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Fatigue In The College Student

Fatigue In The College Student. Bruce Helming, MD, FAAFP University of Arizona Campus Health Service bhelming@email.arizona.edu. To test, or not to test?. Conflict of interest statement:

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Fatigue In The College Student

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  1. Fatigue In The College Student • Bruce Helming, MD, FAAFP • University of Arizona • Campus Health Service • bhelming@email.arizona.edu 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 • 6 - 7 % 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: • http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html

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

  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

  36. Rea, TD, Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr Virus, JABFP, 2001; 14(4): 234-42. 150 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 www.vfce.arizona.edu520-626-6517 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;90:124-31

  46. Iron status in young athletes • Elite athletes from 11-25 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 10.1007/s00421-011-2002-4

  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

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