213 Background: Human papillomavirus (HPV) is the most commonly spread sexually transmitted infection and is implicated in the oncogenesis of several cancers, including cervical, anal,vaginal and oropharyngeal cancers. HPV vaccinations have a high efficacy, and recent data demonstrated adults aged 18-26 years old are not adequately fully vaccinated. Our objective was to assess the current practice regarding HPV vaccination among persons 9-45 years of age, knowledge about the HPV guidelines, and recommendation practice. Methods: A retrospective review was conducted of Internal Medicine residents acting as primary care physicians at an urban clinic based in Hartford, Connecticut, USA. The survey was administered to internal medicine residents and attending physicians to assess the current practice regarding the HPV vaccination for adults and knowledge of the updated guidelines. The key drivers identified were resident knowledge, communication, insurance coverage, and availability of HPV vaccination in the clinic. An educational handout and lecture was provided with a follow-up survey. Results: A total of 347 charts were reviewed. Of those eligible to receive the HPV vaccine, it was found that only 5.2% received the total dosage. The response rate to our initial survey was 60%. 47.83% did not inquire about the HPV vaccination or recommended it to patients compared to 71.43% of attending physicians (AP) who inquired, but only 28.47% discussed it during precepting sessions. 27.7% of the residents and 71.43% AP correctly identified the updated guidelines. The biggest three barriers were unfamiliarity with the availability of HPV vaccination, insurance coverage, and current guidelines. A short educational review and summary were provided to close the gaps identified with the questionnaire.100% of residents correctly identified the updated guidelines, risks, benefits, importance of shared decision-making, and more likely recommend the HPV vaccination. However, 69.2% were unaware that HPV vaccination does not prevent the progression of HPV-related cancers. Conclusions: Adherence to CDC guidelines regarding vaccinating against HPV amongst resident physicians is poor. The percentage of patients, who received the complete Gardasil-9 vaccination series, was significantly below the national average. Our study highlights a large practice gap that exists amongst resident physicians regarding the HPV vaccine. There was minimal documentation amongst resident physicians regarding shared decision-making conversations with patients. We addressed the knowledge and resource deficit with an educational handout and information session. Our intervention demonstrated improved confidence in discussing the vaccine with the patients and resolved the concern of insurance coverage and availability of vaccines in the clinic and pharmacy.

A 57-year-old woman with a history of mantle cell lymphoma presented to the ED with complaints of vomiting, bleeding per rectum, and leg cramps, that started 6 h prior to her arrival. She had received chemotherapy a week prior. Her leg cramps were not associated with pain or swelling of the legs; she also denied any trauma to the legs. She did complain of mild lower abdominal pain at presentation. Review of systems was negative for fever, chills, diarrhea, chest pain, and dizziness. She denied using alcohol or nonsteroidal anti-inflammatory drugs. The patient was tachycardic with a systolic BP (SBP) of 85 mm Hg and was administered 1-L normal saline, with improvement in her SBP to 90 mm Hg. The hematocrit level was 24%, the WBC count was 0.3 Â 10 9 /L, and the platelet count was 6 Â 10 9 /L in the ED. On arrival in the ICU, she was noted to have an SBP of 70 mm Hg. Resuscitation with IV fluids was initiated, followed by transfusion of packed RBCs and platelets, based on the blood counts. Despite aggressive fluid resuscitation and improvement in her hemoglobin, the patient remained persistently hypotensive. The diagnosis of underlying septic shock because of neutropenia was considered; the patient was started on vasopressors and empirical broad-spectrum antibiotics, with improvement in her BP. After this, the patient was sent to radiology for a CT scan of the abdomen and pelvis with contrast to evaluate for mesenteric infarction, enteric or colonic bleeding, and the need for arterial embolization.