Use of TC-325 Hemostatic Powder as a Rescue Monotherapy for Management of Rectal Variceal Bleed.

The use of the endoscopic hemostatic powder TC-325 as a rescue monotherapy or as an adjunct agent in achieving hemostasis has been studied in upper gastrointestinal variceal bleeds and nonvariceal lower gastrointestinal bleeds with promising results. In this report, we describe a case of a successful use of TC-325 as rescue monotherapy to manage rectal variceal bleeding in a patient with alcohol-related cirrhosis with no report of bleeding recurrence and no side effects within the first 7 days, 30 days, or 6 months.

There is hope and help: Reach and reception of a methamphetamine education campaign in Los Angeles County, California.

Introduction: In the context of increasing rates of methamphetamine (meth) overdose in Los Angeles County, California, USA, in 2021 the Los Angeles County Department of Public Health relaunched Meth Free LA County, a methamphetamine public education campaign built on Rescue Agency's Decision BlocksTM Strategic Framework. Methods: To assess campaign reach and reception, we examined media data and an online cross-sectional post-campaign survey in 2021 with a convenience sample of 750 county residents ages 18-54 who had used meth, were at-risk, or had personal relationships with people at-risk. We assessed campaign awareness, receptivity, and perceived effectiveness. Participants also reported concern about meth use in their community, recall of 10 facts from campaign content, and if they had taken promoted actions such as seeking help. We compared proportions between campaign-aware and unaware participants and explored if recall predicted these measures. Results: Most participants recalled the campaign (84.1%), felt it offered a new way of looking at meth (73.8%), and reported it made them feel that help is available (84.0%) or that it could help reduce their own use (82.4%). Video advertisements received high perceived effectiveness scores. Greater campaign recall was associated with significantly increased odds of being concerned about meth use in the community, recalling facts, and taking promoted actions. Conclusion: In 2021, Meth Free LA County reached its high-risk audiences. Unlike fear-based campaigns its message resonated with high-risk individuals, providing an example of how public education campaigns on meth and similar illicit substances can connect with their audiences.

An Electronic Medical Record Pocket Guide for Incoming Internal Medicine Interns: Perceptions and Impact on Patient Information Gathering.

OBJECTIVES: The transition from medical student to intern is associated with a significant increase in workloads and responsibilities. This includes using the electronic medical record (EMR), which can lead to challenges in information gathering and patient care; however, no formal residency interventions exist in the use of an EMR for information gathering, with most EMR training occurring in the clinical setting. The present study aimed to improve information gathering on patient care and enhance the confidence of Internal Medicine interns in information gathering. METHODS: We performed a pre- and postprospective study in July 2021. All of the Internal Medicine interns at our community hospital were included. A pre- and postassessment to evaluate interns' confidence was distributed to participants during orientation week and at the end of the inpatient Internal Medicine rotation. A pre- and postconfidence assessment was collected at the beginning and end, respectively, of each intern's inpatient Internal Medicine rotation. RESULTS: Seventeen (85%) interns completed both the preassessment and postassessment. Use of an EMR guide led to a significant increase in completeness of patient information gathering (preassessment: 73.2% ± 18.4% vs post-EMR guide: 94.7% ± 7.4%, P < 0.001) and in intern confidence (P = 0.001). CONCLUSIONS: The use of an EMR guide was well received among Internal Medicine interns and led to increased completeness in patient information gathering. Residency programs may benefit from developing an EMR guide to improving the transition of interns during residency.

Young Adult Responses to Peer Crowd-Based Targeting in E-cigarette Advertisements: An Experimental Study.

AIMS: To examine the effects of psychographically targeted e-cigarette advertisements on young adults. METHODS: A total of 2100 young adults (18-29 years old) representing five peer crowds (groups with shared values, interests, and lifestyle: Mainstream, Young Professional, Hip Hop, Hipster, and Partier) were recruited from a nationwide opt-in online panel. Participants were randomly assigned to view e-cigarette advertisements featuring characters that either did or did not match their own peer crowd affiliation and evaluated advertising effectiveness using Likert-type and semantic differential scales. Participants also reported their attitudes toward using e-cigarettes. RESULTS: No significant overall effect of peer crowd matching was observed. However, significant two-way interaction effects emerged where matching advertisements yielded higher evaluations than mismatching advertisements among those who currently do not use tobacco and nicotine products and among Mainstream participants. Advertisements featuring Mainstream characters were in general rated more highly than other advertisements. Additional analyses found significant effects of peer crowd matching among those who viewed advertisements featuring non-Mainstream characters. CONCLUSIONS: Peer crowd-based targeting can increase the effectiveness of e-cigarette advertisements which may impact initiation among current nonusers, requiring stricter marketing regulations. More research is needed to determine if anti-tobacco messaging tailored by peer crowds may effectively counteract targeted e-cigarette marketing. IMPLICATIONS: E-cigarette advertisements often use psychographic targeting strategies, using lifestyles, attitudes, and values. Low-risk young adults (eg, those who currently do not use tobacco and nicotine products) are susceptible to psychographically targeted e-cigarette advertisements. This may result in the initiation of e-cigarette use among young adults who would otherwise be less likely to use tobacco and nicotine products. Stricter marketing regulations for emerging tobacco and nicotine products are required to reduce marketing exposure.

Creating More Effective Vape Education Campaigns: Qualitative Feedback from Teens in Nine U.S. States.

Background: Successful media campaigns to reduce teen cigarette smoking indicate a similar approach may work for vaping, though message testing research is necessary to identify effective topics and approaches. Leveraging data from message testing studies across nine U.S. states, we identify promising topics and approaches and explore how the COVID-19 pandemic affected teens' reactions to vape education commercials. Methods: Teens ages 13-18 (N = 337) who vaped or were susceptible nonusers participated in focus groups and interviews (2018-2021) to review 35 creative concepts and commercials for Behind the Haze (BTH), a vaping education campaign. After viewing each video, participants assessed its perceived effectiveness (PE) and discussed their reactions. We conducted a reflexive thematic analysis of transcripts to identify crosscutting themes and compared PE scores for each video. Results: Key features of effective commercials included detailed facts accompanied by explanatory visuals, metaphors, and empathy. Promising topics included chemicals, physical consequences, and mental health, while addiction and industry deception messages were less impactful. The pandemic drew attention to mental health and immunity messages. Impact of one's vaping on friends emerged as a promising topic. Conclusions: While some tactics from successful cigarette prevention campaigns apply to vaping, others like anti-industry messaging do not. Fact-focused messaging on chemicals, physical consequences, and mental health accompanied by impactful graphics and attention-grabbing twists should be the focus of vape education campaigns. Frequent message testing research such as that conducted to inform BTH is necessary to identify promising and sometimes unexpected messaging approaches for timely and relevant teen vaping education materials.

General Surgery Resident Operative Experiences in Solid Organ Injury: An Examination of Case Logs.

BACKGROUND: Non-operative management (NOM) of traumatic solid organ injury (SOI) has become commonplace. This paradigm shift, along with reduced resident work hours, has significantly impacted surgical residents' operative trauma experiences. We examined ongoing changes in residents' operative SOI experience since duty hour restriction implementation, and assessed whether missed operative experiences were gained elsewhere in the resident experience. METHODS: We examined data from American College of Graduate Medical Education case log reports from 2003 to 2018. We collected mean case volumes in the categories of non-operative trauma, trauma laparotomy, and splenic, hepatic, and pancreatic trauma operations; case volumes for comparable non-traumatic solid organ operations were also collected. Solid organ injury operative volumes were compared against non-traumatic cases, and change over time was analyzed. RESULTS: Over the study period, both trauma laparotomies and non-operative traumas increased significantly (P < .001). In contrast, operative volumes for splenic, hepatic, and pancreatic trauma all significantly decreased (P < .001; P = .014; P < .001, respectively). Non-traumatic spleen cases also significantly decreased (P < .001), but liver cases and distal pancreatectomies increased (P < .001; P = .017). Pancreaticoduodenectomies increased, albeit not to a significant degree (P = .052). CONCLUSIONS: Continuing increases in NOM of SOI correlate with declining resident experience with operative solid organ trauma. These decreases can adversely affect residents' technical skills and decision-making, although trends in specific non-traumatic areas may help to mitigate such losses. Further work should determine the impact of these trends on resident competence and autonomy.

Resident duty hours and resident and patient outcomes: Systematic review and meta-analysis.

OBJECTIVES: The policies regarding resident physician work hours are constantly being evaluated and changed. However, the results of randomised control trials (RCTs) are mixed. This systematic review of RCTs aims to synthesise the evidence associated with resident duty hour restrictions and its impact on resident- and patient-based outcomes. METHODS: A comprehensive search of the Cochrane Library, EMBASE and PubMed was conducted from inception until 31 July 2020. Any RCT evaluating the impact of longer resident physician work hours compared to shorter resident physician work hours on resident- and patient-based outcomes was eligible for inclusion. Two reviewers extracted data independently. The primary outcome was the impact of resident duty hour restrictions on emotional exhaustion, depersonalisation and personal accomplishment, as defined by the Maslach Burnout Inventory. The secondary patient-related outcomes were patient hospital length of stay, serious medical errors and preventable adverse events. Data were pooled using a random-effects model. RESULTS: Of the 873 references, nine RCTs met the inclusion criteria. A shorter shift length compared with longer shift length was associated with significantly less emotional exhaustion (standardised mean difference [SMD] = -0.11, 95% CI = -0.21, -0.00) and less dissatisfaction with overall well-being (OR = 0.61, 95% CI 0.38, 0.99) but not with hospital length of stay (SMD = -0.01, 95% CI = -0.05, 0.02, p = 0.45) and serious medical errors per 1000 patient hours (OR = 1.07, 95% CI = 0.52, 2.21; p = 0.86). CONCLUSIONS: Shorter resident duty hours is possibly associated with improvement in resident-based outcomes, specifically, emotional exhaustion, dissatisfaction with overall well-being, sleep duration and sleepiness. These findings may inform the policy change in support of reduced shift hours resulting in overall well-being for the residents with possible reduction in burnout without adverse impact on patient-based outcomes.

Psychographic segmentation to identify higher-risk teen peer crowds for health communications: Validation of Virginia's Mindset Lens Survey.

Audience segmentation is necessary in health communications to ensure equitable resource distribution. Peer crowds, which are macro-level teen subcultures, are effective psychographic segments for health communications because each crowd has unique mindsets, values, norms, and health behavior profiles. These mindsets affect behaviors, and can be used to develop targeted health communication campaigns to reach those in greatest need. Though peer crowd research is plentiful, no existing peer crowd measurement tool has been formally validated. As such, we developed and validated Virginia's Mindset Lens Survey (V-MLS), a mindset-based teen peer crowd segmentation survey to support health communication efforts. Using an online convenience sample of teens (N = 1,113), we assessed convergent and discriminant validity by comparing the V-MLS against an existing, widely-used peer crowd survey (I-Base Survey®) utilizing a multi-trait multi-method matrix. We also examined the V-MLS's predictive ability through a series of regressions using peer crowd scores to predict behaviors, experiences, and traits relevant to health communication campaign planning. The V-MLS demonstrated reliability and convergent and discriminant validity. Additionally, the V-MLS effectively distinguished teen peer crowds with unique health behaviors, experiences, and personal traits. When combined with appropriate information processing and campaign development frameworks, this new tool can complement existing instruments to inform message framing, tone, and style for campaigns that target at-risk teens to increase campaign equity and reach.

Is New York State good at managing hollow viscus injury?

BACKGROUND: There are an estimated 100,000 cases of abdominal injury (ABI) in the USA, annually resulting in over $12 billion in direct medical cost and $18 billion in lost productivity. This study assesses the timeliness, safety, and efficacy of the surgical management of abdominal injuries (ABIs), hollow viscus injuries (HVIs), and colonic injuries (CIs) for patients residing in New York State (NYS). METHODS: Using data from NYS's Statewide Planning and Research Cooperative System (SPARCS), we identified all trauma patients with ABI admitted between 2006 and 2015. We subdivided ABI into HVI and CI using diagnosis and procedure codes and examined processes of care and outcomes adjusting for patient characteristics, injury severity score, structural, and process indicators. RESULTS: We identified 31,043 hospitalized patients with ABI, 71% were incurred from blunt forces. Most patients with ABI (72%) were treated at a Level I/II trauma center (TC) and 7% patients were transferred to Level I/II TC. Failure to be treated at Level I/II TC was associated with 16% increased hazard of death. HVI was diagnosed in 23% of ABI patients (n = 7294); 18% experienced delayed hollow viscus repair (dHVR); dHVR was associated with a 76% increased hazard of death. CI was diagnosed in 9% of ABI patients (n = 2921) and 18% experienced dHVR. Seventy-five percent of CI were repaired primarily (n = 1354). Less than 37% of stomas were reversed by 4 years of index trauma. CONCLUSION: Most abdominal trauma in NYS was caused by motor vehicle accidents, falls, and assault. dHVR and not being treated at Level I/II TC were associated with worse outcomes. More research is needed to reduce under-triage and delays in the operative treatment of blunt abdominal trauma.

An Interesting Presentation of Testosterone-Induced Arterial Thrombosis.

Testosterone replacement therapy (TRT) is an industry on the rise in large part due to an increase in direct-to-customer advertising targeting middle-aged men with non-specific symptoms. The biggest problem with unnecessary prescribing is that testosterone therapy is not without side effects. One of the more common adverse effects is erythrocytosis with subsequent thrombosis. It was originally postulated that thrombosis seen in patients on TRT was solely related to increasing in hemoglobin however, new studies demonstrate increasing episodes of thrombosis unrelated to hemoglobin or hematocrit. We report the case of a 38-year-old white male presenting to the clinic with infarction of bilateral feet and digits due to testosterone-induced thrombosis of dermal and epidermal arteries. Laboratory workup including vasculitis panel was negative and complete blood count (CBC) was within appropriate parameters. He was treated with anticoagulation, pain control, and vasodilatory therapy with subsequent improvement of symptoms. There have been many reported cases of testosterone-induced thrombosis of the venous system with occasional involvement of the renal arteries. However, cases involving thrombosis of dermal or epidermal arteries due to testosterone supplementation have never been reported. It could be beneficial to screen potential patients requiring TRT for hypercoagulable states such as Factor V Leiden and lupus anticoagulant.

Aseptic Meningitis Secondary to Antibiotic Therapy.

Drug-induced aseptic meningitis is a rare entity. Diagnosis of drug-induced aseptic meningitis can be challenging due to the difficulty in distinguishing clinical presentation from bacterial or viral meningitis. We present a case of a 52-year-old Caucasian female patient who presented to the emergency room on two different occasions with severe headache, neck pain, and confusion. Initial cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, and empirical intravenous acyclovir was initiated. Bacterial and viral CSF analysis and cultures were negative. The patient completely recovered. Several days later, the patient returned to the emergency room with similar symptoms. Second CSF analysis revealed neutrophilic pleocytosis, and empirical intravenous antibiotic and antiviral therapy were started. Bacterial, fungal, and viral CSF analysis and cultures were negative. Imaging studies of the brain were unremarkable on both occasions. The patient reported taking trimethoprim-sulfamethoxazole (TMP-SMX) for right foot infection before and after the initial presentation. The patient's symptoms resolved without neurological sequelae after discontinuation of TMP-SMX. This case report highlights the importance of taking a detailed history to diagnose drug-induced aseptic meningitis.

Chronic Lymphocytic Leukemia of the Aortic Valve: A Case Report.

Chronic lymphocytic leukemia (CLL) is characterized by the chronic accumulation of mature B-cell lymphocytes in the bone marrow. CLL accounts for approximately one-quarter of new leukemia cases each year and is the most common leukemia in Western countries. Most notably, this leukemia involves the lymph nodes, spleen, and liver, whereas non-lymphoid tissue is seldom associated with CLL infiltration. A large percentage of patients are asymptomatic at presentation; however, for those who are symptomatic, lymphadenopathy is the most common presenting complaint. This is the case of a 75-year-old Caucasian male with CLL on ibrutinib who presented with chest pressure and worsening shortness of breath. The patient underwent cardiac catheterization, which revealed demonstrable aortic stenosis. His aortic valve was subsequently replaced, and tissue was sent for histochemical analysis. Stains were positive for CD20, BCL2, CD5, and CD23, compatible with the CLL of the valve. To be able to investigate those with a known leukemic disease in patients with valvular disease would be beneficial to clinicians as CLL can present in atypical locations.

Choriocarcinoma Presenting as a Pleural Effusion.

Choriocarcinoma is a germ cell tumor characterized by widespread metastases and poorly differentiated cells. Non-gestational choriocarcinoma, or primary choriocarcinoma is a trophoblastic disease which is associated with a poor patient prognosis and is markedly angioinvasive. Primary non-gestational mediastinal choriocarcinoma is a very rare disease and represents an aggressive malignancy, primarily seen in young males. Those with primary mediastinal choriocarcinoma have symptoms that are non-specific such as cough, dyspnea, hemoptysis, and chest pain. Here we present the case of a 47-year-old Caucasian female who presented with worsening dyspnea and cough. Laboratory testing revealed elevated alkaline phosphatase, human chorionic gonadotropin, and cancer antigen 125. Chest X-ray was significant for a large right pleural effusion and a computed tomography angiogram of the chest showed a soft tissue mass in the anterior medial right lung base/right middle lobe. Thoracentesis yielded results consistent with malignant cells favoring a germ cell tumor. Biopsy of the mediastinal mass revealed positivity for inhibin and both human chorionic gonadotropin and CD-10 which led to the diagnosis of primary choriocarcinoma. Primary mediastinal choriocarcinoma is uncommon and often has a non-specific clinical presentation. A high degree of suspicion is needed as this malignancy can be aggressive, necessitating urgent definitive tissue biopsy diagnosis to guide appropriate therapy.

Transverse colon volvulus in a patient with autism.

Transverse colon volvulus is an extremely rare cause of bowel obstruction with approximately 100 cases reported in literature. Transverse colon volvulus presents with signs and symptoms of large bowel obstruction, but it can become a surgical emergency due to bowel infarction or peritonitis. We present a rare case of transverse colon volvulus in a 36-year-old male patient with severe autism. We hope this case report will raise awareness of this disease.

The Vaping Teenager: Understanding the Psychographics and Interests of Adolescent Vape Users to Inform Health Communication Campaigns.

BACKGROUND: Adolescent vaping continues to rise, yet little is known about teen vape users beyond demographics. Effective intervention requires a deeper understanding of the psychographics and interests of adolescent vape users to facilitate targeted communication campaigns. METHODS: We analyzed the 2017-2018 weighted cross-sectional online survey data from Virginia high school students (N = 1594) to identify and describe subgroups of adolescents who vaped. Participants reported 30-day vape use, identification with 5 peer crowds (Alternative, Country, Hip Hop, Mainstream, Popular), social prioritization, agreement with personal values statements, social media and smartphone use, and television and event preferences. We compared vaping rates and frequency by peer crowd using a chi-square analysis with follow-up testing to identify higher-risk crowds and confirmed associations using binary and multinomial logistic regression models with peer crowd scores predicting vaping, controlling for demographics. We then used chi-square and t tests to describe the psychographics, media use, and interests of higher-risk peer crowds and current vape users within those crowds. RESULTS: Any current vaping was the highest among those with Hip Hop peer crowd identification (25.4%), then Popular (21.3%). Stronger peer crowd identification was associated with increased odds of any current vaping for both crowds, vaping on 1 to 19 days for both crowds, and vaping on 20 to 30 days for Hip Hop only. Compared with other peer crowds and non-users, Hip Hop and Popular youth and current vape users reported greater social prioritization and agreement with values related to being social and fashionable. Hip Hop and Popular youth and current vape users reported heavy Instagram and Snapchat use, as well as unique television show and event preferences. CONCLUSIONS: Hip Hop and Popular adolescents are most likely to vape and should be priority audiences for vaping prevention campaigns. Findings should guide the development of targeted health communication campaigns delivered via carefully designed media strategies.

Systemic Mastocytosis: A Rare Cause of Diarrhea.

Mastocytosis is a spectrum of neoplastic, clonal cell disorders that are characterized by mast cell hyperplasia and accumulation. Disease and clinical presentation can vary depending on the extent of spread, ranging from skin-limited cutaneous mastocytosis to systemic mastocytosis that can mimic other disease processes. Symptoms may include pruritus, flushing, hypotension, headaches, abdominal pain, nausea, vomiting, and diarrhea. Although gastrointestinal (GI) symptoms are present in a majority of patients with systemic disease, the actual percentage of gut mast cell infiltration remains unknown. Here we describe a case of diarrhea secondary to GI involvement of systemic mastocytosis. A 55-year-old woman with a known history of systemic mastocytosis and medical noncompliance complained of persistent chronic diarrhea for one year. She was evaluated for other causes of diarrhea but all additional testing was unrevealing. She ultimately underwent upper endoscopy and colonoscopy in which biopsy and histologic analysis confirmed the presence of mastocyte infiltration. She was restarted on her medical therapy and her symptoms resolved. In conclusion, systemic mastocytosis is an uncommon cause of chronic diarrhea. However, in select patients, it is important to obtain a thorough medical history and exclude other potential causes.

Invasive Lobular Breast Carcinoma Can Be a Challenging Diagnosis Without the Use of Tumor Markers.

Invasive lobular carcinoma is often challenging to diagnose due to the lack of physical examination findings and macrocalcifications on mammography. The cells of invasive lobular carcinoma form a distinct single file pattern that can be identified on histology slides. Often, when patients present, there is metastasis to the bones, lymph nodes, and gastrointestinal tract. Tumor markers are a valuable tool in identification, especially the loss of E-cadherin protein. However, if E-cadherin protein is not available, epidermal membrane antigen, which inhibits E-cadherin, can prove to be a significant diagnostic tool. Epidermal membrane antigen was the key tumor marker in our patient case. Other tumor markers and histology stains can drive treatment plans and help predict prognosis.

Metoprolol-Associated Central Nervous System Complications.

Metoprolol is a common medication used by the elderly because it is affordable and has proven to decrease mortality in cardiovascular disease. Multiple studies have reported central nervous system (CNS) side effects associated with use of beta-blockers. The risk of beta-blocker CNS side effects is directly associated with the lipophilic property of the drug. We present the case of an 84-year-old male presented to the clinic complaining of increased confusion, fatigue, lightheadedness, nightmares, sleep disturbance, and gait problems for four weeks. The patient was evaluated for neurogenic and cardiogenic causes of his symptoms and both were ruled out. We believe that further review of his medical chart and medication reconciliation will lead us to the underlying cause of his symptoms. Despite being an effective treatment option, there are risks associated with beta-blocker therapy. The most common symptoms are psychiatric conditions, bizarre and vivid dreams, sleep disturbances, delirium, psychosis, and visual hallucinations. Elderly patients who are started on beta-blockers require close monitoring for any adverse neurological symptoms.

Hemorrhagic Cholecystitis in a Patient with Cirrhosis and Rectal Cancer.

Hemorrhagic cholecystitis is a rare presentation of acute calculous cholecystitis which presents with abdominal pain, jaundice, and gastrointestinal bleeding. It is a challenging diagnosis to make because it present similar to other common disorders such as calculous cholecystitis. We present a unique case of hemorrhagic cholecystitis in a patient with cirrhosis and rectal cancer.  A 66-year-old male with a history of rectal cancer, alcohol-induced cirrhosis, esophageal varices, stroke, paroxysmal atrial fibrillation, and hypertension presented to the emergency department with complaints of abdominal pain. Patient's computed tomography (CT) scan revealed bleeding from the gallbladder with hemoperitoneum and thickening of the ascending colon. The patient underwent emergent surgery for hemorrhagic cholecystitis. Hemorrhagic cholecystitis is associated with risk factors, including trauma, malignancy, renal failure, cirrhosis, and anticoagulation therapy. Imaging is not always reliable, but ultrasound and CT scan are the preferred options. Treatment options are surgical or nonsurgical approach depending on patient's hemodynamic stability.

Infective Endocarditis Caused by Rhodococcus equi in an Immunocompetent Patient.

Rhodococcus equi (R. equi) is a rare zoonotic organism that is found in the feces of grazing animals and in farm soil. It typically causes pulmonary disease, but it can also cause extrapulmonary disease. Immunocompromised patients are at a higher risk of developing the infection, but it has been reported in individuals with competent immune system as well. We present a unique case of infectious endocarditis (IE) due to a R. equi infection in an immunocompetent patient. A 77-year-old male with a history of coronary artery disease, prior myocardial infarction, systolic heart failure, hypertension, hyperlipidemia, aortic stenosis, and benign prostatic hypertrophy was evaluated by cardiothoracic surgery for coronary and valvular heart disease. His transesophageal echocardiogram and cardiac catheterization demonstrated severe aortic stenosis and multivessel coronary artery disease. The patient underwent coronary artery bypass grafting and simultaneous aortic valve replacement. Intraoperatively, there was exudative material covering his aortic valve, which was sent for tissue culture. Tissue culture was positive for R. equi and Enterococcus faecium.  R. equi endocarditis is a rare presentation of this organism. R. equi endocarditis is a very challenging diagnosis due to its varying presentation compared to typical IE. Detailed history taking and physical exam are extremely important to determine if further evaluation is needed. Prolonged oral and intravenous antibiotics are recommended for effective treatment.