Community-acquired pneumonia is a leading cause of death from infectious diseases globally. Parapneumonic effusion is one of the most common complications of community-acquired pneumonia. As the infection progresses within the pleural space, loculation and empyema may develop. In rare cases, the parapneumonic effusions can progress significantly within 24 hours, which has been described as explosive pleuritis and may confer additional morbidity. Group A Streptococcus is the leading causative microorganism, which in itself has higher rates of parapneumonic effusions. We describe the case of a 30year-old-female with a past medical history of asthma who presented to the emergency department with a sore throat, cough, and runny nose and was discharged on the same day after treatment of asthma exacerbation with upper respiratory tract infection. She re-presented within 24 hours with shortness of breath and right-sided pleuritic chest pain. Chest x-ray showed a new, large right-sided pleural effusion for which pleural fluid culture grew group A Streptococcus. She ultimately had prolonged hospitalization, requiring chest tube placement, and video-assisted thoracoscopic surgery (VATS). VATS was unsuccessful and she was treated with long-term antibiotics. This case demonstrates the dramatic evolution of explosive pleuritis and highlights the typical challenges encountered in these cases.

Introduction Diabetic ketoacidosis (DKA) is an emergency associated with a high mortality rate. 25% of DKA readmissions in the U. S. A are preventable and they lead to an increase in the mortality rate and the length of the hospital stay with each new admission. In our study, we set out to decrease the DKA readmission rate at our hospital which is a community teaching hospital by assessing the predictors of readmission in adults with type 1 diabetics hospitalized for DKA. Methods The study was an interventional study conducted between February 2021 and May 2021. All the type 1 diabetics who were on insulin and had DKA admissions in the past three months were included in the study. After a literature review of the risk factors of DKA readmission, a questionnaire was designed to gather information from the patients. The ABCD (A: age; B: behavioral health; C: coverage; D: drug/alcohol abuse) score was used for DKA readmission risk assessment on admission. The insulin delivery technique of the patients was assessed and proper training on the technique was given before discharge. All the DKA admissions received mandatory endocrinology consult and the note template of the endocrinology consult note in the electronic medical record system was modified to let the primary team know about the discharge instructions, medications, and follow-up appointments in detail. Patients were followed up with a telehealth visit in a week and physical endocrinology clinic follow-up 3 weeks after discharge. Results Our study included 69 patients admitted with a diagnosis of DKA. The average HbA1C in the study was 11.8. Predictors of readmission were female sex (Hazard Ratio [HR]: 1.74, 95% CI: 1.64 - 1.80, p<0. 001), hypertension (HR: 1.98, 95% CI: 1.80 - 1.95, p<0. 001), discharge against medical advice (HR: 1.74, 95% CI: 1.53 - 1.96, p<0. 001). The readmission rate at the hospital was 20.8% initially and dropped to 13.7% after the interventions. 78% of the population were administering insulin the wrong way. The 'ABCD' score of the patients had a statistically significant correlation with the readmission rate. A difference in difference study model was used to assess the significance of the interventions on the readmission rate. Linear regression was run with significant R square, F- test values. Conclusions The study revealed that the major risk factors for readmission were lower socioeconomic status, co-morbidities, poor health literacy, and drug abuse. The study highlighted the importance of inpatient education, specialty care, better discharge instructions, coordination of care, and post-discharge support to reduce the DKA readmission rate. Presentation: No date and time listed

Introduction Pheochromocytomas (PCCs) are rare neuroendocrine tumors that secrete catecholamines. They may be associated with familial syndromes such as Multiple Endocrine Neoplasia type 2 (MEN 2), von Hippel-Lindau disease (VHL), and Neurofibromatosis type 1 (NF 1). PCCs are a common cause of malignant hypertension in pregnancy and can lead to adverse maternal and fetal outcomes if left undiagnosed or untreated. Case Description A 39-year-old Latin American primigravid woman at 8 weeks 4 days gestation was referred to the endocrinology clinic for labile blood pressure (160/90 mmHg at recent ER visit) and a lab finding of elevated catecholamines (plasma norepinephrine 4720 pg/ml; normal 0-874 pg/ml). She reported chronic headaches and 2-lb unintentional weight loss during pregnancy. Past medical history was significant for right adrenal PCC diagnosed at age 13 (currently status post adrenalectomy), and a cerebrovascular accident at age 29. Family history was relevant for PCC in the patient's sister and mother. The patient's home medications were nifedipine 30 mg daily and prenatal vitamins. On physical exam, her blood pressure was 126/76 mm Hg, heart rate was 67/min and a scar of previous right adrenalectomy was noted. Doxazosin 1 mg daily was added to her regimen and nifedipine was discontinued. The patient was initially planned for an elective cesarean section at term. However, at 10 weeks 5 days of gestation, she had a missed abortion. Further genetic testing of syndromic PCC revealed a heterozygous mutation in the VHL gene. Abdominal MRI showed a left adrenal mass (3.6×2.6×3.6 cm3) and retroperitoneal lymphadenopathy. The patient underwent left adrenalectomy and is currently hemodynamically stable on maintenance hydrocortisone and fludrocortisone. Discussion We report a case of PCC complicating pregnancy in a 39-year-old primigravida who had a family history of PCC. In females of reproductive age with a known PCC diagnosis, we suggest early genetic testing as it can further advise family planning, antepartum monitoring, and management. Medically, these patients can be managed with α-adrenergic blockers and calcium-channel blockers, followed by β-blockers. This can improve maternal and fetal outcomes primarily by minimizing paroxysmal elevations in catecholamines. Definitive treatment of PCC is surgical excision, usually performed during the second trimester or postpartum. Management of patients with VHL requires lifelong clinical, laboratory, and imaging surveillance for other manifestations of the disease. References Bancos, Irina et al. Maternal and fetal outcomes in phaeochromocytoma and pregnancy: a multicentre retrospective cohort study and systematic review of literature. Lancet Diabetes Endocrinol 2021; 9: 13–21 Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Introduction Hyperosmolar crisis, which includes diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), is a severe and acute complication of diabetes. The estimated mortality rates of DKA and HHS are 6.8% and 10%, respectively (Benoit, Zhang, Geiss, Gregg, & Albright, 2018) (Pasquel & Umpierrez, 2014). There is limited evidence regarding the clinical characteristics, hospital complications, and mortality rate of patients with combined DKA and HHS. Therefore, we aim to compare hospital outcomes between patients with DKA, HHS, and combined DKA and HHS in a community hospital in Brooklyn, NY. Methodology We performed a retrospective analysis from the patients admitted for DKA and/or HHS at Health+Hospitals / Woodhull from 2019 to 2021. Descriptive statistics were used to determine the frequency of patients in each hyperglycemic group and their clinical characteristics. Using one-way ANOVA and Chi-square test, we compared the demographics and clinical outcomes between subgroups. Multivariate regression analysis and log-rank test were used to assess the influence of multiple variables on hospital mortality and the difference in survival between groups, respectively. Results We studied 263 patients admitted for a hyperglycemic crisis, DKA (58%), HHS (14%), and DKA+HHS (28%). Baseline characteristics of the population include male (60%), African American (42%), Hispanic (32%), and mean BMI of 28±8 kg/m2. No difference was found in mean admission HbA1c (DKA 12±2.6%, HHS 12.7±3%, DKA+HHS 12.7±2.5%, p: 0.08). Patients with HHS were older (mean age 56±15) compared with DKA (47±17) and DKA+HHS (49±18). Patients with DKA+HHS had higher mean admission blood sugar (893±330 mg/dL), compared with DKA (497±206 mg/dL) and HHS (808±346 mg/dL) (p <0.001). There was no difference in the frequency of hypokalemia, K+ <3.5 mEq/L (DKA 26.9%, HHS 6.3%, DKA+HHS 12.6%, p: 0.8); hypoglycemia (DKA 12%, HHS 4.6%, DKA+HHS 7%, p: 0.2); or cerebral edema (DKA 0.8%, HHS 0.4%, DKA+HHS 1.5%, p: 0.1) between the groups. However, the frequency of acute kidney injury (AKI) was higher in DKA (24.7%) than in HHS (7%) or DKA+HHS (16.7%) (p: 0.034). There was no difference in the mean days of hospital stay (DKA 8.5±28, HHS 7±8, DKA+HHS 8±10, p: 0.9) and in-hospital mortality (DKA 3.4%, HHS 3.5%, DKA+HHS 4%, p: 0.069) among the groups. In all subtypes of hyperglycemic crisis, the mortality rate was significantly higher with older age, presence of AKI, cerebral edema, and vasopressor requirement. Conclusions There was no significant difference in mortality, length of admission, prevalence of hypoglycemia, hypokalemia, and cerebral edema between the three groups. The prevalence of AKI was significantly higher in DKA compared with HHS and DKA+HHS. Older age, presence of AKI, cerebral edema, and vasopressor requirement were mortality predictors among hyperglycemic crisis. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.