The Vitals - August 2015

August 2015, Vol 3, No 8 - The Vitals

In This Article

Patients Should Be Cautioned About Symptom Checkers

Although symptom checkers may be useful tools for patients to identify emergent symptoms, these tools are not very accurate for patients seeking a self-diagnosis or -triage, according to data published online in The BMJ.

Hannah L. Semigran, from the Department of Health Care Policy at Harvard Medical School, Boston, MA, and colleagues performed an audit of publicly available, free symptom checkers. Overall, 23 symptom checkers were identified comprising English checkers with advice across a range of conditions. The authors also compiled 45 patient vignettes and categorized them by triage urgency (ie, emergent care required, nonemergent care reasonable, and self-care reasonable). The main outcome of interest for symptom checkers providing diagnoses was whether they provided a correct diagnosis first, or within the first 20 potential diagnoses. For triage symptom checkers, the investigators evaluated whether it provided an accurate recommendation.

A correct diagnosis was provided in 34% of the standardized patient evaluations, listed the correct diagnosis within the top 20 diagnoses given in 58% of the cases, and provided the correct triage advice in 57% of the cases. The appropriate triage was given in 80% of emergent cases, 55% for nonemergent cases, and 33% for self-care.

“Symptom checkers are part of a larger trend of both patients and physicians using the Internet for many healthcare tasks and therefore it seems likely that the use of symptom checkers will only increase,” the study authors concluded.

Healthcare professionals should be aware that an increasing number of patients are using new Internet-based tools, including symptom checkers, to be better informed about their health.

Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ. 2015;351:h3480.

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Patients with Diabetes Nonadherent to Immunization Guidelines

Patients with diabetes who are at increased risk for infection and poor health outcomes are not following national guideline recommendations when it comes to hepatitis B, influenza, and 23-valent pneumococcal polysaccharide immunization, recent data suggest.

“Allocation of health care resources to increase vaccine coverage should remain a priority, with a focus on spreading awareness of the [Advisory Committee on Immunization Practices] hepatitis B vaccine recommendation for people with diabetes,” concluded Matthew J. Alcusky, PharmD, MS, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA, and Jayne Pawasauskas, PharmD, BCPS, University of Rhode Island College of Pharmacy, Kingston, and Kent Hospital, Warwick, RI, in a report published in the July issue of Clinical Diabetes.

The investigators conducted a single-center, cross-sectional study to assess adherence to national guidelines and predictors for the immunization of patients with diabetes with hepatitis B, influenza, and 23-valent pneumococcal polysaccharide vaccines. Data were collected through a retrospective chart review using the electronic medical records at Kent Hospital between September 5, 2013, and January 26, 2014. Patients eligible for inclusion in the analysis were aged ≥19 years, diagnosed with type 1 or 2 diabetes, and using ≥1 chronic medications for their diabetes prior to admission.

Although it was deemed appropriate for 39% of the patients to receive hepatitis B vaccination, none of them started the 3-dose vaccine series; adherence for influenza and pneumococcal immunization were 41% and 37%, respectively. Patients with better glycemic control (A1c <7%) were slightly more likely to receive influenza vaccination compared with patients with poorer glycemic control (P = .11). Adherence to pneumococcal vaccination was increased in the presence of comorbid disease (odds ratio, 0.31); the association was not significant and the odds decreased among patients with cancer. Lastly, patients adherent to pneumococcal vaccination recommendations had a significantly higher mean number of comorbid conditions (P <.01).

As the role of pharmacists in immunization has expanded to include all 50 states, they are in an ideal position to screen, educate, and immunize patients with diabetes.

Alcusky MJ, Pawasauskas J. Adherence to guidelines for hepatitis B, pneumococcal, and influenza vaccination in patients with diabetes. Clin Diabetes. 2015;33:116-122.

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Antibiotics Linked to Juvenile Idiopathic Arthritis

Although the etiology of juvenile idiopathic arthritis (JIA) remains largely unknown and genetic factors have been attributed to 10% to 25% of the disease incidence, recent data published in the July issue of Pediatrics suggest that this condition may be associated with antibiotic use.

Daniel B. Horton, MD, MSCE, and colleagues conducted a nested case-control study using The Health Improvement Network database, which includes a representative sample of medical records from the United Kingdom. As part of their analysis, the investigators compared children with newly diagnosed JIA aged 1 to 15 years with age- and gender-matched controls randomly selected from general practices with at least 1 case.

Among 454,457 children included in the analysis, 152 were diagnosed with JIA; the incidence was 4.9 per 100,000 person-years. After adjusting the data, Horton and colleagues found that receiving ≥1 antibiotics was associated with an increased risk for JIA (adjusted odds ratio [aOR], 2.1). The specific type or number of infections was not correlated with a greater risk for JIA (aOR, 2.0-2.5); however, additional courses of antibiotics were linked with an increased magnitude of the association (P <.001). Although the time to first exposure to antibiotics was not associated with JIA diagnosis, prescription of antibiotics within 1 year of diagnosis and within 6 months of first joint symptom or rheumatology referral had the strongest association with JIA. “Untreated infections were not associated with JIA during any time period,” the study authors noted.

Other potential explanations for this association include treatment of early JIA symptoms with antibiotics (protopathic bias), and confounding from infection, Horton and colleagues reported.

Pharmacists and other healthcare providers should take these data into consideration when prescribing antibiotics to pediatric patients, and be on the lookout for potential JIA symptoms in this patient population.

Horton DB, Scott FI, Haynes K, et al. Antibiotic exposure and juvenile idiopathic arthritis: a case-control study. Pediatrics. 2015;136:e333-e343.

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Vitamin C May Reduce Risk For Heart Disease, All-Cause Mortality

A recent analysis suggests that high intake of fruit and vegetables is associated with a low risk for ischemic heart disease and all-cause mortality. The association, according to the authors, may be in part driven by their high vitamin C concentration.

The data were recently published in the June issue of The American Journal of Clinical Nutrition. As part of their analysis, Camilla J. Kobylecki, from the Department of Clinical Biochemistry and the Copenhagen General Population Study, Copenhagen University Hospital, Herlev, Denmark, and colleagues performed a Mendelian randomized trial to determine whether genetically high concentrations of plasma—similar to high intake of fruits and vegetables—is associated with a lower risk for ischemic heart disease and all-cause mortality.

The investigators genotyped solute carrier family 23 member 1 rs33972313 in the sodium-dependent vitamin C transporter 1 of almost 100,000 individuals; 10,123 of the patients had ischemic heart disease, and 8477 died. Plasma vitamin C was measured in 3512 study participants, and dietary information was collected in 83,256 study participants.

Overall, patients with the highest intake of fruits and vegetables had a 13% lower risk for ischemic heart disease, and a 20% lower risk for all-cause mortality, compared with patients with the lowest intake. The investigators also report data specific to the G allele and AA plus AG genotypes.

These results add to the body of evidence that supports recommending a balanced diet to your patients.

Kobylecki CJ, Afzal S, Davey Smith G, Nordestgaard BG. Genetically high plasma vitamin C, intake of fruit and vegetables, and risk of ischemic heart disease and all-cause mortality: a Mendelian randomization study. Am J Clin Nutr. 2015;101:1135-1143.

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Recommendations Update

Breast Cancer Screening

The US Preventive Services Task Force (USPSTF) released updated guidelines for breast cancer screening for asymptomatic women aged ≥40 years without preexisting breast cancer or a previously diagnosed high-risk breast lesion, and who are not at high risk for breast cancer. These are highlights you should know:

  • The USPSTF continues to recommend biennial screening mammography in women aged 50 to 74 years (Grade B)
  • Screening in women before age 50 years should be made on an individual basis (Grade C)
  • There is insufficient evidence to assess the benefits versus harm of screening mammography in women aged ≥75 years (Grade I)
  • There is insufficient evidence to assess the benefits versus harm of tomosynthesis (3D mammography) as a screening modality for breast cancer (Grade I)
  • There is insufficient evidence to assess the benefit versus harm of adjunctive screening for breast cancer using breast ultrasound, magnetic resonance imaging, tomosynthesis, or other modalities in women identified to have dense breasts on an otherwise negative screening mammogram (Grade I)

US Preventive Services Task Force. Breast cancer: screening. Published April 2015. Accessed July 24, 2015.

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Last modified: September 23, 2015
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