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Item Postpartum Hepatic Infarction in Antiphospholipid Syndrome Patients(2021-03) Joseph, Sophia; Hardman, Sara; Zeh, Janie; Sivamohan, Anjali; Mehta, RakeshCASE: Our patient is a 31-year-old woman with a complicated past medical history of Systemic Lupus Erythematosus (SLE) and Antiphospholipid Ayndrome (APS). She originally presented several years ago when she was found to have Libman-Sacks endocarditis. She was diagnosed with SLE and APS at the time and was subsequently anticoagulated with warfarin. When she became pregnant, warfarin was discontinued and she was managed with a low molecular weight heparin (LMWH). She was continued on LMWH post-partum, but was noncompliant. For a few weeks following delivery, she presented to the hospital on several occasions with acute right upper quadrant pain. CT imaging confirmed several hepatic infarcts and she was treated with steroids, fondaparinux, and plaquenil. CONCLUSIONS: APS poses several risks during and after pregnancy due to susceptibility to venous and arterial thrombosis1. There is an increased risk of thrombosis up to 12 weeks postpartum. Continuation of anticoagulation following delivery is essential in APS women who have a high baseline risk of thrombosis2. Non-compliance with medications may have contributed to this presentation. This case is unique in that hepatic infarcts rarely occur due to the dual blood supply of the liver. Moreover, the diagnosis of hepatic infarction can be difficult as it may present similarly to HELLP, possibly contributing to her multiple admissions with RUQ pain3,4. CLINICAL SIGNIFICANCE: This case is significant because it demonstrates the rare, but life-threatening risk of postpartum hepatic infarction in APS patients. Proper postpartum management and compliance with anticoagulation medications are essential to mitigating risk. Furthermore, providers may face challenges in diagnosing hepatic infarction as it could mimic other diseases.Item Children’s Dietary Quality and Micronutrient Adequacy by Food Security in the Household and among Household Children(2019-04-27) Jun, Shinyoung; Zeh, Mary J.; Eicher-Miller, Heather A.; Bailey, Regan L.Children’s food-security status has been described largely based on either the classification of food security in the household or among household children, but few studies have investigated the relationship between food security among household children and overall dietary quality. Our goal was to examine children’s dietary quality and micronutrient adequacy by food-security classification for the household and among household children. Data from 5540 children (2–17 years) from the National Health and Nutrition Examination Survey (NHANES) 2011–2014 were analyzed. Food-security status was assessed using the U.S. Household Food Security Survey Module and categorized into high, marginal, low, and very low food security for the households and among household children. Dietary quality and micronutrient adequacy were characterized by the Healthy Eating Index (HEI) 2015 and Mean Adequacy Ratio (MAR; based on total nutrient intakes from diet and dietary supplements), respectively. The HEI 2015 scores did not substantially vary by either food-security classification, but the MAR was greater in high compared to very low food security in households and among household children; a linear relationship was found only among household children. In general, very good agreement was observed between the classifications, but the strength of agreement differed by children’s age, race/Hispanic origin, and family income. In conclusion, micronutrient adequacy, but not dietary quality, significantly differed by food-security status. While the agreement between food security in the household and among household children is very good, classification of food security among household children may be more sensitive to detecting differences in exposure to nutrients.Item We Do it For Our Neighbors: Ethics in Action at a Student-Run Free Clinic(2022-03-31) Kabir, JasonThe Covid-19 pandemic presents a disruption in the services offered by healthcare facilities across the nation, including student-run free clinics (SRFCs). SRFCs may face extended disruptions during the pandemic due to the sponsoring schools’ policies to protect students and patients. However, restricting students from participation in SRFCs comes at the cost of acute and chronic disease management of patients, many of whom are marginalized populations whose only source of healthcare is free clinics. In this paper, we will argue how the management of a SRFC and the trust it has built in its community can demonstrate the emphasis on patient care over volunteer or learning experiences for students. There is literature proposing a virtues-based ethical framework with patients’ needs as the first consideration in management of SRFCs(1). We will demonstrate what these principles in the ethics literature look like in practice at a SRFC. We will explain mechanisms by which leaders of a student-run free clinic can take ownership of the care of their patient population, such as by following up appropriately on screening and diagnostic tests offered and having appropriate avenues for referral if results are abnormal. We will present ethical considerations that arise with this ownership and balancing a student-led learning environment with equitable patient care, as well as opportunities for improvement. Implementation of these practices can be used to argue the importance of SRFCs for communities in the face of disruptions related to the Covid-19 pandemic and beyond. 1. Coverdale JH, McCullough LB. Responsibly managing students’ learning experiences in student-run clinics: A virtues-based ethical framework. Teaching and Learning in Medicine [Internet]. 2014 Jul 10 [cited 2021Nov 24];26(3):312-15. Available from: https://doi.org/10.1080/10401334.2014.910460Item Balancing Access to Care and Volunteer Well-Being Through a Student-Run Free Clinic Phone Line Operating Model(2022-03-27) Kabir, Jason; Bednarski, OliviaIntroduction/Problem: Many student-run free clinics (SRFCs) take on the role of primary care for their underinsured patient population, which necessitates patients having access to communication with the clinic. However, this can be difficult for SRFCs due to limited operating hours and competing educational and personal responsibilities of students running the clinic. Several volunteers at our SRFC elect to use their personal phone numbers to communicate with patients throughout the week, but it is important for the clinic to have an official phone number to serve as a centralized contact point for the community members it serves. We will describe various methods of phone communication with our patients and focus on our newly-implemented model for operating a clinic phone line. Methods/Interventions: We maintain a prepaid clinic cellular phone funded by student fundraising efforts. Each week one medical executive board member is in possession of the phone and is responsible for responding to calls. A second board member who is a 4th year medical student (MS4) serves as a back-up call for the first board member to contact should they have questions about how to handle a patient’s inquiry. Board members are expected to keep a log of each phone call, voicemail, or text message and the action they took on a shared HIPAA-secure Google Drive. These logs were reviewed to evaluate this model. Results: Each board member was “on call” for a median number of 2 weeks and each MS4 board member was back-up call for a median of 5 weeks in 2021. Phone logs were kept for 15 weeks from January to November 2021. A total of 87 interactions with patients were documented, including 21 appointment questions, 12 general questions, 8 inquiries about medication refills, and 8 questions following up on their most recent clinic visit. The average monthly cost of keeping the phone line active from January to November 2021 was $28. Conclusion: Maintaining a clinic phone can be a cost-effective method to ensure patients at an SRFC have access to their providers while also protecting volunteers’ privacy and personal time. Dividing responsibilities for making necessary outgoing calls and taking incoming patient calls among clinic leadership reduces the burden on individual leaders. SRFCs are an important part of students’ training, and this model can be implemented at SRFCs to promote a culture of establishing professional boundaries.Item Why Did You Draw My Blood?: A Model for Lab Follow-Up Allowing Dynamic Treatment Plans at a Student-Run Free Clinic(2022-03-26) Kabir, JasonIntroduction/Problem: Prompt review and communication of lab results to patients is critical for forming appropriate treatment plans, but it can be a difficult task for student-run free clinics (SRFCs) due to a number of limiting factors, including week-to-week turnover of clinic volunteers and staff. The previous model employed by our SRFC placed the responsibility on one clinic manager the morning of the following clinic day, one week later. This placed a necessary but disproportionate stress on this clinic manager who was less familiar with the previous week’s patient encounters and could not make dynamic changes in patients’ treatment plans due to time constraints. We will present the details of a new model employed by our SRFC for lab follow-up. Methods/Interventions: The responsibilities of entering lab results into the electronic medical record (EMR) and calling patients with their results is divided among five clinic managers to be completed each week following Saturday clinic. Completion of lab follow-up is documented in a shared HIPAA-secure Google Sheet. This hand-off sheet was reviewed with cross-reference to the EMR to evaluate the new model. Results: From March to November 2021, a total of 324 phone conversations and an additional 170 attempts to communicate lab results with patients were documented. Twenty-four of those conversations resulted in a follow-up appointment being made sooner than planned during the previous encounter; 41 conversations included counseling on lifestyle modifications; and 53 conversations included additional counseling on the results, return/emergency department precautions, or connection to a higher level of care. Seventy-three percent of the conversations communicating abnormal results had actions like these beyond communication of the results documented. Conclusion: Dividing lab follow-up responsibilities among clinic leadership following each clinic day allows patients to be more in control of their health and avoids delays in care. This model also relieves pressure and saves time for volunteers the next clinic day by allowing them to focus on the encounters occurring that day. Developing a systematic approach for communication of lab results was an advancement for our SRFC, and this model can be applied at SRFCs across the nation.Item The Case for the Safe Re-Opening of SRFCs during COVID-19(Journal of Student-Run Free Clinics, 2021) Hopfer, Sarah; Neese, Olivia; Miller, Reese; Swiezy, SarahAt the end of February 2020, the Mollie R. Wheat Memorial Clinic (MWMC), an SRFC in Terre Haute, IN, closed its doors to protect its volunteers and patients from the acute threat of the novel coronavirus. Faced with an uncontrolled contagion and the threat of clinics as a nidus of infection, medical school administrators implemented a short term solution: they shut down all SRFC operations. In October 2020, MWMC, employing student-written infection control protocols, re-opened without students in patient-facing roles as a compromise with medical school administration, who were concerned for the safety of their students, in order to again provide necessary care to its community. This essay, written and submitted during one of the peaks of the pandemic, makes an argument in four parts for opening SRFCs sooner rather than later during a public health crisis, using COVID-19 as its example. The COVID-19 pandemic seems to be waning in America, though the threat of variants loom, and whether or not this is the big pandemic of our lives, over time, there will be other pandemics. The authors hope this essay will provide some future guidance to SRFCs and their medical school administrators for how best to work together to continue serving their communities during a pandemic.Item Being Born into a Pandemic: COVID-19 and Pregnancy(2021) Swiezy, Sarah; Campbell, Meredith; Eckert, NicoleCase #1: 34yo Asian female G2P1001 presents COVID19+ in 1st trimester. PMH insignificant. Meds: prenatal vitamins. Surg Hx: c/s healthy boy (2017). No h/o GHTN, GDM, or eclampsia. D/t COVID19+ infection, frequent fetal u/s monitoring done at 32w5d, 34w5d, 38w0d. Fetal growth over time: 63.4%, 48.8%, 14.3%. Fluid over time: AFI 8.58cm, MVP 4.52cm; AFI 10.86, MVP 3.52; AFI 2.73, MVP <2. Oligohydramnios diagnosed at 38w0d; emergent repeat c/s performed. Mother and baby healthy s/p delivery, d/c home on PPD#2. Pathology of placental tissue shows increases in villous fibrin accumulation and maternal vascular malperfusion. Case #2: 29yo Caucasian female G1P0 presents to ED at 18w4d with c/o runny nose, cough, and headache; temp. 100.3*F; tests COVID+. PMH insignificant. Meds: prenatal vitamins. No h/o GHTN, GDM, or eclampsia. 21w0d u/s: growth 71.4%, normal anatomy. 30w0d u/s: growth at 82.3%, AFI 15.10cm, MVP 5.38cm. At 39w1d, healthy infant boy (7lb12oz) via VAVD. Mother and baby healthy s/p delivery, d/c home on PPD#2. Placenta not sent for surgical pathology. Conclusion Due to the short time course of the COVID19 pandemic, adequate evidence to link maternal-fetal outcomes to infection during pregnancy is just now becoming available. Other coronaviruses, SARS and MERS, are preferentially fatal in pregnant mothers; and, adverse perinatal outcomes in COVID19+ women are appearing. Case reports have associated COVID19 with preterm birth; one study reported 47% preterm deliveries in COVID19+ mothers. Molecular studies have confirmed ACE2 (receptor allowing viral cellular entry) mRNA overexpression in placentas. Placental histopathology has shown maternal-placental interfacing blood vessel anomalies. Clinical Significance COVID19 represents a monumental threat to public health. Pregnant women and fetuses may be at increased risk for complications compared to the general public. As yet, the relationship between COVID19 and pregnancy remains to be clarified and will require further investigations to understand associations and promote evidence-based treatment practices.Item A Case Series of COVID-19 and Pregnancy Outcomes(2021) Swiezy, Sarah; Eckert, Nicole; Campbell, MeredithIntroduction: COVID-19 has been the largest public health crisis of our lifetime. Much of the morbidity and mortality caused by COVID-19 has been due to lack of adequate research and understanding of the virus. In the absence of data for COVID-19, scientists have used evidence collected during other coronavirus outbreaks, including SARS and MERS, to forecast outcomes in different populations. Both of these coronavirus outbreaks were preferentially fatal in pregnant women, suggesting that COVID-19 may also have grave consequences for gravid women and their fetuses. Given that molecular studies have confirmed that COVID-19 enters cells through the ACE-2 receptor, which is also present on human placental cells, there is potential for COVID-19-induced abnormalities in the interface between mom and baby, leading to maternal-fetal morbidity or mortality. To date, several case series have demonstrated adverse perinatal outcomes in COVID-19-positive pregnant women, including placental abnormalities and pre-term birth; however, these studies have been limited in scale and scope. More data is needed to fully understand the implications of COVID-19 infection in pregnancy so that evidence- based treatment recommendations can be made to OB/GYNs caring for COVID+ patients. Methods: We reviewed the charts of all of the pregnant women presenting for routine obstetric care to the UAP OB/GYN offices in Terre Haute, IN between Nov 2020 and Feb 2021. We identified 33 women who were pregnant at the time of COVID-19 infection. Data were input into a Qualtrics survey for ease of viewing the results. Results/Conclusions: We are currently waiting for 6 (18%) of the patients in our sample to deliver in the next 4-6 weeks To date we have a sample of mostly Caucasian women infected in their 2nd and 3rd trimester. Here we evaluate their pre-, peri-, and immediate post-partum maternal and infant outcomes.Item Truth and Transparency in Crisis Pregnancy Centers(Women's Health Reports, 2020-07-27) Polcyn, Carly; Swiezy, Sarah; Genn, Leah; Wickramage, Pavithra; Siddiqui, Neha; Johnson, Candice; Nair, Pooja; Bernard, Caitlin; Miller, VelvetThe prevalence of crisis pregnancy centers (CPCs), their false claims, and the real harm they cause necessitate public education about their unethical practices. Also called ‘‘pregnancy resource centers’’ and ‘‘pregnancy sup- port centers,’’ CPCs are nonmedical institutions designed to deceive women seeking comprehensive pregnancy care, as their volunteers are instructed to pedal misinformation about reproductive health care.Item Endocannabinoids Regulate Cerebellar Granule Cell Differentiation(2017-09) Essex, Amanda; Black, Kylie; Baygani, Shawyon; Mier, Tristan; Martinez, Ricardo; Mackie, Ken; Kalinovsky, AnnaThe cerebellum plays a crucial role in learning and execution of complex automated behaviors, including fine motor skills, language, and emotional regulation. Cerebellar development continues throughout an extended postnatal period. The most numerous neurons in the cerebellum, as well as the entire brain, are the cerebellar granule cells (GCs), which are generated in a dedicated secondary proliferative zone, the external granule cell layer (EGL), during the first three postnatal weeks in mice, and over a year in humans. The robust expansion of granule cells during early development is responsible for the majority of cerebellar expansion. Morphological and molecular changes that drive GC proliferation and differentiation have been extensively characterized, starting from the developmental studies by Santiago Ramón y Cajal. GC progenitors (GCPs) proliferate in the outer EGL (oEGL). As they are pushed into the inner EGL (iEGL) by the newly generated GCPs, they exit the cell cycle and begin differentiation, first extending bipolar neurites, followed by tangential migration, and eventually radial migration to the inner granule cell layer (IGL), their target territory. Deregulation of GCPs expansion, proliferation to differentiation switch, or the rate of migration could contribute to abnormal cerebellar size and compartmentalization and disrupt cerebellar circuits’ wiring and function. Endocannabinoids (eCBs) have been identified as key players regulating neuron proliferation and migration in the fore- and mid-brain development, however their role in cerebellar development has not yet been explored in detail. Our preliminary results show robust expression of cannabinoid receptor 1 (CB1) in iEGL GCs, concomitant with expression diacylglycerol lipase α (DGLα) a major enzyme required for the synthesis of eCB 2-arachidonoylglycerol (2-AG), in PCs. Furthermore, our preliminary results show that cerebellar size is reduced in CB1 KOs. In this study we investigate the mechanisms through which eCB signaling may regulate GC proliferation and differentiation, focusing on the GCPs cycle length, rate of differentiation and migration.