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Updates in College Health: A Review of the Literature

This review discusses newly published research studies relevant to clinical practice in college health. It covers topics such as steroids for reducing throat pain and physical therapy treatment for lower back pain in adolescents.

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Updates in College Health: A Review of the Literature

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  1. Updates in College Health: A Review of the Literature ACHA National Conference Philadelphia, Pennsylvania June, 2010

  2. Objectives • Discuss newly published important research studies and their relevance to clinical practice • Understand common research study designs • Demonstrate evidence based medicine and its application in College Health

  3. Team • Cheryl Flynn, MD, MS, MA • Interim Medical Director, Syracuse University • Family Medicine; epidemiology; family therapy • David Reitman, MD, MBA • University Physician, George Washington University • Pediatrics and Adolescent Medicine • Samuel Seward, MD • Assistant Vice President, Columbia University • Internal Medicine and Pediatrics • Sarah Van Orman, MD • Executive Director, University of Wisconsin-Madison • Internal Medicine and Pediatrics

  4. Process Overview • Team members conducted literature review of studies published during past 24 months • Key search words: • patient population-adolescent, college student, university, young adult • Avoid redundancy of topics presented in 2008 & 2009 Updates

  5. Steroids for reducing throat pain Hayward et al. Corticosteroids for pain relief in sore throat: systematic review and meta-analysis. BMJ 2009; 339: b2976

  6. Background and Question • Sore throat common problem in primary care and college health • Most viral; ~10% Group A Strep • SU experience: 8.7% of provider visits • Question: Are systemic corticosteroids effective in reducing symptoms of sore throat?

  7. Study Design • Systematic review with meta-analysis • Only included placebo controlled randomized controlled trials (RCTs) • Mathematically combined data where possible • Performed sensitivity analyses to assess robustness of findings

  8. Study Methods • Population • ambulatory setting only (ED or primary care) • adults or children with acute tonsillitis/pharyngitis or clinical syndrome of “sore throat” • excluded studies of infectious mono, post-tonsillectomy or intubation, or peri-tonsillar abscess • Intervention • systemic corticosteroids vs placebo • (many concurrently received antibiotics &/or acetaminophen)

  9. Results • 8 RCTs met inclusion criteria • Population • 743 patients, nearly balanced between adults/children • 47% exudative ST; 44% Strep positive • Intervention • Betamethasone IM, dexamethasone IM or PO, prednisone PO • All doses fairly equivalent; ~60mg PO prednisone • Quality of included studies • High; all with adequately concealed allocation

  10. Results—quantitative (meta-analysis) • Complete pain relief • At one day: RR 3.16; NNT = 3.7 • At two days: RR 1.65; NNT = 3.3 • Mean time to onset pain relief • Steroid group 6.3 hr earlier (p<0.001) • Sensitivity analyses found no changes in results • Adult vs child; PO vs IM; Strep vs viral; exudativevs not

  11. Results--Qualitative • Adverse effects (reported in only 1 trial) • 5 hospitalized for IVF (3 steroid, 2 placebo) • 3 developed peri-tonsillar abscess (1 steroid, 2 placebo) • No difference or trend favoring steroids in • Time to complete resolution of pain • Time missed work/school • Recurrent symptoms

  12. Conclusion • Addition of systemic corticosteroids significantly reduces pain in patients with sore throat

  13. Possible confounding of antibiotic use Don’t know effect of steroids independent of antibiotics Relatively small number of RCTs Unable to assess publication bias Limitations

  14. Clinical Bottom Line • Consider adding steroids in patients with severe sore throat in non-mono pharyngitis • 60mg prednisone PO x 1 dose

  15. LBP in Children & Adolescents • Ahlqwist, A et al. Physical therapy treatment of back complaints on children and adolescents. Spine 2008; 33: E721-E727.

  16. Background • LBP is common in college health • Risk factors: • poor physical conditioning, intense exercise, inadequate strength/impaired flexibility, family history • Question: • How does individualized physical therapy compare to a self-training program in adolescents with lower back pain?

  17. Study Methods • Design • Randomized controlled trial • Concealed allocation; blinding not possible • Setting • Primary care • Population • 12-18 y.o., lumbar pain at least 2/10 on pain scale • Excluded those w/serious physical or mental disease, or those who had PT in prior month • N = 45; baseline comparison between groups similar

  18. Study Design • Intervention • Intervention group: individualized PT and exercise plus self-training (PT 1x/wk, exercises 2x/wk) • Control group: self-training only; 3x/wk • Duration: 12 weeks • Outcomes • Measured using validated instruments perceived health, disability, pain, flexibility/endurance • Pre/post within groups • Compared change scores between groups

  19. Perceived health (CHQ-CF) Both groups had statistically significant improvement in nearly all sub-measures pre/post No differences between groups Disability (Roland & Morris Disability Questionnaire) Both groups had improvement pre/post PT -4.6; Control -2.7 p = 0.016 between groups Results

  20. Pain (visual analogue scale 0-10) Drop in pain scores pre/post PT -3.6; Control -3.3 No difference between groups No difference in pain duration or quality of pain Flexibility & muscle endurance (back saver sit and reach) Both groups had improvement pre/post No differences between groups Results

  21. Conclusions • Both groups improved on all parameters measured • Small additional benefit with addition of physical therapy • Perceived health status • Disability ratings

  22. Attribution error Improvement of health attributed to time or interventions? Benefits of PT could be attributed to increased “medical attention” Small #s Lack power to find differences between groups Limitations

  23. Clinical Bottom Line • The benefit of PT for adolescents with back pain is modest at best • If available, reasonable addition • If not, most will improve anyway

  24. Contraception and Weight • Dinger et al. Oral Contraceptive effectiveness according to body mass index, weight, age, and other factors. Am J Obstet Gynecol 2009; 201: 263 e 1-9. • Chi et al. Early weight gain predicting later weight gain among depo medroxyprogesterone acetate users. Obst Gynecol 2009; 114: 279-84

  25. OCP effectiveness across BMI • Research Question • Are OCPs effective across varying BMIs? • Design: Cohort • Subset of prospective surveillance study • Followed ~58K women Q6mo x 5 yr • Contraceptive failure rate was an a priori secondary outcome

  26. Results • Population • 142,475 women years; avg duration follow-up 2.4 years • Mean age 25.2; mean BMI 22.1; 20.4% first time OCP users • Outcomes • OCP failure rate 0.75% year 1  1.67% year 4 • NO DIFFERENCE in effectiveness across BMI range • Limitations • Lower than expected failure rates • Did not enroll morbidly obese women

  27. Predicting weight gain in DMPA users • Research Question: • Does early weight gain in depo-users predict continued excessive weight gain? • Design: Cohort • 240 women 16-33 y.o. choosing depo followed Q 3-6 months for 3 yrs • Depo-users divided into two categories • Avg (<5% by 6mo) vs early wt gainers (>5% by 6mo) • Predictors of excessive gain at 6 mo included • past pregnancy (RR 2.2), BMI<30 (RR 4.0)

  28. Results • Adjusting for other factors, early gainers had 7.03 kg more wt gain at 36mo vsavg group • Limitations • Small n; stats controlled for confounding • Some who gained wt at 3 months dropped out

  29. Clinical Bottom Lines OCPs effectiveness/wt Depo/wt gain Significant weight gain from depo use can be predicted within the first two doses • OCPs are equally effective across weight/BMI spectrum in women who are not morbidly obese

  30. Treatment of Irritable Bowel Syndrome (IBS) • Ford AC, Talley NJ, Spiegel BMR, Foxx-Orenstein AE, Schiller L, Quigley EM, Moayyedi, P. Effect of fibre, antispasmotics, and peppermint oil in the treatment of irritable bowel syndrome: systemic review and meta-analysis. BMJ, 2008; 337a:2313.

  31. Background and Question • Primary care providers frequently treat irritable bowel syndrome (IBS) • Many studies lack sufficient power to demonstrate efficacy of treatments • Conflicting outcomes in various studies • What effect, if any, do fibre, antispasmodics or peppermint oil have on the treatment of IBS symptoms?

  32. Study Methods • Meta-Analysis of randomized controlled trials: • Peppermint Oil (4 studies) • Antispasmodics (22 studies) • Fiber (12 studies) • Primary, Secondary and Tertiary care settings • Population-not specified • Could not have other GI diagnosis

  33. Study Design • Treatment initiated • Follow-up 1 wk – 60 months • Needed to report • Global assessment of cure • Improvement of symptoms • 35 studies met criteria

  34. Results – Peppermint Oil (4 studies, 293 Patients)

  35. Results- Antispasmodics (22 studies, 12 drugs, 1778 Patients)

  36. Results – Fiber (12 Trials, 591 Pts)

  37. Conclusions • Fiber, antispasmodics (e.g. scopolamine) and peppermint oil each more effective than placebo in treating IBS • NNTT • Fiber 11 • Antispasmodics 5 • Peppermint Oil 2.5

  38. Clinical Bottom Line • Of three interventions studied, peppermint oil shows the highest promise for efficacy in treating IBS

  39. Sleep Quality • Lund H, Reider B, Whiting A, Prichard, J. Sleep Patterns and Predictors of Disturbed Sleep in a Large Population of College Students. J Adol Health 46 (2010) 124-142

  40. Background / Question • Much data exists re: consequences of poor sleep in children/younger adolescents • Relatively little data in college age group • NCHA Data • 53% reported sleep problems • 37% sleep had negative impact on academics • In college population….. • What are the predominant sleep habits? • Can quality of sleep hygiene predict physical or behavioral symptoms? • What physical, emotional and psychosocial factors predict poor sleep quality?

  41. Study Methods and Design • Cross-sectional Online Study • Setting: Midwestern University • Population: • College students, age 17-24 • 1125 participants • 27% 1st years, 27% Sophomores, 24% Juniors, 20% Seniors • 420 male, 705 Female • Asked to complete 5 validated surveys to rate • sleep quality, sleepiness, mood, distress, and diurnal symptom variability

  42. Results: Sleep Quality and Quantity • Mean total sleep time 7.02 hrs • 25% < 6.5 hrs • 29.4% ≥ 8hrs • Quality Sleep (PQSI) • 34% “good” • 38% “poor” • Sleepiness (Eppworth Sleepiness Scale) • 25% scored >10 (significant daytime sleepiness)

  43. Results: Sleep Quality, Mood, & Health • Poor Quality Sleepers: • Higher levels of weekday stress (p<0.001) • SUDS : 70.7 vs. 49.9 • Self reported negative moods (p<0.001) • e.g. POMS Depression: 10.66 vs. 7.01 • More physical illnesses (p<0.05) • 12% missed class in a month 3x+ • Increased use of Rx, OTCs and recreational drugs to stay awake and to fall asleep >1x/month

  44. Results: Predictors of Poor Quality Sleep • Stress • Stress about school (39%) • Emotional stress (25%) • Excess noise (33%) • Sleeping Partners (7%) • Talking with friends prior to sleep (6%)

  45. Conclusions • “Epidemic” of insufficient and poor-quality sleep in college students • Perceived stress tends to predict poor quality/ quantity of sleep • Consequences of poor quality sleep include higher stress, poorer moods, increased physical symptoms, missed classes

  46. Limitations • One-time, non-longitudinal survey • Students were from one university • Self-report • No mention of role of ETOH/Drug use

  47. Clinical Bottom Line • Clinicians need to proactively focus on both the quality as well as the quantity of sleep in patient history • Poor Quality Sleepers increased risk of mood disorders, substance abuse disorders and somatic complaints

  48. Douching and STIs • Tsai CS, Shepherd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Amer J Obstetrics and Gynecology. January 2009. 38e1-e8.

  49. Douching and STIs • Question: Is there an association between douching and Trichomonas, Chlamydia, Gonorrhea and Herpes • Design: Observational Prospective (Longitudinal) Cohort • Results: • Assessed time to STI in women who never, sometimes, or always douched • Average age 16.9 yrs. 73% Black. 65% HIV infected • “Always douched” had a shorter STI-free time than those who “never douched.” (2:1) • Commentary/Limitations • High risk adolescents, slightly younger than college age. 2/3 HIV • Couching = independent risk factor for STI acquisition • Clinical bottom line: • Clinicians should counsel female patients about potential STI risks with frequent douching

  50. Antidepressant Treatment • Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, and J. Fawcett. Antidepressant Drug Effects and Depression Severity. JAMA. 2010; 303(1):47-53.

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