IU School of Medicine Correctional Medicine Student Outreach Project

Background: This project was founded on the basis that correctional medicine is an important component frequently missing from medical school curriculums. Opportunities to participate in medical care within correctional facilities, while concurrently engaging in discussions about the institutions that have contributed to disproportionate incarceration of certain populations and mass incarceration as a whole, will cultivate empathetic, socially-engaged, and passionate young physicians. This student organization was formed to facilitate clinical opportunities within correctional facilities and host events that focus on the broader socioeconomic and political context and forms of structural and cultural violence that have contributed to mass incarceration in the United States. Methods: The overall goal of this project is to send medical students into Indiana Department of Corrections (IDOC) facilities, or county jails, to work closely with the medical providers as they provide care to incarcerated individuals. In order to facilitate this goal, a relationship was fostered between IUSM and Dr. Kristen Dauss, the Chief Medical Officer of the IDOC. Upon completion and approval of the contract between Centurion, the IDOC medical provider, and IUSM, students will have opportunities to shadow providers at the Indiana Women’s Prison. This pilot location was chosen due to the unique opportunity it presents to learn about the medical needs of the incarcerated women and young children, as it is the only facility in the state with a mother-baby unit. Since its creation, IUCM has also hosted numerous virtual educational lectures, panels, and journal clubs in collaboration with other student organizations and scholars in the field of correctional health. Lastly, the organization encourages engagement with original research through the IMPRS program, in coordination with Niki Messmore, our faculty advisor. Conclusions: As physicians who will practice medicine in the country with the highest incarceration rate in the world, having a fundamental understanding of topics related to correctional health, adverse health experiences while incarcerated, and longstanding traumatic effects of incarceration is imperative. IUCM’s goal is to create introductory materials and share resources with medical students relating to the create introductory materials and share resources with medical students relating to the Powered by Qualtrics A socioeconomic and political context which has led to mass incarceration, the lived experiences of people who are incarcerated, and the deficits in care for currently and formerly incarcerated people. Developing a better understanding of the justice system as well as the emotional, mental, and physical impact incarceration has on patients, and will stimulate interest in engaging with these concepts through research, volunteer work, educational events, and in patient care. In the future, each campus will partner with local correctional facilities and community organizations. After accruing a critical mass of student involvement at educational events and within facilities, we will utilize surveys to study the impact of the project. Additionally, we hope to expand the project to include other healthcare professional programs, and involve other facilities statewide. Lastly, due to our belief that correctional health should be a component of the core curriculum, we are currently working with IUSM administration to create material for the FCP course related to these topics

Breast Cancer Diagnosed During Pregnancy

Background: Pregnancy-associated breast cancers are cancers diagnosed during pregnancy or within 1 year of delivery. It is rare, occurring in 2.5-7.5/100,000, but these numbers continue to rise as maternal age increases. As a result, prospective studies evaluating diagnosis and treatment are limited. Case Description: Patient is a P1G0 35 yo woman who presented with a new breast mass at 26 wga. Diagnostic workup including core biopsy revealed invasive ductal carcinoma, ER 70%, PR 40%, her-2 negative. After multidisciplinary discussion with the breast team and the patient’s obstetrician, the patient underwent mastectomy with sentinel node biopsy at 28 wga. Pathology showed a 1.9 cm tumor with 5 negative sentinel nodes. Genomic evaluation of her tumor using 21-gene recurrence score revealed significant risk of distant recurrence without chemotherapy. Patient will initiate chemotherapy after delivery. Conclusion: The treatment regimen should be as close to standard of care as possible for a non-pregnant woman with the same cancer. Diagnostic workup should include ultrasound and possible mammogram with shielding of the fetus. Core biopsy can provide definitive diagnosis. Surgery is the mainstay of treatment during pregnancy, and decisions regarding breast conservation are dependent on gestational age at presentation. Adjuvant treatments can be performed with modifications and avoidance of radiotherapy during pregnancy. Decisions regarding treatment require multidisciplinary input between the oncology and obstetric teams to provide effective care with minimal toxicity to the fetus. Clinical Significance: Physiological changes of the breast during pregnancy make diagnosis of new breast cancer difficult. Furthermore, lack of diagnostic suspicion delays diagnosis. Further research is needed to determine the best diagnostic and therapeutic methods to ensure the best prognosis for mother and baby as the prevalence of breast cancer during pregnancy continues to rise

Fatty acid metabolism disorder not found on prenatal testing

Case Description: A 26 year old G3P2001 presented for amniocentesis due to a family history of carnitine palmitoyltransferase 2 (CPTII) deficiency. Her first child developed seizures and passed away soon after birth; CPTII deficiency was diagnosed on the newborn screen. Both parents were confirmed to be carriers. For her second pregnancy, she opted against invasive testing. The newborn was treated proactively. Testing confirmed the child was not affected, and treatment was halted. In the current pregnancy, she opted for amniocentesis, which revealed an affected male. Background: CPT II deficiency is a rare autosomal recessive disease caused by a mutation in a gene encoding carnitine palmitoyltransferase 2, an essential enzyme in fatty acid oxidation. Affected patients are at risk for hypoketotic hypoglycemia, seizures, hepatomegaly, cardiomyopathy, arrhythmias, and other downstream issues. A postnatal diagnosis via the newborn screen does not confer the benefit of advanced awareness of the disease and allow for preemptive treatment. CPT II deficiency can be confirmed prenatally with diagnostic testing. Amniocentesis is an invasive test associated with a low but present risk of pregnancy loss, so some may opt against the test. Conclusion: Carriers of CPT II mutations are counseled that future pregnancies confer a 25% risk of having an affected child. Prenatal diagnostic testing is recommended for prenatal diagnosis, which allows for planning of immediate treatment in the NICU. However, opting to forgo invasive testing and preemptively treat potentially affected child until newborn screening results return, as occurred in this patient’s second pregnancy, is also an option. Clinical Significance: CPT II deficiency is a rare disease that can have devastating effects in newborns without a known diagnosis. Parents with known carrier status must be extensively counseled on their options regarding prenatal and postnatal screening as well as immediate newborn care

Prevalence and Risk Factors of Gestational Diabetes in Twin Pregnancies: Population Based Study

Objective: To assess the prevalence and risk factors of gestational diabetes (GDM) in twin compared with singleton pregnancies. Methods: Population-based study using CDC birth data from 2016-2020. Higher order pregnancies and pre-pregnancy diabetes were excluded. A Chi-square test of independence was performed to identify significant factors associated with GDM in twin versus singleton pregnancies and within each group independently. Multivariable regression analyses were performed first to assess risk factors that are significantly associated with GDM in twins and second to assess the risk of GDM in twin compared with singletons, adjusted for the significant risk factors. P value<0.01 was considered statistically significant Results: Total of 18,173,365 singleton and 611,043 twin pregnancies were included during the study period. Following the regression model, maternal age≥30 years, nulliparous, IVF, chronic hypertension, Hispanic and Non-Hispanic (NH) Asian, foreign-born, overweight and obesity class I/II/II remained significantly associated with GDM in twins. However, maternal age<25 years, NH Black, and W.I.C program reduced that risk. Factors that more than doubled the risk in twins were maternal age≥40 years (OR 2.06 (1.97 – 2.14), P<0.001), NH Asian (OR 2.12 (2.04 – 2.20), P<0.001), and obesity class I, II, and III (OR: 2.22 (2.16 – 2.29), P<0.001, OR:3.01 (2.92 – 3.11), P<0.001, OR: 3.80 (3.67 – 3.93), p<0.001, respectively). Following adjustment for all the significant risk factors, twin pregnancy remained significantly associated with increasing the risk of GDM in twin compared to singleton pregnancies (OR 1.22 (1.21 – 1.23), P<0.001). Conclusion: Of the significant risk factors, maternal age≥40 years, NH Asian, and obesity class I, II, and III more than doubled the risk of GDM in twins. Regardless of maternal demographics, obstetric history, and endocrine factors, twin pregnancy remained significantly associated with GDM compared to singleton pregnancies. These factors can be used in risk prediction models to better counsel and manage twin pregnancies

IU School of Medicine Correctional Medicine Student Outreach Project

Background: This project was founded on the basis that correctional medicine is an important component frequently missing from medical education. Opportunities to participate in medical care within correctional facilities, while concurrently engaging in discussions about disproportionate incarceration of certain populations and mass incarceration as a whole, will cultivate empathetic, socially-engaged, and passionate young physicians. This student organization was formed to facilitate clinical opportunities within correctional facilities and host events that focus on the broader socioeconomic and political context and forms of structural and cultural violence that have contributed to mass incarceration in the United States. Methods: In order to facilitate organizational goals, a relationship was fostered between IUSM and Dr. Kristen Dauss, the Chief Medical Officer of the IDOC. Following affiliation agreements, students may now gain clinical exposure at any facility in the state. Since its creation, IUCM has hosted virtual educational lectures, panels, and journal clubs, in collaboration with other student organizations and scholars in the field. The organization encourages engagement with original research in coordination with faculty advisors. We have also worked with administration to incorporate correctional health topics officially into the curriculum. Conclusions: As physicians who will practice medicine in the country with the highest incarceration rate in the world, having a fundamental understanding of topics related to correctional health, adverse health experiences while incarcerated, and longstanding traumatic effects of incarceration is imperative. IUCM’s goal is to create introductory materials and share resources relating to the socioeconomic and political context which has led to mass incarceration and the deficits in care for currently and formerly incarcerated people. Developing a better understanding of the justice system as well as the emotional, mental, and physical impact incarceration has on patients, and will stimulate interest in engaging with these concepts through research, volunteer work, educational events, and in patient care

Improving Conditions for Incarcerated Individuals

Whereas, in 2019, the United States’ incarceration rate was estimated to be 629 per 100,000 people, which is the highest rate globally and over 8% higher than the closest country; and Whereas, in Indiana, the total jail population has increased 526% from 1970 to 2015 and the total prison population has increased 224% from 1983 to 2018, with our incarceration rates being fourth highest nationally; and Whereas, in 2015, Indiana had the second highest rate of pretrial detainees in the nation at a rate of 272 per 100,000 people; and Whereas, since 2000, the rate of pretrial detainees has increased 72% among Indiana’s 48 rural counties, 43% in 21 small/medium counties, 40% in 22 suburban counties, and 268% in Marion county alone; and Whereas, in the United States, the rate of recidivism is 70% within 5 years of release with few resources to assist reentering individuals find housing, gain employment, or access social services; and Whereas, when connected with employment opportunities, financial planning services, stable housing, and physical and mental health services, rates of recidivism decrease significantly, over 60% amongst those who complete programs, among reentering individuals; and Whereas, incarcerated individuals have higher rates of mental illness than the general population, with approximately 14.5% of men and 31% of women in jails having at least one mental illness as compared to 3.2% and 4.9% respectively amongst the general population; and Whereas, nationally, the number of suicides has increased by 85% in state prisons, 61% in federal prisons, and 13% in local jails from 2001 to 2019, with suicide being the leading cause of death in jails; and Whereas, the risk of suicide in recently released individuals is nearly 6.8 times higher than that of the general population, with most occurring within 28 days of release; and Whereas, in a study of 80 jails by Scheyett et al., 68 reported having no mental health staff who provided care within the jail, 15 reported taking, on average, 5 days or longer to retrieve inmates’ medications and none were utilizing evidence-based screenings to assess for serious mental illnesses, highlighting a concerning disconnect between jail staff and mental health providers; and Whereas, re-entering individuals are unlikely to connect with primary care upon release and very rarely seek mental health services in the months following release; and Whereas, inarcerated individuals are often restricted from accessing rehabilitative social services such as the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid either through a lack of meeting eligibility requirements or personally held beliefs by incarcerated individuals surrounding eligibility and accessing resources; and Whereas, when provided assistance and access to expedited Medicaid enrollment, reentering individuals were more likely to access health services and receive prescriptions; and 263 Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; therefore, be it RESOLVED, that ISMA support legislation that improves access to comprehensive physical and behavioral health care services for juveniles and adults throughout the incarceration process from intake to re-entry into the community; and be it further RESOLVED, that ISMA support legislation that removes barriers and increases access to social services and benefits apropos to the respective situations of incarcerated individuals and re-entering individuals, such as: (a) food subsidies; (b) healthcare, including Medicare and/or Medicaid; and (c) housing; and be it further RESOLVED, that ISMA work with relevant stakeholders to create discharge planning and programs that connect reentering individuals with primary care providers and medical homes within the community

Improving Health in Incarcerated Women

Whereas, research often uses gendered language such as “women” or “woman” to describe patients; however, the authors of this resolution recognize that individuals of all gender identities can become pregnant; and Whereas, between 1980 and 2020, the number of incarcerated women in federal and state prisons and county jails has increased by more than 475%; and Whereas, though more men are incarcerated than women, the rate of growth for incarceration of women has been twice that of men since 1980; and Whereas, the imprisonment rate for Black women was 1.7 times the rate of imprisonment for White women, and the rate of imprisonment for Latinx women was 1.3 times the rate of White women in 2020; and Whereas, in 2020, Indiana had the 12th highest female imprisonment rate nationally, at 64 per 100,000, while the national average was 42 per 100,000; and Whereas, the number of women incarcerated in Indiana’s jails has increased more than 25-fold from 1970 to 2015, while the number of women in Indiana prisons has increased more than 19-fold from 1978 to 2017; and Whereas, a 1999 report by the Federal Bureau of Justice Statistics, which is the most recent report to study abuse prior to incarceration, found that 57% of women in state facilities had experienced sexual or physical abuse prior to their incarceration; and Whereas, the link between domestic violence and incarceration of women is evidenced by the fact that the crimes for which women are incarcerated are often directly related to domestic abuse; and Whereas, a 2008 report from the Bureau of Justice found 4% of state and 3% of federal inmates to be pregnant at the time of admission, while only 54% received some type of prenatal care; and Whereas, Indiana does not provide screening and treatment for high-risk pregnancies and only recently passed legislation to limit the use of restraints; and Whereas, a 2016-2017 survey conducted by the Pregnancy in Prison Statistics Project found 3.8% of newly admitted women and 0.6% of all women were pregnant in December 2016, with 92% of these pregnancies resulting in live births, meaning that policymakers and public health practitioners can optimize outcomes for incarcerated pregnant women and their newborns; and Whereas, a 2008 report from the Bureau of Justice found a statistically significant difference between reported specific medical problems among females (57% in state prisons, 52% in federal prisons) compared to their male counterparts (43% in state prisons, 36% in federal prisons), with arthritis, asthma, and hypertension being the most commonly reported problems; and Whereas, three fourths of incarcerated women are of childbearing age (18-44 years old), and therefore are still menstruating but must pay for their own feminine hygiene products if they do not have the means to afford necessary hygiene products; and Whereas, the AMA (H-525.974) recognizes the financial burden of feminine hygiene products, classifies them as medical necessities, and advocates they be provided free of charge to all incarcerated women; and Whereas, women have specific health needs, including reproductive, gynecologic, and prenatal care, trauma- informed mental health care, and substance abuse care; and Whereas, prisons remain ill-equipped to provide adequate mental and physical healthcare for women inmates; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; therefore, be it 78 RESOLVED, that ISMA seek and support legislation that improves access to comprehensive reproductive and physical health care services to women throughout their incarceration from intake to re-entry into the community; and be it further, RESOLVED, that ISMA seek and support legislation that increases allocation of healthcare for women’s prisons within the Indiana Department of Corrections and local county jails in Indiana; and be it further, RESOLVED, that the ISMA adopt AMA H-525.974, as amended, as follows: AMA ISMA: (1) recognizes encourages the Internal Revenue Service to classify feminine hygiene products as medical necessities; (2) will work with federal, local, state, and specialty medical societies, and other relevant stakeholders to advocate for the removal of barriers to feminine hygiene products in state and local prisons and correctional institutions to ensure incarcerated women be provided free of charge, the appropriate type and quantity of feminine hygiene products including tampons for their needs; and (3) encourages the American National Standards Institute, the Occupational Safety and Health Administration, and other advocates and seeks legislation for the state to provide access to free, readily-available feminine hygiene products to all incarcerated women. relevant stakeholders to establish and enforce a standard of practice for providing free, readily available menstrual care products to meet the needs of workers

Developing a Minimally Invasive Cell-Based Model to Predict Response to Major Trauma

Background. Physical trauma results in a systemic inflammatory response. Preliminary research in orthopedic trauma patients suggests that patients with similar demographics and severity of injury vary in their response to traumatic injury. Analysis of the immunological response post-injury showed a sustained pro-inflammatory response with delayed reparative cytokine expression in trauma sensitive patients, while the trauma tolerant patients had an early inflammatory expression with resolution by 72 hours post-injury. Thus, we hypothesize that differential response to non-traumatic injury might serve as a predictive tool for the identification of trauma tolerant and sensitive patients prior to injury. The goal of this research is to test whether immunological changes to inflammatory stimuli can predict tolerance or sensitivity to trauma using an-vitro cell-based assay. Methods. Splenocytes were isolated from naive C57BL/6 mice and subjected to biological trauma in vitro using LPS (100 ng/mL) or hypoxic trauma using hydrogen peroxide (50 µM, 100 µM, and 200 µM) with or without proinflammatory cytokines, IL-1β (1 ng/mL) , IL-6 (200 ng/mL), and IL-33 (150 ng/mL). Inflammation and hypoxia were assessed using IL-6 and HIF-1ɑ expression respectively via qPCR 24 hours post-treatment. Cell death and pro-inflammatory cytokine production using multiplex analysis were used to measure outcomes. Results. Both types of treatments showed increased cell death compared to the control group. qPCR data is pending. Conclusion. With these studies as a core of the experimental approach, this in vitro cell-based assay will be used to assess immunologic response to inflammatory stimuli across the genetic variation of mouse strains. Findings from this project could enable the development of a clinical test that accurately predicts immunologic response to trauma and related-complications based on patients’ sensitivity to pre-traumatic injury