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Hot Topics: Clinical Medicine. ACHA National Conference Philadelphia, Pennsylvania June, 2010. Discussants. Dennis K. Sullivan , BA, CEM, CHMM, EMT-P Assistant Director, Environmental Health and Safety University of Louisville Brooke Durland , MD, Medical Director
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Hot Topics: Clinical Medicine ACHA National Conference Philadelphia, Pennsylvania June, 2010
Discussants • Dennis K. Sullivan, BA, CEM, CHMM, EMT-P Assistant Director, Environmental Health and Safety University of Louisville • Brooke Durland, MD, Medical Director Rochester Institute of Technology • John Turco, MD, Director, Student Health Service Dartmouth College • Marcy Ferdschneider, DO, Director, Primary Care Medical Services Columbia University
Are College Health Services Ready To Care For Transgendered Students? John Turco, MD
Clinical Observations About Transgendered Patients: One Person’s Experience • Trans population much larger than previously thought • What determines ones gender identity? • Nature vs. nurture? • “Hard wiring” plays a major role (my opinion) • Trans population beginning transitioning at an earlier age • More visible role models • Information and support available on the internet • Patients articulate and introspective • Are there others who have “dysphoria” due to gender identity issues but aren’t able to identify the connection? • Puberty is a very difficult time for many trans individuals
Epidemiology • Wide variation in acceptance in different cultures • Initial estimates • Adult males 1 in 37,000; adult females 1 in 107,000 • Netherlands (estimates of transsexuals) • 1 in 11,900 males; 1 in 30,400 females • U.S. • No reliable large studies • 1993; 6% males and 3% females reported cross dressing • Some estimates as high as 7 million “transgendered individuals” in U.S. • DHMC • Over the last two years I have followed approximately 100-150 patients. • Dartmouth College • Starting to see a few students who are asking for medical help to transition • Age of initiating transitioning appears (to me) to be decreasing • Recent incidence data and alternative methods for estimating the prevalence of transsexualism, all of whichindicate that the lower bound on the prevalence of transsexualism is at least 1:500, and possibly higher. (Femke Olyslager and Lynn Conway)
Trans Issues Colleges Will Need To Deal With? • More students are identifying as trans • It is not a tsunami BUT the tide is definitely coming in • Stages of transitioning seen in trans college students • Rarely students will enter college already on hormones and some may have had partial SRS • Rarely some will have been on medications to “suspend” puberty and will now want to initiate hormones • Many will look at college as a time and place to initiate transitioning after contemplating transitioning for years • Some will “discover” that they are transgendered while in college and look for some guidance • Colleges need to deal with a myriad of other trans related issues • name/gender change, “bathroom issue”, room mates • access to medical/counseling resources if not available on campus
What Will Trans Students Be Looking For From The Health Service? • Respect • more important than understanding • Treat the problem they present with • if they have a sore throat their gender identity is irrelevant • Information about transitioning • names of counselors and physicians who are comfortable and knowledgeable about trans issues • A convenient place to initiate and receive hormones • often students cannot find resources close to campus which can interfere with academic life and be too expensive; college health service is the appropriate place • want to safely take hormones • Partner with trans students and other organizations on campus to help make the college community more trans friendly • help educate campus concerning heterogeneity of trans students including gender variant, gender queer, and gender non-conforming students • create alliances with campus leaders • how to officially change name and gender • the “bathroom issue” (roommate issue, locker room issue, etc.) • partner with GLBT organization and office, Dean’s office • be aware that subgroups within “GLBT” population of students may not agree on all topics
What Should be Expected From College Health Services In 2010? • Educate medical staff about issues • Brown University’s approach • Support and develop some staff members who want to become proficient in caring for trans population or identify appropriate resources close to campus • medical providers who can work with outside endocrinologists and eventually be able to independently initiate and monitor hormones • counselors who have some experience and skills counseling patients who are contemplating transitioning or are actively transitioning • Take the initiative to promote support from trans students
College Health Service 2020 • Trans students will regularly get their medical care at health service • Just as gay/lesbian students are now seen routinely for their care • Trans/gender variant counseling will be available from college counselors • Medical providers will routinely help in the delivery and monitoring of hormones • Similar to what is currently evolving with psyche meds • College Health Service will be taking an active role in helping trans students plan for SRS • SHIP will be covering counseling, medical and SRS treatment for students who are transitioning
Resources Available • Recently developed clinical guidelines produced by The Endocrine Society • www.endo-society.org (look under clinical guidelines) • http://www.wpath.org
Screening College Athletes for Sickle Cell TraitBrooke Durland, MD
Exertional Sickling in Sickle Cell Trait (SCT) • 21 athletes collapsed and died past 10 y • Complications from Sickle Cell Trait with strenuous exertion 1 – Splenic infarction 2 – Hematuria 3 – Rhabdomyolysis • Aggravating factors: 1 – Heat 2 – Dehydration 3 – Altitude 4 – Asthma 5 – Illness
Research SCT-related Sickling • Early studies in military recruits • High altitude sports participation • Case studies from forensic medicine • Exercise physiology studies
Pathophysiology in SCT Athletes • Low oxygen causes change Hgb shape • Sickled rbcs travel in microcirculation – obstructs blood flow • Blockage of vessels starves tissues of blood and oxygen • Large muscles become ischemic - rhabdomyolysis • Setting for Lactic Acidosis
Sickling vs. Heat Cramps • Symptoms abrupt onset • Pain milder • Athletes slump to ground – “weak and wobbly” • Lie still, legs and back hurt, general malaise • Mild case, respond 10 – 15 minutes treatment • Prodrome with twitches and twinges • Excruciating pain of “locked-up” muscles • Athletes hobble off - muscles not work • Cry in pain, muscles ‘rock hard’ • 1-2 hours of treatment before improvement
NCAA Recommendations • 1974: Univ. Colo. player died complications SCT– NCAA adds info to handbook • 2008: Strong statement about risks related to SCT after 2006 death Rice U. football player – Dale Lloyd II • 2010: April this year NCAA voted require athletes submit test, get test or sign declination • Controversies about recent ruling
Response from colleges and universities • 2006 NCAA survey of 92 top level football programs: • 21% required all screened • 64% had some sort of policy • Listserve responses to new NCAA rule – many schools seek to learn from colleagues • Screening protocols • Testing methodologies • Declination forms
The Drive-Thru Influenza Vaccine StrategyDennis K. Sullivan, BA, CEM, CHMM, EMT-P
Operation Inoculation:The Plan • Hold a University/Community H1N1 mass immunization point of dispensing • H1N1 vaccines were administered via one of two methods: • a drive-thru • a walk-up • Injectable and intranasal vaccines available • Vaccine recipients chose preferred method
POD results • Total Hours of Operation – 19 • Totals vaccinated – 19,079 • Day 1 – 12,613 (12 hr) • Day 2 – 6,466 (6 hr) • Walkthru – 6,491 • Drivethru – 12,590 • Avg. 1,004 vaccinations/hour
Cost-effectiveness • Overall cost $13.35/immunization • Costs significantly higher for walk-up method $29.61/immunization (does not include public transportation costs) • Drive-thru method $5.58/immunization
Screening for IPV in the Primary Care Setting Marcy Ferdschneider, D.O.
Barriers – Perceived and Actual • Time • Unrealistic expectations • Lack of confidence • Perceived prevalence of problem • Fear of offending • Safety concerns • System support Michael A. Rodriguez; Heidi M. Bauer; Elizabeth McLoughlin; Kevin GrumbachScreening and Intervention for Intimate Partner Abuse: Practices and Attitudes of Primary Care PhysiciansJAMA. 1999;282(5):468-474
Time • A study by Yarnall, et al, addresses the common complaint that clinicians do not have enough time to provide recommended preventive services according to USPSTF guidelines • A panel of 2500 patients with age and sex distributions based on U.S. population = 7.4 hours per work day Yarnall, Kimberly S. H., Pollak, Kathryn I., Ostbye, Truls, Krause, Katrina M., Michener, J. LloydPrimary Care: Is There Enough Time for Prevention?Am J Public Health 2003 93: 635-641
Common Prevention Guidelines *23.5 minutes Yarnall, et al. Am J Public Health 2003
Prevalence • Nearly 1/3 of women in the United States report being physically or sexually abused by an intimate partner at some point in their lives • The Department of Justice estimates that the highest rate of violence is experienced by women ages 16-24 • On campuses, 1 in 5 report current relationship violence and 70% report knowing someone in an abusive relationship • IPV is linked to 8 out of 10 of the leading health indicators in Healthy People 2010 • American women are killed more often by intimate partners more often than by any other type of perpetrator
Effective Screening Considerations • Engagement of all staff and opportunity for screening at each access point in the visit, including scheduling • Screening is conducted universally with all patients presenting for Women’s Health visits • Screening is conducted in private, confidential setting • Screening is paired with the provision of information on resources
Bibliography • CDC. Understanding Intimate Partner Violence Fact Sheet. www.cdc.gov/injury • Gerber, M.R., Ganz, M.L., Lichter, E., Williams, C.M. & McCloskey, L.A. (2005). Adverse Health Behaviors and the Detection of Partner Violence by Clinicians. Archives of Internal Medicine,165, 1016-1021 • Marcus, E. (2008, May 20). Screening for Abuse May be the Key to Ending it. New York Times, B1. • Sugg, N.K., Thompson, R.S., Thompson, D.C., Maiuro, R. & Rivara, F.P. (1999). Domestic Violence in Primary Care: Attitudes, Practices and Beliefs. Archives of Family Medicine, 8, 301-306. • Klap, R., Lingqi, T., Wells, K., Starks, B.A. & Rodriquez, M.(2007). Screening for Domestic Violence Among Adult Women in the United States. Journal of General Internal Medicine, May; 22(5): 579-584. • New York City Department of Health and Mental Hygiene. Intimate Partner Violence: Encouraging Disclosure and Referral in the Primary Care Setting. City Health Information, October 2008. • Yarnall, Kimberly S. H., Pollak, Kathryn I., Ostbye, Truls, Krause, Katrina M., Michener, J. LloydPrimary Care: Is There Enough Time for Prevention?Am J Public Health 2003 93: 635-641 • Michael A. Rodriguez; Heidi M. Bauer; Elizabeth McLoughlin; Kevin GrumbachScreening and Intervention for Intimate Partner Abuse: Practices and Attitudes of PrimaryCarePhysiciansJAMA. 1999;282(5):468-474