Faculty Bibliography

BACKGROUND:Despite decreasing rates of HIV among many populations, HIV-related health disparities among gay, bisexual and other men who have sex with men persist, with disproportional percentages of new HIV diagnoses among racial and ethnic minority men. Despite increasing awareness of HIV pre-exposure prophylaxis (PrEP), PrEP use remains low. In addition to exploring individual-level factors for this slow uptake, structural drivers of PrEP use must also be identified in order to maximize the effectiveness of biomedical HIV prevention strategies. METHOD/METHODS:Using cross-sectional data from an ongoing cohort study of young sexual minority men (N=492), we examine the extent to which structural-level barriers, including access to health care, medication logistics, counseling support, and stigma are related to PrEP use. RESULTS:While almost all participants indicated awareness of PrEP, only 14% had ever used PrEP. PrEP use was associated with lower concerns about health care access, particularly paying for PrEP. Those with greater concerns talking with their provider about their sexual behaviors were less likely to use PrEP. CONCLUSION/CONCLUSIONS:Paying for PrEP and talking to one's provider about sexual behaviors are concerns for young sexual minority men. In particular, stigma from healthcare providers poses a significant barrier to PrEP use in this population. Providers need not only to increase their own awareness of and advocacy for PrEP as an effective risk-management strategy for HIV prevention, but also must work to create open and non-judgmental spaces in which patients can discuss sexual behaviors without the fear of stigma.

Background/UNASSIGNED:A growing body of research continues to elucidate health inequities experienced by transgender individuals and further underscores the need for medical providers to be appropriately trained to deliver care to this population. Medical education in transgender health can empower physicians to identify and change the systemic barriers to care that cause transgender health inequities as well as improve knowledge about transgender-specific care. Methods/UNASSIGNED:We conducted structured searches of five databases to identify literature related to medical education and transgender health. Of the 1272 papers reviewed, 119 papers were deemed relevant to predefined criteria, medical education, and transgender health topics. Citation tracking was conducted on the 119 papers using Scopus to identify an additional 12 relevant citations (a total of 131 papers). Searches were completed on October 15, 2017 and updated on December 11, 2017. Results/UNASSIGNED:Transgender health has yet to gain widespread curricular exposure, but efforts toward incorporating transgender health into both undergraduate and graduate medical educations are nascent. There is no consensus on the exact educational interventions that should be used to address transgender health. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support. All published interventions proved effective in improving attitudes, knowledge, and/or skills necessary to achieve clinical competency with transgender patients. Conclusion/UNASSIGNED:Transgender populations experience health inequities in part due to the exclusion of transgender-specific health needs from medical school and residency curricula. Currently, transgender medical education is largely composed of one-time attitude and awareness-based interventions that show significant short-term improvements but suffer methodologically. Consensus in the existing literature supports educational efforts to shift toward pedagogical interventions that are longitudinally integrated and clinical skills based, and we include a series of recommendations to affirm and guide such an undertaking.

Learning Objective #1: Discuss typical, atypical clinical & laboratory presentations of acute mononucleosis Learning Objective #2: Review indications for treatment beyond supportive care CASE: A 33 year-old female with 1 prior spontaneous abortion presented with facial swelling, arthralgias and fevers to 102F for 2 weeks. The patient reported environmental exposures as a native of Australia such as outbreaks of Ross River Fever, encounters with flying foxes, a layover in Hong Kong, and a child with a febrile illness. She sought outpatient care and initial bloods revealed WBC 2.52K/uL, platelets 105K/uL and AST/ALT 88/70 ALP 117 U/L. She was prescribed antibiotics without effect. A week later, she developed pleuritic chest pain, was found to have a small pericardial effusion on outpatient echocardiogram and referred to the Emergency Department. Triage vitals were normal. Her exam was notable for periorbital edema, cervical lymphadenopathy and pain in bilateral wrists without effusion. Labs showed recovering blood counts (WBC 9.3K/uL Hgb 13.1g/dL Plt 157 K/uL), unremarkable UA, microalbumin/creatinine ratio and CK, but worsening LFTs with AST 505 ALT 578 ALP 788 U/L. She was admitted for further work-up with rheumatology and infectious disease input. While hospitalized, the patient developed new night sweats and a sore throat. Repeat echocar-diogram revealed a trace pericardial effusion and abdominal ultrasound was normal. C3/C4 levels, beta-2 glycoprotein, cardiolipin, Ro/La, lupus anticoagulant, histone, centromere, and mitochondrial antibodies all returned negative, as did respiratory viral panel, HIV, hepatitis serologies, thick and thin smears, Lyme, Anaplasma and Babesia serologies, Ross River fever, Dengue and Chikungunya. ANA titer and dsDNA Ab were < 1:40 and 9 respectively, but EBV viral capsid IgM returned positive consistent with acute mononucleosis. IMPACT: The triad of acute EBV is well known, but atypical presentations provide diagnostic challenges and warrant further evaluation DISCUSSION: The triad of acute Epstein-Barr viral infection involves high fevers, lymphadenopathy, and pharyngitis, all present in our patient. However, she also exhibited less typical disease features. Her periorbital edema, known as "Hoagland's sign," is caused by viral replication obstructing lymphatic drainage of the nasopharynx. Similarly, infected tonsillar B-cells instigate secretion of polyclonal antibodies (including heterophile and non-specific autoantibodies). This process is normally accompanied by leukocytosis with atypical lymphocytes, but our case presented initially with leukopenia. Further, her degree of transaminitis (levels > 10x) normal is usually restricted to the immunocompromised. Finally, EBV may also cause transient myo-or pericarditis as noted in select case reports. The mainstay of treatment is supportive, although steroids and acyclovir are used in cases of laryngeal edema, liver failure, or hemolytic anemia and thrombocytopenia. These agents have not been proven to reduce the length or severity of illness