Undergraduate Medical Education

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An Abscessed Tooth that Wasn't: An Unusual Case of Mumps in an Elderly Patient
(2020-03) Lin, Jenny; Willhite, Sydney; Moore, Hannah; Smith, Maddie; Duncan, Francesca
Case: A 62-year-old African American female with history of self-resolving parotitis initially presented with progressive neck and bilateral facial swelling. She attributed this to an abscessed tooth. CT revealed parotitis with inflammatory changes and mass effect on the hypopharynx and larynx, although the patient denied breathing difficulty. Antibiotics were administered for two days, discontinuing due to lack of abscess. Six days later, the patient presented with worsening facial swelling, sore throat, and dysphagia. She remained afebrile but with a WBC count of 12.8. Antibiotics and steroids were given. MRI displayed retropharyngeal space involvement of 2.6 cm in thickness. ENT performed surgical debridement and culture collection. Upon return from the OR, respiratory distress and inability to manage secretions resulted in intubation via an upright awake fiberoptic approach given concern for impending airway compromise. Finally, a positive IgM antibody to mumps virus was detected from the debridement culture. Discussion: The differential for nonsuppurative parotitis includes viruses, autoimmune disorders, and granulomatous inflammation. Paramyxovirus, specifically mumps, is the most common viral cause, with EBV, HSV, CMV, and HIV as other concerns. Autoimmune causes are Sjogren syndrome and SLE. Mycobacterium species are the likely granulomatous culprit. Though mumps is the most common viral cause of parotitis, it typically occurs in children and young adults, not fitting of the patient described. However, mumps cases have increased recently. MMR vaccination began in 1967 and cases decreased more than 99%; yet, since 2006 there have been outbreaks. Vaccine-induced protection may wane over time. Mumps is highly contagious and complications include meningitis, encephalitis, pancreatitis, and deafness, occurring more commonly in elderly patients. Patients with nonsuppurative parotitis should thus be surveyed for vaccination history and examined for MMR titers.
Acknowledging Racial and Ethnic Health Disparities in Mass Incarceration
(Indiana State Medical Association, 2022-06-06) Brown, Lucy; Clark, Sydney; Nunge, Rebecca A; Fazle, Trilliah; Cooper, Siena; Robinson, Peyton; Darroca, Roberto
Whereas, the United States incarcerates more people per capita than any country in the world, where the U.S. comprises only 4% of the world’s population, yet is home to nearly 16% of all incarcerated people in the world; and Whereas, in Indiana, the total jail population increased by 526% between 1970 and 2015, while rates of pretrial detainees have increased by 72% in the state’s 48 rural counties, 43% in the state’s 21 small/medium counties, 40% in the state’s 22 suburban counties, and 268% in Marion County alone since 2000; and Whereas, in 2015 in Indiana, when including jail, prison, immigration detention, and juvenile facilities, the incarceration rate was 765 per 100,000 people, well above the rate of the United States as a whole, which was 665 per 100,000 people; and Whereas, Black residents make up 10% of Indiana’s population, but represent 24% of people in jail and 34% of people in prison; additionally, pretrial populations, disproportionately Black and Hispanic, more than doubled from 2002 to 2017; and Whereas, in 2019, Native people made up 2.1% of all federally incarcerated people, larger than their share of the total U.S. population, which was less than one percent; additionally, Native women are particularly overrepresented in the incarcerated population, making up 2.5% of women in prisons and jails and only 0.7% of the total U.S. female population; and Whereas, populations of color are more impacted by the use of money bail, where Black defendants often receive higher bail amounts, even when controlling for legal factors such as offense severity; and Whereas, Black and brown defendants are 10-25% more likely to be detained pretrial or to receive financial conditions of release; and Whereas, significant racial and ethnic disparities exist among policing, arrests, and incarceration rates, which further exacerbate disparate health outcomes for Black communities, including, but not limited to, Black individuals disproportionately being stopped by the police, experiencing use of force and repeated arrests, serving sentences of life and life without parole, being sent to solitary confinement, and receiving convictions that place them on death row; and Whereas, nearly one in three Black men will ever be imprisoned, and nearly half of Black women currently have a family member or extended family member who is in prison; and Whereas, ISMA (RESOLUTION 15-31) advocates for improved health care of incarcerated individuals; however, ISMA has no policy acknowledging the inequitable burden of incarceration and policing on minoritized individuals and communities of color; and Whereas, the AMA (H-65.954) recognizes police brutality as a manifestation of structural racism which disproportionately impacts Black, Indigenous, and other people of color; therefore, be it RESOLVED, that ISMA recognize that unjust and disproportionate racial and ethnic disparities exist in policing, sentencing, and mass incarceration among Black, indigenous, and other people of color (BIPOC) and have devastating impacts on BIPOC communities; and be it further, RESOLVED, that ISMA refer to the Committee on Diversity, Equity and Inclusion for study on what policies would be germane for ISMA to act on regarding racial and ethnic disparities in mass incarceration.
Activation of the oncogene ERG by the Ras/ERK and PI3K/AKT pathways
(2019-08) Willhite, Sydney; Strittmatter, Brady; Hollenhorst, Peter
Background and Hypothesis: The TMPRSS2-ERG re-arrangement occurs in ~50% of prostate cancers and results in aberrant expression of the transcription factor ERG in the prostate. ERG is known to be activated by the Ras/ERK and PI3K/AKT pathways, however, the exact mechanism of this activation is not fully understood. The aim of this project is to identify how activation of these signaling pathways differentially effect transcription of ERG target genes. Experimental Design or Project Methods: In order to test how the Ras/ERK and PI3K/AKT pathways effect ERG target gene transcription, normal prostate epithelial cells (RWPE1) were transfected with constitutively active AKT in combination with phospho-mutants of ERG. These cell lines were then used to conduct Quantitative Reverse Transcription PCR and Western blotting of known downstream ERG target genes to identify how the activation status of these signaling pathways affected transcription and protein production. Results: Overall, our results demonstrate that ERG mediated transcription of the VIM gene, a marker of EMT, was activated by the Ras/ERK pathway and was repressed by the PI3K/AKT pathway. In addition, we found that ERG expression decreased FOXO1 protein expression in our cell lines regardless of Ras/ERK and PI3K/AKT status. Transcription and protein quantification was also measured for ERG target gene VEGFA, a critical regulator of angiogenesis. Conclusion and Potential Impact: This project helps identify the molecular mechanisms by which a common oncogene in prostate cancer is activated. Our results demonstrate how upstream signaling pathways differentially regulate oncogenic transcription and cell transformation. Overall, this project will provide insight to the molecular mechanisms of possible therapeutic targets in prostate cancer, the most common cancer amongst men.
Acute Heart Failure in the Setting of Post-Covid MIS-C: A Case Report
(2023-03-24) Luster, Taylor; Sloat, Brittany; Mederos, Alexa; Karam, Marie; Pavlik, Lauren; Duncan, Francesca
Introduction: Multi-inflammatory Syndrome in Children (MIS-C) has emerged as a rare, but severe complication of SARS-CoV-2 infection. Patients present with persistent fever, abdominal pain, diarrhea, vomiting, rash, mucocutaneous lesions, and in severe cases, shock. The diagnostic criteria are age < 21, fever, laboratory evidence of inflammation, multi-organ involvement, and a positive COVID-19 test or known exposure 4 weeks prior to symptoms onset. Case Description: A 17-year-old female with a history of prior COVID-19 infection presented complaining of chest pain, shortness of breath, headache, and fevers with a Tmax of 105F for 4 days. The patient was hypotensive, tachycardic, tachypneic, and hypoxic. Pertinent labs included: Na 126, BUN 48, Creatinine 2.1, ALT 62, AST 86, WBC 27.4, Hg 10.5, Troponin 0.96, Lactate 3.3, CRP 60, ESR 85, Procalcitonin 75, D-dimer 2.02, Fibrinogen >1000, COVID PCR negative, and COVID Ig-G reactive. CT chest was notable for bibasilar pulmonary opacites, cardiomegaly, and bilateral pleural effusions. Echocardiogram showed left ventricular ejection fraction of 21% and global hypokinesis. She was ultimately intubated due to respiratory failure and started on milrinone and vasopressors. She was treated with IVIG, aspirin, and methylprednisolone for MIS-C. She clinically improved and repeat echo showed an improved EF of 57% and was discharged after 10 days with a prolonged prednisone taper. Clinical Significance: The incidence of MIS-C is 316 per 1 million pediatric SARS-CoV-2 infections. This case demonstrates need for increased awareness of potential acute cardiac failure in adolescents with a recent history of COVID-19 infection, elevated inflammatory markers, and signs of multi-organ failure so that IVIG, aspirin and corticosteroids can be started immediately to avoid progression of MIS-C into acute cardiac failure. Conclusion: Pediatric presentation of SARS-CoV-2 infection can be mild, but there is a subset of patients that have been reported to develop MIS-C, a more severe post viral syndrome.
Adherence Barriers to Breast Cancer Treatment: Fragmentation of Care, Mood Disorders, and Substance Use Disorder
(2021-03) Wells, Lindsey; Brown, Lucy; Heitz, Adaline; Newton, Erin
Case: The patient is a premenopausal, recently divorced 40-year-old female with a history of alcohol use disorder, anxiety, and depression. She presented with a 3-month history of a palpable right sided breast mass and was found to have Stage IIB/IIIA ER+ PR+ invasive ductal carcinoma of her right breast. She successfully completed preoperative therapy followed by a right mastectomy. She subsequently had a relapse in her alcohol use disorder and since then has had inconsistent and incomplete radiation treatment. Her substance use led to the loss of her job, custody of her children, and social support. Conclusions: We identified four primary barriers to adherence to cancer treatment: fragmentation of care, major depressive disorder, generalized anxiety disorder, and substance use disorder. As a result of these mental health and systemic communication challenges, her treatment was discontinued and her care team lost her in follow-up. Clinical Significance: As many as 28% of breast cancer patients do not complete their recommended treatment, which increases risk for recurrent breast cancers. Discontinuation of and non-adherence to therapy for breast cancers are associated with increased mortality. Among breast cancer patients who have difficulty adhering to chemotherapy treatment, a common barrier is fragmentation of care. Studies have also indicated that anxiety and depression may play explanatory roles in non-adherence to breast cancer treatment. Prevalence of depression is as high as 24% among breast cancer patients. Furthermore, rates of co-occurrence of substance use disorders in cancer patients can reach up to 35%. Substance use disorders, including alcoholism, have been associated with increased rates of non-adherence and discontinuation of hormonal treatment in individuals with ER+ breast cancer diagnoses. Interventions addressing the occurrence of mental illness and fragmented cancer care are important steps in increasing adherence among these patients.
Adolescent/Young Adult (AYA) Subspecialty Patient and Parent Views on COVID-19 Vaccination
(2022-03) Hardman, Sara L.; Rahim, Mahvish Q.; Miller, Meagan E.; Coven, Scott L.; Jacob, Seethal A.; Zimet, Gregory D.; Meagher, Carolyn G.; Ott, Mary A.
Purpose: Adolescents/young adults (AYA) with hematologic and oncologic (heme-onc) conditions are important targets for vaccine outreach because they are at increased risk for complications from COVID-19. AYA patients may also need additional support, as they are transitioning from parent to independent vaccine decision-making. AYA with sickle cell disease (SCD) are of particular concern because a high proportion are African American and experience structural racism in addition to their illness. Our objective was to examine AYA and parent attitudes regarding the COVID-19 vaccine among heme-onc populations. Methods: As part of a larger IRB-approved study, we recruited vaccine decision-makers in pediatric SCD and oncology survivor clinics, including parents of adolescents under 18 years (n=35), AYA patients 18-21 years old (n=21), and parents of AYA patients 18-21 years old (n=14). After informed consent, participants completed a demographic survey and a semi-structured interview regarding their vaccine decision-making process. Example questions included “What do you see as the benefits of the COVID-19 vaccine?” and “What are your concerns about the COVID-19 vaccine?”. Saturation was reached. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Codes were developed from the literature and early interviews. Examples included “attitudes against vaccine,” “medical mistrust,” “hesitancy,” “vaccine side effects,” and “vaccine interactions with disease process.” Fisher exact statistical tests were performed to analyze quantitative data. Results: In SCD clinic, we recruited 31 index patients (mean age: 15.1±3.5 years; 30 African American and 1 Other or Mixed), yielding 11 AYA and 26 parent interviews. In survivor clinic, we recruited 26 index patients (mean age: 16.0±3.4 years; 20 White, 2 Hispanic or Latinx; 2 Other or Mixed, 1 African American, and 1 Asian), yielding 10 AYA and 23 parent interviews. Out of the total index patients, 8 had already received the vaccine, 13 were planning to receive it, 27 were considering it, and 9 had declined it. There was no clear relationship between patients’ diagnosis (SCD or cancer) and their vaccine decisions nor between the index patient’s age (under or over 18) and their vaccine decisions. A high proportion of participants saw benefits to vaccination, such as lowering personal risk, community benefits of preventing the spread of COVID-19, and a possible return to “normal.” However, many AYA and parent participants also had concerns toward the vaccine, including concerns about short-term side effects and the potential for unknown, long-term effects. Concerns were also voiced about how rapidly the vaccine was developed and misconceptions about the vaccine were common, namely the vaccine causing infertility or increasing one’s susceptibility to contracting COVID-19. Medical mistrust toward either the vaccine or providers was explicitly stated by several participants, the majority of whom were from minoritized groups. Conclusion: COVID-19 vaccines have the potential to protect medically and socially vulnerable AYA, however patient and parent concerns, misconceptions, and mistrust are still prevalent. These data provide insights into the design and implementation of vaccine counseling interviews for AYA subspecialty patients and families. Educational Objective: Examine adolescent/young adult and parent attitudes regarding the COVID-19 vaccine among hematology and oncology populations.
Age Disparities of Non-Fatal Shooting Victims in Official vs. Media Reports 2020 – 2022 Indianapolis, Indiana.
(2023-01-17) Spivey, Erin; Crawford, Jara; Kaur, Amarpreet; Magee, Lauren; Grommon, Eric
BACKGROUND Trends in the victimology of non-fatal shootings in Indianapolis reported upon by the media differ from official records, with possible implications on the preventative measures taken by the community and officials. OBJECTIVE Examine disparities between media reporting of non-fatal shooting victim ages and official records. KEY FINDINGS Since data collection of media reporting on gun violence victims in Indianapolis began in 2020, 46% of non-fatal shooting victims were reported on by the media. Of those, 9% of victims had a known age. From 2020 through 2022, juvenile victims of non-fatal shootings were 5.8 times more likely to be reported upon than adult victims. An average of 35% of juvenile victims were reported about in the media from 2020 through 2022 while 6% of adult victims were reported upon. The media was 5.3 times more likely to report on juvenile victims than adult victims in 2022 – 32% of juvenile victims were reported on while 6% of adult victims were reported on in 2022. Official records show approximately 89% of non-fatal shooting victims in the past 3 years are adults while 11% are juveniles. Among media reports of non-fatal shooting victims when age was known, 58% were adults and 42% were juveniles.
AMWA Conference: Effective Substance Abuse Treatment- Inpatient Bridges to Outpatient Care
(2021-03-06) Blaettner, Bianca; McKinzie, Alexandra; Young, Allison; Crawford, Jara; Robles MD, Maria
Analysis of Factors Contributing to Antenatal Corticosteroid Administration in Threatened Preterm Labor
(2022-07) Bode, Leah; McKinzie, Alexandra; Gidia, Nadia; Ibrahim, Sherrine; Haas, David
Introduction: Antenatal corticosteroids (ACS) are recommended for pregnant persons who are between 24 and 36+6/7 weeks’ gestational age (GA) and at risk for imminent delivery within 7 days. Many individuals diagnosed as having threatened preterm labor (tPTL) are given ACS but do not deliver until they reach term. This study aimed to describe characteristics of those seen for tPTL who receive ACS to better understand clinical decision-making. Methods: This retrospective cohort study consisted of mothers seen in triage at Eskenazi Hospital in 2021 for tPTL during pregnancy. Multiple demographic variables were evaluated against the primary outcome of ACS administration including maternal age, race/ethnicity, and prior preterm delivery, as well as obstetrical variables such as cervical dilation, effacement, membrane rupture, and tocolytic administration. Results: After exclusions, a cohort of 290 pregnant people with 372 unique encounters remained. The average maternal age was 26.7, and 15.6% of patients had a history of prior preterm birth. 107 patients in 111 encounters received ACS, which were associated with lower BMI, greater cervical dilation, greater effacement, membrane rupture, and more frequent contractions (all p<0.01). The mean GA at triage was 33.5 weeks. Logistic regression, adjusting for significant factors in the univariable analysis, found that BMI (OR 0.93, 0.89-0.97), cervical dilation (OR 1.34, 1.07-1.71), and cervical effacement (OR 1.02, 1.01-1.03) were significantly associated with giving ACS. 44% of those receiving ACS delivered within 7 days, compared to 11% of those who did not receive ACS (p<0.001). Conclusion: Greater cervical dilation and effacement and a lower BMI were associated with ACS administration, though most patients receiving ACS still did not deliver within 7 days. These findings will be further categorized and used to develop a clinical decisional model for administering ACS in those likely to imminently deliver preterm. Presentation recording available online: https://media.dlib.indiana.edu/media_objects/3b5922009
Anxiety or Arrhythmia: When Delayed Diagnosis Leads to Poor Outcomes
(2024-03-22) Morris, Ashlyn; Hornberger, Sydney; O'Farrell, Erin; Jaradat, Ziad

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