1. Clinical Pearls for College Health Providers Summary of relevant research 2013 -4

2. 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

3. The medical literature

4. Your Shuckers… Michelle Paavola, MD Marcy Ferdschneider, DO Cheryl Flynn, MD, MS, MA None of us have disclosures to make

5. 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

6. Now… onto the original research

7. Fasting Time and Lipid Levels Arch Intern Med. 2012; 172(22):1707-1710

8. 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 food Question: Is there an association between fasting times and lipid levels?

9. 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

10. Results Total of 209,180 lipid profiles

11. 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

12. 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

13. 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

14. Three Questions to Dx UTI Ann Fam Med 2013; 11(5): 442-451.

15. 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?

16. Methods Design: cross sectional – All pts administered a structure clinical assmt, urine dip, urine micro, urine culture – Gold standard for UTI was >10 3 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%

17. Methods Outcome: predictability of various models Regression analyses to id predictive factors 5 prediction models: 1.History only 2.Hx + dipstick 3.Hx + dipstick + sediment 4.Hx + dipstick + dipslide 5.Hx + dipstick + sediment + dipslide

18. 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%

19. 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

20. Clinical Pearl: If history is positive for key historical questions, consider empiric treatment 1.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

21. Pyelonephritis: Duration of Treatment The Lancet 2012; 380:484-90

22. 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?

23. 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

24. 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

25. 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%)

26. 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%

27. 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

28. Iron supplementation for fatigue with no anemia? CMAJ 2012; 184 (11):1247-54

29. 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?

30. 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

31. 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

32. 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

33. 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

34. Treatment of acute ACL tear BMJ 2013; 346:f232

35. 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

36. 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

37. 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

38. 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

39. Clinical Recommendation: Physical therapy rehabilitation is the primary treatment option after an acute ACL tear in active young adults BMJ 2013; 346:f232

40. Acute bronchitis: cough duration? Ann Fam Med 2013; 11:5-13

41. 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?

42. 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

43. 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

44. 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

45. 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

46. 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

47. Anti-inflammatory vs. Antibiotic vs. Placebo in Acute Bronchitis BMJ 2013; 347:f5762

48. 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

49. 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

50. Results 1 o outcome: # days with frequent cough – No stat difference Amox/clav: 11 Ibuprofen: 9 Placebo: 11 2 o 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%

51. 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

52. 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

53. Can delayed Rx for URIs decrease Antibiotic use? BMJ 2014; 348: g1606

54. 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?.

55. 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 Rx 2.Post-dated Rx 3.Collection 4.Patient led 5.No Rx at all – All additionally randomly assigned self-care (analgesia, humidified air)

56. 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

57. 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

58. 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%

59. 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

60. 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

61. Association of EC Effectiveness and BMI

62. 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?

63. 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)

64. 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/m 2 LNG (Plan B)UPA (Ella) <251.31.1 25-29.92.51.1 >305.82.6

65. 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

66. 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

67. Can tobacco cessation improve mental health? BMJ 2014; 348:g1151

68. 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?

69. 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)

70. 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

71. Results Outcome# studiesSMDP value Anxiety4-0.370.03 Mixed anx/depr5-0.31<0.001 Depression10-0.25<0.001 Stress3-0.27<0.001 Psychological quality of life 8+0.22<0.001 Positive affect3+0.40<0.001

72. 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

73. 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

74. 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

76. A rec’s & B rec’s Cervical cancer screening: begin cervical CA screening at 21; pap Q3yrs; no screening HPV until age 30 Hep 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

77. Questions, anyone?