Background Englewood Hospital (EH) has over 25 years of experience in patient blood management (PBM) for patients who decline blood transfusions due to religious or personal reasons. The Bloodless Medicine and Surgery Institute has developed a comprehensive protocol for managing severe anemia in bloodless patients, aiming to optimize patient hematopoietic capacity. [1] This approach has been shown to reduce costs, transfusion reactions, and hospital stays. [2] However, the progressive nature of bloodless medicine has presented challenges in physician compliance with hospital guidelines and policies, leading to frequent referrals to the specialized PBM department for guidance. Tools like AvoMD, a clinical decision support (CDS) platform, have helped reduce referrals by providing structured guidance on evidence-based algorithms. Methods EH collaborated with AvoMD to integrate our customized PBM protocol into an interactive interface. This platform enables physicians to select among various clinical conditions, such as patients who are actively bleeding, critically ill or those undergoing a surgical intervention. Management recommendations are then provided based on hemoglobin values according to established protocols. In this study, we closely monitored the number of referrals to the PBM department over a 12-month period after implementation of our PBM protocol via AvoMD. Results The implementation of the AvoMD platform led to a 73% decrease in referrals to the PBM department. Conclusion Managing severe anemia when transfusion is not an option can be challenging. CDS systems integrate patient information with a digital knowledge base to enhance clinical decision-making processes and can be particularly helpful in unique scenarios such as severe anemia in bloodless patients. These systems have shown to decrease misdiagnosis rates and improve patient safety. [4] AvoMD is designed to streamline clinical decision-making by simplifying evidence-based guidelines and algorithms. The implementation of AvoMD decreased the number of PMB referrals in our hospital by empowering physicians with point-of-care recommendations. This CDS integration has proven to reduce the need for specialist consultations and improve guideline adherence in other institutions. [3, 5] Integrating EH PBM protocols into the clinical workflow through the AvoMD platform represents a significant advancement in patient care quality. This project highlights the potential of technology to deliver comprehensive care, enhance patient safety and improve clinical outcomes. The field of CDS is evolving rapidly, and the advent of artificial intelligence (AI) is set to accelerate this transformation. Numerous studies are exploring how AI can improve decision-making processes, increase accuracy, and ultimately lead to better clinical outcomes. [6,7]

Introduction: Wilkie’s syndrome, more commonly called superior mesenteric artery (SMA) syndrome or cast syndrome is characterized by compression of the third part of the duodenum between the SMA and aorta leading to a range of symptoms caused by external obstruction of the duodenum including weight loss, abdominal pain, nausea and vomiting. It has a prevalence of 0.013% to 0.3% and is commonly seen in patients with rapid weight loss, scoliosis surgery and trauma. We present a case of a patient with weight loss and acute onset nausea, vomiting and abdominal pain found to have SMA syndrome on evaluation. Case Description/Methods: A 47-year-old man with a history of ischemic stroke with chronic left-sided hemiparesis, epilepsy and schizoaffective disorder presented from a nursing home due to a 3 day history of fever, nausea, vomiting, abdominal pain and subjective weight loss. Initial laboratory findings included leukocytosis with left shift (WBC 17.73 [4.00-11.00K/mL]) and lactic acidosis (5.0 [0.7-2.0mmol/L]). CT abdomen and pelvis with intravenous contrast demonstrated bibasilar consolidation suggestive of pneumonia as well as marked distension of the stomach and duodenum with transition in the third portion of the duodenum at the level of the superior mesenteric artery. Antibiotics were initiated and gastroenterology was consulted. Gastroscopy exhibited moderate to severe erythema in the gastric body and antrum and retained food contents. Subsequently, an upper gastrointestinal series was ordered which showed markedly increased small bowel transit time with barium contrast reaching the colon after 7 hours with initial holdup of contrast at the level of the proximal third of the duodenum (Figure 1). General surgery was contacted with a decision made to perform duodenojejunostomy, after which the patient reported a significant improvement in his symptoms. Discussion: Wilkie’s syndrome is rare and can be challenging to diagnose due to its nonspecific symptoms, however with CT scan (the modality of choice for diagnosis), the narrowing of the angle between the SMA and aorta with duodenal compression can be seen allowing for early diagnosis. In our case, the patient presented with weight loss and also acutely, compared to other patients who tend to go undiagnosed with chronic intermittent symptoms causing a delay in diagnosis. Early recognition and prompt treatment are essential for prevention of complications such as dehydration and malnutrition.Figure 1.: Upper gastrointestinal series demonstrating initial holdup at the level of the proximal third portion of the duodenum (yellow arrow).

Introduction: Ampullary adenomas are dysplastic lesions that arise in and around the duodenal papilla with a prevalence of 0.04% to 0.12%. They may occur in the setting of familial adenomatous polyposis (FAP) or sporadically, most commonly in patients over age 40. Ampullary adenomas are often asymptomatic and incidentally discovered on endoscopy. We present a case of an asymptomatic 34-year-old woman with incidentally-noted transaminitis found to have an ampullary tubulovillous adenoma. Case Description/Methods: A 34-year-old female with a PMH of DM, HTN, and obesity was incidentally found to have ALP 853, AST 97, ALT 233 during an ambulatory visit. She denied a history of jaundice, abdominal pain, or weight loss at that time. The patient initially underwent laboratory testing for autoimmune and infiltrative disease and was referred for an abdominal ultrasound(US). The lab workup was nonrevealing. Abdominal US showed dilated CBD to 1.2 cm without cholelithiasis and she was referred to Gastroenterology. MRCP was recommended but delayed due to a lack of insurance coverage. In the meantime, she developed abdominal pain. The patient eventually presented to the emergency department with progressive, severe RUQ pain. Laboratory tests showed ALT- 458, AST- 341, ALP - 2,006. Emergent MRCP revealed a polypoid ampullary soft tissue lesion extending into the duodenum and distal CBD(measuring up to 3.3 cm), associated with moderate biliary distention. She underwent endoscopic ultrasound with a biopsy of the mass and subsequent ERCP with sphincterotomy and stent placement. Biopsy confirmed ampullary adenoma with low-grade dysplasia. Given the size and location of the lesion, surgical resection was performed instead of endoscopic resection with significant improvement in her symptoms and laboratory derangements (Figure 1). Discussion: In this young patient with no family or personal history of adenomatous polyposis syndrome and without presenting symptoms, we demonstrate the need to maintain a thorough differential diagnosis when approaching the workup of liver enzyme derangements. Anchoring bias towards more common diagnoses can delay the identification of rarer conditions. Additionally, our patient experienced a delay in diagnosis due to insurance issues resulting in increased morbidity, highlighting a key systems barrier involved in pursuing elective outpatient evaluation. While her pathology was benign, there is a possibility of these lesions harboring adenocarcinoma which can significantly change treatment options and prognosis.Figure 1.: Ampullary mass(A) 7 Fr x 7 cm double pigtail stent in place with bile flow(B) MRCP showing moderate biliary distention(C).

Multisystem inflammatory syndrome in adults (MIS-A) is a rare and severe complication of SARS-CoV-2 infection that is more common in children than adults. It is often underdiagnosed by physicians because of the heterogeneity of symptoms, overlapping comorbid conditions, and a lack of comprehensive work-up. Here, we present a patient case of MIS-A after mild COVID-19 infection in a fully vaccinated adult. The goal of this case is to describe the presentation of MIS-A in adults and review the associated laboratory results that can guide early diagnosis and management to improve outcomes.