Clinical Pearls for College Health Providers Summary of relevant research 2012-13 Objectives • Define & summarize the process for determining relevance of research • Share the recent evidence-based guidelines for preventive services that apply to college health • Summarize the validity, results, and application of the top 12 research articles of the last year The medical literature Your Shuckers… • Marcy Ferdschneider, DO • Michelle Paavola, MD • Cheryl Flynn, MD, MS, MA None of us have disclosures to make The process • Reviewed journals & abstracting services from 8/2012-8/2013; USPSTF guidelines • Selected original research relevant to college health – Relevance = common + patient-oriented outcome + change/re-affirm practice • Consensus for top dozen • Summarize validity, findings, and application to practice Screening for ETOH misuse: B Alcohol misuse screening: • screen those >18y/o • offer brief behavioral interventions to those screen + Cervical Cancer Screening: A Cervical cancer screening: • begin cervical CA screening at 21; • pap Q3yrs; • no screening HPV until age 30 Screening for Hep C: A Hep C screening: • only for those at risk (past/current IVDA, sex w/ IV drug user, blood transfusion before 1992) Screening for HIV: A HIV screening: • screen those 15- 65y/o • interval not clear Screening for Obesity: B Obesity screening: • calculate BMI for adults • refer to intensive behavioral intervention for those w/ BMI >30 Now… onto the original research Fasting Time and Lipid Levels Arch Intern Med. 21012; 172(22):1707-1710 Background • Lipid levels are used for both screening and and diagnostic purposes • Current guidelines recommend measuring lipid levels in a fasting state – Fasting inconvenient – Some may not get testing done • 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: – Cross sectional examination of laboratory data, including: • Duration of fast • Lipid result—Total cholesterol, HDL, LDL, TGs – Performed over 6-month period – Excluded: missing hours from last meal and TGs >400 • Population: – Residents of Calgary, Alberta, Canada • Outcome: – Lipid panel results at 9-12hr, and >8hr Results • Total of 209,180 lipid profiles Results • Variance of 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 • Food choices pre-lab draw were not examined; only time between eating/phlebotomy • Pharmacologic tx of subjects unknown • Those who accept screening lipid panels may not be representative of general population • Data did not include apolipoproteins • gen. population Bottom Line • When ordering screening lipid panels, get the lipids at the same appointment • No need to make people come back in the morning for blood work Self Swab vs. Clinician swab for Gonorrhea/Chlamydia BMJ 2012;345:e8107 Background • Gonorrhea – 2nd most common STI in UK (where study takes place) – Often asymptomatic in females – Can cause PID and possibly lead to infertility – In UK, standard is to obtain a urethral and/or endocervical swab→necessitating a speculum exam • Many women find these embarrassing and uncomfortable • Requires clinic visit, use of exam room, vaginal speculum and a trained clinician • Non-invasive samples eliminate some barriers to screening for GC/chlamydia • Evidence suggests self-taken vaginal swabs have better sensitivity than first catch urine Methods • Design: Prospective study of diagnostic accuracy – Sxs suggestive of bacterial STI were identified (vaginal d/c, dysuria, intermenstrual or postcoital bleeding, deep dyspareunia and low abd pain) – Women were given written and verbal instructions and self swabs performed prior to clinician exam – Two different diagnostic tests were used 1. Urethral and endocervical samples analyzed by culture 2. Vulvovaginal and endocervical samples analyzed by Aptima Combo 2 (AP2) assay (nucleic acid amplification test) – Positive AC2 tests were further analyzed using Aptima GC assay (monospecific platform test with diff target than AC2) • Population: Women, >16 y/o, STI clinic; willing to perform own vag swab • Outcome: accuracy of various collection methods Results • 3859 women Description Value Mean age 25 Self-reported ethnicity White—80%,Black—9% Mixed—7%, Other—4% Previous dx of STI 37% Contact with partner with recent STI dx 7% At least one symptom suggestive of bacterial STI 42% Clinical dx of Cervicitis made 5% Clinical dx of PID 4% Infected with gonorrhea 2.5% (100 women) Those with gonorrhea and co-infected with C trachomatis 55% (55 women) Infected with C trachomatis, but not gonorrhea 9% (355 women) Results Description Value Overall Culture sensitivity 81% Overall Clinician-taken endocervical NAAT 96% Overall Self-taken vulvovaginal NAAT 99% Sensitivities in women with ≥ 1 symptom 3.4 % were infected with gonorrhea Culture: 84% Clinician-taken endocervical: 100% Self-taken vulvovaginal: 100% Sensitivities in women with no symptoms 1.8% were infected with gonorrhea Culture: 78% Clinician-taken endocervical: 90% Self-taken vulvovaginal: 98% Conclusions/Limitations • NAAT tested vulvovaginal swabs obtained by pts are: – Significantly more sensitive than endocervical gonorrhea cultures obtained by clinician – Equivalent to NAAT endocervical samples obtained by clinician • Culture method missed 20% of gonorrhea cases • Single center study • Order of samples was not randomized or rotated→self-taken vulvovaginal swabs were collected first • Negative AC2 tests were not repeated, so could have missed some false negative results (but each woman had 3 different samples analyzed for gonorrhea • Not compared to urine NAAT GC/chlamydia • Comparison of chlamydia accuracy not measured Bottom Line • Consider incorporating the use of self-taken vaginal swabs to test for gonorrhea and chlamydia. Probiotics for Antibiotic-Associated Diarrhea Aliment Pharmacol Ther 2012; 35: 1355-1369 Background • Antibiotic-associated diarrhea (AAD) remains a common condition with a prevalence of 5-39% • AAD can be a limiting factor to adherence to antibiotic regimens • Probiotics have been linked to modulation of gut mucosal immunity, barrier function, metabolism, • Earlier studies and meta analysis have suggested probiotic administration reduces the incidence of AAD • Questions: 1. Do probiotics reduce the incidence of AAD? 2. How about during treatment for H.Pylori? 3. Do the effects vary between children and adults? 4. What probiotic species are more efficacious? Methods • Design: – Meta-analysis of randomized, double-blinded, placebo-controlled trials • Population: – Patients treated with antibiotics and administered a probiotic for at least the duration of the antibiotic treatment • Outcome: – Incidence of diarrhea, irrespective of C.diff or pseudomembranous colitis Results • Total of 34 studies with 4138 patients • Mean age in the 10 pediatric trials→5 • Mean age in 24 adult trials→52 • Probiotics used alone or in combination: – Lactobacilli – Bifidobacteria – Enterococci – Streptococci – Yeast S. boulardii • Duration of treatment varied between 3 days to several weeks Results Studies RR NNT All studies 0.53 8 10 Pediatric studies 0.48 24 Adult studies 0.53 6 H.pylori treatment studies 0.37 5 Pooled studies excluding H. pylori 0.56 9 Conclusions/Limitations • Probiotics are effective • Search strategy/Inclusion criteria may have missed some eligible prevention for developing trials – ie those with non-diarrhea 1o abx-associated diarrhea. outcomes but in which the – present across different incidence of diarrhea was measured probiotic species • Qualitative heterogeneity likely – observed equally in children accounts for varied NNTs: and adults – populations studied (adult vs. peds; inpt vs outpt) – appears to be independent of – Nature and modalities of the concomitant antibiotic intervention (probiotic strains, doses , antibiotics used and used and indication for duration of treatment) antibiotic treatment – outcomes considered (definitions of diarrhea, its incidence and duration of follow up) Bottom Line • Giving probiotics when administering abx can decrease abx-associated diarrhea • No clear recommendations re: type/dose can be made Validation of Clinical Decision Rules for Sore Throat Arch Intern Med. 2012; 172 (11): 947-852 Background • Sore throat is common presenting complaint in college health; often pts worry about strep as cause • Evidence-based clinical scoring tools have supported selective testing &/or empiric tx for strep – Centor criteria and McIssac scores – Both derived on relatively small populations (centor: 286 ED pts; McIssac on 521 FP pts) • This study was aimed at validating existing decision rules Methods • Design: National large-scale validation – Retrospective data collected from pts tested for GAS pharyngitis due to complaints of sore throat – Clinicians adhered to “Strep Pharyngitis Algorithm” from Institute for Clinical Systems Improvement • Population: – Patients who went to Minute Clinic, a large, national, retail health chain – Included 206,870 encounters from 581 sites and 25 states. • 206, 870 patients ≥ 3 years old to validate McIsaac score • 142,081 patients ≥ 15 years old to validate Centor score