Clinical Pearls for College
Health Providers
Summary 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 food
Question: 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 costeffective
– 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.
2.
3.
4.
5.
History only
Hx + dipstick
Hx + dipstick + sediment
Hx + dipstick + dipslide
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
• Hx alone can classify
more than half the
women with suspected
UTI
• Adding +urine dipstick
useful adjunct
– Especially if pre-test
probability 20-80%
&
Limitations
• 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 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
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 preinjury 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.
2.
3.
4.
5.
Recontact for Rx
Post-dated Rx
Collection
Patient led
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
• 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
&
Limitations
• 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 (%)
LNG (Plan B)
UPA (Ella)
<25
1.3
1.1
25-29.9
2.5
1.1
>30
5.8
2.6
BMI kg/m2
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
• ~14% college students
smoke cigarettes
• 4% report smoking daily
• Stress, anxiety & depression
are common in college
students and negatively
impact functioning
• Clinicians may defer
recommendations to quit
smoking in pts with MH
issues, or in times of high
stress
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
Results
Outcome
# 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
• Cigarette smoking
cessation is associated
with an improvement in
mental health on a
variety of measures
&
Limitations
• 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
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)
&
B rec’s
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?