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Background Histoplasma is a common endemic mycosis in multiple Midwestern states. Most of the data defining epidemiologic risk are from 20th century outbreak investigations. A known exacerbating factor is immune suppression; but use of biologics, immunosuppressants (ISP), and chemotherapy has advanced since these investigations were conducted. This study sought to use clinical data from a tertiary care facility to address these gaps to define the evolving epidemiology of histoplasmosis in Ohio. Methods In a single-center retrospective cohort study, we identified adult patients with a histoplasmosis-specific diagnosis, a positive diagnostic test, and an itraconazole/amphotericin B prescription between 1/1/2012 and 10/1/2021. Prisoners were excluded. A random sample of 100 patients underwent in-depth chart review. Comorbidities, environmental risk factors, and ISP use data were collected. Cases were classified by the CDC 2017 Histoplasmosis case definition. “Confirmed” cases had culture growth, a confirmatory lab result, or histopathology plus signs and symptoms of disease, and “probable” cases had a non-confirmatory lab result plus signs and symptoms. Associations between variables were assessed using Fisher’s exact test, p < 0.05. Results Of 100 patients, 56 had confirmed and 22 had probable histoplasmosis (Table 1). Three had confirmed blastomycosis, 15 met definitions for both histoplasmosis and blastomycosis, and 4 met neither definition. These were excluded from analysis. No environmental exposure history was documented for 23 of 78 (29.4%) patients. Of those with documented history, 15 (27.1%) had recent renovation or construction exposure; 14 (25.4%) to soil, gardening, or outdoors; 12 (21.8%) to birds, bats, and farm animals; and 25 (45.4%) had no known exposure. There were 51 (65.4%) exposed to at least one dose of ISP in the year prior to diagnosis, including 41 (52.5%) to corticosteroids. Table 1Characteristics of patient cohort Conclusion In this cohort, more patients with confirmed or probable histoplasmosis were exposed to ISP than had a documented traditional environmental risk factor. This study shows reliance on traditional environmental exposure history might not accurately gauge risk. Further work is needed using ISP exposure to drive appropriate diagnostic testing. Disclosures All Authors: No reported disclosures.

Introduction: Adjunctive ultrasonography for peripheral nerve blocks is the fastest growing area of regional anesthesia.1,2 Increasingly, anesthesiologists are describing new blocks or rediscovering old ones using echoguidance. This newly found enthusiasm, while commendable, can be a double-edge sword: if left unchecked, it will stray from evidence and science. Thus, in this single blind, randomized trial, we set out to formally compare three commonly used methods for brachial plexus anesthesia: ultrasound-guided supraclavicular (SCB), infraclavicular (ICB) and axillary (AXB) blocks Methods: With the approval of our institutional Ethics Board, ninety patients undergoing upper extremity surgery distal to the middle third of the humerus will be randomly allocated to receive an ultrasound-guided SCB, ICB or AXB. A total of 35 ml of lidocaine 1.5% with epinephrine 5μg/ml will be used in each group. The primary outcome will be the performance time (defined as the sum of the imaging and needling times). The success rate (rate of surgical anesthesia), number of needle passes, procedural discomfort, onset of sensory blockade for the four main nerves of the brachial plexus (muscolocutaneus, median, radial and ulnar nerves) and total anesthesia-related time (sum of performance and sensory onset times) will also be assessed by a blinded observer. Side effects will be recorded as well. Results: Forty seven patients have been recruited so far (Table 1). No difference in the rate of surgical anesthesia (94-100%) was found. SCB and ICB were associated with similar performance times (301.61-320.54 sec), sensory onset times (22.5-23.08 min), total anesthesia-related times (28.42-27.21 min) and number of needle passes (2.00). Compared to SCB and ICB, AXB required a longer performance time (515 vs 301.61-320.54 sec; p <0.005). However, no differences in onset and anesthesia-related times were found. Procedural discomfort was low and similar in all three groups. SCB was associated with a higher incidence of side effects. Discussion: Ultrasound-guided SCB, ICB and AXB constitute reliable methods for brachial plexus anesthesia. AXB requires a longer performance time than SCB and ICB; however sensory onset and anesthesia-related time are similar. SCB may be associated with a higher incidence of side effects.