgiMD,MSCS

Title:TheAssociationBetweenPeptidoglycanRecognitionProtein-1andAtheroscleroticCardiovascularDiseaseEventsintheDallasHeartStudy

Abstract:Peptidoglycanrecognitionprotein-1(PGLYRP-1)isapro-inflammatorymoleculeintheinnateimmunesystemthatbindspeptidoglycan,aknownconstituentofhumanatheroma.IncreasingcirculatinglevelsofPGLYRP-1areassociatedwithprevalentsubclinicalatherosclerosis.Therefore,wehypothesizedthatPGLYRP-1levelsareassociatedwithincidentatheroscleroticcardiovasculardisease(ASCVD)events.PGLYRP-1wasmeasuredatbaselinein2,443participantswithoutcardiovasculardiseaseenrolledintheDallasHeartStudy,amulti-ethnicprobability-basedpopulationsampleofDallasCountyresidents,aged30-65.ASCVDwasdefinedasfirstmyocardialinfarction,stroke,coronaryrevascularization,orcardiovasculardeath.

Overameanfollowupof9.9±1.8years,increasingPGLYRP-1wasassociatedwithASCVDevents(p<0.0001).Afteradjustmentfortraditionalriskfactors,therewasa2-foldincreasedriskofASCVDinthetopvs.bottomquartileofPGLYRP-1(HR2.14,95%CI1.33-3.47,p=0.002).AnalysisofPGLYRP-1asacontinuousvariableandserialadjustmentforrenalfunction,inflammatorymarkers,andprevalentcoronarycalciumdidnotalterthefindings.Inalargepopulation-basedcohort,PGLYRP-1isassociatedwithanincreasedriskofincidentASCVD,independentofinflammatorymarkersandsubclinicalcoronaryatherosclerosis.ThesefindingssupporttheroleinnateimmunityincardiovasculareventsandwarrantfurtherstudiesonthemechanismsbywhichPGLYRP-1mayconferincreasedASCVDrisk.


77

Poster#72

Presenter:NicholasKeisukeBrownellAuthors:NicholasK.BrownellMD,ReeniAbrahamMDTitle:TrustingYourClinicalJudgment;ACaseofCryoglobulinemiaA61-year-oldwomanpresentedtoanoutsidehospitalwithepigastricabdominalpain.ACTabdomennotedgallbladdersludge.Whenpainpersistedafteranoutpatientcourseofantibiotics,sheunderwentalaparoscopiccholecystectomy.Anintraoperativeliverbiopsyrevealedsteatosisandbridgingfibrosisconsistentwithearlycirrhosis.Postoperativelyshebeganretainingfluidanddevelopedaleukocytosis;hercreatininerosefromwithinnormallimitstoCr=3.2mg/dL.Shewasstartedonantibioticsanddiureticsandwastransferredtoourinstitutionforpossibledialysisinitiation.Onadmission,shereportedthesameabdominalpainaswellasfatigue,diffusemyalgias,arthalgiasofherbilateralhands,hyperesthesiasinastocking/glovedistribution,anddiarrhea.Shedeniedrashes,hematuria,hemoptysis,familyhistoryofSLEorCKD,andpreviousIVdruguseorbloodtransfusions.Oninitialexam,shewasafebrile,normotensive,tachycardicbutwithanormalrespiratoryrateandnormaloxygenationonroomair.Thepatientwasgrosslyanasarcic.AdmissionlabswerenotableforBUN57mg/dL,Cr=3.47mg/dL;AST39U/L,ALT21U/L,totalbilirubin0.4mg/dL,Alb=1.7g/dL;andWBC=15.91x103/µL,PLT=268x103/µL.Initialurinalysisnotedproteinuriaandgranularcasts.Furtherwork-uprevealedelevatedrheumatoidfactor,decreasedC3/C4levels,positiveHepatitisCantibody,andnegativeHIV,HBV,andANAserologies.Basedonherclinicalpicture,biopsyresults,andlaboratoryfindings,apresumptivediagnosisofcryoglobulinemiaduetohepatitisCwasmade.Subsequently,HepatitisCviralPCR(sensitivity99%andspecificity98-99%)returnednegative.Initialrenalbiopsyresultsnotedcryoglobulinemicmembranoproliferativeglomerulonephritis;thepatientwasstartedonsolumedrolandplasmapheresistotreatcryoglobulinemiaofunclearetiology.GiventhehighclinicalsuspicionforHCVrelatedcryoglobulinemia,theHCVPCRwasrepeated3dayslaterandreturnedelevatedat1,640,000copies.AnothertestconfirmedHCVgenotype2.Asend-outcryoglobulinstudyreturnedasTypeIIcryoglobulinemia(monoclonalIgMkappapluspolyclonalIgG).Withplasmapheresisandsteroids,thepatientimprovedinsymptomsandrenalfunction.ShewasultimatelydischargedtoalongtermcarefacilityandgivencurativeHCVtreatmentwithdaclatasvirandsofosbuvir.Thiscaseillustratestheimportanceofrecognizingthelimitsoflaboratoryresults.Thepatient'spresentationwashighlyconsistentwithcryoglobulinemiasecondarytoHCVinfectiondespiteaninitial,negativeHCVRNA.WhileHCVPCRishighlysensitiveandspecific,falsenegativeHCVPCRresultscanoccurincryoglobulinemia;aproposedmechanismisthatHCVRNAmightbecomeentrappedinthecryoprecipitate,leadingtolowlevelsinplasmaandafalsenegativetest.Thiscasesuggeststhatlabresultsshouldbeviewedintheappropriateclinicalcontextandahealthyskepticismshouldbemaintainedforresultsthatseematoddswiththeoverallclinicalpicture.Clinicalsuspicion,aboveall,shoulddriveadiagnosticworkupandultimatelyleadtothecorrectdiagnosis.


78

Poster#73

Presenter:GlynnisAGarry

Authors:GlynnisA.GarryMD,NingLiuPhD,SvetlanaBezprozvannayaMS,EfrainSanchez-OrtizPhD,BeibeiChenPhD,JohnM.Shelton,RhondaBassel-DubyPhD,EricN.OlsonPhD

Title:ATwist-DependentProgenitorCellContributestoAdultSkeletalMuscle

Abstract:Skeletalmusclepossessesremarkableregenerativepotentialduetosatellitecells,astemcellpopulationlocatedbeneaththemusclebasallamina.BylineagetracingofprogenitorcellsexpressingtheTwist2(Tw2)transcriptionfactorinmice,wediscoveredamyogeniclineagethatresidesoutsidethebasallaminaofadultmuscle.Tw2+progenitorsaremolecularlyandanatomicallydistinctfromsatellitecells,arehighlymyogenicinvitro,andcanfusewithsatellitecells.Tw2+progenitorscontributespecificallytotypeIIb/xmyofibersduringadulthoodandmuscleregeneration,andtheirgeneticablationcauseswastingoftypeIIbmyofibers.WeshowthatTw2expressionmaintainsprogenitorcellsinanundifferentiatedstatethatispoisedtoinitiatemyogenesisinresponsetoappropriatecuesthatsuppressTw2expression.Tw2-expressingprogenitorsrepresentapreviouslyunrecognized,fiber-typespecificprogenitorcellinvolvedinpost-natalmusclegrowthandregeneration.


79

Poster#74

Presenter:RichardA.Mills

Authors:RichardA.MillsMD,AkeelMerchantMD,AbuMinhajuddinPhD,LaurenWehrmannBS,AmandaA.FoxMD,MPH,MichaelE.JessenMD,LynnHuffmanMD,DharamKumbaniMD,SarahK.GualanoMD

Title:BloodTransfusionRatesDecreasedwithNewerGenerationValvesfollowingTranscatheterAorticValveReplacement

Abstract:Introduction:Bloodtransfusionisincreasinglyrecognizedasastrongriskfactorformyocardialinfarction,stroke,death,andacutekidneyinjuryfollowingtranscatheteraorticvalvereplacement(TAVR).TAVRisarapidlyevolvingfieldwithadvancesinvalve/sheathtechnologyandcenterexperience.Itisourhypothesisthatpackedredbloodcell(PRBC)transfusionrateswilldecreasewithimprovedtechnologyandoperatorskill.

Methods:WithIRBapproval,datawereretrospectivelyextractedfromthechartsof87consecutivepatientsundergoingtransfemoralTAVRatasinglecenterbetweenMarch2013andMay2016.Valvetypesweregroupedintothreegenerations.Generation1consistedofEdwardsSapien,Generation2ofEdwardsSapienXTandMedtronicCoreValve,andGeneration3ofEdwardsSapienS3andMedtronicCoreValveEvolut.AlogisticregressionanalysiswasperformedtoevaluateassociationbetweentheneedforPRBCtransfusionintheperi-operativeperiodandvalvegeneration,adjustingforbodysurfaceareaandpre-operativehemoglobin.Asimilarregressionwasruncomparingvalvesheathsizeandbloodtransfusionrates,breakingsheathsizesintosmall12-16,medium18-20,andlarge22-24cohorts.

Results:Eachsuccessivegenerationofpercutaneousvalvehadadecreasedtransfusionratecomparedtopreviousgenerations.Therewasa31.6%transfusionratewithGeneration1valves,27.9%transfusionratewithGeneration2valves,and8.0%transfusionratewithGeneration3valves.NewervalvegenerationwasassociatedwithsignificantlydecreasedPRBCtransfusion(p=0.03)afteradjustmentforbodysurfaceareaandpreoperativehemoglobin.Inparticular,Generation3valveshadamarkedlydecreasedtransfusionriskcomparedtoGeneration1valves[OR0.06(0.01-0.48)]Sheathsizes12-16hadaPRBCtransfusionrateof20.0%,sheathsizes18-20hadatransfusionrateof22.0%,andsheathsizes22-24hadatransfusionrateof33.3%.Althoughtherewasatrendtowardsdecreasedtransfusionwithsmallersheathsizes,therewasnostatisticalsignificanceafteradjustmentforbodysurfaceareaandpreoperativehemoglobin(p=0.12).Thelargestsheathcohort(22-24)wasassociatedwithincreasedoddsoftransfusioncomparedtothesmallestcohort(12-16)[OR5.39(1.05-27.58)].


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Conclusion:Inoursinglecenterstudy,thenewestgenerationofTAVRvalveswasassociatedwithdecreasedPRBCtransfusionscomparedtooldermodels.Thismayinpartbeexplainedbyatrendtowardsdecreasedtransfusionrateswiththesmallersheathsizesfeaturedinnewerpercutaneousvalves.Wesuspectthatincreasingcenterexperienceandawarenessoftheharmimpartedwithbloodtransfusionarealsoactingtodecreasetransfusionrates.


81

Poster#75

Presenter:JoshuaParker

Authors:JoshuaParkerMD,MichinariHiedaMD,SatyamSarmaMD,TanyaRajabi,BenjaminLevineMD

Title:EvaluationofLeftVentricularDiastolicDysfunctionwithCardiacMRIinHFpEF

Abstract:Background:Heartfailurewithpreservedejectionfraction(HFpEF)hasbeencalled'diastolicheartfailure',andisassociatedwithelevatedfillingpressureandslowDopplerindicesofdiastolicfunction.However,diastoleisfundamentallytheabilityofthehearttofillafterejection,sotheseindicesareindirect.Cardiacmagneticresonanceimaging(cMRI)isahighresolutiontoolthatcanallowfortheprecisetrackingoffillingratesandleftventricle(LV)volume-timerelationshipduringthediastolicperiod.

Hypotheses:WehypothesizedthatHFpEFpatientswoulddemonstrateanabnormalLVvolume-timerelationshipaswellasalowerpeakfillingrate(PFR)duringtheearlydiastolicphase.

Methods:Conventionalcine-cMRIwasperformedusing1.5TMRIsystems,aspartofroutineclinicalprotocol.Cineimageswereacquiredinmulti-planarshort-andlong-axisviewswithretrospectiveelectrocardiographicgating.Cineshort-axisviewswereusedformeasurementofLVvolume.Totestthehypothesis,wecomparedthediastolicparameters(PFR/LVend-diastolicvolume(EDV);PFR/EDV/pulmonarycapillarywedgepressure(PCWP);timetopeakfillingrate(TPFR);%TPFRforcardiaccycle)calculatedbycMRIbetweenHFpEFpatients(N=10,73±7yrs)andage-matchedcontrols(N=12,70±3yrs).

Results:Therewerenosignificantbetween-groupdifferencesinage,gender,bodysurfacearea(BSA),heartrate,LVEF,andLVend-diastolicvolumeindex.PCWPwassignificantlygreaterinHFpEFgroupthancontrols(HFpEFvs.Controls:15.6±5.2vs.11.2±1.3mmHg,P=0.0092).PFR/EDVwassignificantlysmallerintheHFpEFgroupthanincontrols(2.68±0.85vs.3.59±0.87EDV/s,respectively,P=0.03),aswasPFR/EDV/PCWP(0.18±0.07vs.0.33±0.10EDV/s/mmHg,respectively,P=0.002).Inaddition,TimetoPFR(246±17.2vs.188±15.7ms,respectively,P=0.04)and%TimetoPFRofcardiaccycle(36.4±10.4vs.25.6±5.9%,respectively,P=0.012)weresignificantlylongerinHFpEFthanincontrols.

Conclusion:TheresultsinthisstudyhighlightthatHFpEFpatientshaveanabnormalvolume-timerelationshipincludinglowerPFR/EDVandprolongedtimetoPFR,resultinginimpairmentofactiverelaxationduringtheearlydiastolicphase.


82

Poster#76

Presenter:AhanaSen

Authors:AhanaSenMD

Title:EfficacyOfGastroduodenalStentingForMalignantGastricOutletObstruction

Abstract:Background:Malignantgastricoutletobstruction(GOO)ishighlymorbidandcanbetreatedwithendoscopicgastroduodenalstenting.Longtermstentefficacyandneedforfurtherinterventioninthesepatientsareunderstudied.Weaimtoassesslongtermefficacyofgastroduodenalstenting,predictorsofstentdysfunction,andoverallmortalityofthesepatients.Methods:WeperformedaretrospectivecohortstudyofallpatientsreferredforendoscopyformalignantGOOfrom2011through2016atasinglecenterandfolloweduntildeathorNovember15,2016.Stentdysfunctionisdefinedasreturnofsymptomsafterinitialstentingnecessitatinganotherendoscopicorsurgicalprocedure.KaplanMeier(KM)analysesofstentdysfunctionandoverallmortalitywereperformed.Patientswerecensoredatdeath(onlyinanalysisofstentdysfunction),lossoffollowup,orendofstudy.Coxproportionalhazardsmodelingwasusedtoassessforpredictorsofstentdysfunction.Results:56of57patients(98%)receivedtechnicallysuccessfulinitialplacementof63stentsandwerefollowedforamedianof110days.6patients(11%)receivedmultiplestentsatinitialEGD.Allstentswereuncoveredand22mmindiameterofvariouslengths(Table).3patients(5%)diedwithin1weekofstentplacement,including1patientat24hours.Nodeathsweredirectlyduetoendoscopy.Nootheradverseevents,includingbleeding,perforation,aspirationpneumonia,orcardiopulmonaryarrest,wereidentifiedonfollowup.4patientswereoutpatients.7inpatientsdiedbeforedischarge.Theremaining45inpatientsweredischargedatamedian5days(range1-19)afterstenting.Onfollowup,10patients(18%)sufferedstentdysfunction;6patientsduetotumoringrowth,2duetostentmigration,1duetoluminalobstructionfromabiliarystentplacedafterinitialluminalstenting,and1patientwastakenforsurgicalbypasswithoutrepeatendoscopy.Ofthe9patientstoreceiverepeatendoscopyforstentdysfunction,6received1morestent,1received2morestents,and1received3morestents.KMstentdysfunctioncurveyieldedamediandysfunctiontimeof292days(Figure).Coxproportionalhazardsmodelingdidnotidentifyanypredictorsofstentdysfunctionamongage,sex,presenceofascites,presenceoflivermetastases,orlengthofinitialstenting(Table).Only3patients(5%)wereconfirmedaliveattheendofthestudyand32patients(57%)wereconfirmeddead.KMsurvivalcurveyieldedamedianoverallsurvivalafterinitialstentingof102days(Figure).Conclusions:GastroduodenalstentingformalignantGOOishighlytechnicallysuccessful.Onlyasmallminorityofpatientssufferfromeventualstentdysfunction.Overallmortalityfrombaselinemalignancyremainshighandmostpatientsareabletobepalliatedwithonestentbeforedeath.


83

Poster#77

Presenter:HeatherWolfe

Authors:HeatherWolfeMD;DavidCarruthersMD

Title:ACutaneousPresentationofPlasmablasticLymphoma

Abstract:AnHIVpositivemanpresentedwithmultiplehemorrhagicnodulesonthelowerextremities.FurtherworkuprevealedpancytopeniaandaCD4T-lymphocytecountof81cells/µL.Biopsyoftheselesionsrevealedatypicallymphoidcellswithplasmacytoidfeatures.TumorcellswerepositiveforplasmacellmarkersandEBV.Adiagnosisofplasmablasticlymphomawasmade.Thereisnostandardtreatmentforthisraredisease.Thepatientwastreatedwithsystemicchemotherapy,butunfortunatelysuccumbedtosepsis.PlasmablasticlymphomaisararebutimportantHIV/AIDS-relatedmalignancyduetoitsaggressivenatureandpoorprognosis.Thepatientpresentswithanuncommonpresentationofthisdisease.


84

Poster#78

Presenter:HeatherWolfe

Authors:HeatherWolfeMD,HaominYeMD,MarkCooperMD

Title:Safeandeffectivemedicalmanagementdependsonsuccessfulpatientselfcare

Abstract:A60-year-oldHispanicmanpresentedwithodynophagiaandadiffuserash.Thepatienthadahistoryofchronicplaquepsoriasistreatedwithmethotrexate.Hehadbeenlosttofollowupindermatologyclinicandreportedthathehadnottakenmethotrexateformanymonths.Physicalexaminationwassignificantfororalulcersandviolaceouserodedplaquesanddiffusebullae.Laboratoryresultsrevealedpancytopeniaandacuterenalfailure.Amethotrexatelevelwasfoundtobeelevated.Skinbiopsyofalesionwasconsistentwithmethotrexatetoxicity.

Duetoitspotentialtoxicities,theuseofmethotrexaterequiresfrequentlaboratorymonitoringandclosefollowupwithprescribingphysicians.Thecombinationofrenalclearanceandnephrotoxicitymakesdosingchallenginginpatientswithchronickidneydisease.Patientadherencetomethotrexatetherapymaybecomplicatedbyitsonceweeklydosingandrequirementforconcomitantfolatetherapy.

Monthspriortoadmission,thepatienthadpresentedtotheEDwithapsoriaticflare.Dermatologyrecommendedmethotrexatebehelduntilhere-establishcarewiththeirclinic.Themethotrexateprescriptionwasrefilledatanacutecarefollowupalthoughhiskidneyfunctionwasdeteriorating.Despitepatientreportsofnottakingthemedication,themethotrexatecontinuedtobefilled.Themethotrexatewasdiscontinuedatalaterhospitalization,buthisaccumulatedhomesupplywassufficienttoallowthepatienttocontinuetherapyagainstmedicaladvice.Rootcauseanalysishighlightedopportunitiestoenactclinicalandpharmacysafetyalerts,simplifyprescribingandmonitoringprocesses,andclarifypatientinstructions.

Therecentintegrationofpharmacy'sinformationsystemswithParkland'sclinicalEMRpermitscoordinatedsafetycontrolsatthepointofprescriptionanddispensation.Aproposedorderpanellinksappropriatefolatetherapyandmonitoringlabsintothemedicationorderentryprocess,andrecommendsdoseadjustments.Engagingamultispecialtyteamrevealedtheopportunitytosimplifypatientinstructions


85

Poster#79

Presenter:LucasPinedaBernal

Authors:LucasPineda,NicoleBitencourt,KiranBatraMD,ElizabethSolowMD

Title:AortitisinGranulomatosiswithPolyangiitismanagedwithRituximabandMethotrexate

Abstract:Largevesselinvolvement,althoughrare,hasbeenincreasinglyrecognizedasacomplicationofGranulomatosiswithPolyangiitis(GPA)inrecentyears.Thepresentationishighlyvariable,rangingfromanincidentalfindingtoaorticdissectionandrupture.TreatmenthaspredominatelyconsistedofacombinationofCyclophosphamideandhighdosesofsteroidswithsurgicalinterventionwhenindicated.Wepresentthecaseofa34-year-oldmalediagnosedwithGPAafterpresentingwithsinusandeyeinvolvementinwhomwork-upincidentallyrevealedlargevesselinvolvementthatremarkablyimprovedaftertreatmentwiththecombinationofRituximabinfusions,Methotrexateandsteroidsaftera6-monthfollowup.


86

Poster#80

Presenter:RobertCarsonSibleyIII

Authors:MohammadToliyatMD,KanwarSinghMD,RobertC.SibleyMD,MurthyChamarthyMD,SanjeevaP.KalvaMD,AnilK.Pillai

Title:Interventionalradiologyinthemanagementofthoracicductinjuries:Anatomy,techniquesandresults

Abstract:Disruptionofthethoracicductcanhavedevastatingconsequencesandbeassociatedwithahighmorbidityandmortality.Conservativetherapieshavebeenattemptedtotreatchylothoraxwithoutmuchsuccess.Surgicalmanagementhastraditionallybeennecessarytoprovidedefinitivetreatmentattheexpenseofincreasedmorbidity.Lymphaticinterventionshaverecentlyemergedasanewfrontierforinterventionalradiologiststoaddvalueandprovideminimallyinvasivetherapiesfordebilitatingconditions.Thegoalofthismanuscriptistoreviewtheanatomyofthethoracicduct,describevariouspercutaneoustechniquesforaccessingtheduct,andbrieflydiscussoutcomesasreportedintheliterature.


87

Poster#81

Presenter:AnanyaKondapalli

Authors:AnanyaKondapalliMD,HaekyungJeon-SlaughterPhD,HoumanKhaliliMD,EhrinJ.ArmstrongMD,NicolasW.ShammasMD,AnandPrasadMD;IanCawichMD,GerardoRodriguezMD,MazenAbu-FadelMD,EmmanouilS.BrilakisMD,PhD,SubhashBanerjeeMD

Title:ComparativeAssessmentofSubintimalVersusIntraluminalCrossingofInfrainguinalPeripheralArteryChronicTotalOcclusions

Abstract:Background:Subintimal(SI)andintraluminal(IL)crossingofinfrainguinalchronictotalocclusion(CTO)lesionsisfrequentlyused,however,comparativeoutcomesarelacking.Thisstudycompares30-dayand12-monthclinicaloutcomes,aswellasperiproceduralcomplicationsbetweenthesetwotechniquesforfemoropoplitealandinfrapoplitealperipheralarteryCTOlesions.

Methods:Weselected1,335CTOinterventionsin1,001patientsfromthemulticenterExcellenceinPeripheralArteryDisease(XLPAD)registryfromJanuary2005toOctober2015.Outcomesare30-dayand12-monthall-causemortality,majoradversecardiovascularevents,repeatendovascularorsurgicalrevascularization,targetlimbmajoramputation,andproceduralcomplications.

Results:ÂSIcrossingtechniquewasusedin388lesions(27%)withlowerprocedural(p<0.01)andtechnical(p<0.01)successthantheILtechnique.Therewerenosignificantgroupdifferencesinproceduralcomplicationsand30-dayand12-monthpostproceduraloutcomesbetweenthetwogroups,exceptahigherdissectionrateinthesubintimalcrossinggroupthantheintraluminalgroupsinfemoropoplitealtargetvessles(p=0.04).LesionsintheSIgroupweresignificantlylonger(111.6±24.4vs.107.7±24.1,p<0.01)andhadalargerreferencevesseldiameter(4.6±0.3vs.4.5±0.4,p<0.01)comparedtotheILgroup.Durationandfluoroscopytimesweresignificantlylongerinthesubintimalcrossinggroup.

Conclusion:Subintimalcrossingofinfrainguinalchronictotalocclusionlesionswasemployedtocrosslongerandmorecomplexlesions.Subintimalcrossingcanbesuccessfullyperformedwithlowperiproceduralcomplications,andfavorableshortandintermediatetermoutcomescomparedwithanintraluminalapproach.


88

Poster#82

Presenter:AnhNguyen

Authors:AnhD.NguyenMD,StuartJ.SpechlerMD,MoniqueN.ShulerMS,RhondaF.SouzaMD,KerryB.DunbarMD,PhD

Title:ClinicalFeaturesofLosAngeles(LA)GradeDEsophagitisDifferSignificantlyfromLAGradeAEsophagitis:EvidencethatFactorsotherthanGERDContributetotheDevelopmentofLAGradeDEsophagitis

Abstract:Background:TheLosAngeles(LA)gradeofrefluxesophagitis(AtoD)isassumedtoreflectseverityoftheunderlyingGERD.Thus,LA-DesophagitispatientsmightbeexpectedtohavethemostconditionspredisposingtoGERD(e.g.obesity,hiatalhernia),andthehighestfrequencyofGERDsymptoms.

Goals:Tocompareclinicalfeaturesofpatientswiththemostsevere(LA-D)andmildest(LA-A)gradesofesophagitis.

Study:Forthiscomparativestudy,wesearchedourendoscopydatabaseforpatientsdiagnosedwithLA-DorLA-Aesophagitis,reviewedtheirendoscopicimages,andreviewedmedicalrecordsofthefirst100weconfirmedtohaveLA-DorLA-Aesophagitis.

Results:ComparedtoLA-Apatients,LA-Dpatientswereolder(meanage65±13.4vs.56±13.4years,p<0.001),hadlowerBMIs(25.9±5.6vs.29.4±5.3,p<0.001),weremorefrequentlyhospitalized(70%vs.3%,p<0.001)andintheICU(15%vs.0%,p<0.001),andhadsignificantlymoreseriouscardiopulmonarydisordersandgastrointestinalbleeding.Conversely,aGERDhistorywasmorecommoninLA-AthanLA-Dpatients(67%vs.45%,p=0.002).HiatalherniawasmorefrequentinLA-ApatientsthanLA-Dpatientsthoughthiswasnotstatisticallysignificant(48%vs.36%,p=0.09).

Conclusions:LA-Desophagitisisnotusuallyanoutpatientdisorder.Itprimarilyaffectshospitalized,older,non-obesepatientswhooftenhavecardiopulmonarydisordersandgastrointestinalbleeding,andnohistoryofGERDorhiatalhernia.Incontrast,LA-Apatientsaregenerallyyounger,obeseoutpatientswhooftenhaveahistoryofGERDandhiatalherniawithoutseriouscomorbidities.TheseprofounddifferencesbetweenLA-AandLA-DpatientssuggestthatfactorsotherthantypicalGERDcontributetoLA-Desophagitispathogenesis.


89

Poster#83

Presenter:MariaClarissaTio

Authors:MariaClarissaTioMD,LParkerGreggMD,XilongLi,BeverleyAdams-HuetMS,JamesdeLemosMD,SusanHedayatiMD

Title:MonocyteChemoattractantProtein-1(Mcp-1)IsAssociatedWithDeathInCKD

Abstract:MCP-1isaninflammatorymarkerimplicatedinatherogenesis.WhileobservationalstudiessuggestaninverseassociationbetweenplasmaMCP-1andGFR,dataregardingtheassociationofMCP-1withdeathinnon-dialysisCKDsamplesislacking.

Westudied3,257participantsoftheDallasHeartStudymultiethniccommunity-basedcohortwithmedian12.5yearsfollow-up.Therewere285(8.8%)withCKD(eGFR<60mL/min/1.73m2oralbuminuria≥17mg/ginmenor≥25inwomen).Proportionwithstages1,2,3,and4-5CKDwere48,27,21,and4%.PlasmaMCP-1levelswerecomparedinCKDvs.non-CKDgroupsandacrossadvancingCKDstagesusingtheWilcoxonRankSumandJonckheere-Terpstratests.CoxproportionalhazardsassessedtheassociationoflogtransformedMCP-1withdeath,adjustingfortraditionalCVriskfactors(age,sex,race,hypertension,diabetes,currentsmoking,totalandHDLcholesterol)andeGFR.

Oursamplewas50%Blacks,31%Caucasians,17%Hispanics,and2%otherraces.Median(IQR)MCP-1was164.7(120.3,220.9)pg/mLinnon-CKDvs.192.2(143.6,269.8)inCKDsubjects,P<0.0001.MedianMCP-1increasedacrossadvancingCKDstages:stage1,177.5(134.4,244.8);stage2,184.3(144.0,249.1);stage3,233.3(164.7,323.7);andstage4-5,294.6(219.4,353.2),P<0.0001fortrend.Therewere332deaths;234(8.7%)diedinthenon-CKDgroupvs.98(37.4%)intheCKDgroup,P<0.0001.MCP-1wasassociatedwithdeathinparticipantswithandwithoutCKDinunadjustedmodelsandwhenadjustedfortraditionalCVriskfactorsandeGFR.However,therewasnotasignificantCKDxMCP-1interaction.

PlasmaMCP-1iselevatedinalbuminuricearlystageCKDandacrossadvancingCKDstages,andisindependentlyassociatedwithdeathinbothCKDandnon-CKDindividuals.


90

Poster#84

Presenter:DeepikaSatish

Authors:DeepikaSatishMD,ZhouwenTangMD,JayaprakashSreenarasimhaiahMD,DeepakAgrawalMD

Title:PrescriptionPracticesofPancreaticEnzymeReplacementTherapyinaPublicHealthSystem

Abstract:Background:Exocrinepancreaticinsufficiency(EPI)canbetheresultofchronicpancreatitis,cysticfibrosis,pancreaticductobstruction,pancreaticresection,andgastroduodenalbypass.ChronicpancreatitisistheleadingcauseofEPIworldwide.Pancreaticenzymereplacementtherapy(PERT)isthemainstayoftreatmentformaldigestionduetoEPI,especiallyforsteatorrhea.However,efficacioustreatmentforsteatorrhearequirespersonalizeddosages,withatleast20,000to30,000unitsoflipasepermeal.

Objective:WeaimtoanalyzetheindicationsforandtheobjectiveevidencesupportingtheprescriptionofPERT,toexaminethedosagesofPERTinitiated,andtoevaluatethepracticesofprescribingPERTatlarge.

Design:WeperformedacrosssectionalstudyofallPERTprescriptionsatan862bedurbanpublichospital.Adatabaseofindicationsforanddosagesofprescription,imagingstudies,biochemicalstudies,anddocumentationofsteatorrheawasconstructed.

Results:OnehundredandfourteenpatientshavehadactiveprescriptionsforPERT,ofwhichchronicpancreatitiswastheinitialindicationforprescriptionfor54(47%)patients.However,ofthese54patientswhowereprescribedPERTforchronicpancreatitis,only26(48%)patientshadcross-sectionalCTorMRIevidenceand8(15%)hadEUSevidenceofchronicpancreatitisatthetimeofinitialprescription.Ofthe114patientswhohavebeenprescribedPERT,40(35%)patientshaddocumentedclinicalsteatorrhea;however,only22(19%)patientshadafecalfatstudy,with12(11%)positive,and5(4%)patientshadafecalelastasetested,with4(4%)positive.Additionally,83(73%)patientswereprescribedlessthan20,000unitsoflipasepermeal.

Conclusion:Atthetimeofinitialprescription,themajorityofpatientswereprescribedPERTforindicationsotherthanchronicpancreatitis.OfthoseprescribedPERTforchronicpancreatitis,asignificantnumberofpatientsdidnothaveimagingfindingsinsupportofthediagnosisorhavedocumentedsteatorrhea.Evenfewerhadobjectiveevidenceofsteatorrhea,asmeasuredbyfecalfatandelastasetests.Furthermore,thevastmajorityofpatientswereprescribedsubtherapeuticdosagesofPERT.


91

Poster#85

Presenter:JasmineSinghAuthors:JasmineSinghMD,FarjanaFattah,TamBurks,JieZheng,XingyaJiang,PamelaKurian,SehreshSaleem,JeanPearson,SaadKhanMDTitle:HomemadeSilverNanoparticlePharmacologyandDramaticActivityinHighlyRefractoryMetastaticHeadandNeckSquamousCellCancerBackground:Silvernanoparticles(SNPs)showhighefficacyastargetedtherapyagainstcancercelllines,buthaveneverbeentestedassystemictherapyinpatients.SNPshavealsobeenmarketedasanticanceragentsandareavailableinanumberofcommercialproducts,althoughdataregardingitsmedicalutilityremainslacking.Wepresentthefirstin-humantrialofSNPsinacancerpatientwithadramaticoutcomeandfurtherinvestigatethiscompound.Methods:HomemadeSNPsolutionispreparedbythepatientwithonlineinstructions.Currentfrom39-voltbatteriesispassedacross99.99%puresilver-barelectrodesindistilledwater,untilthemetalcontentofthewatermeasures0.09-0.15partspermillion.Themanufacturerisa78-year-oldmalewhodevelopedmultiplerecurrencesofnasalcavitysquamouscellcancer.Over2yearsheprogressedonplatinumandtaxanebased-chemotherapy,radiationtwiceand2surgicalresections.LargehepaticandpulmonarymetastaseswereobservedonPET,MRIandCT.Whileonhospiceandwithoutinforminghisoncologist,hebeganmanufacturingandconsumingtheSNPsolution.Results:Thepatientingested120mldailyofthesolutionfor3monthsleadingtorapidclinicalrecoveryandcompleteresolutionofcanceratallsites.Hereceivednoanti-cancertherapyduringthistime,norwasthereanobviousalternateexplanationforhisspontaneousregression.ElectronmicroscopyofthesilversolutionrevealedbimodalSNPsizedistributions;3&12nm.Inductivelycoupledplasmamassspectrometryshowedthebasalbloodsilverionconcentrationof32ng/g.Onehourafteringesting60mlofsilversolutionitroseto46ng/g.PhysiologicstudieswithsimulatedgastricfluidshowedSNP'saggregateintolargernanoparticles,whichwerenotdetectableintheblood.UrineshowednoSNPs.Toxicitieswerenotnotedwiththissilversolution;noevidenceofmyelosuppression,liverorkidneyabnormalitiesonrepeatedtestingover18months.Thepatientunderwentreconstructivesurgerywithexcellentwoundhealing,andhisfunctional/performancestatusisnormal.Hehashadnoclinicalorradiographicevidenceofcancer18monthsafterbeingplacedonhospice.Conclusion:IngestionofSNPsisassociatedwithcompleteregressionofhighlyrefractoryheadandneckcancer,intheabsenceofanyanticancertherapy.Ingestingsilversolutioncausesanoticeableandnearlyimmediateriseinbloodsilverconcentration.SNPgastricabsorptionandbloodtransportiscomplex,thoughurinaryexcretionisnotamajorrouteforclearance.GiventhesedramaticresultspossiblyrelatedtoSNPcombinedwithpromisingpreclinicalefficacy,furtherpatienttestingofSNPshouldbedonetoconfirmitsroleinheadandneckcancer.


92

Poster#86

Presenter:GurshawnSingh

Authors:GurshawnSinghMD,AmitSingalMD,DeepakAgrawalMD

Title:InterobserverreliabilitybetweengastroenterologistsandanesthesiologistsoftheASAphysicalstatusclassificationinpatientsforendoscopy

Abstract:Background:TheAmericanSocietyofAnesthesiologists(ASA)scaleisawidelyusedsubjective,six-pointordinalscalethatallowsanesthesiologiststoassignariskscoretoeachpatientscheduledforanesthesia.ItisroutinetoassignASAscoretopatientsundergoinginvasiveproceduresincludingendoscopy.ASAscoreisusedtodeterminewhetherthepatientshouldhaveendoscopydonewithdeepversusmoderatesedation,orthesiteofendoscopyi.e.atanambulatory/outpatientsurgerycenterversushospitalsettingandalsotodeterminetheamountofpaymentforendoscopy.UseofASAscoreforthesereasonsassumesrobustnessofthisclassificationandagreementbetweenitsusers.Objective:TodetermineagreementbetweengastroenterologistsandanesthesiologistswhenassigningASAscorestopatientsbeforeendoscopy.Methods:Wesentasurveywith10validatedhypotheticalclinicalscenariostoanesthesiaproviders(residents,attendings,andcertifiedregisterednurseanesthetists)andgastroenterologyproviders(attendingsandfellows).Inthesurvey,respondentswereaskedtoassignanASAscorebetween1and5ineachclinicalscenario.ThesurveyalsoassessediftherespondentfeltcomfortableassigningASAscores.TheresponseswereanalyzedusingthePearson'schisquaredanalysis.Results:Atotalof78completeresponseswerereceived.Theseweredividedinto55anesthesiaproviders,and23gastroenterologyproviders.In4outof10casesthegastroenterologistsandanesthesiologistsassignedsignificantlydifferentASAscoresindicatingthatthetypeofsedation,siteofendoscopy,orreimbursementwouldbedifferentdependingonwhethertheanesthesiologistorthegastroenterologistassignedthescore.Therewasnostatisticaldifferenceintheresponsesbetweentheattendingsandtraineesornurses.WhenassessingcomfortlevelforassigningASAscores,84%ofanesthesiologistswereverycomfortable,16%weresomewhatcomfortable.Forgastroenterologistsandtrainees,30%wereverycomfortable,65%weresomewhatcomfortable,and4%wereuncomfortable.Conclusion:ThereisasignificantdiscrepancybetweengastroenterologyandanesthesiaproviderswhenassigningASAscores.ThesubjectivityoftheclassificationanddistributionofscorevariabilitysuggeststhattheASAscoreisnotareliablemeasuretodeterminethetypeofsedationforendoscopy,sitewheretheendoscopyshouldbeperformedandshouldnotbetheprimarydeterminantforinsurancestocoverforanesthesiologistadministeredsedation.

2017 seldin research symposium abstracts...2nd annual donald w. seldin, m.d. research symposium may...

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