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Fluid overload is a common complication in patients with cirrhosis. B-type natriuretic peptide (BNP) is a marker of increased blood volume, commonly used in heart failure, that has been shown to be elevated in patients with liver disease. This study examined if BNP levels can be used to determine prognosis and predict worsening of ascites in patients with cirrhosis without concomitant heart disease. A retrospective study was performed at a large urban hospital in Chicago, Illinois and included 430 patients with cirrhosis who had BNP levels ordered during their hospital stay. Patients with clinical heart failure, arrhythmias or pulmonary hypertension were excluded. The primary outcome was 90-day mortality and the secondary outcome was a requirement for therapeutic paracentesis in the 90 days following BNP results. 53 patients (12%) had BNP levels ≥ 300 pg/mL. They had significantly increased serum levels of creatinine, bilirubin, and International Normalized Ratio (INR) when compared to those with BNP p = 0.037) and were more likely to require therapeutic paracentesis (HR 2.26; p = 0.02) in the next 90 days. A BNP ≥ 300 pg/mL had specificity of 88.2% in predicting 90-day mortality. BNP may serve as a practical and reliable marker of underlying disease severity in patients with cirrhosis, with potential to be included in prognostication tools for assessment of end-stage liver disease.

Primary sternal osteomyelitis (PSO) is a rare clinical entity, and usually, it is associated with predisposing factors such as intravenous drug use, diabetes mellitus, or human deficiency virus infection. In an otherwise healthy adult, it becomes an even rarer entity. Early diagnosis and treatment minimize associated morbidity, like the need for surgical debridement, longer courses of medication, and length of in-hospital stay. We describe the case of a 54-year-old man without any predisposing risk factors for PSO, who presented with chest pain, erythema, tenderness, and warmth at the right parasternal region. A non-enhanced thoracic tomography showed a 33 mm suspicious pulmonary nodule and no signs of sternum abnormalities. To better evaluate this finding, a positron emission tomography with fluorine-18 fluorodeoxyglucose was performed, showing abnormal uptake of the radionuclide at the sternomanubrial synchondrosis and no abnormal uptake at the lung parenchyma. The presence of Staphylococcus aureus in blood cultures, in conjunction with these results, supported the diagnosis of PSO. The patient completed six weeks of microbiologically oriented antibacterial therapy with complete recovery.

The causes and management of pyogenic liver abscess (PLA) have undergone multiple changes over the past decades. It is a relatively rare disease in the USA, and its incidence rate in the USA is increasing. The last US community hospital experience of PLA was published in 2005. We performed a retrospective study of patients admitted with PLA to an urban safety net hospital. To ascertain risk factors, management approaches, and outcomes of PLA. Electronic medical record was queried for diagnosis codes related to PLA during the years 2009–2018. Clinical information was compiled in an electronic database which was later analyzed. Main study outcomes were in-hospital mortality, 30-day readmission rate, and intensive care utilization rate. A total of 77 patients with PLA were admitted in the study period. Most common risk factors were diabetes mellitus (23.4%), previous liver surgery (20.7%), and hepatic malignancy (16.9%). 89% of patients were treated with percutaneous drainage or aspiration, and surgical drainage was reserved for other with other indications for laparotomy. In-hospital mortality, 30-day readmission, and intensive care utilization rates were 2.6%, 7% and 22%, respectively. Median length of stay was 11 days (inter-quartile range 7). Rate of antimicrobial resistance in abscess fluid cultures was 40%; 13 cases of Klebsiella pneumoniae liver abscess were noted in our cohort, most of whom were Hispanic or Asian. PLA was principally managed by percutaneous drainage or aspiration with good outcomes. Further studies investigating the racial predilection of K. pneumoniae liver abscesses could reveal clues to its pathogenesis.

Skin metastasis is an infrequent manifestation in oncology, with reported incidence of about 1.3% in cervical cancer. When present, it usually signals advanced disease with very limited, mostly palliative treatment options. Here we present a patient who was diagnosed with cervical cancer at an early stage and later recurred twice with skin lesions of different morphologies., Highlights • Biopsy should be considered for skin lesions in patients with cervical cancer • Skin metastasis may be the presenting symptom in cervical cancer recurrence • No specific morphology is pathognomonic of cutaneous spread of cervical cancer

The risk of infectious and noninfectious complications associated with long peripheral catheters (LPCs) is unknown. In this retrospective study of 539 catheters, we found LPCs were often placed for the indications of difficult access and long-term antibiotics. Rates of deep vein thrombosis (1.7%) and catheter-related infection (0.6%) were low. LPCs may represent a novel and safe option for short-term venous access.

Uterine carcinosarcoma occurs almost exclusively in post-menopausal women and often carries high rates of disease recurrence and mortality. Central nervous system involvement is extremely rare with less than 10 reported cases in the literature. Here we present a young pre-menopausal patient with metastatic malignant mixed Mullerian tumor who developed cerebral metastasis while on systemic chemotherapy.

Transthyretin cardiac amyloidosis (ATTR) is traditionally associated with HFpEF, but has been reported among those with HFrEF. This has substantial clinical implications, as typical medical therapy for HFrEF can be detrimental among those with ATTR. We sought to determine the prevalence of HFrEF in

7 Background: Palliative care (PC) is heavily centered on patients with advanced and often incurable malignancies. Despite having a comparable symptomatic burden and worse mortality rates than some types of cancer, heart failure (HF) patients have decreased rate of palliative service referral of approximately 7%, as opposed to 48% in those with malignancies. We aim to understand the differences in the attitudes of physicians when addressing the PC needs for patients with advanced HF and malignancies. Methods: All the internal medicine residents at our institute were asked to fill out a structured paper-based questionnaire. The survey tool consisted of both Likert-type scales and open-ended questions focused on their attitude and perceptions while managing patients with advanced HF and Stage IV malignancy. Descriptive statistics and intergroup comparisons were then made for all quantifiable variables (Table). Results: Of the 137 medicine residents, 120 (87.6%) completed the survey. 70% were males and 96.6% residents were in the age group of 25-34 years. 62.5% residents had done a PC rotation prior to answering the survey and they were more comfortable in initiating goals of care (GOC) discussion for these patients. More residents were comfortable communicating the prognosis of patients with HF as compared to cancer patients irrespective of the level of training. Of the 26 residents interested in pursuing cardiology as a subspecialty, only 5 (19.2%) thought that the 5-year mortality of advanced HF ≥50%. Conclusions: Physicians often underestimate the symptom burden and mortality of HF patients and are less likely to consult PC for them. Early integration of PC in the management of HF patients is recommended and physicians need to be educated on these guidelines. [Table: see text]

e18046 Background: Patients with malignancy often require a safe and reliable intravascular access for disease management along the spectrum of diagnosis to end-of-life care. Despite a growing interest on the use of midlines, there is a scarcity of data on their safety in cancer patients. Data from observational studies suggest a lower rate of thrombotic and infectious complications when compared to peripherally-inserted central catheters (PICCs). However, there are no formal recommendations tailored to oncologic patients on when to prefer one type of vascular access versus another. Methods: We retrospectively gathered data from all midline catheters inserted in patients with active cancer at our institution from January 2016 to June 2017, totaling 159 procedures. Our primary analysis sought to determine the incidence of venous thromboembolism (VTE), CRBSI and bleeding. Results: Out of a total of 159 procedures performed in patients with solid tumor and hematologic malignancies, chemotherapy infusion was the indication in 17 (10.69%), with difficult intravenous access being the indication in 97 patients (61%) and prolonged antibiotic therapy in 44 patients (27.6%). Only one patient got a midline for peripheral parenteral nutrition. The mean dwell time of midline catheters was 9.4 days. A total of 5 patients (3.14%) developed catheter-associated thromboembolic episodes. All of them had metastatic solid tumors. No events were reported in patients with hematologic malignancies. Of note, 2 of these 5 patients had a prior history of VTE. The number of days from device insertion to VTE ranged from 2-14 days, with an average of 9.5 days. Catheter-related infection occurred in 1 patient (0.62% or 0.66 per 1000 catheter-days). No bleeding complications were reported. Conclusions: Midline catheters appear to be a safe and cost-effective alternative for secure vascular access, especially in patients with non-metastatic solid tumors and hematologic malignancies. Caution and close monitoring for occurrence of VTE are advised for those with high metastatic burden and prior history of VTE. The rate of infectious complications are low, which is in concordance with previous literature.

e13124 Background: Head and Neck Cancer (HNC) is a common non-AIDS defining malignancy and its risk increases by 1.7 to 4-fold with HIV infection. Little is known about the epidemiology and outcomes in this subset of patients. This study was undertaken to evaluate the characteristics of HIV+ HNC in an inner city minority population. Methods: All patients with a diagnosis of HNC from January 2008 to December 2017 were identified from the Tumor Registry Database of Cook County Health. We screened patients for HIV+ status at the time of HNC diagnosis. Retrospective chart review of those with Squamous cell carcinoma (SCC) was performed and compared to the largest reported HIV+ HNC cohort (SPORE consortium – J Acquir Immune Defic Syndr. 2015; 65(5):603-10). Other histologies were not included. Results: A total of 1379 charts were screened and 38 unique HIV+ patients with SCC were identified. The most common tumor sites were oral cavity (34%), larynx (26%) and oropharynx (26%), similar to SPORE. However, our cohort had a higher number of African Americans (AA) and a greater proportion of female patients. The median age of diagnosis was 52 years, which is similar in both studies but much lower than the non-HIV population (SEER database - median age 65). Over 63% had an undetectable viral load (VL) compared to 1.4% in SPORE, but the median CD4 count did not differ (298 vs 300 cells/µL). Survival information was available for 27 patients, with a median of 21 months (mo) versus 49 mo in SPORE. Overall survival (OS) was higher in non-smokers (34.5 mo vs 21 mo) and those with CD4>500 when compared to CD4

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzyme defect described in humans. Hemolysis in affected patients is usually triggered by circumstances involving free radical damage. While acute HIV infection is known to be a state of overwhelming oxidative stress, virus-induced hemolytic events in G6PD-deficient patients has rarely been reported. Despite an estimated overall prevalence of 6.8%–13% of this disorder in the HIV population, clinically significant hemolysis has been largely attributed to the use of offending medications rather than HIV infection itself. Here, we present a patient whose first episode of G6PD deficiency-associated hemolysis occurred as the main presentation of acute HIV infection.