Heena Mavani, PharmD Candidate 2017

Clinics on or near college campuses can expect students to stroll in with postweekend partying blues or exam stress. Retail health clinicians treat everything from nail fungus picked up in dorm showers to upper respiratory infections. They also counsel students whose first intimate sexual experiences have left them with genital ulcers or urinary tract infections.

Some students’ chief complaints may omit serious, stigma-filled problems—scars you might miss on a quick physical exam.

Studies conducted at American universities reveal that nearly 1 in 5 women has been a victim of attempted or completed rape during freshman year. These acts may occur by force or while they were incapacitated due to alcohol or drugs.

A September 2015 survey commissioned by the Association of American Universities found that more than 27% of female college seniors experienced some form of unwanted sexual contact since entering college. Although the studies were small, the body of evidence suggests a similar pattern on most campuses.

Physical, mental, and spiritual effects following sexual assault and rape are difficult to manage.  Many students will avoid admitting abuse out of fear. It’s common for sexual violence survivors to experience a range of feelings that may be confusing and can produce more anxiety, such as anger, distrust, and feeling unsafe.

When those college students visit clinics, retail health care providers can help. Consider fashioning questions about sexual history, drinking, and emotional stressors into every visit. Stay impartial and refrain from passing judgment—the last thing any clinician wants to do is exacerbate a difficult situation.

Ask the following open-ended questions to every patient—male or female&mdash;at each and every visit, and give them an opportunity to answer:

·      How many sexual partners have you had? Have they been consensual? What type of protection did you use?

·      Rather than asking how many drinks they have a week, ask: How many drinks do you have per day? When is the last time you do not remember the details from a night of drinking?

If a student reports sexual assault to you, follow these steps:

First, explain that the medical exam is a way to preserve physical evidence of a sexual assault, and refer them to the emergency room for a rape kit if they wish to report the event. A police report may help regain a sense of personal power and control. All states require you to report child or elder abuse, and you should be familiar with your state’s specific requirements.

Consider preventive pregnancy treatment where appropriate. Sexual assault can cause bruising, bleeding (vaginal or anal), difficulty walking, soreness, and broken or dislocated bones. Possible prolonged physical effects can include sexually transmitted infections and diseases. Treat these problems with empathy and acknowledge any feelings brought up when exploring best options for self-care.

Laboratory testing for pregnancy, chlamydia, gonorrhea, trichomonas, hepatitis B, and HIV are often appropriate. If you suspect that the patient was given a “date rape drug,” take a urine sample or refer the patient to a clinic that does. Drugs, such as Rohypnol and GHB, are more likely to be detected in urine than in blood.

Connect with local specialists and know what resources to recommend locally. Students may have access to free services through on-campus counseling centers. Many of these resources don’t require insurance.

Support is important immediately after the incident and can lessen aftereffects years later. The healing process takes time. Many victims are reluctant to seek help because of their fear that thinking or talking about their experience will be too painful. However, most victims find counseling helpful in the process of recovering and moving on with their life.

A patient surviving assault can experience chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping patterns, and even sexual dysfunction. Small activities that trigger peace or joy—such as daily mediation, painting, or cooking&mdash;can make a large difference. Early treatment may help to reduce risk of long-term problems with depression, anxiety, or posttraumatic stress disorder.

·      Learn about the different forms of psychotherapy from the American Psychological Association and National Institute of Mental Health.

·      Contact the Substance Abuse and Mental Health Services Administration Treatment Referral Helpline at 1-800-662-HELP (4357), or search for a local treatment center using their locator tool.

·      Crisis centers like the Rape, Abuse, & Incest National Network (1-800-656-HOPE [4673]) offer information about resources and qualified providers in your area. Some hotlines offer a trained crisis          counselor to accompany victims to the hospital.

Articles

Clinics on or near college campuses can expect students to stroll in with postweekend partying blues or exam stress. Retail health clinicians treat everything from nail fungus picked up in dorm showers to upper respiratory infections. They also counsel students whose first intimate sexual experiences have left them with genital ulcers or urinary tract infections. 

Sexual Assault on Campus: How to Help Student Victims

The National Standard for Diabetes Self-Management Education and Support differentiates 2 important ways to improve diabetes care:

“the ongoing process of facilitating knowledge, skill and ability necessary for prediabetes and diabetes self-care.”

“activities that assist the person with prediabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an

We send our children off to school each year for the opportunity to learn, shape their minds, and grow their interests. We know that self-management of life may be complex and that they need proper education. Through a proven curriculum, children develop essential skills—reading, writing, math, art, gym, health, social studies, science&mdash;so they can meet the world confidently and be prepared for their next steps on their own. Along those same lines, diabetes self-management for children is complex and requires special education and support.

The 2010 Affordable Care Act supports coverage for diabetes self-management for children with the Children’s Health Insurance Program Reauthorization Act of 2009. Legislators have recognized self-management education as a key factor in preventing secondary complications, such as peripheral neuropathy, retinopathy, and nephropathy. It’s time now to explore new interventions that can increase self-management and maximize outcomes in this specific population.

One recent review suggests steps from evidence-based practices to develop self-management skills in children and youth with diabetes. The following recommendations deserve consideration in retail health:

1. Consider interventions designed to promote the development of self-management skills in children with type 1 diabetes (T1D)

Protocols for standard T2D therapy in children aren’t well established, so practitioners should consider evidence in either type.

2. Address self-management readiness skills of children with diabetes younger than 14 years (eg, learning about diabetes and how to draw insulin, promoting a healthy and active lifestyle).

Before middle school, children with diabetes may be able to begin to learn skills such as self-administration of insulin, but they may still lack the executive functioning skills to consistently manage their disease autonomously. Consider environmental factors and potential barriers before implementing an intervention.

Consider helpful tricks such as associating pet care with daily and weekly diabetes self-management habits. For example, meal preparation or daily glucose checks when you feed the fish daily, and weekly follow-up with your physician when you change a portion of the water in the fish bowl.

Consider a more comprehensive learning tools like diabetes camp. This program may include daily medical education and discussions, and repeated insulin adjustments and supervised injections, among other useful learning tools. Continue to guide independent change in behavior and perceptions about skills as well as more medically focused indicators of diabetes management (eg, BMI or HbA1C levels).

4. Involve parents or primary caregivers in self-management education and support interventions.

Renegotiate the responsibilities between the parent and child and remind parents—less nagging, and more positive affirmations! Appropriate parental involvement in care increased adherence and the child’s ability to assume responsibility for diabetes care tasks than individual therapy.

5. Consider integrating the use of technology (eg, text message or e-mail reminders) in the self-management intervention.

Evidence suggests cell-phone—based glucose recording systems allow children to feel more independent in caring for their diabetes. This system involves text reminders to check their blood sugar, and the data collected could be shared and monitored by a health care provider as well as the parent. Internet-based intervention with personalized homepages, multimedia presentations, and discussion forums related to diabetes management also improved adherence.

It’s important to choose interventions that fit best into the lifestyle and attitudes of youth and match their readiness skills. Self-management education and support is critical for outcomes in children with either T1D or T2D, but the amount of research supporting different interventions for this population is far from impressive. These tips are critical for all clinicians, and more research will expand these steps and improve outcomes for our children and youth.

Cahill S, et al. Interventions to promote diabetes self-management in children and youth: a scoping review.

The National Standard for Diabetes Self-Management Education and Support differentiates 2 important ways to improve diabetes care. 

5 Tips to Teach Kids Diabetes Self-Management Skills

The Society of General Internal Medicine recognizes that progress has recently stalled in antimicrobial stewardship. Prescribers continue to write scripts for antibiotics for viral infections and select broad-spectrum antibiotics where narrow therapies would be more apt.

The society’s recent study, published in the

, draws attention to the large disparity in antibiotic prescribing across different care settings—specifically, primary care providers’ offices and retail clinics. The study targeted the drivers of this variation by measuring the rates of antibiotic prescribing and imperfect antibiotic prescribing among clinicians in both retail and primary care clinics.

A large fraction of antibiotic prescribing for acute respiratory tract infections falls under the umbrella of “imperfect” prescribing:

Prescribing an antibiotic for a non—antibiotic-appropriate diagnosis (eg, upper respiratory infection, bronchitis, or non-streptococcal pharyngitis)

Failing to prescribe an antibiotic for an antibiotic-appropriate diagnosis (eg, sinusitis, pneumonia, streptococcal pharyngitis, otitis media)

Choosing a non—guideline-concordant antibiotic for an antibiotic-appropriate diagnosis (defined as an antibiotic other than amoxicillin-clavulanate or amoxicillin for sinusitis; a macrolide or doxycycline for pneumonia; amoxicillin or penicillin for streptococcal pharyngitis; and amoxicillin for otitis media)

Retail clinics—the convenient, walk-in health care stations in drug and grocery stores throughout the country&mdash;are primarily staffed by nurse practitioners and physician assistants. Patients often present with acute respiratory infections (eg, common cold, otitis, sinusitis, pharyngitis, acute bronchitis, and pneumonia), which appear to be the most common symptomatic reason for seeking care among patients in the United States, accounting for the majority of all antibiotic prescriptions.

In the study, clinicians in retail clinics prescribed significantly more antibiotics than primary care providers, but had a lower imperfect antibiotic prescribing rate. This supports prior work suggesting that retail clinic staff are more likely to provide guideline-concordant care.

One study limitation is that it only considered one chain of retail clinics across 19 states and collected prescribing data from ICD-9 codes that may not have been accurately matched with true practice.

Interestingly, clinicians in physicians’ offices who had higher rates of imperfect prescribing also had more years of practice and averaged more hours of practice each week compared to the nurse practioners and physician assistants in retail clinics. Survey-reported measures of knowledge, attitudes, and behaviors helped determine factors might lead to higher rates inappropriate prescribing.

: Clinicians who felt rushed in patient visits were more likely to prescribe antibiotics.

: Store brief “talking points” about antibiotics in your clinician arsenal.

: Clinicians who felt less strongly that antibiotics were overused were more likely to prescribe antibiotics.

: Refamiliarize yourself with the guidelines. Remain alert to when antibiotics are necessary and what spectrum of antibiotics may be appropriate.

: Clinicians who didn’t believe patient demand was a problem in their practice were more likely to have imperfect antibiotic prescribing.

: Create barriers for inappropriate prescribing by requiring justification in the electronic medical records for prescribing antibiotics. Educate patients in the waiting room with low-cost posters or pamphlets on antibiotic overuse and beliefs to only prescribe when appropriate.

In the interest of time and preventing patient conflict, clinicians may be tempted to take the path of least resistance. However, silencing patients with prescriptions that may be unnecessary contributes to the rising rate of inappropriate antibiotic use. It also puts patients at greater risk for resistance and unnecessary drug-related adverse effects. Determine alternative recommendations and educate and empower your patients when antibiotics aren’t needed.

Clinicians in retail clinics prescribe significantly more antibiotics than primary care providers, but have a lower imperfect antibiotic prescribing rate. 

Heena Mavani, PharmD Candidate 2017

Articles

Sexual Assault on Campus: How to Help Student Victims

5 Tips to Teach Kids Diabetes Self-Management Skills

Retail Clinicians Prescribe Antibiotics More Appropriately Than Primary Care Providers