All right, good morning, everyone. How are you all today? Yes, we are going to be active today because ASCP told me to. I just want to say again, thank you for getting out of your beds and deciding to come hear my talk about STDs at 9.45 in the morning. Who knew that this would be an opener for Michelle Obama? Isn't that great? Whoo! So, and again, I would like to say thank you to ASCP for offering me this invitation to come and speak about the recent advancements in STI and women's health testing. So, my name is Latanza Adams, and yes, there is an I there, not Latanzia, it's Latanza. Blame my mom. And I'm a staff pathologist at the VA Portland Health Care System in Portland, Oregon. I wear many hats. I'm the medical director for microbiology, molecular microbiology, chemistry, support services, which entitles send-out testing and research. And I'm also the pathology resident co-director there as well. So I do a little something here and there. This will be a little interactive, a little case-based, and I didn't want to do the clicker because I know me and the clicker wouldn't work. So it'll be just a little, you know, we're family, so let's get started. So I have no financial disclosures, and let's see, for our objectives today. Hopefully when you leave here, you have an increased awareness of STIs and STDs in women, the increased awareness of the molecular testing that's out there, the different diagnostic platforms, and the role of point-of-care testing in STDs and STDs. So in 2018, the statistics showed that one in five people had an STD in the U.S. And that equated to nearly 68 million infections in 2018. 26 million new STIs were discovered, were diagnosed in 2018, and almost half of that, which is shocking, the age range between 15 and 24 years old. That related to new STIs totaling nearly $16 billion in direct medical costs for this. In 2019, you can just see from the graph how much that increased. Every year was like a consecutive record-breaking amount of STD cases. From 2018 to 2019 alone for chlamydia, there was a 2.8% increase. For gonorrhea, it was 5.7% increase. And this increase in gonorrhea was 92% from the historical in 2009. So you can see how this is becoming a real issue. Now what did 2020 bring? Well, 2020 brought us partly cloudy skies with a 75% chance of COVID exposure. So nevertheless, our statistics for this wasn't as, there was a lot of uncertainty around this. And in the beginning, the rate seemed low. But towards the end of the year, things started to normalize, you know, trend the same way. And so some of these effects from COVID were reduced screening. You know, there weren't the clinics available and open as they were. Decreased routine visits because we were all on shutdown. And of course, we all know about the supply chain issues that occurred. Also limited resources. Pretty much, we all know, everything was put on the back burner and directed towards COVID. And that were post-challenges and key STD activities. So you didn't have your follow-ups. You didn't have your tracings that you normally would during that time that you would with STDs. Everything was, again, for COVID. Then also social distancing. I'm sorry, social distancing. People were thinking, altering their sexual behaviors. Fear of COVID exposure. That's interesting. You're scared of COVID, but you're not scared of HIV. All right. And also limiting public transportation. So people couldn't get, you know, to their, you know, enjoyment times as they normally would have. So that's another factor that played in that. So yes, the pandemic introduced uncertainty and difficulty in interpreting the data for 2020. But what we could ascertain was that, you know, in 2020, looking at the women, ages 20 to 24, they had the highest rates of reported chlamydia during that time. And then the second were the age range of 15 to 19-year-olds. This I know. What are they doing? Well, we know what they're doing. Same and when we look at statewide, they range from 230 cases per 100,000 women in Vermont to 1,068 cases per 100,000 women in Mississippi. When we look at gonorrhea, it's pretty much the same trend that we saw. Age range 20 to 24 had the highest rate for gonorrhea. And again, 15 to 19-year-olds were second with 1,616 cases per 100,000 people. We'll look at it statewide. It ranged from 20 cases per 100,000 women in New Hampshire and 437 cases per 100,000 women in Mississippi. I don't know what Mississippi is doing. And when you look at the chart for all STD cases, Mississippi was number one for the highest rate. So, that's something to, your facial expressions are classic. Yeah, you know, when you do these talks, you learn something new and the whole time I was doing it, my mouth was just like, holy moly, you know, the whole time. But this is our reality. So now looking at syphilis. As you can see, you know, for the most part, men took the lead in this and women still stayed, you know, on the lower side of primary and secondary syphilis. However, when you stratify those results, you can see over time, looking starting at 2016, women always stayed, you know, pretty much at the bottom. But between 2019 and 2020, there was a 22% increase in the rates of primary and secondary syphilis. Between 2016 and 2020, there was 159% increase of women presenting with primary and secondary syphilis. So, some of the things that we look, how, what's the impact of STDs, how are they different between women and men? So, one, women are less likely than men to have symptoms, which is shocking. Such as for infections of chlamydia and gonorrhea, if they do occur, they can go away, but the female is still infected. So they can still go on and pass, transmit the condition. Also women may confuse their symptoms with other entities. So the burning and the itching and the irritation that women may experience, they may think it's just a yeast infection, when it's actually something else. Signs and symptoms aren't usually visualized. With men, if they have an ulcer, they see it, you know, and it's very concerning, whereas you can have lesions, they can be painless inside the vagina and you don't see it. You don't feel it. And it can be very small and undetectable, you can have changes in the vaginal epithelium as well and don't see it. Also, women visit their doctors consistently, and that's a good thing, however, women may have the conception that as part of their annual visit, STD testing is a part of that and it's not. So you have to ask that for your provider specifically, I would need this testing. And while Pap test screens for cervical cancer, it's not a good test for other types of cancers or STDs. Also the female anatomy puts females at a unique risk. I mean, we were just dealt an interesting hand because the epithelium and the tissue outside the vagina is much thinner, it's more delicate than the skin outside of the penis. And so it's very easy for viruses to penetrate and just the environment itself is a good environment for bacteria to grow. You can have health and reproductive complications. You can get PID, which is pelvic inflammatory disease, infertility, ectopic pregnancy. So there's a lot of impact that these conditions have on women and how it poses more complications than men. Also, women who are pregnant can pass these conditions to their children, HIV, genital herpes, syphilis. Me personally, I remember when I was in training, I had a case of a set of twins that were affected with herpes, disseminated herpes virus, and unfortunately they only lived maybe five days. And yeah, it was very, yeah, it left an impact, left a wrinkle in my brain. So it's important to get this diagnosed appropriately. And then you have HPV, which is the most common sexually transmitted disease and the main cause of cervical cancer. And while it's common in men, men don't develop the serious complications and manifestations as women do. And then just to hit that, you know, go on that, go over that again, some of the consequences of delayed treatment, PID, infertility, ectopic pregnancy. One thing, disseminated gonococcal infection or HPV-associated cancers and neonatal death. So it's very important to get testing to know the criteria for testing as well. So now we're going to get into the interactive portion of this. So since we're in Chicago, I know I work in Oregon, but I'm originally from Gary, Indiana. And so I'm from this region that they call it the region. And so I did a lot of my training in Chicago. So one of the things, I love music. So I will infuse that in my presentation. So we're going to do a case presentation, entity review, and we'll go over a diagnostic platform after each case. All right, case one. We have a 16-year-old G1P1 female who presented to the ER with complaints of increasing crampy right upper quadrant abdominal pain for three days and vaginal bleeding. She denied symptoms of UTI, abnormal vaginal discharge, chills, fever, nausea or vomiting. She had a fever. And upon physical examination, she had exquisite pain in the left upper quadrant and the right upper quadrant of her abdomen. There were no rebound tenderness or guarding. Her pelvic exam showed cervical motion tenderness. And for those who need clarification, that is an indication of peritoneal irritation. There were no masses palpated, and she had left egg nexo tenderness. Her social history revealed she was sexually active with one male three months ago. She reported using condoms with her partner, and that was her preferred method of birth control. They sent an endocervical swap to the lab for NAT testing for CTNG, and it was positive for the most common cause, PID, of those two organisms. So in the words of Marvin Gaye, what's going on? So do we have any takers? What do we think is happening here? Chlamydia. Yes, chlamydia. So yes, chlamydia trachomatis. So we'll go a little history over this. So in 1907, Drs. Provezek and Hall-Besteiter, and I'm, please forgive me, they discovered this entity, and they called it a mantled protozoan from its features and how it was described. And the mantle that they saw in Greek is called chlamys, and so they named it chlamydozoa. Dr. Provezek was a Czech zoologist and parasitologist, and Dr. Hall-Besteiter was a German Jewish radiologist. And in this entity, they came up with what was called the Hall-Besteiter-Provezek bodies, and these are the cytoplasmic inclusions that's located near the nuclei of the conjunctival epithelial cells. So this picture right here is showing Dr. Hall-Besteiter in the left, Dr. Provezek in the center, and the gentleman that's holding the orangutan is their patient. And they were looking at the bodies in the epithelial cells of the trachoma. So it's said that he, the gentleman, was blinded from the chlamydia. So that, and why he's holding an orangutan, I'm not sure about that. I looked and looked. I didn't see if that was like a criteria for a test. I don't know. Yeah, I guess the lab, because I thought it was like, well, did the orangutan have it, or? So yeah, or they were just giving him stuff and saying, hey, what is it? Orangutan. I don't know. But the, this was incorrectly initially classified as a virus, and this was because at the time the filters used, it would filter through all the bacterial filters, and it wasn't growing on your conventional bacteria media. So they thought it was a virus. Actually, it's an obligate intracellular pathogen classified as a gram-negative bacterium. And to culture this, McCoy cells are used for the chlamydia culture. Now, we don't use this for diagnosis. It's more of a research utilization. It's rarely used in the clinical lab. It's very labor-intensive and very, not as sensitive. And so this picture here is showing the presence of chlamydial inclusions as demonstrated by the green fluorescence. So let's look at the life cycle of this. You start out with the infectious elementary bodies, and these come in contact with your epithelium, and they enter the cell. The bacterium develops a membrane-brown reticulate body, and then it will replicate, and you get more of these reticulate bodies by binary fusion. And as they replicate, they start to develop into the elementary bodies, and then these are released by cell lysis of these intact inclusions or exocytosis to go on and infect more epithelial cells. And you can see this happens two to three days very quickly. It's the most common STD, STI in the U.S., causing cervicitis, endometritis, salpingitis. It also causes conjunctival diseases. You see that a lot in the neonates. In the developing world, a leading cause of blindness. Many people who are affected for genital infections are asymptomatic. They can be symptomatic, but most are asymptomatic, again, which is a bit daunting. And then this is also the cause of lymphogranuloma venereum. And this is characterized by enlarged lymph nodes, redness in the genital region. And you can have systemic manifestations of fever, headaches, and malaise. Yes. Adults as well. So an example of that was our gentleman with the orangutan. And so they were looking at the inclusion bodies in the trachoma. So you have a lesion that develops and it's called a trachoma. But it's in the, you can have neonates with that if you can pass it on to your child. And it usually affects the eyes with the conjunctival diseases. But in our other countries, developing countries, you can have that. It's a leading cause of blindness in adults. Some of the challenges. So screening is recommended annually for sexually active females less than 25. Females that are 25 and older, if you're in an increased risk, if you have risky behavior, screening is recommended. Infections can be asymptomatic, as I stated. And also, there's a lack of public awareness and public knowledge of the screening recommendations. Also, there's limited sources and lack of vaccine for this. So one of the platforms that tests for this is the Abbott Alinity. So this is a picture of the Abbott Alinity from my lab back home. And this is, it does 300 samples in about eight hours. It takes about 155 minutes. It uses reverse transcriptase, PCR. There's two flavors of this. And basically, it comes down to the oropharyngeal rectal swab. So there's one testing test that doesn't do the oropharyngeal rectal swab. And another one that does. But they all, it tests for CT and G, mycoplasma genitalium. You can do endocervical swabs, clinical and self-collected vaginal swabs, female and male urine. So case two, we have a 25-year-old G0P0 female presented to the ER with a 24-hour history of dysuria, left and right lower quadrant pain, abdominal pain. And she reported a pus-like vaginal discharge. She denied chills, fever, nausea or vomiting. She, on physical exam, she had 100-degree Fahrenheit fever. There were no rebound tenderness or guarding. Her pelvic exam showed cervical motion tenderness, left and right agnexal tenderness, no masses. Her sexual history involved sexually active with five to six partners in the past six months. Inconsistent use of condoms with partners. For the laboratory investigations, her UH was positive for leukocyte esterase. They had multiple WBCs. Urine culture was negative. They sent an endocervical swab for NAT, CT and G testing. And she was given antimicrobial agents and scheduled for a follow-up visit a week later. A week later, she came back and her symptoms were not resolved. So what do you guys think? So the words of Jackson 5, never can say goodbye. Neisseria gonorrhea. So what's going on here? A little background. So Neisseria gonorrhea is fondly called the clap. And so why? That's the question I had. Like where did this come from? So one theory, there's three theories around this. One theory believes that it's an old English word, clapping which means beating or throbbing which describes these physical symptoms that you have when infected with this. The next theory is pretty interesting. Before antibiotics, men would treat their gonorrhea by slapping their penis against a board and clapping it between their hands to squeeze out the infection. Again, I was like, wow, that's, okay. The third theory is that it's from the French word clapier which means rabbit hutch. And so during this time, that was slang for brothels. And so people, the lesions that you would develop, they would be called a clapier bougou. Your face is hilarious. So yeah, so those are the different theories of why it was called the clap. So I see your gonorrhea is a gram-negative cacopacillus or can be described as gram-negative rod. No symptoms or minimal symptoms. Common signs are urethra, cervix, pharynx or rectum. It reminds me of a time when I first started out. So I first started out on this journey of ASCP. I was a medical technologist actually in Indiana at Munster Community Hospital. And there was one of the techs had a culture, a GC culture. And she's like, oh, it's positive. And so at that point, I was on the respiratory bench. And she's going and she's like, what's going on? And she kept looking and she's looking in the computer, looking at that and looking at the, so I said, what's going on with you? And she says, it's a throat. And I think there's a problem here. I was like, no, it's possible. And then she just stands there and says, how did this happen? I'll just let you think on that. Yeah, and the look on her face, she was just horrified. But so yeah, pharynx or rectum, yeah, that's another common sight. So due to the nature of this, there's aggressive efforts for screening and public health measures. Why? Because of the antimicrobial resistance that is showing up with this. So back in 93, Ciprofloxacin and cephalosporins were the recommended treatment. And so this data comes from the Gonococcal Isolate Surveillance Project, called GISP, at the CDC. And this is a sentinel surveillance system for Neisseria gonorrhea. In 2007, because they were seeing increased resistance with Cipro, cephalosporins alone, such as giving ceftriaxone or ceffixamine, were the recommended treatments. Well, you started seeing resistance to ceffixamine. And so let's double up on the cephalosporin therapy. So 2010, that was the recommended treatment. Of course, you're starting to see increased resistance there. So let's say, hey, ceftriaxone plus azithromycin or doxycycline. Again, you're starting to see some resistance there. So now the current recommendation is ceftriaxone, 500 milligrams intramuscular in a single dose. And then if chlamydia has not been excluded at doxycycline oral. So another testing platform for this is the Roche-Cobas 6800. This is in our molecular department. And they have the chlamydia gonorrhea testing assay. And then they have these mycoplasma genitalia trichomonas vaginalis assay. You can do male-female urine. Again, the whole gamut of swabs. And for mycoplasma genitalia, vaginal swab is preferred for this. Also, what's good, you can test the cervical swabs from the preservazate solution for pap smears. And also, oropharyngeal and anal rectal swabs with this assay can be used. In three hours, you get 96 results. For the 6800, 864 results within like an eight-hour shift. It uses automated qualitative real-time PCR. And they have additional sex health assays. Which I'm pretty excited about with the HPV. So now we can bring in all of our HPV testing in-house. And we can have like our own like system where we collaborate with anatomic pathology. And reflex it, you know, over us to us so we can do the high-risk HPV testing, which is pretty neat. Also, in the pipeline for this, they're doing BV and candidiasis vaginitis testing assay. And then also, which I'm excited about is the mycoplasma genital resistance testing, which we'll talk about a little later. And there's a Neisseria genital, Neisseria gonorrhea resistance testing that's in the pipeline for this assay. I mean, for this testing platform. Yes? That, I'm not sure, it's, like I said, it's in the pipeline. So I'm not sure what testing, like samples you can use. Will it be the same sample types for the screening test? Or it will be something different if you need a new sample? So that I'm not sure about. All right, case three. So we have a 26-year-old G1P1 woman who's referred to public health clinic as a result of contact tracing in the case of gonorrhea. She recently had unprotected sexual intercourse. And she has no symptoms. Her physical examination was all within normal limits. The pelvic examination revealed white vaginal discharge. Otherwise, everything was unremarkable. The discharge was sent off for wet mount and cervical swab for CT and G testing. And so we have a picture, a little video of the wet mount. And I hope it comes up. Okay, let's do that again for the ones in the cheap seats. Let's see. All right, so who can describe what we just saw? Because there may be some new people out here, you know, this new generation. They may not be doing this. So what do we see out here? Yeah. So stop in the name of microbiology. Diana Ross in the Supremes, that was a great hit, yes. Trichomonas vaginalis, yes. So Trichomonas vaginalis is a pear-shaped flagellated protozoan parasite that measures 10 by 7 micrometers. This is the only sexually transmitted anaerobic flagellated protozoan. Common sites are the vagina and urethra. Testing in all women should be done that are seeking treatment for vaginal discharge. Infections, mainly asymptomatic. You can have acute and chronic vaginitis with this as well. So this can be that female that keeps going to Walgreens and getting those little suppositories and thinking that they're curing things, but they're not. So, and then another thing, you know, you keep spraying things down there and trying to make things floral, you're just covering it all up. So it's good that one of the recommendations is if you have vaginal discharge, just go ahead and test for it. Because with this infection, you're doubling your risk for cervical cancer and the risk for HIV can triple for this if you have this infection. And we're going to look, and I'll explain why. So this schematic here is a schematic of the vaginal epithelium. So this area here is the mucus and where things slough off the canal of the vagina. So I'll just get you guys oriented. This is the base of the epithelium. And then as the cells mature, you can see the nuclei get smaller and smaller and smaller. So in this area here, we have what's called the eubiosis. Everyone is happy. We got our nice flora here, our lactobacillus doing its job, making its acidic pH and keeping our, you know, keeping everybody happy. And we get this little fella comes along and he thinks he's going to sneak in there. And he's just minding his business, so to speak. So while he's there, he is releasing cytotoxic proteins. And these cytotoxic proteins destroy the epithelial lining. And what happens is it is increasing the pH. We don't want an increased pH. So that does a lot of things. When you increase the pH, you're changing the environment. And that is allowing these anaerobes to come in. So we got our Gardnerella. We got our Prevotella that comes in. So while you're doing it, that again is affecting the environment. You're releasing more cytotoxic proteins. And that decreases, the lactobacillus doesn't like that. So as time goes on, you can see with the epithelium, you're not having these nice tight junctions and nice tight connections as you did before. You get development of the biofilms. And you're seeing less and less of our normal flora. Now, he's sent out invitations and he's recruiting more of his friends. So they come on in and they start to make these microcolonies that's attaching to the epithelium. This is now going to start causing destruction of the vaginal epithelium. This is why it is easy to get infected with HIV and it increases your risk. And so from this, your cells are still trying to regenerate. And as you can see, we got our basal cells, but these are supposed to be at the top. That's not happening. And with all this, you're going to get some type of mistake, some type of error that's going to occur. That's where you get your development of your cancer. And then as time goes on or as it goes continually untreated, you start to get your host defense. And then you begin to get your neutrophils, your other recruitment of immunocells. Then you get your mycoplasma, which works in conjunction with trichomonas, and they start to infect the epithelium, the vaginal epithelium. And so this is why it's super important that you get tested, treated in an appropriate way because this can lead to a lot of problems for a female. And what's crazy, you have all this going on and you're asymptomatic. So now that we got a visual of what's going on, now you understand why you get this frothy, gray, yellow-green discharge. Because you got all those recruitment of all those neutrophils that's going on there from your body. You get your pruritus. Again, you can be asymptomatic. Something that is characteristic, as you see on all the boards, is the strawberry cervix. While this occurs, it's a strong association, but it's rarely seen. It's probably seen in less than 5% women. And that's an example here. So what is that is the cervical hemorrhage. So you have like little petechiae on your cervix. Another problem with this, you get premature rupture of membranes, pre-intern labor. And that all increases 30% if you're infected with trichomonas. You get low birth weight in your kids and increased risk of PID and increased shedding from in the genital tract. And as you saw from the schematic, how that happens. So the treatment usually is flagell, but like everything, you're starting to see resistance with this as well. And so there is a new drug, denidrazole, that can be used for the metronidazole-resistant strains. So let's go back to the patient. Again, high risk for CT and G co-infection. So she was initially treated for both. her labs come back and she was positive for both, and she was offered HIV testing. So another platform that we have in the lab at Portland is the Cepheid Gene Expert. What's good about this is on demand and it has a pretty decent sex health assay, CTNG, trichomonas, those two are about 90 minutes a piece. They also have group B strep testing as well. It's a NAC PCR, specimens for the CTNG, TB testing urine, male and female. Again, a clinician collected vaginal swabs and they've gotten to the clinician instructed self-collection of the vaginal swabs as well. So any questions? Yes. So far what we've seen, not really, no, no. And that's been a big push as well to have that done. The next thing that people are trying to push and some places are doing it is just to have patients, you send off the kits, they collect it at home and then you can send it back. You have to validate that, your assay for that because right now it's just most assays are just the, in a clinician environment. And some people, facilities broaden that definition with a medical or clinician environment is, but so far to answer your question, no, there hasn't been a difference. And it's pretty, it's good because you get, you know, it's more comfortable for, I mean, you can imagine being a female, it's just common sense. I'd rather take care of it myself than having somebody else playing down there. So, so case four, yeah. So we had a 38-year-old G0P0, let me speed it up, G0P0 female. She presented to her OBGYN with three months, history of persistent genital discomfort. She had lower abdominal pain, post-coital bleeding, denied any discharge or burning. Physical examination was within normal limits. One asymptomatic partner for a year, male partner and then one asymptomatic female partner in the past six months. No protection was used in either encounter. No response to any previous antifungals. Her lab work included HIV, HBV, HCV, syphilis. They did fungal cultures, bacterial cultures, and sent off a vaginal swab for CTNG, trichomonas and mycoplasma genitalia. And they tested for ureaplasma, urolitipum. Everything came back negative except mycoplasma genitalia. So her treatment course, doxy for seven days in February. She returned back in May with the same symptoms, gave her azithromycin. She returned again in August with unresolved symptoms. They gave her moxifloxacin. And then five weeks after each regimen she remained positive for mycoplasma genitalia. So, Rita Franklin said, think. This major thing, like what's happening here? So October 2018, the patient was administered pristinomycin. And within two weeks her symptoms were resolved. And at five weeks she was negative for mycoplasma genitalia. And her partners were tested. They were negative as well. So this was a published case of macrolide and quinolone resistant genitalia out of Lebanon. This belongs in the molecules class. It's the smallest genome of any known bacterium. It's flask shaped, has no cell wall, but is a trilaminar cell membrane. It's extremely fastidious, very hard to grow. Most infections are asymptomatic. And when they do present, they present with symptoms of PID. So the detection challenges is not visible under the microscope. It has a very slow repletive cycle. And overall, molecular assays, molecular is the best option, but it's lax sensitivity and it's a challenge to validate because of the nature of the organism. But NAT testing, more sensitive and timely. So testing recommendations, women with signs and symptoms suggestive of PID and anyone whose current sexual partner is positive or suspected to have mycoplasma genitalia. Now, I apologize for like the poor quality, but it was, you know, this shows that the worldwide prevalence of macrolide and quinolone resistant mycoplasma genitalia. For us in the U.S., macrolide resistant mycoplasma genitalia is up to 50%, 42 to 50%. And this was during the 2013-2014 statistics. As far as quinolone resistant, not so much here, but you can see in other worldwide, it's starting to be a growing problem. Macrolide resistance is increasing. In the U.S., our current percentage is 44 to 90% in the U.S., Canada, Western Europe, and Australia. Fluorocorne resistance is thought to be the S83I mutation. And here, it's 0 to 15% prevalence. So macrolide and fluorocorne resistant is now beginning to be an issue and a growing global concern. So some of the literature that's out there, it's starting to see in Spain, Britain, and England. We're starting to see it in New Zealand and in Hong Kong. So this is a growing concern for this. And the fact of just it's so hard to grow, cultivate, and the testing that's out there is starting to be better. So one other platform is the Hologic Panther, CTNG, trichomonas, mycoplasma, and HPV. These are the current CDC recommendations and considerations for women. So it's very important to be familiar with that. And a big one is that patients that are sexually active under 25 need to be tested and screened. And those that are active over 25 and at an increased risk should be screened for HPV, I mean should be screened for these as well. So we'll finish up with just talk about point of care testing. This is in the archives and it speaks of the advancements in point of care testing for STDs. One of the ways to decide that a test should be or can be a point of care test is that it needs to be affordable, it needs to be sensitive, specific, user-friendly, it shouldn't have all these moving parts. Rapid to be able to diagnose and treat at the same visit. And robust enough to withstand moving, storage, shouldn't need to have refrigeration or things like that. Equipment free, shouldn't need any special separate collection or processing component. And accessible to end users. And this is just showing like where we've come from prior to 2015 to now and beyond. And so what's out there now is two assays. One is the Visby. And this made it on the scene with COVID testing. A lot of airports use this assay. And for STDs, it's clinically waived in 2024. It does CTNG and trichomonas. It's a NAT-PCR. And this does vaginal, patient-collective vaginal swabs. And it's literally you inoculate it and you hit one, two, three. And that's it and you just wait. So it's pretty simple. And it can interface with an LIS system as well. Another one is the Binks Health IO, CLIA waived. This does just CTNG within 30 minutes. It's ultra-rapid PCR. And it has a proprietary electrochemical detection technology. The specimens are clinician and self-collective vaginal swabs in a clinical setting. And first catch urine for men. In the pipeline, they have trichomonas and mycoplasma. That's in development for this platform. So in summary, we've reviewed the STIs, STDs that statistically disproportionately affects women. We've discussed molecular diagnostic platforms and the role of point of care in diagnosis and STD testing. So here are my references. And in the words of Sam and Dave, thank you very much. Thank you. Any questions? Just noticing that you had several platforms there that you're able to use. So when you do get someone and they're testing, say, for chlamydia, which platform do you decide to choose to use? Well, one, it depends on, would you get validated at the time? But we, right now, we do our CTNG testing on the Cepheid right now. We are trying to work with ID to see how, because we, at the VA, we have our main facility, but we also have smaller CBOX that's in. So one, it depends on the volume. Two, how we want to do our workflow. Right now, our next platform that we're bringing up is going to be the Alinity test, because we just, we haven't validated the COBOS just yet for that, but one thing that matters is that with the COBOS, you can do oropharyngeal and rectal swabs, and that's a big push, especially for our MSM population. And so we'll probably switch over to that, because, like I said, the Alinity came in two flavors. There was, there's one, and I don't know why, but there, and what I think it is, is when they initially came out, they didn't have the oropharyngeal and rectal option, and then they came out with the second one. So I think that's what happened with that. And so for us, we have the one without that. So we're probably going to switch over to that. A lot of it, it just depends, but as far as, like, sensitivity and specificity, either one is fine. It basically depends on, like, your workflow and how you want to operate your lab and what you have going on. So I work in a critical care access hospital in rural Alaska, and we have a CEPHID, and we have outlying villages where we get samples from, and it seems to work pretty well, because we test for CT, NG, and trichomonas. But I was curious about the mycoplasma. Do you have any idea of the rates of that, say, across the country? As far as pointed care or on-demand availability for testing, it's not there yet. So right now, we're just seeing it on, like, the whole logic, the bigger platform, 6800. In that case, you probably would. So right now, if we have a request to that, we send it out, because we haven't validated what we have just yet. But we'll be bringing it in-house. So as far as, you know, something small like that, no. But I would assume soon, hopefully, CEPHID should, it would be advisable for them to do so. So I wouldn't be surprised if they did come out with something like that. I don't even know if our providers are aware of it, or if no one's asked us about that kind of testing. A lot of it, what I've found, is people aren't aware of it. They don't know. And it's something that they should know about. And honestly, when I became aware about it, it was in, you know, a situation like this. I took a, you know, went to the conference CME. And I'm like, wait a minute. Why aren't people talking about this? Why isn't our infectious disease asking about this? And so I brought it to their attention and said, hey, we need to start doing this. Yeah, so when you go back, let them know. All right, thank you. I have a two-part question. For the statistics that you showed us, are there equal representation in heterosexual and homosexual couples? And is the increase in infection rate correlating with a lack of sexual education? As far as the population of heterosexual versus non-heterosexual, that, the statistics didn't get into that. It just stratified it between males and females. Why the increase is happening? Honestly, I don't know. I don't know if it's lack of sexual education. I don't know if it's just the change in attitude of, oh, I can just take a pill and it'll be fine. A lack of the appreciation of what the damage that it can cause. Honestly, I'm not sure. But, again, I was astounded at the reason. Again, what was really shocking is the, what was second, is the 15 to 19-year-old population. Yeah. But also, too, it could be the increased need of putting it out there, testing for it, the knowledge of having the clinician being knowledgeable enough to bring it up in conversation. Because it's not a regular part of your visit. Oh, that you bring up a great point, yes. Because when you look at the, when we were talking about how COVID affected it, you have all these dating apps. And what do they do? They get on the train. They get on the bus. Hey, you know, let's meet and have fun, dot com. You know, whatever. I mean, honestly, yeah, you bring up an excellent point. I do think that that has a lot to do with it. Because it's so easy to get in contact with someone and to just casually have an interesting time. So that, I would, yeah, I would say that's a huge correlation with that. Yeah, because you can take a pill. You can take a pill. It's done. You know, it's like, oh, I got a headache. I got chlamydia. You know. So, you know, I think it's a lot with the attitude. I think it's a lot with the ease and accessibility to have those type of encounters. And just the lack of it. And then the lack on the clinician side to bring it up because it's just not out there. You know, I don't know how things are now in the schools. But, you know, we had health and safety courses. And, you know, that could be something. You know, I know, you know, my younger cousins, they no longer have those courses offered to them anymore. And that's where, when I was younger, I was exposed to it. It was like, wear your condom, you know. You can get bad things. You know. But it's just saying, you know, the attitude. It's just everything is so laissez-faire. You know, just take a pill. I'm fine. You know. You know, you just take this one and it's four pills in one. And it's okay. It's just like having diabetes. Yay. But I don't think they understand what could really happen to them. Right. Right. I mean, you can de-stigmatize it. But you have to be responsible as well. There's a full process to that. So. I have a question from Julie in our virtual audience. Hi, Julie. Any literature regarding care for female to male transgender population and male to female who underwent gender-affirming surgeries? Excellent question, Julie. And the answer to that is, no, I did not run across that. I'm sure it may be out there. But, no, I did not run across that. And, I mean, that is a new frontier of that. Because when you're looking at male to female transitioning, you know, you can't apply that. That pathophysiology would not apply there. That's a little different. But some of the things could cause, you know, as far as, because now you've created an environment that you don't see what you used to see. Change is different, you know. So, you know, I'm sure it's, the literature is out there. But I didn't run across it. If there's no questions, am I free to go, assistant? All right, let's go see Michelle.

STDs

Dr. Latanza Adams

statistical data

chlamydia

gonorrhea

COVID-19 impact

molecular testing

sexual behavior