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| BMJ (Photo credit: Wikipedia) |
Mostrando las entradas con la etiqueta Centers for Disease Control and Prevention. Mostrar todas las entradas
Mostrando las entradas con la etiqueta Centers for Disease Control and Prevention. Mostrar todas las entradas
19 junio, 2013
End of the scandal of free Medical Education
10 junio, 2013
Update in infectious diseases: evidence published in 2012
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| Evolution of Infectious Disease (Photo credit: Wikipedia) |
This
Update summarizes studies published in 2012 that the authors consider
highly relevant to the practice of infectious disease. Topics include
sinusitis, azithromycin toxicity, infective endocarditis, asymptomatic
bacteriuria and recurrent urinary tract infection, HIV prevention, a
newly discovered pathogen, Lyme disease, and fungal meningitis.
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06 junio, 2013
Intussusception After Rotavirus Vaccines Reported to US VAERS, 2006–2012
Source: Pediatrics.
(doi:
10.1542/peds.2012-2554) Pediatrics
- Penina Haber, MPHa,
- Manish Patel, MDb,
- Yi Pan, PhDa,
- James Baggs, PhDc,
- Michael Haber, PhDd,
- Oidda Museru, MPHa,
- Xin Yue, MSa,
- Paige Lewis, MSPHa,
- Frank DeStefano, MD, MPHa, and
- Umesh D. Parashar, MBBS, MPHb
+ Author Affiliations
Abstract
BACKGROUND: In 2006 and 2008, 2 new rotavirus vaccines (RotaTeq [RV5] and Rotarix [RV1]) were introduced in the United States.
METHODS: We assessed
intussusception events reported to the Vaccine Adverse Event Reporting
System from February 2006 through April
2012 for RV5 and from April 2008 through April
2012 for RV1. For RV5, we conducted a self-controlled risk interval
analysis
using Poisson regression to estimate the daily
reporting ratio (DRR) of intussusception comparing average daily reports
3
to 6 versus 0 to 2 days after vaccination. We
calculated reporting rate differences based on DRRs and background rates
of
intussusception. Sensitivity analyses were
conducted to assess effects of differential reporting completeness and
inaccuracy
of baseline rates. Few reports were submitted
after RV1, allowing only a descriptive analysis.
RESULTS: The Vaccine
Adverse Event Reporting System received 584 confirmed intussusception
reports after RV5 and 52 after RV1, with
clustering 3 to 6 days after both vaccines. The
DRR comparing the 3- to 6-day and the 0- to 2-day periods after RV5 dose
1
was 3.75 (95% confidence interval = 1.90 to
7.39). There was no significant increase in reporting after dose 2 or
dose 3.
Over all 3 doses, the excess risk of
intussusception was 0.79 events (95% confidence interval = –0.04 to
1.62) per 100 000
vaccinations. From the sensitivity analyses, we
conclude that under a worst-case scenario, the DRR could be 5.00 and
excess
risk per 100 000 doses could be 1.36.
CONCLUSIONS: We
observed a persistent clustering of reported intussusception events 3 to
6 days after the first dose of RV5 vaccination.
This clustering could translate to a small
increased risk of intussusception, which is outweighed by the benefits
of rotavirus
vaccination.
29 mayo, 2013
The Paradox of Mental Health: Over-Treatment and Under-Recognition
Citation: The PLOS Medicine Editors (2013) The Paradox of Mental Health: Over-Treatment and Under-Recognition. PLoS Med 10(5): e1001456. doi:10.1371/journal.pmed.1001456
Published: May 28, 2013
Copyright: © 2013 PLoS Medicine Editors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time.
Competing interests: The authors' individual competing interests are at http://www.plosmedicine.org/static/editorsInterests.action. PLOS is funded partly through manuscript publication charges, but the PLOS Medicine Editors are paid a fixed salary (their salary is not linked to the number of papers published in the journal).
Abbreviations: ADHD, attention deficit hyperactivity disorders; LMIC, low- and middle-income country
Provenance: Written by editorial staff; not externally peer reviewed.
Among all the conditions in the world of health, mental health occupies a unique and paradoxical place.
On the one hand is over-treatment and over-medicalization of mental health issues, often fueled by a pharmaceutical industry interested in the broadening of the boundaries of “illness” and in the creation of more and wider diagnostic categories and thus markets for “selling sickness.” On the other hand exists profound under-recognition of the suffering and breadth of mental health issues affecting millions of people across geographies, which is a global problem.
As a journal, PLOS Medicine has covered both sides of the mental health “coin,” and we continue to make mental health in general a priority area. We recognize that the whole of the field of mental health research is relatively underdeveloped, and that a particular scarcity of clinical trials exists from outside high-income settings and for non-drug interventions. As a result, we also support efforts to improve capacity in mental health research whilst committing to the publication of the state of the art in research and commentary [1],[2].
Over-treatment, especially when it results from “disease mongering,” is a persistent and troubling issue. The harms of over-treatment arise from situations where normal life experiences (such as menopause, shyness, grief, etc.) are deemed illnesses [3] or when diseases are “created” from mild problems and symptoms (such as restless legs syndrome or female sexual dysfunction) [4],[5]. In both situations, people become patients, and their problems are deemed to need medical treatment when they may not need it or could be harmed by it, or when nonmedical options are available. Over-diagnosis and over-treatment have been shown for a range of human conditions [3], but this phenomenon as it relates to mental health is particularly powerful [6]. For example, the widespread over-diagnosis of conditions such as bipolar disorder, autism spectrum disorder, and attention deficit hyperactivity disorders (ADHD), especially among children, is now being documented—the US Centers for Disease Control recently estimated that 6.4 million children aged 4 to 17 had received an ADHD diagnosis at some point in their lives (amounting to 11% of all US children)—a 41% increase in the last decade that has been met with alarm and concern by many doctors and parents [7]. Two thirds of these children are said to be on medication for the condition. Recent Canadian data [8] reaffirm the concerns with excessive labeling of normal child behavior as pathological. Over-diagnosis in mental health risks unnecessary tests and treatment, the stigma associated with being labeled mentally ill, and the considerable costs of testing, treatment, and wasting resources that could be better utilized elsewhere [3],[5].
The recent DSM-5 process is a lightning rod for these concerns: this month's update of the psychiatric diagnostic manual has been widely criticized for continuing the tradition of broadening diagnostic categories and adding new conditions that redefine more people as having mental illness and in need of pharmaceutical treatment [9],[10]. That decisions about DSM-5 categories are made by experts with financial ties to the industry that benefits most from a widened patient population [11],[12], is particularly worrying.
In perhaps the most dedicated venue for discussions of this topic, the Selling Sickness conferences (http://www.sellingsickness.com), which PLOS Medicine has been instrumental in shaping, have brought together academic researchers, medical reformers, consumer advocates, and health journalists with shared interests in examining the problem of disease mongering and developing strategies and coalitions for change. The inaugural conference in 2006 coincided with our launch of the PLOS Medicine Disease Mongering Collection (http://bit.ly/18i6j6h) that to this day remains astonishingly relevant. In February 2013 we participated again, this time in a roundtable on the role of the medical media where we outlined our responsibility as editors to avoid the spin in published articles and the journal's press releases that can fuel hype about new disease categories and treatment [13]; we also highlighted another important role of journals in fighting disease mongering: to require that all clinical trials be registered and data be reported and shared, so that the full picture of the benefits and harms of tested interventions can be seen (see, for example, http://www.alltrials.net). The conference's Call to Action petition (http://sellingsickness.com/final-statement/) is available for readers to view and sign. Later in 2013, two comrade conferences, PharmedOut (http://www.pharmedout.org/) and Avoiding Overdiagnosis (http://www.preventingoverdiagnosis.net/), will continue the conversation about both the extent and the prevention of over-diagnosis, and will undoubtedly provide new insights into the problems associated with over-treatment of mental health.
Equally important, however, is the vast under-recognition of mental health conditions, especially in the developing world. This neglect has occurred at multiple levels including at the national level, where many countries have failed to establish adequate mental health policy. At the level of global health agendas, mental health was essentially ignored in the Millennium Development Goal program and failed to elevate to prominence at the recent United Nations special assembly on non-communicable disease.
As many others have noted [14]–[16], this neglect makes little sense: more than 13% of the global burden of disease is attributable to neuropsychiatric disorders, and over 70% of this burden lies in low- and middle-income countries (LMICs). Almost a quarter of the world's disability burden is now attributable to mental and behavioral disorders (including depression, anxiety, Alzheimer disease, and schizophrenia) [17]. And yet mental health has failed thus far to receive the political priority and international funding commensurate with its global toll [14]. There are signs this tide is shifting, and several prominent groups and organizations are working to raise the profile of global mental health. PLOS Medicine has provided a forum for that effort over the last few years, publishing packages of care for mental health disorders in LMICs [18] and an ongoing series on mental health interventions in practice [2]. And this week we conclude a five-part series that sets out an agenda for integrating mental health care into primary care, maternal health, non-communicable disease, and HIV interventions in the developing world [19]. All of these analyses were done by researchers free of financial links to manufacturers with a stake in expanded markets, thus providing the necessary independent opinion.
In addition, we've recently published high-quality research on a range of topics within mental health that contributes to improved clinical practice, policy, and action. This includes definitive evidence on the long-term health consequences of sexual abuse [20] and trafficking [21], a genome-wide analysis establishing the limited ability of genetic data to predict antidepressant response [22], and a meta-analysis reporting the relative benefits and harms of adjunctive antipsychotic medications in depression [23]. These studies add to a growing evidence base, and signal a growing recognition of the importance of mental health.
Still, our understanding of all aspects of mental health is relatively underdeveloped. As others have acknowledged [3],[24], the research base for over-diagnosis and harm from over-treatment remains limited, and so the new initiatives and calls for action are welcomed. So too is growing recognition and research on genuine mental health issues and the best ways to address and prevent mental health problems, especially in terms of policy and human rights action and in a global context. To the extent that these two areas (over-treatment on one hand, under-recognition on the other hand) represent the paradox of mental health, where's the balance point? We don't have all the answers, but as a journal we reaffirm our commitment to publishing rigorous, insightful research and commentary on the breadth of issues around global mental health, and we welcome continued debate on the challenges this paradox represents. The largest challenge may be to recognize and prioritize mental health globally—with the requisite political visibility, funding, research, and attention—without reducing it to an object for disease mongering, pathologizing, and harmful over-treatment.
On the one hand is over-treatment and over-medicalization of mental health issues, often fueled by a pharmaceutical industry interested in the broadening of the boundaries of “illness” and in the creation of more and wider diagnostic categories and thus markets for “selling sickness.” On the other hand exists profound under-recognition of the suffering and breadth of mental health issues affecting millions of people across geographies, which is a global problem.
As a journal, PLOS Medicine has covered both sides of the mental health “coin,” and we continue to make mental health in general a priority area. We recognize that the whole of the field of mental health research is relatively underdeveloped, and that a particular scarcity of clinical trials exists from outside high-income settings and for non-drug interventions. As a result, we also support efforts to improve capacity in mental health research whilst committing to the publication of the state of the art in research and commentary [1],[2].
Over-treatment, especially when it results from “disease mongering,” is a persistent and troubling issue. The harms of over-treatment arise from situations where normal life experiences (such as menopause, shyness, grief, etc.) are deemed illnesses [3] or when diseases are “created” from mild problems and symptoms (such as restless legs syndrome or female sexual dysfunction) [4],[5]. In both situations, people become patients, and their problems are deemed to need medical treatment when they may not need it or could be harmed by it, or when nonmedical options are available. Over-diagnosis and over-treatment have been shown for a range of human conditions [3], but this phenomenon as it relates to mental health is particularly powerful [6]. For example, the widespread over-diagnosis of conditions such as bipolar disorder, autism spectrum disorder, and attention deficit hyperactivity disorders (ADHD), especially among children, is now being documented—the US Centers for Disease Control recently estimated that 6.4 million children aged 4 to 17 had received an ADHD diagnosis at some point in their lives (amounting to 11% of all US children)—a 41% increase in the last decade that has been met with alarm and concern by many doctors and parents [7]. Two thirds of these children are said to be on medication for the condition. Recent Canadian data [8] reaffirm the concerns with excessive labeling of normal child behavior as pathological. Over-diagnosis in mental health risks unnecessary tests and treatment, the stigma associated with being labeled mentally ill, and the considerable costs of testing, treatment, and wasting resources that could be better utilized elsewhere [3],[5].
The recent DSM-5 process is a lightning rod for these concerns: this month's update of the psychiatric diagnostic manual has been widely criticized for continuing the tradition of broadening diagnostic categories and adding new conditions that redefine more people as having mental illness and in need of pharmaceutical treatment [9],[10]. That decisions about DSM-5 categories are made by experts with financial ties to the industry that benefits most from a widened patient population [11],[12], is particularly worrying.
In perhaps the most dedicated venue for discussions of this topic, the Selling Sickness conferences (http://www.sellingsickness.com), which PLOS Medicine has been instrumental in shaping, have brought together academic researchers, medical reformers, consumer advocates, and health journalists with shared interests in examining the problem of disease mongering and developing strategies and coalitions for change. The inaugural conference in 2006 coincided with our launch of the PLOS Medicine Disease Mongering Collection (http://bit.ly/18i6j6h) that to this day remains astonishingly relevant. In February 2013 we participated again, this time in a roundtable on the role of the medical media where we outlined our responsibility as editors to avoid the spin in published articles and the journal's press releases that can fuel hype about new disease categories and treatment [13]; we also highlighted another important role of journals in fighting disease mongering: to require that all clinical trials be registered and data be reported and shared, so that the full picture of the benefits and harms of tested interventions can be seen (see, for example, http://www.alltrials.net). The conference's Call to Action petition (http://sellingsickness.com/final-statement/) is available for readers to view and sign. Later in 2013, two comrade conferences, PharmedOut (http://www.pharmedout.org/) and Avoiding Overdiagnosis (http://www.preventingoverdiagnosis.net/), will continue the conversation about both the extent and the prevention of over-diagnosis, and will undoubtedly provide new insights into the problems associated with over-treatment of mental health.
Equally important, however, is the vast under-recognition of mental health conditions, especially in the developing world. This neglect has occurred at multiple levels including at the national level, where many countries have failed to establish adequate mental health policy. At the level of global health agendas, mental health was essentially ignored in the Millennium Development Goal program and failed to elevate to prominence at the recent United Nations special assembly on non-communicable disease.
As many others have noted [14]–[16], this neglect makes little sense: more than 13% of the global burden of disease is attributable to neuropsychiatric disorders, and over 70% of this burden lies in low- and middle-income countries (LMICs). Almost a quarter of the world's disability burden is now attributable to mental and behavioral disorders (including depression, anxiety, Alzheimer disease, and schizophrenia) [17]. And yet mental health has failed thus far to receive the political priority and international funding commensurate with its global toll [14]. There are signs this tide is shifting, and several prominent groups and organizations are working to raise the profile of global mental health. PLOS Medicine has provided a forum for that effort over the last few years, publishing packages of care for mental health disorders in LMICs [18] and an ongoing series on mental health interventions in practice [2]. And this week we conclude a five-part series that sets out an agenda for integrating mental health care into primary care, maternal health, non-communicable disease, and HIV interventions in the developing world [19]. All of these analyses were done by researchers free of financial links to manufacturers with a stake in expanded markets, thus providing the necessary independent opinion.
In addition, we've recently published high-quality research on a range of topics within mental health that contributes to improved clinical practice, policy, and action. This includes definitive evidence on the long-term health consequences of sexual abuse [20] and trafficking [21], a genome-wide analysis establishing the limited ability of genetic data to predict antidepressant response [22], and a meta-analysis reporting the relative benefits and harms of adjunctive antipsychotic medications in depression [23]. These studies add to a growing evidence base, and signal a growing recognition of the importance of mental health.
Still, our understanding of all aspects of mental health is relatively underdeveloped. As others have acknowledged [3],[24], the research base for over-diagnosis and harm from over-treatment remains limited, and so the new initiatives and calls for action are welcomed. So too is growing recognition and research on genuine mental health issues and the best ways to address and prevent mental health problems, especially in terms of policy and human rights action and in a global context. To the extent that these two areas (over-treatment on one hand, under-recognition on the other hand) represent the paradox of mental health, where's the balance point? We don't have all the answers, but as a journal we reaffirm our commitment to publishing rigorous, insightful research and commentary on the breadth of issues around global mental health, and we welcome continued debate on the challenges this paradox represents. The largest challenge may be to recognize and prioritize mental health globally—with the requisite political visibility, funding, research, and attention—without reducing it to an object for disease mongering, pathologizing, and harmful over-treatment.
Author Contributions
Wrote the first draft of the manuscript: JC. Contributed to the writing of the manuscript: JC PS MW LC AR. ICMJE criteria for authorship read and met: JC PS MW LC AR. Agree with manuscript results and conclusions: JC PS MW LC AR.References
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New virus after rotavirus vaccinne in USA
 |
| English: Norovirus particles (Photo credit: Wikipedia) |
Norovirus and Medically Attended Gastroenteritis in U.S. Children
N Engl J Med 2013; 368:1121-1130March 21, 2013DOI: 10.1056/NEJMsa1206589
Background
Cases of rotavirus-associated acute gastroenteritis have declined since the introduction of rotavirus vaccines, but the burden of norovirus-associated acute gastroenteritis in children remains to be assessed.
Methods
We conducted active surveillance for laboratory-confirmed cases of norovirus among children younger than 5 years of age with acute gastroenteritis in hospitals, emergency departments, and outpatient clinical settings. The children resided in one of three U.S. counties during the years 2009 and 2010. Fecal specimens were tested for norovirus and rotavirus. We calculated population-based rates of norovirus-associated acute gastroenteritis and reviewed billing records to determine medical costs; these data were extrapolated to the U.S. population of children younger than 5 years of age.
Results
Norovirus was detected in 21% of young children (278 of 1295) seeking medical attention for acute gastroenteritis in 2009 and 2010, with norovirus detected in 22% (165 of 742) in 2009 and 20% (113 of 553) in 2010 (P=0.43). The virus was also detected in 4% of healthy controls (19 of 493) in 2009. Rotavirus was identified in 12% of children with acute gastroenteritis (152 of 1295) in 2009 and 2010. The respective rates of hospitalization, emergency department visits, and outpatient visits for the norovirus were 8.6, 146.7, and 367.7 per 10,000 children younger than 5 years of age in 2009 and 5.8, 134.3, and 260.1 per 10,000 in 2010, with an estimated cost per episode of $3,918, $435, and $151, respectively, in 2009. Nationally, we estimate that the average numbers of annual hospitalizations, emergency department visits, and outpatient visits due to norovirus infection in 2009 and 2010 among U.S. children in this age group exceeded 14,000, 281,000, and 627,000, respectively, with more than $273 million in treatment costs each year.
Conclusions
Since the introduction of rotavirus vaccines, norovirus has become the leading cause of medically attended acute gastroenteritis in U.S. children and is associated with nearly 1 million health care visits annually. (Funded by the Centers for Disease Control and Prevention.)
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