Clinical Pearls for College Health ProvidersSummary of relevant research

2013 -4

Objectives

• Define & summarize the process for determining relevance of research

• Summarize the validity, results, and application of the top 10 research articles of the last year

• Share the recent evidence-based guidelines for preventive services that apply to college health

The medical literature

Your Shuckers…

• Michelle Paavola, MD• Marcy Ferdschneider, DO• Cheryl Flynn, MD, MS, MA

None of us have disclosures to make

The process

• Reviewed journals & abstracting services from 8/2012-5/2014; USPSTF guidelines

• Selected original research relevant to college health– Relevance = common + patient-oriented outcome

+ changes practice• Consensus for top ten• Summarize validity, findings, and application

to practice

Now… onto the original research

Fasting Time and Lipid Levels

Arch Intern Med. 2012; 172(22):1707-1710

Background

• Lipid levels are used to both screening and diagnose

• Fasting labs are inconvenient• Current guidelines recommend measuring

lipid levels in a fasting state• Recent studies suggest there is a minimal

change to lipid levels in response to foodQuestion: Is there an association between fasting times and lipid levels?

Methods

• Design: – Policy change allowed lipids to be check regardless of

fasting time– 6 month cross sectional examination of laboratory data,

including:• Fast duration: 9-12hr vs >8 hr• Lipid result—Total cholesterol, HDL, LDL, TGs

• Population: Residents of Calgary, Alberta, Canada– Excluded: those who did not report hours from last meal

and TGs >400

Results• Total of 209,180 lipid profiles

Results

• Variance between mean cholesterol subclass levels:– Total cholesterol: <2% – HDL: <2%– Calculated LDL: <10%– Triglycerides: <20%

• Statistically significant differences (p<.05) were present for a minority of fasting intervals when compared with either a 9- to 12-hour fasting time or greater than 8-hour fasting time

Conclusions/Limitations

• Fasting time showed little association with lipid subclass level

• Unable to control for recall bias in duration of fasting, and did not seek data on meal content

• No knowledge of pharmacologic treatment of subjects

• Generalizability: study pop was seeking cholesterol screening which could differ from general pop

Clinical Pearl:

• When ordering screening lipid panels, get the lipids at the same appointment

• No need to make people come back fasting for blood work

Arch Intern Med. 2012; 172(22):1707-1710

Three Questions to Dx UTI

Ann Fam Med 2013; 11(5): 442-451.

Background

• UTIs common– 60% women will have at least one in her lifetime– 2013, 9.5% students reported being treated for a UTI

w/in the last year• Empiric treatment based on sx alone cost-effective– Concern re: abx resistance, accuracy of dx

• Predictive rates of hx, tests measured separately

Question: What is the best combo of hx and tests to diagnose UTIs?

Methods

• Design: cross sectional– All pts administered a structure clinical assmt, urine dip,

urine micro, urine culture– Gold standard for UTI was >103 CFU of urinary pathogen

• Population: female >12y/o with dysuria or frequency of less than 1wk duration– primary care practices in Netherlands– Excluded if evidence of pyelo, pregnant/lactating,

immunocompromised– ~200 patients; UTI prevalence in this study population 61%

Methods

• Outcome: predictability of various models

• Regression analyses to id predictive factors• 5 prediction models:

1. History only2. Hx + dipstick3. Hx + dipstick + sediment4. Hx + dipstick + dipslide5. Hx + dipstick + sediment + dipslide

Results• Three historical elements accurately identified

~56% of women – Do you think you have a UTI?– Considerable pain with urination?– Absence of vaginal irritation?

• Adding + urine dipstick, increased dx accuracy to 73%– If only added dipstick to those with variable

answers, accuracy increased to 83%

Conclusions & Limitations

• Hx alone can classify more than half the women with suspected UTI

• Adding +urine dipstick useful adjunct– Especially if pre-test

probability 20-80%

• Suspecting one has a UTI based on past experiences– When reanalyzed with #

previous UTIs and at least one provider dx’d UTI, results did not change

• Statistical model only– not prospectively

validated

Clinical Pearl:

• If history is positive for key historical questions, consider empiric treatment1. Suspect UTI?2. Considerable dysuria?3. Absence of vaginal irritation?

• Addition of a positive urine dipstick w/o microscopic evaluation is sufficient to treat with antibiotics

Pyelonephritis: Duration of Treatment

The Lancet 2012; 380:484-90

Background

• Common infection in women• Antibiotic resistance of E. Coli is increasing• Few controlled trials to assess the optimum

duration of treatment

• Clinical Question: Can a shorter course of cipro for treating pyelo work as well?

Methods

• Design: Prospective, randomized, double-blind, non-inferiority trial with parallel groups– All patients received ciprofloxacin for 7 days– Half received an additional 7 days (14 total) – The other half received an additional 7 days placebo

• Population: – Women aged 18 years and older– From 21 ID Centers in Sweden– Presumptive diagnosis of Pyelonephritis based on:

• Fever of at least 100.4, plus one of the following• Flank pain, CVA tenderness, dysuria, urgency or frequency

Methods

• Outcome: – Compare short-term clinical and bacteriological

efficacy and safety of the 2 regimens. – Assess long-term cumulative efficacy – Assess the consequences of not treating

asymptomatic bacteruria at short-term follow up

Results

Ciprofloxicin – 7 days• n = 73• 88% E. Coli• Short-term efficacy

– 71 cured (97%)– Clinical failure or recurrent

UTI symptoms: 2 (3%)

• Cumulative efficacy– 68 cured (93%)– Clinical failure or recurrent

UTI symptoms: 5 (7%)

Ciprofloxacin – 14 days• n = 83• 95% E. Coli• Short-term efficacy

– 80 cured (96%)– Clinical failure or recurrent

UTI symptoms: 3 (4%)

• Cumulative efficacy– 78 cured (93%)– Clinical failure or recurrent

UTI symptoms: 6 (7%)

Conclusions/Limitations

• Community-acquired acute pyelonephritis in women can be treated successfully and safely with oral ciprofloxacin for 7 days

• Results cannot be extrapolated to other classes of antibiotics

• Fluoroquinolones are recommended as first-line choice for empirical treatment of pyelo as long as the resistance rate does not exceed 10%

Clinical Recommendation:

• In women with acute pyelonephritis a 7 day course of Ciprofloxacin works just as well as a 14 day course

• The choice of a single week of abx:– Will reduce consumption of antibiotics– Could decrease certain side effects by shortening

abx exposure– Follow up cultures not necessary if clinical

resolution of symptoms

The Lancet 2012; 380:484-90

Iron supplementation for fatigue with no anemia?

CMAJ 2012; 184 (11):1247-54

Background

• The prevalence of fatigue ranges from 14% to 27% among patients in Primary Care

• Women are three times more likely than men to mention fatigue

• Unexplained fatigue can be caused by iron deficiency

• Clinical objective: If ferritin is low but the patient is non-anemic, can iron replacement help?

Methods• Design: 12-week multi-center, double-blind, placebo-controlled,

parallel group, pragmatic randomized trail with a 1:1 allocation ratio• Population: 44 private practices in France recruited women presenting

with fatigue who are:– Menstruating– Between 18-50 years old– Report considerable fatigue (>6 on a 1-10 Likert Scale), without obvious

clinical causes– Not anemic (Hgb >12)– Have a low or borderline ferritin level (<50)– Not pregnant or breastfeeding– Not already taking iron supplementation

• Outcome: Improvement of fatigue as measured on the Current and Past Psychological Scale

Results

• Iron supplementation for 12 weeks decreased fatigue by almost 50% from baseline (19% in the placebo group)

• Iron supplementation did not have a significant effect on measured indicators of quality of life (outside of those related to fatigue)

• Iron supplementation improves hemoglobin, ferritin, hematocrit, mcv and soluble transferrin as early as six weeks after starting treatment

Conclusions/Limitations

• Iron deficiency may be an under-recognized cause of fatigue in women of child-bearing age

• For women with unexplained fatigue, iron deficiency should be considered when ferritin values are below 50 micrograms/L, even when hgb values are above 12 g/L

• Blinding is challenging given the side effects of iron • Fatigue is a subjective, patient-centered measure

Clinical Recommendation:

• In women w/ fatigue, check ferritin – If <50, then iron replacement can improve

symptoms.• The addition of this test could save on the use

of other resources, including the attribution of symptoms to emotional or mental health issues

CMAJ 2012; 184 (11):1247-54

Treatment of acute ACL tear

BMJ 2013; 346:f232

Background

• Acute anterior cruciate ligament rupture is a common and serious knee injury in the young active population

• Many patients develop osteoarthritis of the knee irrespective of treatment

• Objective: Compare 2 treatment strategies – structured rehab plus early reconstruction or structured rehab with the option of later reconstruction if needed

Methods

• Design: Randomized, controlled trial (extended follow up of previous trial)

• Population: Active adults ages 18-35 with ACL tears no more than 4 weeks old due to a previously uninjured knee

• Outcome: Change from baseline to five years on patient reported outcomes

Results

• No statistically significant differences in pain, symptoms, function in ADLs, function in sports and recreation, knee related quality of life, general physical or mental health status, current physical activity level, return to pre-injury activity level, radiographic osteoarthritis, or meniscus surgery

Conclusions/Limitations

• In young, active adults with an acute ACL tear, early reconstruction plus rehab does not provide better results than rehab with the option of surgery later

• Results do not apply to professional athletes or to less than moderately active people

Clinical Recommendation:

• Physical therapy rehabilitation is the primary treatment option after an acute ACL tear in active young adults

BMJ 2013; 346:f232

Acute bronchitis: cough duration?

Ann Fam Med 2013; 11:5-13

Background

• Acute cough illness/acute bronchitis very common; 2-3% of all outpatient visits

• Most caused by virus; abx not helpful• Self-limited illness– ~50% still coughing at 2wk– No data re: pt expectation of cough duration though

anecdotally shorter!– Mismatch expectation may lead to requests for abx

• Q: how long does the typical bronchitis last? How does this compare to patients’ expectations?

Methods

Pt expectations• Design: survey sharing

case scenarios (Fever/no F; colored sputum/no sputum)

• Population: random digit dialing, >18 y/o

• Outcome: expected duration of cough; value of abx

Cough duration• Design: meta-analysis of

observational studies, or placebo arm of RCTs– Comprehensive search– Dual data extraction, validity

assessment– Did not seek unpublished

studies

• Population: adult pts with acute cough, no COPD, outpt only

• Outcomes: mean duration of cough in untreated arms

Results: pt expectations

• 493 respondents (43.6%)• Median expected duration of cough 5-7 days– Scenarios with fever > no fever– Green sputum>yellow > dry cough

• Belief that abx were always helpful– Nonwhite race, some college education or less,

past abx use for acute cough

Results: duration of cough

• 19 studies included, with total of 1230 pts• US, Europe, with one study in Kenya

• Mean duration of cough 17.8 days– range 15.3-28.6– Mean duration of productive cough 13.9 days

Conclusions/limitations

• Significant mismatch between pt expectations and actual duration of cough in ACI– 7 days vs 18 days

• Though publication bias possible, unlikely• Data confirms previous research about cough

duration• Survey data of GA residents only, though

demographically diverse

Clinical Pearl:

• Typical cough lasts ~18 days in acute bronchitis; pts expect 7 days or less

• Provider education of patients warranted– may help decrease repeated phone calls,

unnecessary abx

Ann Fam Med 2013; 11:5-13

Anti-inflammatory vs. Antibiotic vs. Placebo in Acute Bronchitis

BMJ 2013; 347:f5762

Background

• Cough is the most common symptom reported by patients with LRI

• Current guidelines do not recommend the routine use of antibiotics for acute bronchitis

• More than 60% of patients receive antibiotics for acute bronchitis

Methods

• Design: Randomized, single blinded, placebo controlled

• Population: Adults aged 18-70 with cough < 1 week, discolored sputum, and at least one other symptoms of LRI: dyspnea, wheezing, chest discomfort, or chest pain

• Outcome: severity and duration of symptoms; adverse effects of meds

Results

• 1o outcome: # days with frequent cough– No stat difference

• Amox/clav: 11 • Ibuprofen: 9 • Placebo: 11

• 2o outcome: days to total sx resolution– No stat difference

• Ibuprofen: 10• Placebo: 13

• Adverse effects– Statistically greater in

the antibiotic group• Amox/clav: 12%• Ibuprofen: 5%• Placebo: 3%

Conclusions/Limitations

• Neither amox/clav or ibuprofen improved the cough severity or duration in patients with acute bronchitis as compared w/ placebo

• Single blinded due to budgetary restrictions• Symptom diaries are subjective

Clinical Recommendation:

• Antibiotics for acute bronchitis – Don’t Do It!– Amox/clav does not shorten cough duration or

severity but does increase the medication side effects

• Anti-inflammatories not proven to lessen cough, though may ease other sx severity and were without notable harm

BMJ 2013; 347:f5762

Can delayed Rx for URIs decrease Antibiotic use?

BMJ 2014; 348: g1606

Background

• URIs top reason to visit student health facilities

• Antibiotics proven ineffective for most infections, yet cont’n to be prescribed and expected

• Pt satisfaction &/or concern of additional medical visits cited as reasons for Rxing

• Question: Is a method of delayed Rx for URIs effective for decreasing Abx use?

.

Methods• Design: unblinded RCT, concealed allocation, intention

to treat analysis• Population: patients >3 y/o with acute respiratory

infections, from 25 primary care practices in UK– Those not deemed to need immed abx were randomized to

1 of 5 groups:1. Recontact for Rx2. Post-dated Rx3. Collection4. Patient led5. No Rx at all

– All additionally randomly assigned self-care (analgesia, humidified air)

Methods

• Outcome: sx severity at days 2-4– Secondary outcomes• Time to sx resolution• Any abx use in 14 days following recruitment• Return visits• Belief in abx effectiveness• Side effects/complications

– Powered at 80%; those who followed up similar to those that didn’t

Results: all patients• 889 pts recruited– 37% given abx immediately – 63% randomized to 1 of 5 delayed abx groups

• Abx usage:– Immediate: 97%– Delayed groups: 37% (no SD between groups)– No Rx at all: 26%

• Sx severity and sx duration:– No difference between those who took/did not take abx

• Belief in efficacy of abx– Greater in the immediate abx group vs delayed

Results: randomized pts

• Pt satisfaction– No stat diff among delayed abx strategies• Though higher in the pt led & collection

• Rates of reconsultation:– No difference in the month following study

• Complications:– No abx 2.5% vs delayed groups 1.4%, NS• Immediate Abx group 2.5%

Conclusions & Limitations

• Delayed abx strategies lead to fewer patients taking antibiotics– Did not significantly

impact pt satisfaction or reconsultation rates

• Taking abx did not improve any clinical outcome

• Immediate Abx group slt more severe sx at onset– Controlling for severity

did not alter findings

• Limited generalizability?– willingness to be

randomized to delayed abx

Clinical Pearl:

• All strategies to delay abx in URIs led to decreased abx use and no difference in clinical outcomes– Pts have slight preference to receive the rx and make

they own choice vs having to call• Clinicians should not prescribe abx for most URIs– If pressure from pt, or concerning severity, consider

issuing a delayed Rx with specific instructions about when to fill

BMJ 2014; 348: g1606

Association of EC Effectiveness and BMI

Background

• EC can prevent pregnancy after unprotected intercourse– Levonorgestrel 1.5mg w/in 72hr: Plan B one step– Ulipristal acetate 30mg w/in 120hr: Ella– Copper IUD insertion

• Varying effectiveness; varying accessibilities– OTC– By Rx only– Requires timely access to medical professional with

appropriate resources, as well as acceptability to the woman

Question: can we identify women at risk for EC failure?

Methods

• Design: meta-analysis of RCTs– Logistical regression to id risks for EC failure– Then sub-analyses of RCT data

• Population: women >16y/o with regular menses presenting for EC– from US & UK; not on hormonal contraception or using IUD– 3445 women included– RCTs compared LNG 1.5mg vs UPA 30mg

• Outcome: EC failure (aka pregnancy)

Results• Covariates id’d as risk for EC failure:– BMI > conception probability > further intercourse

• Combined risk of EC failure– Overweight: 1.53– Obese: 3.60

• Pregnancy rates (%)BMI kg/m2 LNG (Plan B) UPA (Ella)

<25 1.3 1.1

25-29.9 2.5 1.1

>30 5.8 2.6

Conclusions/Limitations

• EC shows a rapid decrease of efficacy with increasing BMI– LNG: no benefit at BMI of >26 (vs no EC use)– UPA: no benefit at BMI of >35

• Post-hoc analysis to id possible factors

Clinical Recommendation:

• If patient interested in using/having EC available:– Levonorgestrel if normal, low BMI– Ulipristal acetate if overweight– Consider IUD for obese women

• Update patient education discussions, materials to include risks for failure to guide informed choice

Can tobacco cessation improve mental health?

BMJ 2014; 348:g1151

Background• Association between smoking

and mental health unclear– People often report smoking

relaxes them– Efforts to quit often considered

to worsen mental health

• Clinicians may defer recommendations to quit smoking in pts with MH issues, or in times of high stress

• ~14% college students smoke cigarettes

• 4% report smoking daily • Stress, anxiety &

depression are common in college students and negatively impact functioning

.Question: Does smoking cessation affect mental health?

Methods• Design: meta-analysis of longitudinal studies (RCTs &

Cohort)

– Comprehensive search– Inclusion criteria & data extraction done by 2 researchers– Considered quality of included studies and many

subanalyses to assess for confounding/heterogeneity

• Population: studies enrolling adult smokers– General population (14), chronic conditions (3), pregnant

women (2), post-op (1); psychiatric conditions (4); and either chronic physical or mental health dx (3)

Methods

• Outcome: 6 measures of mental health– Anxiety– Depression– Mixed anxiety&depression– Positive affect– Psychological quality of life– Stress

• Results reported as standardized mean difference (SMD)– b/c different measures for the various outcomes– Compared pts own baseline pre- to post- intervention

ResultsOutcome # studies SMD P value

Anxiety 4 -0.37 0.03

Mixed anx/depr 5 -0.31 <0.001

Depression 10 -0.25 <0.001

Stress 3 -0.27 <0.001

Psychological quality of life

8 +0.22 <0.001

Positive affect 3 +0.40 <0.001

Results

• Sensitivity & subgroup analyses did not change conclusions:– Study quality– Publication bias, outcome reporting bias– Loss to follow-up– How smoking cessation measured– Baseline motivation to quit– Whether a psychological intervention was included– Clinical population type/subtype– Study design (ie RCT vs cohort)– Length of follow-up

Conclusions & Limitations

• Cigarette smoking cessation is associated with an improvement in mental health on a variety of measures

• Meta-analysis data limited by the validity of the included studies– Methods and subanalyses

support validity of findings

• Cannot demo causality– Does seem the MH

improvement followed tob cessation, not vice versa

– Bio mech exists

Clinical Recommendation:

• Clinicians should counsel patients who smoke cigarettes to quit– Appropriate to cite mental health improvement as a

likely benefit– Incorporate this outcome into motivational

interviewing techniques, pt ed materials– This more “immediate” benefit may have more

impact for young adults who may be less influenced by long term benefits of not smoking

BMJ 2014; 348:g1151

A rec’s & B rec’s

Cervical cancer screening: • begin cervical CA screening

at 21; • pap Q3yrs; • no screening HPV until age

30Hep C screening: • only for those at risk

(past/current IVDA, sex w/ IV drug user, blood transfusion before 1992)

Alcohol misuse screening: • screen those >18y/o• offer brief behavioral

interventions to those screen +

Obesity screening: • calculate BMI for adults• refer to intensive

behavioral intervention for those w/ BMI >30

Questions, anyone?