Hot Topics in Health Care

1. Hot Topics in Health Care Drew Alexander, MD John Kulig, MD, MPH Sara Mackenzie, MD, MPH Gary Strokosch, MD November 18, 2010

2. Learning Objectives As a result of this presentation, participants will: • Implement a comprehensive influenza immunization program for all students and staff on center in accord with current CDC recommendations • Obtain Pap testing only if indicated by current national guidelines • Prescribe and monitor student medications for attention deficit hyperactivity disorder (ADHD) • Counsel students regarding the risks associated with frequent use of “energy drinks” • Offer optional human papillomavirus immunization for both female and male Job Corps students • Recognize students with signs and symptoms of eating disorders

3. Influenza 2010-2011 John Kulig, MD, MPH Lead Medical Specialist Job Corps

4. Influenza • 20% of US population infected with influenza virus annually • 200,000 hospitalizations annually • 20,000 deaths annually • Mortality risk greatest among infants and elderly • Large economic cost in work absenteeism and productivity loss

6. Influenza Vaccine • The seasonal influenza vaccine protects against the three main flu strains that research indicates will cause the most illness during the flu season. • Influenza vaccine for the 2010-2011 season contains three influenza virus strains: an A/California/7/09 (H1N1)-like virus; an A/Perth/16/2009 (H3N2)-like virus; and a B/Brisbane/60/2008-like virus.

7. Influenza Vaccine • CDC recommendations for seasonal influenza vaccination during the 2010-11 season include “universal” annual vaccination for everyone age 6 months and older in the US. • While everyone should get flu vaccine each flu season, it’s especially important that high risk groups get vaccinated.

8. High Risk Groups • Pregnant women • Children younger than 5, but especially children younger than 2 years old • People 50 years of age and older • People of any age with certain chronic medical conditions • People who live in nursing homes and other long-term care facilities • People who live with or care for those at high risk for complications from flu, including: • Health care workers • Household contacts of persons at high risk for complications from the flu • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

9. Job Corps Policy Information Notice 10-28 • Job Corps centers should offer seasonal influenza vaccine on a voluntary basis to all students, not just to students with health conditions placing them at higher risk of medical complications. • One dose of seasonal flu vaccine should be administered as early as September. Early administration of flu vaccine (September) is not associated with loss of protection, and late administration of flu vaccine (March) still affords protection as cases of seasonal flu often peak in late winter. • Injectable vaccine (trivalent inactivated vaccine or TIV) or nasal spray vaccine (live attenuated influenza vaccine or LAIV) may be administered, but nasal spray vaccine should not be administered to pregnant or immunocompromised students.

10. Job Corps Policy Information Notice 10-28 • Centers may wish to offer influenza vaccine administration to students in alternate locations, such as the cafeteria during the lunch break or the dormitories after hours, to increase voluntary participation. • Influenza vaccine should remain available on center throughout the flu season for new students and for students who may initially decline to be immunized. • Influenza vaccination is strongly encouraged for all center health staff members, who could potentially transmit infection to students. Increased absenteeism among health staff could also reduce the capacity of a center to respond to increased demand for care in the event of an influenza outbreak on center.

11. Education Job Corps centers are encouraged to share with students and staff the following tips for controlling the spread of influenza on center: • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after use. • Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective. • Avoid touching your eyes, nose, or mouth. Germs spread that way. • Try to avoid close contact with sick people. • Encourage residential students to report to the Wellness Center if they become ill. Sick nonresidential students and staff should be encouraged to stay home and limit contact with others.

12. Testing and Treatment • Centers should not stockpile diagnostic materials or antiviral medications for influenza, and should only conduct diagnostic testing and begin antiviral treatment or prophylaxis based upon specific recommendations from the state or local health department.

13. Reporting • Centers should continue to use the Significant Incident Report (SIR) system to keep the National and Regional Offices of Job Corps informed about epidemic influenza on center. • For the purpose of reporting, epidemic influenza will be defined by Job Corps as cases affecting 10% or more of on board strength (OBS).

14. CDC Resources • http://www.cdc.gov/flu/ - influenza overview • http://www.cdc.gov/flu/professionals/index.htm - information for health professionals • http://www.cdc.gov/flu/freeresources/index.htm - free influenza resources to download

15. Pap Testing Gary Strokosch, MD Medical Specialist Job Corps

16. Pelvic Exams and Pap Smears • When to Perform a Pelvic Exam and Pap • Which Pap Technique to Use • Reflex Testing for HPV • How to Manage Abnormal Pap Smears

17. A. American Cancer SocietyCervical Cancer ScreeningRecommendations

18. Cervical Cancer Screening Recommendations • Pre-1980 American Cancer Society Cervical Cancer Screening Recommendation • no reference to age • as part of a regular check-up

19. Cervical Cancer Screening Recommendations • 1980-1987 American Cancer Society Cervical Cancer Screening Recommendation • Over 20 • But, under 20 if sexually active • Yearly, but after 2 negative exams 1 year apart, at least every 3 years

20. Cervical Cancer Screening Recommendations • 1987-2002 American Cancer Society Cervical Cancer Screening Recommendation • 18 and over • or sexually active • Yearly, but after 3 consecutive normal exams, less frequently at the discretion of the doctor

21. Cervical Cancer Screening Recommendations • 2003 – Present American Cancer Society Cervical Cancer Screening • Start 3 years after first vaginal intercourse but no later than 21 • Yearly with conventional Pap or every 2 years with liquid-based Pap

22. It is expected that the American Cancer Societywill soon change their recommendations forcervical cancer screening

23. ACOG The American College of Obstetricians and Gynecologists

24. ACOG Recommendations 2003-2009 • Practice Bulletin No. 45, August 2003 • Similar to 2003 ACS recommendations

25. ACOG Revised RecommendationsNovember 20, 2009 • Women should have their first cancer screening at age 21 • Women from 21 to 30 should be screened every two years instead of annually using either conventional Pap or liquid-based cytology

26. Basis of ACOG Revised Recommendations • Although the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare. • The immune system clears the HPV infection within 1-2 years among most adolescent women.

27. Basis of ACOG Revised Recommendations • The adolescent cervix is immature and there is a higher incidence of HPV-related precancerous lesions, but the large majority of cervical dysplasias in adolescents resolve on their own. • A significant increase in premature births has recently been documented among women who have been treated with excisional procedures for dysplasia.

28. Basis of ACOG Revised Recommendations • Adolescents have most of their childbearing years ahead of them and should avoid unnecessary procedures that negatively affect the cervix. • Screening for cervical cancer in adolescents only services to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.

29. PRH Change Notice 09-20March 2, 2010 • Pap Smears obtained from all females ≥ 21 yrs (unless documented Pap smear results within 24 mos before arrival) • Completed within 14 days after arrival • Students < 21 yrs only require pelvic/speculum exam for clinical indications such as pelvic pain, vaginitis, menstrual disorders, pregnancy, etc.

30. B. LIQUID-BASEDCYTOLOGY REPLACINGCONVENTIONAL PAPS Two FDA approved products ThinPrepsince 1996 SurePath since 1999

31. Techniques ofCervical Cytology • Both liquid-based and conventional methods are acceptable for screening. • The majority of screening in the U.S. is liquid-based (90% of OBGYNs in 2003). • Lubricant will interfere with transfer of cells in both methods. • Most contaminating blood and discharge are filtered out with liquid-based technique.

32. Techniques of Cervical Cytology • There is conflicting evidence whether or not the two methods are comparable. • Liquid-based is more expensive. • Liquid-based allows for simpler reflex testing.

33. C. Reflex HPV TestingFDA approved in 2000 • Assesses exfoliated cervical cells for the presence of 1 or more of 13-14 of the 15-18 potentially cancer causing HPV types. • There are two FDA approved products. • Most commonly performed on liquid-based specimen. • Should not be used for females < 21 yrs.

34. Terminology2001 Bethesda System • ASC-US: atypical squamous cells of undetermined significance reflex testing • LSIL: low-grade squamous intraepithelial lesion (mild dysplasia / CIN 1) • HSIL: high-grade squamous intraepithelial lesion (moderate & severe dysplasia / CIN 2 & 3)

35. Rx of Abnormal Pap Smears In Women ≤ 20 yrs old ASCCP 2006 Consensus Guidelines

36. Rx of Abnormal Pap Smears In Women ≥ 21 yrs old ASCCP 2006 Consensus Guidelines

37. ASCUS Reflex HPV Testing (Not Recommended for ≤ 20) ASCCP 2006 Consensus Guidelines

38. References • Job Corps PRH-6: 6.10, R1 • PRH Change Notice No. 09-20 • American College of Obstetricians and Gynecologists (www.acog.org) • American Society for Culposcopy and Cervical Pathology (www.asccp.org)

39. Attention Deficit Disorder (ADD) and Attention Deficit Hyperactive Disorder (ADHD) Drew Alexander, MD Medical Specialist Job Corps

40. Inheritance of ADD/ADHD:Is the Disorder Real? • 25-35% if sibling has ADD • 20-54% if parent has ADD • 78-82% if identical twin has ADD • Ongoing research attempts to isolate alleles

41. Conditions Potentially Leading to ADD • Genetic variable penetrance • Fetal Exposure to smoking, alcohol, trauma • Prematurity • Post natal head and other trauma

42. Core ADD Symptoms • Inattention • Lack of focus • Easy distraction

43. Ancillary ADHD Symptoms • Hyperactivity • Impulsivity • Disruption • Altered judgment • Affect differences • Mood differences

44. Current Types of ADD/ADHD • Inattentive (quiet/often noted in females) • Impulsive (disruptive/often noted in males) • Combined type • Mood and affect disorders associated with attention are not clearly typed

45. Treatment Modalities • Remediation of deficits • Academic, vocational and life coaching (reconfiguring less effective coping styles) • Pharmacology

46. Current Pharmacology • Dopamine enhanced neuro-transmission • Norepinephrine enhanced neuro-transmission • Serotonin enhanced neuro-transmission

47. Dopamine • Methlyphenidate and amphetamine salts (generic) • Ritalin IR and Adderall IR (brand names) • Once a day dosing preferred (multiple products)

48. Norepinephrine • Generic • Strattera and Intuniv (Brand Name) • Once a day dosing preferred but twice daily an option for Strattera

49. Serotonin • SSRI is the class of medication • FDA approves SSRIs for depression • SSRIs help some conditions of inattention • 1986, Prozac is marketed as the first SSRI • Many generics and brands are now available

50. Medication Combinations • Given the specificity of targeting neuro-transmiters combining these meds is effective • Commonly for mood, affect and behavior, disorders serotonin enhancers are used first • When inattention surfaces alone or persists after the serotonin enhancer dopamine is used • Norepinephrine enhancers are added to either of the above meds when indicated