Implementing Scheduled Women’s Health Clinics at Free Student Outreach Clinic

Introduction/Problem: Since 2009, Indiana University Student Outreach Clinic (IU-SOC) has served the underinsured and uninsured members of the Indianapolis community. Many barriers to care exist within this community, from low income to lack of documented immigration status. One of the most concerning vulnerable populations observed was pregnant patients. Five years ago, the IU-SOC addressed this via creation of Women’s Health days on Saturdays every other month and in 2020 by creating an as needed prenatal clinic. However, the need still existed for general, non-prenatal women’s health concerns, which led to the expansion to a twice monthly general women’s clinic staffed by a board-certified obstetrician-gynecologist (OB/GYN). Methods/Interventions: In April 2021, twice monthly scheduled clinics were implemented for two hours on Wednesday evenings staffed by OB/GYNs or obstetrics-trained family medicine physicians. Additionally, the team available on Wednesday clinics expanded to include a women’s health specific clinic manager, women’s health patient navigator to facilitate referrals, and women’s health education specialist to address low health literacy. Results: In 2021, 15 women’s health clinic days have been hosted since April,expanding beyond prenatal patients and resulting in increased volume of this clinic. There were a total of 36 patient encounters from 31 different patients including eight pregnant patients. Other chief concerns addressed at the clinic included: infertility/preconception counseling, abnormal uterine bleeding, pelvic pain/mass, vaginal itching, dyspareunia, and preventive women’s health visit. Six patients received pap smears and sexually transmitted infection (STI) screening. Low pap smear and STI screening rates at the women’s health clinic are attributed to the presence of women’s health fourth year student representatives at general clinic days ensuring most patients receive pap smears and STI screenings prior to referral. Conclusion: We implemented a twice-monthly, referral-based women’s health clinic in 2021 that has successfully provided care for 31 different patients including eight pregnant patients for a variety of chief concerns and preventive care encounters. The presence of a certified OB/GYN has ensured appropriate management of prenatal and primary care women’s health issues. Consistent provision of women’s health care services helps to mitigate the many barriers to women’s health care in our Indianapolis community

Management of Severe Coarctation of the Aorta During Pregnancy

An 18-year-old primigravida woman underwent emergent percutaneous balloon stent repair of a severe coarctation of the aorta, allowing her to undergo an uneventful remaining pregnancy and the delivery of a healthy baby. Her case also demonstrates the association between maternal coarctation and fetal Shone complex. (Level of Difficulty: Beginner.

Multivariate analysis of FcR-mediated NK cell functions identifies unique clustering among humans and rhesus macaques

Rhesus macaques (RMs) are a common pre-clinical model used to test HIV vaccine efficacy and passive immunization strategies. Yet, it remains unclear to what extent the Fc-Fc receptor (FcR) interactions impacting antiviral activities of antibodies in RMs recapitulate those in humans. Here, we evaluated the FcR-related functionality of natural killer cells (NKs) from peripheral blood of uninfected humans and RMs to identify intra- and inter-species variation. NKs were screened for FcγRIIIa (human) and FcγRIII (RM) genotypes (FcγRIII(a)), receptor signaling, and antibody-dependent cellular cytotoxicity (ADCC), the latter mediated by a cocktail of monoclonal IgG1 antibodies with human or RM Fc. FcγRIII(a) genetic polymorphisms alone did not explain differences in NK effector functionality in either species cohort. Using the same parameters, hierarchical clustering separated each species into two clusters. Importantly, in principal components analyses, ADCC magnitude, NK contribution to ADCC, FcγRIII(a) cell-surface expression, and frequency of phosphorylated CD3ζ NK cells all contributed similarly to the first principal component within each species, demonstrating the importance of measuring multiple facets of NK cell function. Although ADCC potency was similar between species, we detected significant differences in frequencies of NK cells and pCD3ζ+ cells, level of cell-surface FcγRIII(a) expression, and NK-mediated ADCC (P<0.001), indicating that a combination of Fc-FcR parameters contribute to overall inter-species functional differences. These data strongly support the importance of multi-parameter analyses of Fc-FcR NK-mediated functions when evaluating efficacy of passive and active immunizations in pre- and clinical trials and identifying correlates of protection. The results also suggest that pre-screening animals for multiple FcR-mediated NK function would ensure even distribution of animals among treatment groups in future preclinical trials

Human Sexuality Case Based Learning: Endocrine, Reproductive, Musculoskeletal and Dermatology Course, IUSM

PURPOSE AND APPROACH: The goal is to help students understand the human sexual response. Students will review sexual health and risks to sexual health. SESSION OBJECTIVES: Describe the definitions of sexual health promoted by the World Health Organization and Centers for Disease Control; explain the four phases of the sexual response cycle (excitement, plateau, orgasm and resolution) in women and men; compare and contrast sexual dysfunction in men and women; list the various sexual practices engaged in by men and women; and explain the health risks associated with various sexual practices, and the interventions recommended to reduce this risk

Treatment for Pelvic Floor Myalgia and Myofascial Pelvic Pain: A Systematic Review

Introduction Pelvic floor myalgia is characterized by muscular tension, tenderness and trigger points of the pelvic floor muscles and connective tissue. Its prevalence varies from 14-78%. Our aim was to review treatment interventions for adult women with pelvic floor myalgia Methods A systematic review of prospective trials was conducted in MEDLINE (Ovid/PubMed), EMBASE, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov. Studies published up until March 2020 were included. After duplicates were removed, 7,711 studies were screened and 992 full texts were reviewed for final inclusion of randomized control trials (RCT) only. To meet inclusion criteria, study participants needed to have pelvic floor myalgia, hypertonicity or pain determined by a physical exam. All interventions were included. Results After final data extraction, 18 studies met inclusion criteria, which included 1043 participants. Most studied interventions were pelvic floor physical therapy (4 studies, 218 participants) and pelvic floor botulinum A toxin injections (4 studies, 281 participants). Other interventions included vaginal diazepam (3 studies, 112 participants), oral desipramine/local lidocaine (1 study, 133 participants), cognitive behavioral therapy (1 study, 117 participants), hypnotherapy (1 study, 36 participants), local anesthetic trigger point injections (1 study, 29 participants), and oxytocin nasal spray (1 study, 21 participants). Conclusions Many studies showed a placebo effect possibly indicating that simple acknowledgement of pain symptoms with a treatment plan can improve pain. Physical therapy showed significant improvement in pain and sexual functioning compared to controls. Botulinum toxin A was not proven to be beneficial for pelvic floor myalgia and hypertonicit

Human Antibody-Dependent Cellular Cytotoxicity-Mediating Antibodies Do Not Recruit Non-Human Primate CD20+ NK Cells

The antibody-dependent cell-mediated cytotoxicity (ADCC) response represents one of mechanisms through which the immune system destroys tumor or infected cells. During the ADCC response to HIV-1, natural killer (NK) cells are recruited by natural infection- or vaccine-induced antibodies (Abs) bound to the HIV-1 envelope glycoproteins expressed on infected CD4+ T cells via Fc-gamma Receptor IIIA (Fc-R IIIA). The NK cells’ Ab-mediated recognition of the infected cells leads to the release of granzymes and perforin by degranulation, triggering apoptotic signal pathways in the infected cells and ultimately leading to their elimination. We have optimized an assay to investigate the degranulation of non-human primate (NHP) NK cells from five different NHP donors by measuring levels of CD107a, a marker present on the inner membranes of NK lysosomes. Using one NHP and two human monoclonal antibodies (mAbs), we compared degranulation of NK in NHP splenocytes, NHP peripheral blood mononuclear cells (PBMC), and human PBMC. We observed that both NHP and human mAbs recruited NHP and human NK effector cells. Of note, we examined the activity of CD20+ and CD20- NK cells, with the former being NK cells from a unique subset of NHP NK splenocytes. Our analysis suggests that CD20+ cells likely do not play a role in the NHP ADCC response. In conclusion, we can identify the cellular populations responsible for the Ab-mediated killing of HIV-1 infected cells, and we will be able to further analyze their full functional profile at the level of messenger RNA expression, i.e. their transcriptomic profile

Long-acting reversible contraception knowledge & intent to use among US university students.

OBJECTIVES: More than 50% of births to women in the United States in their early 20s are unintended, and unintended pregnancies have adverse consequences on students’ education.Long-acting reversible contraceptives (LARC) offer highly-effective, long-term prevention of pregnancy, yet are utilized at low rates. Thus, we sought to assess the level of students’ LARC knowledge and any association with intent to use LARC at a large, urban university in the Midwest United States. We hypothesized that students with higher levels of LARC knowledge would be more likely to intend to use LARC in the future. We also hypothesized that fewer students would use LARC compared to the US rate of 15.8% of all contraceptive users in 2017. Data on student knowledge and attitudes regarding LARC will be used to inform a campus LARC initiative. METHODS: We designed and administered a cross-sectional survey to 300 undergraduates, graduate students, and resident physicians that assessed sexual experiences, contraceptive use, LARC knowledge, and intent to use LARC. The survey was administered at the university’s student center and student health facility in Indianapolis, Indiana. Participants’ demographic characteristics and LARC knowledge were summarized using descriptive statistics. Awareness of different LARC methods was assessed using McNemar’s test. The association between students’ reported LARC knowledge and future intent to use a LARC method was calculated with Fisher’s exact test. RESULTS: Our preliminary analysis includes 126 students. The mean age was 20.2 years. Mean score on the 10-question LARC assessment was 5.2/10. Higher levels of LARC knowledge were positively associated with future intent to use LARC (P < 0.05). Only 7.9% of contraceptive users surveyed used LARC, compared to 15.8% of US contraceptive users in 2017. Differences in awareness of the copper IUD (61.1%), hormonal IUD (74.6%) and implant (88.9%) were statistically significant (P < 0.05). The most common reason cited for not considering LARC use was “need for more information.” Conclusions: University students surveyed displayed low LARC knowledge, low LARC use, and a need for more information on LARC. A positive association between LARC knowledge and future intent to use LARC amongst students at this university further supports need for a campus-wide contraceptive initiative that will empower students to make informed reproductive decisions. Understanding student use and knowledge of LARC could also provide a model for starting other university LARC initiatives across the United States, at which uptake of LARC has been historically low

Myocarditis in an 18-Year-Old with Ulcerative Colitis

Watch video presentation here: [LINK]https://vimeo.com/512369169[/LINK]CASE DESCRIPTION: An 18-year-old woman with recently-diagnosed ulcerative colitis (UC) on mesalamine presented with chest pain worsened by inspiration and exertion, dyspnea, and subjective fever for 6 hours. She had a self-limited dry cough 2 weeks prior. SARS-CoV-2 PCR was negative. At presentation, her hemoglobin was 7.1 g/dL. EKG showed sinus tachycardia. Peak troponin was 0.21 ng/mL. Transthoracic echocardiogram showed a possible mildly hypokinetic apex, and vasodilator stress test was normal. Due to persistent hematochezia and the possibility of mesalamine-induced myocarditis, mesalamine was changed to sulfasalazine for her UC. The patient was otherwise treated supportively and referred for outpatient cardiac MRI, but declined the study. Subsequently, Coxsackie B Virus Antibody Type 3 titer was strongly positive at > 1:640, confirming viral myocarditis. CONCLUSIONS: This case describes the work-up of an 18-year-old female patient with UC presenting with acute onset chest pain and fever. Differential diagnosis included viral myocarditis, mesalamine-induced myocarditis, pericarditis, pulmonary embolism, acute coronary syndrome (ACS), and multisystem inflammatory syndrome in children secondary to SARS-CoV-2. CLINICAL SIGNIFICANCE: Global incidence of viral myocarditis is 22 cases per 100,000 individuals annually; though significantly more common in males, female patients often present with more severe disease. Suspected myocarditis warrants an initial EKG and cardiac biomarkers followed by echocardiography, and when indicated, testing for ACS. While acute myocarditis is most commonly caused by coxsackievirus B3 and adenovirus in the U.S. and is treated supportively, several case reports of mesalamine-induced myocarditis prompted specific management for this patient with newly diagnosed UC. Thus, the acuity and incidence of myocarditis present a learning opportunity for differential diagnosis building and workup for young female patients with acute onset chest pain

Management of Coarctation of the Aorta during Pregnancy: A Case Report.

BACKGROUND: Patients with coarctation of the aorta are increasingly reaching child-bearing age. Unrepaired coarctations and/or repaired coarctations with recurrent or residual stenosis require close monitoring for hypertension and heart failure, which can increase maternal risk for aortic rupture or dissection and neonatal risks for intrauterine growth retardation, abruptio placentae, and premature delivery. The potential for adverse outcomes may necessitate repair during pregnancy. CASE: An 18-year-old primigravida at 11 weeks gestation with history significant for unrepaired coarctation of the aorta presented with chest pain for 2-3 days and nonpalpable lower extremity pulses. She was previously diagnosed with coarctation at age 3 years, which did not require surgical repair and she was subsequently lost to follow up. Echocardiogram (ECHO) showed a dilated ascending and transverse aorta with decreased pulsatility in the descending aorta, consistent with critical coarctation. Emergent cardiac catheterization was performed and a balloon expanded stent was used to dilate the area of coarctation. Post-procedurally she had zero gradient and went on to have an uneventful pregnancy and delivery. She is now a 23-year-old G5P3. She has two living children with Shone’s complex and had two pregnancies end in miscarriages. Fetal ECHO was performed for each pregnancy and the patient received genetic counseling but declined further genetic testing. CLINICAL SIGNIFICANCE: This case illustrates a successful percutaneous repair of coarctation during pregnancy via balloon expanded stent placement. Fetal ECHO should occur from 18-22 weeks gestation in pregnant women with history of coarctation as prevalence of left-sided obstructive lesions may occur in 10–20% of first-degree relatives. As shared cardiac genetic markers exist between coarctation and Shone’s complex, this case also demonstrates the impact prenatal genetic testing can potentially have on subsequent pregnancies and neonatal outcomes

Influenza Group 2 HA Stem-Only Nanoparticles Induce Heterotypic Immune Response

National Institutes of Health Summer Research Progra