Varices are a common cause of gastrointestinal (GI) bleed. When ectopic, there is often a delay in diagnosis as it is difficult to localize these varices. Ectopic small bowel varices usually arise from portal hypertension, which commonly develops in the setting of cirrhosis. This case presents a much rarer cause of bleeding ectopic varices with portal hypertension secondary to chronic superior mesenteric vein (SMV) thrombosis that developed after an episode of hemorrhagic pancreatitis. An 81‐year‐old man with a past medical history of a recent GI bleeds secondary to an arteriovenous malformation presented to the hospital with continued melena after a recent admission at another hospital for the same symptom. Upper endoscopy and colonoscopy showed no evidence of active bleeding. Subsequently computed tomography angiography (CTA) showed bleeding from collaterals in the third part of the duodenum, consistent with ectopic varices. The CTA also showed SMV thrombosis. The patient underwent an ultrasound‐guided transhepatic venogram with coiling and sclerosant embolization of SMV varices and distal SMV balloon angioplasty. Capsule endoscopy after showed no evidence of further bleeding. The patient was discharged 72 h after the intervention with stabilized hemoglobin and resolved melena. Ectopic varices should be on the differential diagnosis for patients presenting with a GI bleed that remains nonlocalized after endoscopy and colonoscopy. EGD or colonoscopy is the first‐line intervention for the treatment of bleeding ectopic varices. If unreachable by these means, percutaneous coil embolization is an alternative way to stabilize the patient. As no general management guidelines exist, treatment of bleeding ectopic varices should continue to be case‐dependent and involve a multidisciplinary team.

Background The importance of effective leadership for improving patient care and physician well-being is gaining increased attention in medicine. Despite this, few residency programs have formalized education on leadership in medicine. The most effective ways to train graduate medical education (GME) trainees in leadership are unclear. Methods Our large internal medicine residency program implemented a book club to develop leadership skills in residency. Through independent reading of the selected book and resident-led small group discussions, we facilitated dialogue on the challenges of leading effectively. Results A survey-based curricular evaluation demonstrated that 61% of respondents felt that the book club influenced their thoughts about leadership and that 66% of participants would recommend the book club to other residency programs. Lack of time was the main barrier to participation while addition of complementary media or alternative book formats were identified as possible solutions to increase engagement. Conclusions Leadership book clubs are a practical and effective way to teach leadership during residency. More research is needed to identify the best formats for book club discussion and to develop additional tools to foster future physician leaders.

Utilization of a smart phone application paired with a time-spaced learning curriculum was investigated to determine its impact on antimicrobial stewardship practice among internal medicine trainees. Stewardship behaviors increased, barriers decreased, and trainees had increased confidence in managing common infectious disease syndromes after the intervention.

Background Use of an application (App) to shape antimicrobial stewardship (AS) practice is largely unknown. Walter Reed National Military Medical Center (WRNNMC) is a tertiary military academic medical center where 2020 AS guidelines transitioned to a mobile App platform. This project aimed to determine barriers to AS and the impact of an App combined with educational sessions (ES) on Internal Medicine (IM) trainee prescribing practices for common Infectious Diseases (ID) syndromes. Methods After an orientation, participants completed a pre-intervention survey. Once weekly ES reinforcing App content was implemented over 12 weeks after which a post-intervention survey was completed. Each weekly session covered a specific ID syndrome. Survey data was analyzed using SPSS Version 27 with paired t-test. Results Amongst 81 IM trainees, 59 (73%) completed both pre- and post-intervention surveys, of whom 39% were PGY1, 31% PGY2, and 27% PGY3. Common AS barriers included lack of knowledge, deference to seniority, established habits, and time needed to make an informed decision. The App and ES improved performance of an antimicrobial timeout (78%), IV to PO switch (61%), therapy de-escalation (56%), and antibiogram knowledge (68%) with 90% of trainees reporting increased access. Weekly ES led to 75% reporting it had at least a moderate impact on learning. Across all ID syndromes, each PGY year reported increased confidence in management post-intervention (P< 0.001) but PGY1s in particular saw the largest gain in confidence with antibiogram, febrile neutropenia, and hospital/ventilator acquired pneumonia categories. Usage of the App increased from 42% to 90% after the intervention, and 95% modified their prescribing practice based on the App. The most common barrier to App usage was forgetting to use the App. Conclusion Utilization of an App combined with ES improved multiple domains of AS practice among IM trainees leading to a modification in antimicrobial prescribing practice in the vast majority of participants. PGY1 trainees in particular may see a large benefit which supports implementation of AS training early in the academic year. This model can be used to build a sustainable AS trainee curriculum augmenting the learning and management of common ID syndromes. Disclosures All Authors: No reported disclosures

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