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Disaster Medicine Certificate Series hosts active shooter disaster drill Saturday, March 30

Bystanders should be aware of visual, sound effects and avoid area unless necessary.

The UofL School of Medicine Disaster Medicine Certificate Series will hold an Active Shooter Disaster Drill on the Health Sciences Center campus from 6 a.m. to 3 p.m., Saturday, March 30.

This will be a live-action (not tabletop) drill, complete with actors portraying both perpetrators and victims, and visual, sound and other effects to simulate reality.  The location will be the Instructional Building and the HSC Plaza, 500 S. Preston St. The second floor of Kornhauser Library will be open.

Due to the large-scale nature of this drill, bystanders may hear simulated gunshots or explosions, and see a large police presence on campus. Bystanders should not be alarmed, and should not call 911 as this is only a drill.

In order for this drill to be safe and effective, the number of people on campus must be minimized. If anyone does not have to be on the HSC campus on March 30, please avoid the area.

For additional information, contact Madison Kommor, madison.kommor@louisville.edu, or Jill Scoggins, jill.scoggins@louisville.edu. 

Where to seek care when you’re sick or injured

UofL doctors discuss health care options
Where to seek care when you’re sick or injured

Ashley Iles, M.D.

We’ve all been there. Perhaps you have a mild sore throat and cough on Friday but by Saturday afternoon the cough has worsened. Or you wake up in the middle of the night with extreme nausea and a high fever. What is the most appropriate place to receive care in the most timely manner? 

Primary Care Providers

One of the best ways to care for your own health is to establish a primary care provider (PCP), says Ashley Iles M.D., assistant professor in the University of Louisville Department of Family and Geriatric Medicine and a physician with UofL Physicians Centers for Primary Care at Cardinal Station.

“Primary care refers to medical care given by a provider - physician, nurse practitioner or physician’s assistant. This is the first point of contact for patients’ non-emergent symptoms, disease management and health concerns. 

“For an acute illness like a sinus infection or earache that comes on suddenly during the week, a primary care provider should be your first point of contact,” she said. 

PCPs also encompass preventative types of care including cancer screening, vaccinations, health maintenance exams and patient education. 

“Think of your PCP facility as your medical home,” Iles said. 

Urgent or Immediate Care

An urgent care or immediate care center, however, may be the best option for after hours for worsening acute illness or injuries like mild sprains. These facilities may have an X-ray machine and the ability to perform some lab tests on-the-spot. 

“Think episodic care for urgent care centers,” Iles said. “If you need non-emergency care at a time when you can’t get to your primary care provider, these are good alternatives.” 

But Iles says patients should understand that urgent care facilities don’t keep track of their medical problems, prescriptions or visits the way a primary care provider would. 

“Be sure to follow-up with your primary care provider if you’ve gone to immediate care so they can update your medical records,” Iles. 

Emergency Care

Emergency rooms should be reserved for life-threatening conditions or injuries that could result in serious complications if not immediately addressed, says Adam Ross, M.D., medical director of UofL’s Department of Emergency Medicine.

National statistics indicate that between 5.5 – 8 percent of ER visits are non-urgent.

“However, as you can imagine, someone may come in with chest pain, concerned about a heart attack, and after a workup in the emergency room (EKG, chest x-ray, blood tests, etc.), it’s determined their pain was from GERD or heartburn” Ross said. “While their diagnosis is not an emergent one, the symptom they presented with certainly is.”  

It is better to be safe than sorry, says Ross.

“Always go to the ER when you feel life or limb are at risk: chest pain, shortness of breath, severe headache, weakness, numbness or speech difficulty, severe cuts, excessive bleeding, broken bones or other symptoms with which you are emergently concerned,” he said.

Call 9-1-1 if you are experiencing what seems to be a life-threatening condition. Otherwise, patients can often call their medical insurance company hotlines to speak with an on-call providers that can give advice on what to do. UofL Centers for Primary Care at Cardinal Station can often see patients for acute illnesses or minor injuries the same week. Make an appointment by calling 502-588-8700. An on-call doctor is available to answer urgent medical questions after hours.

About UofL Centers for Primary Care at Cardinal Station

Located at 215 Central Ave. in Louisville, UofL Centers for Primary Care at Cardinal Station offer a full range of primary care services including acute illness visits, annual health maintenance visits, cancer screenings, STI screenings and vaccinations for both children and adults of any age. Additionally, the centers have a wide range of women’s health services including appropriate annual screenings and all types of non-surgical birth control including implantable devices. The office also is home to multiple Sports Medicine specialists who can offer on-site x-rays, acute injury management, chronic conditions management, physical therapy referrals and joint injections. For information and appointments, call 502-588-8700.

More than 150 girls expected at first UofL STEM+H event

School of Medicine co-hosts event to interest girls in science, technology, engineering, mathematics and health careers
More than 150 girls expected at first UofL STEM+H event

An attendee at the E-Expo 2018, the forerunner of the Girls Rule STEM+H Summit 2019.

To demonstrate the kinds of careers available to women in the science, technology, engineering, mathematics and health (STEM+H) fields, the University of Louisville is hosting its first Girls Rule STEM+H Summit event, Saturday, April 6.

More than 150 girls and young women ages 8-18 are registered to attend the 9 a.m.-2 p.m. event at the Belknap Academic Building. While the 3rd to 12th-grade students participate in hands-on workshops and activities, accompanying adults will be offered information sessions on how to prepare for higher education and careers in STEM+H.

Among the workshops, all taught by UofL students and faculty, will be robotics, medicine and genetics.

While UofL has hosted STEM introductory events for girls in past years, 2019 marks the first year health education and careers will be included. The event is co-sponsored by the J.B. Speed School of Engineering, the School of Medicine and the UofL Army ROTC program.

 “We are delighted to once again open our doors and show girls and women the variety of careers in these exciting areas,” said Emmanuel G. Collins, dean of the Speed School. “These careers of the future need more women and under-represented minorities and we hope to inspire by example.”

A short informational video can be found here.

For further information, contact Kari Donahue, 502-852-6279, kari.donahue@louisville.edu.

Gift to UofL aids research into biomarkers for cardiovascular disease

Late James Ryan made donation to lab of Andrew DeFilippis, M.D.
Gift to UofL aids research into biomarkers for cardiovascular disease

DeFilippis and Ryan

A half-million-dollar gift to the laboratory of University of Louisville cardiologist Andrew DeFilippis, M.D., by the late James Ryan will aid in research into biomarkers for cardiovascular disease.

The $500,000 gift to the Division of Cardiovascular Medicine at the UofL School of Medicine establishes the James Ryan Fund for Cardiovascular Biomarker Research. Ryan pledged the gift before he passed away at age 81 in 2018.

“Thanks to Jim, we can help physicians everywhere in diagnosing what is one of the most common causes of death in the world,” DeFilippis said. “He was always interested in others and what their dreams were, their goals in life, their happiness and how he could help.”

The fund will support annual operating expenses for the research led by DeFilippis, who is director of Cardiovascular Disease Prevention and an associate professor in cardiovascular medicine at UofL. DeFilippis is an expert in cardiovascular diseases and cardiac intensive care. His research focuses on cardiovascular risk prediction and the identification of biomarkers that will allow physicians to diagnose the cause of different types of heart attacks, also called myocardial infarction.

A heart attack is death of heart muscle. There are many causes, including the most well-recognized that occurs when one of the heart’s coronary arteries is suddenly blocked or has very slow blood flow secondary to the formation of a blood clot.

Atherosclerotic cardiovascular disease progresses over time, allowing time for screening and early detection. Advances in biomarker research and other developments have led to more sensitive screening methods and a greater emphasis on early detection and diagnosis.

“We’re working to develop biomarkers that will allow clinicians to differentiate among the many different types of heart attacks that can occur,” DeFilippis said. “Not all are the same, and even in the medical community that’s not always given much thought. But if we can differentiate, it will help us better treat patients, allowing us to limit or stop heart damage.”

A biomarker is a biological characteristic that can be measured and evaluated as an indicator of normal biological or pathological processes or a response to a therapeutic intervention. Examples include patterns of gene expression, levels of a particular protein in body fluids or changes in electrical activity in the heart.

Ryan, an active philanthropist and retired insurance executive, suffered from a heart condition himself. A native of Pittsburgh who graduated from UofL and lived most of his life in Louisville, he was on a quest to ensure his estate went to good use. He and DeFilippis forged a friendship through their activities with the American Heart Association. He visited DeFilippis’ lab within the Division of Cardiovascular Medicine several times, even bringing a group of friends.

“He was really involved – he was more than a donor,” DeFilippis said. “He gave advice and offered assistance in business, enabling us to partner with industry to bring our discoveries to market. We really enjoyed his company. The two of us went to lunch several times and talked about lots of things – the lab, his struggles with congestive heart failure and his bucket list. He had a great sense of humor.

“He was an extraordinarily happy man with a deep voice that was very distinctive,” DeFilippis said. “We will certainly miss his presence and his inspiring words about the work we were doing. We take it as a tremendous compliment that he chose to donate to us. Jim was looking for a quality program, great ideas and things that really make sense to improve the health of world.”

DeFilippis and one of his colleagues, Patrick Trainor, Ph.D., recently were invited editorialists for a new study published in the Annals of Internal Medicine that indicates current risk calculators for heart attack and stroke can sometimes be wrong, significantly overestimating some people’s risk while underestimating others' risk. As a result, many people may be unnecessarily taking medication to control risk factors such as high cholesterol and high blood pressure, and others may not be getting enough treatment. The researchers developed a new risk calculation method with a more sophisticated statistical model and newer population data, suggesting it could be more accurate.

Immunotherapy drug gives colon cancer patient another chance at life

First approved for melanoma, Keytruda® now can be used with several types of cancer
Immunotherapy drug gives colon cancer patient another chance at life

Rebecca Redman, MD and Lana Boes

Three years ago, Lana Boes of Charlestown, Ind., was at the end of her rope. She had been fighting colon cancer for nearly two years with multiple surgeries, two different chemotherapies, regular blood transfusions and more. But the cancer had returned and the chemotherapy no longer was working.

“I was down to 100 pounds. I really couldn’t eat. I had to take medicine to help me with my appetite. I just couldn’t do it anymore,” Boes said.

First diagnosed at age 43, Boes’s first surgery went well, but the cancer returned. After her second surgery, Boes started chemotherapy. Genetic testing revealed she had Lynch Syndrome, a genetic mutation that carries a higher-than-normal risk for cancer. When the first chemotherapy drug failed her, Boes started another, harsher chemo drug. That drug, too, eventually failed.

At that point, she was offered the chance to participate in a clinical trial for pembrolizumab, better known as Keytruda®, an immunotherapy drug previously successful in treating other types of cancer, but not yet FDA approved for the type of cancer Boes had.

“Lana started to suffer not only from the side effects of her cancer progressing, but also the side effects of treatment. It was clear that we needed something new and different,” said Rebecca Redman, M.D., Boes’s oncologist and deputy director of clinical research at the UofL James Graham Brown Cancer Center. “This clinical trial became available right around that time. It was based on some early evidence that suggested immunotherapy would be a really great option for Lana’s type of cancer.”

Keytruda is a type of immunotherapy that engages a patient’s own immune system to fight cancer. Cancer cells use a protein called PD-1 to hide from the immune system. Keytruda blocks the PD-1 pathway, Redman said, allowing the patient's immune system to recognize the cancer as something that doesn't belong and destroy it.

With support from her husband, Tim, Boes decided to enter the trial. She started receiving Keytruda in June 2016, and her condition improved almost immediately.

“With Keytruda, I got my life back. With chemo I went home and went to bed and you didn’t see me for the weekend,” Boes said. “With Keytruda, I didn’t go home and go to bed. I started getting an appetite and some strength back. I was able to enjoy doing things outside of my house again with family and friends.”

She remained on the immunotherapy drug for two years, completing the trial in June 2018. Regular checkups show that as of March 2019, Boes’s cancer is not detectable in scans or exams, and her cancer tumor marker numbers have remained within normal range. Redman considers her cancer in remission.

Boes says she has a fresh outlook on life, and can plan for her future.

“I used to refuse to book anything in advance. Everything we did was always last minute because I didn’t know if I was going to get to go,” Boes said. “I didn’t buy things that were for the future. I couldn’t talk about the future.”

Now she has plans to celebrate a special milestone in 2020.

“I never used to care about birthdays, but every birthday is a big deal to me now,” Boes said. “I turn 50 next November and I told my husband, ‘I never thought I was going to see 50, so I want to go to Italy.’ It’s huge for me in so many ways.”

While she is grateful for having the chance to participate in the trial with Keytruda, Boes also is grateful to Redman and to the staff at the Brown Cancer Center.

“Just seeing Dr. Redman made me feel better. She saved my life. She treats me with so much care. She sits down and she listens to me,” Boes said. “Every person at Brown is just so kind and they genuinely care. That makes such a huge difference when you are not feeling good.”

Redman, also associate professor at the UofL School of Medicine, said she has seen good results with immunotherapy in other patients with cancer like Boes’s. Unlike chemotherapy, which requires continued treatment, in some cases immunotherapy may allow a patient’s body to continue to control the cancer for an extended period of time.

“The most exciting thing about immunotherapy is that not only are we seeing remarkable tumor responses, but those responses seem to last a long time,” Redman said. “For some patients, it appears that once you train the immune system to attack the cancer, it may continue to do so for some time, possibly even after the immunotherapy has been stopped.”

Keytruda is the first drug approved by the FDA for the treatment of cancers based on a specific change in the DNA of the tumor, microsatellite instability (MSI), instead of where the cancer is in the body. MSI can be present in colon cancer but also in other organ cancers, and Keytruda is FDA-approved to treat cancers with MSI anywhere in the body.

Redman said that through her participation in the trial, Boes helped make it possible for other patients to have access to Keytruda for their MSI cancer. FDA approval typically means an insurance company will cover the treatment and makes the drug available to all patients.

“By participating in this trial, she has allowed this drug to move toward FDA approval, so immunotherapy now is a standard treatment for patients with microsatellite unstable cancers,” Redman said. “Thanks to patients like Lana who participate in clinical trials and take that extra step a little bit into the unknown, thousands of people will benefit and will have their lives turned around.”

Boes is most grateful to have the chance to live without cancer.

“I’m living my life normally,” Boes said. “I’m not cancer. Nobody treats me as cancer. I’m just me again and that is the best feeling ever.”

Participate in clinical trials

Volunteers always are needed to assist researchers solve health problems. Even if you do not have a health concern, you can be part of clinical trial research at UofL and at research institutions around the nation by registering at UofL.me/researchmatch. This nationwide database allows anyone to take part in important health research. Learn more by registering today.

To learn more about cancer clinical trials, visit the UofL James Graham Brown Cancer Center’s clinical trials page.

UofL researcher developing drug to treat emerging encephalitis viruses

NIH dedicates $21 million to prepare antiviral drug for clinical trials
UofL researcher developing drug to treat emerging encephalitis viruses

Donghoon Chung, Ph.D., in the Regional Biocontainment Lab

Donghoon Chung, Ph.D., a virologist at the University of Louisville, is one of three principal investigators with a new center working to advance new drugs for the treatment of equine encephalitis viruses in humans. The project, Center of Excellence for Encephalitic Alphavirus Therapeutics, is funded by a $21 million grant from the National Institutes of Health over five years.

The center, headquartered at the University of Tennessee Health Science Center in Memphis, will develop therapeutic drugs to treat three mosquito-borne alphaviruses that cause serious illness in humans and horses: Venezuelan equine encephalitis virus (VEEV), Eastern equine encephalitis virus (EEEV) and Western equine encephalitis virus (WEEV). Although a vaccine is available for horses, there are no FDA-approved treatments or preventive vaccines for these viruses in humans.

Chung, an associate professor in the Center for Predictive Medicine and Department of Microbiology & Immunology at UofL, said the center’s goal is to refine potent small molecule compounds the researchers previously identified as promising as antiviral drugs for treating the encephalitis viruses, and enable those compounds to move to the next step of research, clinical trials in humans.

“In my previous research I found that these compounds inhibit the viral replication cycle. However, we want to further understand which target molecules are interacting with the compound,” Chung said. He described the mechanism of the compounds the group is investigating as similar to the way the drug nevirapine, a non-nucleoside reverse transcriptase inhibitor, works in treating human immunodeficiency virus (HIV).

“This project is to develop a new antiviral compound to treat these diseases in humans,” Chung said. “However, we do not limit our applications of this drug to only humans, as it may be possible to adapt it for treating horses as well.”

These equine encephalitis viruses infect humans and horses through the bite of an infected mosquito. According to the Centers for Disease Control and Prevention (CDC), symptoms of infection include fever, chills, headache and vomiting. Outbreaks of the Western and Venezuelan viruses are uncommon, and an average of only seven human cases of EEEV have been reported annually in the United States over the past ten years. However, the disease may leave people with permanent neurological symptoms, and approximately 30 percent of people who contract the Eastern equine encephalitis virus will die from the disease.

According to Chung, the potential for the viruses to be used in bioterrorism is perhaps even more worrisome. The CDC recognizes viral encephalitis as a Category B human biothreat, making the development of a treatment important.

Chung’s co-principal investigators in the center are Colleen Jonsson, Ph.D., of the University of Tennessee Health Science Center who directs the center, and Jennifer E. Golden, Ph.D., of the University of Wisconsin-Madison School of Pharmacy.

“The goal of our new Center of Excellence is to further develop novel therapeutic molecules discovered by our team that are highly potent across all three viruses, moving the optimal ones forward into pre-clinical development,” said Jonsson, formerly director of the UofL Center for Predictive Medicine.

Chung will test the compounds for toxicity against human cells in vitro, deciphering their molecular mechanisms and determining their resistance threshold utilizing the facilities and staff at the Regional Biocontainment Laboratory at UofL. He also will test the compounds’ resistance threshold that inevitably develops over time, along with Juw Won Park, Ph.D., assistant professor of computer engineering in the J.B. Speed School of Engineering at UofL.

Once their work is completed, the researchers expect the new drugs would be ready to begin clinical trial testing in humans.

UofL-founded company secures $100 million to advance cell therapy to improve organ transplant outcomes

UofL-founded company secures $100 million to advance cell therapy to improve organ transplant outcomes

Suzanne Ildstad, M.D.

A company born at the University of Louisville has raised $100 million from investors to develop a therapy based on UofL research that could improve the lives of kidney transplant recipients.

Talaris Therapeutics, Inc, formerly known as Regenerex LLC, is using technology developed at UofL to allow living donor kidney transplant recipients to stay off immunosuppression drugs for the rest of their lives. In a Phase 2 study, the cell therapy, called FCR001, allowed 70 percent of living donor kidney transplant patients to be durably weaned off all of their immunosuppression treatments.

The unique cell therapy technology is a result of pioneering research conducted at UofL by the team of Suzanne Ildstad, M.D. Ildstad has spent 21 years as a “Bucks for Brains” researcher at UofL. She founded Talaris around her research and is the company’s chief scientific officer.

“This financing moves us one step closer to helping organ transplant recipients no longer be dependent on immunosuppressive drugs, resulting in a greatly improved quality of life,” Ildstad said. “The support and research infrastructure at UofL have been invaluable in our journey to this important juncture.”

The technology developed by Ildstad’s team was patented at UofL and is exclusively licensed by Talaris from UofL’s Office of the Executive Vice President for Research and Innovation. Talaris plans to use the new funding to carry out a Phase 3 clinical trial of FCR001. Longer term, the company plans to study whether FCR001 could be used for other organ transplants.

Talaris has approximately 25 employees in Louisville. Talaris’ research and cell processing facilities are based at UofL and the company also has a corporate office in Boston. As part of its licensing agreement with Talaris, the university will receive royalties from sales of any licensed products.

"This cutting-edge UofL research can have a significant impact on human health,” said UofL President Neeli Bendapudi, Ph.D.. “This is a prime example of our ability to work with industry partners and investors to help turn innovative research into valuable new products.”

 

Not your father’s tobacco: A scientist’s perspective on health risks of e-cigarettes

Beer with a Scientist, May 15
Not your father’s tobacco: A scientist’s perspective on health risks of e-cigarettes

Daniel Conklin, Ph.D.

What would you guess is the average age when someone starts smoking?

Perhaps early 20’s? Maybe even 16?

“The average chronic smoker begins smoking at 13.7 years old,” says Daniel Conklin, Ph.D. “And if you know anything about averages, that’s...not good.”

Conklin, a professor of medicine at the University of Louisville, specializes in cardiovascular research and what environmental pollutants do to our bodies. At this month’s Beer with a Scientist, Conklin will discuss smoking and what we do (and don’t) know about the harm caused by electronic cigarettes.

“Essentially, we’re trying to separate fact from fiction. We’re currently part of an American Heart Association Tobacco Regulation Center to investigate emerging tobacco products and their potential to cause harm to the cardiovascular system,” Conklin said. “We’re trying to figure out the best way to regulate these products.”

Scientists have known that conventional tobacco products are associated with cardiovascular disease risk since the 1960s, Conklin said. However, with new technology comes a new generation of health risks and the emerging science showing what vaping does to the body may shock you.

Conklin’s talk will begin at 7 p.m. on Wednesday, May 15, at Holsopple Brewing, 8023 Catherine Lane. A 30-minute presentation will be followed by an informal Q&A session.

Admission is free. Purchase of beer or other items is not required but is encouraged. Organizers encourage Beer with a Scientist patrons to drink responsibly.

UofL cancer researcher Levi Beverly, Ph.D., created the Beer with a Scientist program in 2014 as a way to bring science to the public in an informal setting. At these events, the public is invited to enjoy exactly what the title promises:  beer and science.

Multiple honors for UofL LGBT health education

UofL shares knowledge with Harvard, receives national award, publishes clinical skills toolkit
Multiple honors for UofL LGBT health education

UofL medical education presenters with Harvard hosts

The University of Louisville shared its pioneering work in educating health professionals to provide quality health care to LGBTQ patients with faculty at Harvard Medical School in Boston last month. In New York, the university also received a national leadership award for workforce development for the same work on May 3. Earlier this year, UofL published The eQuality Toolkit, a clinical skills training manual to help others develop the specific clinical skills needed to provide high quality care to LGBTQ patients.

At the Seventh Annual National LGBT Health Workforce Conference, held last week in New York, UofL received the Organization Leadership Award from Building the Next Generation of Academic Physicians (BNGAP), an organization founded in 2008 to cultivate a more diverse workforce in academic medicine. The award highlights commitment, scholarship and dedication to the development of a health workforce that is responsive to the unique health issues and disparities of LGBT communities. Previous winners are Penn Medicine and the University of Rochester Medical Center.

A week prior, leaders from UofL’s eQuality program presented Grand Rounds to faculty at the Harvard Medical School Academy on incorporating training for the care of LGBTQ patients into the medical school curriculum. Amy Holthouser, M.D., senior associate dean for medical education, Susan Sawning, M.S.S.W., director of medical education research, and UofL School of Medicine alumni Rhiannon Ledgerwood, M.D., and Adam Neff, M.D., presented “Lessons from eQuality at University of Louisville: Successful collaborations for integrating sexual and gender minority health into medical education.”

David Hirsh, M.D., director of the Academy at Harvard Medical School, said the presentation from Holthouser and Sawning inspired the participants, who are planning to launch a similar program at Harvard.

“I was so moved by your advocacy and accomplishments and so taken by your style and grace, strength and conviction, wisdom and humility,” Hirsh said of the UofL group. “The grand rounds made an enormous difference. We will be speaking about it for a long time to come.  I am so grateful to learn from you and to have been present for such an important and transformative launch.”

Beginning in 2014, UofL served as the pilot program for the development of curriculum to incorporate competencies published by the Association of American Medical Colleges (AAMC) related to provision of care for LGBT individuals and other sexual and gender minorities (SGM). Through the eQuality program, information related to care for SGM patients was embedded throughout the curriculum studied by all students in the UofL School of Medicine.

Jennifer Potter, M.D., professor of medicine and advisory dean and director of William Bosworth Castle Society at Harvard Medical School, invited the UofL team to The Academy at Harvard Medical School, which is responsible for professional development of faculty who teach in the MD program.

You care about the fact that SGM people experience health inequities,” Potter said of the UofL presenters. “You talk with your colleagues and students about the fact that these inequities are unacceptable. Then you go one step further – you actually TAKE ACTION to address the inequities with sheer grace, humility, positivity, a sense of humor and brilliance ... and in true collaboration with your local SGM community.”

“It is so rewarding to see the work that has been done here at UofL to improve health care for LGBT patients is valued by an institution as highly respected as Harvard,” said Toni Ganzel, M.D., M.B.A., dean of the UofL School of Medicine. “In addition, it is an honor to receive a national award from a well-respected organization such as BNGAP. We are pleased to be able to share this knowledge with educators and influencers throughout the United States.”

The eQuality Toolkit, published with funding from the National Institute of Health Care Management Foundation, is available to all health professionals at no charge to enhance competency nationwide in caring for LGBTQ patients.