185479646What with all the coverage of Ebola virus infection taking first place in news outlets, you may have missed another viral infection that's likely to be much more impactful here in the US, also originally an African import: Chikungunya.  As Rick and I discuss on PodMed this week and featured in an online first release in JAMA, the first two cases of local transmission of Chikungunya have occurred here in Florida, so it's official: Chikungunya has arrived on mainland USA.  And it's not cause for celebration.

As the report notes, since late last year the number of cases of Chikungunya has been increasing worldwide, with some 400,000 or so cases reported by the Pan American Health Organization.  The virus has been wreaking havoc in the Caribbean this summer, with tens of thousands of infections spread over much of the region. Until now, most cases in the United States have been the result of people traveling to the Caribbean islands and becoming infected there, then returning home.

Now, however, the typical pattern of infection has taken place in Florida, where an infected mosquito bites someone who is infected, then transmits that infection to the next person it bites.  The mosquito is merely the vector for the virus to pass from one person to another.  The virus has mutated such that it can now infect two species of mosquito:  Aedes aegypti and Aedes albopictus.  Aedes aegypti is the preferred and longstanding host, but acquisition of a single point mutation by the virus now allows it to be transmitted by A.albopictus as well.

So what about these mosquitos? A.aegypti makes its home in the southeastern US and parts of the southwest, while A.albopictus also forays further north to the mid-Atlantic and lower Midwest regions.  It's worth pointing out that in contrast to many of their peers, these two species of mosquito feed during daytime hours so wisdom regarding bite avoidance at twilight is sketchy at best.  In view of the fact that the infection mimics the flu except for joint pain many describe as 'excruciating' and 'disabling,' and can last as long as six months post-acutely, we all would like to avoid infection, so what should we do? Rick emphasizes that mosquito control is the best strategy, primarily by eliminating areas of standing water, such as flower pots, kiddie pools and the like.  Use of insect repellants and clothing is also helpful.  He points out to healthcare providers that Chikungunya is a reportable disease, so samples should be sent to local health authority or CDC labs for confirmation.

Good news has emerged also with release of data from a very early study on a vaccine candidate for Chikungunya reported in the Lancet.  In this small trial using a virus-like particle approach, volunteers did mount neutralizing antibodies to the virus and few side effects of vaccination.  Stay tuned.

Other topics this week include a number of studies examining the role of salt with hypertension and cardiovascular disease in NEJM, flexible sigmoidoscopy benefits in JAMA, and BMI and cancer in the Lancet.  Until next week, y'all live well.

 

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464185873Back in the day when I was dissecting cadavers, a note of warning swirled around the cadaver lab, advising students to read the tags accompanying their specimens to see if dementia was listed in causes of death.  If so, the advice was to double-glove, in order to avoid potential contagion with prions.  Yikes!  What are these unseen, subviral beasties about, that can survive an often prolonged bath in formalin and phenol and produce dementia in those unlucky enough to become infected?  On PodMed this week, Rick and I discuss one of them: Creutzfeldt Jakob disease, the subject of two very elegant studies in this week's New England Journal of Medicine, that may well result in a means to easily diagnose the condition in people.  First a bit of background, then let's look at the studies.

Prions are misfolded forms of a normal protein found inside cells known as the prion protein. Once inside a cell, in contrast to viruses that subvert cellular machinery in order to generate more copies of themselves, the prions simply replicate again and again, ultimately producing many copies of themselves that accumulate mostly in the central nervous system, although very minute amounts are seen elsewhere in the body. The cardinal clinical symptom is dementia.  It is the presence of these aforementioned very minute amounts of prion in other tissues that are exploited in these two studies: one in urine and the other in brushings of the olfactory epithelium at the top of the nasal cavity. If brought to clinical fruition these studies represent a great advantage over other diagnostic techniques such as brain biopsy (!) or post-mortem examination.

Urine was used to test for the presence of prions in a study of two groups of patients: 68 with one form of Creutzfeldt Jakob known as sporadic, and 14 with a variant form transmitted to humans from cows.  Regarding this group of people, the condition in cows is bovine spongiform encephalopathy.  Current known cases of the variant form number 228 but estimates are that as many as 30,000 people in the UK may be infected.

Samples obtained from these folks were centrifuged and the pellet utilized in something known as 'the protein misfolding cyclic amplification (PMCA) assay.'  This assay produces many copies of the prion so that it can be detected, and detect it they did, with almost 93% sensitivity and 100% specificity.

How about the olfactory epithelial brushings study?  This much more humane than biopsy of olfactory epithelium technique produced the following impressive results: [samples] "were positive in 30 of 31 patients with Creutzfeldt–Jakob disease (15 of 15 with definite sporadic Creutzfeldt–Jakob disease, 13 of 14 with probable sporadic Creutzfeldt–Jakob disease, and 2 of 2 with inherited Creutzfeldt–Jakob disease) but were negative in 43 of 43 patients without Creutzfeldt–Jakob disease, indicating a sensitivity of 97%... and specificity of 100%... for the detection of Creutzfeldt–Jakob disease."  Both studies used controls with dementia resulting from other causes as controls.

Good news, then, for detection, and very impressive technology.  Rick and I agree, however, that the likelihood that either of these methods will be widely applied to many is low. And of course then we have the problem of effective intervention, but that's another story. Other topics this week include 'immunonutrition' in JAMA  , an update on Ebola in NEJM and in CDC communications, and a lack of efficacy with brief drug interventions in JAMA .  Until next week, y'all live well.

 

 

 

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451876561-120x86Are you a runner?  I'm not, preferring instead to pound out the miles on my bike, the same as Rick, as listeners to PodMed know very well. Now comes a study in the Journal of the American College of Cardiology that may change my mind.  That's because this huge study examining all-cause and cardiovascular mortality risks in over 55,000 adults with an average followup of 15 years showed that running less than 51 minutes weekly, clocking in less than six miles, in one to two sessions each week was sufficient to rack up impressive reductions in mortality risk compared with not running.  Yay, I say.  Since so many of the clothes and shoes one wears to run are so cool, I think I'll be looking into this further.  For now, let's take a closer look at the study.

The study population is part of the Aerobics Center Longitudinal Study at the Cooper Clinic in Dallas, TX, designed to examine the relationship between physical fitness and activity and a variety of health outcomes.  Subjects may come to the study by self-referral, or via their employer or physician, and these ranged in age from 18 to 100 years, with women comprising 26% of the final group included in this analysis. Running or jogging in the previous three months was assessed with the baseline physical activity questionnaire, with distance, speed, duration and frequency data queried. The running data rendered the group into 6 subgroups, one non-runners and five based on running speed, duration, metabolic equivalents, amount and frequency. Participants who became runners or gave up running were accounted for, as was all physical activity that was not running or jogging, such as cycling, swimming, and so on, also subcategorized based on METs and corrected for in calculating the impact of running or jogging.

The study found that in those subjects 50 years of age or older, runners experienced a 29% lower mortality risk compared with non-runners. Regarding the entire cohort, "During a mean follow-up of 15 years, 3,413 all-cause and 1,217 cardiovascular deaths occurred. Approximately 24% of adults participated in running in this population. Compared with nonrunners, runners had 30% and 45% lower adjusted risks of all-cause and cardiovascular mortality, respectively, with a 3-year life expectancy benefit." Importantly, even a very modest 5-10 minutes per day of running provided benefit, compared with no running.  Seems to me that even if you loath the activity, don't want to get sweaty, are prone to shin splints or whatever else may ail you regarding running, five minutes a day is doable.  We have a well-known and much publicized problem with obesity and all the attendant conditions and diseases.  A simple and easy strategy like running five minutes a day may reduce this societal burden considerably, as well as simply help people feel better.  Running shoe shopping, anyone?

Other topics this week include the impact eating fruits and vegetables has on mortality in the BMJ, screening for teen substance abuse with computers in the waiting room in JAMA Pediatrics, and managing stable ischemic heart disease in Circulation (Rick is co-author!).  Until next week, y'all live well.

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72991367Handoffs, or to wax PC, handovers, are those circumstances where the person who's been managing a patient during a particular time period in the hospital meets with those just coming on to the unit and recites what's been done, current status, medications and so on relative to the patient's care as they end their shift. As Rick and I discuss on PodMed this week, and as published in a study in JAMA Internal Medicine, this is prime time for medical errors, some of which could seriously compromise patient care.  And as Rick laments on the podcast, this problem has been recognized for some time in academic medicine but has so far proven quite resistant to attempted remedies.  What did they do here?

Investigators tagged along on morning handover in two tertiary care academic medical centers in Toronto, Canada, on the general internal medicine service. Medical care on these services is provided during the day by a team consisting of one attending physician, one senior resident, at least two interns, and two medical students. At night an on-call trainee provides care, and this is usually a member of the daytime team but may be a trainee from another service or team.  Electronic medical records are employed in both centers but notes by both physicians and nurses occur on paper. The verbal handover process is supported by an Internet-based written sign out tool.

The researcher took notes during morning handover and in particular the occurrence of interruptions or distractions during the process. Each case was reviewed by investigators and pertinent data and notes by care providers integrated. Data from 26 observations revealed that  "The on-call trainee did not verbally hand over 40.4% (95% CI, 32.3%-48.5%) of the clinically important overnight issues and did not document a progress note for 85.8% (95% CI, 80.1%-91.6%) of these issues. Trainees documented 7.8% (95% CI, 3.4%-12.2%) of clinically important issues in the Internet-based written sign-out tool. There were 52 (36.9%; 95% CI, 28.9%-44.8%) clinically important issues that were neither handed over nor documented by the on-call trainee."

Wow.  That's a lot of important information relevant to a patient's care that wasn't revealed in the handoff, and didn't appear elsewhere either. Factors that may have contributed include the following: "Handover took place in many different locations in the hospital  and occurred in a dedicated team room only 41% of the time. Teams divided the handover process into more than 1 encounter 68% of the time (eg, handover of overnight issues occurred before and after morning teaching rounds). Teams met for a mean total of 71 (26) minutes to review new cases and hand over overnight issues. Teams spent most of their time reviewing new information on patients admitted during the previous night, with a mean of only 11 (10) minutes dedicated to handing over on-call overnight issues. During these interactions, teams experienced 6.1 (7.1) distractions per hour resulting in 2.6 (2.9) interruptions per hour."  As Rick opines in the podcast, these findings point to clear ways to redesign the process to help minimize the errors, while I assert that this is clearly a place where family or loved ones can help support the team in providing care by also reviewing the chart, medications, tests and so forth.  Seems a likely place where substantial improvements can be made.

Other topics this week include catheter-based thrombolysis for deep vein thrombosis in the same journal, morcellation and uterine fibroids in JAMA, and a new pathway identified in antiphospholipid antibody syndrome in NEJM.  Until next week, y'all live well.

 

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481422389Electronically based interventions in clinical care have thus far proven somewhat disappointing, as Rick and I have discussed on PodMed many times, but this week, we talk about a study utilizing electronic devices, telephone or Internet interface, and nurses to help people manage their chronic pain. The results, reported in JAMA, appear very encouraging.  Here's what they did:

Two hundred fifty people with chronic pain of at least three months duration were randomized to either usual care, administered by a physician, to manage their pain, or to automated symptom monitoring either by phone or Internet, weekly for one month, followed by every other month for months 2 and 3, and then monthly for months 4 through 12.  Subjects answered 23 questions to assess pain level, anxiety level, depression, the degree to which pain was disabling, whether current medications were being taken as prescribed and how well they were working, and whether a call with a nurse was needed.

The study utilized a stepped care analgesic optimization algorithm developed on a review of the literature relative to pharmacologic management of pain. 6 classes of analgesics were employed, ranging from acetaminophen and NSAIDs to opioids. Adjustments in type or dose of analgesic were determined by the nurse and prescribed by a study physician in the intervention group  if the subject requested a change, less than 30% improvement in the overall pain score was seen, or global improvement was not at least moderate. The control group was managed by their primary care physician.

All study participants had pain of musculoskeletal origin. People in the intervention group had greater improvement in their pain control and reductions in pain severity than the usual care group, and these results did not differ by age, gender, education level, race or socioeconomic status.  There was no difference between the telephone and Internet interface groups. Finally, when we cite that current favorite in the medical literature, number needed to treat, we see a very modest 4:1 ratio, indicating that 4 patients must be treated for one to improve significantly.  That's pretty good, considering the fact that we routinely advocate for treatments and interventions with much higher numbers, and that the intervention is inexpensive, and convenient for both patient and provider.

How about that other hot button issue right now, opioid use? Although one-third of all subjects were taking these medications at the start of the study, very few people in either group started opioids for the first time or increased their dose during the study period.  The authors opine that the systematic approach to pain assessment and medication use utilized in this study helps, and that the addition of other strategies such as cognitive behavioral therapy might further improve these results. Since pain is the most commonly reported symptom in the general population, getting our arms around best care practices is crucial.

Other topics this week include two on stroke in JAMA, pill changes and compliance in Annals of Internal Medicine, and niacin for the prevention of cardiovascular disease in NEJM.  Until next week, y'all live well.

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470639625Carotid artery stenosis.  Well, if there was ever a bit of medicalese this is it. So let's dissect the term, as Rick and I do on PodMed this week, so we can further dissect new recommendations of the United States Preventive Services Task Force or USPSTF published in Annals of Internal Medicine regarding the condition.

The carotid artery is the major blood vessel carrying blood to your head, including that critical structure: your brain.  You have two of these arteries that pass upward on either side of your neck and then divide into internal and external carotid arteries, where they may dive deep into the brain itself or supply the face, respectively. As you can feel on your own by placing your fingers on the side of your neck and feeling for your pulse, this is a sizable vessel with a big job.  So if/when blockages start to impede the flow of blood through the carotid, so-called 'stenosis' or narrowing, the consequences can be dire. Enter then the strategy of screening for carotid artery stenosis, employed some years ago now by simply listening, with a stethoscope, to blood roiling around in the artery.  This is underpinned by ultrasound examination of the artery, with both of these techniques having the advantage of being quick, inexpensive, noninvasive, and painless.  Sounds great, huh?  But does screening people who don't have symptoms result in less stroke, the aforementioned dire potential consequence of carotid artery stenosis? And once identified, does treating narrowing of the vessel really help reduce the risk of stroke or result in other deleterious consequences of treatment?

As Rick would say, that was the subject of this USPSTF guideline, based on examination of all the evidence relative to screening asymptomatic people, possibly treating them, and their subsequent risk for stroke on the same side of the body in which stenosis was identified? In short, the evidence argues against screening at all, in view of the chance that such screening will result in treatment and its host of potential side effects, none of them good.  To begin with, the use of ultrasound to screen in a population in whom the prevalence of the condition is low results in a very large number of false positive results. A perioperative stroke or death rate of less than 3% was seen in this analysis when carotid enarterectomy to remove plaque inside the artery was employed, but the authors state that observational trial results are much higher.  Finally, in comparison to medical therapy surgery is no longer emerging as the superior choice.  To sum then, in people without symptoms looks like screening for carotid artery stenosis isn't helpful and shouldn't be done.  For those of you considering such an examination as a gift for a loved one, why not choose a golf outing instead?

Other topics this week include infusion pumps for hard to control diabetes in the Lancet, medications for neuropathy in JAMA, and varenicline and a nicotine patch for smoking cessation in JAMA.  Until next week, y'all live well.

 

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imagesCAJIMJS6Most adults will have at least one episode of noteworthy back pain in their lifetime, with many experiencing persistent and often disabling symptoms. In fact, back issues are one major reason people miss work and/or seek medical attention.  Enter then the medicalization of this condition, with a fast forward to injections into the space around affected nerves emerging from the spine, so-called 'epidural' injections, to treat pain.  On PodMed this week Rick and I offer kudos to the authors of this study published in NEJM, assessing whether this strategy is actually of any benefit in alleviating pain.  While for those unfortunate folks who got a dose of fungus along with their injection for back pain this study comes too late, we hope it will turn the tide of epidural injections commonly being employed for this purpose.

Investigators randomized 400 people with lumbar spinal stenosis, or narrowing of the canal through which the spinal cord and nerves must pass down the back, and who also had moderate to severe leg pain because of the condition, to one of two treatments: epidural injections of steroid medication plus a local anesthetic called lidocaine, or simply lidocaine alone. Subjects could receive either one or two injections and were subsequently evaluated six weeks after their first (and perhaps only) injection. Both a disability and a pain scale questionnaire were utilized as the primary outcome measures.

People who received the steroid medication, ostensibly to reduce inflammation in the nerve root and the putative cause of the pain, did no better at the six week assessment than those who received the local anesthetic alone.  Wow!  As background it's worth noting that injections for spinal stenosis have increased by about 300% in Medicare and Veteran's Administration populations over the last two decades, with a concomitant increase in costs. So a huge amount of resources have been devoted to the employment of this technique and this study at least suggests we've been wasting our money.

To be fair it must be admitted that there are several causes of back pain other than lumbar spinal stenosis, and these may be amenable to this strategy.  These authors note that about a quarter of all epidural injections for back pain in the Medicare population and 75% of those in the VA population are due to this condition.  Clearly then the technique cannot be soundly panned until additional studies are carried out but Rick and I both feel it should be considered much more judiciously. As we have advocated in the past, the tincture of time is well worth attempting, and in the case of low back pain, so is weight loss and exercise, perhaps taught with a physical therapist's help.

Other topics this week include an assessment of how often physicians talk about sunscreen with their patients in JAMA Dermatology, bone marrow transplantation for sickle cell disease in JAMA, and celiac disease and a genetic assessment in NEJM.  Until next week, y'all live well.

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451096797Anyone out there remember the TV show 'The Bionic Man'? The central premise involves a guy who is severely injured and subsequently largely rebuilt using bionic parts.  What exactly is bionic?  Wikipedia defines the term this way: Bionics (also known as bionical creativity engineering) is the application of biological methods and systems found in nature to the study and design of engineering systems and modern technology.  Rick and I discuss a bionic pancreas on PodMed this week, based on a study presented at the American Diabetes Association meeting and published in NEJM. This study's senior author is a biomedical engineer who designed an artificial pancreas to resemble a human one, using both insulin and glucagon, the two hormones primarily responsible for regulating blood sugar, to manage same.  The early results look promising indeed, if not quite yet ready for prime time (pun intended).

The paper reports the results of two five-day trials, one in adults and one in adolescents, with type 1 diabetes, who were fitted with a bionic pancreas that automatically monitored blood glucose and utilized either insulin or glucagon to achieve a desirable level with an iPhone app interface.  Previous work by the same group established that in an inpatient setting, the device was capable of managing blood glucose effectively for 48 hours.

So what about the outpatient setting, where variability in all sorts of parameters that directly and indirectly affect blood glucose are operational? Assessing the device in this setting was the intention of the current study. All subjects had previous experience with insulin pumps and glucose monitoring. The adults were resident in a hotel geographically close to the hospital, and their activities were limited to an area within three square miles of the hospital for the duration of the study.  They were also accompanied by a staff member. During the study period they could eat whatever they liked, exercise at will, and were allowed to consume 3 alcoholic drinks per day for men and 2 for women.  The adolescents were resident in a camp for people with diabetes.  For the duration of the study they ate the same meals and participated in the same activities as other campers.  Both groups had abundant data collected on blood glucose, episodes of hypoglycemia and other adverse events, and they all acted as their own controls with a five-day usual care period during which all parameters were recorded as well.

Here's what they found: the bionic pancreas was able to decrease the number of episodes of hypoglycemia in the adult population but not in the adolescents.  The authors speculate this may be due to prompt intervention in the camp setting to avoid such an outcome. Both groups saw a lower mean blood glucose level with use of the bionic pancreas compared to usual care. There were a few issues with the iPhone interface but these spontaneously resolved and infusions resumed as appropriate. The authors caution that the device may overestimate blood glucose if acetaminophen is used, and that currently available glucagon must be reconstituted daily, but Rick and I agree that this is a great proof of concept study that clearly should be ramped up. And it's cool!

Other studies this week include thrombolysis for pulmonary embolism in JAMA, exercise for depression in JAMA Internal Medicine, and mammography outcomes in the BMJ.  Until next week, y'all live well.

 

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479517651Parkinson's disease (PD), a consequence of death of neurons in the brain area known as the substantia nigra, is the second most common neurodegenerative disease in the world, after Alzheimer's disease. This movement disorder affects about 7 million people worldwide and 1 million in the US alone currently, with more to come as many more of us age into our 80s and older since PD occurs more often as people age.  Now for the good news:  in what's known as a 'pragmatic' trial undertaken in the UK and reported in the Lancet, as Rick and I discuss on PodMed this week, an old drug known as L-DOPA or levodopa seems the best choice for most when it comes to initial medical management.

Pragmatic trials attempt to assess interventions as they are implemented in the real world rather than the rarified air of a clinical trial. In this case 1620 people newly diagnosed with PD were randomly assigned to either levodopa, another type of drug known as a dopamine agonist, or yet another class called monoamine oxidase type B inhibitors.  Each of these three types of drugs works by a different mechanism in an attempt to overcome loss of the neurotransmitter called dopamine, normally produced by the neurons that die. People entering the trial were diagnosed by movement disorder experts, were either untreated previously or treated for less than six months with levodopa.  Both subjects and clinicians were aware of which drug was selected.

Data from 7 years of follow-up is presented in this study.  One outcome measure was the mobility subscale of a questionnaire known as the PDQ-39. This self-report data is sensitive to items regarded as important to people with PD but that may not be represented on clinical rating scales. Quality-adjusted life-years were determined along with a host of other outcomes such as  changes in the mini-mental state examination, hospitalizations, and mortality. The study determined that for those assigned to the levodopa arm, small but persistent benefits in mobility scores by self-report were seen.  Moreover, with regard to compliance, "179 (28%) of 632 patients allocated dopamine agonists and 104 (23%) of 460 patients allocated MAOBI discontinued allocated treatment because of side-effects compared with 11 (2%) of 528 patients allocated levodopa (p<0·0001)."  As Rick and I opine in the podcast, this may be regarded as good news since levodopa is off-patent, we have an abundant track record regarding its use, and more sensitive titration of the drug clinically may preclude some of the side effects or at least delay them.

The authors have done a cost analysis that is forthcoming, but predict that the economic analysis will also favor use of L-DOPA.  Since we have so many people who will undoubtedly develop PD in the near term, this is of public health benefit as well.  Finally, Rick and I do mention other strategies such as electrode implantation as promising, but agree that for now, knowing which medication is likely to be most beneficial is very helpful for all concerned.

Other topics this week include two studies from NEJM on managing another common condition, obstructive sleep apnea.  We also look at statins and physical activity in older men in JAMA Internal Medicine, and what happens when insulin is added to metformin for the management of type 2 diabetes in JAMA.  Until next week, y'all live well.

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154216694How many children are maltreated, with 'maltreatment' including neglect, sexual, physical or emotional abuse, each year in the United States?  While it's a safe bet no one really knows the absolute number, a very sobering study Rick and I discuss on PodMed this week and published in JAMA Pediatrics attempts to estimate that number, with disconcerting results.  And by the way, almost everyone agrees said results are almost surely an underestimate.  Okay, what about the study?

Researchers crunched data from the National Child Abuse and Neglect Data System (NCANDS) Child File, which included reports on 5 689 900 children filed between 2004 and 2011 of maltreatment confirmed by Child Protective Services. The main outcome measures of the analysis include the cumulative prevalence of confirmed child maltreatment by race/ethnicity, sex, and year.

Here are the numbers, directly from the manuscript: "At 2011 rates, 12.5% (95% CI, 12.5%-12.6%) of US children will experience a confirmed case of maltreatment by 18 years of age. Girls have a higher cumulative prevalence (13.0% [95% CI, 12.9%-13.0%]) than boys (12.0% [12.0%-12.1%]). Black (20.9% [95% CI, 20.8%-21.1%]), Native American (14.5% [14.2%-14.9%]), and Hispanic (13.0% [12.9%-13.1%]) children have higher prevalences than white (10.7% [10.6%-10.8%]) or Asian/Pacific Islander (3.8% [3.7%-3.8%]) children. The risk for maltreatment is highest in the first few years of life; 2.1% (95% CI, 2.1%-2.1%) of children have confirmed maltreatment by 1 year of age, and 5.8% (5.8%-5.9%), by 5 years of age. Estimates from 2011 were consistent with those from 2004 through 2010."

Yikes!  I am especially taken aback by the fact that most maltreatment occurs while children are very young, and often preverbal. Rick and I both agree that the onus is on healthcare providers, who may be some of the few people who will interact with children at this point in their lives, to be on hyperalert to signs of maltreatment. Rick also points out, as do the authors of the study, that child maltreatment really is a health issue: those who have been maltreated as children are at greater risk for obesity, HIV infection, and mortality than those who have not been maltreated.  They're more likely to engage in criminal behavior, experience mental health problems, and are 5 times as likely to attempt suicide as their non-maltreated counterparts. Indeed, the authors provide the estimate that the cost to society of child maltreatment exceeds or equals that of stroke and type 2 diabetes!

Clearly, these rates of child maltreatment are intolerable.  As the authors state, "these data highlight that the burden of confirmed maltreatment is far greater than suggested by single-year national estimates of confirmed child maltreatment and that the risk for maltreatment is particularly high for black children (between 1 in 4 and 1 in 5, my addition)." This study provides us with greater awareness of the problem, now policies and practices must be developed and implemented to address what is obviously a public health issue.

Other topics this week include the utility of colorectal cancer screening in previously unscreened elderly in Annals of Internal Medicine, and two from the BMJ: early stroke thrombolysis benefit, and the statin/diabetes relationship.  Until next week, y'all live well.

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