Hot Topics: Clinical Medicine

1. Hot Topics: Clinical Medicine ACHA National Conference Philadelphia, Pennsylvania June, 2010

2. 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

3. Are College Health Services Ready To Care For Transgendered Students? John Turco, MD

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. Resources Available • Recently developed clinical guidelines produced by The Endocrine Society • www.endo-society.org (look under clinical guidelines) • http://www.wpath.org

11. Questions

12. Screening College Athletes for Sickle Cell TraitBrooke Durland, MD

13. 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

14. Research SCT-related Sickling • Early studies in military recruits • High altitude sports participation • Case studies from forensic medicine • Exercise physiology studies

15. 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

16. Road to Rhabdomyolysis

17. 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

18. 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

19. 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

20. Questions

21. The Drive-Thru Influenza Vaccine StrategyDennis K. Sullivan, BA, CEM, CHMM, EMT-P

22. 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

25. 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

26. 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

27. Questions

28. Screening for IPV in the Primary Care Setting Marcy Ferdschneider, D.O.

29. 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

30. 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

31. USPSTF

32. Common Prevention Guidelines *23.5 minutes Yarnall, et al. Am J Public Health 2003

33. 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

34. NCHA

35. NCHA

36. Screening Tool

37. Screening Results

38. 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

39. 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

40. Screening for Intimate Partner Violence