Transcript Hot Topics: Clinical Medicine

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
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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 which indicate 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
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Recently developed clinical guidelines produced by The Endocrine Society
– www.endo-society.org (look under clinical guidelines)
– http://www.wpath.org
Questions
Screening College Athletes for Sickle
Cell Trait
Brooke 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
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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
Road to Rhabdomyolysis
Low oxygen
causes
change Hgb
shape
Sickled rbcs
travel in
microcirculation –
‘sticky’, ‘log
jam’
Blockage of
vessels
starves
tissues of
blood and
oxygen
Large
muscles
become
ischemic
Muscle
breakdown
(rhabdomyolysis) and
lactic acidosis
Athlete
collapse:
death can
result from
renal failure
and 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
Questions
The Drive-Thru Influenza Vaccine
Strategy
Dennis 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
WALK-UP,
6491, 34.02%
• Avg. 1,004 vaccinations/hour
DRIVETHRU,
12590,
65.98%
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
Questions
Screening for IPV in the Primary
Care Setting
Marcy Ferdschneider, D.O.
Barriers – Perceived and Actual
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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 Grumbach
Screening and Intervention for Intimate Partner Abuse: Practices and Attitudes of Primary Care Physicians
JAMA. 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. Lloyd
Primary Care: Is There Enough Time for Prevention?
Am J Public Health 2003 93: 635-641
USPSTF
Common Prevention Guidelines
Guideline
Grade
Estimated Time
Pap Test
A
3 minutes
Assess for problem
drinking
B
0.5 minutes
Counsel for problem
drinking
B
5 minutes
Tobacco cessation
A
3 minutes
Regular Physical Activity
A
4 minutes
STI prevention
B
3 minutes
Contraception
B
3 minutes
DV Screen
I
2 minutes
*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
NCHA
NCHA
Screening Tool
Screening Results
Results for AY 09-10
(out of 2930 respondents)
30, 11%
67, 26%
86, 33%
78, 30%
Q1
Q2
Q3
Q4
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
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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. Lloyd
Primary Care: Is There Enough Time for Prevention?
Am J Public Health 2003 93: 635-641
Michael A. Rodriguez; Heidi M. Bauer; Elizabeth McLoughlin; Kevin Grumbach
Screening and Intervention for Intimate Partner Abuse: Practices and Attitudes of Primary Care Physicians
JAMA. 1999;282(5):468-474
Screening for Intimate Partner
Violence