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Updates in College Health: A Review of the Literature ACHA National Conference Philadelphia, Pennsylvania June, 2010.

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Presentation on theme: "Updates in College Health: A Review of the Literature ACHA National Conference Philadelphia, Pennsylvania June, 2010."— Presentation transcript:

1 Updates in College Health: A Review of the Literature ACHA National Conference Philadelphia, Pennsylvania June, 2010

2 Objectives Discuss newly published important research studies and their relevance to clinical practice Understand common research study designs Demonstrate evidence based medicine and its application in College Health

3 Team Cheryl Flynn, MD, MS, MA – Interim Medical Director, Syracuse University – Family Medicine; epidemiology; family therapy David Reitman, MD, MBA – University Physician, George Washington University – Pediatrics and Adolescent Medicine Samuel Seward, MD – Assistant Vice President, Columbia University – Internal Medicine and Pediatrics Sarah Van Orman, MD – Executive Director, University of Wisconsin-Madison – Internal Medicine and Pediatrics

4 Process Overview Team members conducted literature review of studies published during past 24 months Key search words: – patient population-adolescent, college student, university, young adult Avoid redundancy of topics presented in 2008 & 2009 Updates

5 Steroids for reducing throat pain Hayward et al. Corticosteroids for pain relief in sore throat: systematic review and meta- analysis. BMJ 2009; 339: b2976

6 Background and Question Sore throat common problem in primary care and college health – Most viral; ~10% Group A Strep – SU experience: 8.7% of provider visits Question: Are systemic corticosteroids effective in reducing symptoms of sore throat?

7 Study Design Systematic review with meta-analysis – Only included placebo controlled randomized controlled trials (RCTs) – Mathematically combined data where possible Performed sensitivity analyses to assess robustness of findings

8 Study Methods Population – ambulatory setting only (ED or primary care) – adults or children with acute tonsillitis/pharyngitis or clinical syndrome of “sore throat” – excluded studies of infectious mono, post-tonsillectomy or intubation, or peri-tonsillar abscess Intervention – systemic corticosteroids vs placebo – (many concurrently received antibiotics &/or acetaminophen)

9 Results 8 RCTs met inclusion criteria – Population 743 patients, nearly balanced between adults/children 47% exudative ST; 44% Strep positive – Intervention Betamethasone IM, dexamethasone IM or PO, prednisone PO All doses fairly equivalent; ~60mg PO prednisone – Quality of included studies High; all with adequately concealed allocation

10 Results— quantitative (meta-analysis) Complete pain relief – At one day: RR 3.16; NNT = 3.7 – At two days: RR 1.65; NNT = 3.3 Mean time to onset pain relief – Steroid group 6.3 hr earlier (p<0.001) Sensitivity analyses found no changes in results – Adult vs child; PO vs IM; Strep vs viral; exudative vs not

11 Results-- Qualitative Adverse effects (reported in only 1 trial) – 5 hospitalized for IVF (3 steroid, 2 placebo) – 3 developed peri-tonsillar abscess (1 steroid, 2 placebo) No difference or trend favoring steroids in – Time to complete resolution of pain – Time missed work/school – Recurrent symptoms

12 Conclusion Addition of systemic corticosteroids significantly reduces pain in patients with sore throat

13 Limitations Possible confounding of antibiotic use – Don’t know effect of steroids independent of antibiotics Relatively small number of RCTs – Unable to assess publication bias

14 Clinical Bottom Line Consider adding steroids in patients with severe sore throat in non-mono pharyngitis – 60mg prednisone PO x 1 dose

15 LBP in Children & Adolescents Ahlqwist, A et al. Physical therapy treatment of back complaints on children and adolescents. Spine 2008; 33: E721-E727.

16 Background LBP is common in college health Risk factors: – poor physical conditioning, intense exercise, inadequate strength/impaired flexibility, family history Question: – How does individualized physical therapy compare to a self-training program in adolescents with lower back pain?

17 Study Methods Design – Randomized controlled trial – Concealed allocation; blinding not possible Setting – Primary care Population – y.o., lumbar pain at least 2/10 on pain scale – Excluded those w/serious physical or mental disease, or those who had PT in prior month – N = 45; baseline comparison between groups similar

18 Study Design Intervention – Intervention group: individualized PT and exercise plus self- training (PT 1x/wk, exercises 2x/wk) – Control group: self-training only; 3x/wk – Duration: 12 weeks Outcomes – Measured using validated instruments perceived health, disability, pain, flexibility/endurance Pre/post within groups Compared change scores between groups

19 Results Perceived health (CHQ-CF) – Both groups had statistically significant improvement in nearly all sub-measures pre/post – No differences between groups Disability (Roland & Morris Disability Questionnaire) – Both groups had improvement pre/post PT -4.6; Control -2.7 – p = between groups

20 Results Pain (visual analogue scale 0-10) – Drop in pain scores pre/post PT -3.6; Control -3.3 – No difference between groups No difference in pain duration or quality of pain Flexibility & muscle endurance (back saver sit and reach) – Both groups had improvement pre/post – No differences between groups

21 Conclusions Both groups improved on all parameters measured Small additional benefit with addition of physical therapy – Perceived health status – Disability ratings

22 Limitations Attribution error – Improvement of health attributed to time or interventions? – Benefits of PT could be attributed to increased “medical attention” Small #s – Lack power to find differences between groups

23 Clinical Bottom Line The benefit of PT for adolescents with back pain is modest at best – If available, reasonable addition – If not, most will improve anyway

24 Contraception and Weight Dinger et al. Oral Contraceptive effectiveness according to body mass index, weight, age, and other factors. Am J Obstet Gynecol 2009; 201: 263 e 1-9. Chi et al. Early weight gain predicting later weight gain among depo medroxyprogesterone acetate users. Obst Gynecol 2009; 114:

25 OCP effectiveness across BMI Research Question – Are OCPs effective across varying BMIs? Design: Cohort – Subset of prospective surveillance study – Followed ~58K women Q6mo x 5 yr – Contraceptive failure rate was an a priori secondary outcome

26 Results Population – 142,475 women years; avg duration follow-up 2.4 years – Mean age 25.2; mean BMI 22.1; 20.4% first time OCP users Outcomes – OCP failure rate 0.75% year 1  1.67% year 4 – NO DIFFERENCE in effectiveness across BMI range Limitations – Lower than expected failure rates – Did not enroll morbidly obese women

27 Predicting weight gain in DMPA users Research Question: – Does early weight gain in depo-users predict continued excessive weight gain? Design: Cohort 240 women y.o. choosing depo followed Q 3-6 months for 3 yrs Depo-users divided into two categories – Avg ( 5% by 6mo) – Predictors of excessive gain at 6 mo included » past pregnancy (RR 2.2), BMI<30 (RR 4.0)

28 Results Adjusting for other factors, early gainers had 7.03 kg more wt gain at 36mo vs avg group Limitations – Small n; stats controlled for confounding – Some who gained wt at 3 months dropped out 12 mo24 mo36 mo Avg (N=144)0.63 kg1.48 kg2.49 kg Early (N=51)8.04 kg10.86 kg11.08 kg

29 Clinical Bottom Lines OCPs effectiveness/wt OCPs are equally effective across weight/BMI spectrum in women who are not morbidly obese Depo/wt gain Significant weight gain from depo use can be predicted within the first two doses

30 Treatment of Irritable Bowel Syndrome (IBS) Ford AC, Talley NJ, Spiegel BMR, Foxx- Orenstein AE, Schiller L, Quigley EM, Moayyedi, P. Effect of fibre, antispasmotics, and peppermint oil in the treatment of irritable bowel syndrome: systemic review and meta-analysis. BMJ, 2008; 337a:2313.

31 Background and Question Primary care providers frequently treat irritable bowel syndrome (IBS) Many studies lack sufficient power to demonstrate efficacy of treatments Conflicting outcomes in various studies What effect, if any, do fibre, antispasmodics or peppermint oil have on the treatment of IBS symptoms?

32 Study Methods Meta-Analysis of randomized controlled trials: Peppermint Oil (4 studies) Antispasmodics (22 studies) Fiber (12 studies) Primary, Secondary and Tertiary care settings Population-not specified Could not have other GI diagnosis

33 Study Design Treatment initiated Follow-up 1 wk – 60 months Needed to report Global assessment of cure Improvement of symptoms 35 studies met criteria

34 Results – Peppermint Oil (4 studies, 293 Patients)

35 Results- Antispasmodics (22 studies, 12 drugs, 1778 Patients)

36 Results – Fiber (12 Trials, 591 Pts)

37 Conclusions Fiber, antispasmodics (e.g. scopolamine) and peppermint oil each more effective than placebo in treating IBS NNTT Fiber 11 Antispasmodics 5 Peppermint Oil 2.5

38 Clinical Bottom Line Of three interventions studied, peppermint oil shows the highest promise for efficacy in treating IBS

39 Sleep Quality Lund H, Reider B, Whiting A, Prichard, J. Sleep Patterns and Predictors of Disturbed Sleep in a Large Population of College Students. J Adol Health 46 (2010)

40 Background / Question Much data exists re: consequences of poor sleep in children/younger adolescents Relatively little data in college age group NCHA Data 53% reported sleep problems 37% sleep had negative impact on academics In college population….. What are the predominant sleep habits? Can quality of sleep hygiene predict physical or behavioral symptoms? What physical, emotional and psychosocial factors predict poor sleep quality?

41 Study Methods and Design Cross-sectional Online Study Setting: Midwestern University Population: College students, age participants 27% 1 st years, 27% Sophomores, 24% Juniors, 20% Seniors 420 male, 705 Female Asked to complete 5 validated surveys to rate – sleep quality, sleepiness, mood, distress, and diurnal symptom variability

42 Results: Sleep Quality and Quantity Mean total sleep time 7.02 hrs 25% < 6.5 hrs 29.4% ≥ 8hrs Quality Sleep (PQSI) – 34% “good” – 38% “poor” Sleepiness (Eppworth Sleepiness Scale) – 25% scored >10 (significant daytime sleepiness)

43 Results: Sleep Quality, Mood, & Health Poor Quality Sleepers: – Higher levels of weekday stress (p<0.001) – SUDS : 70.7 vs – Self reported negative moods (p<0.001) – e.g. POMS Depression: vs – More physical illnesses (p<0.05) – 12% missed class in a month 3x+ – Increased use of Rx, OTCs and recreational drugs to stay awake and to fall asleep >1x/month

44 Results: Predictors of Poor Quality Sleep Stress – Stress about school (39%) – Emotional stress (25%) Excess noise (33%) Sleeping Partners (7%) Talking with friends prior to sleep (6%)

45 Conclusions “Epidemic” of insufficient and poor-quality sleep in college students Perceived stress tends to predict poor quality/ quantity of sleep Consequences of poor quality sleep include higher stress, poorer moods, increased physical symptoms, missed classes

46 Limitations One-time, non-longitudinal survey Students were from one university Self-report No mention of role of ETOH/Drug use

47 Clinical Bottom Line Clinicians need to proactively focus on both the quality as well as the quantity of sleep in patient history Poor Quality Sleepers increased risk of mood disorders, substance abuse disorders and somatic complaints

48 Douching and STIs Tsai CS, Shepherd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Amer J Obstetrics and Gynecology. January e1-e8.

49 Douching and STIs Question: Is there an association between douching and Trichomonas, Chlamydia, Gonorrhea and Herpes Design: Observational Prospective (Longitudinal) Cohort Results: – Assessed time to STI in women who never, sometimes, or always douched – Average age 16.9 yrs. 73% Black. 65% HIV infected – “Always douched” had a shorter STI-free time than those who “never douched.” (2:1) Commentary/Limitations – High risk adolescents, slightly younger than college age. 2/3 HIV – Couching = independent risk factor for STI acquisition Clinical bottom line: Clinicians should counsel female patients about potential STI risks with frequent douching

50 Antidepressant Treatment Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, and J. Fawcett. Antidepressant Drug Effects and Depression Severity. JAMA. 2010; 303(1):47-53.

51 Background and Question Most studies for antidepressant effectiveness in severely depressed patients Majority of patients treated with antidepressants have mild to moderate symptoms Question: What is the relative benefit of antidepressant medication vs. placebo across a range of depression symptom severity?

52 Study Methods Meta-analysis of 6 randomized placebo controlled trials Setting-outpatient Population – Adults > age 18 yrs – 5 Major depression; 1 minor depression

53 Study Design Intervention – Treatment Range 6-11weeks – 434 Antidepressant vs. 284 placebo – 3 imipramine and 3 paroxetine Outcome – Hamilton Depression Rating Scale (HDRS) Mild to moderate < 18 Severe Very severe > 23 – HDRS 3-point difference-clinically significant

54 Results Baseline HDRS Threshold for effect initial HDRS > 25 Medium effect HDRS > 25 Large effect HDRS > 27 Drop-out rates 9-34%

55 Conclusions Antidepressant drug effect varies as function of disease severity Antidepressant drug effect appears to be negligible with mild to moderate depression Antidepressant drug effect was large only for very severe depression

56 Commentary/Limitations Few patients with HDRS scores < 13 Considered only acute treatment Did not include newer antidepressants Increased effectiveness of anti-depressant vs. reduced effectiveness of placebo

57 Clinical Bottom Line Effect of antidepressant therapy on mild to moderate depression unclear

58 Hair Shedding Kunz M, Seifert B, and RM Trueb. Seasonality of Hair Shedding in Healthy Women Complaining of Hair Loss. Dermatology. 2009;219:

59 Hair Shedding Question: Is hair shedding seasonal? Study Design: Retrospective Case Study Results/Conclusions – Assessed telogen rates – 823 women, aged – 79% with female pattern hair loss (FPHL) – Telogen rates showed annual periodicity with peak in July and April

60 Hair Shedding Commentary – Most marked in women with FPHL – Student population may have higher rates of telogen effluvium Clinical Bottom Line: Seasonal variation may be important to consider for patient counseling and for response to treatment

61 Value of Family History Wilson B, Quresh N, Santaguida P, Little J, Carroll J, Allanson J, and P Raina. Systematic Review: Family History in Risk Assessment for Common Diseases. Annals of Internal Medicine. 151(12):

62 Background Family history associated with risk for many common diseases Knowledge of family history may motivate behavior change Collecting family history is associated with risks and benefits Collecting family history requires clinician time

63 Questions #1 Improved Health What is the direct evidence that getting a family history will improve health outcomes for the patient or family?” #2 Harm What is the direct evidence that getting a family history will result in adverse outcomes for the patient or family? #3 Key Elements What are the key elements of a family history in a primary care setting for the purposes of risk assessment for common diseases? #4 Accuracy What is the accuracy of family history, and under what conditions does the accuracy vary?

64 Study Methods Systematic Review, – 137studies met criteria – 69 reviewed Unable to perform meta-analysis

65 Results #1: Improved Health Studies – 2 uncontrolled studies, high-study bias Outcomes – No studies with direct health effects – Increased uptake in breast cancer screening only

66 Results #2-Harm Studies – 1 randomized controlled; 2 uncontrolled studies – 2 generic family history; 1 cancer risk Outcomes – 1 study found short-term increase in anxiety, gone at 3 months – No long-term adverse effect found

67 Results #3-Key Elements Studies – 20 longitudinal, 21 cross-sectional studies – Cancer, coronary heart disease, stroke, diabetes – 40 definitions of positive history Outcomes – Sensitivity greatest Parents or other 1 st degree relatives – Specificity greatest Relative identified > 1 relative required Age of onset

68 Results #4-Accuracy Studies – Specialized disease clinics – 23-Longitudinal, Case-control, and Case series – Patient report vs. relative’s medical records Outcomes – Informants disease status did not affect accuracy – Less accurate for 2nd and 3 rd degree relatives – Widely varying sensitivity and specificity – Specificity (absence of disease) better than sensitivity (presence of history)

69 Conclusions No evidence that family history leads to improved health – Insufficient evidence of changed health behaviors No definitive evidence of lack of harm Best method in primary care unclear Best for 1 st degree relatives Accuracy often low, better for absence of disease

70 Commentary/Limitations Few well done studies Most included patients with the condition of interest leading to selection bias Many studies not done in primary care settings Better studies are needed

71 Clinical Bottom Line Family history collection is considered to be a standard of good care, but value is unknown. If collected, practitioners should focus on 1 st degree relatives.

72 Dexamethasone for Migraine Singh A, Alter H, Zaia B. Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta-analysis and Systematic Review of the Literature. Acad Emerg Med. Dec, 2008.

73 Background and Question Migraine is common Recurrent migraine after abortive therapy is common: – Up to 2/3 patients treated in ED within 48 hours Does addition of Decadron to standard therapy decrease incidence of recurrent migraine?

74 Study Methods Meta-analysis of RCT’s Inclusion criteria: – Double blind – Acute Migraine Dx – Emergency Department (ED) – Presence of control group – Adequate follow-up 7 studies fulfilled criteria (n=742)

75 Study Design Intervention: “standard therapy” + Decadron (IV or PO) Outcome: moderate or severe migraine at 24 to 72 hours

76 Results Modest but statistically significant benefit to adjunctive Rx with Decadron – ARR = 9.7% – RR = 0.87 – 95% CI = 0.80 to 0.95 Adverse side effects: – 26% of Decadron pts – 23% placebo pts

77 Conclusions Decadron, in this analysis, shown to decrease rate of moderate or severe headache hours after initial ED Rx

78 Commentary/Limitations “Standard Treatment” defined broadly—and, in some studies, arguably unusually ED setting Not a large n Dose and route of Decadron

79 Clinical Bottom Line Decadron may have some value in abortive Rx of acute migraine

80 X-rays and Harm Fazel R, Krumholz H, Yongei Wang SM, et al. Exposure to Low-Dose Ionizing Radiation from Medical Imaging. NEJM. August, 2009.

81 Background Patients, over their lifetimes, are getting increasing #’s of studies with radiation Ongoing concern about link between low- dose radiation and – solid tumors – leukemia Patients often unaware of potential risk Not all imaging procedures evidence-based

82 Background Growth in Use of Advanced Imaging under Medicare, 1995–2005

83 Background Imaging ProcedureAverage Effective Radiation Dose Plain Film0.01 – 10 mSv CT2 – 20 mSv Nuclear0.3 – 20 mSv Interventional5 – 70 mSv

84 Study Methods Retrospective cohort study United Healthcare enrollee records

85 Study Design January 1, 2005 to December 31, 2007 Ages 18 – 64 yo 5 sites – Arizona, Dallas, Orlando, South Florida, Wisconsin CPT codes Standard definitions of “Effective Dosing” for radiation

86 Results 1M total patients – 68.8% at least one imaging procedure – 655,613 patients Higher in older age groups: – 85.9% of years – 49.5% years Higher by gender: – Women: 78.7% and Men: 57.9% – Mean: 1.2 +/- 1.8 procedures/patient/year – Median: 0.7 procedures/patient/year

87 Results Distribution of Annual Effective Doses of Radiation Stratified by Gender

88 Conclusions Nearly 70% study population underwent ≥1 imaging procedure during 3-year study period Gender-specific findings bear further study

89 Commentary/Limitations Imagining procedures are a source of radiation exposure in the United States – can result, over time, in high cumulative effective doses – Young people included Challenge = balancing immediate clinical need with LT dose effect Selection bias Claims data

90 Clinical Bottom Line More is being discovered about imaging practices in the U.S. and their potential negative relation to long-term health effects. Primum non nocere

91 Radiologic Work-Up for Acute Abd Pain—What Helps Nail the Dx? Lameris W, van Randen A, van Es HW, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ. March 2009.

92 Background Abdominal pain is common: – 5-10% ED visits – Columbia AY 08-09: 830 cases CT and U/S have both been shown to – Positively effect diagnostic accuracy – Impact management decisions Both costly CT = radiation exposure

93 Question What is the optimal imaging strategy for accurate diagnosis of urgent conditions related to acute abdominal pain?

94 Study Methods Prospective, paired diagnostic accuracy study 6 academic medical centers – Adults ≥ 18yo with acute non-traumatic abdominal pain – ED setting – Exclude: Pregnancy Shock Ruptured AAA Patients for whom no imaging indicated

95 Study Design Diagnostic Strategies: 1.Diagnosis following clinical evaluation (CE) 2.CE + plain films 3.CE + U/S 4.CE + CT 5.CE + U/S + CT (if U/S negative or inconclusive)

96 Results 1021 patients – ED/Urgent Care settings – Mean age: 47 years – 55% female – Ethnicity/Race not specified 66% of patients hospitalized following ED evaluation 47% required surgical procedure

97 Results DiagnosisNo (%) Appendicitis284 (28) Cholecystitis52 (5) Gynecological27 (3) Urological22 (2) Pneumonia11 (1) Total661 (65) Final Diagnoses: URGENT

98 Results DiagnosisNo (%) Non-specific Abdominal Pain183 (18) IBD30 (3) Gynecological9 (1) Total360 (35) Final Diagnoses : NON-URGENT

99 Conclusions Imaging StrategySensitivit y SpecificityFalse Negatives False Positives 1) Clinical Exam ) CE + Plain Films ) CE + U/S ) CE + CT ) CE + U/S +/- CT All values in percentages (95% confidence intervals)  Strategy 5 approximately ½ total number of CTs completed in strategy 4

100 Commentary/Limitations More than one way to peel a banana Stepped approach to w/u may or may not be practical depending on patient/sx severity – And, if time allows, U/S before CT has merits Non-randomized Most patients referred to ED—selection bias

101 Clinical Bottom Line As a single imaging strategy, CT is overall better than U/S for urgent conditions A conditional strategy with CT reserved for -/inconclusive U/S provides: – highest sensitivity – reduced population-based radiation exposure


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