Protocol for the Evaluation of Data-Related Processes and Challenges at Level 1-4 Trauma Centers in Arkansas: A Mixed-Methods Case Study.

Background: In the following manuscript, we describe the detailed protocol for a mixed-methods, observational case study conducted to identify and evaluate existing data-related processes and challenges currently faced by trauma centers in a rural state. The data will be utilized to assess the impact of these challenges on registry data collection. Methods: The study relies on a series of interviews and observations to collect data from trauma registry staff at level 1-4 trauma centers across the state of Arkansas. A think-aloud protocol will be used to facilitate observations to gather keystroke-level modeling data and insight into site processes and workflows for collecting and submitting data to the Arkansas Trauma Registry. Informal, semi-structured interviews will follow the observation period to assess the participant's perspective on current processes, potential barriers to data collection or submission to the registry, and recommendations for improvement. Each session will be recorded, and de-identified transcripts and session notes will be used for analysis. Keystroke level modeling data derived from observations will be extracted and analyzed quantitatively to determine time spent performing end-to-end registry-related activities. Qualitative data from interviews will be reviewed and coded by 2 independent reviewers following a thematic analysis methodology. Each set of codes will then be adjudicated by the reviewers using a consensus-driven approach to extrapolate the final set of themes. Discussion: We will utilize a mixed methods approach to understand existing processes and barriers to data collection for the Arkansas Trauma Registry. Anticipated results will provide a baseline measure of the data collection and submission processes at various trauma centers across the state. We aim to assess strengths and limitations of existing processes and identify existing barriers to interoperability. These results will provide first-hand knowledge on existing practices for the trauma registry use case and will provide quantifiable data that can be utilized in future research to measure outcomes of future process improvement efforts. The potential implications of this study can form the basis for identifying potential solutions for streamlining data collection, exchange, and utilization of trauma registry data for clinical practice, public health, and clinical and translational research.

A Rare Case of Cutaneous Leishmaniasis Presenting to the Emergency Department of a Large Community Hospital.

Cutaneous leishmaniasis should be considered a possible cause of skin ulcers in a patient who has traveled abroad recently and comes to the emergency department (ED) for an assessment. Before getting an accurate diagnosis, ED assessment, and proper treatment with intravenous amphotericin B, the patient presented to several other healthcare providers. This case displays the importance of a multidisciplinary approach with consultation from infectious diseases to determine an accurate diagnosis and effective treatment plan for patients with cutaneous leishmaniasis.

Measuring the Coverage of the HL7® FHIR® Standard in Supporting Data Acquisition for 3 Public Health Registries.

With the increasing need for timely submission of data to state and national public health registries, current manual approaches to data acquisition and submission are insufficient. In clinical practice, federal regulations are now mandating the use of data messaging standards, i.e., the Health Level Seven (HL7®) Fast Healthcare Interoperability Resources (FHIR®) standard, to facilitate the electronic exchange of clinical (patient) data. In both research and public health practice, we can also leverage FHIR® ‒ and the infrastructure already in place for supporting exchange of clinical practice data ‒ to enable seamless exchange between the electronic medical record and public health registries. That said, in order to understand the current utility of FHIR® for supporting the public health use case, we must first measure the extent to which the standard resources map to the required registry data elements. Thus, using a systematic mapping approach, we evaluated the level of completeness of the FHIR® standard to support data collection for three public health registries (Trauma, Stroke, and National Surgical Quality Improvement Program). On average, approximately 80% of data elements were available in FHIR® (71%, 77%, and 92%, respectively; inter-annotator agreement rates: 82%, 78%, and 72%, respectively). This tells us that there is the potential for significant automation to support EHR-to-Registry data exchange, which will reduce the amount of manual, error-prone processes and ensure higher data quality. Further, identification of the remaining 20% of data elements that are "not mapped" will enable us to improve the standard and develop profiles that will better fit the registry data model.

Transition of Resuscitative Endovascular Balloon Occlusion of the Aorta from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued Hemorrhage.

INTRODUCTION: Noncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse. MATERIALS AND METHODS: Yorkshire male swine (70-90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a "hospital phase" was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups. RESULTS: No significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1-treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group. CONCLUSIONS: In this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia-reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.

Protocol for the Evaluation of Data-Related Processes and Challenges at Level 1-4 Trauma Centers in Arkansas: A Mixed-Methods Case Study.

Background: In the following manuscript, we describe the detailed protocol for a mixed-methods, observational case study conducted to identify and evaluate existing data-related processes and challenges currently faced by trauma centers in a rural state. The data will be utilized to assess the impact of these challenges on registry data collection. Methods: The study relies on a series of interviews and observations to collect data from trauma registry staff at level 1-4 trauma centers across the state of Arkansas. A think-aloud protocol will be used to facilitate observations as a means to gather keystroke-level modeling data and insight into site processes and workflows for collecting and submitting data to the Arkansas Trauma Registry. Informal, semi-structured interviews will follow the observation period to assess the participant's perspective on current processes, potential barriers to data collection or submission to the registry, and recommendations for improvement. Each session will be recorded and de-identified transcripts and session notes will be used for analysis. Keystroke level modeling data derived from observations will be extracted and analyzed quantitatively to determine time spent performing end-to-end registry-related activities. Qualitative data from interviews will be reviewed and coded by 2 independent reviewers following a thematic analysis methodology. Each set of codes will then be adjudicated by the reviewers using a consensus-driven approach to extrapolate the final set of themes. Discussion: We will utilize a mixed methods approach to understand existing processes and barriers to data collection for the Arkansas Trauma Registry. Anticipated results will provide a baseline measure of the data collection and submission processes at various trauma centers across the state. We aim to assess strengths and limitations of existing processes and identify existing barriers to interoperability. These results will provide first-hand knowledge on existing practices for the trauma registry use case and will provide quantifiable data that can be utilized in future research to measure outcomes of future process improvement efforts. The potential implications of this study can form the basis for identifying potential solutions for streamlining data collection, exchange, and utilization of trauma registry data for clinical practice, public health, and clinical and translational research.

Prophylaxis for the Unexpected: An Unusual Case of Herpes B Coverage for an Orangutan Bite in an Emergency Department Patient.

Patients presenting to the emergency department (ED) with an orangutan bite require a series of prophylactic treatments. We present a unique case of an orangutan bite in a 29-year-old male ED patient who was brought by Emergency Medical Services (EMS) for evaluation of an orangutan bite to the right upper extremity with a suspected fourth proximal phalanx fracture. He was referred to hand surgery for a washout and open reduction. Upon discharge, prophylactic medical treatments for unusual pathologies such as herpes B were considered. Appropriate evaluation and treatment of this unique ED condition is necessary to prevent additional patient morbidity.

COVID-19 Vaccine Hesitancy Among Parents: A Qualitative Study.

OBJECTIVES: Addressing parental/caregivers' coronavirus disease 2019 (COVID-19) vaccine hesitancy is critical to improving vaccine uptake in children. Common concerns have been previously reported through online surveys, but qualitative data from KII and focus groups may add much-needed context. Our objective was to examine factors impacting pediatric COVID-19 vaccine decision-making in Black, Spanish-speaking, and rural white parents/caregivers to inform the content design of a mobile application to improve pediatric COVID-19 vaccine uptake. METHODS: Parents/caregivers of children aged 2 to 17 years from groups disproportionately affected by COVID-19-related vaccine hesitancy (rural-dwelling persons of any race/ethnicity, urban Black persons, and Spanish-speaking persons) were included on the basis of their self-reported vaccine hesitancy and stratified by race/ethnicity. Those expressing vaccine acceptance or refusal participated in KII, and those expressing hesitancy in focus groups. Deidentified transcripts underwent discourse analysis and thematic analysis, both individually and as a collection. Themes were revised until coders reached consensus. RESULTS: Overall, 36 participants completed the study: 4 vaccine acceptors and 4 refusers via KIIs, and the remaining 28 participated in focus groups. Participants from all focus groups expressed that they would listen to their doctor for information about COVID-19 vaccines. Infertility was a common concern, along with general concerns about vaccines. Vaccine decision-making was informed by the amount of information available to parents/caregivers, including scientific research; possible positive and negative long-term effects; and potential impacts of vaccination on preexisting medical conditions. CONCLUSIONS: Parents/caregivers report numerous addressable vaccine concerns. Our results will inform specific, targeted interventions for improving COVID-19 vaccine confidence.

An Emergency Department Patient With Pharyngitis and Final Diagnosis of Rare T-cell Acute Lymphoblastic Leukemia With a Copy of Retinoic Acid Receptor Alpha Gene.

A 21-year-old female with a past medical history of chronic tonsilitis presented to the emergency department (ED) with a sore throat and swelling in her neck for a two-week duration. The patient was noted to have pancytopenia with blasts on peripheral blood differential, so she was transferred for admission at an outside facility for further evaluation and management. Bone marrow biopsy revealed T-cell acute lymphoblastic leukemia (ALL) with 39.5% blasts. CALGB 10403 treatment protocol was initiated two days after her presentation to the ED. The patient also had an extra copy of the retinoic acid receptor alpha (RARA) gene. One year later, the patient was in remission, and cytogenetic results showed a normal female karyotype indicating that the patient no longer had ALL or RARA gene abnormalities. While a sore throat can be a common chief complaint in the ED, ED providers need to keep a broad differential as there are many serious and potentially life-threatening etiologies such as T-cell ALL. T-cell ALL diagnosis is established with the presence of >20% of lymphoblasts in the bone marrow or peripheral blood draw. Cytogenetic changes play a significant role in determining the prognostic factors and management of ALL.

Renal Artery Dissection in an Emergency Department Patient With a Near Fall.

51-year-old male presented to the emergency department with left flank pain after a near fall on steps. Computed tomography of the abdomen and pelvis with contrast showed a non-enhancing left kidney, secondary to suspected acute traumatic dissection of the left renal artery. Renal artery dissection is typically affiliated with blunt abdominal trauma, though it can also occur spontaneously. The diagnosis of a renal artery dissection after minor trauma can often go unrecognized due to a lack of initial severe symptoms.Management will vary upon the age of the injury, the preservation of the kidney, and the extent of associated injuries.Ultimately, management should be dictated by discussion with trauma surgery, vascular surgery, urology, or interventional radiology consultants. Knowing the mechanism of injury and patient risk factors can help guide your ability to successfully identify and treat the patient, limiting delays in care and potentially lowering the incidence of organ injury.

Disruption of the early-life microbiota alters Peyer's patch development and germinal center formation in gastrointestinal-associated lymphoid tissue.

During postnatal development, both the maturing microbiome and the host immune system are susceptible to environmental perturbations such as antibiotic use. The impact of timing in which antibiotic exposure occurs was investigated by treating mice from days 5-9 with amoxicillin or azithromycin, two of the most commonly prescribed medications in children. Both early-life antibiotic regimens disrupted Peyer's patch development and immune cell abundance, with a sustained decrease in germinal center formation and diminished intestinal immunoglobulin A (IgA) production. These effects were less pronounced in adult mice. Through comparative analysis of microbial taxa, Bifidobacterium longum abundance was found to be associated with germinal center frequency. When re-introduced to antibiotic-exposed mice, B. longum partially rescued the immunological deficits. These findings suggest that early-life antibiotic use affects the development of intestinal IgA-producing B cell functions and that probiotic strains could be used to restore normal development after antibiotic exposure.

Social Determinants of Health Data Quality at Different Levels of Geographic Detail.

Social determinants of health (SDOH) impact 80% of health outcomes from acute to chronic disorders, and attempts are underway to provide these data elements to clinicians. It is, however, difficult to collect SDOH data through (1) surveys, which provide inconsistent and incomplete data, or (2) aggregates at the neighborhood level. Data from these sources is not sufficiently accurate, complete, and up-to-date. To demonstrate this, we have compared the Area Deprivation Index (ADI) to purchased commercial consumer data at the individual-household level. The ADI is composed of income, education, employment, and housing quality information. Although this index does a good job of representing populations, it is not adequate to describe individuals, especially in a healthcare context. Aggregate measures are, by definition, not sufficiently granular to describe each individual within the population they represent and may result in biased or imprecise data when simply assigned to the individual. Moreover, this problem is generalizable to any community-level element, not just ADI, in so far as they are an aggregate of the individual community members.

Vaccine target and carrier molecule nontypeable Haemophilus influenzae protein D dimerizes like the close Escherichia coli GlpQ homolog but unlike other known homolog dimers.

We have determined the 1.8 Å X-ray crystal structure of nonlipidated (i.e., N-terminally truncated) nontypeable Haemophilus influenzae (NTHi; H. influenzae) protein D. Protein D exists on outer membranes of H. influenzae strains and acts as a virulence factor that helps invade human cells. Protein D is a proven successful antigen in animal models to treat obstructive pulmonary disease (COPD) and otitis media (OM), and when conjugated to polysaccharides also has been used as a carrier molecule for human vaccines, for example in GlaxoSmithKline Synflorix™. NTHi protein D shares high sequence and structural identify to the Escherichia coli (E. coli) glpQ gene product (GlpQ). E. coli GlpQ is a glycerophosphodiester phosphodiesterase (GDPD) with a known dimeric structure in the Protein Structural Database, albeit without an associated publication. We show here that both structures exhibit similar homodimer organization despite slightly different crystal lattices. Additionally, we have observed both the presence of weak dimerization and the lack of dimerization in solution during size exclusion chromatography (SEC) experiments yet have distinctly observed dimerization in native mass spectrometry analyses. Comparison of NTHi protein D and E. coli GlpQ with other homologous homodimers and monomers shows that the E. coli and NTHi homodimer interfaces are distinct. Despite this distinction, NTHi protein D and E. coli GlpQ possess a triose-phosphate isomerase (TIM) barrel domain seen in many of the other homologs. The active site of NTHi protein D is located near the center of this TIM barrel. A putative glycerol moiety was modeled in two different conformations (occupancies) in the active site of our NTHi protein D structure and we compared this to ligands modeled in homologous structures. Our structural analysis should aid in future efforts to determine structures of protein D bound to substrates, analog intermediates, and products, to fully appreciate this reaction scheme and aiding in future inhibitor design.

Maternal undernutrition results in transcript changes in male offspring that may promote resistance to high fat diet induced weight gain.

Maternal nutrition during embryonic development and lactation influences multiple aspects of offspring health. Using mice, this study investigates the effects of maternal caloric restriction (CR) during mid-gestation and lactation on offspring neonatal development and on adult metabolic function when challenged by a high fat diet (HFD). The CR maternal model produced male and female offspring that were significantly smaller, in terms of weight and length, and females had delayed puberty. Adult offspring born to CR dams had a sexually dimorphic response to the high fat diet. Compared to offspring of maternal control dams, adult female, but not male, CR offspring gained more weight in response to high fat diet at 10 weeks. In adipose tissue of male HFD offspring, maternal undernutrition resulted in blunted expression of genes associated with weight gain and increased expression of genes that protect against weight gain. Regardless of maternal nutrition status, HFD male offspring showed increased expression of genes associated with progression toward nonalcoholic fatty liver disease (NAFLD). Furthermore, we observed significant, sexually dimorphic differences in serum TSH. These data reveal tissue- and sex-specific changes in gene and hormone regulation following mild maternal undernutrition, which may offer protection against diet induced weight gain in adult male offspring.

4D flow cardiovascular magnetic resonance recovery profiles following pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension.

BACKGROUND: Four-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) allows comprehensive assessment of pulmonary artery (PA) flow dynamics. Few studies have characterized longitudinal changes in pulmonary flow dynamics and right ventricular (RV) recovery following a pulmonary endarterectomy (PEA) for patients with chronic thromboembolic pulmonary hypertension (CTEPH). This can provide novel insights of RV and PA dynamics during recovery. We investigated the longitudinal trajectory of 4D flow metrics following a PEA including velocity, vorticity, helicity, and PA vessel wall stiffness. METHODS: Twenty patients with CTEPH underwent pre-PEA and > 6 months post-PEA CMR imaging including 4D flow CMR; right heart catheter measurements were performed in 18 of these patients. We developed a semi-automated pipeline to extract integrated 4D flow-derived main, left, and right PA (MPA, LPA, RPA) volumes, velocity flow profiles, and secondary flow profiles. We focused on secondary flow metrics of vorticity, volume fraction of positive helicity (clockwise rotation), and the helical flow index (HFI) that measures helicity intensity. RESULTS: Mean PA pressures (mPAP), total pulmonary resistance (TPR), and normalized RV end-systolic volume (RVESV) decreased significantly post-PEA (P < 0.002). 4D flow-derived PA volumes decreased (P < 0.001) and stiffness, velocity, and vorticity increased (P < 0.01) post-PEA. Longitudinal improvements from pre- to post-PEA in mPAP were associated with longitudinal decreases in MPA area (r = 0.68, P = 0.002). Longitudinal improvements in TPR were associated with longitudinal increases in the maximum RPA HFI (r=-0.85, P < 0.001). Longitudinal improvements in RVESV were associated with longitudinal decreases in MPA fraction of positive helicity (r = 0.75, P = 0.003) and minimum MPA HFI (r=-0.72, P = 0.005). CONCLUSION: We developed a semi-automated pipeline for analyzing 4D flow metrics of vessel stiffness and flow profiles. PEA was associated with changes in 4D flow metrics of PA flow profiles and vessel stiffness. Longitudinal analysis revealed that PA helicity was associated with pulmonary remodeling and RV reverse remodeling following a PEA.

Quality control recommendations for RNASeq using FFPE samples based on pre-sequencing lab metrics and post-sequencing bioinformatics metrics.

BACKGROUND: Formalin-fixed, paraffin-embedded (FFPE) tissues have many advantages for identification of risk biomarkers, including wide availability and potential for extended follow-up endpoints. However, RNA derived from archival FFPE samples has limited quality. Here we identified parameters that determine which FFPE samples have the potential for successful RNA extraction, library preparation, and generation of usable RNAseq data. METHODS: We optimized library preparation protocols designed for use with FFPE samples using seven FFPE and Fresh Frozen replicate pairs, and tested optimized protocols using a study set of 130 FFPE biopsies from women with benign breast disease. Metrics from RNA extraction and preparation procedures were collected and compared with bioinformatics sequencing summary statistics. Finally, a decision tree model was built to learn the relationship between pre-sequencing lab metrics and qc pass/fail status as determined by bioinformatics metrics. RESULTS: Samples that failed bioinformatics qc tended to have low median sample-wise correlation within the cohort (Spearman correlation < 0.75), low number of reads mapped to gene regions (< 25 million), or low number of detectable genes (11,400 # of detected genes with TPM > 4). The median RNA concentration and pre-capture library Qubit values for qc failed samples were 18.9 ng/ul and 2.08 ng/ul respectively, which were significantly lower than those of qc pass samples (40.8 ng/ul and 5.82 ng/ul). We built a decision tree model based on input RNA concentration, input library qubit values, and achieved an F score of 0.848 in predicting QC status (pass/fail) of FFPE samples. CONCLUSIONS: We provide a bioinformatics quality control recommendation for FFPE samples from breast tissue by evaluating bioinformatic and sample metrics. Our results suggest a minimum concentration of 25 ng/ul FFPE-extracted RNA for library preparation and 1.7 ng/ul pre-capture library output to achieve adequate RNA-seq data for downstream bioinformatics analysis.

Repeatable enhancement of healthcare data with social determinants of health.

Background: Social and behavioral aspects of our lives significantly impact our health, yet minimal social determinants of health (SDOH) data elements are collected in the healthcare system. Methods: In this proof-of-concept study we developed a repeatable SDOH enrichment and integration process to incorporate dynamically evolving SDOH domain concepts from consumers into clinical data. This process included SDOH mapping, linking compiled consumer data to patient records in Electronic Health Records, data quality analysis and preprocessing, and storage. Results: Consumer compilers data coverage ranged from ~90 to ~54% and the percentage match rate between compilers was between ~21 and 64%. Our preliminary analysis showed that apart from demographic factors, several SDOH factors like home-ownership, marital-status, presence of children, number of members per household, economic stability and education were significantly different between the COVID-19 positive and negative patient groups while estimated family-income and home market-value were not. Conclusion: Our preliminary analysis shows commercial consumer data can be a viable source of SDOH factor at an individual-level for clinical data thus providing a path for clinicians to improve patient treatment and care.

Preprocessing to Address Bias in Healthcare Data.

Multimorbidity, having a diagnosis of two or more chronic conditions, increases as people age. It is a predictor used in clinical decision-making, but underdiagnosis in underserved populations produces bias in the data that support algorithms used in the healthcare processes. Artificial intelligence (AI) systems could produce inaccurate predictions if patients have multiple unknown conditions. Rural patients are more likely to be underserved and also more likely to have multiple chronic conditions. In this study, data collected during the course of care in a centrally located academic hospital, multimorbidity decreased with rurality. This decrease suggests a bias against rural patients for algorithms that rely on diagnosis information to calculate risk. To test preprocessing to address bias in healthcare data, we measured the amount of discrimination in favor of metropolitan patients in the classification of multimorbidity. We built a model using the biased data to test optimum classification performance. A new unbiased training data set and model were created and tested against unaltered validation data. The new model's classification performance on unaltered data did not diverge significantly from the performance of the initial optimal model trained on the biased data suggesting that bias can be removed with preprocessing.

Covid-19 Positivity Differences Among Patients of a Rural, Southern US State Hospital System Based on Population Density, Rural-Urban Classification, and Area Deprivation Index.

In this study we examined the correlation of COVID-19 positivity with area deprivation index (ADI), social determinants of health (SDOH) factors based on a consumer and electronic medical record (EMR) data and population density in a patient population from a tertiary healthcare system in Arkansas. COVID-19 positivity was significantly associated with population density, age, race, and household size. Understanding health disparities and SDOH data can add value to health and the creation of trustable AI.

A Terrible Sore Throat: Pharyngitis in an Emergency Department Patient With a Final Diagnosis of Acute Myelogenous Leukemia.

Acute pharyngitis is a common complaint in emergency department (ED), urgent care, and primary care settings. Most cases are due to bacterial or viral infections easily treated with antibiotics or supportive care. However, serious pathologies in the pharyngitis differential include Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, and bacterial tracheitis. Rarely, oncologic conditions such as leukemia may initially present as pharyngitis in an acute care setting. We present a case of pharyngitis in a 32-year-old male ED patient with a final diagnosis of acute myelogenous leukemia (AML). Knowledge of the appropriate ED evaluation of AML is key for accurate diagnosis and prompt referral to avoid unnecessary patient morbidity and mortality.