North Texas GME Research Forum 2023

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  2023 North Texas Division Research Forum Program

  HCA Healthcare

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  2023 Virtual Keynote and Oral Presentation Session - North Texas Division Research Forum

  Rita Devine, Christopher Wong, Kahmalia Sada, Mark Cheneler, Dawson Hinkley, Sunitha Valayil, Stephen Shey, Asma Tahir Toor, Yen Chung Wang, Marshall Hall, and Riddhiben Patel

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  2023 Virtual Poster Session - North Texas Research Forum

  Christoffer A. Amdahl, Michael Armstrong, Andrew H. Cushing, Kiana Clem, Srujana Dasari, Henry Lim, Makenzie Morrissey, Riddhi H. Patel, Akshaj Pole, Ramya Ramachandran, Sherwin Thomas, Ahmad Ahsen, Ali Nazim, Joseph Kim, William W. Mangin, Daniel A. Nguyen, Diana Roy, Stephen Shey, Chrystal Stallworth, Hiral trivedi, Alllison Walworth, Christian Scheufele, and Kahmalia Sada

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  51-Year-Old Female with Epistaxis and Generalized Weakness for 2 Months Diagnosed with RPGN

  Meihuan Lin

  Rapidly progressive glomerulonephritis (RPGN)’s clinical presentation including acute onset of macroscopic hematuria, decreased urine output, acute onset of hypertension, and edema. Other clinical findings include nephritis presentation on urine analysis with proteinuria, micro and macroscopic hematuria, red blood cells, dysmorphic RBC and RBC casts. Pathological findings characterized extensive crescent formation. Untreated patients can rapidly progress to end-stage kidney disease over a very short periods (days to months). Renal biopsy can further differentiate the types of crescentic glomerulonephritis. There are three major types of RPGN: 1. Anti-glomerular basement membrane (GBM) disease cause by anti-GBM antibodies. It is also associated with pulmonary component with cross-reaction of the antibodies with membrane of the pulmonary capillaries. 1. Immune complexes RPGN associated with immune complexes in the glomeruli such as IgA deposits, antistreptococcal antibodies and subepithelial humps, and antinuclear antibodies and subepithelial deposits in lupus nephritis. 3. Pauci immune RPGN associated with small vessel vasculitis, a necrotizing GN with few or negative immune deposits. It is often antineutrophil cytoplasmic antibody (ANCA) positive. An urgent diagnosis is important in the patient who presenting with clinical findings of RPGN. Serologic tests such as a ANCA, anti-BGM antibodies, ANA, and others with biopsy results. Prompt diagnosis with kidney biopsy and serological test with early therapy is the key to minimize the kidney injury. Specific treatment can be given once the diagnosis is made. Patient is a 51 years old female with history of hypothyroidism and iron deficiency anemia presented with nosebleed and generalized weakness for 2 months. Her baseline creatine was 0.6 back in August 2022. On admission, her creatine was 17.9 along with hyperkalemia which required urgent hemodialysis. Serological studies and renal biopsy were done and confirmed with Pauci Immune Glomerulonephritis with positive P-ANCA, negative anti-GBM antibodies. Patient was treated with IV Solu Medrol 1 gram daily. Hem/Onc was consulted and patient was transferred to Presbyterian [REDACTED] for emergent chemotherapy.

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  A Case of Erythema Nodosum

  Mahmood Ahmad and Sunitha Valayil

  Background: Erythema nodosum (EN) is characterized as a delayed hypersensitivity reaction to subcutaneous adipose tissue. This panniculitis process presents as erythematous, tender nodules and plaques most commonly located on the pretibial areas. EN may be idiopathic or may be caused by a number of factors such as infection, chronic systemic inflammatory processes, drugs or malignancy.

  Case presentation: A 29-year-old male with no significant past medical history presented with a 2-week history of worsening bilateral lower extremity erythema, nodules and pain. This patient was initially seen in the emergency department after a 4-day history of his symptoms. At this time, he reported that he had a fever and sore throat 1 week prior to the start of this symptoms that had since resolved. He denied any recent travel history, illicit drug use, animal bites, allergies, sick contacts, new sexual partners, family history of autoimmune diseases, changes in diet, or recent occupational or environmental exposures. On presentation, the patient was mildly tachycardic and had mild leukocytosis. His group A beta strep Ag test was negative. The patient was given Bactrim and Keflex to cover for possible infectious etiology as well as the possibility of cellulitis. One week later, the patient returned to the emergency department with worsening erythema and joint pain after completing the course of antibiotics. The patient had erythematous nodules that now appeared on his forearms as well. The patient was tachycardic and was mildly hypertensive. Labs showed mild leukocytosis, normocytic anemia, elevated CRP and sedimentation rate, and thrombocytosis. UDS was positive for THC, UA was positive for blood, protein and few bacteria. The patient was then started on steroids, cefazolin and given naproxen for pain. Both infectious disease and rheumatology were consulted. The patient was continued on steroids, switched to PO doxycycline and continued on naproxen. The patient had significant improvement in symptoms was discharged after one day of hospitalization. His ASO- titer came back significantly elevated which helped confirm our diagnosis.

  Conclusion: We present this case to discuss the course and management of erythema nodosum. Erythema nodosum can occur secondary to various causes and this case report provides more information and understanding of how to approach an unique disorder.

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  A Case of Unilateral Jerking Movements in a Patient with Uncontrolled Type 2 Diabetes Mellitus

  Mark Cheneler, Tapannita Padhi, Khizir Qureshi, and Carlos Bahrami

  Hemichorea-hemiballismus (HCHB) syndrome is a syndrome characterized by choreic movements which are irregular, nonrepetitive, and random movements and ballismus which are spontaneous, violent movements. HCHB syndrome is a rare presentation which can be precipitated by uncontrolled diabetes and is thought to have multiple plausible mechanisms. One mechanism of HCHB with uncontrolled diabetes is ischemic injury in the basal ganglia causing impaired gross motor control. Presented here is a case of HCHB syndrome initially seen on imaging and later correlated with physical examination. This patient presented for nonspecific complaints of fatigue, generalized weakness, and lower extremity weakness. On evaluation by EMS prior to arrival, she was found to be obtunded with a blood glucose of greater than 500 mg/dL and was treated with insulin in the field prior to arrival. On arrival, her mentation had improved and she was able to answer clarifying questions of noncompliance with her antihyperglycemic medications and lower extremity weakness. She had a head CT performed which showed lesions in the right caudate nucleus and putamen consistent with HCHB syndrome. She was started on treatment for nonketotic hyperglycemia with insulin. As her mentation improved, she was able to cooperate with neurological physical examination, which was positive for irregular and violent movements in the left upper and lower extremities. She had mild improvement in her hemichorea and hemiballismus with improved glycemic control and she was able to be discharged to a skilled nursing facility for further rehabilitation. She has had further hospitalizations, after initial evaluation, for poor glycemic control and repeat head CT imaging has continued to show right basal ganglia lesions. This case represents a rare complication with hemichorea-hemiballismus syndrome due to uncontrolled diabetes mellitus. HCHB syndrome associated with uncontrolled diabetes is also referred to as diabetic striatopathy and is characterized by poor glycemic control, unilateral striatal hyperdensity on CT imaging, and contralateral choreic movements. Diabetic striatopathy remains a poorly understood disease and the exact pathophysiologic mechanism has not been definitively elucidated. Antidopaminergic medications may be used to control the choreic movements of diabetic striatopathy; however, the mainstay of treatment is glycemic control, most commonly with insulin therapy.

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  A Case of Viral Pneumonia and Acute Respiratory Distress Syndrome During the COVID-19 Pandemic

  Mark Cheneler, Khizir Qureshi, and Carlos Bahrami

  Acute respiratory distress syndrome (ARDS) remains a major cause of morbidity and mortality in the ICU setting and a continued source for investigation to improve outcomes. It is characterized by acute respiratory failure with an identifiable insult, bilateral infiltrates on imaging, and a PaO2/FiO2 ratio (PF ratio) of less than 300 mmHg. It can be further classified into mild, moderate, and severe ARDS with a PF ratio of less than 300, 200, and 100 mmHg respectfully. Treatment requires elucidation of the underlying insult to the pulmonary system and prompt treatment. Presented here is a case of ARDS secondary to herpes simplex virus (HSV) pneumonia in an immunocompetent adult. This patient presented for evaluation during the COVID-19 pandemic with nonspecific respiratory symptoms and bilateral pulmonary infiltrates which would be consistent with COVID pneumonia; however, multiple rapid and PCR COVID-19 nasal testing swabs showed nonreactivity. Her respiratory status ultimately continued to decline while on noninvasive ventilation with Bipap and required intubation. After intubation, a bronchoscopy was performed and bacterial and mycobacterial cultures were obtained and showed no growth. Viral PCR panel was performed and a diagnosis of HSV pneumonia was made. She was started on systemic acyclovir treatment but unfortunately expired before her antiviral course could be completed due to worsening of ARDS and inability to oxygenate. A literature review shows HSV pneumonia to be a rare cause for ARDS especially in the immunocompetent individual with few cases being reported in immunocompetent individuals. Treatment of HSV pneumonia can show reversibility in the lung damage as visualized on imaging which has been shown in another case report. Extracorporeal membrane oxygenation may be utilized as a bridge for treatment when the insult is identified quickly before permanent damage has been done to the lungs. This was unfortunately not an option for this patient due to the limitations of the facility and the time to diagnosis of her condition. This case demonstrates the importance of maintaining a broad differential diagnosis when respiratory status becomes compromised and prompt treatment once an identifiable cause is found.

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  An Exceedingly Rare Case of Bilateral Synchronous Germ Cell Testicular Tumors of Different Histological Types

  Joseph Kim, Ray Page, Gregory Moses, and Rod Carlo Columbres

  It is exceedingly rare to find a case of bilateral synchronous germ cell testicular tumors of different histological types, and there have been only a handful of cases because of a lack of connections through lymphatic or vascular pathways between the testes. Here we present a unique case of a 43-year-old man who initially presented to the primary care physician for increasing right testicular swelling. He had a testicular sonogram that showed a large right testicular mass as well as a 1.7 cm left testicular mass suspicious of malignancy. Pre-surgical laboratories showed PSA 0.97, alpha-fetoprotein 1875, quantitative hCG 2508, and LDH 448. He proceeded with a right inguinal orchiectomy and the pathology revealed a 9-cm embryonal carcinoma limited to the testes. Negative lymphovascular invasion with clear margins, stage IS (pT1b N0 M0). Post-surgery, the tumor markers normalized. CT scan of the abdomen and pelvis showed postsurgical changes but no evidence of lymphadenopathy or metastatic disease. Chest x-ray showed no evidence of metastatic disease. This was subsequently followed by a left inguinal orchiectomy and the final pathology revealed a seminoma, negative margins, no invasion, stage IA (pT1a N0 M0). Because of the rarity of synchronous bilateral testicular neoplasm, treatment is unique and based on the tumor stage and managed separately with close surveillance in accordance with National Comprehensive Cancer Network guidelines.

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  An Innovative Model for Graduate Medical Education Faculty Development through Physician In Training Delivery

  Daniel A. Nguyen, Christopher Wong, Christian Scheufele, Michael Carletti, and Stephen Weis

  BACKGROUND/INTRODUCTION: Faculty development is an important component for ACGME accreditation of residency programs. 1-3 There are multiple strategies for faculty development with methods including workshops, lunch-ins, and online modules. 10-12 Having successful approaches to develop faculty has lead to self-reported improvement in teaching and clinical skills, intrapersonal and interpersonal growth with faculty given more positive ratings by learners. 8,9 Beyond the individual faculty, there can be system wide cultural shifts supportive of scholarly teaching. 10 Delivering content that is convenient and valuable to the faculty can be challenging. 3,4 If resident physicians can deliver effective convenient faculty development programs then faculty and resident physicians would both grow as teachers. Resident physician participation in this project will contribute to growth in multiple ACGME core competencies.

  METHODOLOGY: We implemented a quality improvement project where resident physicians deliver content to faculty at each rotation in their curriculum. Our objective was successful implementation of the quality improvement project with improvement or increase in faculty development received. Study population includes HCA Medical City Fort Worth Dermatology / UNTHSC faculty with rotating residents

  RESULTS: Five dermatology residents delivered 45 presentations to 15 faculty individuals over a 30 month period. Not a single attending declined the faculty development topic. Five different topics were presented. The first topic "Teaching House Staff Safely During the COVID19 Era” was delivered 8 times. The second topic “Faculty Wellness” was delivered 10 times. The third topic “Case-Based Collaborative Learning” was delivered 15 times. The forth topic “From Burnout to Engagement” was delivered 9 times. The fifth topic “Burnout” was delivered 3 times. Faculty who had never completed faculty development participated for the first time.

  CONCLUSION/DISCUSSION: Physician In Training delivered faculty development is an original, innovative model that can increase education. By providing faculty development as a convenient and consistent model, residency programs may satisfy ACGME core competencies while improving the quality of physician education programs. BACKGROUND/INTRODUCTION: Faculty development is an important component for ACGME accreditation of residency programs. 1-3 There are multiple strategies for faculty development with methods including workshops, lunch-ins, and online modules. 10-12 Having successful approaches to develop faculty has lead to self-reported improvement in teaching and clinical skills, intrapersonal and interpersonal growth with faculty given more positive ratings by learners. 8,9 Beyond the individual faculty, there can be system wide cultural shifts supportive of scholarly teaching. 10 Delivering content that is convenient and valuable to the faculty can be challenging. 3,4 If resident physicians can deliver effective convenient faculty development programs then faculty and resident physicians would both grow as teachers. Resident physician participation in this project will contribute to growth in multiple ACGME core competencies. METHODOLOGY: We implemented a quality improvement project where resident physicians deliver content to faculty at each rotation in their curriculum. Our objective was successful implementation of the quality improvement project with improvement or increase in faculty development received. Study population includes HCA Medical City Fort Worth Dermatology / UNTHSC faculty with rotating residents RESULTS: Five dermatology residents delivered 45 presentations to 15 faculty individuals over a 30 month period. Not a single attending declined the faculty development topic. Five different topics were presented. The first topic "Teaching House Staff Safely During the COVID19 Era” was delivered 8 times. The second topic “Faculty Wellness” was delivered 10 times. The third topic “Case-Based Collaborative Learning” was delivered 15 times. The forth topic “From Burnout to Engagement” was delivered 9 times. The fifth topic “Burnout” was delivered 3 times. Faculty who had never completed faculty development participated for the first time. CONCLUSION/DISCUSSION: Physician In Training delivered faculty development is an original, innovative model that can increase education. By providing faculty development as a convenient and consistent model, residency programs may satisfy ACGME core competencies while improving the quality of physician education programs.

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  An Interesting Case of Suppurative Thrombophlebitis and Perivascular Abscesses as a Cause of Complicated MRSA Bacteremia

  Ramya Ramachandran, Punjan Patel, Nasima Mehraban, and Win Leth Shwe Yee

  Methicillin resistant staph aureus (MRSA) Bacteremia has become a serious re-emerging infection. As per the Centers of Disease Control (CDC), the worsening opioid epidemic has created a snowballing effect, in that there is not only an increase in invasive MRSA infections but also in complications from MRSA. Early source control through the form of early foci identification, obtaining serial blood cultures, decolonization and hygiene measures, appropriate antibiotic stewardship are used to eradicate this bacteria and prevent its spread. There are multiple challenges in treating injection drug users with MRSA bacteremia is not only in medical management but also in trying to help them overcome their intravenous (IV) drug abuse and reduce the risk of subsequent infection. This is a unique case report of a 30-year-old female with a past medical history of polysubstance and intravenous heroin use who presented with a painful swelling and blister around the left ankle for the past two weeks. She was found to have MRSA bacteremia with septic pulmonary emboli and suppurative thrombophlebitis of the left lower extremity veins. She had extensive work up to look for the source of infection and her septic embolism. Ultimately, patient centered approach had to be followed given her clinical history and persistent MRSA bacteremia. She was found to have septic thrombophlebitis with multiple abscesses along the left great saphenous vein( GSV). Ultimately, she underwent incision and drainage of her surface abscesses, but the GSV had to be excised as well. Her story highlights the importance of MRSA management from medical and patient standpoint, early source control from endovascular complications and the essential role addiction medicine plays into caring for IV Drug Users.

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  An Interesting Occurrence Of Bell’s Palsy With Atypical Presentation After Contracting COVID-19 Infection

  Yen-Chung Wang, Yen-Hsiang Wang, and Christian Sanchez

  Introduction: COVID-19 has been identified as primarily a respiratory illness, however, with its clinical manifestation of involvement with multiple organs, it is now considered a systemic illness. In particular, it also can elicit a broad spectrum of neurological symptoms. One of the proposed manifestations is Bell’s Palsy, an acute idiopathic facial nerve palsy that affects the lower motor neuron. Here we have a patient with recent COVID infection who presents with a unilateral facial droop along with unilateral weakness/tingling of extremities and was diagnosed with Bell’s Palsy.

  Case Description: Patient is a 47-year-old male with a past medical history of alcohol and methamphetamine abuse who presented to the hospital for unresolved facial droop. Patient was seen at the emergency department with symptoms of left-sided eyelid droop and difficulty swallowing two days prior. CT head and CTA head/neck then were negative. Patient’s symptoms resolved and he left against medical advice. However, symptoms reappeared two days later and now with right-sided facial droop along with dysphagia,and left sided extremities with weakness/tingling sensation. Of note, the daughter stated that the patient was tested positive with COVID about 1.5 weeks ago and had upper respiratory infection symptoms that had resolved. Repeat CT head without contrast and MRI brain w/wo contrast were unremarkable. Transthoracic echocardiogram showed no patent foramen ovale. He was diagnosed with Bell's palsy and the MRI neck was done for his unilateral tingling, which showed minimal posterior disc bulging. Patient was recommended eye drops, eye patch and discharged on prednisone taper with valacyclovir and instructions to follow up outpatient

  Discussion: Bell’s Palsy presents with a sudden onset of unilateral facial weakness. The hallmark to distinguish it from central pathology is the involvement of the forehead. However, because this patient also had unusual presentation of switching sides of facial droop along unilateral weakness/throbbing of extremities, cerebral vascular accident had to be ruled out as well as other etiologies. The annual incidence is 15 to 20 per 100,000 individuals with up to 12% recurrence rate. Interestingly, there is a higher incidence of Bell’s Palsy in those with COVID-19 and there is an increased relative risk with Bell’s Palsy in those with COVID-19 in comparison to those who were vaccinated. Of note, the patient is unvaccinated. We present this case in hope to bring awareness to the medical society on a possible COVID-19 Infection related neurological manifestation in hope that it can be recognized and intervened early.

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  An Interesting Twist: An Adult Midgut Volvulus Presenting as a Transverse Colon Volvulus, Both Rare Phenomena

  Allison Walworth and Danielle Ford

  Introduction and Case Presentation: We report an unusual case of an adult midgut volvulus presenting first as a transverse colon volvulus. A 62-year-old man with no significant past medical history presented to the emergency department with complaints of intractable nausea, vomiting, and abdominal pain for twenty-four hours. He had been evaluated at an outside hospital where an abdominal and pelvis computed tomography was read as a transverse colon volvulus, a vanishingly rare medical condition. A CT reimaging of the abdomen and pelvis illustrated a whirlpool sign in the region of the small bowel, consistent with a small bowel volvulus. In the emergency department, his blood pressure was 143/79 and his heart rate was 58. His physical exam showed abdominal tenderness to palpation. Pertinent labs include blood urea nitrogen of 26 mg/dL and a creatinine of 2.1 mg/dL. The patient underwent exploratory laparotomy. Operative findings revealed a loop of jejunum that was adhered down to the anterior pelvis wall along a previous peritoneal flap dissection. This created an internal hernia with multiple loops of small bowel that were herniated underneath. It is surmised that that loop of jejunum and internal hernia created the small bowel volvulus and, hence, the rare “whirlpool sign” on the CT scan. No other evidence was identified of any small bowel pathology that could have caused any of the patient’s symptoms. After the loop of jejunum was lysed the patient recovered without any more symptoms and was able to return home. Learning Points: This case conveys that a volvulus can be something ephemeral that may resolve after showing characteristic signs of its presence in imaging and causing its characteristic symptoms in patients.

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  An Unusual Presentation of Subcutaneous Inguinal Hematoma Mimicking Ovarian Torsion: A Case Report and Review of Literature

  Chrystal Stallworth, Victoria Panzanaro, and Timothy Kremer

  This is a report of a 36-year-old female who presented with severe, acute onset pelvic pain and prominent bruising on her left groin area following intercourse. Transvaginal ultrasound revealed the presence of a left ovarian cyst and lack of arterial blood flow to the left ovary, indicating the possibility of a left ovarian torsion. The patient underwent diagnostic laparoscopy with left oophorectomy. However, during the procedure an aberrant vessel was identified branching from the left IP ligament, running through the inguinal canal, and terminating at the anterior abdominal wall. Intraoperatively the vessel was ligated, and the patient ultimately recovered without complications. At the time of post operative evaluation, the patient was without any recurring symptoms. This case report examines an unusual presentation of symptoms mimicking ovarian torsion with accompanying ipsilateral subcutaneous inguinal hematoma secondary to aberrant pelvic vasculature.

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  A Rare Case of Gigantic Ascending Aortic Arch Thrombus

  Srujana Dasari, Akhil R. Gade, Nethuja Salagundla, Chandralekha Ashangari, and Rashonda Carlisle

  An ascending aortic arch thrombus (ACT) is a rare finding in an anatomically normal aorta. It can be seen with aortic dissection or aneurysm. Complications of large thrombus like stroke or systemic emboli are less likely when found in normal aorta. Even with the low risk embolic events, it is even less likely if patients are on therapeutic anticoagulation. Here we discuss this rare case in detail. 49 y/o with PMHx of HTN, HLD, COVID19, DVT s/p thrombectomy, noncompliant with warfarin, ICH from fall presents with left-sided weakness and blurry vision. MRI head showed scattered acute infarction along right PCA with occlusion, an old right ACA infarct, and left cerebellar hemorrhage. The patient was not a candidate for intervention or IV alteplase. TTE showed normal LVEF, a large mobile ACT. TEE showed an 8.7 cm pedunculated heterogeneous ACT, traversing into the aortic arch. No evidence of AFib activity on telemetry. CTS and hematology were consulted. The patient was negative for inherited hypercoagulable disease or malignancy. The ACT was attributed to the history of COVID19, and the patient was medically managed on coumadin. Shortly after, they presented to ED with recurrent stroke-like symptoms. CTS resected ACT and did hemiarch repair. The mass was sent for pathology, which confirmed an organized thrombus. The patient was discharged on Eliquis given the development of stroke on warfarin. There is limited evidence on optimal management of an ACT. Treatments include medical management with anticoagulation or in combination with surgical interventions. Anticoagulation alone has a risk of clot dissolution and deadly embolic events. Factors favoring the surgery include patient history, size, location, mobility of thrombus, or an inability to distinguish ACT from mass on imaging. A combination is recommended postoperatively.

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  A Rare Case of Persistent Left Superior Vena Cava Discovered During an Intracardiac Echocardiography Procedure

  Riddhi H. Patel and Bilal Ayub

  Background: Isolated persistent left superior vena cava (PLSVC), also known as persistent left superior vena cava (SVC) with absent right SVC, affects 0.09-0.13% of the population. Right SVC is present in the majority of people with left SVC. Rarely, the right SVC may be missing. Here, we discuss a rare case of PLSVC found incidentally in a patient with paroxysmal atrial fibrillation (PAF).

  Case: A 63-year-old female patient with a history of Paroxysmal Atrial flutter (AFL) and atrial fibrillation (AF) on apixaban, HTN, and HLD was brought to the electrophysiology lab for electrophysiology study (EPS) and AF/AFL ablation due to recurrent symptomatic episodes of AF and AFL despite being on antiarrhythmic medications. Pre-ablation CT chest was not performed as the patient’s baseline creatinine was 1.4 mg/dl.

  Decision‐making: After the placement of venous access sheaths, intracardiac echocardiogram (ICE) was advanced and ICE imaging was performed. No right-sided SVC was identifiable with the inability to visualize superior aspect of interatrial septum and pulmonary veins. Large coronary sinus was noted. Additionally, we were unable to advance the guidewire into the SVC. Due to abnormal cardiac anatomy and the inability to perform a transseptal puncture, AF ablation was not performed. The patient’s repeat creatinine was 1.2 mg/dl and a CT chest was performed which confirmed the absence of right sided SVC and the presence of PLSVC. Patient was discharged on Dofetilide for rhythm management.

  Conclusion: During the normal cardiac development, the left-sided anterior venous cardinal system vanishes. However, the left SVC persists when the left anterior cardinal vein is unable to close. The left SVC almost always empties into the right atrium via an expanded coronary sinus. Rarely, the persistent left SVC can reach the left atrium directly, which can cause a partial anomalous systemic venous return. Abnormality of the SVC has implications for electrophysiology procedures and ICE/CT and cMRI imaging are helpful in delineating the anatomy.

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  A Rare Case of Rapidly Progressive CLL/SLL Presenting as Bilateral Tonsillar Enlargement and Upper Airway Obstruction

  William Mangin and Kashif Aslam

  Although chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) differ in clinical presentation, they are both arise from the same pathologic process, namely the clonal expansion of mature B-cells. This malignancy is usually quite indolent and carries a favorable prognosis. Thanks to a number of highly-effective oral targeted therapies, such as the Bruton tyrosine kinase (BTK) inhibitor, Ibrutinib, patient outcomes have improved significantly. Unfortunately, these therapies are not always well tolerated and many patients are forced to discontinue the medication due to side effects. Many patients experience a disease flair and some even transformation to a high-grade malignancy after the discontinuation of one of these targeted maintenance therapies. Respiratory complications of CLL/SLL are not uncommon and are most often the result of infection. Airway obstruction is seen much less frequently and is usually caused by severe hilar or mediastinal lymphadenophy. CLL/SLL presenting as bilateral tonsillar enlargement is quite rare and the majority of cases described were incidental findings or presented as obstructive sleep apnea. Herein we present a case of rapidly progressive CLL/SLL that presented as upper airway obstruction due to bilateral tonsillar hypertrophy shortly after discontinuation of Ibrutinib maintenance therapy. Patient required fiberoptic nasotracheal intubation. His lengthy hospital course significant for severe leukocytosis (max WBC 439), pseudohyperkalemia, neoplastic fever, hypotension requiring vasopressors, and concern for tumor lysis syndrome. After tonsillar biopsy confirmed diagnosis and ruled out transformation, patient was started on CHOP chemotherapy. Although patient’s leukocytosis initially decreased after initiation of chemotherapy, it quickly rebounded, indicating unresponsiveness to treatment. Patient’s family ultimately elected for comfort care and patient expired soon after. This unique case has several important teaching points ranging from hematology/oncology, critical care, infectious disease, surgery, and laboratory science. This rare presentation of CLL/SLL after Ibrutinib discontinuation includes the management of a critical upper airway obstruction and neoplastic fever, reminder of the laboratory error caused by severe leukocytosis, and how to recognize and help prevent tumor lysis syndrome. Less than 10 cases of CLL/SLL presenting as bilateral tonsillar enlargement have been described in English literature, highlighting the rarity of this case. However, unlike the others, the case presented here was quite severe and progressed rapidly, unfortunately leading to a poor outcome. As targeted therapies continue to replace chemotherapy in treatment of CLL/SLL, this indolent malignancy may more frequently present in unusual and potentially devastating ways when these treatments are discontinued.

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  A Rare Case of Von Gierke causing Severe Aortic Stenosis

  Srujana Dasari, Akhil R. Gade, Nethuja Salagundla, Chandralekha Ashangari, and Rashonda Carlisle

  Von Gierke disease is an inherited Glycogen Storage disease - type 1 resulting from deficiencies in the specific enzymes glucose 6 phosphatase(1a), and/or glucose 6 phosphate translocase(1b) glycogen metabolism pathway. Von Gierke disease is commonly seen in the pediatric population and is known for his hepatic and renal manifestations. Here we discuss a rare case of Von Gierke’s disease causing some rare cardiac manifestations. 41yo M with PMHx significant for Von Gierke type 1a, HFrEF complicated by VT s/p ICD, HTN who presented for complaints of continued SOB with new muscle soreness. On arrival, lactic acid was elevated at 5.2, troponin and EKG were not obtained in the ED. Trans-thoracic echocardiogram obtained was consistent with HFrEF with a LVEF 30-35%, severe diffuse hypokinesis, bileaflet aortic valve, severely calcified aortic stenosis with a peak systolic velocity 3.2m/sec, peak systolic gradient 50 mmhg, mean gradient 30 mmhg, and valve area 1.1. The patient was evaluated for aortic valve replacement. Left and right heart catheterization shows an invasive gradient of 20 mmhg and angiographically normal epicardial coronary arteries. As mentioned, Von Gierkes is not typically seen in this middle aged group let alone with unexplained cardiac manifestations. Our patient had heart failure for 10 years prior to presentation and risk factors for CAD and ischemic cardiomyopathy were ruled out. Although not confirmed by biopsy, as the management would not change, the etiology is likely attributed to this patient's von Gierke's disease due to deposition of glycogen in the cardiac membrane. This patient lived longer than most individuals with this disease. It is important to bring awareness to this rare disease with even more rare cardiac manifestations that have not been well studied. Patients should undergo screening from an early age to identify cardiac manifestations and be provided appropriate resources including genetic counseling.

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  A Residency Wellness Survey: Understanding Baseline Resident Wellness: Developing Residency Program Specific Wellness Interventions

  Andrew H. Cushing and Michele McCarroll

  Residency is a demanding period of training that requires long hours and prolonged periods of high mental functioning coupled with an emotionally and physically exhausting work load. Nearly half of all physicians experience burnout. Research has suggested that symptoms of burnout are present even in the earliest parts of physician training and the COVID-19 pandemic presented unique factors to the most recent groups of residents. The various burnout screening tools discussed in literature are limited by barriers of cost and lack of specificity for residency. In response to these findings, program specific resident wellness initiatives are now required for accreditation. Research utilizing standardized wellness interventions suggests that there is need for a wellness program that is directed toward the specific needs of a resident community. Two different graduate medical education programs developed a survey to measure resident wellness; the survey includes parameters regarding burnout, depression, personality, optimism, life satisfaction, and social desirability. Utilizing this ten-item scale, residents from Healthcare Corporation of America (HCA) North Texas (NTX) Healthcare Consortium were invited to participate in an anonymous wellness survey. There were total 45 responses to the survey. As these are baseline parameters with no comparative measures, results were grouped into greatest three subjective strengths and weaknesses of the program. Top three strengths were as follows: Feeling supported by coworkers; knowing who to call when something tragic happened; feeling proud of the work you did. Top three weaknesses were as follows: Feeling of connection to work; feeling that one’s work makes the world a better place; feeling eager to come back to work tomorrow. Using these initial results, more specific wellness interventions within the HCA NTX Program can be tailored to its specific strengths and weaknesses. It can be extrapolated from the survey results that residents feel a relatively strong sense of interpersonal support and personal pride in their work, however there is relative negative perception of the overall healthcare environment. The next step in the process is to organize regular resident feedback sessions to identify more specific interventions for resident wellness. Currently a quality improvement project is underway to implements several of these measures. Repeat resident wellness surveys will be administered to estimate the effect of these interventions.

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  Capnocytophaga canimorsus Infection in a Hispanic Male After a Dog Bite

  Ahmad Ahsen, Shin Kang, Jack Lee, Jose Sanchez, Fadi Albahra, Stephen Chabot, Tariq Zain, and Ranjit Nair

  Here we present a unique case of a 38-year-old Hispanic male with a history of alcohol abuse and multiple sexual partners, who presented with fulminant sepsis with shock, multiorgan failure, and livedo racemosa after a dog bite a week prior. Patient was intubated on arrival and started on vasopressors and antibiotics. He later developed gangrene of all of extremities, due to the severity of hypoperfusion and disseminated intravascular coagulation (DIC). Eventually, the patient’s clinical status improved, and he was transferred out of the intensive care unit (ICU). Peripheral blood smear showed gram-negative intracellular rods. Blood cultures tested positive for gram-negative rods one day after collection and later speciated to Capnocytophaga Canimorsus. One should have a high index of suspicion of Capnocytophaga if a patient presents with septic shock, has a history of dog bite, has a rash consistent with livedo racemosa, and slow-growing gram-negative intracellular rods on peripheral blood smear. Treatment should include meropenem and clindamycin. Adjunctive treatment with intravenous immunoglobulin is another consideration.

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  Case of Shiga-Toxin Producing E. coli Dysentery in Adult Patient in the Absence of Diarrhea

  Diana Roy

  This is a unique case of a 38 year old Caucasian female with no significant medical history who presented to the hospital with complaint of 3 days of abdominal pain, nausea/vomiting, dark red formed stool, and fever (TMax 102F), as well as dizziness, body aches and throat pain. She reported eating meatloaf with her daughter two days before symptom onset, and daughter was reported to be ill as well. Upon initial exam, patient was found to have temp 100F, was hypotensive and tachycardic with lactate of 4.2. FOBT was positive. Significant lab values include creatinine 3.39 (baseline normal), hemoglobin of 11.9 and platelet count of 50. CT abdomen and pelvis showed no evidence of enterocolitis. Patient was diagnosed with severe sepsis with hypotension due to unknown source and admitted for further workup. Infectious disease, nephrology, and hematology were consulted. Initial infectious workup including blood cultures, respiratory viral panel, hepatitis panel, and HIV testing were all negative. Patient developed high fevers during course of stay, Tmax 102.9F. Patient was started on broad spectrum antibiotic coverage. Patient was unable to provide a stool sample for the first two days of admission, however on day 3 of admission patient produced a small formed dark stool which was collected for cultures. Stool cultures grew Shiga-toxin 1, leading to diagnosis of Shiga-toxin producing E. coli dysentery. Patient appeared to be in a hemolytic state based on anemia, thrombocytopenia, low haptoglobin and reticulocyte count, which along with severe renal failure on presentation suggested possibility of hemolytic-uremic syndrome (HUS). However, no schistocytes were seen on peripheral smear, therefore HUS was not diagnosed. Antibiotics were stopped, and steroids were given to treat possible cytokine storm which significantly improved patient’s fever and overall condition. Most cases of severe Shiga-toxin producing E. coli (STEC) O157H7 dysentery are seen in children and the elderly, however the infection can occur in people of all ages and range in severity. Multiple episodes of large volume bloody diarrhea is typically the major presenting symptom of STEC dysentery. A retrospective review of 32 confirmed adult cases of STEC infection in Scotland between 1997-2000 showed that 94% of cases presented with bloody diarrhea (1). Our case did not present with the classic clinical signs described above, therefore the knowledge of this atypical presentation may allow clinicians to consider the presence of dysentery even in the absence of classic symptoms, and test accordingly.

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  COVID-19 Masking an Atypical presentation of Hairy Cell Leukemia

  Kahmalia-Kalee Sada

  Hairy cell leukemia is a rare lymphoid neoplasm of small mature B cell lymphoid cells. Hairy cell leukemia only accounts for about 1 to 2 percent of adult leukemia cases. Early diagnosis of Hairy cell Leukemia is important, it is proven that without treatment the median survival of this cancer is four years. After numerous studies the age-adjusted risk of death with proper diagnosis and treatment has decreased by 85%. The greatest outcomes are seen in individuals who are younger with earlier diagnosis. Hairy Cell Leukemia is a rare leukemia seen with the classic triad of splenomegaly, pancytopenia, and “hairy” appearing leukemic b cells in the bone marrow. Most patients will classically present with a constellation of symptoms that correspond to pancytopenia such as fatigue, easy bruising, bleeding, dizziness, weakness, or recurrent infections. However, sometimes a diagnosis can be missed if the patient does not present with typical symptoms. In this case report patient had a medical history of COPD, presenting with shortness of breath tested positive for COVID. Prior hospital visits were just shortness of breath with anemia and thrombocytopenia where patient was treated for COPD and sent home. This case highlights the journey of a middle-aged male with baseline respiratory issues and recent COVID vaccine, which almost caused a near missed diagnosis of a rare Hairy Cell Leukemia.

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  Decreasing rate of CLABSI at Medical City North Hills with Implementation of a “Central Line Cart”

  William Mangin, Hong Lou, and David Maldonado

  Central line associated blood stream infections (CLABSI) impart both a significant increase in mortality but also a substantial financial burden onto hospitals. Several processes have been shown to reduce the rate of CLABSIs, most of which have already been implemented at Medical City North Hills (MCNH) Hospital. Key areas of improvement are in those of compliance; namely, the implementation of a dedicated central line cart and a reminder check list to help staff. The project involved implementation of a dedicated line cart at MCNH Hospital. The cart contains supplies for placement of central lines, including trialysis catheters, and arterial lines. Supplies include: ChloraPrep, Leur Lock Caps, sterile gloves, sterile gowns, saline flushes, dressing kits, chlorhexidine BioPatches, ultrasound gel packets, sterile ultrasound probe covers, and razors. The cart also contains a check list of proper central line placement protocol. The check list acts as a reminder to both the physician placing the line and the nurse supervising the procedure. The cart is restocked on a bimonthly and as needed basis in conjunction with the restocking of the ICU supply room. This quality improvement proposal was presented to the Medical City North Hills Hospital Quality Committee. Not only were funds to purchase the proposed cart approved, funds were also allocated for a second cart for the cardiovascular ICU and 2 EZ IO (intraosseous line) kits. After carts were delivered, they were stocked and implemented in both of the hospital ICUs. Data on CLABSI rates are is still pending but anecdotally the carts have helped cut down on procedural preparation time. Evidence shows that CLABSI are a potentially preventable healthcare-associated infection. The changes presented here will hopefully not only help decrease the incidence of CLABSIs towards the goal of zero, but also help improve procedural efficiency.

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  Does Brief Intervention in the Form of a Lecture Improve Resident Knowledge About Hep C Screening?

  Mary DaCosta, Evelyn Chicas, Kiana Clem, and Shelby Collymore

  The prevalence for hepatitis C during 2013-2016 was about ~2.4 million. Screening helps to prevent chronic hepatitis C or start early curative treatment. USPSTF recently changed their guidelines in 2021 for Hepatitis C screening to now include all asymptomatic patients from ages from 18-79 years old without liver disease. Screening usually includes the Hepatitis C Antibody test. Further testing includes Hepatitis C mRNA PCR if screening test is positive. High risk patients should have periodic screening. Since the change, this project was done to ensure the appropriate screening and testing thereafter was done, as well as appropriate communication and documentation. Residents who were educated on the recent screening guidelines for hepatitis c set by USPSTF retained this knowledge to a satisfactory degree immediately after our lecture on hep c. Prior to our lecture, resident average score on hepatitis c screening knowledge was 52%. Immediately after our lecture, residents scored 84%. Resident knowledge was still greater 6 weeks after our lecture when compared to pre-test results.

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  Early Diagnosis of Purulent Pericarditis Secondary to Methicillin-Sensitive Staphylococcus Aureus in an End-Stage Renal Disease Patient

  Stephen Shey, Alejandro Espinosa-Tello, and Amnah Andrabi

  Introduction Purulent pericarditis is a rare illness in the modern age of medicine due to the increased usage of antibiotics. Unfortunately, diagnosis of this disease is often delayed due to its nonspecific symptoms. Without treatment, the mortality is nearly one hundred percent due to major complications such as cardiac tamponade and constrictive pericarditis. As a result, most cases of purulent pericarditis are discovered post-mortem. This case report details an early diagnosis of purulent pericarditis secondary to methicillin-sensitive Staphylococcus aureus (MSSA) in an end-stage renal disease (ESRD) patient. Case Presentation A 66-year-old female with past medical history of ESRD initially presented to the emergency room complaining of shortness of breath for the past few days. She denied any other symptoms including fevers, chills or chest pain at the time. She was initially admitted inpatient and scheduled for immediate hemodialysis. She was unable to tolerate hemodialysis due to respiratory distress and was kept inpatient for another night. On the second night of hospitalization, patient developed a fever of 102.2 degrees Fahrenheit. Blood cultures were drawn at the time which grew positive for MSSA two days later. A CT scan of the abdomen and pelvis along with a transthoracic echocardiogram were ordered, both of which showed a large pericardial effusion with fibrinous strands suspicious for loculations. Cardiothoracic surgery was consulted for suspected purulent pericarditis. A pericardial window was performed which drained 700 mL of purulent fluid. Patient was subsequently treated with eight weeks of intravenous cefazolin and gentamicin without any complications. Learning Points Patients with purulent pericarditis can present only with nonspecific symptoms such as fevers and lack common features of pericarditis such as chest pain or pericardial friction rub. There should be a low threshold for suspecting purulent pericarditis in patients with MSSA bacteremia and fevers. If diagnosed early on, patient can be treated with drainage of the pericardium and directed antimicrobial therapy before complications such as cardiac tamponade or constrictive pericarditis can arise.

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  Electrolyte Abnormalities and Seizure Like Activity Unmasking an Underlying Rare Genetic Disorder

  Riddhiben Patel, Andrew Cushing, Amnah Andrabi, and Sathish Karmegam

  Fahr's syndrome, or idiopathic basal ganglia calcification, is a rare neurological disorder that runs in families as an autosomal dominant trait. It is associated with a variety of other diseases, especially Parkinson’s disease, but the etiology remains a mystery. On imaging, it presents as abnormal calcium deposits found primarily in the basal ganglia and cerebral cortex, both of which are areas responsible for controlling movement. A 73-year old woman with a past medical history of hypertension and seizures presented to the emergency department due to altered mental status. The patient was indulged in a conversation with her daughter when all of a sudden, she became silent. Within a few seconds she became very stiff with arms extended, her head turned towards the left, and her eyes rolled towards the back of her head. After unsuccessful re-orientation, EMS was called and upon awakening she became postictal, lethargic, confused, disoriented, and nonverbal. Her only further complaint is that she felt numbness to her lower and upper extremities. On further questioning it was revealed that about 20 years ago, the patient was advised to take medication for hypocalcemia, but was non-compliant. Initial lab findings revealed critically low calcium and parathyroid hormone levels, and normal vitamin D levels. Computed Tomography (CT) head/brain revealed extensive intracranial calcification and mineralization. Subsequently, Magnetic Resonance Imaging of head/brain was completed and revealed bilateral basal ganglia, thalami, and cerebellar abnormal signals corresponding to calcifications seen on CT scan. Electroencephalography revealed some bifrontal fast activity which constitutes a characteristic electrophysiological pattern in focal seizures of human epilepsy. Based on the workup, it was suggested that these findings are concerning for Fahr’s syndrome, which is secondary to underlying hypoparathyroidism. When the electrolyte abnormalities were corrected and patient returned to baseline, she was determined stable for discharge. At discharge, the patient was continued on calcium and Vitamin D supplements, and Levetiracetam 500mg twice daily for seizure prophylaxis. She was also advised to see an endocrinologist for further management of her hypoparathyroidism. This case illustrates that a rare disorder like Fahr’s syndrome has a similar presentation to various other neurological diseases but no etiological agent has been established. To reduce the loss of functionality associated with the condition, new therapeutic approaches must be identified and implemented. Additionally, it is critical to stress the importance of genetic counseling for known at-risk parents before to conception.

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  Euglycemic Diabetic Ketoacidosis Secondary to SGLT2 Inhibitors in Combination with a Low-Carbohydrate Diet

  George Yeung, Nhi Duong, Akshaj Pole, Benjamin Larsen, and Syed Ahmed

  Euglycemic diabetic ketoacidosis (EuDKA) is a rare complication of type 2 diabetes mellitus (T2DM) characterized by normoglycemia in the presence of anion gap metabolic acidosis and blood ketone. EuDKA has been associated with the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) but the reported adverse events are scarce. We present a case of a 68-year-old gentleman with T2DM and coronary artery disease, who developed EuDKA after starting empagliflozin (Jardiance) with a low-carbohydrate diet for a few days. SGLT2i block proximal tubule glucose reabsorption, resulting in a state of carbohydrate starvation and subsequent ketosis. The combination of SGLT2i with a low-carbohydrate diet can enhance ketosis further, causing EuDKA. Because EuDKA is uncommon, delayed diagnosis and treatment can lead to other complications and prolonged hospitalization. SGLT2i has become popular for its antihyperglycemic, cardiovascular, and renal health benefits; however, physicians should be cautious to prescribe this medication when the patient is on a low-carbohydrate diet.

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  Extraintestinal Salmonellosis Unmasked in a Parotid Mass

  Kahmalia-Kalee Sada

  Salmonella infection can cause a wide range of presentations, predominantly gastrointestinal but occasionally with cardiovascular or other extraintestinal manifestations. The diagnosis of extraintestinal salmonellosis requires a high degree of clinical suspicion and should be considered in patients with deep-seated abscesses. [1]. Typically, these types of infections, are extremely rare, and when revealed are typically seen in the immunocompromised patient with chronic illness, HIV, or Hepatitis. While the incidence of nontyphoid salmonellosis is estimated at over 2 million cases annually, extraintestinal manifestations account for less than 1% of cases. Studies have revealed that individuals with diabetes have risk for salmonellosis due to gastric impairments, this case serves as an example. A 71-year-old male with past medical history of diabetes type 2, hypertension, presents to the ED for left facial swelling. The left infraauricular pain traveled to his upper jaw and has been ongoing for the past 3 days. He followed up with his primary care physician, received oral antibiotics and an injection of antibiotics along with some pain medications and has been taking those for 2 days without relief. He received Rocephin and vancomycin upon arrival. His laboratory values were within normal limits except a White Blood count which was mildly elevated. CT scan was completed which revealed a large enhancing mass with a fluid collection in the center. A needle aspiration biopsy of the large mass was read by the pathologist and found to have inflammatory cells and polymicrobial flora was growing from the cultures that were sent as a result of that. Patient underwent and incision and drainage twice for excessive fluid collection and swelling with ENT. Cultures grew Extended spectrum beta lactamases Salmonella. With collective findings of the parotitis growing extraintestinal salmonellosis, he was placed on Levaquin for two weeks for treatment. From what we know of the literature, this patient is a chronic Salmonella carrier state, which can lead to progressing extra intestinal salmonellosis. This case illustrates a rare entity of extraintestinal salmonellosis which can be seen in immunocompromised, even less common in immunocompetent individuals. A highly unusual diagnosis, that was seen in this patient. He was likely a chronic Salmonella carrier state, which lead to the extraintestinal findings of the parotid mass. Recognition of the chronic carrier state of salmonella is important to keep Salmonella as a plausible organism when dealing with infectious cases, and for appropriate therapy.

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  It Wasn’t a Duck: A Case of the Misdiagnosis of Ketoacidosis

  Shiva Mohan, Brandon Vu, and Danielle Ford

  Introduction Most clinicians have heard the old adage: if it looks like a duck, walks like a duck, and quacks like a duck, it’s a duck. However, this is not always true. Ketoacidosis is a complicated physiological state resulting from fatty acid and amino acid degradation often associated with type 1 diabetics. It can also arise with excess alcoholism, pregnancy, starvation, and exercise. Diabetic, alcoholic, and starvation ketoacidosis may present similarly. Clinicians can often mistake alcoholic and starvation ketoacidosis for diabetic ketoacidosis due to its common presentation. We present a case of a young non-pregnant woman with a history of alcoholism, treated on several admissions for presumed diabetic ketoacidosis, whose ketoacidosis improved clinically with treatment targeted at starvation ketoacidosis and without the administration of insulin. Case Presentation A 31-year-old woman with a past medical history of alcoholism presented with a five-day history of diffuse achy abdominal pain and intermittent nausea and vomiting. She endorsed increased urinary urgency, fatigue, decreased appetite, and 20 pounds of unintentional weight loss. In the preceding five months, she was admitted three times with similar symptoms and was diagnosed with diabetic ketoacidosis. She was treated with and discharged on insulin each visit. She was initially compliant with her home insulin regimen but stopped taking it due to recurrent hypoglycemia. Her workup was significant for a blood glucose of 240 mg/dL, an anion gap of 15 mmol/L, and an elevated serum beta-hydroxybutyrate of 26.64 mg/dL. Her hemoglobin A1C was normal at 5.5%. She was symptomatically managed with antiemetics and intravenous (IV) hydration. Crucially, her blood ketone and glucose levels normalized without insulin but with the initiation of a dextrose and water infusion and IV thiamine. She was discharged on oral thiamine, and her home insulin was discontinued. Her thiamine level was confirmed low at 51.9 nmol/L post discharge. Discussion The presence of ketoacidosis and hyperglycemia may cause clinicians to suspect diabetic ketoacidosis; however, this may be a misdiagnosis. Our patient’s initial hyperglycemia was likely multifactorial from rebound hyperglycemia after inappropriate insulin administration, stress-induced, chronic alcohol use, and starvation ketoacidosis. Our patient was initially diagnosed with pre-diabetes. She was subsequently diagnosed with diabetes mellitus type 2, with non-compliance to insulin. The diagnosis was carried forward for several encounters despite a normal hemoglobin A1C and hypoglycemia with insulin administration. This case highlights the importance of looking holistically at a patient’s case without prejudice, persuasion, or repetition of previous diagnoses without consideration of alternatives.

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  Lesion Size Inclusion on Dermatopathology Requisition Forms: a Quality Improvement Project

  Christopher M. Wong, Henry Lim, Christian Scheufele, Daniel A. Nguyen, Ashleigh E. Hermann, Michael Carletti, and Stephen Weis

  Introduction: Dermatopathology requisition forms (RFs) are a critical communication tool between dermatologists and dermatopathologists. Including detailed information on RFs improves the diagnostic accuracy of the consulting dermatopathologist. However, the diameter of the biopsied lesion is often omitted on RFs. This study aimed to increase the rate of reporting lesion diameters on RFs from an academic outpatient dermatology clinic to greater than 65% through education, reinforcement, and evaluation. Methods: This quality improvement project retrospectively and prospectively analyzed the inclusion rate of lesion diameters on dermatopathology RFs from a single institution. In Phase 1, data was collected from all skin biopsies performed between July 1, 2021 and February 4, 2022, and the presence or absence of lesion diameters on RFs was recorded. A single intervention was conducted on February 4, 2022 to educate the authors on societal guidelines for reporting lesion diameters on RFs. Phase 2 evaluated short-term efficacy through data collection and analysis of RFs for biopsies obtained from February 5, 2022 to June 14, 2022. Long-term efficacy will be assessed through data collection and analysis of RFs for biopsies obtained from January 1, 2023 to June 30, 2023. Results: During Phase 1, 839 skin biopsies were performed, with 594 biopsies meeting the criteria for analysis. 49 samples included lesion diameters, resulting in a final reporting rate of 8.25%. In Phase 2, after the intervention, there was a statistically significant reporting rate increase to 49.71% (85/171) in the intervention group (chi-squared test, p < 0.001). The intervention group had a statistically significant increase in reporting rate compared to the control group not receiving the intervention (1.73%, 5/289, chi-squared test, p < 0.001). Long-term efficacy results from Phase 3 are yet to be reported. Conclusion: The intervention in this study successfully increased the rate of reporting lesion diameters on RFs from an academic outpatient dermatology clinic, demonstrating the importance of education and reinforcement in improving quality. Further studies will determine the long-term efficacy of the intervention.

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  Low-grade Adenosquamous Carcinoma of the Breast in a Pregnant Patient: Case Report and Literature Review

  David Bassa, Makenzie Morrissey, Adewuni Ojo, and Adeel Raza

  Low-grade Adenosquamous Carcinoma of the Breast: Case Report and Literature Review Authors: David Bassa DO, MaKenzie Morrissey MD, Adewuni Ojo MD, Adeel Raza MD Abstract: Introduction: Low-grade adenosquamous carcinoma (LGASC) is a rare variant of metaplastic carcinomas of the breast. It is characterized by its clinical indolence and low-grade cytomorphology. Presentation is typically asymptomatic with indeterminate imaging characteristics with diagnosis dependent solely on histopathology findings. We herein describe a case of LGASC presenting in a young premenopausal female, an extremely rare occurrence. Case presentation: A 23-year-old woman presented to the breast clinic with a left breast ultrasound demonstrating a heterogeneous ill-defined hypoechoic area in the left upper inner quadrant. She stopped breastfeeds three years postpartum and noticed a palpable left breast mass a week later. She was otherwise asymptomatic. A left breast biopsy revealed stromal fibrosis and an ultrasound-guided excisional biopsy revealed sclerosing adenosis and fibrocystic changes. Due to the discordant clinical findings, both biopsies were sent to Weill Cornell Medicine for histopathological review. The review revealed low-grade adenosquamous carcinoma arising within the background of a complex radial sclerosing lesion. The tumor was ER low positive, PR positive, and HER2 negative. Conclusion: LGASC of the breasts remains a diagnostic and therapeutic challenge. Despite being a variant of metaplastic breast carcinomas, which present as triple negative tumors with poor prognosis, this indolent lesion has a more favorable prognosis when recognized early. Given the rarity of this cancer, there are no current guidelines for best practice management of adjuvant chemoradiation. Keywords: Low-grade adenosquamous carcinoma, metaplastic breast cancer, sclerosing lesions of the breast, indolent breast cancer

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  Monitoring Concordance in the Management of Transfusing Blood Components in Cirrhotic Patients for Paracentesis with Evidence-Based Guidelines

  Joseph Kim and Gregory Moses

  Initiative to decrease unnecessary hemostatic agent transfusion in cirrhotic patients undergoing paracentesis: a resident-led approach quality improvement project to prevent transfusion overuse. Currently, there is no official guideline placed in the hospital for the administration of a hemostatic agent such as fresh frozen plasma in the setting of an elevated international normalized ratio, which paradoxically is an anticipated finding in cirrhotic patients. This process leads to unnecessarily prolonging the duration of the hospital course due to delays in performing the interventional procedures and interruptions in scheduling. The goal of this project is to educate and provide physicians with the most recent guidelines for managing bleeding risks with periprocedural procedures.

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  Outpatient Breast Cancer Screening Documentation

  Christoffer A. Amdahl and Jeremy Smith

  Introduction: Over 264,000 cases of breast cancer are diagnosed annually within the United States, with 99% of them being in women. Regarding prevention of this terrible disease, early detection of such cancers through screening mammography has up to a 20% reduction in breast cancer mortality. Therefore, the USPSTF recommends screening of women who are 50-74 years of age via mammography at average risk of breast cancer every two years. The goal of this study was to measure, track, and increase compliance with these screening recommendations within the Medical City resident clinics.

  Method: Family medicine residents working were presented with a standardized electronic medical record template to improve the rate of recorded breast cancer screenings within appropriately aged women. The template would be used for patients who are referred for the imaging study, and completed once the patient presented the results of the completed study. Residents were additionally tracked on how many patients they appropriately referred for screening. Education was given to all residents and nurses responsible for the referral process and on the importance of the correct implementation and recording of a successful mammogram referral. The developed protocol was used within the Family Medicine outpatient clinic sites at Grand Prairie, North Hills, and Denton to increase screening compliance.

  Results: All three clinic sites measured in the study showed an overall compliance rate of 17.35%. Data was also grouped by resident year and individual. However, this data may not represent the true compliance rate, as reports were frequently not attached to the initial screening template order by nursing staff secondary to high clinic staff turnover rates.

  Conclusion: Efforts to improve compliance with current USPSTF guidelines on breast cancer screening were not reflective of adherence to the standardized template, and will require additional study design improvement. Additional cycles of the study will feature nursing specific education didactic sessions regarding proper, and data from both pre- and post- education sessions will be compared to measure true resident screening compliance rates.

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  PHQ -9 Utilization in the Primary Care Setting

  Michael Armstrong, Ramisa Rahman, Ceferino Cruz IV, and Afsha Rais Kaisani

  INTRODUCTION: The Patient Health Questionnaire-9 (PHQ-9) is a tool used to help diagnose depression and assess a patient’s response to treatment. Quality metric (QM) 371 is a measure of PHQ-9 utilization in patients with depression, and Medical City Family Medicine tracks QM 371 in order to improve the quality of care provided to our patients. This project sought to assess utilization of the PHQ-9 in our clinical practice. At the time of this QI project’s inception, QM 371 was reporting at 0%.

  METHODS: Our intervention was to give an educational presentation regarding depression, the PHQ-9, as well as how to properly document the PHQ-9 in eClinicalWorks (eCW) for data tracking. QM 371 is calculated as follow: the denominator includes patients 12 years and older with a diagnosis of Major Depression or Dysthymia within the eligible 4-month period, and the numerator includes all patients age 12 and older that have completed the PHQ-9 at least once within the 4-month period. Our educational presentation was given on Sept 1st at the start of the reporting period for QM 371 and included screen shots depicting the workflow for inputting the PHQ-9 into the eCW smart form.

  RESULTS: A data query 2 months in showed that QM 371 continued to measure 0%, however the authors of this study knew that a value of 0% should not be possible. We at least, were properly documenting PHQ-9 utilization. The query was escalated multiple times until it was discovered that Centers for Medicare and Medicaid Services (CMS) discontinued QM 371. The Division Director of Quality Initiatives provided us with the data that QM 371 would have been tracking if it were still in use. The results indicate that all three clinical sites, at the time of the data query, were close-to or at the goal of 22.09%. Data received mid-November showed the Arlington site at 17.82%, the North Hills site at 26.32% and the Denton site at 22.41% year-to-date (YTD).

  CONCLUSION: It was discovered that QM 371 was discontinued by CMS, unbeknownst to anyone in our organization. Our QI project identified a major gap between our clinical practices, in this case use of the PHQ-9, and the clinical informatics that were being reported. Awareness of this gap creates opportunity to determine a new way to measure and improve the quality of care we provide to patients with depression.

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  Platelets in Preeclamptic Pregnancies Fail to Exhibit the Decrease in Mitochondrial Oxygen Consumption Rate Seen in Normal Pregnancies

  Joseph Kim, Andrew Malinow, and Rosemary Schuh

  Cellular oxygen consumption and lactate production rates have been measured in both placental and myometrial cells to study obstetrics-related disease states such as preeclampsia. Platelet metabolic alterations indicate systemic bioenergetic changes that can be useful as disease biomarkers. We tested the hypothesis that platelet mitochondria display functional alterations in preeclampsia. Platelets were harvested from women in the third trimester of either a healthy, non-preeclamptic or preeclamptic pregnancy, and from healthy, non-pregnant women. Using Seahorse respirometry, we analyzed platelets for oxygen consumption (OCR) and extracellular acidification (ECAR) rates, indicators of mitochondrial electron transport and glucose metabolism, respectively. There was a 37% decrease in the maximal respiratory capacity measured in platelets from healthy, non-preeclamptic compared with preeclamptic pregnancy (P

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  Post-Thrombotic Syndrome: Assessing Medical City Weatherford Resident Physicians’ Knowledge in Diagnosis, Treatment, and Prevention

  Hiral Thakkar and Aaron Kolar

  Post-thrombotic syndrome (PTS) is a relatively understudied sequelae of deep vein thrombosis (DVT). PTS typically presents with similar signs and symptoms as chronic venous insufficiency (CVI) and treatment modalities also mirror each other with the use of compression therapy, emollients, and topical steroids. The contrast is PTS is a direct result of a DVT, and DVTs can be prevented. Thus, it is essential that physicians are able to differentiate and effectively treat both PTS and CVI. Since PTS is widely understudied, the goal of our project is educate residents and other medical professionals on the full scope of PTS including pathophysiology, epidemiology, clinical features, diagnosis, treatment and prognosis through a single-session one-hour oral presentation. We will measure resident knowledge through a short survey/assessment administered before and after the presentation. We expect that the oral presentation will lead to a score increase of 20% from pre-survey to post-survey. These results would suggest that our target audience will be more conscience of preventing DVT; as well as, treating patient’s appropriately when they present with PTS. Therefore, this improvement on the survey will lead to better patient care, improvement of quality life and reduction in healthcare cost.

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  Presentations of Tumor Recurrence of Non-Melanoma Skin Cancer After Treatment with Low-Energy Superficial Radiation Therapy

  Marshall Hall, Henry Lim, Christian Scheufele, Christopher M. Wong, Daniel A. Nguyen, Michael Carletti, and Stephen Weis

  Background: Basal cell carcinoma and squamous cell carcinoma are the most common types of non-melanoma skin cancers.1 Superficial radiation therapy (SRT) is a treatment modality that utilizes low-energy x-rays to disrupt cell mitosis.2 While this technique has been used for over a century, it has recently gained favor in clinical practice.3,4 This method of treatment offers favorable outcomes and advantages for select patients. Although the incidence of cancer recurrence after superficial radiation therapy is low, relatively little is known regarding predictive patterns. The frequency and timing of cancer recurrence is not well defined using SRT delivered technology with an image-guided approach utilizing high-frequency ultrasound capabilities.3,5 Methods: A retrospective chart review study was performed on patients treated with image-guided SRT at an academic dermatology clinic between December 2018 to December 2021. Follow-up was through December 2022. Demographic information and medical history related to the population were analyzed as part of the data set. Treatment failure and cancer recurrence were monitored to compare possible differences in treatment response. The primary endpoint was any histologically confirmed non-melanoma skin cancer identified within the treatment field at any follow-up visit. Results: There were 341 non-melanoma skin cancers treated with SRT in 165 individuals during the reviewed dates. Out of 341 individual cases of malignancy, four were suspected of recurrence during follow-up visits. Subsequently, all four cases were biopsied and confirmed histologically as cancer recurrence. All of the relapses originally had squamous cell carcinoma. None of the patients with basal cell carcinoma relapsed. The time frame for recurrence varied between 3 to 18 months after the final treatment visit. All four cases of recurrences were found in adult males, and the cancers were limited to the head and neck area. Conclusion: Cancer recurrence outcomes of persons treated with high-frequency ultrasound-guided SRT were comparable to those reported for surgical treatment of non-melanoma skin cancer. Further prospective studies with longer follow-up periods would be valuable to in assessing the risk of recurrences after SRT, and to refine treatment protocols to minimize treatment failures and tumor recurrence. This would improve patients’ ability to make informed decisions regarding their treatment options for non-melanoma skin cancer.

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  Rare Presentation of Primary Malignant Peripheral Nerve Sheath Tumor of the Femur in Neurofibromatosis-1

  Akshaj Pole, Danielle Ford, and Elizabeth Pollard

  Malignant peripheral nerve sheath tumors (MPNSTs) are rare sarcomas, most commonly seen in patients with Neurofibromatosis type 1 (NF1), that are characterized as aggressive with high rate of local recurrence. Among NF1 patients, the risk of developing MNPSTs is approximately 8-13% over a lifetime. Primary MPNST is exceedingly rare, of which the vast majority are concentrated in the head and neck region. Here, we present a case of a 40-year-old male with NF1 who presented with a giant MPNST that originated in the right proximal femur. The mass was treated with complete surgical resection with right hip disarticulation. In a matter of 4 months, the patient had a rapid progression with metastatic disease to the brain and lungs. We will use this case as an opportunity to explore the current guidelines for post-surgical malignant sarcomas especially in those with neurofibromatosis and the need for more aggressive and active adjuvant treatments.

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  Retrospective Review of Adverse Events Following Treatment of Non-Melanoma Skin Cancer with Low-Energy Superficial Radiation Therapy

  Marshall Hall, Henry Lim, Christian Scheufele, Christopher Wong, Daniel A. Nguyen, Michael Carletti, and Stephen Weis

  Background: Basal cell carcinoma and squamous cell carcinoma are the most common types of non-melanoma skin cancer.1 Superficial radiation therapy (SRT) is a treatment modality that utilizes low-energy x-rays to disrupt cell mitosis directly and indirectly.2 This method of treatment offers advantages for select patients. While this technique has been utilized for over a century, it has recently begun to gain favor in clinical practice.1,3 Although SRT has shown favorable outcomes with a low risk of complications, it still poses a risk for adverse events.1,3,4 The frequency and severity of adverse events are not well-defined with SRT delivered technology with an image-guided approach utilizing high-frequency ultrasound capabilities.3,5

  Methods: A retrospective chart review study was performed on patients treated with image-guided SRT at an academic dermatology clinic between December 2018 to December 2021. Demographic information and medical history related to the population were analyzed as part of the data set. All patients were questioned about risk factors for radiation complications, including a history of cutaneous lupus, prior to SRT. Complications were defined as adverse events within the treatment site persisting beyond the treatment period. Adverse events including erythema, desquamation, radiation dermatitis, and radiation necrosis were collected during the treatment period and subsequent follow-up visits. The primary endpoint was any dermatologic diagnosis or condition requiring treatment beyond the 2-week follow-up visit.

  Results: Three of 165 patients treated with SRT during the reviewed dates experienced adverse events beyond erythema and desquamation during the treatment period. Two patients experienced ulceration of the lower extremities. Both patients with ulcerations had venous stasis with chronic edema. One patient developed radiation-induced cutaneous lupus erythematosus. The patient who developed cutaneous lupus after therapy had no prior history systemic or cutaneous lupus.

  Conclusion: Treatment complications were rare, and all were expected complications of radiation therapy. They occurred despite precautions intended to minimize these complications. High-frequency ultrasound image-guided SRT is a well-tolerated treatment for non-melanoma skin cancer. Conducting further controlled studies on adverse events, risk factors, treatments, and prevention strategies for non-melanoma skin cancer would enhance patients’ ability to make informed decisions regarding their treatment options.

  References: 1. McGregor S, Minni J, Herold D. Superficial Radiation Therapy for the Treatment of Nonmelanoma Skin Cancers. J Clin Aesthet Dermatol. Dec 2015;8(12):12-4. 2. Gianfaldoni S, Gianfaldoni R, Wollina U, Lotti J, Tchernev G, Lotti T. An Overview on Radiotherapy: From Its History to Its Current Applications in Dermatology. Open Access Maced J Med Sci. Jul 25 2017;5(4):521-525. doi:10.3889/oamjms.2017.122 3. Han H, Gade A, Ceci FM, Lawson A, Auerbach S, Nestor MS. Superficial radiation therapy for nonmelanoma skin cancer: A review. Dermatological Reviews. 2023;3(6):409-417. doi:10.1002/der2.174 4. Hernandez-Machin B, Borrego L, Gil-Garcia M, Hernandez BH. Office-based radiation therapy for cutaneous carcinoma: evaluation of 710 treatments. Int J Dermatol. May 2007;46(5):453-9. doi:10.1111/j.1365-4632.2006.03108.x 5. Yu L, Oh C, Shea CR. The Treatment of Non-Melanoma Skin Cancer with Image-Guided Superficial Radiation Therapy: An Analysis of 2917 Invasive and In Situ Keratinocytic Carcinoma Lesions. Oncol Ther. Jun 2021;9(1):153-166. doi:10.1007/s40487-021-00138-4

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  The Domino Effect: Spontaneous Abortions as a Sequela of Eisenmenger Syndrome

  Riddhiben Patel, Anas Hamadeh, Laura Montoya, and Senthil Thambidorai

  Background: Eisenmenger's syndrome (ES) is a congenital cardiac abnormality in which a significant chronic left-to-right shunt results in pulmonary arterial hypertension and a reversal of the shunting direction. A woman with ES should ideally avoid conception given the increased risk of unexpected fetal demise and maternal mortality. Case: We present a case of a 35-year-old female patient G3, P0, at 9 weeks gestation with reported PMHx of erythrocytosis and spontaneous abortions who presented to the hospital with complaints of vaginal bleeding and worsening SOB. She was noted to have a Hct of 70 and a Hb of 23.8, with SaO2 of 86% on room air upon initial evaluation. A transthoracic echocardiogram revealed a medium to large perimembranous ventricular septal defect (VSD) measuring 6 mm with predominantly right to left shunting with a QP/QS ratio of 0.66. The patient's right ventricle was dilated with systolic and diastolic septal flattening suggestive of pulmonary hypertension. CMR confirmed enlargement of the right and left ventricular areas at both end-systole and end-diastole. Further workup revealed persistent hypoxia caused by ES secondary to VSD. JAK2 studies were negative, ruling out a myeloproliferative neoplasm. Measured beta-hCG was not in range with 9-weeks of pregnancy. Additionally, the pregnancy USS revealed a non-viable fetus, concluding that a spontaneous abortion was inevitable. Transfer to another facility for higher level of care and evaluation by adult congenital heart disease cardiologist was not available due to financial reasons. She was ultimately discharged home on oxygen with regular outpatient follow ups. Conclusion: The prognosis of ES pregnancy has not greatly improved despite contemporary advancements in obstetric and cardiovascular medicine. Pregnancy termination is typically advised because spontaneous pregnancy loss/perinatal morbidity are about 30% and maternal mortality for women with ES is reported to be 30-50%. Prolonged bed rest, continuous oxygen therapy, and anticoagulation under hemodynamic observation can positively influence maternal and fetal outcomes.

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  West Nile Virus Encephalitis with Status Epilepticus Treated with High-Dose Steroids: A Case Study

  Sherwin Thomas and Sawroop Sandhu

  West Nile virus (WNV) is a flavivirus endemic in the United States. WNV infection can present with a variety of non-neurologic and neurologic symptoms. Patients who present with WNV neuroinvasive disease have significant morbidity and mortality, with about 10% of cases resulting in death. There is currently no evidence-based treatment for WNV infection. Management is typically with supportive care. Some limited data shows corticosteroids as a possible treatment for neuroinvasive disease. This case report discusses a 55-year-old female patient who presented with altered mental status. She was found to be septic overnight and was found to be in status epilepticus on EEG. The patient was intubated and sedated, started on multiple antiepileptic medications. Sepsis workup was initiated, and empiric antibiotics were started. A lumbar puncture was performed, showing findings consistent with a viral encephalitis. Continuous EEG showed frequent seizures and other epileptiform discharges. Due to no significant improvement, the patient was started on high dose intravenous corticosteroids. The infectious workup eventually revealed that the patient had West Nile virus infection. With the antiepileptic medications and high dose steroids, the patient had a rapid recovery. She was soon able to be extubated and discharged to a rehab facility. There are some conflicting data, with case reports and small retrospective studies, about the efficacy of corticosteroids in the management of WNV neuroinvasive disease. A possible mechanism is corticosteroids having anti-inflammatory properties that can improve the perivascular inflammation associated with WNV neuroinvasive disease. High dose corticosteroids were found to be very effective for the management of WNV neuroinvasive disease in this case.