Fournier's gangrene (FG) is a rare but severe infection in the soft tissue, leading to necrosis in the perineum, perianal and genitourinary area. This infection can spread rapidly in the body and lead to multi-organ failure, septic shock, and death. This life-threatening infection is usually caused by polymicrobial agents like Group A -Beta Hemolytic Streptococcus-Streptococcus pyogenes, Staphylococcus aureus, Escherichia coli, Klebsiella pneumonia, Proteus, and anaerobes like Bacteroides and Clostridium perfringes. Risk factors related to the development of FG are obesity, uncontrolled diabetes, lack of education, poor personal hygiene, especially in the genital region, history of fungal infection, recurrent urinary tract infection, smoking, immunosuppression, and medication. In 2018, a safety warning was issued by The U.S. Food and Drug Administration (FDA) on sodium-glucose cotransporter-2 (SGLT2) inhibitors, causing a rare but serious adverse outcome of FG in patients with type 2 diabetes mellitus. It is established that the increased urinary glucose concentration caused by SGLT-2 inhibitors creates a suitable environment for the growth of the infection in the urinary and genital area, leading to the development of FG. Here we present a case of life -threatening FG in an obese female with a past medical history of type 2 diabetes mellitus with recurrent history of genital yeast infection four months after starting an SGLT2 inhibitor, empagliflozin. This study aims to understand the relationship between the FG and SGLT-2 inhibitor, overall the benefits of SGLT2 inhibitors outweighs the risk manyfold, therefore, raising awareness among clinician to be vigilant, keep a high index of suspicion and focus on the safe use of SGLT2 inhibitors, especially before and after prescribing SGLT-2 inhibitor with a close follow-up to prevent its serious and life-threatening emergency like Fournier's gangrene and necrotizing fasciitis.

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

SESSION TITLE: Drug-Induced Lung Injury Pathology Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Immune checkpoint inhibitors (ICI) recently have provided promising development in the field of advanced cancer by blocking the interchange between Programmed cell death protein 1 (PD-1) on T cells and Program cell death ligand 1(PD-L1) on cancer cells which produces immense T cell response. However, these amplified T-cell responses can fabricate immune-related adverse events which can mimic tumor progression and creates a diagnostic dilemma. Here we present a rare case of ICI-induced lymphadenitis and upper airway obstruction, which was successfully managed with steroids and airway stents.CASE PRESENTATION: A 64-year-old- female presented with a 5 cm right upper lobe(RUL) squamous cell carcinoma and 1.5cm left upper lobe squamous cell carcinoma with metastasis to the left hilum, where both had 5% expression of PDL1. She underwent mediastinoscopy followed by video-assisted thoracic surgery (VATS) with right upper lobectomy. Adjuvant chemotherapy and ICI were initiated. Three month later she presented with worsening shortness of breath and positron emission tomography avid subcarinal mass causing right main-stem bronchus (RMSB) compression with resolution of left sided nodules and left hilar node. Repeat Endobronchial ultrasound (EBUS)- trans-bronchial needle aspiration(TBNA) demonstrated no evidence of malignancy but confirmed marked extrinsic compression of the RMSB extending into right middle lobe. A self expandable fully covered 10X20mm stent was deployed into the right bronchus and a second balloon expandable 7X16mm stent was deployed into the right middle lobe. ICI was immediately discontinued and started on steroids. A repeat chest CT 3 months later showed marked reduction in subcarinal mass and bronchial stents were removed.DISCUSSION: Pembrolizumab, has become the first line of treatment in metastatic non-small cell lung cancer (NSCLC), particularly patients with PD-L1 Expression >50%[1]. Lately Atezolizumab has been FDA approved in an adjuvant setting for stage II and stage IIIA non small cell lung cancer[2]. Despite its robust clinical benefit, It can cause immune related adverse events which can create a diagnostic dilemma in interpreting between disease progression and immunotherapy side effects. In our case, RMSB obstruction by large subcarinal mass was observed after ICI therapy, which was successfully managed with two bronchial stents. There is paucity of literature on the use of bronchial stents in such situations. Himeji et al described a severe tracheal compression following initiation of ICI managed with a silicone Y stent[3]. Immediate discontinuation of ICI and prolonged steroids therapy significantly decreased lymphadenopathy in our case.CONCLUSIONS: Clinicians should be aware of ICI mediated lymphadenitis which can result in central airway obstruction. Once recurrent cancer is excluded, prolonged course of steroids and occasionally airway stenting may be necessary.Reference #1: https://www.sciencedirect.com/science/article/pii/S2213007119301108Reference #2: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(21)02098-5.pdfReference #3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704354/DISCLOSURES: No relevant relationships by Nasser Altorkino disclosure submitted for Sadaf Hossain;No relevant relationships by Tahmina JahirNo relevant relationships by Eugene Shostak SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Immune checkpoint inhibitors (ICI) recently have provided promising development in the field of advanced cancer by blocking the interchange between Programmed cell death protein 1 (PD-1) on T cells and Program cell death ligand 1(PD-L1) on cancer cells which produces immense T cell response. However, these amplified T-cell responses can fabricate immune-related adverse events which can mimic tumor progression and creates a diagnostic dilemma. Here we present a rare case of ICI-induced lymphadenitis and upper airway obstruction, which was successfully managed with steroids and airway stents. CASE PRESENTATION: A 64-year-old- female presented with a 5 cm right upper lobe(RUL) squamous cell carcinoma and 1.5cm left upper lobe squamous cell carcinoma with metastasis to the left hilum, where both had 5% expression of PDL1. She underwent mediastinoscopy followed by video-assisted thoracic surgery (VATS) with right upper lobectomy. Adjuvant chemotherapy and ICI were initiated. Three month later she presented with worsening shortness of breath and positron emission tomography avid subcarinal mass causing right main-stem bronchus (RMSB) compression with resolution of left sided nodules and left hilar node. Repeat Endobronchial ultrasound (EBUS)- trans-bronchial needle aspiration(TBNA) demonstrated no evidence of malignancy but confirmed marked extrinsic compression of the RMSB extending into right middle lobe. A self expandable fully covered 10X20mm stent was deployed into the right bronchus and a second balloon expandable 7X16mm stent was deployed into the right middle lobe. ICI was immediately discontinued and started on steroids. A repeat chest CT 3 months later showed marked reduction in subcarinal mass and bronchial stents were removed. DISCUSSION: Pembrolizumab, has become the first line of treatment in metastatic non-small cell lung cancer (NSCLC), particularly patients with PD-L1 Expression >50%[1]. Lately Atezolizumab has been FDA approved in an adjuvant setting for stage II and stage IIIA non small cell lung cancer[2]. Despite its robust clinical benefit, It can cause immune related adverse events which can create a diagnostic dilemma in interpreting between disease progression and immunotherapy side effects. In our case, RMSB obstruction by large subcarinal mass was observed after ICI therapy, which was successfully managed with two bronchial stents. There is paucity of literature on the use of bronchial stents in such situations. Himeji et al described a severe tracheal compression following initiation of ICI managed with a silicone Y stent[3]. Immediate discontinuation of ICI and prolonged steroids therapy significantly decreased lymphadenopathy in our case. CONCLUSIONS: Clinicians should be aware of ICI mediated lymphadenitis which can result in central airway obstruction. Once recurrent cancer is excluded, prolonged course of steroids and occasionally airway stenting may be necessary. Reference #1: https://www.sciencedirect.com/science/article/pii/S2213007119301108 Reference #2: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(21)02098-5.pdf Reference #3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704354/ DISCLOSURES: No relevant relationships by Nasser Altorki no disclosure submitted for Sadaf Hossain; No relevant relationships by Tahmina Jahir No relevant relationships by Eugene Shostak

A 51-year-old male presented with intermittent chest pain for one month and productive cough with yellow sputum for seven days. He had a history of chronic kidney disease stage G3, depression, and polysubstance abuse. His chest X-ray revealed mild hazy opacity in the right lower lobe, followed by a chest computed tomography without contrast that indicated multiple nodular opacities in the left mainstem bronchus with clear lungs. The patient underwent flexible bronchoscopy where the left mainstem bronchus was found to be completely occluded by three clear plastic bags, about 1 x 0.5 cm in size containing whitish content consistent with the appearance of crack cocaine. A high index of suspicion is crucial in patients with suspected foreign body aspiration as prompt extraction of foreign bodies may prevent complications.

Objectives The objective of this study was to analyze the differences in the prevalence and association of medical and psychiatric comorbidities in bipolar disorder (BD) patients versus the general inpatient population. Methods A cross-sectional analysis was conducted using the national inpatient sample (NIS). Using the international classification of diseases, ninth revision (ICD-9) diagnostic codes, we extracted the BD inpatients and then obtained information about comorbidities. The odds ratio (OR) of comorbidities in BD inpatients were evaluated using a logistic regression model. Results Hypertension (31.1%), asthma (11.7%) and diabetes, obesity, and hypothyroidism (11% each) were the prevalent medical comorbidities found in BD inpatients. Hypothyroidism, asthma, and migraine were seen in BD inpatients (OR 1.59, OR 1.37 and OR 1.23; respectively) compared to general inpatients. Drug abuse (33.5%), anxiety disorders (31.8%), and alcohol abuse (18.3%) were the most prevalent psychiatric comorbidities in BD inpatients. They had a seven-fold higher likelihood of comorbid borderline personality disorders compared to general inpatients. Among other psychiatric comorbidities, the odds of the association were higher for drug abuse (OR 4.33), ADHD (OR 3.06), and PTSD (2.44). Conclusion A higher burden of medical and psychiatric comorbidities is seen in BD inpatients compare to the general inpatient population. A collaborative care model is required for early diagnosis and management of these comorbidities to improve the health-related quality of life.

Background Depression and psychosis are common comorbidities that significantly affects the quality of life and disease outcomes in Parkinson's disease (PD) patients. Objective The aim of this study was to analyze and discern the differences in the hospitalization outcomes, comorbidities, and utilization of deep brain stimulation (DBS) in PD patients with comorbid depression and comorbid psychosis. Methods We used the Nationwide Inpatient Sample (2010-2014) and identified PD as a primary diagnosis (N = 62,783), and depression (N = 11,358) and psychosis (N = 2,475) as co-diagnosis using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Pearson's chi-square test and independent-sample t-test were used for categorical data and continuous data, respectively. Results White male, older age, and comorbid psychosis were significantly associated with higher odds of having major severity of illness in PD inpatients. The mean length of stay (LOS) was higher in PD patients with psychosis compared to PD with depression (7.32 days vs. 4.23 days; P < 0.001), though the mean total charges of hospitalization were lower in psychosis ($31,240 vs. $38,581; P < 0.001). Utilization of DBS was lower in PD patients with psychosis versus with depression (3.9% vs. 24.3%; P < 0.001). Conclusion Psychiatric comorbidities are prevalent in PD patients and are associated with more disease severity, impaired quality of life, and increased use of healthcare resources (higher LOS and cost). They should be considered an integral part of the disease, and a multidisciplinary approach to managing this disease is crucial to improve the health-related quality of life of PD patients.

Pimavanserin was approved for treating Parkinson’s disease (PD) psychosis, based upon 21 completed studies. This review article is to understand PD psychosis and assess the efficacy and safety of pimavanserin. A literature search was carried out using the keyword “pimavanserin” and cross-referencing it with PD, psychosis, efficacy, safety and clinical trial. Participants in pimavanserin group were associated with a 5.79-point decrease in symptoms for PD psychosis (SAPS-PD) scale compared to the 2.73-point decrease seen in the placebo group (P < .001). There were statistically significant improvements in the persecutory delusions, ideas of reference, and global ratings of delusions in pimavanserin group. Pimavanserin was well tolerated with no significant adverse events or worsening of motor function. Pimavanserin at 34 mg daily was shown to be effective for PD-induced psychosis in past clinical trials.

Physician burnout is an emerging condition that can adversely affect the performance of modern-day medicine. Its three domains are emotional exhaustion, depersonalization, and a sense of reduced accomplishment among physicians, with the Maslach Burnout Inventory (MBI) being the gold standard questionnaire used to scale physician burnout. This concern not only impacts physicians but the entire healthcare system in general. There is growing awareness regarding the mental health of physicians and the consequences faced by the healthcare system as a result of burnout. According to a recent study, more than 50% of physicians reported suffering from at least one burnout symptom. In this review article, we aim to identify the causes leading to burnout, its impact on physicians, and hospital management as well as interventions to reduce this work-related syndrome. Some contributing factors leading to burnout are poor working conditions with long work shifts, stressful on-call duties, lack of appreciation, and poor social interactions. Burnout can lead to adverse consequences, such as depression, substance use, and suicidal ideation in physicians and residents. This can result in poor patient care increasing total length of stay, re-admissions, and major medical errors. Due to increased scrutiny of patient and healthcare costs, along with increased lawsuits as a result of major medical errors, it is crucial for both the hospital management and physicians to recognize and address burnout among physicians. Comprehensive professional training such as Cognitive behavioral therapy (CBT), stress-reducing activities such as mindfulness and group activities, and strict implementation of work-hour limitations recommended by Accreditation Council for Graduate Medical Education (ACGME) for residents are a few methods that may help to manage burnout and increase productivity in hospitals.

Objective: To evaluate the impact of antepartum mental disorders (AMD) in medical and psychiatric comorbidities, and inpatient outcomes during hospitalizations for pregnancy/birth-related complications. Methods: We used the national inpatient sample (NIS) data and included 19,170,562 female patients (age, 12-40 years) with a principal diagnosis of pregnancy/birth-related complications and grouped by co-diagnoses of AMD (N = 897,397). We used a binomial logistic regression model to evaluate the odds ratio (OR) for major severity of illness and adjusted for demographic confounders. Results: The hospitalizations with AMD increased by 22.1% (p < 0.001) from 2010 to 2014. White females (66.1%) and those from low-income families (<25th percentile, 31.8%) majorly had comorbid AMD. Depression (43.8%) and drug abuse (27%) were prevalent psychiatric disorders in AMD inpatients. Comorbid AMD inpatients had a higher likelihood for major severity of illness (OR 2.475, 95% CI 2.459-2.491, p < 0.001). They also had a longer hospitalization stay with a mean difference of 0.486 days (95% CI 0.480-0.491) and higher total charges by $1889.420 per admission (95% CI 1852.670-1926.170) than non-AMD inpatients. Conclusions: AMD is associated with worsening of severity of illness in pregnancy/birth-related complications and require acute inpatient care. Mental health assessment and treatment of AMD, and education about efficacy and safety of psychiatric medications may help to improve outcomes in these patients.