Medical Society of the State of New York

Resident, Fellow andMedical Student

Poster Symposium

Abstract Book

April 21, 2017MSSNY House of Delegates

Tarrytown, New York

2

MSSNY Resident, Fellow and Medical Student Poster SymposiumApril 21, 2017

Tarrytown, New York

We gratefully acknowledge the

Medical Liability Mutual Insurance Company (MLMIC)

for their generous support of this program

as well as our other contributors

Pier 17 Professional Medical Billing and ManagementCarl Needy, MD

Raymond Pastore, MDRichard Petrillo, MD

Philip Reitz, MDEugene Santilli, MDJoseph Sirna, MD

JUDGES (as of date of printing)

Sana Bloch, MDShobhana Chaudhari, MD

Jose David, MDT.S. Dharmarajan, MD

Laleh Hakima, MDBrian Johnson, MD

Alan Kaell, MDSamer Khader, MD

Peter Kim, MDPanagiota Korenis, MDPeter Lombardo, MD

Uma Mishra, MDRizwan Naeem, MD

Sarah Nosal, MDJohn Phillips, MD

Michael Richter, MDNidhi Shah, MD

Puneeta Sharma, MDKeivan Shifteh, MD

Zebulon Taintor, MDPeter Wyer, MD

Stephanie Zeszutek, DO

ABSTRACT REVIEWERS

Travis Bench, MDSana Bloch, MDJay Brenner, MDAman Deep, MDErick Eiting, MD

Hilary Fairbrother, MD, MPHAlok Gandhi, MDThomas Gift, MD

Ruth Hart, MD Alan Kaell, MDPeter Kim, MD

Panagiota Korenis, MDDan Nicoll, MDLisa Paulis, MDJana Preis, MD

Harini Sarva, MDAlana Sigmund, MDRobert Sporter, MD

Kelly Steed, MDPeter Wyer, MD

Samantha Xavier, MD

Submission Guidelines for the 12th Annual MSSNY Resident/Fellow and Medical Student Poster Symposium

April 21, 2017, 2 pm – 4:30 pmMSSNY House of Delegates Meeting1

Westchester MarriottTarrytown, New York

1. Submission Rulesa) MSSNY medical student and resident/fellow members are invited to submit abstracts to be considered for poster presentation. (Please note that

medical student membership requires enrollment in a LCME or COCA accredited school. However, non-LCME/COCA students doing rotations in New York hospitals may participate without membership.)

b) A $50 non-refundable symposium entry fee will be charged upon abstract submission. c) Deadline for abstract submission is 4 pm on Tuesday, January 31, 2017.d) We can only guarantee scoring of the first 100 resident/fellow abstracts and the first 40 student abstracts received. If we have enough abstract

scorers, we will score more. Abstracts must be scored to be considered for poster presentation. We will refund any fees paid for abstracts over the 100/40 that are not able to be scored.

e) The top 50 resident/fellow and top 20 medical student scores will be invited to present posters in April.f) Each applicant may submit only one abstract. g) Those submitting abstracts for consideration must be first authors of the research. h) You must be a MSSNY member to participate (see student exception in a) above). All dues must be up to date. Co-authors are not required to

be MSSNY members.i) Non-member first authors must apply for MSSNY membership. First time resident/fellow membership is free. If you are a former MSSNY

resident member, you will have to rejoin and pay current dues. Residents and students can join online at www.mssny.org. j) All submissions must be original works of individuals actively engaged in residency or fellowship training, or enrolled in medical school. k) Posters previously entered in a MSSNY symposium cannot be resubmitted. l) Entries may have been published in abstract form elsewhere, but may not be taken from previously published papers. (Authors should also be

aware that acceptance at this meeting may preclude an abstract’s candidacy for submission elsewhere.)m) Authors of entries accepted for the symposium must be able to attend the meeting and be present to discuss their submissions.

n) All submitters will be notified via e-mail regarding acceptance or rejection of their abstracts as soon as all abstracts have been scored. MAKE SURE TO PROVIDE AN EMAIL ADDRESS THAT YOU LOOK AT!

o) Questions? Email sbennett@mssny.org or call 516-488-6100 x 383.

2. Abstract Categoriesa) Resident/Fellows may submit entries in one of two categories:

1) Clinical Medicine includes basic science, quality improvement, health policy, clinical research and medical education.2) Clinical Vignettes involve the presentation of one or more patient encounters that illuminate unique observations of a known disease

or describe a novel disease process; use of a new procedure, treatment or medication; medical mysteries; patient, family and physician relationships; ethical issues. These are expected to include clinical patient information such as history, physical exam, and clinical data, as well as an analysis of how such observations might contribute to existing medical or scientific knowledge.

1 The House of Delegates is an annual weekend meeting during which MSSNY officers, councilors, trustees and designated delegates from county medical societies and recognized specialty societies formulate MSSNY policy and elect officers. Accepted symposium participants who wish to are invited to attend all meeting activities. A Daily Guide will be posted on the MSSNY website as the meeting approaches.

3

b) Medical students may submit abstracts of their scientific research (biochemistry/cell biology, cancer biology, clinical outcomes and healthcare improvement, immunology/infectious disease/inflammation, neurobiology/neuroscience, public health and epidemiology, radiology/imaging, surgery/biomedical engineering) as well as clinical vignettes.

3. Abstract Criteria – PLEASE FOLLOW THESE INSTRUCTIONS CAREFULLYa) Submit abstracts as email attachments in MS WORD, 10 point Arial font, to sbennett@mssny.org. Deadline is Tuesday, January 31, 2017 at 4

pm. b) To pay the $50 non-refundable entry fee

1. Pay online at https://www.medicaleducationny.com/checkout/order.aspx?&forid=3 OR 2. Call 516-488-6100 ext. 383 with credit card information

c) The following information must appear at the top of the abstract : 1. For Vignettes: the specialty under which it falls (e.g. Cardiology, Nephrology, Hematology, etc.) 2. Title3. Authors’ names4. Institution affiliations5. Program director’s name6. As appropriate, entrant's medical school and graduation year; or PG year and expected date of completion of training; specialty

(residents/fellows); address, and emaild) Once an abstract is submitted, it cannot be modified (i.e., an updated version will not be accepted later, even if before the submission deadline).

Please thoroughly proofread your abstract before submitting it. e) Maximum length for research abstract is 250 words. Maximum length for vignette abstract is 400 words. Title, authors and institution

affiliations are not included in word count. Do not include captions from photos or graphs in abstract text. f) The body of the abstract should include, if applicable, background, methods, results and conclusions. Clinical medicine submissions should

include clinical relevance. g) Define all abbreviations in abstract that are exclusive to your institution and not commonly used (to the best of your judgment)h) Graphs, figures and photos should not be included in the submitted abstract, but should be incorporated into the poster for presentation at the

meeting. i) Authors may only submit one entry to the 2017 symposium. j) Resident/fellow abstracts are scored on five criteria, each worth 0 to 5 points, for a maximum score of 25 points. The five criteria are:

1. Importance: innovation, relevance, creativity, new or cutting-edge information, originality of approach/intervention, significance or interest to the audience.

2. Methodology: appropriateness of conceptual basis and design for the identified purpose of the study, appropriateness of data collection techniques, development stage (level of data collection completeness); OR lessons learned: appropriateness of conceptual basis and design for the activity, extent to which the lessons learned merit the conclusions.

3. Clarity: development and communication of ideas and findings.4. Conclusion consistent with data and/or observations. Potential pitfalls of methodology or interpretation addressed. Potential significance

of experiments placed in proper perspective 5. Abstract is in required form and organized, well written, concise, and readable.

k) Student abstracts are scored on five criteria, each worth 0 to 5 points, for a maximum score of 25 points. The five criteria are:1. Project demonstrates a novel approach and/or idea. 2. Identification of all significant variables and clarity of efforts to eliminate bias between control and experimental groups; OR lessons

learned: appropriateness of conceptual basis and design for the activity, extent to which the lessons learned merit the conclusions. 3. Clarity. Clear organization of project and evidence of effective use of scientific method. 4. Conclusion consistent with data and/or observations. Potential pitfalls of methodology or interpretation addressed. Potential significance

of experiments placed in proper perspective.

4

5. Abstract is in required form and organized, well written, concise, and readable. l) MSSNY RFS members will review abstracts submitted by medical students. Reviewing student abstracts does not disqualify resident/fellows

from submitting their own abstracts. m) Authors will be contacted via e-mail regarding acceptance or denial as soon as the abstract committee has made its selections.

4. Poster Presentationa) Poster display boards will be provided. b) Posters must fit within a display area that is 6 feet wide by just under 4 feet high. c) Push pins will be provided.d) Posters should include title, authors, institution affiliations, and a detailed description of methods and results. Graphs, tables and photos are

welcome on posters.e) Poster text should be in 16 point font or larger. f) No word count is assigned to poster text, but please limit narrative. g) Posters will be displayed on boards in a gallery area, where entrants must be present to discuss their submissions.h) Judges will visit and examine each presentation between 2 pm and approximately 4:00 pm. Authors must be available for questions during this

time. i) Between approximately 4:00 and 4:30 pm, participants are invited to circulate and visit each other’s posters. j) All participation costs are the responsibility of the entrants. If you leave your poster behind, MSSNY cannot guarantee its return.

5. Judging and Awardsa) Bring an 8 ½” x 11” copy of your poster and hand it in at the registration table – this will be a great aid to the judges as they conduct their final

deliberations. Write your last name in the upper right corner of this copy.b) A panel of poster competition judges will be selected by MSSNY prior to the meeting.

1. Each judge will assess approximately eight posters. 2. Each contestant will be visited by at least one, but probably two or more judges. 3. Judges will be wearing a ribbon on their nametag marked “JUDGE.” 4. Judges will be assigned posters as they arrive at the symposium. They do not all come at once, so the actual start time for each individual’s judging will vary. We respectfully request your patience.5. Final judging will be done after the symposium. We regret that due to the exigencies of the meeting of which the symposium is a part, we cannot guarantee final results until later in the day or evening. Final results will be emailed to all participants as soon as possible.

c) Authors must be available for questions during the judging and are encouraged to prepare a 2-4 minute oral overview of their posters for the judges as they walk around.

d) Posters will be judged within their category and will be given a final grade, as follows:

6 criteria, each worth up to 10 points; highest score = 60

I. ORIGINALITY: How original is the concept presented in the poster? Or, how original is the new approach to an old problem?

2. SIGNIFICANCE: How significant are the poster’s conclusions in increasing understanding of a disease process; in improving the diagnosis or treatment of a disease state; in disease prevention or health promotion?

3. PRESENTATION: How logical are the ideas presented in the poster? How interesting is the manner of presentation?

5

4. METHODS: How suitable is the research design for the stated objectives, and how appropriate are any statistical techniques applied? For case vignettes, are sound scientific principles used in analysis/interpretation/discussion?

5. VISUAL IMPACT: How effective is the poster visually? How valuable is each figure and graph in furthering viewers’ understanding of the research subject?

6. INTERVIEW: How knowledgeable and conversant is the presenting author with the research presented in the poster?

e) Residents/Fellows: There will be up to three awards per each category: first prize, second prize and honorable mention. Vignettes may have a third prize category.

f) Students: There will be up to three awards in the student category: first prize, second prize and honorable mention.g) Winners will receive an award certificate. We hope to be able to give first and second prize winners a monetary award. All poster contestants

will receive a certificate of participation.

6

S U B M I S S I O N S

Medical Students

(Poster) #

FirstName

LastName School Title E-Mail Page

1. Sandip Tarpada MS3, MD Candidate, Class of 2018Albert Einstein College of MedicineBronx NY

Utility of supine lateral radiographs in assessment of lumbar segmental instability in degenerative lumbar spondylolisthesis

tarpada@mail.einstein.yu.edu 15

2. Sophia Halassy MS4: American University of the Caribbean, expected completion of MD program in May, 2017

Maximum Reduction of Surgical Site Infections after Major Gynecological Surgeries

sophiahalassy@students.aucmed.edu 15

3. Brian Emmert, Jr.

MS2, Class of 2019, Hofstra Northwell School of Medicine500 Hofstra BoulevardHempstead, NY 11549

Teaching End of Life at the Beginning of the Journey

bemmer1@pride.hofstra.edu 16

4. Clancy Mullan Hofstra Northwell School of Medicine, Class of 2018 Department of Cardiovascular and Thoracic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY

Tracheal Schwannoma Presenting as Chronic Chest Pain and Asthma

CMullan@northwell.edu 16

5. Anthony Bui Icahn School of Medicine at Mount Sinai, Graduating 2019Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY

Is Video Observation as Effective as Live Observation in Improving Operating Room Teamwork?

anthony.bui@icahn.mssm.edu 17

6. Charles Sanky Medical Student, Class of 2020Icahn School of Medicine at Mount Sinai

Residents’ Perceptions of Inappropriate Consults: Expectations of Expertise Among Medicine and Neurology Residents

charles.sanky@icahn.mssm.edu 17

7. Benjamin Boodaie MD Candidate, Icahn School of Medicine at Mount Sinai, Surgery, New York, NY Class of 2019 (MS-2) 1

A perioperative care map improves outcomes in morbidly obese patients

bboodaie@gmail.com 18

8. Akbar Maniya MS3; Expected Graduation May 2018. Icahn School of Medicine at Mount SinaiDepartment of Neurosurgery1 Gustave L. Levy Place, P.O. Box 1136, Annenberg 8th FloorNew York, NY 10029

Factors Affecting Length of Stay After Anterior and Posterior Cervical Spine Surgery

Akbar.maniya@icahn.mssm.edu 18

9. Megan Lin OMS III, Class of 2018NYIT College of Osteopathic Medicine

A Rare Case of Clostridium difficile Small Bowel Infection Post Colectomy

mlin08@nyit.edu 19

10. Enea Himi OMS III NYIT-COMGraduating year: 2018 New York Institute of Technology-College of Osteopathic Medicine

Trichomoniasis in a patient with metronidazole allergy successfully treated with paromomycin: a case report

ehimi@nyit.edu 19

11. Akhil Saji New York Medical College Class of 2018 (MS3)

Determinants of Default from Follow-Up Care in a Prostate Cancer Screening Program

asajinx@gmail.com 20

7

(Poster) #

FirstName

LastName School Title E-Mail Page

12. Kimberly Katz New York Medical College Class of 2018 Nodular Scabies Mimicking Urticaria Pigmentosa

Kimberly_Katz@nymc.edu 20

13. Daniel Buchalter New York University School of Medicine, Class of 2017Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York University Langone Medical Center, New York NY

Two-Stage Revision for Infected Shoulder Arthroplasty

Daniel.buchalter@nyumc.org 21

14. Michael Meade CUNY Queens CollegeStony Brook School of Medicine, Class of 2020

Epidermal DBL-1/BMP Signaling: Collagen-Dependent Modulation of Body Size and Non-Cell Autonomous Lipid Regulation in C. elegans

Michael.meade@stonybrookmedicine.edu

21

15. Pierce Janssen MD Candidate, Class of 2018 (MSIII)Stony Brook University School of Medicine

An Examination of venous thromboembolism risk using Caprini scores amongst outpatient aesthetic surgery patients who receive no chemoprophylaxis

pierce.janssen@stonybrookmedicine.edu 22

16. Robert Kim SUNY Downstate College of Medicine, Class of 2019

Addressing Medical School Culture Around Mental Health - A Novel Approach to Promoting Medical School Wellness

Rkim253@gmail.com 22

17. Jonathan Smerling MD Candidate class of 2020SUNY Downstate College of Medicine450 Clarkson Avenue, Box 98, BSB 1-112, Brooklyn NY 11203-2098

Higher Case Volumes of Percutaneous Coronary Intervention are Associated with Improved Risk Adjusted Mortality Rates in 33 New York State Hospitals

jonathan.smerling@downstate.edu 23

18. Andrea Attenasio OMSII, Touro College of Osteopathic Medicine Middletown, NY Class of 2019

Influence of Single Polymorphic Nucleotides Known to Affect Pediatric Body Mass Index on Musculoskeletal Phenotypes in Children and Young Adults

aattenas@student.touro.edu 23

8

Residents/FellowsClinical Medicine

FirstName LastName Des Title E-Mail Program Page19. Samson Alliu MD,

MPHAssociation between Marijuana Use and Tako Tsubo Cardiomyopathy (TTC); Analysis from the National Inpatient Survey (NIS) 2012 – 2014

salliu@maimonidesmed.org PGY-3 Expected Date Completion Training June 2017Department of MedicineMaimonides Medical Center4802 10 Avenue, Brooklyn, NY 11219

24

20. Clarisse Cadang MD Blood Culture Contamination, can it be solved? - Initiatives in a Tertiary Teaching Hospital

CCADANGMD@gmail.com Richmond University Medical Center, affiliate of The Mount Sinai Hospital and the Icahn School of MedicineDepartment of Internal Medicine, Staten Island, NY

24

21. Chukwunonso Chime MD Avoiding Antibiotic Use in Acute Bronchitis – An Integrated Approach

cchime@bronxleb.org Internal Medicine PGY4 complete training 06/30/2017Bronx Lebanon Hospital Center1650 Selwyn Avenue, 10C, Bronx NY 10457

25

22. Basma Elsawy MD Statins Ameliorating Viremia Severity on Hepatitis C Initial Diagnosis

basmaelsawy.md@gmail.com PGY II IM DepartmentConey Island Hospital2601 Ocean PKWY, Room 4N98Brooklyn, NY 11235

25

23. Johanna Ferreira MD Barriers and Predictors of Medication Adherence in Diverse Inner City Pediatric Patients with Inflammatory Bowel Disease

johannaferreiramd@gmail.com Division of Pediatric Gastroenterology, Hepatology and Nutrition The Children’s Hospital at MontefioreThe University Hospital for Albert Einstein College of MedicineBronx NY

26

24. Radhika Ghosh MD Predictors of Parental Consent for Donor Human Milk in the NICU

radhika.ghosh16@gmail.com Pediatric PGY-2 - Date of Entry: June 2015Staten Island University Hospital, Northwell Hofstra School of Medicine

26

25. Arpita Hazra MD Comparison of Length of Stay and Discharge Disposition between Anticoagulants for Secondary Stroke Prevention in Atrial Fibrillation

drarpitahazra@gmail.com Osh State University Medical Faculty, 2011Hofstra Northwell School of Medicine /Northwell Health, Manhasset NY

27

26. Sheikh Islam MD De-Prescribing in Older Adults Is Possible; Success Varies With Medication Class: A QI Initiative

drjahid43@gmail.com Fellow, Division of GeriatricsMontefiore Medical Center (Wakefield), Bronx NY

27

27. Ying Hui Luu MD Prevalence of QT prolongation and LVEF changes in patients admitted with diabetes mellitus (DM) over a 4-year time period

YLuu@matherhospital.org PGY2 SUNY Stony Brook Internal Medicine at John T. Mather Memorial Hospital, 75 North Country Rd, Port Jefferson NY 11777

28

9

FirstName LastName Des Title E-Mail Program Page28. Shoshanna Miller MD OPaL, A Mobile and Online Tool for

Documenting Residency Competencies and Milestones

shoshanna_Miller@URMC.Rochester.edu Resident General Preventive MedicineSchool of Medicine & DentistryDepartment of Public Health Sciences Public Health Sciences, University of Rochester Medical Center, Rochester, New York| 14642

28

29. Neha Naik MD An Interdisciplinary Approach to Improving Care and Reducing Length of Stay in Patients with Cellulitis

nnaik@matherhospital.org PGY3, BSN SUNY Stony Brook at John T. Mather Memorial Hospital Internal Medicine Residency ProgramPort Jefferson NY

29

30. Michelle Pintea MD Incidence and Predictors of Recurrent Atrio-Ventricular Nodal Reentrant Tachycardia (AVNRT) After Successful Ablation: A > 10-Year, Single Center Study

mdpintea@gmail.com Trinity School of Medicine 2016Electrophysiology Services, NewYork-Presbyterian Brooklyn Methodist Hospital

29

31. Randolph Sanchez MD The Effectiveness of Grand Rounds on Referrals to Rheumatology for Shoulder Pain

Randolph.Sanchez@downstate.edu PGY-2 (2018) Department of Medicine SUNY Downstate Medical Center450 Clarkson Ave. Brooklyn NY

30

32. Dinesh Sangroula MD Modafinil Treatment of Cocaine Dependence: A Systematic Review and Meta-analysis

dinesh15us@yahoo.com Department of Psychiatry, Jamaica Hospital Medical Center, New York, NY

30

33. Pooja Thimmappa

MD Are Hematological indices useful in identifying culture negative early onset sepsis and guiding antibiotic therapy in well appearing late preterm and term neonates?

Pooja.thimmappa@stonybrookmedicine.edu

PGY3 expected graduation 2017Pediatrics, Stony Brook Children’s Hospital, Stony Brook, New York 11794100 Nicolls RdStony Brook NY 11794

31

34. Benjamin Whigham MD Ophthalmology consult rates are influenced by season, temperature, and precipitation

benjamin.whigham@gmail.com Department of PGY-3, Ophthalmology Ophthalmology, SUNY Downstate School of Medicine, Brooklyn NY

31

10

Residents/FellowsVignettes

35. Richard Jesse

Durrance MD Cardiology Chagas Cardiomyopathy presenting as Symptomatic Bradycardia: An under-appreciated emerging public health problem in the United States

jessedurrance@gmail.com PGY 1 Internal Medicine graduation date: June 2019Department of Internal Medicine Jamaica Hospital Medical Center8900 Van Wyck ExpresswayJamaica NY 11418

32

36. Mathew Jose

Kottarathara

MD Cardiology Unilateral Pulmonary Edema: The forgotten Differential Diagnosis in Asymmetric Radiographic Opacities of the Lungs

mathen1988@gmail.com PGY1 Internal MedicineJamaica Hospital Medical Center8900 Van Wyck ExpyJamaica NY 11418

32

37. Anooj Patel MD Cardiology Takotsubo Cardiomyopathy After Pacemaker Implantation

anoojptl@gmail.com PGY-1 Internal Medicine at John T. Mather Hospital, 75 N Country Rd, Port Jefferson, NY 11777

33

38. William Li MD/MPH

Critical Care The Curious Case of a Cardiac Tamponade in the Hypertensive Patient Presenting as Abdominal Fullness

liwi@upstate.edu PGY-2Internal MedicineSUNY Upstate Medical University

33

39. Zulekha Atif MD Endocrinology

Brown Tumor: A rare complication of secondary hyperparathyroidism

zulekha.atif@outlook.com PG2, Internal Medicine Jamaica Hospital Medical Center 8900 Van Wyck Expressway Jamaica NY 11418

34

40. Pardeep Masuta MD Endocrinology/Critical Care

SGLT-2 Inhibitor Use Leading to Life Threatening Euglycemic Ketoacidosis

masutap@upstate.edu PGY-2SUNY Upstate Medical University

34

41, Phillip Ulyanovskiy

MD Family Medicine

Refractory Acute Kidney Injury Secondary to Hypothyroid Induced Myopathy: A Contemporary Case Report

phil.ulyanovskiy@gmail.com PGY2 Family MedicineBrooklyn Hospital Center Icahn School of Medicine at Mount Sinai121 Dekalb Avenue Brooklyn NY

35

42. Sandra Gómez-Paz

MD Gastroenterology

An Unusual Case of Gallbladder Cancer in a Young Male

sandragp@outlook.com Nassau University Medical Center, East Meadow, NY

35

43. Lev Platsman MD Gastroenterology/Endocrinology

Insulin Infusion and Subcutaneous Heparin to manage severe hypertriglyceridemia in an adolescent girl with Type 2 Diabetes: A Case Report

lplatsman@rumcsi.org PGY 2 Department of Pediatrics, Richmond University Medical Center, Staten Island NY

36

44. Tamoor Shahid MD Gastroenterology/Hepatology

Myopathy and Hepatotoxicity from combined use of Statin and Azole Antifungal

tshahid@montefiore.org Internal Medicine Resident Montefiore Medical Center, Wakefield Campus, Bronx NY

36

11

45. Semaan Kobrossi MD Hematology A Surprising Case of Chronic Myelogenous Leukemia with Acute Lymphoblastic Crisis

semaankobrossi@gmail.com

PGY-2; Internal Medicine, expected date completion of training June 2018SUNY Upstate Medical University

37

46. Jhavene Morrison MD Hematology Acute Immune Hemolytic Anemia after administration of high dose IVIG in a child with Kawasaki disease

Jhavene21@hotmail.com PGY 2: Pediatrics expected date completion 06/30/2018 Richmond University Medical Center, Staten Island, NY – an Affiliate of Mount Sinai Health

37

47. Odia Obadan MD Hematology Oncology

Look Again! T cell Lymphoma presenting as a testicular mass. A rare case

odiaobadan@yahoo.com PGY3 Internal MedicineSt Johns Episcopal HospitalFar Rockaway, New York 11691

38

48. Boris Betancourt

MD Hematology/Critical Care

Thrombotic Thrombocytopenic Purpura: A Hematologic Emergency

bbetancourt79@gmail.com PGY 2, Expected graduation by 2018, Internal MedicineSt John’s Episcopal Hospital/State University of New York Downstate Medical Center

38

49. Maya Ignaszewski

MD Hematology/Oncology

Spontaneous Tumor Lysis Syndrome: An Unusual Suspect

mayaigna@gmail.com SUNY Upstate Medical University

39

50. Moumita

Sarker MD Infectious Diasease

Metatarsal Osteomyelitis: A Rare Case of Osteoarticular Tuberculosis

mm4.ohio@gmail.com PGY 3 Internal Medicine Expected date of completion of training: June, 2017Department of Internal Medicine, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica NY 11418

39

51. Umut Gomceli MD Infectious Disease

A Rare Case of Didanosine Related Severe Lactic Acidosis Predisposing to Infection with Mucormycosis

ugomceli@bronxleb.org Chief Resident, Department of MedicineBronx Lebanon Hospital Center affiliated with Icahn School of Medicine1650 Selwyn Ave. 10M Bronx NY 10457

40

52. Scott Statman MD Infectious Disease

Bacterial Pyomyositis - A Unique Etiology of Persistent Musculoskeletal Pain

Scott.Statman@nyumc.org PGY-2NYU Internal MedicineExpected Date of Graduation June 30, 2018

40

53. Hamead Reza

Moshrefi DO Infectious disease/Hematology and Oncology

CNS toxoplasmosis encephalitis in CLL – A challenge to diagnose and treat

moshrefi.reza@gmail.com PGY2 Internal MedicineSUNY Stony Brook Mather program

41

54. Het Dharia MD Infectious Disease/Neurology/Immunology

Teriflunamide Induced Clostridium difficile Sepsis: A rare adverse reaction with an interesting solution

dhariahe@upstate.edu PGY-1 Internal Medicine; Expected date of graduation 06/2019SUNY Upstate

41

12

55. Julia Frydman MD Infectious Diseases

A Case of Pulmonary Tuberculosis in Alcoholic Cirrhosis

frydman.julia@gmail.com PGY-1 Internal MedicineExpected Date of Completion 6/2019New York University School of Medicine550 First AvenueNew York, NY 10016

42

56. Joselle Cook MD General internal Medicine

Highest CPK in Sickle cell trait associated Rhabdomyolysis

joselle.cook@downstate.edu PGY 2 Internal medicine Expected completion 2018SUNY Downstate Health Science Center, Department of Medicine

42

57. Radhika Gali MD Internal Medicine

Albuterol induced lactic acidosis It pays to Search for an Explanation in Lactic Acidosis

rgali@montefiore.org PGY-1 Montefiore Medical Center Department of Medicine(Wakefield Campus) Bronx NY

43

58. Junaid Habibullah

MD Internal Medicine

The Fire in the Cave jhabibulla@northwell.edu PGY1 Graduation 2019 Internal Medicine Hofstra Northwell Health300 Community Drive Manhasset NY 11030

43

59. Laxmi Upadhyay

MD Internal Medicine

Transient ST segment elevation with gastric distention

upadhyay143laxmi@gmail.com

PGY1, Graduation year: 2019Montefiore New Rochelle Hospital and Albert Einstein College of Medicine, New Rochelle, New York

44

60. Ismaela Teferi MD Nephrology Focal Segmental Glomerulosclerosis in Malaria

ismaelatt@gmail.com PGY 2, Internal Medicine, June 2018Department of Internal Medicine, Jamaica Hospital Medical Center8900 Van Wyck Expressway, Jamaica, NY 11418

44

61. Joel Thomas MD Oncology/Hematology/Pulmonary/Hepatology

Unexplained Multiple Pulmonary Emboli: A Harbinger for Hepatocellular Carcinoma in a Non-Cirrhotic Liver Without Known Risk Factors

Jthoma18@gmail.com PGY-1SUNY Stony Brook at John T. Mather Memorial Hospital75 North Country Rd Port Jefferson NY 11777

45

62. Lauren Sielert MD Ophthalmology

Bilateral Panuveitis as the presenting sign of multiple sclerosis

sielertl@upstate.edu PGY-3 Ophthalmology Expected date completion training: 6/2018SUNY Upstate Medical University550 Harrison Street, Suite L, Syracuse NY 13202

45

63. Ayesha Hameed MD Pain Medicine Ultrasound Guided Single Injection Quadratus Lumborum Block for Postoperative Pain Control in Patients’ Undergoing Total Hip Arthroplasty

ahameed100@gmail.com CA2, Class of 2018Northwell Health System Anesthesia Residency270-05 76th AvenueNew Hyde Park, NY 11040

46

13

64. Mustafa Caylan MD Palliative Care and Hospice Medicine

How Palliative Care changed a Child’s Life with a Very Rare Disease: A Case with Cerebrocostomandibular syndrome (CCMS)

mscaylan.md@gmail.com PGY4, expected date of completion of training: 06/30/2016Lincoln Medical Center, 234 E 149th St, Bronx, NY 10451

46

65. Arash Ronaghy MD PhD

Pathology PD-L1 and Notch1 Expression in KSHV/HHV-8- and -EBV Associated Germinotropic Lymphoproliferative Disorder: Case Report and Review of the Literature

aronaghy13@northwell.edu PGY-4; 06/30/17 residency completion dateDepartment of Pathology and Laboratory MedicineHofstra North Shore-LIJ School of MedicineLake Success NY

47

66. Hina Zaidi MD Pediatric Infectious Diseases

Hypotonia and Lethargy in a 5 week old girl

hina.zaidi@stonybrookmedicine.edu

PGY-6 fellowship graduation 7/2017 Pediatric Infectious DiseasesStony Brook Children’s Hospital, 101 Nicolls Rd, Stony Brook NY

47

67. Zabeer Bhatti MD Pulmonary and Critical Care

Fatal Acute Respiratory Distress Syndrome from Adenovirus

bhattiz@upstate.edu PGY-2 Internal Medicine Resident: Expected to graduate in June 2018SUNY Upstate Medical University

48

68. Malahat Movahedian

MD Rheumatology

Massive Gluteal Abscess caused by Methicillin Resistant Staphylococcus Aureus in a Patient with Systemic Lupus Erythematosous

malahat.movahedian@gmail.com

PGY 2 graduation date: June, 2018Department of Internal Medicine, Jamaica Hospital Medical Center, 8900 Van Wyck Expy, Richmond Hills, NY 11418

48

69. Ricardo Alonso MD Sports Medicine

Avoiding long term outcomes doctor_alonso@outlook.com The Brooklyn Hospital CenterFamily MedicineExpected date of completion of training Jul/2019

49

70. An Chen MD Sports Medicine

Alcohol leading to a “Pirates Gait” anchen84@gmail.com PGY 2 Family Medicine class of 2018The Brooklyn Hospital Center affiliated with Mount Sinai

49

14

POSTER # 1Utility of supine lateral radiographs in assessment of lumbar segmental instability in degenerative lumbar spondylolisthesisSandip P. Tarpada, BA1;Foster Chen, MD2; Woojin Cho, MD PhD2; Louis Amorosa, MD2

1Albert Einstein College of Medicine, Bronx, NY2Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NYSandip Tarpada is an MS3 at Albert Einstein College of MedicineIntroductionAccurate evaluation of segmental instability is critical to the management of lumbar spondylolisthesis. Standing flexion-extension lateral radiographs are routinely obtained, as it is believed to precipitate the forward-backward motion of the segment; however recent studies with MRI and CT have shown that the relaxed supine position can facilitate the reduction of the anterolisthesed segment. Here, we show that inclusion of supine lateral radiographs increases the amount of segmental instability seen in single-level lumbar spondylolisthesis when compared to traditional lateral radiographs.MethodsSupine lateral radiographs were added to the routine evaluation (standing neutral/flexion/extension lateral radiographs) of symptomatic spondylolisthesis at our institution. In this retrospective study, 66 patients were included. The amount of listhesis was measured and compared on each radiograph: Standing neutral lateral (“neutral”), Standing flexion lateral (“flexion”), Standing extension lateral ( “extension”), and Supine lateral (“supine”).Results66 patients (56 female, 10 male), with a mean age of 60.9 years (+/- 11.8 years) were included in this study. The mean mobility seen with flexion-extension was 5.57%. The mean mobility seen with flexion-supine was 8.13%. This difference was significant in paired t-test (p<0.001), and independent of age and BMI. Maximal mobility was seen between flexion and supine radiographs in 40 patients, between neutral and supine radiographs in 14 cases, and between traditional flexion-extension studies in only 11 cases.Conclusion:Supine radiograph demonstrates more reduction in anterolisthesis than the extension radiograph. Incorporation of a supine lateral radiograph in place of extension radiograph can improve our understanding of segmental mobility when evaluating spondylolisthesis.

POSTER # 2Maximum Reduction of Surgical Site Infections after Major Gynecological SurgeriesSophia D. Halassy, MS4, Kenia I. Edwards, MD, Paul C. Liu, JD MDInstitution: Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554Program Director: Maggie Tetrokalashvili, MDAuthor Information: Sophia D. Halassy, MS4: American University of the Caribbean,

expected completion of MD program in May, 2017; sophiahalassy@students.aucmed.edu

Kenia I. Edwards, MD: PGY2, expected completion in 2019; OB/GYN; kedward1@numc.edu

OBJECTIVE:To study the impact of the use of post-operative chlorhexidine in decreasing the incidence of hospital-acquired surgical site infections (SSIs) following major gynecologic procedures at Nassau University Medical Center (NUMC). METHODS:A retrospective comparison of women who had undergone gynecological surgery at Nassau University Medical Centre between January 2013-August 2014 and September 2014-April 2016 was done. Those who had surgery after August 2014 were subject to daily post-operative chlorhexidine washing of the incision site. We gathered information on the number, type, and cultured pathogen of each reported SSI.RESULTS: Two thousand three hundred ninety-two women underwent a major gynecological surgery between January 2013 and April 2016. Prior to any intervention directed toward decreasing SSI incidence, the percentage of surgeries complicated by an SSI was 1.32%. Following implementation of a daily chlorhexidine wash of the incision site until discharge, this rate decreased to 0.51% (p=0.038). CONCLUSION:We conclude that daily wound care with a chlorhexidine wash decreases the incidence of SSI in women undergoing major gynecological procedures. This should become standard of care for post-operative wound management.

15

POSTER # 3Teaching End of Life at the Beginning of the JourneyBrian E. Emmert Jr., B.S., Danielle Qing, B.A., Tara A Liberman, D.O.Hofstra Northwell School of Medicine500 Hofstra BoulevardHempstead, NY 11549Program Director: Samara Ginzburg, M.D.Corresponding Author: Brian E. Emmert, Jr., MS2, Class of 2019Bemmer1@pride.hofstra.edu

Introduction: As the population ages and more people live with chronic disease, suffering, especially during the advanced stages of illness, will increase. Palliative and hospice care medicine play an integral role in caring for these patients. Delivery of these services to suffering patients can be improved by educating future doctors about the intricacies and importance of these subspecialties early in their careers. However, concerns are voiced regarding the most appropriate time to introduce palliative and hospice care in a medical school curriculum. Data is needed to elucidate students’ readiness to learn these crucial subspecialties.

Methods: A voluntary, uncompensated, 13-item survey was administered to all students at Hofstra Northwell School of Medicine via e-mail. The survey canvassed students’ knowledge about hospice/palliative care and opinion regarding teaching it during the first two years of medical school. Results: Students over all four years had a strong interest in learning hospice/palliative care during the first two years of medical school (84% positive, 16% negative; X2=0.15, p=0.9025). They reported interest in early, hands-on clinical experience. Pre-clinical students reported having insufficient knowledge about hospice/palliative care as compared to elder students (26% for pre-clinical students; 74% for clinical students; X2=13.255, p=0.0003). Finally, having clinical experience in palliative/hospice care during medical school improved knowledge of these fields (χ2=19.321, p<0.001).

Conclusion: The present study demonstrated that students are interested, willing, and ready to learn about palliative and hospice care medicine during the first two years of medical school. Thus, early education in these subspecialties proves worthwhile and beneficial.

POSTER # 4Tracheal Schwannoma Presenting as Chronic Chest Pain and AsthmaClancy Mullan B.S., Kyle Riggs M.D., and David Zeltsman M.D.Hofstra Northwell School of Medicine, Dep Cardiovascular and Thoracic Surgery, Long Island Jewish Medical Center, New Hyde Park, NYClancy Mullan, Hofstra Northwell School of Medicine Class of 2018 (cmullan@northwell.edu)Introduction: Primary tracheal tumors occur rarely, and benign tracheal tumors comprise only one third of tracheal tumors. Tracheal schwannomas are among the rarest, with approximately thirty cases reported. We describe a case of tracheal schwannoma, its minimally invasive management, and the related pathology. Case: A 36-year-old man with history of costochondritis presented to the emergency department with three-days of left chest pain. Prior workup included a negative stress test, normal laboratory investigations, and normal sinus rhythm on EKG. The patient denied shortness of breath but admitted to using a rescue inhaler over the past two years for what he believed to be asthma, providing modest relief. On exam, vital signs were normal, and physical examination was unrevealing. Chest x-ray was performed and revealed a well-rounded soft tissue density overlying the mid trachea. A confirmatory CT scan showed the mass was mildly heterogeneous and partially lobulated, measuring 1.8 cm x 1.4 cm x 1.8 cm with significant occlusion of the trachea, without lung nodules or lymphadenopathy. In retrospect, the same density appeared on a chest x-ray from two years prior, read as normal and demonstrated minimal growth over that time, suggesting this mass was present then and likely benign. The patient was electively taken to the operating room for excision by flexible bronchoscopy.The mass appeared consistent with imaging, was attached by a stalk to the right lateral wall, and oscillated on its pedicle with respiration. A CO2 laser was used to free the mass from the wall and achieve hemostasis. Grossly, the lesion measured 3.7 cm x 1.9 cm x 1.6 cm. Microscopy revealed spindle cells with focal cystic degeneration and ossification consistent with schwannoma. The patient tolerated the procedure well and was discharged home from the recovery room.Discussion: In patients presenting with refractory or atypical symptoms of asthma, tracheal lesions should be considered. Primary tracheal tumors are a rare diagnosis; tracheal schwannomas are even rarer and tend to present late, after occluding upwards of 90% of the trachea. Although schwannomas are the most common tumor of peripheral nerves, they typically manifest on flexor surfaces but can occur anywhere, classically with palisading spindle cells and variable degenerative changes on histology. Visceral schwannomas are often found without an identifiable associated nerve, making optimal management uncertain. As in this case, we find that even large tracheal schwannoma can be managed endoscopically without need for tracheal resection.

16

POSTER # 5Is Video Observation as Effective as Live Observation in Improving Operating Room Teamwork?Anthony Bui, Medical StudentIcahn School of Medicine at Mount Sinai2019Authors: Anthony H. Bui, BS1; Shanice Guerrier, MS1, David L. Feldman, MD, MBA, FACS1,2, Patricia Kischak, MBA2, Santosh Mudiraj, MBBS, MPH2, Donna Somerville, MS, CPHQ2, Minimole Shebeen, RN1, Cynthia Girdusky, RN, CNOR1, I. Michael Leitman, MD, FACS1

Author Affiliations: 1Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 2Hospitals Insurance Company, New York, NY, USAProgram Director: I. Michael Leitman, MD, FACS

Background: Operating room (OR) teamwork reduces the risk of preventable patient harm. Observation in the OR allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote OR teamwork.

Methods: Video and audio cameras were installed in 2014 into all ORs at an 875-bed urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPSTM skills during surgical briefs and debriefs.

Results: A total of 1,410 briefs were evaluated: 325 (23%) through live observation, 1,085 (77%) through video. 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for team membership recognition (87% vs. 44%, p<0.001), complex procedural event anticipation (61% vs. 45%, p<0.001), and resource monitoring (58% vs. 42%, p<0.001). For debriefs, greater compliance was observed under live observation for team structure determination (90% vs. 60%, p<0.001), establishment of a leader (70% vs. 51%, p<0.001), postoperative planning (77% vs. 48%, p<0.001), case review and feedback (49% vs. 33%, p<0.001), team engagement (64% vs. 41%, p<0.001), and check back (61% vs. 46%, p<0.001) compared to video. Conclusions: Video observations may not be as effective as evaluating live performance in promoting OR teamwork. Live observation enables immediate feedback, which may improve behavior and reduce barriers to compliance with surgical safety practices.

POSTER # 6Residents’ Perceptions of Inappropriate Consults: Expectations of Expertise Among Medicine and Neurology ResidentsCharles Sanky (Medical Student, Class of 2020, charles.sanky@icahn.mssm.edu)Eric Bortnick MD (PGY-1 Pre-urology, eric.bortnick2@mountsinai.org)Stephen C. Krieger MD (Associate Professor in Neurology, Director of Neurology Residency Training Program, stephen.krieger@mssm.edu)Icahn School of Medicine at Mount Sinai

Background: Through residency programs, trainees delve into their specialties, sometimes neglecting the medical knowledge of other fields. This leads to two fallacies: 1) Other physicians ought to have similar knowledge; 2) Unfamiliar situations are beyond their scope. Such fallacies inspire a perception of “inappropriate consults,” impeding the efficacy of interdisciplinary care.

Objective: To assess residents’ perceptions of “inappropriate consults” and medical knowledge across specialties.

Methods: 13 Neurology residents (NRs) and 10 Internal Medicine residents (IMRs) at the Icahn School of Medicine at Mount Sinai answered 5 neurology and 5 medicine board-style questions reflecting typical consultation scenarios. After each, residents rated to what extent the solution should be common knowledge to both specialties, was actually common knowledge, and if a consult was warranted.

Results: Paired sample t-tests revealed that IMRs correctly answered more medicine than neurology questions (3.80 v. 1.90, p<0.001), while NRs correctly answered 2.92 medicine and 2.85 neurology questions (p=0.856). Additionally, NRs answered more neurology questions correctly than IMRs (p=0.013) and thought IMRs should know more neurology answers than IMRs did (p=0.049). Conversely, IMRs expected NRs to know more neurology answers than NRs knew (p=0.003). IMRs thought medicine questions deserved consults more than NRs (p=0.014).

Conclusions: Both groups expected the other to have specialty clinical knowledge and disagreed on whether consults were appropriate. Group differences regarding the perceived appropriateness of consultations reflect these fallacies of medical knowledge. Future research should include other specialties and examine the effects of interdisciplinary team education.

17

POSTER # 7A perioperative care map improves outcomes in morbidly obese patientsBenjamin Boodaie1, Anthony Bui1, David L Feldman1,2, Michael Brodman1, Peter Shamamian3, Ron Kaleya4, Meg Rosenblatt1, Donna Somerville2, Patricia Kischak2, Michael Leitman1 1 Icahn School Of Medicine At Mount Sinai, Surgery, New York, NY, USA; 2 Hospitals Insurance Company, New York, NY, USA; 3 Albert Einstein College Of Medicine, Surgery, Bronx, NY, USA; 4 Maimonides Medical Center, Brooklyn, NY, USABackground: A perioperative care map was developed that expanded best practices already used for bariatric patients to morbidly obese patients undergoing all types of surgery. The care map calls for a supplemental consent form, perioperative medical assessments including nutrition and mobility, stringent guidelines for anesthetic care, the availability of bariatric equipment, and evaluation for anticoagulation among other items. In 2013, the care map was implemented at four large urban teaching hospitals, which required its use for morbidly obese patients (BMI>=40) undergoing all types of inpatient surgery. Here, the impact on patient outcomes was evaluated.Methods: ACS NSQIP data was used to compare 30-day outcomes for morbidly obese patients before (2013) and after (2015) care map implementation. Mixed effects regression models were fitted that adjusted for all available demographic, preoperative, and operative variables (as fixed effects) as well as for hospital and surgical service (as random effects). To control for secular trends in care quality caused by factors other than the care map, changes in outcomes were compared to those for non-morbidly obese patients using an interaction term between year and morbid obesity. Results: For morbidly obese patients, there was a decrease in rate of unplanned return to operating room (OR=.49; p=0.039), unplanned readmission (OR=.57; p=0.006), total LOS (-0.87 days; p=0.009), and postoperative LOS (-0.69 days; p=.007). Of these, total LOS (-0.86 days; p=0.015), and postoperative LOS (-0.69 days; p=.012) improved significantly more for morbidly obese patients than non-morbidly obese patientsConclusions: This care map should be further investigated and considered for more widespread use.

POSTER # 8Factors Affecting Length of Stay After Anterior and Posterior Cervical Spine SurgeryAkbar Y. Maniya1, Frank J. Yuk MD1, Tanvir Choudhri MD1

1Department of NeurosurgeryIcahn School of Medicine at Mount Sinai1 Gustave L. Levy Place, P.O. Box 1136, Annenberg 8th FloorNew York, NY 10029Corresponding Author:Akbar Y. Maniya, MS3; Expected Graduation May 2018Background:Cervical spinal cord disease is widely prevalent, most commonly caused by degenerative changes. The symptoms are weakness, stiffness, pain, and paresthesias.  Surgical intervention can improve these disabling symptoms. Two approaches utilized are anterior and posterior.Hypothesis:It was hypothesized that a difference exists in hospital length of stay (LOS) status post anterior versus posterior surgery.Aims of Study:The goal was to identify a possible LOS discrepancy between the two major approaches. A secondary goal was to identify contributing factors.Methods:A retrospective study was performed on 509 elective patients (251 male, 258 female, 328 anterior, 181 posterior) that underwent surgeries between October 2001 and March 2014. Data was obtained via EMR.Results:Chi-squared tests for BMI, hypertension, CAD, CHF, COPD, and asthma showed no significant difference between anterior and posterior patients.Average LOS was 3.10 0.27 days for anterior patients, 4.86 0.34 days for posterior. P-value < 0.02.Average estimated blood loss (EBL) was 190mL for anterior, 320mL for posterior, p-value < 0.001. Average incision length was 5.7cm for anterior, 9.1cm for posterior, p-value < 0.001. Average operative time was 4.1 hours for anterior, 4.5 hours for posterior, p-value < 0.01.Conclusions:Patients with anterior surgeries stayed 1.76 days less post-operatively than posterior patients. Higher EBL, longer incisions, and operating time were significantly associated with the posterior approach.The primary limitation was that the data came from one surgeon. Future studies would be to create a model that could accurately predict the post-operative length of stay based on patient and operative factors.

18

POSTER # 9A Rare Case of Clostridium difficile Small Bowel Infection Post ColectomyMegan Lin, NYITCOM Class of 2018, mlin08@nyit.edu Christopher Amen, NYITCOM Class of 2018, camen@nyit.eduArthur Gran, MD, Infectious Disease Medicine, St. Catherine of Siena Medical Center, Smithtown, NYIntroduction: Clostridium difficile is a gram-positive, anaerobic, spore-forming bacillus and a well-recognized cause of diarrhea and colitis in the setting of antibiotic therapy. Clostridium difficile infection is classically an infection of the colon; however, we report a rare case of Clostridium difficile small bowel infection in a patient with a history of total proctocolectomy with ileal pouch. Case Presentation: A 56 year-old female, post proctocolectomy with Kock pouch for ulcerative colitis, presented with four days of watery, non-bloody diarrhea, stomal incontinence, abdominal cramping, anorexia, and increased stool frequency. She was hospitalized one month ago for similar symptoms. A computed tomography scan of the abdomen at that time was negative for acute pathology. She was diagnosed with suspected enteritis of unknown origin with superimposed urinary tract infection and treated with ceftriaxone for three days. She was now found to be dehydrated with acute renal failure. Clostridium difficile toxin polymerase chain reaction was positive. Her renal failure and dehydration improved and she was started on metronidazole 500mg every eight hours for ten days and discharged home. Watery diarrhea and stoma incontinence resolved after treatment.Discussion: Several aspects of an ileal pouch may predispose patients to Clostridium difficile enteritis. An environment similar to the colon is created in the ileal pouch, as small bowel flora transition to colonic flora1, and the ileal pouch mucosa undergoes cellular changes. The morphologic changes that have been described include partial villous atrophy, Paneth’s cell hyperplasia, and partial transition to colonic mucin phenotype without complete metaplasia2. This change in flora and morphology may be due to the difference in transit time in a patient with an ileal pouch compared to an anatomically normal bowel. This suggests that fecal stasis in the newly formed ileal pouch might allow for growth of flora normally found in the colon to grow in the small bowel. Clostridium difficile enteritis has been shown to have high rates of sepsis and perforation3. It is therefore important for clinicians to have a high index of suspicion in any patient presenting with classic symptoms of Clostridium difficile infection even in the absence of a colon.Conclusion: Clostridium difficile enteritis is dangerous and potentially overlooked in patients with a history of colectomy. As evident by our case, absence of colon does not rule out Clostridium difficile infection; rather, changes in the anatomy stemming from creation of a pouch may even predispose these patients to infection.

POSTER # 10Trichomoniasis in a patient with metronidazole allergy successfully treated with paromomycin: a case reportEnea Himi, Ayesha Mannan, Rmneek Kaur: 3rd year medical students- New York Institute of Technology-College of Osteopathic Medicine, Graduating year: 2018Background: Long considered as the most frequent non-viral sexually transmitted infection in the US, Trichomonas vaginalis is a common colonizer of the female lower genitourinary tract. This protozoal parasite is responsible for producing a grey-green, foul-smelling vaginal discharge, itching and erythema. FDA-approved treatment for T. vaginalis infection is metronidazole or tinidazole. These two nitroimidazoles work by covalently binding to DNA and preventing nucleic acid synthesis. Rarely, patients may have nitroimidazole–resistant infection or hypersensitivity to nitroimidazoles creating therapeutic dilemma. We present a case of trichomoniasis in an allergic patient.Case: A 23 year-old sexually active female with no significant medical history presented with grey-brown vaginal discharge. Nucleic acid amplification testing (NAAT) confirmed the diagnosis of T. vaginalis. Testing for chlamydia, gonorrhea, and HIV were negative. She had developed urticaria after using metronidazole gel several months prior for treatment of bacterial vaginosis. She was reluctant to agree to desensitization to metronidazole by an allergist. She was given paromomycin 250mg nightly for two weeks in a vaginal based cream prepared by a compounding pharmacy. She developed vaginal pain after seven days and stopped her treatment early. No vaginal ulcers were noted. Vaginal discharge completely resolved. Repeat NAAT for T. vaginalis was negative. Discussion: The Centers for Disease Control recommends desensitization in cases of metronidazole hypersensitivity for the treatment of trichomoniasis. Desensitization poses some challenges such as availability, cost, tolerance of treatment, and risk to the patient. Other drug treatments have been proposed, albeit with limited efficacy, such as a betadine douche, clotrimazole, furazoline, and acetersol. An alternate drug described in literature is paromomycin, an aminoglycoside sometimes used in the treatment of intestinal protozoa. Due to poor absorption from the gastrointestinal tract, paromomycin can be applied topically to the vaginal canal. However, there are few case reports on clinical outcomes. The largest review of paromomycin use in thrichomoniasis was by Nyirjsey et. al and involved 9 patients with metronidazole hypersensitivity who were given paromomycin 250mg nightly for two weeks. 6 of 9 patients were cured. Review of literature found an additional six cases that were treated similarly; three were cured. Drawbacks to paromomycin use include local irritation, no standardization of therapy dose or duration, suggestion of lower cure rates than nitroimidazoles, and availability of the drug. However, paromomycin may represent an appealing alternative to desensitization for patients with metronidazole hypersensitivity.

19

POSTER # 11Determinants of Default from Follow-Up Care in a Prostate Cancer Screening ProgramAkhil A. Saji, New York Medical College Class of 2018 (MS3)Authors: Akhil A. Saji1, Mark Ferretti2, Michael E. Goltzman1, Neel Patel2, Sean Fullerton2, Denton Allman2, Gerald Matthews2, John Phillips2

1School of Medicine, New York Medical College; 2Department of Urology, New York Medical College

Background: The curability of high-risk prostate cancer (PCa) may depend on early diagnosis and compliance with management modalities. Delayed or incomplete treatment for PCa may result in inferior clinical outcomes and lower survival rates. We sought to identify the proportion of and predictors of loss of follow-up care after positive prostate biopsy in a single-institution, retrospective cohort study.

Methods: Patients who ‘defaulted’ from follow-up were defined as those who had failed to return for treatment or follow-up discussion after PCa diagnosis. Demographic and clinical characteristics were compared between defaulters and non-defaulters using multiple linear regression.

Results: From October 2008 to April 2013, 6182 patients receiving 12,930 PSA tests were identified. 574 (9%) patients had at least one PSA test >4 ng/mL. 210 patients underwent biopsy for suspected PCa of which 141 had PSA >4. PCa was diagnosed in 85 (41%) patients of which 17 (20%) defaulted. Defaulters were younger (61.8 } 2.0y) �compared to non-defaulters (65.8 } 1.0y, t(83)=1.8, p=0.04). Defaulters �were more likely to be uninsured (24%), less likely to have a designated primary care provider at our institution (p<0.001), and more likely to self-identify as Latino (41%) (p=0.01). Multiple linear regression of age, insurance status, race, and PCP access predicted default (p<0.0005, R2=.430).

Conclusions: At our institution, males at highest risk of default from care after PCa diagnosis were younger, uninsured, Latino males without centralized healthcare. The defaulters in our series had a higher incidence of high-risk PCa (81% Gleason ≥7) emphasizing the importance of early aggressive treatment.

POSTER # 12Nodular Scabies Mimicking Urticaria PigmentosaAuthors: Kimberly Katz1, Nick Nguyen2, Falguni Asrani2, Bijan Safai21 School of Medicine, New York Medical College; 2Department of Dermatology, New York Medical College Program Director: Bijan Safai, MD, D.Sc.Entrant: Kimberly Katz, New York Medical College Class of 2018

Introduction: Scabies and urticaria pigmentosa are both prevalent under the age of 2 and share similar clinical findings namely red brown macules, papules, and nodules. In children scabies can mimic a variety of other cutaneous pathologies making it difficult to diagnose and often overlooked initially. Here we describe an unusual case of nodular scabies that presented with a positive Darier’s sign suggestive of urticaria pigmentosa.Case: A 2-month-old, otherwise healthy female infant, presented with a 4-week history of pruritic lesions, distributed throughout her lower trunk, with trace involvement of the proximal upper extremities, sparing the remainder of her body. No household members exhibited similar dermatologic findings. A positive Darier’s sign (the development of urticaria and an erythematous halo upon rubbing a lesion) was noted, a finding consistent with a diagnosis of urticaria pigmentosa. Thus a biopsy was done on another lesion, locally anesthetized using lidocaine without epinephrine, to exclude urticaria pigmentosa. The histopathology revealed an interstitial dermatitis with eosinophils and eosinophilic spongiosis, suggestive of an arthropod bite reaction, and a Giemsa stain was negative for urticaria pigmentosa. A serum tryptase was found to be within normal limits. Two weeks later, the eruption progressed to involve her arms, hands, palms, axillae, and groin area. Given the clinical progression pattern and biopsy results, a clinical diagnosis of nodular scabies was made and a treatment course with permethrin 5% cream of the patient and all household members was begun. The patient showed significant improvement and resolution of the eruption by 6 weeks.Discussion: Early identification and treatment of scabies in the pediatric population is crucial since associated pruritus and scratching can lead to eczematous changes that harbor secondary bacterial infection with Staphylococcus aureus and Streptococcus pyogenes.  Additionally, scabies has been reported as a risk factor the development of post-streptococcal glomerulonephritis. The presence of a positive Darier’s sign, although clinically diagnostic for urticaria pigmentosa, has been reported in a few rare incidents of scabies. Our case underscores the importance of keeping scabies on the differential diagnosis when a young patient presents with erythematous and tan papules that become indurated and edematous when the lesions are stroked.

20

POSTER # 13Two-Stage Revision for Infected Shoulder ArthroplastyDaniel B. Buchalter, BA, Siddharth A. Mahure, MD, Brent Mollon, MD FRCSC, Stephen Yu, MD, Young W. Kwon, MD PhD, & Joseph D. Zuckerman, MDDepartment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York University Langone Medical Center, New York, NY, USA Program Director: Dr. Kenneth A. Egol, MDDaniel B. Buchalter, New York University School of Medicine, Class of 2017

Background: Periprosthetic shoulder infections (PSIs) are challenging to treat and often result in significant patient morbidity. Without a standardized treatment protocol, PSIs are often managed similarly to periprosthetic hip and knee infections. Because two-stage revision is the gold standard for treating periprosthetic hip and knee infections, we performed a case series and literature review to determine its effectiveness in PSIs.

Methods: We identified nineteen patients from our institution that were treated with two-stage revision after presenting with a PSI. Minimum follow-up for all patients was 2 years. Mean patient age was 63 +/- 9 years, 14/19 patients were male, and average BMI was 30.8 +/- 5.8. Average time from index arthroplasty to treatment was 40 months, 8/13 positive cultures were P. acnes, and 9/19 patients had multiple shoulder operations before presenting with infection.

Results: After a mean follow up of 63 months (Range 25-184 months), 15/19 patients in our study were successfully treated for PSI. Average postoperative ASES score was 69 (32-98) and average postoperative forward elevation was significantly increased from 58 to 119 degrees (p < 0.001). The incidence of recurrent infection was 26%; the rate of non-infection complications was 16% for a total complication rate of 42%.

Conclusion: In patients with PSIs, especially those with intractable, chronic infections, a two-stage revision represents a viable treatment option for eradicating infection and restoring function. However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population.

POSTER # 14Epidermal DBL-1/BMP Signaling: Collagen-Dependent Modulation of Body Size and Non-Cell Autonomous Lipid Regulation in C. elegansMichael Meade1,2, Uday Madaan1, Edlira Yzeiraj1, Cathy Savage-Dunn1

1CUNY Queens CollegePrincipal Investigator: Cathy Savage-Dunn1

2Stony Brook School of Medicine, Class of 2020

Aberrant Transforming Growth Factor-beta (TGF-β) related signaling has broad pathological implications, including neoplasia and cardiovascular disease, underscoring the importance of characterizing the superfamily’s effect on growth and metabolism. Utilizing a microarray, we previously identified specific collagen genes of the cuticle exoskeleton to be targets of DBL-1/BMP signaling, a TGF-β related signaling pathway. We now show both positive and negative modulation of cuticle collagen genes regulate body size in C. elegans. Through electrophoretic mobility shift assays, we demonstrate SMA-4, a signal transducer in the DBL-1/BMP pathway, binds the intergenic region between col-141 and col-142 directly, the first demonstration that C. elegans’ BMP signal-transducing Smads bind DNA in vitro. Utilizing both overexpression and RNA interference experiments, we demonstrate cuticle collagen genes can modulate body size as a negative regulator (col-141), or as a dose-dependent regulator (rol-6). DBL-1/BMP signaling in the epidermis, the tissue responsible for secretion of the cuticle in C. elegans, warranted further investigation after we had previously shown epidermal expression of SMA-3, a signal transducer in the DBL-1/BMP pathway, to be both necessary and sufficient for normal body size. Utilizing Oil Red O staining of neutral lipid stores in strains with tissue-specific expression of the signal transducer, we now similarly identify epidermal expression of SMA-3 to be both necessary and sufficient for normal fat accumulation as well. This result suggests a non-cell autonomous mechanism of epidermal DBL-1/BMP signaling in the lipid storage phenotype, and underlines the importance of elucidating tissue interactions of TGF-β related signaling in an in vivo model.

21

POSTER # 15An Examination of venous thromboembolism risk using Caprini scores amongst outpatient aesthetic surgery patients who receive no chemoprophylaxis

Pierce Janssen, BS, Michael Trostler, MD, Christopher J. Pannucci, MD, MS, Sami U. Khan, MDPierce Janssen, MD Candidate, Class of 2018 (MSIII)Stony Brook University School of Medicine

BACKGROUND: The Caprini Risk Assessment Model is a widely utilized tool for venous thromboembolism (VTE) risk stratification and surgical prophylaxis. There is a paucity of data demonstrating Caprini effectiveness for ambulatory aesthetic surgery populations. Furthermore, many surgeons still use their own judgement for VTE prophylaxis due to concerns for postoperative bleeding. This study aims to assess VTE risk in ambulatory aesthetic surgery patients based on Caprini stratification. 

METHODS: A retrospective review of 2,595 patients undergoing ambulatory aesthetic surgery between October 2000 and January 2005 was performed. Caprini scores were calculated for each patient and stratified into risk categories: (1-2), (3-4), (5-6), (7-8), (>8). All patients received general anesthesia and mechanical VTE prophylaxis. The incidence of hematomas, reoperations, and VTE events were evaluated.

RESULTS: Among 2,595 patients, Caprini risk stratification was as follows: 30.2% (1-2), 59.5% (3-4), 9.8% (5-6), 0.5% (7-8) and 0% (>8). Postoperative incidence of hematomas and VTE were 2.8% (73/2595) and 0.077% (2/2595), respectively. VTE patients had Caprini scores of 4 (moderate risk) and 5 (high risk).

CONCLUSIONS: Ambulatory aesthetic surgery patients are at a very low baseline risk for VTE. Only 0.08% of patients in this large cohort, receiving only mechanical prophylaxis, experienced a VTE event. Only 0.5% fell into the Caprini ≥7 strata, known to be highest risk among surgery inpatients. Given the low number of VTE outcome events in this cohort of over 2,500 aesthetic patients, we can only say that the predictive value of the Caprini score for VTE events requires further study.

POSTER # 16Addressing Medical School Culture Around Mental Health - A Novel Approach to Promoting Medical School WellnessRobert Kim, Michael Levine, Shajoti Rahman, Emily Carbaugh, and Melissa HirschSUNY Downstate College of Medicine, Class of 2019

Evidence that medical students are at high risk for depression and burn-out have emphasized the need to integrate personal well being and mental health content into the medical school curriculum. We examined the association between rates of depression and burnout with the participation in a peer-led wellness curriculum that employed evidence-based psychological interventions. The nine one-hour sessions were administered at SUNY Downstate to all incoming students (N=200) and facilitated by two assigned second-year medical students (M2) mentors. Sessions developed strategies to maintain a healthy life balance, build resilience against stressful events, use criticism as a means of self-improvement, and limit stigma surrounding mental illness. To evaluate the program’s efficacy, students anonymously completed pre- and post-intervention surveys measuring depression, anxiety, loneliness, and burnout (the Malasch Burnout scale, PQ-9, GAD-7). M1 respondents were stratified based on session attendance (0-2 sessions, 3-5 sessions, 6-7 sessions) and compared to current M1’s at another SUNY medical school who did not participate in this program. Preliminary data show significant decrease in levels of anxiety, depression, and burnout. Moreover, participants report a stronger sense of connection among their classmates and increased emotional resilience. The integration of these evidence-based interventions into the school's curriculum prioritizes the values of physician wellness and work-life balance. This program may provide a cost-effective and peer-driven model curriculum that combats the high risk of depression and burn-out across the medical professions.

22

POSTER # 17Higher Case Volumes of Percutaneous Coronary Intervention are Associated with Improved Risk Adjusted Mortality Rates in 33 New York State HospitalsJonathan Smerlinga, Abhi Amarnanib, Debashree Senguptac

SUNY Downstate College of Medicine, New York, NY 450 Clarkson Avenue, Box 98, BSB 1-112, Brooklyn, NY 11203-2098jonathan.smerling@downstate.eduaMD Candidate class of 2020bMD PHD Candidate cMD Candidate class of 2017

Background: Percutaneous coronary intervention (PCI) is a nonsurgical technique for opening a blocked coronary. The American College of Cardiology recommends that hospitals perform > 400 PCI cases/year to maintain quality. We asked whether current and future PCI case volumes for NYS hospitals (2000-2013) were associated with risk adjusted mortality rate (RAMR), measured as the observed mortality rate/expected mortality rate multiplied by an adjustment factor. RAMR values > 1 indicate poor performance.

Methods: Using data from the NYS Department of Health PCI reports, a time series regression model was constructed to estimate the correlation between the number of PCI cases and RAMR. A modified model was used to ask if prior RAMRs were correlated with future PCI volume.

Results: Hospital PCI volume was inversely correlated to the RAMR (β= -6.31e -4, p< 0.005, R2= 0.11). Hospital non-emergent PCI volume was also inversely correlated with the non-emergent RAMR (β= -4.18e -4, p< 0.05, R2=0.6). Although the R2 values are low, the correlations are significant due to the large number of cases (n= 423). Based on the model, hospitals performing >360 cases a year had a RAMR that approached 1.00 after several years. The one-year lagged RAMR was not significantly correlated to the current PCI case volume (p = 1.62).

Conclusions: Our results suggest that higher volumes of PCI are associated with safer care. We found that a hospital’s RAMR was not significantly correlated with future PCI case volume, suggesting that good performance may not be rewarded with an increased number of cases.

POSTER # 18Influence of Single Polymorphic Nucleotides Known to Affect Pediatric Body Mass Index on Musculoskeletal Phenotypes in Children and Young AdultsAndrea Attenasio1,2,3, Jordan Cohen3,4, Samuel Swenson3,4, Alex Gu3,4,

Marianne Floor5, Heather Gordish-Dressman3, Brennan Harmon3, Eric Hoffman3, Dustin Hittel6, Leticia M. Ryan7, Susan Knoblach3, Joseph Devaney3, Laura L. Tosi 3,4,5

1Touro College of Osteopathic Medicine, Middletown, NY, 2Nth Dimensions Educational Solutions, Chicago, IL, 3Center for Genetic Medicine, Children’s National Health System, Washington DC, 4The School of Medicine and Health Sciences, George Washington University, Washington DC, 5Division of Orthopaedics and Sport Medicine, Children’s National Health System, Washington, DC, 6Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Alberta, Canada, 7Johns Hopkins Children’s Center, Baltimore, MD Entrant: Andrea Attenasio, OMSII, Touro College of Osteopathic Medicine Middletown, NY Class of 2019

Genome-wide association studies (GWAS) have identified numerous loci associated with BMI. A study by Felix et al. described the association of three novel single nucleotide polymorphisms (SNPs), rs13253111, rs8092503, and rs13387838, near ELP3, RAB27B and ADAM23 and 12 established SNPs with increased BMI in children. Our study seeks to explore whether BMI related SNPs identified by Felix, et al. influence additional musculoskeletal phenotypes in children and young adults. Two cohorts of young adults and one cohort of children were genotyped using Taqman allelic discrimination assays or an Illumina Multi-Ethnic Genotyping Array. ANCOVA models were used to test for a relationship between bone, muscle, and fat phenotypes and genotype. All outcomes were adjusted for age and tested in gender-specific cohorts using dominant genetic models. We found the established SNPs but not the novel SNPs to be associated with measures of BMI and fat. The rare allele of BMI variants is associated with increased muscle volume and strength but with decreased bone mineral density (BMD), BMD z-scores, cortical robustness, polar moment of inertia (PMI), and relative cortical volume. Of the 3 novel BMI SNPs, the rare alleles for rs13253111 and rs8092503 are significantly associated with decreased exercised arm robustness, decreased PMI in both arms, and increased dominant arm grip strength. The rare alleles of variants rs4854349, rs13130484, rs1421085, and rs6567160 are associated with larger, stronger muscles, but lower BMD, robustness, PMI, and relative cortical volume. These results suggest a potential to use BMI variants to predict a broader range of musculoskeletal outcomes.

23

POSTER # 19Association between Marijuana Use and Tako Tsubo Cardiomyopathy (TTC); Analysis from the National Inpatient Survey (NIS) 2012 – 2014.Alliu Samson MD, MPH1, Adejumo Adeyinka MD, MS2, Adegbala Oluwole MD, MPH3, Ajayi Tokunbo MD4, Namana Vinod MD, MPH1, Durojaiye Modupe MS5, Chetana Pendkar MD1, Yevgeniya Borovinskaya6, Wolf Lawrence MD1, Hecht Melvyn MD1, Jacob Shani MD1, Hollander Gerald MD1, Edgar Lichstein MD7, Kamholz Stephan MD1

Institution affiliations(1) Maimonides Medical Center, Brooklyn, NY. (2) University of

Massachusetts Medical School, Worcester, MA. (3) Englewood Hospital and Medical Center, Englewood, NY. (4) Johns Hopkins Medicine, Howard County General Hospital, Columbia, MD. (5) University of Alabama at Birmingham, Birmingham, AL. (6) New York Institute of Technology, Old Westbury, NY. (7) Albert Einstein College of Medicine, Bronx, NY.

Author Information: Alliu Samson PGY-3, Expected Date of Completion of Training: June 2017

Background and Objective: Marijuana causes catecholamine surge with consequent tachycardia and hypertension immediately after use. It is unclear if the adrenergic surge is sufficient to cause left ventricular wall apical ballooning (Tako Tsubo Cardiomyopathy (TTC)). Given the similarity in the pathophysiology of TTC and mechanism of action of cannabis, we sought to investigate if there is any association.Methods: We obtained data from the HCUP-NIS of all patients older than 45 years hospitalized between 2012 - 2014. Our outcome was diagnosis of TTC and main exposure variable was cannabis use both identified using the ICD-9 codes. Using the SURVEYLOGISTICS procedure we performed logistic regressions to estimate the odds of TTC among cannabis users adjusting for demographics, comorbidities and other recreational drugs. Results: Of the 7,805,400 hospitalized patients who were > 45 years, 10,160 (0.1%) had a diagnosis of TTC, 54,311 (0.7%) were non-dependent cannabis user and 5,045 (0.1%) were dependent cannabis users. After adjusting for potential confounders such as age, race, gender, median family income, hypertension, diabetes, renal failure, cocaine, amphetamine and alcohol, we observed a 2-fold increased odds of TTC among nondependent cannabis users (AOR 2.00 [1.61-2.40]). However, the association was not significant among dependent cannabis users (AOR 0.70[0.25-1.92]) as compared to non-users. Conclusion: Nondependent cannabis use is associated with increased risk of TTC while dependent cannabis users have the same risk as the general population. With increasing states legalization of cannabis, our study adds to the body of knowledge on the effect of cannabis on the human body.

POSTER # 20Blood Culture Contamination, can it be solved? - Initiatives in a Tertiary Teaching HospitalCadang MD, Benmoussa MD, Beverido MD, Fuoching MD, Repudi MD, Iqbal MD, Sriskandaraja MD, Thu MD, Saverimuttu MD, Palladino MD, Arsura MD. Richmond University Medical Center, affiliate of The Mount Sinai Hospital and the Icahn School of Medicine, Department of Internal Medicine, Staten Island, NYIntroduction: Bacteremia is a significant cause of morbidity and mortality in hospitalized patients. Therefore identifying blood cultures as true positives is paramount to the management of patients. Despite advances in protocol for proper blood culture collection, the possibility of contamination is still a concern. Contamination requires repeat blood cultures, use of antibiotics, delays in procedures, prolonged length of stay, and increased cost. Thus, it is imperative to identify sources of contamination and prevent recurrence. Objective: Assess the rate of blood culture contamination at RUMC, identify the causes and implement corrective actions to achieve the national target contamination rate.Materials/Methods: The study included patients over 18 years of age. Using data from electronic medical records, we collected blood cultures drawn in the emergency department, intensive care units, and general medical floors in April 2014, 2015 and May 2016. The organisms considered contaminants were obtained from the CDC common commensal list. Results: In all surveys more than 50% of contaminated blood cultures were drawn in the ER. The most common contaminants were Coagulase Negative Staphylococci.Discussion/Intervention: The national target contamination rate is set at 2-3%. In the College of American Pathology Q-Tracks Study the Median Contamination rate was 2.92%. Our goal was to reduce contamination rate from 5.07% as identified in April of 2014, to as low as possible. To achieve this, we adopted the PDCA model (Plan, Do, Check Act). We suggested a multi-disciplinary approach focused on education. We required all staff attend a video tutorial on proper sterile technique and compliance with chlorhexidine skin antisepsis. It was mandatory that all staff complete an online assessment to receive certification. Also a customized blood collection kit was instituted. This was initiated in the year 2014 to 2015. In 2015 to 2016 the education was ongoing, phlebotomists with contamination were notified, and a new customized blood collection kit was introduced in the Emergency Room which was piloted in the month of May 2016.Conclusion: Blood culture contamination is a patient safety of care issue. Not only does it increase the risk of potential harm to the patient, it increases the overall cost and decreases patient satisfaction. In order to reduce the blood culture contamination rate at RUMC we adopted the PDCA model, identified factors and instituted corrective actions, namely, having a mandatory online course with ongoing education, Customized blood culture collection kit, feed back to phlebotomists with contamination, and finally altering the kit to fit the ER requirements. As a result of this we were able to reduce the rate from 5.07% to 2.56% between the years of 2014 to 2016.

24

POSTER # 21Avoiding Antibiotics Use in Acute Bronchitis – An Integrated ApproachChime Chukwunonso 1, Thomas Shawn1, McCaleb Chase1, Dapkins Isaac1, Chilimuri Sridhar (Program Director)11. Bronx Lebanon Hospital CenterInternal Medicine PGY4 – complete training 06/30/20171650 Selwyn Avenue, 10C, Bronx.NY.10457, cchime@bronxleb.org

Background : Acute bronchitis is usually due to viral infections and according to the Centers for Disease Control, antibiotics are almost never needed. However CDC reports a high rate of antibiotic use in patients with Acute Bronchitis. Prior research in Quality Improvement has shown that education alone is rarely effective.

Aim Statement : Our aim is to educate clinicians and develop EMR algorithms to help reduce inappropriate use of antibiotics.

Methods : We collected data on use of antibiotics for acute bronchitis in all patients in our clinics under a specific health plan from 2014 to 2016 using our EMR and Claims reports

Intervention: 1. Clinicians were educated on the new HEDIS measures regarding avoidance of antibiotics use in acute bronchitis.2. In mid-2015, a pop-up order alert was implemented in the EMR to inform physicians to avoid antibiotics prescription in patients with diagnosis of Acute Bronchitis.

Data: In 2014, only 15 out of 68 clinic patients with acute bronchitis did not receive antibiotics (22%), that number was 16 out of 50 in 2015 (32%) and increased to 24 out of 52 in 2016 (46%) after intervention. {P < 0.01 from 2014-2016}

Conclusion: A multistep approach of education and EMR alerts can reduce inappropriate use of antibiotics in patients with Acute Bronchitis.

POSTER # 22Statins Ameliorating Viremia Severity on Hepatitis C Initial Diagnosis Basma Elsawy MD, Moustafa Elsheshtawy MD, Abdel Hamid Abd El Shafy MD, Rada Yerneni MD, Amy Moore MS, and Michael Bernstein MD.Affiliation: Department of Medicine. Coney Island Hospital, Brooklyn, NY 11235, USA. Corresponding author: Basma Elsawy MD PGY II. Department of Medicine. Coney Island Hospital. 2601 Ocean PKWY, Room 4N98, Brooklyn, NY 11235.

Background: Statins interfere with lipid metabolism, including the membranous web of hepatitis C viral replication, resulting in reduced viremia. There are no studies to date demonstrating statins effect on initial viral load, in contrast to few published studies displaying the potential role of statin on the viral load in known patients with hepatitis C.

Methods: Patients’ medical records with a confirmed discharge diagnosis of chronic Hepatitis C (ICD-9 070.54) between January 2000 and December 2013 were retrospectively analyzed. The objective of the study was to determine the relationship between statin-use and viral load for Hepatitis-C patients. Descriptive statistics were performed on continuous variables. Frequency tabulations were used for discrete variables. Secondary analysis involved controlling for age group with age 55 as the cut-off between younger and older patients. The Student-T test, a parameter test-statistic, was conducted on the log viral load to evaluate statin-use. The Wilcoxon test statistic, a non-parametric test was also used for sub-group analysis.

Results: There was a statistical significance between the log viral load and statin use, regardless of the age group (P-value= 0.0187). Statins exerted an inhibitory effect on the log viral load when adjusted for the younger age group <55 (P-value = 0.0015). There was a statistically significant difference between Statin users and Log Viral Load for Females (P-Value=0.0148).

Conclusion: Statins were found to be associated with decreased hepatitis C viremia at time of diagnosis. Statins might be a valid future avenue to be included on the standard therapy for hepatitis C treatment.

25

POSTER # 23Barriers and Predictors of Medication Adherence in Diverse Inner City Pediatric Patients with Inflammatory Bowel Disease.Johanna Ferreira, MD1, Lindsey Gummer, MD2, Rebecca Lois, PhD3, Donald E. Morisky4, Sc.D., M.S.P.H., Mimi Kim, Sc.D5, Xianhong Xie, PhD5, Gitit Tomer, MD1. 1. Division of Pediatric Gastroenterology, Hepatology and Nutrition. The

Children’s Hospital at Montefiore. The University Hospital for Albert Einstein College of Medicine. Bronx,NY

2. Division of Pediatric Gastroenterology, Hepatology and Nutrition. The Children’s Hospital of Colorado. Aurora, CO

3. Department of Psychology NYU Langone Medical Center New York, NY

4. Department of Community Health Sciences. UCLA School of Public Health. Los Angeles, CA.

5. Department of Epidemiology & Population Health. Albert Einstein College of Medicine. Bronx, NY.

Background: Inflammatory bowel diseases (IBD) are chronic gastrointestinal diseases requiring medical therapy to maintain clinical remission. Non-adherence to medications is associated with poor outcome. Identifying non-adherence, medication barriers, and depression can lead to interventions that will improve clinical remission.Methods: IBD patients ages 11 to 21 years were asked to fill out the Adolescent Medication Barrier Scale, 8-item Morisky Medication Adherence Scale and a 9-item depression scale at their visit. Parents were asked to fill a demographic questionnaire and Parent Medication Barrier Scale. Physician global assessment was collected from patient charts.Results: Sixty-four IBD patients were studied. Hispanics comprised 51.4% of our patients and African Americans 25% of our patients. Eighteen percent of participants met criteria for high adherence, with 33% and 48% falling in the medium and low categories. Physicians classified correctly only 50% and 25% of patients with low and medium adherence. Fifteen subjects (25%) were identified to have mild depression, two (3%) moderate and one (2%) moderate to severe depression. Depression and disease duration correlated with lower adherence scores (P=0.03). The most common patient-reported barriers were feeling tired of having a medical condition and tired of taking medications. Parents perceived children feeling tired of having a medical condition and being forgetful as major barriers for adherence.Conclusions: This study reveals that adherence to medications is challenging for diverse pediatric IBD patients. Routine screening for adherence, depression and medication barriers identify patients at risk of non-adherence who might benefit from interventions that will improve patient care and outcome.

POSTER # 24Predictors of Parental Consent for Donor Human Milk in the NICU

Radhika Ghosh, Divya Periasamy, Patricia Discenza, Josef Newman, Seleshi Demissie, Philip Roth, Jonathan Blau

Staten Island University Hospital, Northwell Hofstra School of MedicineRadhika Ghosh, MD, Pediatric PGY-2 - Date of Entry :June 2015Expected date of graduation: June 2018Email: radhika.ghosh16@gmail.com

Background: Numerous studies have documented beneficial effects of Donor Human Milk (DHM) use when expressed HM is unavailable. DHM is considered a human tissue by NY State & therefore requires parental consent. Despite anecdotal reports of parental refusal of DHM, scant literature exists on reasons parents grant/refuse consent.

Objective: We aim to determine factors affecting parental consent for DHM. We hypothesize that multiple factors, including maternal age, socioeconomic, educational & marital status; racial, & religious backgrounds, and prior breastfeeding history are responsible for parental consent/non-consent.

Methods: This survey study was administered to postpartum mothers at SIUH whose newborns were admitted to NICU. The survey gathered maternal/neonatal characteristics, asked whether mothers would consent to DHM and ascertained reasons for granting/refusing consent.

Statistical analysis: The primary outcome variable was desire to consent. For categorical variables, comparisons were made using Chi-square test or Fisher exact test. For continuous variables, comparisons were made using two sample t-tests.

26

Results: 214 patients admitted during a 9-month period were included. (P-value < 0.05 = * significant)

1. Religious mothers were more likely to refuse consent. (*0.018)

2. More premature and lower birth weight predicted consent. (*0.006, *0.035 respectively)

3. Intention to BF after discharge predicted consent. (*0.049)

4. Higher maternal education level predicted non-consent. (*0.013)

Conclusion: Several maternal/neonatal factors were associated with DHM consent. These data should increase understanding of issues affecting parental consent therefore improving informed consent process in our newly launched DHM program.

POSTER # 25Comparison of Length of Stay and Discharge Disposition between Anticoagulants for Secondary Stroke Prevention in Atrial FibrillationArpita Hazra, Sanskriti Mishra, Kinsuk Chauhan, Michelle Gribko, Rohan Arora.Arpita Hazra, Sanskriti Mishra, Michelle Gribko, Rohan Arora - Hofstra Northwell School of Medicine /Northwell Health, Manhasset NY, Kinsuk Chauhan-Icahn School of Medicine at Mount Sinai, New York

Background: Novel oral anticoagulants(NOACs) are approved for secondary stroke prevention in patients who have non-valvular atrial fibrillation(AF). Studies show that patients with AF who are treated with NOACs have shorter admissions. This study determines if patients treated with NOACs have shorter length of stay(LOS) and are more likely to have a favorable discharge disposition vs. those treated with warfarin.

Methods: Study population included 2236 ischemic stroke or transient ischemic attack(TIA) patients with non-valvular AF admitted to a comprehensive stroke center in Long Island, NY between 2012-2016. We compared LOS and disposition of patients discharged on warfarin vs. NOACs(apixaban, rivoraxaban, dabigatran). Logistic regression analysis used to calculate the odds ratio (OR), 95% confidence interval (CI) and p-values.

Results: Out of 2236 patients, 17% had pre-existing AF and 83% had new-onset AF. 10.6% of the patients were on warfarin and 8.4% were on NOACs(apixaban 4.3%, rivaroxaban 2.5% and dabigatran 1.9%). Median LOS for our cohort was 4 days. There is no difference in the median LOS between classes of anticoagulants(median 4). Of the 583 patients with prolonged LOS(>7 days), 46.8% went to inpatient rehabilitation facility, 24.4% went to skilled nursing facility and 22.1% were discharged home. Among these patients, 9.4% were discharged on warfarin vs. 8.1% on NOACs. Prolonged LOS was most commonly associated with hypertension(68.27%), dyslipidemia(44.25%) and diabetes mellitus(31.73%). Among patients who were discharged home, there was no statistically significant difference between those who were treated with warfarin vs. NOACs.

Conclusion: Choice of anticoagulation for secondary stroke prevention in patients with ischemic strokes and TIAs secondary to non-valvular AF did not have a significant effect on LOS and discharge disposition.

27

POSTER # 26De-Prescribing in Older Adults Is Possible; Success Varies With Medication Class: A QI Initiative

S Islam MD, K Kanagala MD, M Nashid MD, E Chijoke MD, S Reddy MD, A Daniel MD, A Lebelt, P Murakonda MD, TS Dharmarajan MD, MACP

Division of Geriatrics, Montefiore Medical Center (Wakefield), Bronx, NY

Background: Polypharmacy is the inappropriate and excessive use of medications, common in the old. Polypharmacy contributes to adverse drug events (ADEs) which manifest as falls, dementia, syncope, organ dysfunction besides non-adherence, hospitalization and mortality. Older adults account for 13% of the U.S. population, but utilize 33% of prescribed medications. De-Prescribing (DeP) refers to the process of safe and appropriate tapering, stopping, or withdrawing medications that are unnecessary or inappropriate, aimed to minimize ADEs, improve outcomes and reduce costs. While relatively safe, clinicians find it difficult to carry this out in practice.Methods: As a Quality Improvement Initiative, DeP was attempted in our community (C ) and long-term care (LTC) patients by fellows in geriatrics under supervision of attending faculty. Data on demographics, (age, gender, C/ LTC stay), co morbidity, medication classes and patient willingness or reluctance were collected and tabulated using a tool. The aim was to discontinue or reduce dosage of medications in a safe manner, if patient was agreeable. Data gathered from 330 patients; 30 eliminated ( incomplete data). Females 182/300(61%); age range <65 yrs (8%),<66-75yrs( 20%) >76yrs (72%). Nursing home residents 218 (73%), community 92(27%)Results:

MedicationClass

PatientNumber (by Class)

Dose Reduction (Number)

F M PercentDose Reduction

Discontinued(Number)

F

Proton pump inhibitors

73 3 3 0 4.10% 16 13

Asthma 48 1 1 0 2.08% 4 3Diuretics 49 2 2 0 4.08% 4 2

Anticoagulants 37 0 0 0 0 3 2

Antipsychotics 48 2 1 1 4.16% 3 1Antihypertensives 205 10 6 4 4.87% 12 8

Vitamins / Minerals 242 3 2 1 1.2% 14 8

Oral hypoglycemics 54 4 2 2 7.4% 3 2Anti-lipidemic 157 3 3 0 1.91% 8 3

Laxatives / softeners 191 4 3 1 2.09% 6 4

Analgesics 196 4 2 2 2.04% 4 0Antidepressants 112 1 1 0 0.89% 3 1

Other classes 155 2 2 0 1.29% 12 8

Conclusions: Successful DePrescribing of medications is possible and best achieved with

PPIs, asthma/COPD medications, diuretics, anticoagulants and antipsychotics.

Several factors influenced ability to de-prescribe, including provider effort, patient cooperation and co-morbidities.

28

POSTER # 27Prevalence of QT prolongation and LVEF changes in patients admitted with diabetes mellitus (DM) over a 4-year time periodIRB approved studyYing Luu, MD, PGY2; Zhongju Lu, MD, PhD, PGY 3; Mohit Sharma, MD, PGY 3; Joan Faro, MD, MBA; Alan Kaell, MDSUNY Stony Brook Internal Medicine at John T. Mather Memorial Hospital, 75 North Country Rd, Port Jefferson, NY 11777Ying Luu, MD PGY 2

Aim: To evaluate the prevalence and longitudinal changes of prolonged QTc in DM patients admitted to our community hospital, and to determine, if any, its correlation with changes of left ventricular ejection fraction (LVEF).

Methods: Retrospective chart review of patients with Type 1 (T1DM) and Type 2 (T2DM) with at least two admissions during a 4 year period was performed to identify QTc interval, and LVEF, as measured on transthoracic echocardiogram. Changes in QTc and LVEF between patient hospital admissions were compared.

Results: For T1DM, prolonged QTc was prevalent in 66.7% (n=16/24) and for T2DM, in 51.0% (n=79/154). Mean QTc in T1DM was 457.8±5.9ms during initial hospitalization and 464.2±6.5ms during the last (p=0.48, n=24), with a median time interval of 20.5 months (95% CI:14.7-28.1). The corresponding LVEF were 63.2±2.2% and 61.8±2.0% (p=0.63), respectively (Figure1). Mean QTc interval was 450.9±3.2ms during the initial hospitalization and 453.8±3.8ms during the last (p=0.56, n=154), with a median time interval of 17.3 months (95% CI: 14.4-20.2 (Figure2)). Corresponding LVEFs were 60.4±1.4% (n=70) and 55.1±2.0% (n=37) respectively, (p=0.03) (Figure 3). 62% of T2DM patients with longitudinal data (n=23/37) had a reduction of LVEF between admissions, from 62.4±1.9% to 55.5±2.0% (p<0.001, paired t-test) (Figure4).

Discussion/Conclusion: High prevalence of QTc prolongation was confirmed in hospitalized patients with in both T1DM and T2DM. Significant reduction of LVEF correlated with QTc prolongation over a mean of 17.3 months in T2DM patients and may have implications for interventions (Table1). Importantly, QT prolongation was never captured by neither provider nor coders. The implications and limitations of this research are presented in Table2.

POSTER # 28OPaL, A Mobile and Online Tool for Documenting Residency Competencies and Milestones Shoshanna Miller MD, Mohammad Fidahusain MBBS, Yule Lee MD, Raquel Benchoam MD, Ryan Pastena MD, James A. Tacci MD JD MPH, Scott McIntosh PhDPublic Health Sciences, University of Rochester Medical Center, Rochester, New York 14642

Background/Purpose: The University of Rochester General Preventive Medicine Residency Program provides multi-discipline training and experience for identified ACGME Competencies and Milestones. Documentation of the training and practicum experiences occur across a variety of clinical and public health settings. Evaluation processes currently include standardized forms (completed and reviewed at mid- and post-rotation), and permit a wide variety of documentation styles and levels of detail. Innovation is needed for the development and pilot implementation of a flexible experience-tracking tool to facilitate standardized, timely and accurate documentation of required competency-related activities. The current tool is being piloted and evaluated for ease of access and usefulness in evaluation.

Methods: Using REDCap software (a HIPAA secure survey platform), a simple online (and mobile-accessible) formwas created for Preventive Medicine Residents who were encouraged to enter checklist data and brief summaries(daily or weekly) across three Domains: 1) OPaL (categorize a task or assignment as either Observational,Participatory or Leadership), 2) Competency category (Patient Care, Medical Knowledge, etc.), and 3) PreventiveMedicine Milestones within each Competency (e.g., “PC1: Emergency Preparedness and Response: Apply skills in Emergency Preparedness and Response”).

Results/Educational Outcomes: There was general consensus that the OPaL tool was easy to use and useful in identifying specific milestones (for both the resident and the rotation preceptor). Early results indicate improved accuracy of evaluation, increased numbers of competencies and milestones identified, and improved documentation of details.

Conclusions/Strength of Innovation: The online platform resource can be shared with other residency programs to improve resident activity documentation and evaluation.

29

POSTER # 29An Interdisciplinary Approach to Improving Care and Reducing Length of Stay in Patients with Cellulitis

Neha R. Naik, MD, PGY3, BSN; Michael E. Tofano, MD; Richard Poveromo, LMSW, CCM; Nirupa Ramji-Singh, RPA-C; David Galinkin, DO, MPH; Maricelle O. Monteagudu-Chu, PharmD, BCPS (AQ-ID); Lois McCarthy, RN, BSN; Liza M. Dominioni, C-TAGME

Institution Affiliation: SUNY Stony Brook at John T. Mather Memorial Hospital Internal Medicine Residency Program, Port Jefferson, New York

Background: A community teaching hospital was in variance (outside the expected norm) to the state and regional benchmarks on average length of stay and readmission rate for patients admitted with cellulitis over a six quarter period. An interdisciplinary approach was utilized to develop and implement an evidenced based customized program to address the variance.

Methods: An interdisciplinary team consisting of Medicine, Nursing, Social Work, Pharmacy, Infectious Diseases and Information Technology was developed to address the variance. The team in collaboration developed and implemented a customized program for (n=260 patients) over a 12 month period aimed to decrease the average length of stay and readmissions of patients diagnosed with cellulitis. The program consisted of a monitoring group, daily reporting on cellulitis cases, interdisciplinary daily rounding and resident education, infectious diseases consultation, early of broad spectrum antibiotics, an antibiotic stewardship program, and an early transition to skilled care in the community.

Results: The average length of stay for patients with cellulitis decreased from 6.31 days to 4.85 days and the readmissions rate for cellulitis decreased by 23.2%, resulting in a substantial cost savings.

Clinical Relevance & Conclusions: Interdisciplinary collaboration is essential for developing and implementing customized programs to address identified variances in length of stay and readmissions related to cellulitis. However, the interdisciplinary approach utilized here is replicable and applicable across multiple medical diagnoses and serves as an exemplar for not only reducing costs to the health care institution but also improving patient outcomes.

POSTER # 30Incidence And Predictors of Recurrent Atrio-Ventricular Nodal Reentrant Tachycardia (AVNRT) After Successful Ablation: A > 10-Year, Single Center StudyMichelle Pintea, MD, Keshwar Ramkissoon, MD & Gioia Turitto, MDElectrophysiology Services, NewYork-Presbyterian Brooklyn Methodist Hospital

Between January 2005 and December 2014, a single operator performed ablation for documented or suspected supraventricular tachycardia secondary to AVNRT in 150 patients with long-term follow-up data available for review. During a mean follow-up of 57 months, 9 patients experienced recurrent palpitations requiring ER visits (n=4), or had a repeat ablation (n=5) for recurrent AVNRT. The overall arrhythmia recurrence rate was 5.7%. The mean time interval between the first procedure and the recurrence of symptoms and/or the repeat procedure was 52+/-46 months (range:23-156).

The following variables were analyzed to predict recurrent AVNRT: age, gender, follow-up, multiple slow pathways, inducibility, need for isoproterenol, multiple AVNRT types, AVNRT cycle length, endpoint of complete slow AVN pathway abolition vs persistence of slow pathway with ≤1 echo, fluoroscopy time, and lesion time.

On univariate analysis, significant predictors of recurrent AVNRT were: female gender (100% vs 67%, p<0.05), multiple slow pathways (22% vs 2%, p<0.001) and multiple AVNRT types (13% vs 1% p<0.05). On multivariate analysis, female gender remained significantly correlated to recurrence rates (p<0.03), while the presence of multiple slow AVN pathways and inducibility of >1 type of AVNRT had marginal p values (0.06 and 0.054, respectively).

Our study showed that recurrence rates after AVNRT ablation are low during a very long-term follow-up; surprisingly, patients may experience recurrences even >10 years after the initial procedure. Female gender may predispose to recurrent AVNRT, while procedural variables are less predictive; complete abolition of slow pathway conduction may not be necessary to achieve satisfactory long-term results.

30

POSTER # 31The Effectiveness of Grand Rounds on Referrals to Rheumatology for Shoulder PainRandolph Sanchez, M.D 1, Deana Lazaro, M.D. 2

1Department of Medicine, PGY-2 (2018) SUNY Downstate Medical Center, 450 Clarkson Ave. Brooklyn, NY 2Chief of Department of Rheumatology, Brooklyn VA Medical Center

BackgroundShoulder pain is a common clinical problem in ambulatory settings. A common problem is incomplete work-up and examinations prior to meeting with rheumatologists. We analyzed the effectiveness of delivering grand rounds on complete shoulder examination and work-up prior to referral as a modality to improve shoulder pain evaluations and referrals to rheumatology.

Methods A cross-sectional analysis was performed on shoulder pain consults 6 months before and after a Grand Rounds (GR) discussion presented by Dr. Lazaro, August, 2015, consisting of shoulder examination review, work-up, differential diagnosis, and referral. Referrals totaled 47 (44 Men, 3 women) over 12 months. Quality metrics included shoulder examination, imaging, intervention administered prior to referral, referrals for steroid injections, and consult volume.

Results Overall volume was 22 consults prior to GR, 1 day of GR, 24 consults after GR. Of the 47 consults, 55% of consults were for non-specific shoulder pain, 13 before and 12 after GR. Of the 47 diagnoses given prior to referral, 14% corresponded with final diagnoses. 11 of 47 consults were for steroid injections, 7 receiving and 4 not qualifying. 21 of 47 consults qualified for steroid injections as treatment. 16 of 47 consults were treated with analgesics and/or activity modification and/or PT, 7 before and 9 after GR.

ConclusionWe did not observe a change in quality when comparing groups before and after GR. Delivering information requiring multiple steps and procedures may require more extensive learning tools than Grand Rounds Discussions.

POSTER # 32Modafinil Treatment of Cocaine Dependence: A Systematic Review and Meta-analysisDinesh Sangroula, MD; Department of Psychiatry, Jamaica Hospital Medical Center, New York, NYBackground: Currently, there is none FDA approved medication to treat cocaine dependency. Studies conducted with various drugs, including antipsychotics, antidepressants, anticonvulsants, and others, revealed inconsistent results. Aim: To meta-analytically investigate the efficacy and safety of modafinil in the treatment of cocaine dependence.Method: Randomized controlled trials with ≥20 subjects comparing the numerical therapeutic outcomes of modafinil with placebo were identified in databases, such as PUBMED, psycINFO, EMBASE, and Clinicaltrials.gov and relevant data on efficacy and safety were extracted. Relative Risk (RR) and Standardized Mean Difference (SMD) were applied for reporting dichotomous outcomes and continuous outcomes respectively and random effects, subgroup, and meta-regression analyses were performed. Result: In total, 11 studies (participants, n=896, duration=6.7±1.9 weeks) comparing modafinil with placebo were systematically analyzed which indicated that modafinil was not superior to placebo in improving the treatment retention rate (studies, N=11, n=891, RR=1.030, 95% CI=0.918-1.156, p=0.613) or achieving cocaine abstinence (N=7, n=696, RR=1.259, 95% CI=0.813-1.949, p=0.302). However, subgroup analysis of six studies conducted in the United States demonstrated modafinil’s superiority in cocaine abstinence rate (N=6, n=669, 95 % CI=1.027-2.020, p=0.035). Additionally, no evidence suggested modafinil-related discontinuation or specific adverse events than placebo.Literature review and discussion: Earlier meta-analysis of nine studies by Castells et al. with 640 participants on five different psychostimulants (modafinil, mazindol, dextroamphetamine, methylphenidate, and bupropion) evidenced non-significant results for any of the drugs in reducing cocaine use and improving retention rate. Subsequent meta-analysis by the same author on 16 RCTs (n=1345) on two additional psycho-stimulants (methamphetamine and selegeline) replicated same results with additional trend of significance for dextroamphetamine and modafinil for improving sustained cocaine abstinence. However, in these meta-analyses, the number of RCT's included was very small (N=2). Conclusions: Overall, there is no evidence to conclude modafinil’s superiority in increasing cocaine abstinence and treatment retention rate. However, promising result in subgroup analysis of cocaine abstinence, secondary outcomes, and good safety profile urged the need of larger studies to derive more conclusive results. Significance: Though being widely studied, there are insufficient data to prove the efficacy and routine use of modafinil in the treatment of cocaine dependent individuals. However, if used with behavioral therapy, it could possibly be safe and beneficial in selected cocaine dependent individuals with other modafinil indication, such as narcolepsy and work shift-/sleep apnea-related sleep disorder.

31

POSTER # 33Are Hematological indices useful in identifying culture negative early onset sepsis and guiding antibiotic therapy in well appearing late preterm and term neonates?P. Thimmappa PGY3 expected graduation 2017, S. SridharInstitution: Pediatrics, Stony Brook Children’s Hospital, Stony Brook, New York 11794Background: Sepsis in the newborn period primarily occurs in the setting of clinical or histological chorioamnionitis, both of which are associated with abnormalities in hematological indices. A small group of infants however, in absence of chorioamnionitis are admitted to the NICU with a diagnosis of presumed sepsis due to abnormal lab values on their screening CBC done in the newborn nursery. These infants are then exposed to antibiotics for a 48 or greater hour period based on the clinician’s discretion.Objective: This study is to evaluate the association between abnormal hematologic indices such as WBC, IT ratio, CRP and degenerative neutrophils and its relationship to true placental inflammation in well appearing late preterm to term infants with negative cultures; In addition to determining the need for antibiotics beyond 48 hours.Design/Methods: Retrospective Cohort study on infants born > 35 weeks GA near term and late term infants admitted to the NICU who received a sepsis evaluation and at least 48 hours of antibiotics. All infants were initially admitted to well-baby nursery and had a screening CBC done at 6hrs of age were well appearing at birth none of whose mothers had fever.Results: Of the 100 infants in our study 70 had placental pathology available and only 22% (16 infants) were found to have histological evidence of fetal placental inflammation, also called funisitis. For these infants the IT ratios,12 and 24 hour CRP were elevated showing statistical significance and a negative predictive value of 76%, 75%and 76% respectively. The data showed that the negative predictive value for degenerative neutrophils and WBC were at 93% and 84% respectively. Of the infants that received antibiotics, only 17% of those in the >2 days group and 14% in the <=2 days group showed funisitis and all had significant CRP and/or IT ratios. Conclusion(s): Per our Cohort appears that IT ratio and 12 and 24 hour CRPs showed a statistical significance in patients with evidence of placental inflammation. In a hand full of patients it appears that an elevated CRP or IT ratio would be more concerning for true infection while those with elevation is only WBC or with evidence of degenerative neutrophils might not be correlated with true infection. Future large center may be helpful in managing culture negative sepsis, as this could decrease hospitalization costs, risks for hospital acquired infections and could potentially decrease the use of unnecessary antibiotic therapy.

POSTER # 34Ophthalmology consult rates are influenced by season, temperature, and precipitationWhigham, Benjamin; Shinder, RomanDepartment of Ophthalmology, SUNY Downstate School of Medicine, Brooklyn, NY, United States. Entrant info: PGY-3, Ophthalmology

Background: It is unclear if weather and season affect ophthalmology consultation rates.

Clinical Relevance: Recognize factors that influence acute ophthalmic presentations.

Methods: We reviewed resident-maintained records of ophthalmology consults at Kings County Hospital Center from 7/1/2010 to 6/30/2016. For each date, mean temperature (Fahrenheit) and precipitation (clear, rain, or snow) were determined. The rate of consultation was determined for each category of precipitation; for each 10-degree increment of temperature; and for each month of year. The analysis was repeated for specific diagnoses including orbital fractures and herpetic eye disease. Tests of significance were performed using a Chi Square Test.

Results: A total of 10,605 unique ophthalmology consults were identified in the study period. Rates of consults varied by month (p= 1x10-21) with generally higher rates in summer months. The highest rate of consultation was observed in August (5.6/day) and the lowest in January (4.1/day). Consult rates varied by mean daily temperature (p=2x10-6) and were less at colder temperatures (4.3/day at 21-30°F compared to 5.1/day at 71-80°F). Precipitation reached significance (p=6x10-9) with more consults seen during clear weather (4.9/day) than rain (4.4/day) or snow (4.0/day). Orbital fractures (n=1,181) were significantly overrepresented at warmer temperature (p=0.01) and on clear days (p=0.0001). Herpetic presentations including zoster and simplex (n=247) were more frequent at colder temperatures (p=0.03) and on days with snow (p=0.003).

Conclusions: Overall rates of ophthalmology consultation decreased in winter months, with colder temperatures, and with precipitation. This pattern held for orbital fracture consults but was reversed for herpetic eye presentations.

32

POSTER # 35Chagas Cardiomyopathy presenting as Symptomatic Bradycardia: An under-appreciated emerging public health problem in the United StatesDurrance RJ¹, Ullah T2, Atif Z¹, Frumkin W3, Doshi K¹¹Department of Internal Medicine, Jamaica Hospital Medical Center 2Department of Clinical Research, Jamaica Hospital Medical Center 3Department of Cardiology, Jamaica Hospital Medical Center

Chagas cardiomyopathy is a vector-borne parasitic infection caused by the protozoa Trypanosoma cruzi (T. cruzi). The disease is endemic in Latin America and is the leading cause of non-ischemic cardiomyopathy in the region. While Chagas has traditionally been considered a disease restricted to areas of endemnicity, there are an estimated 300,000 people living in the United States with Chagas today, the majority of which are suspected to have acquired the disease from areas which they emigrated. We present a case of Chagas cardiomyopathy acquired in an endemic area, and detected in its early stage. This case is representative of the under-appreciated prevalence of the disease and its consequences in an area with a large immigrant population of Latin American origin.

A 42-year-old El Salvadoran woman presented to the ED with left sided chest pain radiating to her left arm followed by dizziness and a syncopal episode lasting 5 minutes. She admitted to multiple similar episodes over the past year. She had been advised to see a cardiologist for symptomatic bradycardia, but never followed up. Significant family history includes a sister in El Salvador who also began suffering similar episodes.

On examination, she was found to be bradycardic with heart rate fluctuating between 30-42 beats/minute and an EKG significant for sinus bradycardia with conserved axis and segment intervals, and no other conduction abnormalities. Laboratory investigations were unremarkable. Her cardiac ultrasound showed an EF of 62%. The patient was diagnosed with symptomatic sinus bradycardia and a pacemaker was placed.

During her initial hospital course, a first Chagas serology test was ordered given that the patient had no other identifiable causes or risk factors for cardiomyopathy beyond the epidemiological context from which she came. This result came back positive after discharge, and diagnosis was confirmed with a second serology. Without any other clear etiology, it is suspected that Chagas was the cause of the cardiomyopathy.

This case highlights the under-recognized prevalence of Chagas in the United States and the importance of considering Chagas in the etiological differential diagnosis of electrocardiographic changes among Latin American immigrants. While the United States is not considered an endemic area for Chagas disease, the influx of Latin American immigrants has created a new challenge to identify susceptible populations, diagnose suspected cases, and provide adequate treatment for this disease.

POSTER # 36Unilateral Pulmonary Edema: The forgotten Differential Diagnosis in Asymmetric Radiographic Opacities of the LungsMathew Jose Kottarathara*1, Liliana Espinosa Chang*3, Arun Mangla*$, Ahmed Al-Chalabi*3. * Jamaica Hospital Medical Center, Internal medicine deparment. 1 PGY1, internal medicine. 3 PGY3, internal medicine. $ Cardiologist

Background: Unilateral pulmonary edema (UPE) is a rare but known clinical entity, which has been mainly described in severe mitral regurgitation or ipsilateral pathology of pulmonary veins. Misdiagnosis often occurs due to similar clinical presentations and unusual chest X-ray findings. We report a case of a 59-year-old male presented with cough associated with scant mucoid sputum, shortness of breath and pleuritic chest pain of one day duration. He denied fever or any other complaints. He reported that his son was having symptoms of upper respiratory infection for 1 week. Past history was significant for diabetes mellitus, hypertension and noncompliance with medications or vaccinations. Coronary angiography done 1 year prior to presentation revealed non-obstructive coronary artery disease. On examination, blood pressure was 195/91, heart rate 88 bpm, respiratory rate 22/min, temperature 99°F and oxygen saturation 90-92%, respectively. There were bilateral crackles on auscultation, more pronounced on the right side. Heart sounds were unremarkable. Chest X-ray revealed alveolar opacities over the right lung and bilateral perihilar interstitial changes. EKG revealed 1st degree AV block with nonspecific ST-T wave changes. Complete blood count and basic metabolic panel were unremarkable except for mild leukocytosis of 12.1 K/uL. Troponin was 0.091 ng/ml. Initial diagnosis of community-acquired pneumonia was made and the patient was started on antibiotics (azithromycin and ceftriaxone). Antihypertensive medications were adjusted. No diuretics were given. In the course of two days, patient’s symptoms resolved. Further testing showed elevated BNP of 3340 pg/ml. The influenza rapid antigen and the Streptococcus pneumoniae and Legionella urine antigens were negative. The blood cultures failed to show any pathogens. Repeat chest X ray after 3 days showed complete resolution of initial findings. Echocardiography was consistent with an ejection fraction of 50% and a grade 2 diastolic left ventricular dysfunction. Moderate concentric hypertrophy of myocardium was evident. Final diagnosis was UPE in the setting of heart failure with preserved ejection fraction (HFpEF). Patient was discharged to follow-up with cardiologist. Conclusions: A high index of suspicion is essential for diagnosing UPE when evaluating asymmetric opacities on chest X-ray. Most case reports were described on the right side as in our case. This has been explained by poorer lymphatic drainage of the right lung or prolonged resting on one side. Absence of fever, rapid onset (and resolution) of symptoms and elevated BNP are suggested indicators of a cardiac disease rather than pneumonia and may help in avoiding delay of treatment.

33

POSTER # 37Takotsubo Cardiomyopathy After Pacemaker ImplantationAnooj Patel MD PGY-1, Shruthi Bhatt DO PGY-2, Anna Dewan MD PGY-3, Aditya Mohanty MD PGY-1, Tien Lau MD PGY-1, Aneeta Joseph MD PGY-1, Michael Tofano MD. Stony Brook University Hospital Internal Medicine at John T. Mather HospitalBackground: Takotsubo Cardiomyopathy is rarely reported as a complication of pacemaker placement (Table 1).Case: A 77-year-old female patient with history of atrial fibrillation had a pacemaker placement 3 days prior to developing the sudden onset of DOE. She was admitted for flash pulmonary edema versus congestive heart failure exacerbation and started on intravenous furosemide. Her physical exam is positive tachypnea saturating at 97% RA, basilar crackle bilaterally and an incision site of PPM was clean and dry, No JVD, hepatojugular reflux, RRR, no murmurs. Course of DOE improved only minimally despite adequate diuresis with a net negative fluid balance. Patient’s troponin levels peaked at 0.08ng/ml (reference <0.06ng/ml). Electrocardiogram was ventricularly paced without evidence of MI. A prior echocardiogram done four months prior to PPM placement showed EF of 51% with grade 4 diastolic dysfunction and borderline global hypokinesis. However, a repeat echocardiogram during this current hospitalization revealed moderate to severely reduced LV function with EF 29% and hypokinesis of mid-inferioseptal, mid-anterolateral, apical septal, and apical lateral segments. Cardiac catheterization revealed non-obstructive CAD with cardiomyopathy consistent with Takotsubo. She was stabilized and discharged to home. Repeat echocardiogram at 1 month follow up visit demonstrated that global left ventricular systolic function had recovered to her lower limits of normal, with EF of 53%, with regional wall motion abnormalities (figure 1).Discussion: Takotsubo cardiomyopathy was first described in Japan in the 1990s. It is characterized by transient regional systolic dysfunction of the left ventricle in the absence of angiographic evidence of obstructive CAD or acute plaque rupture. It is a transient cardiomyopathy that predominantly affects postmenopausal women and is often precipitated by emotional stress. The Mayo Clinic diagnostic criteria is used to diagnose Takotsubo cardiomyopathy and requires all 4 criteria to be fulfilled: 1. Transient LV systolic dysfunction (hypokinesis, akinesis, or dyskinesis) 2. Absence of obstructive CAD 3. New EKG ST-T wave abnormalities or modest elevation in troponin levels 4. Absence of pheochromocytoma or myocarditis (table 2) Conclusion: Our patient fulfils the diagnostic criteria of Takotsubo cardiomyopathy, however, no emotional stress was reported. Systematic literature review revealed a three published case reports which describe Takotsubo cardiomyopathy after pacemaker implantation in the absence of emotional stress (Table 1). Therefore, as our case illustrates, this diagnosis should be considered a possible complication of pacemaker implantation, however the time course may vary. The Etio-pathogenesis in this setting is unknown.

POSTER # 38The Curious Case of a Cardiac Tamponade in the Hypertensive Patient Presenting as Abdominal Fullness William Li, Rogin Subedi, Bhaskara Madhira SUNY Upstate Medical University Internal Medicine Resident PGY-2. Expected Completion in June 2018

Introduction: Cardiac tamponade is a medical emergency consisting of an accumulation of fluid in the pericardial space resulting in the reduction of ventricular filling followed by hemodynamic compromise which requires prompt recognition and management because if left untreated is rapidly progressing and universally fatal. Typical presenting findings include elevated jugular venous pressure, pulsus paradoxus, hypotension, chest pressure, oliguria, and dyspnea with echocardiography being a typical study implemented for diagnostic visualization. However because cardiac tamponade is ultimately a clinical diagnosis, mindful consideration for atypical presentations is essential for the reduction of mortality in the acute setting. Case: We present a 77 year-old female who was admitted after presenting with general malaise, weakness, somnolence, altered mental status and urinary incontinence found to have CML (chronic myeloid leukemia) on confirmatory bone marrow biopsy after suspicions arose from a leukocytosis of 34,000 cells per mcL with 85% neutrophils and elevated blasts (8%). Initial vital signs revealed mild tachycardia, mild tachypnea and blood pressure elevated to 162/84 mmHg along with a temperature of 38.7 degrees C and oxygen saturation of 96% on 2 liters by nasal cannula. She received the standard of care for a community acquired pneumonia and was started on treatment with decitabine chemotherapy. An abdominal CT performed for a complaint of abdominal fullness and general discomfort later displayed an incidental large pericardial effusion. Subsequent repeat echocardiography exhibited findings of a right atrial diastolic collapse, inferior vena cava dilatation (IVC) without inspiratory collapse > 50% and the large pericardial effusion consistent with tamponade physiology. The patient’s blood pressure remained hypertensive in the interim until she suddenly went into cardiac arrest after being intubated for a pericardial window in the operating room (OR) and expired. Discussion: The diagnosis of a cardiac tamponade requires a high index of suspicion together with correlated echocardiographic signs and symptoms. Our patient however did not present with the classic findings described as Beck’s triad of jugular venous distention, muffled heart sounds or relative hypotension in addition to lacking electrical alternans on EKG or pulsus paradoxus. Her presentation mimicking intra-abdominal pathology further obscures the likelihood of diagnosis. Also, while previous studies have documented approximately 20-25% of cardiac tamponade cases being hypertensive, those individuals typically have advanced renal disease 1. Our case highlights the need to keep cardiac tamponade as a differential in the hypertensive individual with abdominal complaints as atypical presentations can obscure diagnosis, delay treatment and increase mortality.

34

POSTER # 39Brown Tumor: A rare complication of secondary hyperparathyroidismZulekha Atif1, Kinjal Solanki1, Sudheer Chauhan1, Richard Pinsker1

1 Jamaica Hospital Medical Center, Jamaica, NY Richard Pinsker (PD)PG2, Internal Medicine Jamaica Hospital Medical Center

Osteitis fibrosa cystica, commonly known as brown tumor, are seen in patients with uncontrolled primary, secondary or tertiary hyperparathyroidism. They appear as expansive lytic lesions radiographically. Brown tumors are mostly seen in patients with primary hyperparathyroidism, with prevalence of 4.5%, but may be present in 1.5-1.7% of cases of secondary hyperparathyroidism. We present a case of a female with ESRD on hemodialysis who was diagnosed with a brown tumor secondary to refractory hyperparathyroidism. A 43-year-old-female with ESRD on hemodialysis for the past 14 years presented to the ED complaining of malfunctioning dialysis catheter. Admission labs showed hematocrit 25.1% (37-47%), BUN 70 (7-17 mg/dl), creatinine 15 (0.5-1.0 mg/dl), bicarbonate 20 (22-30 mEq/L), calcium 7.1 (8.4-10.2 mEq/L), and phosphorus 6.8 (2.5-4.5 mg/dl). Incidentally, her chest X-ray showed a left sided pleural based mass. CT of chest with contrast showed an expansive lobulated mass (2.5 x 3.6 x 2.1 cm) arising from the left lateral third rib with cortical breakthrough. CT-guided biopsy showed focal intramedullary fibrosis, scattered collection of hemosiderin and remodeling boney trabeculae with few osteoclastic multinucleatic giant cells, consistent with the osteitis fibrosa cytica. Parathyroid level was 892 (14-64 pg/ml) and alkaline phosphatase was 187 (37-126 U/L). These findings were compatible with hyperparathyroidism and brown tumor.

Brown tumors are rarely in patients with untreated hyperparathyroidism, total incidence being 0.1%. When present, these lesions are seen in the long bones, ribs, clavicle and pelvic girdle, although they can occur at any other site. Hypocalcemia and hyperphosphatemia leads to elevated parathyroid levels, which increases osteoclastic activity and bone remodeling. If bony lesions are found in patients with hemodialysis, osteitis fibrosa cytica should be excluded. Treatment should target normalizing parathyroid levels with medication, dialysis, parathyroidectomy or kidney transplantation. Surgical resection of the lesion itself is only recommended if it does not regress after 1-2 years of treatment or it compromises body funcitons. If medical management with calcitriol and phosphate binders fail, parathyroidectomy is the next step.

POSTER # 40SGLT-2 Inhibitor Use Leading to Life Threatening Euglycemic KetoacidosisPardeep Masuta MD, PGY-2 Resident, SUNY Upstate Medical University; Geetanjali Johri MD, PGY-3 Resident, SUNY Upstate Medical University; Anshu Nepal MBBS, PGY-2 Resident, SUNY Upstate Medical University; Manju Paul MD, Assistant Professor of Medicine, Pulmonary/Critical Care, SUNY Upstate Medical University

Diabetic ketoacidosis (DKA) is a well-known life-threatening complication of type 1 diabetes. It is characterized by elevated blood ketones, metabolic acidosis, and uncontrolled hyperglycemia. Hyperglycemia with a glucose greater than 200-250 is a key diagnostic criterion of DKA.  In rare instances, ketonemia and acidemia can occur with normal to mildly elevated glucose levels, even in type 2 diabetics. It is can be caused by sodium glucose co-transporter 2 (SGLT2) inhibitors in up to 1 in 1000 patients per year.

A 58-year-old female with history significant for type 2 diabetes and hypertension presented with a two-day history of nausea, vomiting and diffuse abdominal pain.  She was taking insulin glargine and metformin for her diabetes.  She had started taking canagliflozin two weeks earlier.  Upon presentation, she was afebrile but tachycardic with systolic blood pressures in the low 100s.  She appeared severely dehydrated.  Her initial blood work revealed a leukocytosis of 15.1, glucose of 146, anion gap of 37, acidemia with a bicarbonate of 7 and a pH of 7.08.  Beta-hydroxybutyrate was 13 while the lactate was less than 1.  Imaging, urine studies and toxicology studies could not explain an alternative reason for her clinical picture.  She was treated with an insulin infusion and dextrose with half normal saline fluid resuscitation.  Within 24 hours, her anion gap normalized and her symptoms had completely resolved.  It was suspected that the canagliflozin was causing euglycemic ketoacidosis and was discontinued indefinitely.  She has not reported any further episodes since then.

SGLT2 inhibitors improve glycemic control by preventing renal proximal tubule reabsorption of glucose. They can decrease glycosylated hemoglobin levels by up to 1.5%.  However, they have been linked to several cases of euglycemic ketoacidosis.  The proposed mechanism is from stimulation of glucagon release.  Urinary excretion of glucose results in euglycemia and inhibition of insulin release from the pancreas.  This increases compensatory beta oxidation, lipolysis and ketone production which causes dangerous acidemia.  This can be exacerbated during periods of fasting or illness when the body’s energy expenditure increases. A point worth emphasizing is that euglycemic ketoacidosis can be easily missed based on clinical manifestations alone since it is not always associated with the typical manifestations of DKA.  Awareness of this situation caused by SGLT2 inhibitors may limit how we prescribe them and improve how quickly we treat this potentially deadly adverse effect.

35

POSTER # 41Refractory Acute Kidney Injury Secondary to Hypothyroid Induced Myopathy: A Contemporary Case ReportPhillip Ulyanovskiy (PGY2) a, Deborah Dergan (PGY2) b, Shams Abbas c, Prabhjot Manes (Attending MD) d, Irina Erlikh (Attending MD) e

The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai

This is a case report describing how severe hypothyroid induced myopathy can lead to refractory kidney injury, becoming unreceptive to standard medical care and hemodialysis interventions.

A 70 year old female with extensive medical comorbidities including adult onset hypothyroidism, hypertension, hyperlipidemia, and normal baseline renal function presented with shortness of breath, myalgias, edema, and facial swelling. The patient was found to have a TSH of 169.8 MCIU/ML, CPK 42,670 u/L, BUN of 70 MG/DL, a creatinine of 12.1 MG/DL, and GFR of 3mL/min/1.73m². She was initiated on aggressive intravenous isotonic rehydration, along with intensive intravenous thyroid hormone replacement therapy and hydrocortisone treatment as well. Her renal status failed to improve adequately and she was started on sodium bicarbonate for urinary alkalinization. With the preceding interventions deemed medically futile for renal amelioration, the patient was started on acute hemodialysis. Over the course of 2 weeks and 6 hemodialysis treatments the patient's renal status failed to improve. The patient finally refused any further hemodialysis or medical interventions seeing that her kidneys failed to respond to treatment, and her clinical prognosis remained poor. This case report illustrates how severe symptomatic hypothyroidism can induce rhabdomyolyisis leading to intractable kidney failure, unreceptive to standard medical therapy and hemodialysis.

POSTER # 42An Unusual Case of Gallbladder Cancer in a Young MaleShruti Patel, MD; Sandra Gomez-Paz, MD; Kaleem Rizvon, MDNassau University Medical Center, East Meadow, NYIntroduction: Gallbladder cancer is a rare and lethal disease, often diagnosed at advance stages, known for being two to three times more common in women compared to men worldwide. It is usually associated with obesity, advanced age, biliary tract pathology and certain bacterial infections. We present a case of a relatively young male diagnosed with gallbladder cancer, without any of the known associated risk factors.Case Presentation: A 41-year old Hispanic man with no past medical history, presented with diffuse abdominal discomfort, fatigue, generalized pruritus, scleral icterus, and unintentional five pound weight loss over one month. There was no history of fever, alcohol, tobacco or illicit drug use, family history of cancer, recent travels or exposure to any medications or heavy metals. Vitals were within normal limits. Patient had a thin body habitus (BMI 23.5). Physical exam was remarkable for scleral icterus, jaundice and mild right upper quadrant and epigastric tenderness. Laboratory investigations showed microcytic anemia, significantly elevated AST (231 U/L), ALT (187 U/L), GGT (723 U/L) and alkaline phosphatase (1082 U/L), as well as direct hyperbilirubinemia. Abdominal ultrasound, CT abdomen, and MRCP were performed, which showed signs highly suggestive of gallbladder cancer with liver and biliary duct involvement, with presence of portocaval adenopathies. CT guided liver biopsy confirmed presence of adenocarcinoma of the gallbladder. Stent deployment via ERCP and percutaneous drainage for improvement of obstructive jaundice was not possible due to high risk of cholangitis and failure of stent placement since no common biliary duct or intrahepatic duct dilation was appreciated. Incidental finding of bilateral pulmonary embolism on CT was addressed by implementing immediate anticoagulation therapy. Palliative care was provided for generalized pruritus. Patient was eventually discharged with follow up with gastroenterology and oncology. Discussion: Demographic factors worldwide in the incidence of gallbladder cancer, a rare entity in the western world, are skewed towards female gender, obesity, advanced age (average age is 72), certain bacterial infections (Salmonella, Helicobacter) and underlying biliary tract pathologies such as cholelithiasis, porcelain gallbladder, pancreaticobiliary maljunction anomalies and chronic inflammatory processes such as primary sclerosing cholangitis. We present the case of a relatively young male with primary gallbladder adenocarcinoma, without any of the risk factors aforementioned, however sharing the known feature of diagnosis at a later stage of this disease process.Conclusion: Even though rare, gallbladder cancer can occur in young male patients with low index of suspicion.

36

POSTER # 43Insulin Infusion and Subcutaneous Heparin to manage severe hypertriglyceridemia in an adolescent girl with Type 2 Diabetes: A Case ReportLev Platsman MD, Larisa Rusyn MD, Melissa Grageda MDAffiliation: Department of Pediatrics, Richmond University Medical Center, Staten Island, New YorkBackground: Severe hypertriglyceridemia should be treated emergently and aggressively due to the associated risk for hyperlipemic acute pancreatitis. In children, there is no general consensus for treatment, although previous case reports/series describe the success of insulin infusion, low molecular weight heparin (LMWH) therapy, and plasmapheresis (single or combined therapies).Case: We report the case of a hispanic 12-year old girl with metabolic syndrome and sent to our institution for management of an elevated triglyceride level (2613mg/dL) and glucose level (530mg/dL). She has a history of polyuria and polydipsia. Her cholesterol levels were mildly elevated for the last year, and treated with lifestyle modification. Family history is significant for Type 2 diabetes and hypercholesterolemia. Physical examination revealed an obese child (BMI 35) in no acute distress. Acanthosis nigricans was noted over the dorsal aspect of the neck. Liver function testing revealed mild transaminitis. Lipase and amylase levels were normal. Abdominal ultrasonography revealed mild hepatomegaly with diffuse fat deposition. The patient was started and remained on a low-dose insulin infusion for three days. Triglyceride levels gradually decreased over the next 4 days (1339mg/dL to 765mg/dL), although episodes of hypoglycemia resulted in either a decrease or intermittent cessation of the insulin infusion. On the fourth hospital day, the patient was transitioned to subcutaneous insulin glargine. Metformin, niacin and enoxaparin were added as well. Throughout the hospital stay, the patient did not have any signs and symptoms of acute pancreatitis and/or bleeding. On the ninth hospital day, her triglyceride level was 290 mg/dL. She was discharged home with additional diagnoses of Type 2 Diabetes and Hypertriglyceridemia. Discharge medications included niacin, metformin, vitamin E and subcutaneous insulin glargine. Discussion: Lipoprotein Lipase (LPL) is a water-soluble enzyme that hydrolyzes triglycerides. Exogenous insulin decreases triglyceride levels via increases in peripheral synthesis of plasma LPL contained in muscle and adipose tissues. Unfractionated heparin works by releasing endothelial LPL. In our patient, the triglyceride levels were noted to gradually decrease with the insulin infusion and subsequent LMWH therapy. Aside from few episodes of hypoglycemia which were treated appropriately, there were no other adverse effects noted from the two abovementioned therapies used to manage hypertriglyceridemia. Conclusion: Insulin and heparin were safe and effective treatment modalities for severe hypertriglyceridemia in an adolescent patient with Type 2 Diabetes.

POSTER # 44Myopathy and Hepatotoxicity from combined use of Statin and Azole AntifungalTamoor Shahid MD, Dipti Sagar MD, Kamran Zahid MD, Hiliary Hertan MD, FACG. Montefiore Medical Center, Wakefield Campus, Bronx NYIntroduction: Statins are widely used for the management of hypercholesterolemia and have mortality benefits in both coronary artery disease and cerebrovascular disease. Myopathy and hepatotoxicity are well-documented side effects of statins. Risk of these side effects is further increased when statin is co-administered with the medications that decrease its metabolism, such as azole antifungal agents. We present a case in which statin and azole co-administration led to development of myopathy and hepatotoxicity.Case report: A 76 year-old man was admitted to hospital for acute hypoxic respiratory failure due to severe COPD exacerbation requiring intravenous steroids and antibiotics. On day four of hospitalization, he developed chest pain and was diagnosed with non-ST-elevation myocardial infarction. He was treated with dual anti-platelet therapy, intravenous heparin, and atorvastatin. Patient spiked fever during hospital course and sepsis workup revealed Aspergillus fumigatus positive respiratory culture. Voriconazole was introduced to the treatment regimen . Later on during hospital course, he complained of extreme fatigue and muscle aches. Laboratory studies showed elevated creatine kinase (CK) 4929 Units/L, AST 111 Units/L and ALT 172 Units/L with normal bilirubin and alkaline phosphatase. Liver chemistry and CK were normal at time of admission. He was managed conservatively with intravenous hydration and discontinuation of atorvastatin; patient had already finished voriconazole course. Patient’s transaminases reached plateau of AST 258 U/L and ALT 337 U/L. Viral Hepatitis panel was negative and right upper quadrant ultrasound did not reveal acute pathology. Serial monitoring of liver chemistry and CK showed significant improvement.Discussion: Atorvastatin is inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) Reductase, the rate-limiting enzyme in cholesterol synthesis; this then results in stimulation of LDL catabolism. Atorvastatin is primarily metabolized by cytochrome P450 3A4 hydroxylation. Statin use is associated with arthralgia (10 %), myalgia (4% to 8%), musculoskeletal pain (5%), muscle spasm (4% to 5%) and increased serum transaminases (≤2%). Inhibitors of CYP3A4 increase the plasma concentration of statins, which increases the risk and frequency of side effects. If antifungal treatment is indicated in a patient using a CYP3A4-metabolised statin, it is recommend to use topical antifungal agent, if possible. Use of a non-CYP3A4 inhibiting antifungal drug such as terbinafine or temporary discontinuation of statins are reasonable alternatives. Conservative management with oral or intravenous hydration and discontinuing these medications are management options. Learning points:1) Risk of statin induced myopathy and hepatotoxicity is increased when co-administered with with azole antifungals.2) Drug-Drug interaction is an important part of medication reconciliation.

37

POSTER # 45A Surprising Case of Chronic Myelogenous Leukemia with Acute Lymphoblastic CrisisSemaan Kobrossi, MD, Wasnard Victor, MD, Abdullah Ladha, MD, Teresa Gentile, MD. SUNY Upstate Medical UniversityIntroduction: Chronic Myelogenous Leukemia is a myeloproliferative disorder where over a period of time, 15-20% of patients show blastic transformation with majority transforming into acute myeloid leukemia and less frequently as acute lymphoblastic leukemia. Correct diagnosis is important as both entities are treated differently. Case: Patient is a 45 year-old female with past medical history of asthma, presented to our hospital after unwitnessed syncope. She had been having myalgia, chills, fevers, night sweats and decreased appetite for 2 weeks. She was found on the bathroom floor by her husband who heard the fall. She regained consciousness within minutes, and had no urinary incontinence or confusion. Upon presentation, neurological exam was intact and CT brain showed no acute hemorrhage or infarct. Patient was febrile at 102 F. CBC showed leukocytosis (white blood cells count of 49.4 k/uL), normocytic anemia (hemoglobin of 11.7 g/dL), thrombocytopenia (platelets of 105 k/uL) and a predominance of myelocytes and metamyelocytes. Abdominal CT demonstrated splenomegaly. Bone marrow aspirate showed 30-40% blasts, consistent with AML, with maturing cells in periphery and splenomegaly that may indicate prior CML. Patient was scheduled to receive induction chemotherapy with 7+3 regimen. However, on the same day, we got a call from the pathology lab, that flow cytometry was consistent with B-cell ALL (not AML as expected from appearance on bone marrow aspirate and peripheral blood). Cytogenetics and FISH were consistent with t(9;22). Philadelphia chromosome was positive with p210-type BCR-ABL transcript in 90% of the cells. Flow cytometry showed low expression of CD20 on blasts (15-20%). Patient was treated as B-ALL and received Hyperfractionated Cyclophosphamide, Vincristine, Doxorubicin, Dexamethasone plus Imatinib. Hospital stay was complicated by DIC and chemical meningitis likely from the intrathecal chemotherapy. Otherwise, patient did fairly well after her first cycle.Discussion: This case presented a diagnostic dilemma, as clinical characteristics of CML in lymphoid blast crisis can resemble those of Philadelphia chromosome-positive ALL. Peripheral morphology showing myelocytes and metamyelocytes and clinical exam showing splenomegaly suggested transformation of CML into blast crisis. Another way to differentiate the two entities is cytogenetics with the pattern of BCR-ABL transcripts. The 210 kDa BCR-ABL protein has been reported in CML, whereas the 190 kDa protein is specific for ALL. It is important to identify blast crisis correctly to initiate appropriate therapy.

POSTER # 46Acute Immune Hemolytic Anemia after administration of high dose IVIG in a child with Kawasaki diseaseJhavene Morrison, MD, Aqsa Inkisar MD, , Melissa Grageda, MD, Rudrani Belnekar, MDDepartment of Pediatrics, Richmond University Medical Center, Staten Island, NY – an affiliate of Mount Sinai HealthPGY 2: expected date of completion 06/30/2018; Resident, Pediatrics Background: Kawasaki disease is an acute febrile illness of unknown etiology, characterized by vasculitis of medium -sized arteries with a predilection for the coronary arteries. It is the leading cause of acquired heart disease in childhood with 20-25% of untreated children developing coronary artery abnormalities. The mainstays of therapy are intravenous Immunoglobulin (IVIG) and high dose aspirin to prevent or modify the most serious cardiac sequelae. Though rare, immune-mediated hemolysis is a recognized and potentially catastrophic side effect of administration.Case: A 4-year-old male presented to our emergency department with a 7-day history of fever, diffuse maculopapular rash, and strawberry tongue. Physical examination revealed conjunctival injection with perilimbal sparing, and lymph node enlargement. Pertinent test results include mild hepatomegaly with transaminitis, obstructive jaundice and elevated erythrocyte sedimentation rate. An echocardiogram revealed mild ectasia of the left coronary artery. He was diagnosed with Kawasaki disease and received IVIG along with aspirin. Due to persistent high fevers, a second dose of IVIG was given approximately 36 hours after the first dose. Hemoglobin levels were noted to gradually trend downwards (11.5 to 10.5g/dL) but significantly decreased (6.5g/dL) 4 days after the second dose. Review of the blood peripheral smear revealed micro- and macrospherocytosis consistent with antibody-mediated hemolysis. Direct antiglobulin test (DAT) was positive for IgG and C3D. Further investigation revealed reticulocytosis (15.7%), increased lactate dehydrogenase and bilirubin levels, and blood group type A. Clinically, the patient developed increasing tachycardia with a new onset murmur. He was transfused on the eighth hospital day with packed red cells, and had subsequent clinical improvement. He was discharged home in stable condition with a hemoglobin of 9.8g/dl.Discussion: IVIG is a therapeutic preparation of polyclonal IgG purified from human plasma which contributes to its antigenic diversity. It has gained popularity in the treatment of many inflammatory disorders including Kawasaki Disease. Despite its advantages, significant hemolysis requiring transfusion can occur within 5-10 days of infusion. The risk is dose-related and particularly increased in patients who receive more than one dose, as illustrated in our patient. IVIG-mediated hemolysis appears to have a more profound fall in hemoglobin (5.1 ± 0.36g/dl, Gordon et al) in pediatric patients compared to adults (3.2g/dl, Daw et al). Other risk factors include non-O blood groups (also seen in our patient). Conclusion: Clinicians should be aware of rare potential life-threatening complications of IVIG such as hemolysis and anemia.

38

POSTER # 47Look Again! T cell Lymphoma presenting as a testicular mass. A rare case. Odianosen Obadan, MD, Mirette Salib, MD, Jose Pace, MD, Mendel Warshawsky, MD. Saint John’s Episcopal Hospital, Far Rockaway, NY First Author: Odianosen Obadan, PGY level- 3

Introduction T cell lymphoma of the testis is very rare and aggressive. Very few cases are reported in literature. Testicular lymphoma comprises 1% of all lymphomas and 5% of testicular malignancies. Testicular lymphomas are usually B cell lineage ( 70 to 90 % of reported cases) . We report a case of T cell lymphoma presenting as a testicular mass with metastasis.Case Report A 51 year old man presented at the University Hospital with 5 days of vomiting and decreased oral intake and a history of scrotal swelling. No family history of cancers and patient denied tobacco or recreational drug use. He underwent right total orchiectomy in 11/2015 in Nigeria. He developed complications and decided to seek better care in the United States. On physical examination, he had right nystagmus, no hepatosplenomegaly, no lymph nodes palpable. Right testicle was absent. Labs revealed a low sodium level (117). Wbc count of 3.9, Hemoglobin of 11. Platelet count of 126. HIV negative, HTLV 1 and 2 antibody negative, EBVIgM negative. LDH- elevated at 1349. ferritin- 27,210. AST- 361, ALT- 365.Alkphos- 347.Bilirubin -2. Ultrasound of the abdomen showed a hypo echoic mass of the right supra renal fossa, likely of adrenal origin and a hypo echoic mass of the right lobe of the liver. CT Chest- scattered ground glass opacities and mild interstitial thickening. MRI could not be performed due to body shrapnel from prior gunshot wound. CT abdomen showed bilateral suprarenal lesions, matted peri aortic and retroperitoneal lymphadenopathy with encasement of the IVC and bilateral renal veins, 2.3cm hypoattenuating lesion in the liver with hepatic venous flow, soft tissue density obscuring the bilateral adrenal glands. Lymph node Biopsy repeated was consistent with peripheral T cell lymphoma positive for CD3. He was started on Ifosphamide, Carboplatin and Etoposide and intrathecal methotrexate. Conclusion- Testicular lymphomas are a rare and aggressive form of NHL with high incidence of extra nodal occurrence. They comprise about 1-2% of tumors in men with a mean age > 60 years. Only a few cases of primary T cell lymphoma presenting in the testis have been reported in the US. Our case was present in a male with typical elevated LDH and biopsy results, abdominal and leptomeningeal metastasis. His International Prognostic Index score was intermediate-high. Education is needed for diagnosis and better treatment because of poor prognosis.'

POSTER # 48Thrombotic Thrombocytopenic Purpura: A Hematologic Emergency Betancourt, Boris, MD, Riffel, Gustavo, MD, Guddati, Achuta K., MD St John’s Episcopal Hospital/State University of New York Downstate Medical CenterFirst author: Boris Betancourt, MD PGY 2, Expected graduation by 2018, Internal Medicine.

The Thrombotic Thrombocytopenic Purpura (TTP) is a rare disorder characterized by Micro Angiopathic Hemolytic Anemia (MAHA) and platelet micro-thrombi. The national incidence is 3 cases per million. It is associated with a classic medical pentad: fever, thrombocytopenia, neurological deficits, hemolytic anemia, and renal failure in 30% of the cases. The mortality rate is 95% when left untreated. It is caused by a deficiency of A Desintegrin-like And Metalloproteinase with a Thrombospondin type 1 and Motif13 (ADAMTS13); which may be inherited with mutations in chromosome 9q34 (<10%), but commonly acquired due to autoantibodies (45%). Low levels of ADAMTS13 results in increased Ultra Large Von Willebrand Factor inducing platelet adhesion and thrombosis. The pillar of treatment is Plasma Exchange (PEX).A 75-year-old, black woman with history of hypertension, obesity, SLE in remission, CKD stage IV, remote ischemic stroke without residual deficit taking amlodipine, clonidine, furosemide, and sodium bicarbonate presented with dysarthria and generalized weakness for eight hours. She did not present, hepatosplenomegaly, icterus or overt bleeding Twelve hours after admission mental status deteriorated requiring intubation. Tomography of the head did not show acute changes. Leucocytes 4.4/dL, Hemoglobin 6.9 g/dL, Platelets 8000 /dL, Reticulocyte 2.1%, BUN 54 mg/dL, Creatinine 2.96 mg/dL, Total Bilirubin 2.4 mg/dL, Indirect Bilirubin 2.0 mg/dL, normal liver enzymes, LDH 586 mg/dL, C3 normal, Coagulation profile normal, D-dimers normal, ANA 1:20, Coombs test negative, drug screen negative. Blood smear review presented occasional fragmented red cells schistocytes. ADAMTS 13 less than 10 %, ADAMTS13 antibodies 76 U/mg, Haptoglobin < 30 mg/dL. The patient was evaluated by hematology and started on PEX, FFP and PRBC transfusions, Methylprednisolone 1 gm intravenous for 3 days, and empiric intravenous antibiotics. The patient was extubated next day but continue with PEX and FFP. Within next week LDH normalized, blood cultures finalized negative, she kept clinical improvement but platelets still 21000/dL and she was started on Rituximab.TTP is a rare and life-threatening blood disorder associated with multi organ dysfunction. Early recognition is critical on successful treatment. Schistocytes in blood smear is the hallmark for diagnosis. Highly specific ADAMTS13 levels are not routinely available. Platelet transfusion is not recommended in consumptive/destructive blood disorders such as TTP. It is essential to start emergent therapy with Plasma Exchange and FFP. High doses of steroids and Rituximab, are recommended for severe cases. Plasmapheresis should continue until two days of normal platelet count. Splenectomy and chemotherapy are options for refractory cases.

39

POSTER # 49Spontaneous Tumor Lysis Syndrome: An Unusual SuspectMaya Ignaszewski, MD – SUNY Upstate Medical UniversityAttending: Patrick Kohlitz, MD – SUNY Upstate Medical University

Tumor lysis syndrome (TLS) is an oncological emergency that occurs as a consequence of rapid neoplastic cell turnover leading to metabolic derangements such as hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia and acute renal failure. It is most commonly seen after initiation of chemotherapy in hematologic malignancies; however, spontaneous TLS in the absence of chemotherapy in solid tumors has also been reported. We present a rare case of spontaneous TLS in a patient with metastatic prostate adenocarcinoma.

A 69-year-old male with past medical history of hypertension, hyperlipidemia and stage IV prostate adenocarcinoma with metastasis to spine and liver, who had undergone chemotherapy with Cabazitaxel greater than 1-month prior, initially presented to the emergency department with nausea, vomiting, weakness, dizziness and abdominal pain. On arrival, the patient was hypotensive to 96/60 with a pulse of 120, respiratory rate of 22 and 92% oxygen saturation on 4L nasal cannula. Physical examination revealed dry oral mucosa, tachycardia, tachypnea, abdominal distension and hepatomegaly. The patient’s course was complicated by acute respiratory failure requiring intubation. Laboratory work revealed sodium of 121, potassium of 6.4, bicarbonate of 15, BUN of 90, creatinine of 5.9, magnesium of 2.5, phosphorus of 9.3, lactate dehydrogenase of 1050, uric acid of 14.7, total bilirubin of 4.5, alkaline phosphatase of 710, ALT of 306 and AST of 410. Abdominal imaging revealed significant tumor burden in the liver with extension into the spine. Hematology/Oncology was consulted and together with the patient’s new oliguria and varying laboratory abnormalities, a diagnosis of TLS was made. Nephrology was consulted; the patient was started on IV fluids, Rasburicase and underwent urgent dialysis. Despite aggressive resuscitative efforts, the patient continued to decline with worsening uremia, hemodynamic instability, somnolence, and expired shortly thereafter.

To our knowledge, this is only the second reported case of spontaneous TLS occurring in metastatic prostate adenocarcinoma. This highlights not only the rarity of this disease, but also serves as evidence that solid tumors with high tumor burden can predispose a patient to this potentially fatal condition. Clinicians must be vigilant in entertaining this diagnosis when faced with deranged laboratory work up despite this condition being most common in hematologic malignancies. Prompt recognition and timely initiation of treatment is paramount to improving patient survival in this otherwise destructive and potentially fatal syndrome.

POSTER # 50Metatarsal Osteomyelitis: A Rare Case of Osteoarticular TuberculosisMoumita Sarker a, Rupesh Bhimani a, Zufisan Akhter b,Nilesh Patel a, Farshad Bagheri a.

a Department of Internal Medicine, Jamaica Hospital Medical Center, b

Department of Clinical Research, Jamaica Hospital Medical Center, PGY 3 Internal Medicine resident; expected date of completion of training: June, 2017

In this article, we present a rare instance of Osteoarticular Tuberculosis (OATB). OATB refers to TB involving the bones and the joints. In the United States, this is responsible for about 10% of extra-pulmonary cases of TB. Weight-bearing joints, such as the spine, hip, and the knees, are the most commonly affected sites of OATB. Ten percent of OATB involves the bones of the foot where calcaneus is the most common followed by the tarsal and metatarsal bones. Up to 50% of patients do not show any pulmonary manifestation. The patient's prognosis depends on whether the lesions are interosseous or involving a joint.

A 44-year-old male without any past medical history presented with non-traumatic left foot pain, swelling, and redness for 2 months. There was no drainage from site or any constitutional symptoms. On examination, there was swelling and erythema on the dorsum of the left foot without any open lesions. Sensation was intact and the pulses were non-palpable. Significant labs included elevated ESR of 125 (0-15 mm/hr). X-ray of the foot showed diffuse soft tissue swelling of the metatarsal phalangeal joints with extensive erosive changes of the second metatarsal and proximal phalanx of the second ray. MRI showed an enhanced fluid collection with destruction of the mid/distal second metatarsal, consistent with an abscess. Abnormal enhancement in the base/proximal second metatarsal suggested osteomyelitis. Patient underwent an open biopsy and wound debridement. A bone biopsy showed chronic granulomatous lesions with non-caseating necrosis with a positive quantiferon test. Bone culture grew Mycobacterium tuberculosis complex and the patient was started on an anti-tubercular regimen.

The significance of our finding is that the incidence of missed cases of TB is rising due to unusual presentations and non-specific outcomes on imaging. Diagnosis can be based on an MRI, which is superior to an X-ray or a CT scan, but histological findings from a surgical biopsy is the gold standard. The pathogenesis of TB involving the bony structures is related to the reactivation of hematogenous foci or a spread from the adjacent paravertebral lymph nodes. It is crucial to diagnose the patient when the disease is limited since medical treatment leads to very good outcomes. In advanced stages where the infection spreads to the joints or nearby structures, permanent residual deformity can occur.

40

POSTER # 51A Rare Case of Didanosine Related Severe Lactic Acidosis Predisposing to Infection with MucormycosisUmut Gomceli, Srija Vangala, Efrain Gonzalez, Manisha Singh, Zeana CosminaDepartment of Medicine, Bronx Lebanon Hospital Center affiliated by Icahn School of MedicineIntroduction:Mucormycosis is uncommon in advanced HIV infected patients. Usual risk factors include diabetes mellitus, hematologic malignancies, immunosuppression and neutropenia. We present a rare case of pulmonary mucormycosis in an AIDS patient with didanosine induced lactic acidosis.Case description:A 38 year-old female with AIDS on didanosine, tenofovir, darunavir and ritonavir with a CD4 count of 114 and an undetectable viral load, was brought to the emergency department for worsening lethargy of one week duration. Initial labs revealed severe anion gap metabolic acidosis, with a lactic acid level of 7.7 and elevated liver function tests. Antiretrovirals were discontinued. She was started on broad spectrum antibiotics and was admitted to the ICU for suspected sepsis. Chest X-ray revealed no infiltrates, CT of the abdomen demonstrated hepatomegaly and chronic thickening of the colon wall. Septic workup was negative. On the 3rd day of admission she was intubated and was started on pressors due to persistent hypotension. Her lactic acidosis persisted with levels as high as 20. Hemodialysis was unsuccessful in lowering the lactate. Her clinical condition deteriorated and she expired on the 14th day of hospitalization. Autopsy was performed which revealed pulmonary mucormycosis with extensive angioinvasion, hemorrhages, edema and emphysematous lung changes. Discussion:Mucormycosis in advanced HIV infected patients is rare. Only a few cases have been described in HIV patients with history of injection drug use and neutropenia. Neutropenia or neutrophil dysfunction either due to hyperglycemia or acidosis that impair chemotaxis, phagocytosis and intracellular killing increases the risk of mucormycosis. We believe that the prolonged lactic acidosis was the predisposing condition for the development of invasive mucormycosis in our patient. This is the first case of invasive pulmonary mucormycosis in a HIV patient with severe lactic acidosis due to didanosine induced mitochondrial toxicity. Its onset is usually insidious in HIV infected patients and warrants high clinical suspicion. Hence we suggest that mucormysosis should be considered as a differential diagnosis in HIV patients on NRTI presenting with lactic acidosis, as early diagnosis and aggressive management maximize the chances for cure.

POSTER # 52Bacterial Pyomyositis - A Unique Etiology of Persistent Musculoskeletal PainScott Statman, MD. New York University, Internal Medicine Residency Post-Graduate Year 2, Expected Date of Graduation June 30, 2018

A 42-year-old male with alcoholic cirrhosis and uncontrolled diabetes presented with insidious onset of atraumatic left thigh and right shoulder pain and swelling. Over three weeks he developed malaise, night sweats, and 15lb weight loss. The pain worsened, waking him from sleep and preventing ambulation. He underwent evaluation in the emergency department twice, where labs did not show leukocytosis, x-rays were negative for acute pathology, and lower extremity ultrasound did not reveal abscess or venous thrombosis.

He re-presented with a month of progressive symptoms. On exam he was afebrile, tachycardic, and uncomfortable. His left thigh was edematous with tender erythema and induration. His right shoulder was diffusely tender with range of motion severely limited by pain. Labs showed WBC 19.0k/L (78% neutrophils) and negative HIV screen. CT revealed multiloculated intramuscular abscesses with surrounding myositis involving the deep left thigh and right rotator cuff, as well as right pyelonephritis. MRI suggested septic arthritis of the glenohumoral joint, without evidence of osteomyelitis at either site. Methicillin-sensitive staphylococcus aureus (MSSA) grew in initial blood cultures, thigh and shoulder aspirations, and a urine culture collected one week prior. TTE was negative for vegetations. Following initiation of intravenous antibiotics, he remained afebrile and blood cultures were negative. He underwent percutaneous drainage of the thigh and open shoulder washout, after which leukocytosis resolved. He continued intravenous antibiotics with drains in place for four weeks until repeat imaging confirmed improvement.

Musculoskeletal complaints are commonplace and often benign. However as illustrated by this case, persistent atraumatic musculoskeletal symptoms require practitioners to think broadly, especially in immunocompromised patients. Pyomyositis refers to pus within large skeletal muscles. Original cases describe a disease of healthy young adults in the tropics, often following trauma. Paralleling the rise of HIV, clinicians noted an increasing number of cases in temperate regions, particularly among immunocompromised patients. These differing presentations reflect the condition’s numerous risk factors including HIV, diabetes, malignancy, cirrhosis, malnutrition, parasitic infection, and trauma. Staphylococcus aureus is the cause of pyomyositis in the majority of cases; infection is thought to arise from hematogenous seeding of damaged muscle following transient bacteremia. MRI is preferred over CT due to its high sensitivity for early detection of inflammation prior to abscess formation. While uncommon, pyomyositis is a life threatening condition that presents with nonspecific musculoskeletal pain and requires a high index suspicion for appropriate diagnostic imaging to be obtained in a timely manner.

POSTER # 5341

CNS toxoplasmosis encephalitis in CLL – A challenge to diagnose and treatHamead Reza Moshrefi, DO (PGY2) Aaron Charniak (PGY3) Sean Caine, DO (PGY2), Dharscika Anandaoomaraswamy, MD (PGY1), Olga Kurylo, MD (PGY1), Ricci St. Jules, DO (PGY1), Joseph Chandrankunnel, MD Faculty, Internal Medicine SUNY Stony Brook at Mather Hospital Internal Medicine ProgramIntroduction: Infection accounts for 60% mortality in CLL1. The presentation of toxoplasmosis encephalitis manifests similarly to metastatic disease in immunocompromised patients, and can delay diagnosis2-4. Our case reinforces principles that are challenging to implement in a timely fashion.Case: A 79-year-old Caucasian female with a 3-year history of CLL presented with a 6-week history of LLE weakness, recurrent falls and 2 days of focal seizures manifesting as 1 minute episodic, involuntary, rhythmic jerking motions of her LLE. CLL had been in remission for 4 months after completing 6 rounds of bendamustine and rituximab.  Physical exam revealed LLE with 4/5 muscle strength, clonus in left foot with abnormal plantar reflex, normal sensation and deep tendon reflexes. Neurological exam was otherwise non-focal. Results/Course: Initial CT brain showed areas of vasogenic edema and MRI brain with contrast revealed three ring enhancing lesions surrounded by vasogenic edema. CT chest, abdomen and pelvis revealed a spiculated right upper lobe nodule. Lung biopsy showed necrotizing granulomas. Lumbar puncture showed elevated protein levels with a normal glucose, initially non-diagnostic, but later returned positive for toxoplasmosis antibody. A transcranial brain biopsy of the left frontal lobe lesion was initially read as negative, but second opinion found the biopsy positive for bradyzoites and tachyzoites with multiple necrotizing granulomas consistent with the diagnosis of toxoplasmosis encephalitis. Serologic studies were positive for toxoplasmosis IgG 31.7 IU/mL and negative toxoplasmosis IgM. Patient was treated with prednisone, sulfadiazine and atovaquone. At one month follow up patient is alive with some residual weakness and no recurrent falls.  She remains on lifelong immunosuppression therapy with pyrimethamine and sulfadiazine. Discussion: Toxoplasmosis in immunocompromised patients is the result of a reactivated latent infection, and often has a self-limiting course without treatment in immunocompetent patients7,11. In CLL, PubMed found 3 case reports of CNS toxoplasmosis5-9. One lived and 2 died shortly after diagnosis. A case most similar to ours was misdiagnosed as relapsing lymphoma without biopsy of a spinal cord lesion, treated with radiation and steroids, and patient died three days later10. Autopsy revealed high burden of toxoplasmosis in the brain. Conclusion: Our CLL case with non-specific neurological complaints and radiographic findings mimicking neoplastic disease required a high clinical suspicion to aggressively pursue the treatable and diagnosable CNS toxoplasmosis. CLL patients with similar neurologic presentation require aggressive pursuit if hoping to avoid fatality.

POSTER # 54

Teriflunamide Induced Clostridium difficile Sepsis: A rare adverse reaction with an interesting solutionHet Dharia, MBBS; Abdullah Al Twal, MD; Patrick Kohlitz, MDSUNY Upstate Medical UniversityBackground: Teriflunomide is a pyrimidine synthesis inhibitor used in management of Relapsing Remitting Multiple Sclerosis (RRMS). Leflunomide is the active agent which has been used in rheumatoid arthritis. Chronic diarrhea has been associated with both of these. However, there is no evidence in literature to suggest clostridium difficile (C.Diff) diarrhea associated with these agents. We present a unique case of C.Diff colitis in a patient on this immunosuppressive agent.Methods / Case Report: A 47-year-old female with a history of RRMS on Teriflunomide and Dalfampridine presented to the emergency department with complaints of nausea, vomiting, diarrhea and abdominal pain. She also had reactivation of prior neurological deficits that was considered to be pseudo-exacerbation of MS. There was no history suggestive of recent use of antibiotics or change in her home medications. The patient then developed signs of severe sepsis with worsening diarrhea and was admitted to the intensive care unit for severe C.Diff infection. Teriflunomide was considered as a causative agent and was withheld after consultation with neurology. Dalfampridine was also discontinued. Patient received appropriate antibiotics with complete resolution of her infection. Results / Discussion: Teriflunomide and leflunomide are associated with diarrhea. Severe infections are also reported due to immunosuppression. However, C.Diff infection has not been previously reported. In the post-marketing survey of use of teriflunomide, only two cases reported C.Diff colitis which led to drug discontinuation and changes in management of RRMS. In both these cases, patients were also taking dalfampridine. The timing of C.Diff infection in both cases was within 6 months of initiating Teriflunomide. Currently there are no guidelines on management of C.Diff infections in such cases however teriflunomide has a long half-life ( > 20 days) and requires drug elimination procedures such as use of cholestyramine / activated charcoal to hasten the elimination. Unfortunately, this was not performed in our patient and that was the likely cause of C. Diff relapse she developed after 2 weeks of discontinuation of the medication.Conclusions: We report a case of a patient who presented with severe C.Diff colitis that was attributed to the use of teriflunomide. Since guidelines were not available, drug elimination procedures were not performed. However, this should likely be considered to reduce chance of infection relapse or antibiotic resistance. Further studies and extrapolation of data from use of other immunosuppressive agent should be considered in treating such complex cases.

POSTER # 55

42

A Case of Pulmonary Tuberculosis in Alcoholic Cirrhosis Julia L. Frydman MD1, Ofole Mgbako MD1, Max Berger MD1, Benjamin Milgrom MD1, Elias Sakalis MD1. 1New York University School of MedicinePGY-1 Internal Medicine. Expected Date of Completion 6/2019

Case Presentation: A 42-year-old homeless man with a history of alcohol abuse and cirrhosis presented to our hospital with alcohol intoxication and 2 weeks of progressive abdominal distention. He also complained of a chronic dry cough, but denied fevers and shortness of breath. He reported drinking 10 beers daily for the past 20 years. He emigrated from Mexico to New York City in 2001. The patient appeared chronically ill and jaundiced. His initial vital signs were notable for fever, tachycardia, and hypoxia. His exam was significant for rhonchi over the left lung field, increased abdominal girth, and lower extremity edema. His labs were notable for leukocytosis, thrombocytopenia, and elevated liver enzymes. He was HIV negative. Chest radiograph demonstrated a heterogeneous dense opacity of the left lung. He was diagnosed with acute alcoholic hepatitis and started on antibiotics for community-acquired pneumonia. The patient improved clinically over 2 days however continued to have daily fevers, therefore his antibiotics were broadened to cover multi-drug resistant organisms. After 5 days, a computed tomography scan demonstrated left lung consolidation with areas of cavitation in the left upper lobe. The patient was placed on airborne precautions for suspected mycobacterium tuberculosis (MTB). Sputum smear revealed acid-fast bacilli, and MTB PCR returned positive. He was started on a liver-sparing MTB regimen on hospital day 6. Over the subsequent weeks, his alcoholic hepatitis and pneumonia improved. Discussion: Cirrhosis-associated immune dysfunction (CAID) is a clinical syndrome characterized by acquired immunodeficiency and inappropriate systemic inflammation.1 CAID leads to impaired immunity by decreasing immune surveillance, neutrophil and macrophage activity, and immunoglobulin synthesis.2 In addition, heavy alcohol consumption independently leads to further immunocompromise.2,3 The most common infections in cirrhotic patients are spontaneous bacterial peritonitis (25%), urinary tract infections (20%), and pneumonia (15%), and patients with decompensated cirrhosis have an even greater risk of infection.4 Patients with CAID also have an increased susceptibility to opportunistic pathogens, including MTB, cryptococcus, and vibrio species.5 Clinical presentations of MTB in immunocompromised patients are often atypical, which complicates diagnosis and management. Furthermore, an exaggerated pro-inflammatory response in cirrhotic patients more frequently leads to sepsis, septic shock and multi-organ failure than in immunocompetent hosts.5 Conclusion: Cirrhosis and alcohol consumption in a patient presenting with pneumonia should prompt a broad differential diagnosis including common and opportunistic pathogens. Given that CAID leads to increased morbidity and mortality, appropriate identification and treatment of infection in this patient population is critical.

POSTER # 56

Highest CPK in Sickle cell trait associated RhabdomyolysisJoselle Cook MD1, Steven Song MD1: 1SUNY Downstate Health Science Center, Department of MedicineIntroduction: Rhabdomyolysis has received new attention after being implicated in dramatic sequelae after spinning classes and boot camps among recreational and professional athletes, and military personnel. Several large population based studies now demonstrate the association and causation of the otherwise benign sickle cell trait in causing massive rhabdomyolysis; a ubiquitous heterozygous condition in African Americans that is significantly overlooked. We describe phenomenal elevation of creatinine phosphokinase (CPK) up to 1.34 million IU/ml in a 38 year-old healthy female with sickle cell trait presenting with rhabdomyolysis. Case Presentation: A 38 year-old African American female veteran with sickle cell trait presented with complaints of myalgias and dark urine for 4 days. She endorsed recent moderate exercise but denied travel, sick contacts, new medications, antibiotics, or use of over-the-counter preparations. Medical history was notable for exercise-induced rhabdomyolysis while training in the army 10 years before. Her physical exam was significant for generalized muscle and chest wall tenderness. Initial labs demonstrated acute kidney injury with creatinine 1.9 mg/dl, acutely elevated transaminases (AST 2556mg/dl, ALT 382mg/dl), hypocalcemia (7.8mg/dl), hyperphosphatemia (9 mg/dl), and hyperuricemia (9.9mg/dl). The CPK resulted to 1.34million IU/ml. She was admitted to intensive care where renal function rapidly declined; hyperkalemia (6meq/ml) and metabolic acidosis ensued (pH 7.236, pCO2 27.5mmHg, calculated HCO3 10meq/ml) and urgent hemodialysis was instituted. Viral panel and ANA, Anti-Jo, Anti-HMGCR antibodies were negative. Kidney biopsy demonstrated acute tubular necrosis secondary to myoglobinuria. Muscle biopsy demonstrated extensive muscle necrosis; histochemical staining for cytochrome oxidase, succinic dehydrogenase, myophosphorylase, phosphofructokinase, and myoadenylate deaminase were all negative. After profound electrolyte fluctuations and protracted hospital course, the patient was discharged to continue outpatient HD.Discussion and Clinical relevance: Sickle cell trait, the heterozygous condition thought to be mostly benign and often overlooked is now recognized as a pertinent association with rhabdomyolysis, compartment syndrome and sudden cardiac death. Recent population based studies validate the profound effects in young black athletes and military recruits with the trait. The index case highlights a dramatic presentation of rhabdomyolysis and sickle trait with highest recorded CPK at 1.34 million IU/ml resulting in substantial renal impairment. Workup was negative for other potential causes for her rhabdomyolysis. The association of sickle trait was likely unheeded in her previous presentation of rhabdomyolysis years prior. Though a multitude of causes for rhabdomyolysis exist, it is important for physicians to consider the role of sickle cell trait in African American patients presenting with rhabdomyolysis.

43

POSTER # 57Albuterol Induced Lactic Acidosis: It pays to Search for an Explanation in Lactic AcidosisRadhika Gali MD, K Swedish MD, TS Dharmarajan MDDepartment of Medicine, Montefiore Medical Center (Wakefield Campus), Bronx, NYIntroduction: Albuterol is a potential cause of lactic acidosis in acute asthma exacerbation, often under-recognized. Alternative etiologies for lactic acidosis should always be sought out to avoid needless medical interventions or therapy. Case: 54 year- old woman, with long- standing history of persistent asthma requiring multiple intubations presented with chest tightness and wheezing for one day. She used rescue albuterol inhaler four times at home without relief. She is a smoker, without additional asthma triggers; last asthma exacerbation was three years ago. Blood pressure was 151/50, heart rate 113/min, respiratory rate 28/min, oxygen saturation 100% on 2 liters nasal cannula. She was unable to speak in full sentences, using accessory muscles, and had expiratory wheezing bilaterally. Her peak flow on arrival was 160 L/min. Arterial blood gas (ABG) revealed lactate of 2.7 mg/dL. Continuous albuterol-ipratropium nebulizers and IV methylprednisolone were administered. Peak flow improved to 250 L/min (her baseline), but tachypnea worsened. She was placed on BIPAP to decrease respiratory effort. Repeat lactate increased to 7.1 mg/dL; remainder of labs and chest X-ray were normal. Albuterol was considered the source of lactic acidosis and discontinued. Repeat ABG 5 hours later showed a lactate of 4.5mg/dL, eventually becoming normal.Discussion: Lactic acidosis is a common clinical marker for sepsis and shock. In the absence of tissue hypoperfusion, alternate explanations must be sought. Type A lactic acidosis is associated with impaired tissue oxygenation. Type B lactic acidosis occurs without overt systemic hypoperfusion, such as malignancy, alcoholism, and medications like metformin, β2-agonists, and nucleoside reverse transcriptase inhibitors. Enhanced β2 receptor activity leads to increased glycogenolysis and lipolysis, increasing conversion of pyruvate to lactic acid. Albuterol- induced lactic acidosis creates a paradoxical worsening of tachypnea as a compensation for metabolic acidosis, which is often misleading, leading to intensification of albuterol therapy. Respiratory muscle fatigue can also be a cause of lactic acidosis in this scenario. Serial peak flow measurements and clinical improvement are the ideal means to assess treatment responsiveness. Lessons learnt:

Albuterol as a cause of lactic acidosis is often under-recognized in the course of managing asthma exacerbation.

Worsening of respiratory status and lactic acidosis during bronchodilator therapy should raise suspicion for albuterol induced lactic acidosis, while avoiding needless interventions.

Respiratory muscle fatigue often occurs in such settings and may be a contributory factor for lactic acidosis.

POSTER # 58The Fire in the Cave Junaid M. Habibullah, PGY1 Yonathan Litwock, PGY3 Matthew Czaja, Attending. Hofstra Northwell HealthInternal Medicine PGY1 Graduation 2019

Introduction: We present a case of bacterial sinusitis following an URI causing profound physical exam findings and significant lingering symptoms. Case: A 61 year old male with no past medical history presents with fever, chills, fatigue, headache and myalgias for the last 3 days. The patient also endorsed the development of photophobia, double vision, left sided neck pain and stiffness with nausea over the last 24 hours. Patient had recently recovered from an upper respiratory infection that lasted 3 weeks. On exam the patient was febrile, had neck tenderness on flexion, negative Brudzinski’s sign, limited jaw movement due to pain, and left abducens nerve palsy. Lab work showed a WBC count of 21k/uL, Lactate 2.6. A lumbar puncture showed glucose 50 mg/dl, protein 68 mg/dl, and nucleated cell count was 56 with neutrophil predominance. CT scan of the head showed air fluid level with sub-total opacification of the right ethmoid, maxillary and sphenoid sinus. A MRI of the head showed fullness to the cavernous sinuses bilaterally with inflammation of the dura of the cavernous sinuses and small abscesses within the cavernous sinus. The patient underwent drainage of the sinuses. Blood cultures returned positive for streptococcus constellatus. Patient was treated with ceftriaxone, vancomycin and decadron on admission. Following drainage the patient continued to have double vision requiring close follow up after discharge. Discussion: The case illustrates that cavernous sinus abscess can occur as a sequelae of sinusitis. Given the location of the sinuses, the spread of infection can affect the orbit, surrounding tissues and the CNS. The cavernous sinus is the most frequent dural sinus to be infected due to its central location and its proximity of multiple air sinuses. The sphenoid sinus lies just medial to the cavernous sinus, and infections can spread through the lateral air sinus wall. The ethmoid sinus can spread via the ophthalmic vein. Septic cavernous sinus thrombosis commonly presents with headache, fever, eye swelling and diplopia. Given cranial nerve VI is located more medial than the other cranial nerves (III, IV, V1-2) it is more susceptible to inflammatory damage as seen in the above patient who suffered from a 6thnerve palsy. In this case, extensive involvement of all the major air sinuses on the patient’s right side, led to the development of multiple infections involving the meninges and cavernous sinus, displaying that sinusitis left untreated can advance to significant and debilitating effect.

44

POSTER # 59Transient ST segment elevation with gastric distentionLaxmi Upadhyay MD, Prakash Acharya MD, Prasanta Basak MD, Tamarin Frank MD, Stephen Jesmajian MDMontefiore New Rochelle Hospital and Albert Einstein College of Medicine, New Rochelle, New YorkPGY1, Graduation year: 2019.

Introduction: ST segment elevation in an electrocardiogram (ECG) is an important marker for myocardial infarction unless proven otherwise. However, there could be various other cardiac and non-cardiac causes of ST segment elevation. We present a case of transient ST segment elevation in a patient with acute gastric distension.Case Presentation: A 66-year-old male with a history of seizure disorder and hypertension presented with sudden onset left sided weakness and altered mental status. Vitals- heart rate: 118/minute and blood pressure: 188/123 mmHg. He was not oriented to time, place and person. Neurologic examination revealed left sided weakness. Computed tomography (CT) head was negative for acute stroke. Cardiac enzymes were negative and ECG showed normal sinus rhythm at 95/minute with no acute ST-T changes. Patient was started on Keppra for possible seizures and rectal aspirin. On the third day of admission, he developed vomiting and epigastric pain. He was noted to have marked abdominal distension with diffuse tympany on abdominal percussion. ECG showed sinus tachycardia at 140/minute with ST elevation in leads II, III and aVF.  Rectal aspirin was continued; heparin drip and intravenous metoprolol were started. Troponin was negative twice. Electrolytes were normal.  Abdominal X-ray showed gastric distension. CT abdomen showed gastric lumen tapering at the pylorus possibly secondary to gastroparesis or stricture. No evidence of small bowel obstruction or free air was noted. Nasogastric tube was placed and 3.5 liters of fluid was drained. Patient reported almost immediate relief. ECG repeated after 12 hours showed sinus tachycardia at 100/minute but the ST segment elevation had resolved. Follow up abdominal X-ray showed resolution of gastric distension. Echocardiogram showed hyperdynamic left ventricular systolic function with estimated ejection fraction of 70%, without any wall motion abnormality. Patient’s neurological status also improved and he was subsequently discharged.Discussion: Various hypotheses have been proposed regarding the exact mechanism of ST segment elevation. Gastric distention can displace the intrathoracic contents, producing a shift in the main QRS axis of the heart. Change in position of heart in the anterio-posterior plane has been shown to produce transient ST segment elevation in the inferior leads. Direct compression by the distended abdomen on the inferior wall of the heart could also cause the ECG changes. Hence, gastric distention should be considered as a rare but reversible cause of ST segment elevation.

POSTER # 60Focal Segmental Glomerulosclerosis in MalariaIsmaela Teferi1, Mona Pourramazan1, Edward Epstein2, Sudheer Chauhan1 1Department of Internal Medicine, Jamaica Hospital Medical Center2Department of Nephrology, Jamaica Hospital Medical CenterPGY 2, Internal Medicine, June 2018

Focal segmental glomerulosclerosis (FSGS) is the most common cause of nephrotic syndrome in American adults, accounting for about 4% of end stage renal disease. Although numerous etiologies have been reported, few cases illustrate the association between acute tubular injury (in this case due to malaria) and FSGS.

A 56-years-old African male presented directly from the airport with complaints of dark urine, cough, body aches, and fever that began three weeks ago. The patient was travelling from the Ivory Coast where he was undergoing medical treatment for malaria; he had not completed the recommended course of treatment. Prior to arrival, he had intermittent symptoms of myalgia and fatigue for two weeks and was told by his physician that he had a low platelet count. On examination, the patient was febrile and tachycardic, appeared lethargic and confused, and had icteric conjunctiva. Laboratory investigations were significant for platelet count of 25 (130-400 K/µL), blood urea nitrogen of 27 (9-20 mg/dL), creatinine of 1.6 (0.7-1.3mg/dL), sodium of 126 (137-145 mEq/L), potassium of 2.9 (3.5-5.1 mEq/L), albumin of 2.6 (3.5-5 g/dL), and C-reactive protein of 20.5 (0.7-1 mg/dL). Peripheral blood smear confirmed the presence of Plasmodium falciparum. The serological tests for viral hepatitis, dengue, and HIV were negative. The renal biopsy was consistent with FSGS collapsing glomerulopathy associated with acute tubular injury. The patient was treated with three days of atovaqone-proguanil. Repeated peripheral smear showed no parasite and an improved platelet count. The patients renal function improved without the use of steroids or hemodialysis and he was discharged with outpatient follow up.

Previous studies reveal that malaria induced FSGS has poor prognosis with progression to ESRD despite treatment. This case exemplifies how early intervention in treatment of malaria with collapsing glomerulopathy could indeed be a good prognostic indicator.

45

POSTER # 61Unexplained Multiple Pulmonary Emboli: A Harbinger for Hepatocellular Carcinoma in a Non-Cirrhotic Liver Without Known Risk FactorsJoel Thomas, MD PGY-1; Neha Naik, MD PGY-3; Jacob Sokol MD; Alan Kaell, MDSUNY Stony Brook at John T. Mather Memorial Hospital, Port Jefferson

Background: Hepatocellular carcinomas (HCC) typically develop in liver disorders characterized by chronic inflammation with or without cirrhosis. HCCs that develop in noncirrhotic and cirrhotic patients may have distinct etiologic, clinical, cytogenetic, and/or histopathologic features (Table 1). The presentation, prognosis, and management for each individual may vary depending upon such features. We present a case of HCC without known etiology or risk factors. Our case had unexplained pulmonary embolus confirmed 2 months prior to HCC diagnosis and, in hindsight, may have been a harbinger of this occult malignancy.Methods/Case: A 57 year old Caucasian female with BMI of 49.1 presented on apixaban to the ED with 4 days of acute severe, sharp, lower abdominal pain associated with nausea and non-bloody emesis without fever or diarrhea. Three weeks prior, she consumed daily ibuprofen 400 mg for a mild, intermittent, RUQ abdominal pain. Two months prior, she experienced acute shortness of breath, which prompted evaluation and treatment for multiple bilateral pulmonary emboli without evidence of DVT or thrombophilia. Physical exam on admission was pertinent for fever, tachycardia, and diffuse abdominal tenderness without acute abdomen, hepatomegaly and equal trace bilateral lower extremity edema. Course: Apixaban and ibuprofen were discontinued. CTA of the Chest/Abdomen/Pelvis revealed several abnormalities including acute diverticulitis and a large ill-defined liver tumor mass with extension into the IVC (Figure 1).  Acute diverticulitis was treated with hydration and empiric IV antibiotics. On the second day of treatment, she continued to have persistent pain, pyrexia, and acute abdomen on physical exam, which prompted a repeat CT abdomen and she was transferred to the ICU.  This CT revealed microperforations and she was taken to the OR for an emergent exploratory laparotomy, sigmoid colectomy, colostomy placement, IVC filter, and liver lesion biopsy.   Results: Pathology of the liver biopsy was compatible with HCC sine cirrhosis (Figure 2). Risk factors for HCC were absent (Table 2). Discussion/Importance: An unprovoked primary DVT or pulmonary embolism without thrombophilia risk factors may herald malignancy. Our case highlights that clinicians maintain vigilance. Why apixiban was selected over warfarin on for the original first pulmonary emboli is undocumented. Novel oral anticoagulant (NOAC) use is challenging given the risk of bleeding with exploratory laparotomy and liver biopsy that was unanticipated in this patient. We plan to reinforce counseling of all patients on a NOAC or warfarin to avoid OTC NSAIDs and ASA products. Written instructions and teach-back methods are useful andragogical techniques.

POSTER # 62

Bilateral Panuveitis as the presenting sign of multiple sclerosis

Lauren A. Sielert, MD1 and Robert T. Swan, MD1. 1SUNY Upstate Medical University, Department of Ophthalmology

PG year: PGY-3 Ophthalmology

Expected date of completion of training: 6/2018

Case Description: A 39-year-old caucasian female with past medical history of seasonal allergies and carpal tunnel syndrome presented to our clinic for evaluation of bilateral uveitis. Thirteen days earlier she developed gradually worsening blurry vision accompanied by pain and redness of each eye while on vacation. She was seen by a local ophthalmologist who diagnosed bilateral anterior uveitis and started systemic and topical steroids and cycloplegia. Upon return to New York she presented to our clinic. Thorough history and review of systems were negative for autoimmune disease or neurologic symptoms. Exam in our office revealed vision of 20/100 right eye and 20/25 left eye and significant anterior chamber and vitreous inflammation. With the exception of a weakly positive ANA (titer 1:40), an extensive serologic investigation for infectious and inflammatory etiologies was negative. Given the severity of disease, patient demographic, and largely normal laboratory work up an MRI brain was pursued to evaluate for multiple sclerosis (MS). This showed foci of abnormal signal intensity within the periventricular and subcortical white matter consistent with MS. After the MRI was obtained she recalled history of fatigue and episodes of bilateral upper extremity numbness and tingling which had been attributed to carpal tunnel syndrome. The patient was referred for neurologic evaluation and was diagnosed with relapsing-remitting MS in accordance with the modified McDonald Criteria. Glatiramer acetate was initiated. The association of MS and uveitis is described but uncommon. The exact pathogenic relationship is unknown however some propose a common antigenic factor in uveal tissue and the central nervous system. Large retrospective studies show the prevalence of uveitis in MS patients to be around 1%. Of patients with MS and uveitis, simultaneous diagnosis has been shown to occur in 15%. Therapy for MS can also control the ocular inflammation, though this is not universally the case. Our patient had prompt relapse of inflammation when the corticosteroids were initially tapered. However, once the glatiramer acetate was at the therapeutic level, corticosteroids were tapered and she has not had inflammation for five months.

46

Clinical relevance: MS and uveitis are both disease which can start in an occult fashion but, with chronicity, can cause significant patient morbidity. MS should be considered in patients presenting with bilateral uveitis and uveitis should be considered in multiple sclerosis patients with eye complaints of floaters, pain, light sensitivity, and/or decreased vision.

POSTER # 63Ultrasound Guided Single Injection Quadratus Lumborum Block for Postoperative Pain Control in Patients’ Undergoing Total Hip ArthroplastyHameed, A1., Kassin, E1., Bejar, L1., Dowling, O1.1. Department of Anesthesiology, Northwell Health System, New Hyde

Park, NY 11040Ayesha Hameed, CA2, Class of 2018

Introduction: Adequate pain control is essential to patient recovery following total hip arthroplasty (THA) which continues to be a concern. The goal of contemporary analgesic interventions after THA is to minimize pain, promote early mobilization and reduce opioid use. Postoperative THA pain control modalities include NSAIDs, local infiltration analgesia, intrathecal opioids and lumbar plexus block. Due to lack of evidence, a gold standard has not been established. This case series describes the effective use of a single shot quadratus lumborum (QL) block for postoperative pain control in two patients who presented with challenging aspects to their anesthetic management due to significant comorbidities.Results/Case Report: Our institution was able to utilize a single injection ultrasound guided QL block to manage postoperative THA pain effectively. Firstly, a 79 year old male with history of poorly controlled primary hypertension and hyperlipidemia who underwent a direct anterior approach right THA with 15 mL bupivacaine 0.25% infiltration of the right QL. During his intraoperative course and hospital stay, patient did not require any intravenous narcotics. He complained minimally of pain during the recovery period and was able to tolerate physical therapy by ambulation with a walker. Second case is a 52 year old female BMI 40 kg/m2 with history of gallstones and menorrhagia who underwent a direct anterior approach right THA with 40 mL bupivacaine 0.125% infiltration of the right QL. Her analgesia during the operative course only consisted of ketorolac, as per surgeon’s request, yet no narcotics. During recovery, the patient received minimal intravenous narcotic, tolerated physical therapy and achieved milestones at goal.Discussion: The ultrasound guided transversus abdominis plane (TAP) block, covering nerve roots T10-T12, has gained popularity for analgesia in abdominal and retroperitoneal procedures. Recently, the QL block has been utilized for similar procedures and found to be further effective given wider blockade comprising T6-L1 is achieved. Given the potential for extensive sensory analgesia, the QL block has been expanded to lower extremity procedures. In particular, a continuous QL catheter was noted to be

successful for total hip arthroplasty which was expanded to a single shot injection of quadratus lumborum utilized for minimally invasive hip surgery. Our case series enhances the potential of a single shot injection QL block to be effective pain control for postoperative THA. This regional method provided an effective method of analgesia for otherwise challenging cases due to patients’ complex comorbidities.

47

POSTER # 64How Palliative Care changed a Child’s Life with a Very Rare Disease: A Case with Cerebrocostomandibular syndrome (CCMS) Mustafa S. Caylan, MD, Lincoln Medical Center, New York, NYAlvin Moyer, MD, Elizbeth Seton Pediatric Center, New York, NYPGY4, expected date of completion of training: 06/30/2016

Background: CCMS is an extremely rare, inherited disorder characterized by micrognathia, palate malformations, glossoptosis, and rib dysplasia. In most cases, such abnormalities contribute to respiratory insufficiency in early infancy. Although some affected individuals have normal intelligence, others exhibit moderate to severe mental retardation. There are no conventional treatments to reverse this syndrome and the approaches are directed towards improving patient’s functioning and comfort. In children with CCMS, a palliative/integrative medicine approach may improve outcomes and help both children and the families. Elizbeth Seton Pediatric Center (ESPC) is a 137-bed pediatric specialty nursing facility, serving some of most medically complex children in NY, from infancy through age 21, providing comprehensive healthcare, rehabilitation and special education services to its residents. The services ESPC offers include but are not limited to physical therapy, occupational therapy, speech and swallow therapy, music therapy, art therapy, child life, social work and spiritual care working along with medical team.Case Description: P, is a 9-year-old female with CCMS, restrictive lung disease, chronic respiratory failure, FTT, GERD, hearing loss, bilateral cholesteatoma and severe scoliosis, born at 31 weeks of GA via emergency C-section due to lack of fetal movement. Prenatal US was concerning for a cystic hygroma and micrognatia. NICU course was characterized by immediate respiratory distress for which she was intubated. Micrognatia, scapular and vertebral anomalies and rib dysplasia was found as well as narrow external auditory canals and low set ears which were all consistent with CCMS. Weaning off ventilator was unsuccessful so she underwent tracheostomy at 4 months of age and gastrostomy at 5 months of age. She was diagnosed with pulmonary hypertension and restrictive lung disease. She was discharged from NICU at 7 months of age. Initial years of her life was complicated with multiple ventilator associated pneumonias and multiple admissions to different acute care and long term care hospitals. After admission to ESPC in 2014 her symptoms and frequent acute illnesses have been well controlled. She is receiving multidisciplinary services and developing at her maximum capacity. She can sit without support, walk independently, has good hand function, learning sign language and is now toilet trained. She goes to school and enjoys her time with her friends and her teachers. Conclusion: This case demonstrates how Pediatric Palliative Care, provided using an integrated trans-disciplinary approach, can be used to improve the quality of life of children with significant health care needs and their caregivers.

POSTER # 65PD-L1 and Notch1 Expression in KSHV/HHV-8- and -EBV Associated Germinotropic Lymphoproliferative Disorder: Case Report and Review of the LiteratureArash Ronaghy MD PhD1, Huan-You Wang MD PhD2, John A. Thorson MD PhD2, L. Jeffrey Medeiros MD3, Silvia G Spitzer PhD1, Yi Xie MD PhD4, Alyssa Yurovitsky MD1, Solaiman Futuri MD5, Haris Sheikh MD1, Eugene Santagada BA1, Shannon L St Clair MD6¸ Judith Brody MD1, Tianyu Yang, MD PhD1, Maria Delcarmen Navarro, MD1, Peihong Hsu MD1, Xinmin Zhang MD1, Silvat Sheikh-Fayyaz MD1 , 1 Department of Pathology and Laboratory Medicine, Hofstra North Shore-LIJ School of Medicine, Lake Success, NY, USA.2 Department of Pathology, University of California San Diego, La Jolla, CA 92093-0918, USA.3 Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX.4 Hematopathology Section, Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, MD.5 Staten Island University Hospital Hematology Oncology Group.6 Department of Radiology, Lenox Hill Hospital, NY, NY, USA.PGY-4 Resident; 06/30/17 residency completion date; PathologyBackground: We present an extremely rare case of Kaposi sarcoma herpesvirus (KSHV)/Human Herpes virus 8(HHV8)/Epstein-Barr virus (EBV) associated germinotropic lymphoproliferative disorder (GLD) in a healthy 73-year-old man. Methods: We used imaging, histology, immunohistochemistry, FISH, and molecular studies to characterize this disorder. Results: A 4.1 cm para-aortic lymph node found incidentally and partially effaced by multiple, germinotropic, clusters and nodules of large atypical cells. The germinotropic large atypical cells had a round to oval nucleus, vesicular chromatin, 1-2 prominent nucleoli, ample basophilic cytoplasm resembling plasmablasts (GLD cells). By immunohistochemistry, the plasmablasts were positive for KSHV/HHV8, EBV, viral IL-6, CD138, CD38 (weak), MUM-1/IRF-4, surface IgM, Notch1, PD-L1, and negative for other lymphoid markers. Immunoglobulin gene rearrangement studies using PCR-based methods showed a smear pattern consistent with polyclonal B-cells. No deleterious gene mutations, amplifications or translocations were demonstrated by targeted NGS analysis of 464 genes or FISH studies of the PD-L1 and PD-L2 gene region. Conclusions: This is the first reported GLD demonstrating expression of PD-L1 and Notch1, and the first study investigating the mutational landscape of GLD by targeted NGS. Similar to other cases reported previously, this patient had localized lymphadenopathy and manifested an indolent clinical course. Clinical relevance: First, it is critical that clinicians, surgeons, and pathologists be familiar with this entity to avoid overtreatment as it generally has an excellent prognosis and the differential diagnostic considerations have an exceedingly poor prognosis. Second, this is the first report to demonstrate Notch1 and PD-L1 positivity potentially leading to future novel therapeutic approaches.

48

POSTER # 66Hypotonia and Lethargy in a 5 week old girlHina Zaidi1, MD,* Aderonke Adefisayo, MD,* Laura Monahan, MD,* Christy Beneri, DO (Program Director)* *Stony Brook Children’s Hospital, NY1PGY-6, fellowship graduation 7/2017 Case: A 5-week old girl, born full term, now presenting with 1 day of increased sleepiness and a weak cry. Her formula intake has decreased, but she has normal wet diapers and soft stooling. On presentation, she is afebrile with normal vitals. On exam, she is normal cephalic, atraumatic, anterior fontanelle open and flat, right lower extremity with asymmetric gluteal cleft; normal cardiac, respiratory and abdominal exam. Neurology exam progresses from normal to hypotonia, areflexia and appearance of somnolence. Pupillary light reactivity is sluggish initially, though no evidence of pupillary fatigue with repetitive stimulation, while corneal reflex is absent and gag reflex intact. Sepsis work up and empirical Ceftriaxone and Vancomycin initiated. She is admitted to PICU, develops hypoxia, hypothermia, bradycardia and apnea, leading to Code Blue requiring intubation for respiratory support. Peripheral white blood cell count is 5.31 K/uL, hemoglobin 7.9 g/dL, hematocrit 22.3 %, platelets 291 K/uL; electrolytes, anion gap, lactic acid, LFTs and coagulation studies are normal. CSF show no pleocytosis. Blood and CSF cultures and herpes PCR are negative. Other labs, including ammonia, magnesium and thyroid function tests are normal and urine toxicology negative. Head CT and MRI of brain and spine is normal (except arachnoid cyst T1-L4/5). VEEG confirms no seizure activity and nerve conduction studies (EMG) demonstrates normal rapid repetitive stimulation activity. Botulism is suspected despite inconsistent EMG. Infant stool is tested for botulinum toxin, identifying Clostridium botulinum Toxin gene B by real time PCR and mass spectrometry. The infant receives Baby Botulinum Immunoglubulin (BabyBIG) on day 6 of illness. She clinically improves, weans off respiratory support 4 days post treatment and is discharged home 7 days post treatment, with NG feeding tube due to poor suck. DISCUSSION: It was discovered the father, who is in close contact with the infant, participates in dirt biking in Buck’s County, Pennsylvania. This location carries a high burden of Clostridium botulinum spores. Giving Baby BIG early, within the first week of presentation improves prognosis. Though this infant presented as clinical sepsis, a close history and careful exam helped guide the true diagnosis of infantile botulism. CONCLUSION: Infantile Botulism should be considered in all infants presenting with hypotonia, lethargy, unexplained respiratory failure, and symmetric bulbar palsies, particularly in the setting of lack of temperature dysregulation. Infantile Botulism can be fatal but if identified early and treated with BIG, the prognosis is good for full recovery.

POSTER # 67Fatal Acute Respiratory Distress Syndrome from AdenovirusZabeer Bhatti M.D.1, Amit Dhamoon M.D. Ph.D1

(1) SUNY Upstate Medical University PGY-2 Internal Medicine Resident: Expected to graduate in June 2018

Adenovirus is a non-enveloped double-stranded DNA virus [1]. Most commonly, adenovirus infection is associated with mild, self-limited upper respiratory illness. Severe or life-threatening infections are usually encountered in children and immunocompromised patients [1]. There are few reports of adenovirus causing severe disease or fatal acute respiratory distress syndrome (ARDS) in immunocompetent adults. We present a case of severe adenovirus infection in a woman who presented with mild respiratory symptoms and rapidly progressed to respiratory failure.

A 27 year-old African American woman presented to our emergency department with complaints of cough and shortness of breath for the last two days. Her past medical history included obesity and mild persistent asthma. She also reported smoking one pack per-day. On admission, her vital signs were within normal limits. Physical examination was significant for wheezing in both lung fields. Initial laboratory tests were unremarkable. Respiratory panel was positive for adenovirus. Chest radiograph showed a hazy ill-defined opacity in the left mid-lung. She was diagnosed with viral pneumonia and was empirically started on ceftriaxone and azithromycin. Within twenty-four hours of admission, she developed worsening hypoxemia that was not responding to nebulized albuterol and supplemental oxygen. She was subsequently intubated. Chest radiographs demonstrated worsening bilateral lung opacities. She became increasingly hypoxemic requiring 100% supplemental oxygen, consistent with severe acute respiratory distress syndrome. Due to respiratory failure refractory to medical management, veno-venous extracorporeal membrane oxygenation (ECMO) was initiated. Within a few hours of starting ECMO the patient developed a change in mental status followed by cardiac arrest. Cardiopulmonary resuscitation was unsuccessful and the patient expired.

Adenovirus is one of the most common causes of upper respiratory infections in adults and children [1]. The patient we described did not have any known risk factors for severe adenoviral infection. ECMO is an option to provide life-sustaining oxygenation and CO2 removal and allow and time for the lung to heal. In our patient however, cardiac arrest and death occurred within hours.

Our care report illustrates that while rare in immunocompetent adults, adenovirus can cause severe pneumonia, acute respiratory distress syndrome and severe sepsis and multi-organ failure, and should be considered in the differential diagnosis. The mortality in cases such as ours is high, and the clinical benefit of various treatment strategies, including anti-viral agents and ECMO, is controversial (1). Further research is needed to establish effective treatment options for patients with severe adenovirus pneumonia.

49

POSTER # 68Massive Gluteal Abscess caused by Methicillin Resistant Staphylococcus Aureus in a Patient with Systemic Lupus ErythematosousMalahat Movahedian a,c, Tofura Ullah b, Farshad Bagheri a, Katerina Teller a

a Department of Internal Medicine, Jamaica Hospital Medical Centerb Department of Clinical Research, Jamaica Hospital Medical Centerc Corresponding author: Malahat Movahedian, Department of Internal Medicine, Jamaica Hospital Medical CenterPGY 2 Internal Medicine resident, graduation date: June, 2018

Systemic Lupus Erythmatosous (SLE) is a chronic autoimmune disease involving multiple organ systems. Due to the nature of the disease, as well as the treatment modalities that can cause immunosuppression, patients with SLE are more susceptible to infections. Massive gluteal abscess due to methicillin-resistant Staphylococcus aureus (MRSA) is a rare entity that can affect immunocompromised patient with SLE, specifically those who are on immunosuppressive drugs or have other comorbidities.

A 48-years-old-female presented with left gluteal pain, swelling, and redness associated with fever and chills for several days. The patient was diagnosed with SLE 15 years prior and was on chronic prednisone therapy of 10 mg per day, occasionally increased to 20 mg daily for few days. She was on no additional immunosuppressive treatments due to development of side effects in the past. She reported history of well-controlled diabetes mellitus with no other significant medical condition present.

Initial labs revealed significant leukocytosis, 29 (4.8-10.8 K/uL). On examination, she was found to have hypotension, and tachycardia and was admitted for severe sepsis. A massive gluteal abscess was identified on CT scan of the pelvis with contrast. Cultures of the purulent fluid returned positive for MRSA. The patient underwent emergent incision and debridement and received intravenous antibiotic therapy of ceftaroline, meropenem, and clindamycin. A significant improvement was seen clinically and in her laboratory values following treatment. She continued to be on 10 mg Prednisone to control her Lupus symptoms.

This case illustrates the importance in recognizing unusual primary sources of infection in immunocompromised patient with SLE, especially those on immunosuppressive therapy. Although rarely reported, gluteal abscess should be considered as a differential diagnosis of bacterial infection source in SLE patients with septic features. Careful titration of steroids and other immunosuppressive medications to control disease activity will remain a challenging dilemma until new medications for SLE are developed.

POSTER # 69Avoiding long term outcomesRicardo Alonso, MD, The Brooklyn Hospital CenterExpected date of completion of training Jul/2019

80-year-old right hand dominant female with 3 years of progressive stiffness of right shoulder. No recent trauma or falls but history of right rotator cuff tear 20 years ago that was treated with conservative management because she believed she was “too old for surgery”. Currently the patient denies pain but reports shoulder stiffness that doesn't improve with utilization and limits ADL's like brushing her teeth, dressing and eating. Right shoulder physical exam reveals hypertrophic bone deformity, muscle wasting, no tenderness. Passive range of motion was painless but severely restricted to extension 10°, forward flexion 110°, abduction 90°, adduction 10°, external rotation 15°, internal rotation 20°. Motor strength 1-2/5 in the right shoulder, intact sensation. Differential diagnoses included osteoarthritis, rheumatoid arthritis, adhesive capsulitis, rotator cuff arthropathy and subacromial bursitis. Shoulder X-ray revealed marked enlargement and deformity of distal acromion, deformity of the humeral head with subchondral cystic and sclerotic changes, consistent with severe osteoarthritis. These findings may have been sequelae of previous trauma and old   fracture. Periarticular ossified densities suggesting heterotopic bone and calcific tendinitis; soft tissue wasting. Patient was diagnosed with severe glenohumeral osteoarthritis.

Glenohumeral osteoarthritis results from destruction of articular cartilage and subchondral bone. This causes increased friction within joint spaces producing pain and disability. This pathology mostly affects women over the age of 60. Risk factors also include weight, genetic predisposition and history of previous injuries. The main goal for treatment of glenohumeral osteoarthritis is to reduce pain and improve functionality. Pain management, physical therapy and surgical options exist to accomplish this goal; however, management should be guided by shared decision making.

Orthopedic surgeon suggested reverse total shoulder arthroplasty; but the overall goal would be pain control as functional status can't improve. She was advised to apply topical NSAID   as needed and start treatment with physical therapy.

This case highlights the importance of proper patient education. Although not all rotator cuff tears require surgery, her current symptoms were a consequence of a complete chronic rotator cuff tear that could have been surgically repaired before severe muscular atrophy developed. Would she have declined surgery if she knew she was at risk of developing severe osteoarthritis later in life? Unfortunately, now treatment options are limited. Our patient’s presentation also illustrates that X-ray findings do not always correlate with the severity of pain. Our patient’s X-ray revealed severe osteoarthritis with calcific tendinitis which would theoretically cause severe pain.

50

POSTER # 70Alcohol leading to a “Pirates Gait”An Chen MD, Camillo Villabos MD, Alexis Harman MD, Haidy Rivero MDThe Brooklyn Hospital Center affiliated with Mount Sinai Residency: PGY 2 - Family Medicine class of 2018

We have a 40 year old male with history of donor nephrectomy presents for bilateral hip pain for the past 2 years that has gotten worse in the past month. Pain is 8/10, intermittent, sharp and shoots down the mid gluteal area to the back of the knee, aggravated with standing, bending forward and prolonged sitting, alleviated with rest and ibuprofen. Pain is not associated with any numbness, urinary/fecal incontinence or retention. Denies any history of trauma, steroid use, or any past injuries. Surgical history include being a kidney donor to his father. Family history is positive for father having bilateral hip replacement in his 40s. Social history is positive for 20 years of heavy alcohol and cocaine abuse. 

Physical exam shows a well dressed male, not in any distress. On musculoskeletal exam – there were no evident hip deformity or tenderness to palpation. There was however, restricted and painful range of motion of bilateral hips. Labs were unremarkable. MRI showed severe osteoarthritis of bilateral hips with likely early avascular necrosis of femoral heads bilaterally.

Avascular necrosis is cellular death of bone due to lack of blood supply resulting in pain and loss of joint function. Risk factors include glucocorticoid use, alcohol, SLE, trauma, sickle cell hemoglobinopathies. Early diagnosis and appropriate intervention can delay the need for joint replacement.

Hip pain has traditionally been present in two populations based on age, either the limping child or the crippling geriatric. Hip pain is less common in young adults aged 20-50. The purpose of this case is to highlight an uncommon cause of hip pain in young adults. Our patient had chronic bilateral hip pain due to avascular necrosis of the hips from excessive alcohol consumption.

Treatment of osteonecrosis is one of the most controversial subjects in orthopedic literature. Three options exist – pharmacologic management, core decompression, and surgical joint replacement.Without proper treatment, the process is always progressive, leading to joint destruction within 5 years. However, early detection and innovations in core decompression therapy show promising results.

51