Presentation is loading. Please wait.

Presentation is loading. Please wait.

Fatigue In The College Student Bruce Helming, MD, FAAFP University of Arizona Campus Health Service To test, or not to test?

Similar presentations


Presentation on theme: "Fatigue In The College Student Bruce Helming, MD, FAAFP University of Arizona Campus Health Service To test, or not to test?"— Presentation transcript:

1 Fatigue In The College Student Bruce Helming, MD, FAAFP University of Arizona Campus Health Service To test, or not to test?

2 Conflict of interest statement: I have NO actual or potential conflict of interest in relation to this educational activity or presentation.

3 Objectives Describe clinical fatigue Identify warning signs for serious illness Identify risk factors for iron deficiency Identify common infectious causes of fatigue Describe screening, diagnostic and general treatment options for depression

4 Fatigue Facts % prevalence $136 billion in lost productivity 7 million office visits In primary care: 21 to 33 % report “Significant fatigue” 1/3 of adolescents report it

5 Definition – Clinical Fatigue Inability to initiate activity perception of generalized weakness, in the absence of objective findings Reduced capacity to maintain activity easy fatiguability with exertion Difficulty with concentration, memory, and emotional stability mental fatigue

6 Case 1 25 year old male graduate student with about 4 weeks of fatigue with exercise, mild shortness of breath and cough

7 Case 2 22 year old female student with about 2 months of fatigue with exercise, and non-specific leg pain

8 Case 3 24 year old male graduate student with about 8 weeks of generalized fatigue, worse with exercise, as well as some motivation and concentration problems that he attributes to grad school

9 Case 4 19 year old female student-athlete with about 2 weeks of fatigue with exercise, diminished performance in her sport

10 Case 5 22 year old male student-athlete with about 8 weeks of fatigue with exercise, mild shortness of breath with exercise, some generalized daytime fatigue

11 Fatigue in Athletes Real or perceived: Decrease in performance (exercise capacity) Plateau in performance Lack of improvement with training Intolerance to increased training intensity “Run down” without specific complaint Patient-driven or from peers, coaches, family

12 Basic Assumptions Healthy population New onset Reliable historians No secondary gain

13 Red Flags Fever/Chills Night sweats Weight loss Bleeding disorders Trouble with daily activities Amenorrhea Stress fracture Low BMI

14 Trouble Diabetes Leukemia / cancer Heart disease Congenital Myocarditis Hypercalcemia Acute infection HIV, Hepatitis Pulmonary embolism

15 Concussion Remember to ask about recent head injury “Follow up accident (MVA)” visits Many patients are not educated about concussion Leave ER with lots of normal xrays Lingering effects on mood, energy, sleep and concentration are common CDC Concussion information is excellent:

16 Fatigue Neuropsych Infectious Functional Metabolic Nutrition Exercise Sleep Pregnancy Asthma Allergies Celiac Stress Diabetes Thyroid Anemia Iron Vitamin D Depression Grief Adjustment Disorder Concussion Domestic violence Substance abuse Mono Cocci HIV Chronic Infection

17 History Onset - abrupt or gradual, related to event or illness Course - stable, improving or worsening Duration and daily pattern Factors that alleviate or exacerbate symptoms Impact on daily life - ability to work, socialize, participate in family activities Accommodations patient has made to adjust

18 History, part deux Depression/anxiety Current life stress, relationships, school, work Past trauma or abuse Change in activity or diet Medications, substance use History of anemia, iron deficiency, mood or eating disorders Menstrual patterns Family history

19 More History... Sleep habits, quality Nutrition: meal schedule/size, restrictions, caloric intake Digestive: diarrhea, bloating, discomfort Exercise: frequency, intensity, duration, effect on symptoms Social history: interest in school, social activities/support system, hours in work/school

20 Physical Exam General Alertness, appearance, mood/affect Neck Lymphadenopathy, goiter, thyroid nodules Chest Murmurs, crackles, wheezing Neurologic Tone, bulk, reflexes Extremities Edema

21 Lab Workup Unknown etiology CBC with differential Chemistry profile TSH, with reflex freeT4 Ferritin, ESR Consider Urinalysis EBV/Mono, Cocci Pregnancy, Vitamin D Creatine Kinase, HIV PPD/IGRA (Interferon gamma release assay for tuberculosis)

22 US Olympic Blood Workup RBC, Hgb, Hct, WBC, Differential Chemistry, Creatine Kinase (CK), LDH Ferritin, Iron, TIBC, Transferrin Saturation Cortisol Lipids, Urine specific gravity

23 Clinical Indicators for Lab Tests Hemoglobin/Ferritin Pallor, tachycardia, dyspnea, symptoms of anemia Dietary, personal or family history of anemia risk: Heavy exercise, meat restriction/vegetarian White blood cell count Fever, evidence of infection Weight loss, lymphadenopathy Erythrocyte sedimentation rate (ESR) Arthralgia, arthritis, concern for malignancy

24 Clinical Indicators for Lab Test Electrolytes Medications: Diuretics, steroids Renal function Elevated blood pressure, edema, pruritis Medication affecting renal function Glucose Polydipsia, polyuria, polyphagia, family history Thyroid Stimulating Hormone (TSH) Dry hair/skin, change in bowel habits, menses

25 Lab Utility Primary care 5% hit rate Higher in students? Useful in students Positive Iron, anemia, mono, thyroid Negative Depression, stress, sleep, nutrition, overtraining

26 Psychiatric Depression / Anxiety Adjustment disorder, somatization − Stress, expectations − Family/relationship − Domestic violence Disordered eating − Anorexia, Bulimia Substance abuse Grief

27 Feeling bad on Facebook 200 Facebook profiles were evaluated 25% displayed depressive symptoms –2.5% met criteria for Major Depressive Episode References to depression were more common when a response to prior disclosure occurred Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on a social networking site, Depression and Anxiety, 2011, 0:1-9

28 Depression Seen in 2-10 % of college population Overlap with Adjustment disorder Grief Stress & Anxiety Sleep disturbances Responsive to: Counseling Medication Self-management

29 Depression loss of interest in pleasure loss of motivation loss of sense of control functional impairment may not relate with severity of depression denial is frequent Ask about mood, stressors, and suicide

30 Depression Screening & Treatment We’re implementing screening with PHQ-2, followed by PHQ-9 Sharing of notes and care manager between counseling and medical sides Screening is a gateway to conversation about mood, sleep, suicidal thoughts Objective measure of mood for tracking Tools for providers to assess, diagnose, treat and track are available in EMR (medical record)

31 Infectious Acute, subacute, chronic Mono, CMV, HIV Cocci (Valley Fever) cough, fevers, rash erythema nodosum College lifestyle can cause: Inadequate recovery Impaired healing Weakened immunity

32 50 Fatigued Aussie Athletes } 50%

33 Mononucleosis Epstein-Barr Virus Upper respiratory infection followed by fatigue/malaise Posterior cervical nodes Splenic rupture Risk estimates ~ 1:500 Spontaneous, Valsalva or traumatic Rest from sports, strenuous activity for 4 weeks

34 Mononucleosis 4-6 week incubation no quarantine EBV serology to confirm simultaneous Strep common rupture most likely in 3 weeks as late as 7 weeks if feeling well, light exercise at 3 weeks, progress slowly rare prolonged fatigue syndrome typical recovery by 6-8 weeks

35 Natural History of Mono 150 patients aged 16 and up, followed for 6 months SymptomInitial %1 Mo2 Mo6 Mo Sore Throat Fatigue Sleeping too much Headache Sore muscles281411

36 Rea, TD, Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr Virus, JABFP, 2001; 14(4): patients aged 16 and up, followed for 6 months

37 Coccidioidomycosis (Valley Fever) AKA: Valley Fever, Cocci, Desert Rheumatism, San Joaquin Valley Fever AZ, CA, NV, UT, NM, TX, Mexico, Guatemala, Honduras, Equador, Paraguay, Argentina Caused by inhaling spore found in soil: fungal infection Severity: mild (60%), moderate (30%), severe (10%) NOT contagious, incubation period of 7-21 days Majority have mild symptoms, and do not seek care

38 Cocci Valley Fever Center for Excellence web search: "CDC Valley Fever"

39 Cocci Symptoms: Fatigue, night sweats, cough, chest pain, dyspnea, hemoptysis, headache, arthralgias (diffuse/migratory) Signs: Fever, weight loss, erythema nodosum/multiforme, eosinophilia, elevated ESR Xray: infiltrates (unilateral), hilar adenopathy, effusions 30% of Community Acquired Pneumonia cases in Tucson –80% had at least one course of antibiotics 31% received multiple courses Averaged 5 months and 3 clinic visits to reach correct diagnosis (in adult population)

40 Cocci Serologies Positive: suggestive, especially in light of clinical history Negative: NEVER excludes the diagnosis Risk factors: Immunosupression, Diabetes, Pregnancy Treatment: reserved for serious infections, antifungals, fluconazole, itraconazole Complications: Bone infection, cavitary lung lesions, systemic Prognosis: Good, but very slow (weeks to months)

41 Endocrine/Hematologic Iron deficiency Anemia Hypothyroid Diabetes Polydipsia, Polyphagia Polyuria, Weight loss Vitamin D deficiency

42 Iron deficiency History Meat restriction Insidious Females Increased activity Screening CBC, Ferritin, iron studies Treatment Oral iron, nutrition

43 Iron deficiency ferritin < 35 ng/ml precedes anemia declining MCV absorbed in proximal small bowel give with vitamin C or OJ plan 3-4 months of iron recheck at 4-6 weeks female vegans have 40% risk

44 Decline in iron during boot camp Basic Combat Training, female recruits –7% at start were iron deficient –18% at end –iron status correlated with running performance 1 to 1.5 hours of exercise –4-6 days/week, for 9 weeks –16,000 steps/day vs 8,000 for civilians ~1 lb weight gain over 9 weeks McClung, JP, Longitudinal decrements in iron status during military training in female soldiers. Br J Nutr, 2009; 102: 605-9

45 Added iron in female soldiers 219 female Army soldiers 8 week basic combat training 20% had iron deficiency anemia 100 mg of ferrous sulfate daily vs placebo –Iron improved Vigor scores –on Profile of Mood States (POMS) –Limited iron loss associated with BCT Did NOT eliminate it at this dose –Improved running performance only if anemic McClung, JP, Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers during military training: effects on iron status, physical performance, and mood. Am J Clin Nutr 2009;90:

46 Iron status in young athletes Elite athletes from years old Most females failed to meet iron RDA 63% vs 19% for males Low ferritin <35 more common 57% vs 31% for males Low levels associated with: diet in females higher expenditures in males –Koehler, K, Iron status in elite young athletes: gender-dependent influences of diet and exercise, Eur J Appl Physiology, 2011, DOI /s

47 Iron and the body Iron deficiency affects: physical endurance immune response temperature regulation energy metabolism cognitive performance behavior disturbances Murray-Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778-87

48 Iron Supplementation Improves: Performance (ferritin below 20) Increased speed on 15 km bike ergometer Increased VO2Max, and oxygen consumption “Maximal voluntary contraction strength” in knee extension (response to training effect) Labs: Increase in ferritin, may see Hgb rise Subjective (ferritin below 35) Decreased sensation of “Fatigue” in adult females (non-athletes)

49 Iron and cognition Blinded, placebo controlled study comparing: Normal vs Iron deficient (ID) vs Iron deficiency anemia (IDA) (Hb >= 10.5 and < 12) IDA < ID < Normal on baseline cognitive testing Increased Ferritin responders Attention and Learning scores increased significantly Memory score increased as well (p<0.07) Increased Hemoglobin responders Attention and memory scores increased Learning task speed improved Murray-Kolb, LE, Iron treatment normalizes cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778-87

50 Types of iron supplements Ferrous sulfate Ferrous gluconate Iron/Vit C - FerroGels Forte ascorbic acid, folic acid, cyanocobalamin, and ferrous fumarate Iron/Colace - Ferro-Sequel Ferrous fumarate, sodium docusate Vegetarian/Kosher Solgar Gentle Iron

51 Anemia History Prior diagnosis Unable to donate blood Trial with iron Check response dilutional or sports anemia Thalassemia trait - anemia will not respond to iron supplements

52 Anemia fatigue with activity pica - compulsive ingestion of nonnutratives pagophagia - ice chewing anemia can be relative additional workup when appropriate Eichner, ER. Iron Deficiency Anemia, Cur Sp Med Rep, 2010; 9(3): 122-3

53 Hypothyroid 15% of women 3-4% of men weight gain, fatigue, cold intolerance, constipation, weakness thyroid stimulating hormone (TSH), usually reflex fT4 levothyroxine replacement Target TSH?

54 Vitamin D - Basics Both a hormone and vitamin Calcium absorption, utilization and release Affects parathyroid levels Receptors for gene signaling Diet sources and direct conversion in skin with light (UV) exposure Symptoms: Nonspecific musculoskeletal complaints, fatigue, weakness, fractures/rickets Risk factors: Malabsorption, low dietary intake, limited sun exposure, darker skin coloration

55 Vitamin D - Diagnosis Measure: 25 hydroxy-vitamin D 25-OH-D Deficiency (insufficiency) is common (ages > 11): > 30% deficient (less than 20 ng/ml 25-OH-D) > 70% insufficient (less than 32 ng/ml 25 OH-D) Target levels are controversial ng/ml Sun absorption/exposure varies greatly Treat for 2-3 months, discuss ongoing dose

56 Vitamin D RDA 600 iu/day D3 Max routine daily intake 4000 iu/day D3 Daily iu D3 (cholecalciferol) Weekly 50,000 iu D3 or D2 (ergocalciferol) Ensure 1000 mg of calcium/day Other research findings: 500,000 iu once a year D3 was NOT effective toxicity at 60,000 iu D3 DAILY 1500/day=10,500/week=45000/month

57 Vitamin D Some evidence for mood benefits IOM summary: Good bone health evidence

58 Cardiopulmonary Myocarditis Recent infection with new chest pain and fatigue Asthma Diminished exercise capacity Allergic Exercise-induced

59 Functional Nutrition Disordered eating Inadequate caloric intake Inadequate recovery Sleep, sleep, sleep Pregnancy Female athlete triad disordered eating amenorrhea/oligomenorrhea osteopenia

60 Functional suspect nutrition: change in activity intensity weight loss intense exercise sleep/rest are essential deficient sleep is common

61 Female athletic performance Strong relationship between caloric restriction and vegetarian diet Causal relationship between energy balance and menstrual dysfunction Energy deficit associated with poor athletic performance VanHeest, JL, Female Athletes: Factors Impacting Successful Performance, Cur Sp Med Reports, 2007; 6:

62 Insomnia 1/3 of adults report problems in last 12 months Triggers: Stress, illness, scheduling, mood disorders, drugs Risk factor for depression, drug abuse, suicide Self-management, counseling (CBT), medications rarely

63 Insomnia Educational challenge in this population: Many have tried OTC sleep aids Few understand basic sleep hygiene/physiology Misunderstand the role of medication and effectiveness of behavioral changes FamilyDoctor.org: Insomnia: How to Get a Good Night's Sleep

64 Allergies Food allergies Blood and skin testing Elimination diets Chronic seasonal

65 Celiac Disease Autoimmune response to gluten exposure Strong genetic component, HLA-related Prevalence 1% Typical: Diarrhea, malabsorption, weight loss, nutrient deficiencies Atypical: anemia, osteoporosis, neurologic symptoms Histologic: tissue changes in small bowel, villous atrophy, crypt hyperplasia, progressive

66 Celiac Disease Screening: Tissue transglutaminase antibodies Confirm: Endomysial antibodies (EMA) Ab levels proportional to gluten load –Histological changes in intestine Gluten-Free Diet (GFD) is treatment Cross-contamination of food is common –US threshold is 20 ppm –Levels as low as 100 ppm can worsen disease

67 Celiac Prevalence and Mortality Comparison of 50 year-old serum samples to matched modern samples –Matched with two groups, similar aged males now and males with same birthdates Four-fold increase in prevalence (now 1%) Four-fold increase in mortality Rubio-Tapia, A, Increased Prevalence and Mortality in Undiagnosed Celiac Disease, Gastroenterology, 2009; 137:88-93

68 Iatrogenic Medications hypnotics muscle relaxants antidepressants !!! antihistamines beta blockers antibiotics Paradoxical fatigue with imposed rest especially in active individuals

69 Exercise improves (relieves) fatigue Acute: Over 6 weeks, increased vigor and decreased fatigue in college students Chronic: 10 to 20 weeks, increased energy in fatigued subjects Dishman, RK, Effects of cycling exercise on vigor, fatigue, and EEG activity among young adults who report persistent fatigue. Psychophysiology, 2010; 47(6): O'Connor, PJ, Chronic physical activity and feelings of energy and fatigue, Med Sci Sports Exerc, 2005; 37(2):

70 Case 1 25 year old male graduate student with about 4 weeks of fatigue with exercise, mild shortness of breath and cough Asthma treatment was not helpful Infection workup negative (not Cocci) More detailed history reveals history of air travel and some mild leg pain preceding fatigue DX: Pulmonary embolism

71 Case 2 22 year old female student with about 2 months of fatigue with exercise, and non-specific leg pain Physical exam reveals very fair skin, little to no evidence of solar damage (after 4 years in Tucson, 360 days of sunshine per year) Basic lab workup is negative, except vitamin D DX: Vitamin D deficiency Symptoms resolve with vitamin D replacement

72 Case 3 24 year old male graduate student with about 8 weeks of generalized fatigue, worse with exercise, as well as some motivation and concentration problems that he attributes to grad school History reveals: Recreational runner, minutes daily, vegetarian DX: Iron deficiency anemia Treated with iron: energy and exercise symptoms improve, but not mood symptoms DX: Depression & IDA, responds to iron & SSRI

73 Case 4 19 year old female student-athlete with about 2 weeks of fatigue with exercise, diminished performance History: distance runner, prior history of iron deficiency anemia, treated for 3 months, improved, stopped iron. Now a year later similar symptoms, labs confirm low iron and hemoglobin DX: Iron deficiency anemia - improved with iron, after her counts normalize start daily maintenance iron supplement while training/exercising

74 Case 5 22 year old male student-athlete with about 8 weeks of fatigue with exercise, shortness of breath with exercise, some generalized daytime fatigue History: Not helpful, extensive asthma workup was negative Labs: Elevated TSH DX: Hypothyroid - Responds well to levothyroxine replacement

75 Summary Careful history Timing, habits, mood, nutrition, illness Screening labs when needed Iron, thyroid, infection, vitamin D Remember Stress, mood, sleep, workload Young adults are at risk

76 References UptoDate Catassi, C, Celiac Disease, Cur Opin Gastroenterology, 2008; 24: Eichner, ER. Iron Deficiency Anemia, Cur Sp Med Rep, 2010; 9(3): Fallon, K, Clinical utility of blood tests in elite athletes with short term fatigue,BJSM, 2006;40:541–544 Fallon, K, Utility of Hematological and Iron-Related Screening in Elite Athletes, CJSM, 2004;14:145–152 Killip, S, Iron Deficiency Anemia, AFP, 2007;75:671-8 Koehler, K, Iron status in elite young athletes: gender-dependent influences of diet and exercise, Eur J Appl Physiology, 2011, DOI /s Kurowski, K, Food Allergies: Detection and Management, AFP, 2008; 77(12): Kurpa, K, Diagnosing MIld Enteropathy Celiac Disease: A Randomized, Controlled Clinical Study, Gastroenterology, 2009; 136: McClung, JP, Longitudinal decrements in iron status during military training in female soldiers. Br J Nutr, 2009; 102: McClung, JP, Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers during military training: effects on iron status, physical performance, and mood. Am J Clin Nutr 2009;90: Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on a social networking site, Depression and Anxiety, 2011, 0:1-9 Murray-Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J Clin Nutr, 2007; 85: O'Conor, P, Chronic Physical Activity and Feelings of Energy and Fatigue, Med Sci Sports Exer, 2005;37: Rea, TD, Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr Virus, JABFP, 2001; 14(4): Reid, VL, Clinical investigation of athletes with persistent fatigue and/or recurrent infections, BJSM, 2004;38:42-45 Reynolds, Gretchen, Crash and Burnout, NY Times, 3/2/2008 Ricci, JA, J Occup Environ Med 2007;49:1 Rodenberg, R, Iron as an Ergogenic Aid: Ironclad Evidence?, CSMR, 2007;6: Rosenthal, T, Fatigue: An Overview, AFP, 2008;78: Rubio-Tapia, A, Increased Prevalence and Mortality in Undiagnosed Celiac Disease, Gastroenterology, 2009; 137:88-93 VanHeest, JL, Female Athletes: Factors Impacting Successful Performance, Cur Sp Med Reports, 2007; 6: Verdon, V, Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial, BMJ, 2003;326:1124 Zotter, H, Abnormally high serum ferritin levels among professional road cyclists, BJSM, 2004;38: Photos: AbnelPhoto.com, Adam Piggott, *Sean, fffriendly, John Althouse Cohen, MarcoIE, Mariano Kamp, OskarN, Raphael Goetter, SirMervs, Sister72, Slaff, Thomas Hawk, future15pic, chotda, UA athletics, vramak, Barry Yankowitz, Maurese Polizio, Tezza#, Martin Gommel[Flickr.com]

77 Medicine & Science in Sports & Exercise. 34(3): , March GLEESON, MAREE; PYNE, DAVID B.; P. AUSTIN, JASON; LYNN FRANCIS, J.; CLANCY, ROBERT L.; MCDONALD, WARREN A.; FRICKER, PETER A. GLEESON, M., D. B. PYNE, J. P. AUSTIN, J. L. FRANCIS, R. L. CLANCY, W. A. MCDONALD, and P. A. FRICKER. Epstein-Barr virus reactivation and upper-respiratory illness in elite swimmers. Med. Sci. Sports Exerc.,Vol. 34, No. 3, pp , Purpose: The aim of this study was to investigate the relationships between latent viral shedding of Epstein-Barr virus (EBV) in saliva, upper-respiratory illness, and mucosal immune suppression in a cohort of highly trained swimmers undertaking intensive training. Methods: Saliva was collected before selected training sessions from 14 elite male swimmers during a 30-d period of intensive training. Prior infection with EBV was determined by EBV antibody serology. Salivary IgA concentrations were measured by enzyme linked immunosorbent assay (ELISA), and EBV viral shedding (EBV-DNA) was detected by polymerase chain reaction (PCR). Symptoms of upper-respiratory illness were recorded daily. Results: Eleven swimmers (79%) were seropositive for prior EBV infection. Seven EBV seropositive swimmers (64%) had EBV-DNA detected during the study period. Upper-respiratory symptoms (URS) were reported in six of seven swimmers in whom EBV-DNA was detected and in three of four swimmers with no EBV-DNA detection. No URS were reported in the EBV seronegative swimmers. There was a statistically significant relationship between EBV serology status and URS (P = 0.027). EBV-DNA was detected in saliva before the appearance of URS. Salivary IgA levels were significantly lower immediately before the URS (P = 0.01) compared with subsequent peak IgA levels and declined to pre-URS levels on average 11 d after the first appearance of URS. Conclusions: The time course of appearance of EBV-DNA in relation to URS suggests latent viral EBV shedding may be a contributing factor in the URS. The low levels of salivary IgA detected before the URS indicated transient mucosal immune suppression in the study cohort. The viral shedding may alternatively be a reflection of the altered immune control mechanisms that occur in response to intensive exercise and unrelated to the URS. (C)2002The American College of Sports Medicine

78 FATIGUE Functional Nutrition, Overtraining Pregnancy, Asthma Allergies, Celiac Sleep, Stress Neuropsych Depression, Grief Adjustment Disorder Concussion Domestic violence Substance abuse Metabolic Diabetes, Thyroid Anemia, Iron Vitamin D Infectious Mono, Cocci, HIV, Sinusitis Chronic Infection Multifactorial Nature of Fatigue

79 Hematologic Screening Australian Institute of Sport CBC, ferritin, iron, transferrin 120 males, and 174 females over 2 years Males 8 % had abnormal results 4 % had low ferritin Females 51 % had abnormal results 16 % had low ferritin One had hemachromatosis (persistent ↑ iron)


Download ppt "Fatigue In The College Student Bruce Helming, MD, FAAFP University of Arizona Campus Health Service To test, or not to test?"

Similar presentations


Ads by Google