The Wound Healing Society guidelines for the treatment of arterial insufficiency ulcers were originally published in 2006, with the last update in 2014. These guidelines provided recommendations, along with their respective levels of evidence, on seven categories: diagnosis, surgery, infection control, wound bed preparation, dressings, adjuvant therapy and long-term maintenance. Over the last 9 years, additional literature regarding these aspects of arterial ulcer management has been published. An advisory panel comprised of academicians, clinicians and researchers was chosen to update the 2014 guidelines. Members included vascular surgeons, internists, plastic surgeons, anaesthesiologists, emergency medicine physicians and dermatologists, all with expertise in wound healing. The goal of this article is to evaluate relevant new findings upon which an updated version of the guidelines will be based.

This study evaluated both randomized and nonrandomized trials of battlefield acupuncture for the treatment of both acute and chronic pain. Studies published between May 2016 and November 2019 were found through PubMed, the Cochrane Library, or Scopus, concerned with the treatment of pain using auricular acupuncture in accordance with battlefield acupuncture protocol. Search terms were battlefield acupuncture AND pain or auricular acupuncture AND pain. Case reports, literature reviews, meta-analyses, and expert opinions were not included. Bias risk was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We found 12 studies with a combined sample size of 12,326. All five of the included nonrandomized trials reported positive outcomes, while five of seven of the included randomized trials reached statistical significance in their primary outcome. Six of the randomized trials were considered to have a high risk of bias resulting from the lack of blinding. The one randomized trial with moderate bias risk was a positive study. No severe adverse events were reported. Clinicians may consider battlefield acupuncture as a safe treatment for pain while the evidence base grows; however, we conclude that widespread adoption of battlefield acupuncture will require further high-quality studies drawing from diverse settings and patient populations. In addition, future studies should attempt to achieve blinding.

An 87-year-old man with a history of osteoarthritis presented with worsening knee pain. He was prescribed acetaminophen with codeine. A few days later, he developed a rash on his right buttock and proximal thigh, similar to a rash he experienced in the past when he took over-the-counter (OTC) acetamenophen and an unknown lozenge to treat a presumed viral illness. A fixed drug eruption (FDE) was diagnosed and the patient was asked to avoid Tylenol and other OTC lozenges. Tylenol was entered as an allergy in the electronic medical records. However, since Tylenol, not acetaminophen was listed in the allergy profile, the order for acetaminophen and codeine did not generate an alert for the prescribing physician. Additionally, the dispensing pharmacist did not question the prescribing physician and the patient, unaware that acetaminophen in the pain medication is the same drug as Tylenol, took it and developed recurrent FDE.

Objectives: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. Research Design: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. Methods: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. Results: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was −2.5 points (SD=2.2) at the initial BFA treatment, and −2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. Conclusion: VHA’s rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Background The global pandemic of Severe Acute Respiratory Syndrome-Related Coronavirus 2 (SARS-CoV2) has resulted in unprecedented challenges for healthcare systems. One barrier to widespread testing has been a paucity of traditional respiratory viral swab collection kits relative to the demand. Whether other sample collection kits, such as widely available MRSA nasal swabs can be used to detect SARS-CoV-2 is unknown. Methods We compared simultaneous nasal MRSA swabs (COPAN ESwabs ® 480C flocked nasal swab in 1mL of liquid Amies medium) and virals wabs (BD H192(07) flexible mini-tip flocked nasopharyngeal swabs in 3mL Universal Transport Medium) for SARS-CoV-2 PCR testing using Simplexa COVID-19 Direct assay on patients over a 4-day period. When the results were discordant, the viral swab sample was run again on the Cepheid Xpert Xpress ® SARS-CoV-2 assay. Results Of the 81 included samples, there were 19 positives and 62 negatives in viral media and 18 positives and 63 negative in the MRSA swabs. Amongst all included samples, there was concordance between the COPAN ESwabs ® 480C and the viral swabs in 78 (96.3%). Conclusion We found a high rate of concordance in test results between COPAN ESwabs ® 480C in Amies solution and BD H192(07) nasopharyngeal swabs in in 3 mL of Universal Viral Transport medium viral media. Clinicians and laboratories should feel better informed and assured using COPAN ESwabs ® 480C to help in the diagnosis of COVID-19.

A veteran with a history of mental illness and drug and alcohol misuse developed a bleeding lesion on his tongue, which raised concerns of self-injury.

To the Editor: We read with interest the article by Privalle et al.1Privalle A. Havighurst T. Kim K. Bennett D.D. Xu Y.G. Number of skin biopsies needed per malignancy: comparing the use of skin biopsies among dermatologists and nondermatologist clinicians.J Am Acad Dermatol. 2020; 82: 110-116Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar When we first described and termed the malignancy ratio in 2004, we studied 11,072 cutaneous tumors sent to the dermatopathology laboratory at the University of Miami Department of Dermatology and Cutaneous Surgery. We evaluated all tumor types as well as individual tumor types, and among dermatologists, we reported a malignancy ratio of 41.7%,2Green A.R. Elgart G.W. Ma F. Federman D.G. Kirsner R.S. Documenting dermatology practice: ratio of cutaneous tumors biopsied that are malignant.Dermatol Surg. 2004; 30: 1208-1209Crossref PubMed Scopus (10) Google Scholar which is not dissimilar from the 36.3% reported for dermatologists by Privalle et al. We suggested that this number serve as a benchmark by which providers can assess their own practice patterns. After multivariate analysis evaluating a variety of factors (including whether a dermatologist was a general or surgical dermatologist, use of dermoscopy, provider years in practice, and provider age) like Privalle et al, we also found provider age predictive of higher malignancy ratio, underscoring the importance of clinical experience. We did suggest that perhaps geographic location, different practice styles, or different systems with different payers might influence the malignancy ratio. We did not evaluate advanced practitioners in our study, but the results reported by Privalle et al underscore the importance of training and experience. We were pleased to see our malignancy ratio used and many of our observations confirmed. We applaud the investigators in using the malignancy ratio to determine the number needed to biopsy. As discussed in their limitations, these investigators were unable to ascertain geographic variability within the United States because their data were from a single academic center, and practice patterns may differ between the Midwest, South, and Northeast. Similarly, they acknowledge that they did not account for the use of dermoscopy, which has gained widespread use since our study was published. We know that even for experienced dermatologists, not aided by dermoscopy, 1 of 5 tumors highly suggestive of basal cell carcinoma is benign on histology, suggesting that some number less than 100% represents the target malignancy ratio.3Schwartzberg J.B. Elgart G.W. Romanelli P. Ma F. Federman D.G. Kirsner R.S. Accuracy and predictors of basal cell carcinoma diagnosis.Dermatol Surg. 2005; 31: 534-537Crossref PubMed Scopus (22) Google Scholar We hope that the malignancy ratio or its correlate, number needed to biopsy, continues to be used by dermatologists and other caregivers to assess their own care and for systems to evaluate and improve quality of care. Number of skin biopsies needed per malignancy: Comparing the use of skin biopsies among dermatologists and nondermatologist cliniciansJournal of the American Academy of DermatologyVol. 82Issue 1PreviewThere are too few board-certified dermatologists to treat all patients with skin disease. Primary care physicians often serve at the frontline of skin cancer screening. Full-Text PDF

Background: Little is known about patient preference regarding the physical exam in non-urgent primary care settings.Objective: To determine the differences between a patient's expectations of the physical exam and the actual components of the physical examination performed during a non-urgent visit.Design: A total of 452 surveys administered in the waiting room of a VA primary care clinic in West Haven, CT.Key results: The response rate was 91.6% (n = 414). For 15 of 16 maneuvers on the survey, more respondents believed a reasonable provider should conduct it than received it at their annual physical exam; for 7 of them (breast, axillary, rectal, pelvic, total body skin exam, electrocardiogram, and stress test), over twice as many respondents believed they should be done than received them. There was an association between a patient's perception of their primary care provider and the number of maneuvers recalled at their annual exam (P < 0.001), and a gap in the number of maneuvers expected from a reasonable provider by nonwhite and white patients (P < 0.001).Limitations: Convenience sample, response bias (healthy patients are more likely to respond) and recall bias.Conclusion: Patient perception of their primary care provider is strongly associated with the number of maneuvers recalled during an annual physical. Furthermore, the number of maneuvers expected by a patient is influenced by race, with nonwhite patients desiring more. This suggests the need for further research on the role of race in the expectations of healthcare providers.

Background: Stethoscope hygiene is rarely done despite guideline recommendations. We wanted to determine whether demonstrating what is growing on the stethoscopes of providers via culture or bioluminescence technology alters perceptions and improves compliance. Methods: Providers were given the opportunity to (1) culture their stethoscopes before and after disinfection with alcohol pads, alcohol-based hand rub, or hydrogen peroxide disinfectant wipes and (2) swab stethoscopes for bioluminescence-based adenosine triphosphate testing before and after disinfection. Outcomes were observed for hand and stethoscope hygiene rates and before and after intervention survey responses. The bacteria that were isolated, colony-forming units (CFU), and bioluminescence scores were tracked. Results: A total of 1,245 observed hand hygiene opportunities showed that compliance improved from 72.5%-82.3% (P < .001). In addition, 590 observed patient-provider encounters revealed no significant change in stethoscope hygiene rates of 10% initially and 5% afterward (P = .08), although self-reported rates trended from 56%-67% postintervention (P = .06). Perceptions regarding stethoscope hygiene importance improved (8.5/10 to 9.3/10; P = .04). Disinfection with alcohol pads, alcohol-based hand rub, and hydrogen peroxide disinfectant wipes were equivalent in CFU reduction (P = .21). Conclusions: Showing providers what is growing on their stethoscopes via cultures and bioluminescence technology before and after disinfection improved "buy in" regarding stethoscope hygiene importance. Both methods were rated as having an equal impact, however, objective observations failed to show improvement. (C) 2019 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.

When I lecture about pain to large groups of health-care providers, I begin by asking the audience, ‘Please raise your hands if you care for people with pain’; virtually everyone raises their arm a...

The term “going down the rabbit hole,” based on Lewis Carroll's Alice's Adventures in Wonderland, is a metaphor for an entry into the unknown, the disorienting, or the mentally deranging. Although the case of a patient with a nonhealing ulcer did not set us on a path with these exact qualities, it did remind us that ulcers could, at times, be associated with unexpected diagnoses.

Twenty children, six teachers, two sets of eyes, and a dog were a terribly tragic catalyst for my metamorphosis as a physician and person. Let me explain. Until the cataclysmic event, I was an academic physician at an Ivy League institution who worshipped at the altar of evidence-based medicine and thought housestaff and students should supplicate alongside me. If a physician were to affect a change in plan for a patient, I demanded they knew the evidence to support the intervention, especially when there existed what I considered to be a landmark study. It was as if I had a secret love affair with acronyms: TIMI, CAPRIE, ALLHAT, 4S, and so forth, and my learners rewarded me and reinforced this practice with glowing evaluations. But then on a mid-December day a little more than 5 years ago something happened, something so heinous and vile that it will always be one of those things you'll remember where you were when you heard about it, like where you were when Kennedy was assassinated and where you were on 9/11. That's the day when a gravely mentally ill young man entered an elementary school, Sandy Hook Elementary School, in our idyllic rural Connecticut town that we called home for 20 years, and robbed the world of those educators and innocent elementary school children in one of the most deplorable acts in American history. He was a classmate of my son. Newtown is a small town, one where we run into one another at the diner, or the general store, or Ferris Acres farms, home of what has to be the best ice cream in Connecticut. If you're in the area, I highly recommend the Moose Tracks or the Bada-Bing in a waffle cone. You can add sprinkles for a nominal charge, if you like. Although my children were not directly involved in the massacre, because it is a small town, we knew so many who were directly affected: teachers at the school, some who heroically saved children, parents who received calls summoning them to the firehouse to find out their child's fate, physicians summoned to the emergency department to await children who never arrived, and yes, someone who lost her precious son, Noah. It was at his family's Shiva, a Jewish ritual of mourning, where I stumbled to find a few impossible words of solace for a grieving mother when I encountered those eyes, the tortured eyes of a mother who had innocently sent her son to school one morning and never had another opportunity to hear his laugh or feel his loving hug. Her faraway eyes told a story of dark despair and unimaginable, unrelenting pain. Those eyes and her pain haunted me long after I left the home. I saw them at night when I tried to sleep, I saw them when I watched Anderson Cooper interview friends and neighbors on TV, I saw them as the incessant news trucks rode through town, I even saw them when I was with patients. During the ensuing days, I cried every day; often sobbing, shoulder-shaking, nose-running cries. By day, I went to work. I was there, for sure, but I was certainly not present. When I walked the halls of my Veterans Affairs hospital, my second home, I could not look anyone in the eyes when I passed them. While normally I walk the halls looking to greet or interact with anyone I pass, during this time, the floor seemed a much more hospitable place to entrust my gaze. During that time social media was our form of communication—we learned where funerals were to be held, where physicians against gun violence was going to meet, what our politicians were trying to do, and how the National Rifle Association was reacting to their cries for reform. That is where I first saw the dogs. After they kept appearing on Facebook, instead of quickly scrolling past them, I read that healing dogs were working with the children. My initial reaction was skeptical. What can a healing dog really do in the face of such unimaginable horror? Where do they poo? Is there any liability if a dog bites someone? Being a doctor makes you think about liability sometimes, even when you don't want to. I went on crying daily. I was clinically depressed, but too dedicated to miss work and too proud to seek professional help. It was at the 1-month anniversary candlelight vigil in town where I had my epiphany. My wife, son, and I encountered a lady with a dog. His purple vest informed us that this was no ordinary mutt. When we chatted its owner up, we found out that he was a healing dog, and together, they had made a 5-hour drive from Baltimore to help our community heal. We were moved by this truly selfless and generous act of kindness in a world that had seemed so far off its axis. Because nobody was interacting with them, I somehow felt it was my responsibility to interact with the dog, if only to allow her to go home and feel good about herself and perhaps give the dog a treat. I never would have predicted what transpired in that moment. It was as if something magical occurred as we looked into each other's eyes. I don't know what my new purple-vested friend saw in my eyes, but I saw unconditional love and innocence in his. I can't really explain it more than that, but from then on, I stopped crying. I began to see a mother's pained eyes less often and more of the panting, smiling dog's. When I returned to work and reflected, the evidence-based me realized that there are no randomized, controlled trials published in respected peer-reviewed journals demonstrating the salutary effect of healing dogs in school shootings in small-town Connecticut. Just because there is no study to support something doesn't mean it doesn't work, it certainly did for me. Similarly, for many situations where there is “good evidence” to support something, because of some artificial study conditions and inclusion-exclusion criteria, the evidence may not apply to the human being before you. If a healing dog could help me, perhaps other integrative medicine modalities could help others. I now embrace practices such as auricular acupuncture, turmeric ingestion, meditation, and mindfulness in ways I have never before. I write this with a heavy and grieving heart, the day after another senseless tragic school shooting, this one in Parkland, Florida—on Valentine's Day, of all days. I don't need a P value or confidence interval to know that we need fewer assault weapons, and unfortunately, unless we as a society address the causes of these tragedies, we will continue to need more dogs in purple vests. Both as citizens and physicians, we need to do what we need to do.

Objective To obtain preliminary data on the short- and intermediate-term effects of battlefield acupuncture (BFA) on self-reported pain intensity in a relatively large cohort of veterans to assess whether a more comprehensive clinical trial evaluation is warranted. Methods The treatment, in an outpatient group setting, consisted of up to five auricular semipermanent needles inserted into each ear at prespecified points. Efficacy of treatment was measured by self-reported pain, using the Defense and Veterans Pain Rating Scale, just before treatment and at posttreatment days 0, 1, 7, and 30. Results A total of 112 patients attended the group clinics. The mean pretreatment pain score was 6.8, with an immediate postprocedure decrease of 2.4 points. The proportion of patients reporting decreased pain was 88.4%, 80.7%, 52.4%, and 51% at posttreatment days 0, 1, 7, and 30, respectively. Conclusions The short- and intermediate-term beneficial effect of BFA on chronic pain is clinically meaningful. The large proportion of patients reporting decreased pain even 30 days after treatment suggests that the long-term effect of BFA merits further investigation.

Background: Auricular acupuncture is effective for many patients with pain. Many skin malignancies and precancerous lesions are found on the head and neck. Practitioners of acupuncture are in a unique situation to detect cutaneous malignancy at an early state. Case: An 83-year-old man referred for Battlefield Acupuncture was found to have a scalp lesion suspicious for malignancy as well as several precancerous lesions. Results: Referral to a dermatologist led to excision of a basal-cell cancer and treatment of actinic keratoses. Conclusions: Practitioners of auricular acupuncture should be familiar with common skin cancers and precancerous lesions; these practitioners are in a unique situation to detect these common skin lesions.

OBJECTIVES:'he number of consults and response times to our Emergency Department (ED) were tracked to understand the effects on patient flow and outcomes.STUDY DESIGN:We conducted a prospective observational study using convenience samples.METHODS:There were 992 requests for physician consultations or logistical services (bed manager, transport, or room cleaning) logged during ED shifts from January through July, 2014 at the VA CT Healthcare System West Haven Campus (VACHS). Services were paged every 15 minutes until a response was received; the total response time was then recorded. One-hundred-eighty-six requests were triggered by one author's cohort of 392 patients, for which age, disposition, and outcomes were also tracked.RESULTS:The median response times were one to six minutes depending on the service requested; outli- ers exceeded an hour. A patient's ED stay duration increased with the number of services paged. The number of services paged was associated with mortality despite adjusting for age, ED waiting time, ED total time, and disposition (odds ratio = 3.14, P = .02) although comorbidity scores were not tracked.CONCLUSIONS:Response time to ED pages varies widely. The number of services paged correlated with ED length of stay and possibly inpatient mortality.

When legendary bank robber Willie Sutton was asked why he robbed banks, he purportedly replied, “Because that's where the money is.” In medicine, “Sutton's Law,” based on the criminal's comeback, states that while diagnosing a malady, one should not overlook the obvious. That logic was invoked to answer a resident physician who asked, “Why are my patient's nails yellow?”

Objectives Communication between hospitalists and primary care providers (PCPs) upon discharge has been much discussed, but the transition from outpatient to inpatient has received less attention. We questioned whether a brief, standardized e-mail from the hospitalist to the PCP upon admission could facilitate information exchange, increase communication, elucidate PCP preferences, and improve outcomes. Methods This prospective single-center study with a preintervention-to-postintervention design involved 300 inpatient admissions from June 2015 through October 2015 in the Veterans Affairs Connecticut Healthcare System. Hospitalists e-mailed an encrypted notification of admission along with standardized questions to PCPs within 1 day of admission. Measurements included the number of communications between PCPs and hospitalists, length of stay (LOS), 30-day readmissions, 30-day emergency department (ED) utilization rates, PCP preferences with regard to communication, and follow-up. Results Preintervention data for 94 patients during a 6-week period revealed 0.11 communications per patient, an LOS of 4.18 days, 30-day readmissions of 28.7%, and 30-day ED visits of 32%. Postintervention data on 206 patients during the next 12 weeks showed statistically significant increased communications per patient (0.5), and a nonsignificant decrease in LOS (3.96 days), 30-day readmissions (22.3%), and 30-day ED visits (31%). P values were <0.001, 0.67, 0.4, and 0.79, respectively. PCPs preferred e-mail communication upon discharge (40%) to telephone (25%) or instant messaging (13%), and 39% wanted a follow-up appointment within 2 weeks, regardless of what transpired. Conclusions A hospitalist-led transition-of-care intervention designed to improve communication and information exchange between PCPs and hospitalists at the time of admission demonstrated that encrypted e-mail could be used as a tool to obtain useful additional medical and psychosocial information and to better understand PCP attitudes and preferences. The increased level of communication did not yield statistically significant decreases in LOS, 30-day readmission rates, or 30-day post-discharge ED visits, however.

As the population ages and incidence of basal cell carcinoma continues to increase, we will be faced more frequently with difficult treatment decisions for basal cell carcinoma in the elderly. Different treatment options, including surgical excision, electrodessication and curettage, cryosurgery, imiquimod, photodynamic therapy, 5-fluorouracil, radiation therapy, vismodegib, combination therapy, and observation, may be considered on the basis of tumor characteristics. Given the wide range of therapeutic options, treatments can be tailored to achieve patients' goals of care within their anticipated life expectancy.

In one memorable case, the patient's attire told physicians more about his health than the initial interview and physical examination. A 65-year-old veteran with a history of dyslipidemia, hypothyroidism, and post-traumatic stress disorder presented for a routine primary care visit and had no symptoms. He specifically denied having any chest pain. When asked about the unusual pattern of wear on his sweatshirt (Figure A and B), the patient admitted to having daily exertional chest pressure over the previous 7 months. This was relieved by rest and by pushing down on the area of discomfort and rubbing it. An electrocardiogram was unremarkable. A nuclear stress test revealed a large area of reversible ischemia. On the basis of the severity of his symptoms, the patient opted to undergo invasive testing. He was noted to have significant multivessel coronary artery disease on cardiac catheterization (Figure C) (70% blockage, left main coronary artery; 99% blockage, left anterior descending artery; 80% blockage, diagonal branch of the left anterior descending artery, 99% blockage, obtuse marginal branch of the circumflex artery; and 90% blockage, right coronary artery). The patient underwent successful coronary artery bypass grafting. Atrial fibrillation developed 3 months later and has been managed with amiodarone. Clinicians should remember to ask patients whether they are experiencing “chest discomfort” rather than “chest pain.” It is also essential to be aware of the sweatshirt sign, which we call “the abnormal wear sign.”

A 60 year-old male Veteran with medical history of COPD, hypertension, and a 45 pack-year smoking history presented to his primary care provider. Routine lab work incidentally showed a 31% eosinophilia, corresponding to a total eosinophil count of 2000/lL. The remainder of a complete blood count at initial and subsequent presentations are shown in Table I. He had no diarrhea, sick contacts, or recent travel. He did not report any food, drug, or seasonal allergies, and his physical exam was unrevealing. He did not have any Agent Orange exposure and had no family history of hematologic malignancy. A limited workup for his eosinophilia included negative stool testing for ova and parasites and a negative Strongyloides antibody. Eosinophilia is defined as an absolute eosinophil count (AEC) in the peripheral blood of 500 eosinophils/mL. Marked eosinophilia refers to a more significant increase in eosinophil counts to 1500 eosinophils/mL. The differential diagnosis for marked eosinophilia is broad and includes primary (clonal), secondary (reactive), and idiopathic causes [1]. This patient’s military history, and associated travel to endemic regions, puts him at risk for helminthic infections such as Strongyloidiasis, Toxocariasis, Trichinellosis, and Hookworm. In the general population, other secondary causes include allergic disorders (such as asthma, allergic rhinitis, allergic broncho-pulmonary aspergillosis, eosinophilic esophagitis), drug reactions, adrenal insufficiency, and a variety of rheumatologic diseases [such as dermatomyositis and eosinophilic granulomatosis with polyangiitis (EGPA)]. Worldwide, the most common causes of eosinophilia are parasitic diseases, while in developed countries, allergic processes are most frequent [2]. Primary causes for hypereosinophilia are rare and are due to myeloproliferative or lymphoproliferative disorders. They should be considered when secondary causes have been ruled out. When a patient presents with marked eosinophilia, one should focus on ruling out the most common secondary causes without completing an extensive workup. Initial tests include a complete blood cell count (CBC), blood smear, as well as an assessment of allergies and parasites (with antibodies to Strongyloides and Schistosomiasis as well as stool ova and parasites, if indicated). Screening tests should be done to exclude organ involvement, with attention to cardiac and pulmonary involvement: basic metabolic panel, urinalysis, liver function tests, cardiac biomarkers, and chest radiography. For eosinophilia persisting beyond one month, more extensive diagnostic studies including flow cytometry and consultation with a hematologist are indicated. Our patient remained asymptomatic and presented four months later when he was admitted to an outside hospital with severe left upper quadrant abdominal pain. The pain was accompanied by nausea and non-bloody, non-bilious emesis. CT imaging of the abdomen revealed multiple wedge-shaped splenic infarcts. A workup for splenic infarcts was initiated and included a negative thromboembolic workup, without evidence for atrial fibrillation on ECG or valvular vegetations on echocardiogram. Hypercoagulability testing showed negative lupus anticoagulant, anticardiolipin antibodies, and beta-2 glycoprotein. Antinuclear antibody (ANA) was positive (1:160) and anti-neutrophil cytoplasmic antibody (ANCA) testing was negative. Anticoagulation was initiated, and he was eventually transitioned to aspirin. Labs were significant for leukocytosis, polycythemia, thrombocytosis, and worsening eosinophilia (WBC 21.4 K/lL, Hb 17.0 g/dL, Platelets 470 K/cmm, Eosinophils 25% (5350/lL). Persistent eosinophilia combined with erythocytosis and thrombocytosis in the absence of secondary causes raises the suspicion for lymphoproliferative or myeloproliferative conditions. This patient merits further evaluation for clonal disorders in the bone marrow, including chronic myeloid leukemia, essential thrombocytosis, polycythemia vera, eosinophilic leukemia, and mastocytosis. At this point, hypereosinophilic syndrome (HES), a primary idiopathic bone marrow disorder, should also be considered. In 1975, Chusid et al. defined the three features required for a diagnosis of HES [3,4]